Sepsis Prevention to Improve Clinical Outcomes

Whether the Study Purpose Is an Important Clinical Issue

According to the World Health Organization, sepsis has had a gradually increasing prevalence and incidence in the last years. Globally, the incidence rate of sepsis is approximated to be 31.5 million and an estimated 19 million of cases of severe sepsis occur yearly (Rudd et al., 2018).  In the United States, there are approximately more than 750,000 patients with sepsis and this population is gradually increasing with a mortality rate of 20-30%. With an increasingly aging population that suffers more from chronic conditions, there is an increase in the use of immunosuppressive therapies, chemotherapy, invasive procedures and transplants (Rudd et al., 2018).   Therefore, the high trends of severe sepsis are expected to continue. It should also be noted that, despite a decline in the mortality and morbidity rates due to sepsis in the past decades following advancements in supportive care, they are still unacceptably high. Additionally, most survivals are often associated with long term morbidities (Rudd et al., 2018).   It is for this reason that researchers, clinicians and other healthcare providers continue to engage in evidence-based research to develop strategies of improving care and health outcomes.Sepsis Prevention to Improve Clinical Outcomes

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What This Research Means For Clinical Practice In My Unit

            Patients with sepsis usually develop multi-organ system failure. Sepsis is also considered to be a leading cause of mortality and morbidity among patients admitted in Intensive Care Units. In clinical practice, this research means that nurses should engage in the development of guidelines and strategies to prevent sepsis or improve the management of infections among patients admitted in the Intensive Care Unit (Rudd et al., 2018).  This is attributed to the fact that patients in such units are at a very high risk of complications. Therefore, with such guidelines in place, improved clinical outcomes are guaranteed which will lead to high quality care and effective patient outcomes.

Reference

Rudd, K. E., Kissoon, N., Limmathurotsakul, D., Bory, S., Mutahunga, B., Seymour, C. W., & West, T. E. (2018). The global burden of sepsis: barriers and potential solutions. Critical Care, 22(1), 232.

Introduction

Among people of all ages admitted in intensive care units, sepsis is one of the most common causes of death. According to the World Health Organization, Sepsis mortalities are high and it is the leading cause of death among pediatric, adult and geriatric patients admitted in intensive care units. Basically, sepsis is defined as an acute syndrome which results from a systemic inflammation following a severe infection. Annually in the United States, approximately 750,000 cases of sepsis are reported and this presents a significant burden to the healthcare system. Despite minimal outcomes in improvement, sepsis continues to have morbidity and mortality rates which are unacceptably high. It is for this reason that healthcare providers continue to engage in evidence-based research to devise strategies that will positively impact clinical outcomes in the prevention of sepsis. The purpose of this paper is to conduct a critical appraisal of a quantitative study and come up with a PICOT statement that will guide evidence-based research to improve clinical nursing outcomes among hospitalized patients with sepsis.

Simplified Severe Sepsis Protocol: A Randomized Controlled Trial of Modified Early Goal-Directed Therapy in Zambia

The study by Andrews et al. (2014) was a non-blinded randomized controlled clinical trial that was triggered by high rates of sepsis-related deaths among immunosuppressed adults infected with HIV, cryptococcal meningitis and tuberculosis in Sub-Saharan Africa. The high rates were as a result of controversies in optimal management strategies. From previous studies, it was noted that goal-oriented therapy through aggressive administration of IV fluids, blood transfusion, and hemodynamic support proved effective in developed nations of Europe and North America (Andrews et al., 2014).  However, the use of these approaches in Sub-Saharan Africa was noted to be minimal due to limited resources.Sepsis Prevention to Improve Clinical Outcomes

Problem/Purpose Statement

Andrews et al., (2014) purposed to find out whether early goal-directed therapy protocols could be effective in reducing sepsis-related deaths as compared to the usual care given to patients with severe sepsis in Africa.  The researchers, therefore, designed a simple severe sepsis protocol, whose goal-oriented interventions aimed at administering fluids, blood transfusion or dopamine and being closely monitored by nurses with early initiation of antibiotics and blood cultures (Andrews et al., 2014). Although the research questions are not directly stated, based on this study purpose, the broad research question that the researchers wanted to address was:

Can goal-oriented interventions of administering fluids, transfusing blood and administering dopamine help to reduce sepsis-related deaths of patients hospitalized in intensive-care units?

To predict the relationship between variables, the researchers hypothesized that a simplified treatment protocol that is defined by early goal-oriented therapy protocols can reduce sepsis-related mortalities in comparison to the routine care given to patients with severe sepsis in Africa. The dependent variable was therefore severe sepsis and the independent variables were fluid administration, blood transfusion and dopamine administration (Andrews et al., 2014).

Severe sepsis was defined by the researchers as the presence of  infection  based on the suspicion of a treating doctor, presence of a systemic inflammatory response syndrome (a heart rate >  90b/min, respiratory rate > 20 breaths/min, temp >=38.00c or <= 36.00c, WBC>12,000/cmm or <4,000/cmm) and one or more signs of organ dysfunction(Andrews et al., 2014).

Literature Review

The researchers used both qualitative and quantitative peer-reviewed articles that were specific to the purpose of the study. Although some references were older than 5 years, they were still relevant. Based on the references used, some studies supported the use of goal-oriented therapy (blood transfusion, hemodynamic support, and administration of fluids) to reduce mortality due to sepsis (Andrews et al., 2014). However, opposing articles were still used and demonstrated that the use of goal-oriented therapies especially in Sub-Saharan Africa is still non-existent due to limited resources. The same way, other opposing articles mention some of the risks and benefits of aggressive resuscitation using fluids, which is one of the therapies under being used in this study (Andrews et al., 2014).Sepsis Prevention to Improve Clinical Outcomes

Method

According to this study, the dependent variable was severe sepsis and the independent variables were; fluid administration, blood transfusion, and dopamine administration. Among the participants, the only patient who had severe sepsis which was the dependent variable was clearly defined. Severe sepsis was defined as the presence of infection based on the suspicion of a treating doctor, presence of a systemic inflammatory response syndrome (a heart rate > 90b/min, respiratory rate > 20 breaths/min, temp >=38.00c or <= 36.00c, WBC>12,000/cmm or <4,000/cmm) and one or more signs of organ dysfunction (Andrews et al., 2014).

Among the independent variables, fluid administration was defined as administration of a 2-liter bolus of either Ringer’s Lactate or Normal Saline within the 1^st hour of assessment followed by 2 liters of fluid over 4 hours totaling to 4 liters over the initial 5-6 hours.

Blood transfusion was defined as the administration of whole blood to patients who had a hemoglobin of < 7g/dl(Andrews et al., 2014).

Dopamine administration was defined as the infusion of dopamine at a rate of 10mcg/kg/min which is gradually titrated to maintain a MAP>=65mmHg.

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            To address the hypothesis, the researchers overall plan was to conduct a randomized clinical trial of two groups of patients; one group of patients received usual care according to the orders provided by the physicians in the emergency room where antibiotics, IV fluids and non-titrated dopamine were administered while the other group received protocol-based care the initial 6 hours following enrollment (Andrews et al., 2014).

Participants

The study populations as described by the researchers were a total of 109 patients aged 18 years or older who presented at the emergency room of the University Teaching Hospital Lusaka, Zambia. The patients were required to meet the criteria for severe sepsis for selection during the presentation. Those who showed signs of severe sepsis after arrival were also included as long as they stayed in the emergency room for less than 24 hours after arrival but within 6 hours of initially meeting the criteria for severe sepsis. In this context, severe sepsis referred to the probability of infection with systemic inflammatory response syndrome and organ dysfunction (Andrews et al., 2014).

It is also clearly mentioned that the researchers got the ethical approval to conduct this study from the Biomedical Research Ethics Committee of the University of Zambia as well as the Institutional Review Board of Vanderbilt University (Andrews et al., 2014). Before conducting the study after the study participants were obtained, the researchers ensured that written consent was obtained to safeguard the interests of both the patients and the researchers.Sepsis Prevention to Improve Clinical Outcomes

Data Collection

The researchers explained that data was collected by nurses who monitored patients in both groups and recorded their vital signs every 6 hourly. The nurses also had the responsibility of ensuring that all orders were executed and that physicians in the emergency room were immediately notified of changes in the conditions of patients including but not limited to respiratory status, fluid resuscitation and oxyhemoglobin saturation within the first 72 hours. For both patient groups, blood cultures were also collected and outcomes recorded in patient files by the nurses (Andrews et al., 2014). The researchers used a significance level of 0.05 to test the hypothesis, t-tests to measure the continuous variables, chi-squared and Fisher’s test to measure categorical variables and Kaplan-Meier and log-rank test to compare survival by intervention up to the 28^th-day admission. These data collection and analysis instruments are what helped to maintain the validity and reliability of the results (Andrews et al., 2014).

Results

According to the study findings, it was noted that goal-oriented therapy protocols which comprise of aggressive administration of fluids, blood transfusion and dopamine are not effective approaches to reduce sepsis-related deaths among hospitalized patients as compared to the usual care (Andrews et al., 2014). This, therefore, means that the study hypothesis was answered. Some of the limitations described by the researchers include:

It is also worth noting that, the researchers made a decision to stop the study after making an observation that patients who had hypoxemic respiratory distress were at high risk from the researcher’s interventions. Therefore, to either revise or replace the study, it is recommended that future sepsis studies which involve the administration of IV fluids should prioritize measures that are more reliable for hypoperfusion (Andrews et al., 2014). Form the study it was also notable that patients who presented with confusion from meningitis or respiratory distress due to pulmonary edema have other mechanisms of organ damage which can worsen following a thorough administration of fluids, it is right to conclude that the findings of this study cannot be generalized (Andrews et al., 2014).

Application to Nursing

The implications of the findings of this study in nursing practice are evident. First, it is advisable that nurses should use severe tachycardia as a measure of hypo-perfusion among patients with sepsis as it is the only measure that reflects anemia, hypoxemia, hypovolemia and high fever. They should use severe tachycardia to decide the appropriate interventions to institute for a patient rather than using organ dysfunction. Secondly, when managing patients with severe sepsis with respiratory distress, when ventilator support is not available, nurses should take a lot of caution when administering IV fluids as boluses. The best was of taking caution is to perform thorough scrutiny of such patients to determine whether or not the intervention will be of more harm than benefit before making a decision. Alternatively, nurses should consider using adjunctive therapies such as non-invasive positive pressure ventilation for such patients. In most Sub-Saharan areas, tuberculosis should be noted as the primary cause of a leading etiology of sepsis and therefore, anti-tuberculous therapy should not be delayed. In the ICU, most patients usually present with multiple comorbidities and underlying conditions which increases their risk for sepsis. Therefore, the results can readily be applied to my patients to improve health outcomes.Sepsis Prevention to Improve Clinical Outcomes

PICOT Question

The findings of this study and the background clinical problem, therefore, lead to the following PICOT Question:

Among hospitalized patients aged 18 years or older (P), how does fluid administration (I) compared to administration of antibiotics (P) help to prevent severe sepsis (O) within 72 hours (T)?Sepsis Prevention to Improve Clinical Outcomes