What Is A Nursing Diagnosis

[ music ] >> good afternoon, and welcometo today's webinar, empowering nurses for early sepsis recognitionhosted by the centers for disease control and prevention in collaboration with the society for critical care medicine andamerican nurses association. my name is abbigail tumpey. i'm associate director for communicationsscience at the centers for disease control and prevention, division ofhealthcare quality promotion. this webinar is part of a series of webinarsthat cdc will be hosting with a variety

of external partners and experts. today's webinar features an expertpanel, including dr. ernest grant, president of the american nursesassociation; dr. anthony fiore, chief of the epidemiology research andinnovations grant at cdc's division of healthcare quality promotion,who will provide an overview of cdc's recently released vital signsreport on sepsis; dr. sean townsend, vice president of quality and safetyat california pacific medical center, who will discuss expanding sepsis earlyrecognition and lessons learned from engagement of nurses; mary ann barnes-daly, clinicalimprovement performance specialist

at sutter health system,who will discuss a pilot of sepsis early recognition in sutter health. also joining us is christa schorr,associate professor of medicine at cooper university hospital,who will discuss lessons learned from implementing sepsisscreening on hospital wards. before we get started, there area few housekeeping items to cover. first of all, we welcome your questions. please submit any questions or commentsyou have via the chat window located at the lower left-hand sideof your webinar screen.

you may submit questions at anytime during the presentation. questions will be addressed afterall presentations as time allows. to ask for help, please pressthe "raise hand" button located at the top left-hand side of your screen. if you need to chat with ameeting chair person for assistance on technical difficulties during the webinar. as a reminder, the audio for today's webinarshould be coming through your computer speakers. please ensure that your speakersare turned on with the volume up. now it's my pleasure to introduce dr. ernestgrant, president of american nurses association.

dr. grant? >> thank you, abbigail, forthat kind introduction. although i must make a correction. i am the vice president ofthe ana, not president. but it is my pleasure to say a few wordsabout the american nurses association and the nurse's role in sepsisrecognition during sepsis awareness month. first, a few words about ana. ana has a long history of supportingthe nation's registered nurses. this year, we're celebratingour 120th anniversary.

as the premier organization forall rns, we represent the interest of the nation's 3.6 million registered nurses. ana is at the forefront of improvingthe quality of care for all. infection prevention is a majorpriority for ana and the nation's nurses. ana knows that nurses play apivotal role in recognizing and preventing sepsis for a number of reasons. as the most trusted profession14 years in a row now, nurses share in patients'most vulnerable moments. there is also strength in numbers.

3.6 million rns means that there aremore than 7 million eyes on patients, monitoring their vitals, and looking forthe key signs of sepsis, including fever, disorientation or shortness of breath. finally, nurses spend themost time with patients. it's likely that a nurse will be able torecognize subtle changes in health status and behavior that could indicatethe onset of sepsis. one common way for patients to develop sepsisis through urinary tract infections, or utis. in fact, utis are the most commonreported hospital acquired condition. and 75% of utis are catheter-associated utis.

rns can play a major role in reducingcauti rates to save lives and prevent harm, including the development of sepsis. this is why ana developed thisevidence-based clinical tool in conjunction with leading experts, includingmany from the cdc. the tool is an easy-to-use checklist anddecision algorithm and free to download. please see the ana cautiwebsite for more information. this tool is just one way ana is working to help nurses prevent infectionthat can lead to sepsis. in closing, ana is proud to partner with thecenters for disease control and prevention

on this webinar and in a number of other ways. over the next two years, ana and the cdcwill be working together to enhance education and training on infectioncontrol for u.s. nurses. ana will leverage its relationship with morethan 20 specialty nursing organization partners to develop training, to improvenurses' adherence to, and confidence in performinginfection control procedures that could protect both themselvesand their patients. ana and the cdc have also partnered to identifynurses' roles in antibiotic stewardship. through this work, we will codify how nursescontribute to antibiotic stewardship programs.

as we know, antibiotic misusecontributes to the emergence and spread of antibiotic-resistant superbugs that can lead to sepsis. finally, as part of our ongoing partnershipwith the association of professionals in infection control and epidemiology,ana has launched our infection prevention and control website shown on the slide. i encourage you to take a lookat the evidence-based prevention and control practices on the site. as you will hear throughout the hour, nurses arevital to preventing sepsis and other infection. i look forward to hearingfrom our esteemed panelists.

now i'd like to turn this overto dr. fiore with the cdc. >> thank you, dr. grant. i'm really happy to be here and to-- i lookforward to hearing more from the other speakers about the important rolethe nursing staff can play. so i'll be very brief in describing whatcame out of the cdc vital signs report on august 23rd, and that we continue to promoteover the course of sepsis awareness month. first, we found that sepsis begins outsideof the hospital for nearly 80% of patients. another important finding with finding that 7 in10 patients with sepsis had recently interacted with healthcare providerswho had chronic diseases

that required them to get frequent medical care. and what this tells us is that there areopportunities to better prevent infections and recognize sepsis early to save lives. there's a chance here for providers to talkto the patients about infections and sepsis, about how infections that can lead tosepsis can be prevented or recognized early, and what they can do if an infectionis not getting better and looks like it could be at risk for sepsis. now, nursing staff, of course, plays a roleboth in in-patient and out-patient settings. and you'll hear a lot aboutthe in-patient setting.

and i'm talking now a little bit about what goes on with what happens beforepeople get to the hospital. but it's also important to know about therisk factors for sepsis, and this applies both to people in and out of the hospital. sepsis most often occurs in thepeople that are most vulnerable. and those are over the ages of 65, infantsthat are less than one year of age, those with chronic diseases, particularlydiabetes or weakened immune systems. it also most commonly occurs after aninfection in the sites of the lung, of the urinary tract, the skin or the gut.

there are certain very commonbacteria that cause sepsis. and it's going to come as no surprise to youthat the most common are staphylococcus aureus, e. coli and some types of streptococcus. however, for many patients, no causeof bacteria is ever actually isolated. but it's important to remember despiteme telling you about the risk factors that even healthy people candevelop sepsis from an infection. and it's especially true if the infectionis not treated properly and early. so what can healthcare providers do? well, you're going to hear a whole wealth ofpractical information in just a few minutes.

but the overarching message is thathealthcare providers really are the key to preventing the illnessesthat can lead to sepsis. they should educate their patients and theirfamilies about the early signs and symptoms, what to do if they feel like something,that infection is not getting better. and this is especially important forthose at higher risk of getting sepsis. remind patients that taking care of chronicillnesses is one way to prevent infections that can lead to sepsis, and encouragetypical infection control measures, including things like handhygiene and also vaccination against infections that can cause sepsis.

and what you'll hear particularly more abouttoday is sepsis recognition and treatment. so it's important that healthcareproviders think sepsis and knowing about sepsis signs and symptoms. act fast if it's suspected. and then once the intervention bubbles havebegun, reassess patient management and tailor it to the conditions of the patient, includingchanging antibiotic therapy as cultures and other laboratory tests dictate. and so with that brief overviewof the vital signs report, i'm going to turn it over to dr. sean townsend.

>> thank you, dr. fiore. appreciate that very much,very important information and very interesting vital signs report. as part of our work today, i'd like to introducethe topic regarding how the surviving sepsis campaign worked to improve sepsis recognitionin the wards and how we worked with nurses across the country to make this possible. we have several objectivesthat we'd like to accomplish. i want to talk, of course, about sepsis onthe boards, and what we did to get there, and my colleagues will speak mainly about this.

we'll talk a bit about the pilot program we didand how we got this started across the country. and then we're going to talk aboutlessons learned along the way. and integral to all of this, ofcourse, was the key assistance of nurses to make the work possible. i'd like to start, though, first by tellinga story about a patient who developed sepsis. this is rory staunton. rory staunton was 12 years old, living in newyork city when he was playing sports outside, outside of school with hisfriends, and he slipped and fell on the basketball court and scraped his arm.

rory then got that wound dressed,went home and was brought home by his parents and started to feel ill. he developed a fever that day and thenbecame nauseous and vomited several times. this didn't stop and he becameprogressively more ill. his parents got rather concerned. they contacted a pediatrician. and the pediatrician said that he probably hadgastroenteritis and thought he was dehydrated. he recommended that rory be brought toan emergency department for rehydration. and, in fact, his parents did that.

they brought him to the hospital. when rory was seen in the hospital, hegot some iv hydration, they took his labs, and they also checked his vital signs. but after the hydration finished, he was discharged from the emergency departmentbefore his labs were actually finally checked, the final results were in and when hislast set of vital signs were taken. had he not been discharged so quickly afterreceiving his fluids, they would have noticed that rory had a very high white blood cellcount and that he had tachycardia in excess of what you would expect for his age.

he did go home, however, andhe got worse that evening. he became progressively ill, morenausea, more vomiting, very high fevers, couldn't sleep that night andneither could his parents. by the time he got so ill that he was notresponding to his parents appropriately, they brought him back tothe emergency department. and unfortunately, for rory's case, when hearrived, he was unable to tolerate the burden of his illness anymore andsuffered cardiac arrest and died. this story is integral because it'sreally changed the face of the way we look at sepsis in the last four or five years.

rory's tragedy, of course, wasn'ttaken lightly by his parents. they took the matter into theirown hands because of the fact that he left the emergency departmentwithout having a complete check of his vitals and a complete check of his labs. and they recognized something that we've allcome to know now, which is that sepsis is hard to identify, and that even when at thehospital and in the presence of providers, you can oftentimes miss the disease. rory's parents are shown here in this slide,and you can see that they got to the-- they made it to the todayshow to tell their story.

and they not only were on the today show, they continued to advance thisstory and didn't let go of it. they, in fact, have now started afoundation to advance the care of patients that have sepsis, severe sepsis and shock. and they've tried very hard to makean impression upon our leaders. they did, in fact, approach the departmentof public health in new york state, and they worked very closely with thatdepartment to begin the process of finding ways for hospitals to improve thecare for sepsis patients. they didn't stop there, though.

they went to the u.s. congress, thedepartment of health and human services, they testified before the senatehouse and human services subcommittee. and they also lobbied the centers for medicareand medicaid very effectively about the need to establish measurement with theway we care for patients with sepsis. you can see that they ultimatelyachieved success in new york first. governor cuomo signed into effect rules thatrequired every hospital in the state of new york to report on the processes of care that theywere going to use to identify sepsis parents, and then to care for thosepatients after that time. this landscape clearly was changed byrory's story, and governments began

to respond to the nature of the disease. in the united kingdom, all of great britaindeveloped sepsis measures very similar to the ones that were put in place innew york state in the united states. there were some reasons why thecenters for medicare and medicaid began to take root or notice too of this disease. not only were rory's parents lobbying cms to getthe work done that was necessary to improve care for sepsis, but there were somedemographic reasons why also medicare and medicaid began to look at this more closely. so here you're seeing data from thecenter for health statistics, part of hhs,

and what you'll see is in the blue, you'vegot men in blue and women are listed by the green chart, the green bars. across the bottom on the x axis, you haveh. and on the y axis, on the far left, you have the rate of the disease perhundred or rather 10,000 of the population. and what's pretty clear, i think, from thisgraph, is that the disease takes its effect and begins to pick up at age 65 to 74. at 75 to 84, it's even moreprevalent to the population. and finally, 85 and over is thehighest incidence of the disease. of course, this is very important to medicare.

unlike rory's story, rory, of course, beingonly 12 was somewhere down here in this fraction of folks who developed the disease. but what you see in this peer grouphere is what medicare's population was. and so hence there was a great emphasis toestablish a sepsis measure across the country. the next slide shows you the final reason whyi think medicare took an interest in this. and this has got a lot to do with thework of nurses and doctors at the bedside. you can see between the years 2000 and 2008 onthe x axis on the bottom, the rate per 10,000 of population for diagnosis of sepsis, greenrepresents here sepsis as a primary diagnosis, and blue represents sepsis as aprimary or a secondary diagnosis.

and just looking at the greenline, you can see back in 2000, the rate per 10,000 of population was 11.6. that rate nearly doubled by 2008 to 24.0. and the reason for this are two things. the population was aging, for one thing. and we just saw in the previousslide that as the population ages, we're likely to detect thedisease more frequently since it is a disease mainly of the elderly. but also the work that was happening with thesurviving sepsis campaign encouraging screening.

and the screening that was goingon by bedside nurses began to pick up increasingly across the country. with increased screening and detection, ofcourse the incidence would rise as well. these things together brought a new eraof sepsis measurement to our hospitals under the form of sep-1, thenational measure for sepsis. key to detecting that, however,there was going be the work that nurses do to do the screening for sepsis. finally, one key point to makehere on demographics is just this. sepsis remains the number one cause ofin-patient death across the country.

this is data from my own institution,sutter health in northern california. and in 2014, if you look at all thedischarges in our hospital on the far left, you see that only 11% of them hadsepsis as a diagnosis at discharge. but if we looked at the deaths thatoccurred in my health system in 2014, 48% of the patients someplace had adiagnosis of sepsis in their chart. and so this remains truenot only at my institution, sutter health, but it's a national trend. and we know that the majority of deathsthat occur in hospitals share a diagnosis of some type of sepsis atthe point of discharge.

so people do die from this disease. and where they die is animportant consideration. i'd like to just point out to you that the work on medical surgical floors is really criticallyimportant to finding patients with this disease. the ed is where we typically present, we thinkpeople present to, much like rory's case. he came into the emergency department. but there are a large number of patients whoare already in the hospital who develop sepsis, and the work on the medical surgical floorsis very important to detect sepsis there. in this publication, you can see thatthe source is listed on the far left

and where the patients presented from. and the mortality is listed on the far right. and please note here that thepatients who are on the wards where their sepsis was identifiedhad the highest mortality compared to the emergency department and the icu. at 46.8%, that's higher than the icu patients who did develop sepsis at41%, and the ed at 27.6%. so clearly, the high mortality in the wardsjustifies a good screening effort that we hope to do on medical surgical floors.

and that can all be said one other way. if we risk-adjust all that data andsay, well, let's look at these patients to see what their co-morbidities were, doesthat still stand out that patients who presented in the wards are more likely to die thanpatients who come from the emergency department? well, the answer is yes. the same publication showed that the oddsratio of death for patients who present on the medical surgical floors is 1.87. and clearly that's an unacceptable risk overall. this makes the work that we're going to describe

to you really important onthe medical surgical floors. and it's my pleasure now tointroduce mary ann barnes-daly, who's going to tell you quite abit more about that initiative. >> thank you, dr. townsend. good afternoon, or good morning, everyone. i would like to take this opportunity toshare with you some work that was done at sutter health in 2010, about the same time that the article was publishedthat dr. townsend just shared. it was clearly understood that although muchwork was happening in the emergency departments

where patients typically present, and also inthe icu where we treated our most ill patients, typically with septic shock, thatthere was a missed population. that is, patients who were right underour noses who either had worsening sepsis or were developing severe sepsis orshock while patients in our hospital. i'm going to briefly describe toyou a program that was undertaken at sutter health in northern california. this project was supported in part by a grantfrom the gordon and betty moore foundation. and the foundation tasked us with continuing tomake improvements in both the ed and icu venues, but to add a new focus to our work,and that is early identification

and the early implementation of treatmentfor patients in the med-surg areas to prevent those patientsfrom worsening and dying. in the particular hospital where wepiloted, we made up a great little acronym, the medical oncology surgicaland telemetry patients, or most. and they were, in fact, most of thepatients who were in our hospital. our outcomes were for those patients who were eventually transferredto the intensive care unit. we looked at mortality and bundlecompliance data for these patients. they were analyzed by their locationat time of sepsis presentation.

and we used these data forcontinuous quality improvement. i'd like to share with you ourbaseline and then outcome findings. so you'll see here in the blue bars are data formortality rates for the calendar year of 2010. you can see that our overall combinedmortality rate for patients who went to the icu, both coming from the emergency departmentdirectly or from an in-patient med-surg unit, combined we had a mortality rateoverall of severe sepsis of 22.8%. what you'll also notice here isexactly what dr. townsend shared with the surviving sepsis campaigndata is that patients going directly from the emergency department tothe icu, although presumably sicker,

actually had a lower mortality rate thanpatients who were identified on the in-patient or most units who eventuallywere transferred to the icu. so we set about to create a model or a protocolaround which we would have better opportunities to recognize and interveneearlier in this patient population. so we created a protocol by which the med-surgnurses would screen patients once per shift, they would call a sepsis alert atwhich point the rapid response team and the physician would respond, andthey would begin the severe sepsis bundle and evaluate the patients forthe presence of septic shock. after piloting, implementingand piloting that for a year,

we then felt we had sustainmentthe following year in 2011, and we collected and reported data at that time. you can see then the 2011 datarepresented in the red bars, and we see two things that are very notable. the first is that our overallcombined mortality rate was about dropped in half based on the work. the second thing that we can see is thatthe mortality rate for patients originating in the emergency department was almost identicalto the mortality rate for those patients who were identified on the most units.

we felt that that showed that we hadcorrectly identified and intervened on that patient population, and we felt thatat that point that our program was a success. we spread it then to the other sevenhospitals in that region of our medical system, and ultimately to our entire 25 hospitalacute care, our 25 acute care hospitals. i would like at this time to turn thepresentation over to christa schorr. >> thanks, mary ann. i'm actually just going to give an overviewof the surviving sepsis campaign phase for sepsis on the wards collaborative. and this is actually springboarded from some ofthe work that actually mary ann has presented

in addition to our continuation of thesurviving sepsis campaign work in phase 3, the data that actually dr. townsend had shared. this is the timeline forthe phase 4 collaborative. we had 60 volunteer participating sites within4 regions of the united states, the east coast, west coast, midwest and southernstates primarily within florida, the adventist health system. we kicked off the project in january, 2014. we had three in-person learningsessions within the four regions. each had three sessions.

we also included either a monthlywebinar or a conference call, coaching calls to help thesites move the project forward. each particular region actually had aspecific faculty that included a member of the surviving sepsis campaignleadership, a nurse leader, a performance improvementleader, as well as a hospital. and we thought that that was really important. we did partner with the societyof hospital medicine, recognizing that our hospitalist partners weregoing to be key in moving this program forward. and, again, the project was funded in partby the gordon and betty moore foundation.

>> christa, if i can just pause you for asecond, if you could get closer to your phone. some of our participants arehaving trouble hearing you. >> okay, is that better? >> yep. even a little louder would be great. >> okay, so our primary focuswas on early identification. so, again, similar to what mary annhad mentioned, our goals really were to identify patients early, whether it was aconfirmed diagnosis or a suspected diagnosis, our goal was really to identify patientsearly so that we can implement the bundle. so our focus on the wards was really thethree-hour bundle, which includes lactate,

blood cultures, early antibiotics,and if necessary, implementation of early fluid resuscitation. and, again, we felt that theseinterventions could be implemented on the general medical floor. and if we were able to identify patients earlyand implement these three-hour bundle elements, that potentially the patient couldremain on that general medical floor. or if they did require an icustay, that our thought was that their outcomes would be improved, ortheir stay in the icu would be shortened. the tool that we provided at our firstlearning session, again, was the evaluation

for severe sepsis screening tool, which we hadused in the emergency department and the icu in collaborative in previous work. and our goal really was to use a toolthat we had shown that was successful, and this is actually very useful in ageneral medical floor in identifying patients with infections, signs and symptomsof infection, and organ dysfunction. and what is unique about this particular toolis that the thought process behind the tool is that we could help the nurses understand all thepotential signs and symptoms to be observant of and to assess patients for thedevelopment of organ dysfunction, and those patients potentially thatare being treated for an infection.

so, for instance, if we have a patientwho is admitted to a general medical floor with pneumonia, and they're actively beingtreated with antibiotics, and on day two or day three, the patient is notimproving or actually worsening, developing a new organ dysfunction, our thoughtbehind this was that the nurses would be able to recognize that and intervene sooner. because the patients actuallyhave a progression of the disease, and the nurse can potentiallyintervene at that particular point. so, again, this particular screening tool wefelt was really important and a paper form that the nurses understand the process andhow to think critically through each stage

to identify a patient that is developingsevere sepsis or who is presenting even. unfortunately, we do have patients thatdevelop nosocomial infections and can progress through this process very quickly. so, again, we felt that this tool wasessential to share with the collaborative sites. we opted to let the sitesdetermine how they were going to incorporate this toolinto their screening process. so some sites opted to use the paper screeningtool, and others actually incorporated into their electronic health record as an alert. again, this actually took some time.

so some sites right away we got started withthe paper tool, and other sites, you know, slowly incorporated this into their electronicmedical record, which took several months. so there are varying degrees as to how longthis actually took in these particular sites. one particular point i wanted to make was werecommended that the sites only pilot this on one particular unit because werecognize that this was a lot of work, and understanding how this particularscreening process would unfold in a hospital setting, we really were unsure. but based on the work that mary ann did, therecommendation was that we pilot this on a unit, and then when we learn from that success,then we can trickle along to other units.

so we actually recommended this as well. the mantra that we acquired during this processwas screen every patient every shift every day. and one point that mary and i feel verystrongly about is that it is important that we have the nurses understand the screeningtool prior to implementing the electronic alert, because they need to understand the backgroundfor why an alert is potentially firing. and i learned this the hard way when i was in arecent meeting with new nurses in my facility, and i mentioned that i was involvedwith sepsis performance improvement, and i heard a lot of sighs. and the challenge behind that isthat there is an electronic alert.

but the new nurses really don't understand thebackground as to why that alert is in place. and i think it's important that we understandthat there are folks that are actually coming to our facility at different time points,and that we need to educate the nursing staff as to why some of these alerts are in place,and they often need to understand the steps, the critical steps in identifying a patient thatpotentially is actually on a downward spiral from an infection that isaccurately being treated. so the pilot unit, so we actually had the unitsparticipate in a survey, so there's 60 sites that participated in thisnationwide collaborative. the units that participated wereprimarily medical surgical units at 50%;

straight medical units, 34%; and thenwe had the other, which was about 16%. and some of these units were verysimilar to what mary ann described as the most units, you know, the oncology unit. we did have one or two labor and delivery or high-risk maternity unitsthat were incorporated here. but, again, the nurse/patient ratio in theseparticular units range between 1 and 5. and there was one particular pilotunit that actually had a 1 to 9 ratio, which we found somewhat challenging. but the important thing about sharing thisdata is that the pilot units that participated

in this program had a variety of patientpopulations, as well as nurse/patient ratios. and they were not only academic centers, butthey were also community facilities as well. so we had a variety of participantsin this collaborative. so the inspiration i thinkshould be there for other sites to incorporate this program into their facility. at the end of the program, wesubmitted another survey and looked at the screening complianceon these particular units. and 75% of the sites actually achieved greaterthan or equal to 80% screening compliance in every patient every day and every shift.

so when we think about the work that is actuallyrequired from the nurses in screening a patient, this is very doable, and we did show success. it was a time sequence. you know, it did take a bit of time. but this is very possible. so if you're going to present this to theleadership in your facility or the nurses on your particular unit, i thinkwe need to ensure that we can share that despite this being a challengeand may be difficult upfront, it is a possibility, andwe can do this together.

so how we actually go about doing this,and mary ann and i both feel very strongly that nurses are in a great positionto help this program move forward. and i think the physicians inour group, the faculty leadership and the collaborative felt verystrongly that there was no way that this wards program would get off the groundwithout the assistance of the nursing staff. so we feel very strongly, and verysimilar to what dr. grant had mentioned, that the nurses are the eye from the patient. so these are the key staffmembers that are really going to help us move this program forward.

so i think what i'm going to do is overthe next several slides show some methods on how we can inspire nurses to do theirroutine screening that would include leadership and staff, how and why we're doing sepsisscreening, and how to implement the program. and i just wanted to make a point here thatif you're going to introduce this program, i learned this again the hard way, that wedon't want nurse buy-in on this program. we want nurse engagement. because if we think about buy-in, it'sbasically someone else coming up with an idea and asking the nurses toaccept that idea, move forward. if we have nurse engagement, they're actuallyabsorbing this particular disease process,

they understand the pathophysiologybehind it, they understand the why, they understand the data,which dr. townsend had shown, and they understand the impactthis is having on their facility, as well as their patients on that unit. so nurse engagement is going to be key. nurses, again, are in the bestposition, we felt, to make a difference. they're the main caregiversin the hospital setting. again, all the eyes are on the patient. they are able to recognize thechanges in the patient condition.

and sometimes we, as nurses, seechanges in the patient's condition, but we're not sure what todo with that information. how do we report it? how is it received by our clinical partners? again, we need to partner with our hospitalsand our internal medicine and our providers, if we have nurse practitionersand physician's assistants, again, partnering with our providers is keyinto moving this process forward. and again, the nurses arethere, coordinating care. so we need to offer assistance and supportalong the way to make this program successful.

so the purpose of nurse screeningfor sepsis, again, we share all this information with the nurses. we're not just going to ask the nursesto start using a screening tool. we need to have the nurseseducated as to why we're doing this. what's the purpose of this screening? show me a patient on our unit whounfortunately had a sepsis episode, and maybe had to get transferred to theicu or had a poor outcome or a patient where we actually had a good outcome. show me a patient where we did everythingright, where we were able to recognize the signs

and symptoms early, where wewere able to intervene early. again, i mentioned about the organ dysfunction. i think progression of organ dysfunctionis sometimes what really is a detriment to these patients. so if we're able to identify thepatients early and prevent progression of organ dysfunction, that's key. and it's very difficult to measure prevention. but i think in the overallscheme of the hospital, you'll recognize that the mortalityfor this disease will go down.

and then the other importantfactor is evaluating patients. so if we're treating a patient for an infection, such as pneumonia, is thepatient getting better? are we evaluating their condition to see if are we treating the patientwith the appropriate antibiotic? so, again, i think the nurses are in aperfect position to make a difference with early intervention,prevention, as well as evaluation. understanding why, i did mention that. it is important for the nurses to understandwhy we're using that particular screening tool,

why we're asking them to screen forsevere sepsis or sepsis in our facility. you know, they need to understand there'sa pathophysiology that's occurring behind the scenes. we're not just asking them to look forpatients with a fever and a high white count. there are other signs andsymptoms that are in the mix. how does infection and resuscitationgo hand in hand? so, again, the understanding of how all thesethings come together to display a patient with severe sepsis is really important. and i think we need to give our tools tothe nurses so that they're knowledgeable,

so when they're delivering thisinformation to the healthcare providers, that they feel confident inthis particular diagnosis. and i feel personally that the nurseshave the capability of doing this. we just need to give them permission andthe tools to move this program forward. so i'm going to pass thepresentation on to mary ann, and she's going to continueon with the education process. >> thank you, christa. to further add to what christa mentioned, whenwe empower the nurses with the understanding of the pathophysiology of sepsis,particularly things such as vasodilation,

capillary leaking, a decreased cardiac function. when nurses understand that's why they'rescreening for the items in the sepsis screen, and that they can literally save a life withsome normal saline and an early hung antibiotic, they become zealous for using thesepsis screen and early identification. but in addition to the understandingof the pathophysiology of sepsis as previously mentioned, rnsreally need to be trained to effectively communicate theresults of the sepsis screen. and most importantly, they need to besupported and empowered to make a recommendation for the next steps for patient care.

in order to do that, rns need to know andunderstand the elements of the sepsis bundles in order to make those recommendations, and also to prioritize interventionsand to optimize resources. for example, if a patient is going torequire both a 2-liter saline bolus and a broad spectrum antibiotic, itwould be important for the nurse then to prioritize starting the bolus first, and also to give the antibiotic while the bolusis running so that everything can be given to the patient as early as possible. sbar is a tool that's usedsuccessfully for communication.

it's widely used and has demonstratedsuccess when nurses are sharing information with providers and physician colleagues. the nurses need to understandthe components of the bundles. here is a pretty handy badge card that'savailable on the surviving sepsis campaign, i'm sorry, society of critical care medicine'swebsite, which allows nurses when communicating with providers to not have to rememberwhat the steps of the bundle are, but to have them available for reference asthey're speaking to their physician colleagues. important is for the nurses to understand wherescreening plays a role in their assessments of their patients, both when they starttheir shift and on an ongoing basis.

so christa shared the mantra, screenevery patient every shift every day. so that starts off with screening apatient at the start of every shift. implicit in that is also screening apatient that's received in transfer or from another unit, or,of course, a new admission. it's also important to criticallythink, as christa mentioned, that if a patient does have a change incondition, and the fact that sepsis is one of the most common occurrences in our hospitals,that when a change of condition does happen, we invite and encourage our nurses touse a sepsis screen to either rule in or rule out sepsis as a possibility.

there should also be things in placeto help the nurse properly respond or to share information whenthe screen is positive. and often, that is in the form of aconsult with the rapid response team, where a nurse with a higher level of trainingor more experience would come to verify the fact that the sepsis screen is positive, andto help implement a proper response. consider using standard work as away to empower the nurses to respond and share information arounda positive sepsis screen. this might be a policy or analgorithm for nurses to follow in response to a positive screen.

it would allow the nurse tocoordinate with providers on the rapid response team as a second tier. also consider in that standard worka nursing standardized procedure, which will allow specially trained nurseslike the rapid response nurse, for instance, to initiate labs and perhaps a fluidbolus for hypotension during the time in which the physician is being contacted. it's also helpful, as i mentioned earlier, forthe rapid response nurse, when he or she comes to the bedside, to eitherverify or not the sepsis screen. in addition to providing encouragementand feedback to the bedside nurse,

it's a very important teaching moment. the rapid response nurse caninitiate the standardized procedure, and also help with the facilitationof communication with the provider. this is an example of effectivecommunication using the sbar format. in this case, the nurse contacts theprovider and says the situation first. mr. smith was admitted early this morningwith cellulitis of his left lower extremity. he states the pain in his leg hasincreased, and the redness has extended. another option for providing informationstarting an sbar using situation is simply saying, mr. smith in room 307 nowhas a new positive sepsis screen.

the background then would be briefly about mr.smith, his age, his history of co-morbidities, and the fact that his wound on his left lowerleg has been present for about two weeks, and he was admitted throughthe emergency department. the assessment then that the rn provides isthe vital signs this morning and any changes or concerns with those vital signs asreported to the physician in addition to laboratory results that are germane. and most importantly then is the recommendation. in this case, the nurse says, i would liketo request an order for a chemistry panel, a cbc with differential, and a lactate level.

based on the patient's vital signs, the nursemay also ask for a fluid bolus order in review of current antibiotics to be sure that we areadequately covering any suspected organisms, or perhaps ask for an order togive a broad spectrum antibiotic if the organisms have not been yet identified. it is so important to empower the nurses tofeel comfortable providing this information to physicians on the phone and the presenceof the rapid response nurse or having that nurse actually provide the communication tothe physician can model and mentor this behavior to the bedside nurse who may feel less confidentand encourage that nurse to use the same type of communication strategyand to improve confidence

with the next time a call needs to occur. if you haven't yet started a programsuch as this on your in-patient units, there are considerations for piloting theprogram as christa elucidated earlier. it's really important to choosea single unit to start first. as in the ihi model for improvement, doingsmall tests of change are really important, both to not overwhelm people, but toalso implement a project and then learn from several iterations over time. when you're considering aunit in which to pilot, these considerations we feel are important.

choose a unit with a positive environment. we all know that med-surg nurses areamong the busiest in our hospitals. and it's important to choose an environment in which you think the testor pilot could be successful. it's also important to have engagedand supportive unit leadership. and also supportive leadership in nursingadministration all the way up to the cno. choose a unit that has goodteamwork and coordination. and also be sure that when the sepsis screen istaught and the standard work is put into place, that when the nurses pick up the phone,

they'll be contacting supportiveand responsive providers. i made the mistake and learned that it'snot sufficient to simply train nurses on the pathophysiology andthe use of the sepsis screen. it's also important to engage and educate. those folks are going to be on the otherend of the phone receiving the information with an expectation to act and rapidlyimplement the items in the sepsis bundle. while you're piloting, it is of paramountimportance to get feedback from all staff. as i mentioned earlier, using rapid-cycleimprovement with a plan to study act for instance, to implement a smalltest of change with maybe one nurse

with just two patients on one day, to learn fromthat first test, to iterate, change or update, and then plan how to improvewith the next cycle. when you feel you have something that couldbe relatively successful, at that point then, spread to more nurses and more patients. when you feel that you have a systemin place that works on your unit, then consider piloting it on one or two otherunits until you ultimately reach the spread through your entire med-surgpopulation in your hospital. it's also important to rewardengagement and innovation. remember, we don't want tostart with the laggards.

you want to start with folks that areinterested and passionate about the work. it is also important, though, toinclude people who may be resistant, to have them in at the outset ofthe project, to allow them to feel as if they have been given input andthat their input is important and valued, and to reward your nurses for doinga good job and highlight their work when you're spreading to other units. i'd like to pass off to christathen to summarize our presentation. i think this was very informativefrom several different aspects. and i think one piece that i think is reallyimportant and hopefully sean will comment

on this as well is that we reallyneed to partner with our hospitals and our physicians and theirproviders on the unit. so this is not a process where thenurses are actually diagnosing patients, but yet working with their providersto recognize patients early. so we do understand that hospitalizationfor sepsis is common, it's costly, and ward patients have disproportionatelyhigh mortality, as dr. townsend had eluded to in his presentation, nurse engagement andsepsis screening programs may be accomplished, but it's necessary that weinclude our leaders and our staff. and it's important that weestablish an understanding

as to why sepsis screening is important. we need to put a face to thesepatients so that the nurses feel a sense of engagement as opposed to buy-in. and we can do this througheducation and support. and i cannot underestimate the need for support. this is not something that you roll out andexpect that this is going to flow on its own. we do need to support thenurses through this process. and we need to also introduce this programon a pilot unit and test processes, allow staff feedback and modification ofthe program before spreading to other units.

and i want to encourage youthat this is possible. we've had success with this. and i wish you all the best in your endeavors to implement this type ofprogram in your institutions. thank you so much, and we appreciate your time. >> so thank you, dr. townsendand mary ann and christa. we have several questions, andwe have about 10 minutes left. so i'd like to go ahead and take theopportunity to jump into questions. we have over 2,200 people who have loggedin to some portion of this webinar.

and we have dozens of questionsthat have come in. many of the questions are around screening. so the first one is, many of our staffare struggling with screening the patients with regards to "suspected source of infection." any suggestions for in-patient nurseson how they can identify this rapidly? >> so one of the-- and i'lllet mary ann comment as well. one of the things-- we actually had this samequestion when we initiated this collaborative. and basically, what we did was we taught ahead-to-toe assessment assessing for infections. so we look at, you know, wounds,lines, signs and symptoms.

we really taught the nurses to think critically when they're doing their physicalassessment for the patients. and we didn't want them to have to diagnose,so we can even basically say to them, do you think the patient has a suspicion oran active infection that is being treated? we didn't necessarily require them to saythe patient has endocarditis or pneumonia. basically, if they could come up with thepieces of information that identified a patient as having a potential infection, thatwas really our potential first goal. and then the nurses actuallybuild on that process. and mary ann, you might havecomments on that as well.

>> yeah, christa, and i thinkyou're absolutely right. to delve a little bit further,when we educated our nurses, we told them that they should understand thatthe most likely causes of infection that lead to sepsis are pneumonia,urinary tract infection, wounds or infections of theskin, and in the gut. so when we ask nurses, again, as christasaid, not to diagnose these things, but to look at patients admittingdiagnosis, and combine that with findings of their physical exam, tosee if there was a likelihood that any of those things may be present.

the easy part of this is if a patient isadmitted with a diagnosis of infection or is on any type of antibioticsthat are not considered prophylactic, but nurses soon became pretty astute atrecognizing the fact that, for instance, if a patient came from a skilled nursingfacility with an upper respiratory infection, cough, or it had an indwelling foley, that therewas a likelihood because those two things are so prevalent that there was apossibility of an infection. again, i think two things toremember with sepsis screening, particularly on the med-surg unit, numberone, this is a screen and not a diagnosis. we expect to cast a broad net with our screen.

and we're not always going to be right. the goal of a screen being sensitive enough is that we will have some false-positivesthat we don't miss patients. it is then up to the collaboration of the rnand the provider to decide whether the findings of the screen are, in fact,linked to an infection, and whether the patient actuallydoes have sepsis. the second important thing to rememberis that the rate of positive screens in the med-surg area shouldactually be quite low. so often nurses feel a little bit frustratedwith the fact that they're doing hundreds

of screens maybe in a month, and they'reonly getting one or two positives. i think we should educate the nurses to expectthis, but to still understand the importance of the screen when it is positive, and alsoto communicate the findings of those screens to providers to implement care if required. >> so i think your comment seguesinto our next series of questions. we've had several questions withregards to use of a paper tool. so if you're using a paper screeningtool, where would you keep it, how would you communicate those results? and any advice that you guys have on collectingthe data and communicating it back in realtime.

>> yeah, this is mary ann. the paper tools are definitely challenging. but on the other hand, they alsofacilitate learning and early adoption. so in our-- as christa mentioned earlierwhen she described the collaborative, she said we basically had threesituations with implementing a screen. we had sites that were not yet using an emr. and so they documented everything on paper. and so that was really their only option. and in those cases, once the screen wasaccepted as part of the medical record

after several tests and iterations, itactually became part of the paper record. we also had two other cohorts, two othersections of our collaborative who had, as christa mentioned, had implemented an emr. but because it took basically an act of godto get anything added in a quick manner, they began doing sepsis screens on paper. and to be honest, it was not really ideal. obviously those screens could bescanned and put into the emrs. but for collecting data from those screens,it was manual and very labor intensive. and then we had our third group, who had emrimplementation already, and they were able

to either access a screen alreadypresent in their emr or they were able to rapidly add one that the nurses could use. i think christa touched on one other issue. and that is the use of alerts. and so alerts are really important because thenurses aren't always in the patient's chart. and usually clinical decision support, orcds, running in the background that looks at new findings such as newly enteredvital signs or new lab results, and can alert the provider,either the nurse or the physician, to a change in the patient'scondition that may indicate sepsis.

those prompts should really be used to encouragethe nurse to perform an actual sepsis screen. number one, as advanced as our clinicaldecision support may be, in my opinion, it does not ever substitute for thecritical thinking of a well-trained rn. it also allows the nurse to take part in thescreening and continually familiarize themselves with the contents of the screenand what the findings mean, and also to have a betterunderstanding of the assessment when they're communicating with their provider. christa, or dr. townsend, anything to add? >> so i just wanted to add to the beginningpart of the question, you know, how do you--

what do you do with a tool afterthe nurse has actually completed it? and i failed to mention that all theunits we actually had nurse champions, whether it was an educator or a staff nurse onthe different shift, there would be support, another set of eyes, actually,on the screening tool. so the one question, you know,said, is there realtime feedback? and having that champion would actuallyallow the nurse who is screening the patient to confirm or accelerate the processup the ladder to the provider in making the determination as to whether ornot the patient actually met the screening tool. and then that information was actually collated,and there was someone designated on the unit,

whether it was the nurse manager or thenurse educator, to review those forms, look for false-positives, false-negatives, andlearn from that and get feedback to the team. so it wasn't just that thenurses were completing this form and then there was no one looking at it. we actually did look at compliance. we were looking to see that every nursewas screening every patient every shift. and even if the patient was admitted with asepsis diagnosis, we still required the nurses to screen that patient every dayevery shift because it's possible that the patient could progress,maybe develop a new organ dysfunction

that we could identify early. so this screening tool was used. it was evaluated. and, again, that's why werecommend that you only use-- pilot the program on one unit becausewe recognize the work that's involved in getting this program up and off the groundand offering the support that the nurses need to feel confident about the program. >> so one last question. we've been talking quite a bitabout screening patients on wards,

but we're also getting questions about patientspresenting in the emergency department. what advice do you have on how triagenurses can quickly assess for infection and overcome any barriers to quicklyrecognizing and initiating sepsis protocols? >> sean, do you have comments on that? >> i do. i think, you know, to a largeextent, what's really important i think is that we empower nurses to start touse their judgment and have the sense that the patient is becominginfected for some reason or another. and i think to a large extentnurses actually do know that. and it's only through lack of willingnessto speak their minds in certain cases,

or out of fear that they could bewrong, that they sometimes don't. there's oftentimes a very clear sensethat the patient may be infected, but a reluctance to actually express that. and so working to overcome thatby having a positive program that empowers people i thinkis an important feature. the other thing is that, some very practicaladvice, if that's just too difficult to do, is to rely on sirs criteriato point you in that direction at screening an emergencydepartment, for example. at triage, you can check for fever, youcan check for elevated respiratory rate.

those things are easily availableto you at that point. tachycardia is easily assessed at triage. and patients who have those signs ofinflammation, if they're positive, can lead you to think, well, wait, i betterask the question, is there an infection here, and then look more carefully at that point. so there are some objective data points,even in triage and in an emergency department where you can say, well, if i'vegot some positive sirs criteria, perhaps i have to make a little bit deeperof a dive to see if there's an infection. >> so we're at time.

i want to thank dr. sean townsend,mary ann barnes-daly and christa schorr for their time today, as well as thesociety of critical care medicine and american nurses association forsponsoring this webinar with us. we know that there are severalquestions that we are not able to answer, and we'll try to answer someof those in follow-up e-mails. when you close out on the webinar,a post-meeting web page will appear, which will have detailed instructions about completing the continuingeducation post-test and evaluation. the access code for accessing thecontinuing education is wc0922.

and with that, thank you forjoining our webinar today.