Screening for sepsis improves early identification, and when combined with a management approach, as part of a performance improvement process, it decreases sepsis-related mortality (Levy, 2010, 2014; Schorr, 2009; Black, 2012; Moore, 2009; Rivers, 2008).
Quick SOFA (qSOFA)
In the emergency department or general hospital ward settings, adult patients with suspected infection can be rapidly identified as being more likely to have poor outcomes typical of sepsis if they have at least two of the three criteria from the qSOFA score (respiratory rate of 22/min or greater, altered mentation, or systolic blood pressure of 100 mm Hg or less).
Prevention Bundles for Healthcare Associated Infections
Prevention of UTI – Non-Catheter-Associated Urinary Tract Infection Bundle (Saskatchewan 2013)
- Ensure proper hydration and nutrition.
- Provide good perineal hygiene.
- Promote healthy voiding habits.
Prevention of CAUTIs
(APIC 2014, Meddings 2014, IHI 2011, Gould 2010, Lo 2014)
- CAUTI Risk Assessment:
- Assess whether an effective organizational program exists.
- Assess population at risk.
- Assess baseline data.
- Measurement/Surveillance: Surveillance and reporting program in place with standardized definitions.
- Insertion: Use appropriate technique for catheter insertion -
- Only trained persons to insert and maintain catheter.
- Insert urinary catheters only when necessary for patient care and leave in place only as long as indications remain.
- Consider other methods for bladder management, such as intermittent catheterization, where appropriate.
- Practice good hand hygiene and routine IPAC practices.
- Use aseptic technique and sterile equipment for catheter insertion.
- Use sterile gloves, drape, and sponges; a sterile or antiseptic solution for cleaning the urethral meatus; and a sterile single-use packet of lubricant jelly for insertion.
- Use as small a catheter as possible consistent with proper drainage, to minimize urethral trauma.
- Maintenance: Ensure appropriate maintenance of indwelling catheters -
- Properly secure indwelling catheters after insertion to prevent movement and urethral traction.
- Maintain a sterile, continuously closed drainage system.
- Replace the catheter and the collecting system using aseptic technique when breaks in aseptic technique, disconnection, or leakage occur.
- For examination of fresh urine, collect a small sample by aspirating urine from the needleless sampling port with a sterile syringe/cannula adaptor after cleansing the port with disinfectant. Obtain larger volumes of urine for special analyses aseptically from the drainage bag.
- Maintain unobstructed urine flow:
- Keep the collecting bag below the level of the bladder at all times; do not place the bag on the floor;
- Keep catheter and collecting tube free from kinking;
- Empty the collecting bag regularly using a separate collecting container for each patient. Avoid touching the draining spigot to the collecting container.
- Employ routine hygiene; cleaning the meatal area with antiseptic solutions is unnecessary.
- Do not change indwelling catheters or urinary drainage bags at arbitrarily fixed intervals.
- Removal: Review urinary catheter necessity daily against pre-specified criteria -
- Urinary catheter reminders.
- Urinary catheter automatic stop orders.
- Medical directives for nurse-guided urinary catheter removal.
- Post-catheter care:
- Develop a protocol for management of postoperative urinary retention, including nurse-directed use of intermittent catheterization and use of bladder scanners.
(Safer Healthcare Now! Central Line-Associated Bloodstream Infection, 2012)
- Central Line Insertion Bundle:
- Hand hygiene.
- Maximal barrier precautions.
- Chlorhexidine skin antisepsis.
- Optimal catheter type and site selection.
- Daily review of line necessity, with prompt removal of unnecessary lines.
- Aseptic lumen access.
- Catheter site and tubing care.
(Safer Healthcare Now! Ventilator-Associated Pneumonia, 2012)
- Elevation of the head of the bed to 45° when possible, otherwise attempt to maintain the head of the bed greater than 30° should be considered.
- Daily evaluation of readiness for extubation.
- The utilization of endotracheal tubes with subglottic secretion drainage.
- Oral care and decontamination with Chlorhexidine.
- Initiation of safe enteral nutrition within 24-48h of ICU admission.
(Safer Healthcare Now! Surgical Site Infection, 2014)
- Prophylactic antimicrobial coverage:
- Appropriate use of prophylactic antibiotics;
- Antiseptic use;
- Antiseptic Coated Suture.
- Appropriate hair removal.
- Maintenance of perioperative glucose control.
- Perioperative normothermia.
Surviving Sepsis - 3-hour and 6-hour bundles (2015 update)
To be completed within 3 hours of time of presentation*:
1. Measure lactate level.
2. Obtain blood cultures prior to administration of antibiotics.
3. Administer broad spectrum antibiotics1.
4. Administer 30ml/kg crystalloid for hypotension or lactate ≥4mmol/L
To be completed within 6 hours of time of presentation*:
5. Apply vasopressors2 (for hypotension that does not respond to initial fluid resuscitation) to maintain a mean arterial pressure (MAP) ≥ 65mmHg.
6. In the event of persistent hypotension after initial fluid administration (MAP < 65 mm Hg) or if initial lactate was ≥ 4 mmol/L, reassess volume status and tissue perfusion and document findings3
7. Re-measure lactate if initial lactate elevated.
*Time of presentation" is defined as the time of triage in the emergency department or, if presenting from another care venue, from the earliest chart annotation consistent with all elements of sepsis ascertained through chart review.
- Administer antibiotics as soon as possible, preferably within the first hour of recognition of septic illness
- Norepinephrine is the first-choice vasopressor to maintain mean arterial pressure ≥= 65 mm Hg
- Document reassessment of volume status and tissue perfusion with:
- Repeat focused exam (after initial fluid resuscitation) by licensed independent practitioner including vital signs, cardiopulmonary, capillary refill, pulse, and skin findings.
OR/ two of the following:
- Measure CVP
- Measure ScvO2
- Bedside cardiovascular ultrasound
- Dynamic assessment of fluid responsiveness with passive leg raise or fluid challenge
Additional Evidence-Based Components of Care
The reader is referred to the Surviving Sepsis Campaign 2012 (Dellinger, 2013) for other practice interventions that complement the initial management of sepsis such as specific aspects of resuscitation fluids, antimicrobials, source and infection control, hemodynamic support and adjunctive therapies and other supportive therapies (Dellinger, 2013).
Specific Considerations for Pediatric and Maternal Sepsis
Please refer to Surviving Sepsis Campaign 2012 (Dellinger, 2013) and the Canadian Patient Safety Institute's
Safer Healthcare Now!
Sepsis Getting Started Kit (Safer Healthcare Now!, Sepsis, 2015).
- Do not wait for intensive care unit transfer to initiate resuscitation measures.
- Seek infection source identification and control early according to the clinical situation.
- Reassess antimicrobial therapy daily for de-escalation, when appropriate.
Conduct Clinical and System Reviews (see details below)
Given the broad range of potential causes of this clinical group, in addition to recommendations listed above, we recommend conducting clinical and system reviews to identify latent causes and determine appropriate recommendations.
Clinical and System Reviews, Incident Analyses
Occurrences of harm are often complex with many contributing factors. Organizations need to:
- Measure and monitor the types and frequency of these occurrences.
- Use appropriate analytical methods to understand the contributing factors.
- Identify and implement solutions or interventions that are designed to prevent recurrence and reduce risk of harm.
- Have mechanisms in place to mitigate consequences of harm when it occurs.
To develop a more in-depth understanding of the care delivered to patients, chart audits, incident analyses and prospective analyses can be helpful in identifying quality improvement opportunities. Links to key resources for analysis methods are included in Resources for Conducting Incident and/or Prospective Analyses section of the Introduction to the Hospital Harm Improvement Resource.
Chart audits are recommended as a means to develop a more in-depth understanding of the care delivered to patients identified by the HHI. Chart audits help identify quality improvement opportunities.
Useful resources for conducting clinical and system reviews: