Sepsis: A Hidden Threat Every Nurse Must Recognize to Save Lives

Overview of Sepsis

September is Sepsis Awareness Month, a great time to renew your focus on sepsis readiness and care. Sepsis is a life-threatening syndrome of physiologic, pathologic and biochemical abnormalities induced by infection, and a major public health concern. In 2018, it was reported that in the U.S., the hospital cost of sepsis is about $16,324 for sepsis without organ dysfunction, $24,638 for severe sepsis and $38,298 for septic shock. Each year, according to the Centers for Disease Control and Prevention (CDC)​, at ​least 1.7 million adults in the U.S. develop sepsis, and at least 350,000 people die as a result. The infection, which is most commonly bacterial, can also be fungal, parasitic or viral (COVID-19 or influenza). Respiratory, gastrointestinal tract, urinary tract and skin infections are the most common sources of infections that can lead to sepsis.

As many as 87% of sepsis cases originate in the community and not in the hospital. Even though most sepsis cases start in the community, hospitalized patients are at high risk for hospital-associated infections (HAIs) and for developing sepsis related to invasive devices and lines such as ventilators, intravenous catheters, central lines, etc. Many patients who are admitted to the hospital are on one or more antibiotics. It puts them at risk for Clostridioides difficile (C. diff), which can lead to sepsis.

Sepsis Definitions

The first consensus definition of sepsis was published in 1992, after being developed in 1991 during the American College of Chest Physicians (ACCP)/Society of Critical Care Medicine (SCCM) Consensus Conference. Sepsis definitions have evolved over time to the most recent Sepsis 3 definition presented at the SCCM Critical Care Congress in 2016, where sepsis was defined as "life-threatening organ dysfunction caused by a dysregulated host response to infection."

Patient Population at Risk for Sepsis

Sepsis is an equal-opportunity disease that can happen to anyone. However, the following risk factors put people at higher risk of developing sepsis:

• Ages 65 and older, and younger than 1 year old
• Recent birth, miscarriage or abortion
• Chronic conditions such as diabetes, lung disease, cancer, kidney disease or chronic obstructive pulmonary disease (COPD)
• Weakened immune system due to chemotherapy treatment, HIV or a recent organ transplant, a genetic disorder, such as Down syndrome or sickle cell disease, that affects the immune system
• Splenectomy
• Recent surgery or a serious illness
• Surviving sepsis; once someone has had sepsis, they're more likely to get it again.

Early Recognition of Sepsis

Early recognition of sepsis is critical, whether it's in the hospital, outpatient care facility or the community. An 8% increase in mortality for patients with septic shock occurs every hour of delay in antibiotic administration. Sepsis is frequently challenging to recognize early, which is the optimal time to begin treatment. It is said that sepsis is difficult to recognize when it is easy to treat and easy to recognize when it is difficult to treat. Based on research data, Sepsis Alliance estimates that as many as 80% of sepsis deaths could be prevented with rapid evaluation and treatment. Delays in sepsis recognition and treatment increase morbidity and mortality.

Sepsis Management Guidelines

The Surviving Sepsis Campaign began in 2002. Currently, approximately 24 medical societies, including ESICM and SCCM, endorse the guidelines. Guidelines for sepsis management (Adult Sepsis Guidelines, Pediatric Sepsis Guidelines, COVID-19 Sepsis Guidelines) are continually updated to reflect the latest clinical evidence.

Antimicrobial Stewardship

The Infectious Diseases Society of America (IDSA), the Society for Healthcare Epidemiology of America (SHEA) and the Pediatric Infectious Diseases Society (PIDS) define antibiotic stewardship as "coordinated interventions designed to improve and measure the appropriate use of [antibiotic] agents by promoting the selection of the optimal [antibiotic] drug regimen including dosing, duration of therapy, and route of administration." The guidance focuses on strong recommendations for antimicrobial therapy, which means the guideline applies not only to antibiotics but also to antifungals and antivirals.

Antibiotic administration is a key component of managing sepsis, and it's critical to start antibiotics targeted for the suspected or known pathogen as soon as possible, optimally within one hour of the recognition of sepsis. Appropriate antibiotic use is critical to optimize clinical outcomes for patients with sepsis, minimize risk of C. diff infection and prevent antimicrobial resistance. Nurses can play a key role in reviewing antibiotics daily. Consider asking yourself, "Are there any new, related lab results that may influence an antibiotic change or discontinuation? Is the administration of antimicrobials appropriate for this patient?"

Resources for Antimicrobial Stewardship

• CDC Core Elements of Antibiotic Stewardship

Steps nurses can take to help improve sepsis care:

• Practice and share information about infection prevention.
• Increase sepsis awareness in your communities.
• Educate patients, families and the community about sepsis, symptoms and, importantly, why it's a medical emergency.
• Always consider a diagnosis of sepsis! Rule it out when you're assessing patients.
  • When patients are triaged and seen in the emergency department, urgent care or even their primary care physician's office, clinicians should work to rule out sepsis, just as they would acute myocardial infarction or stroke.
• Recognize the unique physiological changes of obstetric patients, and screen for sepsis using the two-step process. Step 1: Initial screen for serious infection, and Step 2: Bedside Sepsis Evaluation
• Always consider antibiotic use through the lens of antibiotic stewardship as a key strategy to improve sepsis care and decrease antibiotic resistance.
• Apply an equity lens:
  • Racial disparities - The sepsis mortality of hospitalized patients is reported to be higher for diverse racial and ethnic patients compared with white patients. A recent retrospective study of patients with a diagnosis of septic shock found that Black patients had 1.57 times the odds of 90-day mortality compared with non-Hispanic white patients. Potential contributing factors that need further investigation include potential disparities in sepsis recognition leading to delayed treatment that may result in poor clinical outcomes.
• Clarify misconceptions about sepsis such as:
  • Misconception 1: If you don't have a fever, you don't have an infection or sepsis.
    Fact: Older adults frequently don't have a fever with infection and sepsis due to the aging process; therefore, temperature is not a good indicator of whether a patient has infection or sepsis.
  • Misconception 2: Sepsis is blood poisoning and contagious.
    Fact: Sepsis is not blood poisoning and is not contagious. The infection may be contagious but not sepsis, which is the body's response to infection.
  • Misconception 3: Only people with chronic conditions develop sepsis.
    Fact: Anybody can develop sepsis.
• Show a Sepsis Alliance Faces of Sepsis video at a unit meeting.
• Earn the American Association of Critical-Care Nurses (AACN) Sepsis Micro-Credential.
• Learn more through the following resources:
  • AACN Clinical Resources for Sepsis
  • Current Guidelines for Management of Sepsis and Septic Shock 2021
  • Sepsis Alliance Institute - Education and Resources for Healthcare Professionals and Individuals Working in Healthcare
  • Resources you can share with patients and caregivers
  • Sepsis Alliance
  • CDC Hospital Sepsis Program Core Elements

Maternal Sepsis

Maternal sepsis is the second leading cause of maternal mortality in the United States and affects an estimated 5.7 per 10,000 pregnancies. The distinctive and complicated maternal immune system puts people throughout pregnancy at risk for infection and sepsis.

The World Health Organization (WHO) says maternal sepsis is a life-threatening condition defined as organ dysfunction resulting from infection during pregnancy, childbirth, postabortion or the postpartum period. Maternal sepsis is frequently preventable. Normal physiologic changes during pregnancy such as a high heart rate, high respiratory rate, decreased blood pressure and increased white blood cell count are similar to signs of sepsis. These normal changes contribute to delays in recognition, prompt appropriate treatment and escalation to a higher level of care that leads to high rates of maternal sepsis.

The American College of Obstetricians and Gynecologists (ACOG) recently released a Consensus Statement through the Alliance for Innovation on Maternal Health (AIM), which focuses on sepsis in obstetric care consensus bundle.

Significant racial disparities occur in maternal sepsis similar to those in other sepsis populations. Black, Asian/Pacific Islander and American Indian/Alaska Native obstetric patients have a diagnosis of sepsis at significantly higher rates than white patients.

Maternal Sepsis Resources

• California Maternal Quality Care Collaborative (CMQCC): Improving Diagnosis and Treatment of Maternal Sepsis toolkit
• ACOG Sepsis in Obstetric Care Safety Bundle
• AIM Urgent Early Warning Signs
• Advocacy Language for Patients
• Sepsis Alliance: Pregnancy & Childbirth

Pediatric Sepsis

Every day, more than 200 children are diagnosed with severe sepsis in the U.S., which is more than 75,000 annual cases. Mortality rates are high with as many as 9% of children hospitalized with sepsis die in the U.S. (6,800 children, or more than 18 on an average day).

The Phoenix sepsis criteria for sepsis and septic shock in children were derived and validated by the international SCCM Pediatric Sepsis Definition Task Force. A Phoenix Sepsis Score of at least 2 identifies potentially life-threatening organ dysfunction in children with infection who are younger than 18 years. Using this screening method can potentially improve the care of patients with pediatric sepsis and septic shock.

Pediatric Sepsis Resources

• Preventing Infections Helps Prevent Sepsis
• Video: Bug Helps You Learn to Stay Sepsis Safe
• Infection Prevention Is Sepsis Prevention in Young Children
• Infection Prevention Is Sepsis Prevention in Teens

Life After Sepsis

Up to 50% of sepsis survivors have long-term physical and/or psychological issues, a condition known as post-sepsis syndrome. These effects include:

• Insomnia, which is difficulty getting to sleep or staying asleep
• Nightmares, vivid hallucinations and panic attacks
• Disabling muscle and joint pain
• Extreme fatigue
• Poor concentration
• Decreased mental (cognitive) functioning
• Loss of self-esteem and self-belief

Resources for Life After Sepsis

• Sepsis Alliance Connect: a virtual support community
• Life After Sepsis video

Concepts to Remember About Sepsis

• Sepsis is the body's overwhelming reaction to infection.
• Infection prevention is sepsis prevention.
• Sepsis is a medical emergency.
• Early treatment of sepsis is critically important to improve clinical outcomes.
• Infection and sepsis can happen during pregnancy, childbirth, postabortion or a postpartum period and should be screened and managed differently than the general adult population.
• Provide education and resources to patients with sepsis and their caregivers throughout the hospital stay and at discharge.
• Get involved in your workplace and community to increase sepsis readiness and awareness.

What is your hospital's initiative to prevent and manage sepsis?