Sepsis Screening?

Nurses General Nursing

Published

Hi there,

I would like some opinions about a clinical situation.

At the community hospital I work at, we do a sepsis screening w/ each assessment and anytime the patient's temperature is greater or equal to 100.3. If the patient screens positive then we have to call the doctor and ask if they want to initiate the "sepsis bundle" of orders. These orders consist of fluid bolus, lactate level, blood cultures and initiation of empiric antibiotics. We are also supposed to initiate a rapid response.

So, I had a young patient who had a lap appy after a perforation.

dream'n, BSN, RN

1,162 Posts

Specializes in UR/PA, Hematology/Oncology, Med Surg, Psych.

And????

Specializes in Critical Care, Education.

Was there a question in there somewhere?

Increased focus on early sepsis detection is (literally) a life saver. It needs to become a standard part of nursing practice. FWIW, multiple family members & acquaintances have been affected by undetected sepsis... many times with horrible and life-changing consequences. Ask around, you'll probably discover the same thing among any group of people who have had experience with hospitalization.

annie.rn

546 Posts

Sorry, I hit send too soon and then spent too much time in edit mode so the whole thing couldn't post. Below will be the edited (completed) version:

VANurse2010

1,526 Posts

I would say you should have at least 2/4 SIRS criteria before going ape**** with boluses and lactic acid labs. Sometimes a post-op fever is just a fever. Grab the incentive spirometer.

annie.rn

546 Posts

Hi there,

I would like some opinions about a clinical situation.

So, I had a young patient who had a lap appy after a perforation. He was post-op day one, going on day two (night shift). I was told in report that he had spiked a 101.9 temp. and that his incision looked a bit red. Also, he had a JP drain left in place to drain the infected fluid in his abdomen which was putting out large amounts (120cc/8hr) of cloudy yellow drainage. The drainage did not have any odor. Doctor had been notified by day nurse w/ no new orders. Pt. was already on Maxipime 1 gram q12hrs.

So, my alarm bells were going off...quietly, but going off nonetheless. I designated him my "one to watch" for my shift. For me, he was pretty perky. He had a low grade fever (Tmax 99.0). I gave him an incentive spirometer and showed him how to use it. He was a good trouper and using it as instructed w/ good technique. I kept a very close eye on his incision and it never increased in redness. The JP was still sucking out a good amount. He was eating and drinking very well, putting out a good amount of urine and had NS running at 125cc/hr. BP 110's/60's. HR in the 70's. Sats mid to high 90's on room air. RR 12-16.

Fast forward to 0400. He wakes up feeling crappy...fever and nausea are his main complaints. I check his vitals: T 101.6 HR mid 90's BP 130's/70's RR 22 O2 Sat 85% on room air which I verified w/ a different machine and several different fingers. Placed O2 at 2L NC and sats bumped up to 92% and stayed there.

I placed a call to the doctor while simultaneously getting a dose of Zofran in him so that he could take some Tylenol w/o throwing it up. Doc calls me back pretty quickly. It happened to be the patient's doctor so he was pretty familiar w/ the goings on. I informed him of all the details and that he screened positive for early sepsis. Also told him that the patient had never gotten a set if blood cultures draw or a lactate level. The MD would not order the sepsis bundle b/c the pt. had an known infection. He ordered a CXR and told me to make the pt. use his incentive spirometer (which I had already been doing and I told the MD this). I asked him if he thought the abx. should be adjusted and he did end up adding Vancomycin 1gm q12hr IV which I hung immediately.

So! Here's my thoughts and I would like opinions. Isn't it possible that the Maxipime was not killing off whatever bacteria this guy had in his belly and said bacteria could now be in his blood? (BTW, there were no cultures done of the purulence) Wouldn't blood cultures have been helpful for this reason? Do you find push back from MD's not wanting to initiate the protocol?

I was really irritated and nervous for my patient. I spoke to the nursing supervisor about it and she agreed the scenario sounded bad but she said I had to do what he ordered. She didn't go take a look at him and told me not to call a rapid.

I was on that patient like white on rice the rest of the shift and luckily he perked up pretty quickly and I had him up walking in the halls at change of shift. It could have gone differently, though. Another nurse had a 40 yo lap appy pt. code and die on our unit about a year ago.

I'm frustrated.

So

Specializes in Palliative, Onc, Med-Surg, Home Hospice.

Document, document, document. That is about all you can do once you notify the doc. Just make sure you document all you did, that you spoke with the doc and what orders were received (or not received). And continue to monitor. And document again.

annie.rn

546 Posts

Document, document, document. That is about all you can do once you notify the doc. Just make sure you document all you did, that you spoke with the doc and what orders were received (or not received). And continue to monitor. And document again.

Thank you. I did just that. I'm big on very detailed documentation. I document what I told the doctor, what orders I asked for based on my findings, the orders I then received, when received orders were carried out and how the pt. responded.

annie.rn

546 Posts

Was there a question in there somewhere?

Increased focus on early sepsis detection is (literally) a life saver. It needs to become a standard part of nursing practice. FWIW, multiple family members & acquaintances have been affected by undetected sepsis... many times with horrible and life-changing consequences. Ask around, you'll probably discover the same thing among any group of people who have had experience with hospitalization.

On our unit we do really well with implementing the early sepsis screens and everyone is good about calling the MD's when a pt. screens positive. However, it seems like the MD's aren't on board with following through with the orders. If the patient is already on abx., the MDs rarely want to initiate the protocol. A patient can still become septic if they are on abx. already, correct? I don't see why it's any skin off their noses.

I think that's why they are now telling us to call a rapid response for positive screens. We have standing rapid response orders that the RR nurses can initiate. They let the doctor know what was ordered after the fact. It just seems a little backward to me. We don't have a dedicated RR team so I'd rather not pull the ICU nurse away from his/her patients in order to get labs ordered that the MD could just order in the first place.

I think the floor nurses should be allowed to order blood cultures and lactate levels as a protocol order for positive sepsis screens. The doctors, of course, would have to order the fluids and abx.

I found a power point presentation online from UCLA medical center and that is how they do it. How do they do it where you work? Where everyone else works?

Specializes in Acute Care Pediatrics.

We only have sepsis protocols in place for our babies under 1. I'd love to know what your protocols look like? Can you share?

As for this particular patient, nothing that you posted would have flagged for me as septic. Perf'd and ruptured appys are NASTY. We take care of them often, seriously I feel like they have a season when they run by one get one free - and nothing in the clinical picture that you described made my hair stand on end. 101.6 is a pretty standard run of the mill late night/post op/perf'd appy temp. The drainage sounds pretty run of the mill too. I have had some of the most disgusting JP drains after Perf'd and ruptured appys. They are some of the sickest kiddos we can get sometimes... and the doc is right, there is already a raging infection present. I'll be honest.... I would be more worried if in a day or two of treatment the kids temp dropped to 95 and his HR was clacking along at 140.

I really would love to hear your protocols though... I'm intrigued!

annie.rn

546 Posts

I'll do my best from memory. This is for an adult (I work adult Med/Surg).

First level of screening:

Completed q shift and if temp. greater than 100.3 F.

HR >90?

RR>20?

Temp > 100.9 or

WBC > 12,000?

If yes to 2 or more then you proceed to second level of screening:

Does pt. have suspected or known infection?

Is pt. on abx.?

If yes to one or more, proceed to third level of screening:

Answer a system by system check for dysfunction/deterioration.

If any one system is positive for deterioration from baseline then you initiate the Sepsis Protocol:

Call MD to notify him/her of positive sepsis screen along with reasons why pt. met the criteria.

Call a rapid response. (This gets a bit iffy. I don't see why they always need to be notified. I explained a bit more in one of my above posts.)

MD decides whether or not to order sepsis bundle. Bundle includes:

Fluid bolus

BC x 2

Lactate level

Initiation of antibiotics

We have an intervention in our charting system (Meditech) to document all of this.

In my scenario I was concerned about the pt. because he clearly met several of the sepsis criteria and he just looked bad. I've taken care of a lot of post-op perforated appy patients and he got my antenna wiggling.

Swellz

746 Posts

Specializes in oncology, MS/tele/stepdown.

You call an RRT with every SIRS alert? Or do you just have to notify them so the patient is on their radar? We have a dedicated RRT nurse, and they keep track of everyone on the SIRS watch list.

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