INSTITUTO POLITÉCNICO DE SANTARÉM

ESCOLA SUPERIOR DE SAÚDE DE SANTARÉM

THE IMPACT OF UTILIZING A SEPSIS PROTOCOL ON THE OUTCOME OF

SEPTIC SHOCK AMONG CRITICALLY-ILL ADULT PATIENTS: A SYSTEMATIC REVIEW

ADVANCED CLINICAL NURSING

Developed by:

ADRIANA AZURA
BOSITANGULI KEREMU
ALDIN GASPAR
MICHAEL ANGELO LIBUNAO

Santarem, 16/12/2014

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 ABSTRACT

Background & Relevance. Sepsis is a potentially fatal condition and its occurrence is
steadily escalating especially among critically-ill adult patients, yet health professionals are
often unable to recognize its symptoms and treat or manage on its early phase. Evidence
shows that early recognition and aggressive management of sepsis improves outcomes of a
patient with sepsis. However, advanced age & multiple co-morbidities compromise their
immunity and therefore they may be prone to succumbing to severe infection and have poorer
outcomes. Recent evidence-based protocols outline strategies for the early recognition and
management of sepsis, and studies have shown that early implementation of these guidelines
improves survival and patient outcomes in the critical care setting.
Objectives. The ultimate purpose of this systematic review was to identify the impact
of sepsis protocol on the outcome of septic shock among critically-ill adult patients.
Specifically, it discussed evidence-based data on the early recognition/ assessment,
treatment/management, nurse-specific interventions and outcomes of utilizing sepsis
protocols among critically-ill adult patients.
Methodology, design and data search. This article utilized a systematic review process
and mainly involved twelve (12) reearch which were found via a systematic search process.
PubMed, EBSCO Academic Search Premier, OvidSP, ProQuest Health, AACN, and Elsevier or
Science Direct were used in the search using both MeSH terms and keywords by the option
“Search all text”. The original primary keywords utilized for search process were: adult patient;
septic shock OR sepsis OR severe sepsis; nursing care; and critical care OR intensive care OR
acute care. These keywords were also united to the terms risk assessment, incidence, outcome,
protocol, guidelines, and bundle. Studies published between 2000 and 2014 were shosen.
Conclusions. Majority (10 out of 12) of the research studies included in the systematic
review revealed that utilization of sepsis protocols, guidelines or algorithms significantly
improve outcomes of critically-ill adult patients with septic shock. These guidelines (which
include early recognition and management) have provided healthcare professionals valuable
guidance in caring for patients with severe sepsis or septic shock. In turn, the utilization of
these protocols simplifies the complex care and treatment of patients in critical care setting.
Keywords. Sepsis, septic shock, outcome, critical care, acute care, adult patient,
nursing care, protocol, bundle, guidelines

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 TABLE OF CONTENTS

Abstract ..................................................................................................................................... 1

List of Tables and Figures .......................................................................................................... 3

I. Introduction..................................................................................................................... 4
A. Background/Overview............................................................................................ 4
B. Relevance to Nursing Practice................................................................................ 5
C. Research Question ................................................................................................. 6
D. Goal and Objectives ............................................................................................... 6
II. Methodology .................................................................................................................. 7
A. Systematic Review Method .................................................................................... 7
B. Databases and Keywords ....................................................................................... 7
C. Inclusion and Exclusion Criteria.............................................................................. 8
D. Database Search ..................................................................................................... 8
E. Search Process Findings ......................................................................................... 9
F. Description of Chosen Studies .............................................................................. 18
III. Results (Literature review)............................................................................................. 19
A. Theoretical and Conceptual Frameworks ............................................................. 19
i. Donabedian’s Structure-Process-Outcome Model ......................................... 19
ii. Nursing Role Effectiveness Model .................................................................. 20
iii. Myra Levine’s Conservation Theory ............................................................... 22
B. Early recognition and assessment of septic shock ................................................ 23
C. Early intervention (treatment and management) of septic shock ....................... 25
D. Nursing interventions for septic shock.................................................................. 33
E. Impact of sepsis protocol on outcome of septic shock ......................................... 34
IV. Discussion ....................................................................................................................... 37
A. Review of the Findings ............................................................................................. 37
B. Reliability and Validity of the Research Studies ....................................................... 38
C. Limitations of the Research ...................................................................................... 39
D. Conclusion and Recommendations .......................................................................... 40
V. References ...................................................................................................................... 43
VI. Appendices

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 LIST OF TABLES AND FIGURES

Table Number and Title Page

Table 1. Assessment of quality of articles using the modified JBI Critical Appraisal Checklist . 10
Table 2. Summary of information from all researh studies for systematic review................... 13
Table 3. Factors determining strong vs. weak recommendation on SCC Guidelines (2013) ... 26
Table 4. Recommendations: Initial resuscitation and infection issues (SSC, 2013) .................. 28
Table 5. Recommendations: Hemodynamic support and adjunctive therapy (SSC, 2013) ...... 29
Table 6. Recommendations: Other supportive therapy of severe sepsis (SSC, 2013) ............ 31

Figure Number and Title Page

Figure 1. Database search process algorithm ............................................................................ 9
Figure 2. Search process findings ............................................................................................. 12
Figure 3. Donabedian’s Structure-Process-Outcome Model (1966) ........................................ 19
Figure 4. Nursing Role Effectiveness Model (Irvine et al., 1998) .............................................. 20
Figure 5. Surviving Sepsis Campaign Bundles ........................................................................... 25

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 INTRODUCTION

Background/Overview of the Problem

In intensive care units, severe sepsis and septic shock are the leading causes of
multiple organ failure and mortality (Moore et al., 2009). In addition, according to the Center
for Disease Control, sepsis is known to be the 10th leading cause of death (Moore et al., 2009).
Most patients experience involvement of one or more organs (Benson, Hasenau, O’Connor, &
Burgermeister, 2014); hence, comes the term multi-system organ failure (MSOF). Mortality
rates associated with sepsis have continued to climb at an alarming rate since 1979 (Benson et
al., 2014). It could develop in nearly 10% of intensive care unit’s patients with an associated
mortality rate from 20 to 60% (Lefrant et al., 2010). Lefrant et al., (2010) have identified the
rate of mortality to be between 20% and 60% with septic patients. Identifying patients who are
at greatest risk of progressing to severe sepsis is absolutely critical; a delay in identifying and
evaluating for a treatment plan can substantially increase the risk of extended hospital stays
and even mortality (Moore et al., 2009). Sepsis and septic shock account for approximately
10% of the admissions to intensive care units (Lefrant et al., 2010).Moore et al. (2009) explains
that early recognition of septic patients will greatly diminish the potential for severe sepsis
which ultimately leads to multi-system organ dysfunction, septic shock, and death.

Severe sepsis and septic shock are syndromes resulting in a systemic inflammatory
response syndrome (SIRS), the presence, or suspicion, of infection as the cause and the
presence of one or more organ system dysfunction (Baldwin et al., 20008). According to
Lefrant et al. (2010), SIRS is manifested by two or more of the following:
• High or low temperature > 38 or < 36 degrees Centigrade.
• Heart rate > 90 beats per minute.
• Respiratory rate > 20 breaths per minute (or) PaCO2 <4.3kPa.
• High or low white blood cell count >12,000 or <4,000.

The goals of sepsis treatment are to manage the infection and the body’s response to
the infection. Sepsis prevention is always the best option. However, once an infection is
present, treatment must be prompt. Furthermore, once severe sepsis has begun, treatment

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options are limited. In order to standardize treatment options, the Surviving Sepsis Campaign
presented several evidence-based treatments for severe sepsis. The goal of providing these
guidelines or protocols is to standardize the treatment of severe sepsis and generate an
improved outcome (Baldwin et al., 2008).

The Surviving Sepsis Campaign is a worldwide project with the goal of decreasing
mortality due to sepsis by 25% in the next 5 years. It reflects the commitment and deliberation
of critical care experts from 11 international organizations ( Dellinger and Vincent, 2005 in
Baldwin et al., 2008). After more than a year of systematic review and study, 45
recommendations for care were announced and officially implemented in February 2004 at
the Society of Critical Care Medicine Congress. The protocols are to be regularly reviewed and
updated at least annually based on cutting-edge research. From these protocols, two distinct
components were produced. They were a resuscitation care bundle outlining the process for
the first 6 h after diagnosis of severe sepsis, and a management care bundle that describes the
specific process and care to be delivered for the next 24 h. In recent times the care bundle has
been further refined to include six elements of care to be delivered to the patient within the
first hour (Baldwin et al., 2008).

Rapid progression to sepsis, severe sepsis, and septic shock can occur within just hours
of presentation to a medical facility. It is speculated that if all nurses comply with the use of
evidence based protocols, it will promote patient safety, reduce hospital costs and improve
patient outcomes (Campbell, 2008).

Relevance to Nursing Practice

With the implementation of sepsis bundles nursing staff will have an established
protocol by which they can thoroughly, and appropriately, assess patients at risk for severe
sepsis. The expectation will be enhanced nursing care and prevention of disease progression of
severe sepsis to death. Protocols for sepsis management will guide therapy for patients upon
entering the emergency department, as well as arrival to the intensive care units.
Management will include procedures such as fluid replacement, antibiotic therapy selections,
cultures, as well as guiding medical personnel for adherence to a strict timeline for optimal

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success toward treatment of patients. Shorr, Micek, Jackson, and Kollef (2007) state that the
purpose for protocols is to “optimize the delivery of care and to create a continuum for sepsis
management that runs from the emergency department to the intensive care unit”.

With sepsis bundles available, nurses would have specific guidelines for a globally
recognized, optimum standard of care in treating septic patients. Ahrens & Tuggle (2004)
states that critical care nurses must familiarize themselves with the new guidelines and serve
as change agents in establishing systems for adopting them into their unit protocols. Nurses on
the wards, emergency department, and critical care need to collaborate and recognize how
early goal-directed therapy can improve outcomes in patients who present with signs and
symptoms of sepsis.

Research Question

What are the effects or impacts of a sepsis protocol (Intervention) on the outcome of
septic shock (Context) among critically-ill adult patients (Population)?

Goal and Objectives

The ultimate goal of this systematic review was to identify the impact of sepsis
protocol on the outcome of septic shock among critically-ill adult patients. Specifically, it aims
to answer the following objectives:
1. Provide an overview and identify the prevalence and incidence rates of septic shock
among critically-ill adult patients.
2. Present theoretical and conceptual frameworks related to the topic.
3. Discuss evidence-based data on the early recognition and assessment of sepsis among
critically-ill adult patients.
4. Discuss evidence-based treatment and management of sepsis among critically-ill adult
patients.
5. Enumerate nurse-specific interventions for sepsis among critically-ill adult patients.
6. Present evidence-based data on the outcomes of utilizing a sepsis protocol among
critically-ill adult patients.

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 METHODOLOGY

Systematic Review Method

This article utilized a systematic search and review methodology. A systematic

review is a critical assessment and evaluation of all research studies that address a particular
clinical issue – in this case, the impact of a sepsis protocol on the outcome of septic shock
among critically-ill adult patients. The researchers used an organized method of locating,
assembling, and evaluating a body of literature on the aforementioned topic using a set of
specific criteria. For this particular manuscript, formulating the research questions, inclusion
and exclusion criteria, following a database keywords and search processes, evaluating the
articles and critically appraising and analyzing these, were the major phases of the
methodology.

When formulating a systematic review question, the PICO (or PICo) model is often
utilized. It helps define relevant population groups, interventions, comparators, and outcomes
of interest. In some cases, the context is taken into consideration. It also helps to define
inclusion and exclusion criteria, which are essential for identifying relevant literature. For this
particular task, the PICo was as follows: What are the effects of a sepsis protocol (Intervention)
on the outcome of septic shock (Context) among critically-ill adult patients (Population)?

Databases and Keywords

The following electronic databases were used: PubMed, EBSCO Academic Search
Premier, OvidSP, ProQuest Health, AACN, and Elsevier or Science Direct. A manual search of
articles was also performed. The search was performed using both MeSH terms and keywords
by the options “Search all text”. The original primary keywords utilized for search process
were: adult patient; septic shock OR sepsis OR severe sepsis; nursing care; and critical care OR
intensive care OR acute care. These keywords were also united to the terms risk assessment,
incidence, outcome, protocol, guidelines and bundle. Studies published between 2000 to
present were chosen so as to allow collection of more timely, current and updated data
regarding the issue.

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Inclusion Criteria

Inclusion criteria for the studies were the following: (1) written in English; (2) free full-
text research studies; (3) systematic reviews, JBI evidence summaries and high-quality
quantitative and qualitative studies where septic shock in critically-ill adults were described;
(4) selected studies must have been carried out or be applied in the critical care and adult care;
and (5) studies which employ screening tools for septic shock in the acute or critical care
settings. The authors did not require to use a lower and higher age limit in order to not exclude
some relevant studies.

Exclusion criteria

The following studies were excluded from the search process: (1) case studies,
literature reviews and incomplete studies; (2) abstract-only studies; (3) studies with non-adult
population; (4) studies which employ non-acute or critical care septic shock screening tool; and
(5) studies with locale of non-critical care areas (such as wards and outpatient departments).

Database Search

Due to time constraints, the authors performed database searches during the month
of November 2014. Upon completing the research question, objectives, and creating inclusion
and exclusion criteria, a concise database search process algorithm [Refer to Figure 1] was
utilized. The researchers looked independently through all the titles and selected relevant
titles for abstract-level review. Abstracts were inspected independently. Out of these relevant
abstracts, relevant full-text articles were chosen after a consensus discussion and decision. All
four authors evaluated the quality of articles independently based on modified JBI Critical
Appraisal Checklists for specific studies. After individual evaluation, results were compared,
and if there were differences in the scoring or rating, discussions were taken into account to
reach a consensus. Results sections of the selected studies were analyzed using literature
review / critical appraisal [Refer to Appendix 1 and Table 2].

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 Formulate the research Search for relevant
Formulate inclusion and
question and articles using keywords
exclusion criteria.
objective/s of the study. and MeSH terms.

Choose relevant full-text Inspect abstracts Select relevant titles for

articles. independently. abstract-level review.

Evaluate quality of Compare results.

articles independently
based on modified JBI
Critical Appraisal
Checklists for specific
studies.
Analyzed Results
Discussions will be
sections of selected
taken into account to
studies using literature
reach a consensus for
review / critical
choosing relevant
appraisal.
articles.

Figure 1. Database search process algorithm

Search Process Findings

Utilizing the keywords enumerated previously, 428 potential papers were found from
all databases and manual searches done. At the title-level search and after choosing “Full text
only” option, PubMed gave 78 hits, AACN 4, EBSCO 38, Ovid SP 110, ProQuest Health 50,
Science Direct/Elsevier 15, and manual search 5 hits. One hundred and forty (140) articles
were removed from the potential list of articles.

After scrutinizing the abstracts, a total of 85 articles were then selected for detailed
examination of contents: PubMed 0, AACN 4, EBSCO 4, OvidSP 8, ProQuest Health 4, Science
Direct /Elsevier 5, and manual search 5. A large number of 203 articles were excluded at this
phase of the search process.

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 Upon evaluating the full texts, fifty seven (57) articles were rejected, and only thirty
(30) articles were deemed potential papers for systematic review purposes. AACN 4, EBSCO 4,
OvidSP 8, ProQuest Health 4, Science Direct /Elsevier 5, and manual search 5. These articles
were involved in criteria assessment using the modified JBI Critical Appraisal Checklist, where
ten parameters were utilized to assess and critically appraise the contents of the papers. In the
end, after removing duplicated articles, twelve (12) of these were chosen to comprise the data
for this systematic review [Refer to Table 1].

Table 1. Assessment of quality of articles using the modified JBI Critical Appraisal Checklist
Assessment criteria of the studies
References
1 2 3 4 5 6 7 8 9 10
Baldwin, L.N., Smith, S.A., Fender, V., Gisby, S. & Fraser,
√ √ √ √ √ √ - √ √ √
J., 2008
Lefrant, J.Y., Muller, L., Raillard, A., Jung, B., Beaudroit,
L., Favier, L., Masson, B., Dingemans, G., Thevenot, F.,
√ √ √ √ √ √ √ √ √ √
Selcer, D., Jonquet, O., Capdevila, X., Fabbro-Peray, P.,
& Jaber, S., 2010
Chamberlain, D.J., Willis, E.M. & Bersten, A.B., 2011 √ √ √ √ √ √ - √ √ √
Raghavan, M. & Marik, P.E, 2006 x x x x x x x x x x
Rivers, E.P. & Ahrens, T., 2008 x x x x x x x x x x
Moore, L.J., Jones, S.L., Kreiner, L.A., McKinley, B.,
Sucher, J.F., Todd, S.R., Turner, K.L., Valdivia, A. & √ √ √ √ √ √ √ √ √ √
Moore, F.A., 2009
McClelland, H. & Moxon, A., 2014 x x x x x x x x x x
El Sohl, A.A., Akinnusi, M.E., Alsawalha, L.N. & Pineda,
√ √ √ √ √ √ √ √ √ √
L.A., 2008
Nasa, P., Juneja, D., Singh, O., Dang, Rohit & Arora, V.,
√ √ √ √ √ √ √ √ √ √
2011
Girard, T.D., Opal, S.M. & Ely, E.W., 2005 x x x x x x x x x x
Bridges, E.J. & Dukes, S., 2005 x x x x x x x x x x
Giuliano, K., 2007 √ √ √ √ √ √ - √ √ √
Kleinpell, R., Aitken, L. & Schorr, C.A., 2013 x x x x x x x x x x
Picard, K.M., O’Donoghue, S.C., Young-Kershaw, D.A. &
x x x x x x x x x x
Russell, K.J., 2006
Napoli, A.M., Corl, K. Gardiner, F. & Forcada, A., 2011 √ √ √ √ √ √ √ √ √ √
Aitken, L.M., Williams, G., Harvey, M., Blot, S., Kleinpell,
R., Labeau, S., Marshall, A., Ray-Barruel, G., Moloney-
x x x x x x x x x x
Harmon, P.A., Robson, W., Johnson, A.P., Lan, P.N. &
Ahrens, T., 2007
Casserly, B., Baram, M., Walsh, P., Sucov, A., Ward, N.S.
√ √ √ √ √ √ √ √ √ √
& Levy, M.M., 2010
DUPLICATE: McClelland, H. & Moxon, A., 2014 - - - - - - - - - -
Rivers, E.P., McIntyre, L., Morro, D.C. & Rivers, K.K., x x x x x x x x x x

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2005
Ahrens, T. & Tuggle, D., 2004 x x x x x x x x x x
DUPLICATE: Rivers, E.P. & Ahrens, T., 2008 - - - - - - - - - -
DUPLICATE: Bridges, E.J. & Dukes, S., 2005 - - - - - - - - - -
Buck, K., 2014 x x x x x x x x x x
Warren, M.L. & Ruppert, S.D., 2012 x x x x x x x x x x
Campbell, J., 2008 √ √ √ √ √ √ √ √ √ √
Benson, L., Hesenau, S., O’Connor, N. & Burgermeister,
√ √ √ √ √ √ √ √ √ √
D., 2014
Nee, P.A., 2006 x x x x x x x x x x
Caterino, J.M., Jalbuena, T. & Bogucki, B., 2009 √ √ √ √ √ √ √ √ √ x
Giuliano, K.K., 2006 x x x x x x x x x x
Girardis, M., Rinaldi, L., Donno, L., Marietta, M.,
√ √ √ √ √ √ √ √ √ √
Codeluppi, M., Marchegiano, P. & Venturelli, C. 2009
Assessment criteria: Legend:
1) Study background & theoretical framework are √ Satisfies assessment criterion
clearly defined. x Does not satisfy assessment criterion
2) Purpose, aim and research questions are clearly - Not applicable
defined.
3) The design is clearly stated.
4) The setting is clearly defined. - Included
5) Independent, dependent & confounding variables - Excluded
are defined. - Duplicate
6) Data sources and analysis methods are clearly
described.
7) Describes any efforts to address potential sources of
bias and ethical issues.
8) Answers the research question (PICo) logically.
9) Discuss the study’s limitations and generalizability.
10) Relevance to the topic.

The most frequent reasons for rejecting the articles were that the topic was not the
focused for systematic review, these were narrative reviews or did not fulfil the
methodological quality demands, and they were a duplicate of an article found in another
database. A large number of articles were also removed upon choosing the “Full text only”
option. All other rejected articles were used as additional refernces for the whole systematic
review.

The diagram below describes and shows the results of the search process of articles
[Refer to Figure 2]. Data from the twelve articles were then extracted using a table of summary
of the basic features of the selected research studies [Refer to Table 2], and these were
utilized in the presentation of the results and findings of this systematic review.

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Figure 2. The search process findings

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Description of the Chosen Studies

In the 30 potential articles for systematic review purposes, only 12 were selected for
final evaluation and appraisal. Most of the issues and problems are related to the type of
research study, description of variables, data sources and analysis methods as well as
relevance to the main topic. The reviewers evaluated that the 18 (three were duplicates)
excluded potential studies were totally in the focus of this review; however, these were only
utilized as additional references and not as part of the systematic review itself. Nine (9) of the
12 selected studies fulfilled 10 out of 10 quality criteria in full; and all of them achieved at least
9 criteria according to the modified JBI Critical Appraisal Checklist.

Out of the 12 selected articles, seven (7) were from the USA, while the other five (5)
were research studies from the UK, Australia, France, Italy and India. In the 12 studies, the
main focus was on the impact of sepsis protocols on the outcome of septic shock among
critically-ill adult patients. However, it is important to note that 3 articles specifically focused
on the geriatrics population.

There were six (6) prospective observational cohort studies, two (2) retrospective
observational studies, one (1) meta-analysis, one (1) randomized control trial experiment, one
(1) quasi-experimental study, and one (1) pilot study. The pilot study was deemed potential
article for systematic review by the authors because it has been peer-reviewed, the sample
was large, the research type is a prospective observational cohort study, and it all complied the
quality criteria as specified in the JBI Critical Appraisal Checklist. Case studies and incomplete
studies were excluded, but were used as supplementary references for the manuscript.

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 RESULTS (LITERATURE REVIEW)

Theoretical and Conceptual Frameworks

Due to the extensive nature of the topics: septic shock among critically-ill adults and
the impact of sepsis protocol on the outcome of septic shock, three inter-related frameworks
will be utilized for this particular case study. For the systematic and literature review parts,
which focuses on the impact of utilizing a sepsis protocol on patient outcome, Donabedian’s
structure-process-outcome model (1966) and Nursing Role Effectiveness Model (NREM) by Irvin
et al (1998) were utilized. For the nursing process (i.e. assessment, diagnosis, planning,
implementation and evaluation) part, Myra Levine’s Conservation Model (1967) was used.

Donnabedian’s Structure-Process-Outcome Model (1966)

Measuring patient safety outcomes has been an arduous task for healthcare providers.
For almost 5 decades, Donabedian’s structure-process-outcome model [Refer to Figure 3] has
served as a unifying framework for examining health services and assessing patient safety
outcomes. In Donabedian’s model, structure denotes the agency’s characteristics including
physical structure, properties, procedures, policies, standards, resources, equipment, and
personnel. On the other hand, process describes events or activities performed by the staff
that impact the quantity and quality of care delivery. Lastly, outcome is the result that leads to
any type of change in the patient’s health condition (Donabedian, 1988).

Figure 3. Donabedian’s structure-process-outcome model (1966)

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 In the context of this study, nurses were viewed as an element of structure, in addition
to the physical structure and organization of the clinical setting; implementation and utilization
of sepsis protocol and rendering excellent nursing care were understood as the process
elements; and the improvement in patient outcome (i.e. decreased mortality rate) and
increased quality of patient’s life were the outcomes.

The structure of an organization allows for safe patient care delivery by providing role
clarification, operation guidelines, authority, performance competencies, and human and
material resources. According to Donabedian (1988), high-quality care must not just focus on
process and outcome alone but must also focus on the structure. Incorporating nurse
champions into its organizational structure is one way an organization can enhance the
structure and potentially influence process and outcome.

Nursing Role Effectiveness Model (1998)

A more specific nurse-centered model was also utilized for this case study. The Nursing
Role Effectiveness Model was developed by Irvine et al. (1998) to identify the contribution of
nurses’ roles to outcome achievement. The model is based on the structure- process- outcome
model of quality care (Donabedian, 1966) described above. It has been reformulated based on
empirical testing (Doran et al., 2006) [Refer to Figure 4].

Figure 4. Nursing Role Effectiveness Model (Irvine et al., 1998)

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 As it is shown on the diagram above, the structure component consists of nurses,
patients, and organizational variables that influence the processes and outcomes of care.
Nurse variables includes professional characteristics such as experience, knowledge, and skill
levels, which can influence the quality of nursing care. Patient variables include personal and
health- or illness- related characteristics, such as age, type and severity of illness, and
comorbidities, that affect either the delivery of care or the achievement of outcomes.
Organizational variables focus on staffing and nursing assignment patterns, which directly
affect the delivery of nursing care.

The process component consists of the nurses’ independent, medical care- related,
and interdependent roles. The independent role concerns functions and activities initiated by
professional nurses. They refer to autonomous actions initiated by the nurse in response to
the patients’ problems; they do not require a physician’s order. The medical care- related role
concerns functions and activities initiated by nurses in response to a medical order. They
include the nurse’s clinical judgment, implementation of medically directed care, and
evaluation of the patient’s response to the care. The interdependent role concerns functions
and activities in which nurses engage that are shared by other members of the healthcare
team. They include activities such as interdisciplinary team communication, care coordination,
and health system maintenance and improvement.

The outcome component consists of nursing- sensitive patient outcomes. These are
classified into six categories: (a) prevention of complications like injury or nosocomial
infections, (b) clinical outcomes such as symptom control, (c) knowledge of the disease, its
treatment, and management of side effects, (d) functional health outcomes such as physical,
social, cognitive, mental functioning, and self- care abilities, (e) satisfaction with care, and (f)
cost.

Irvine et al. (1998) proposed that the structure variables influence the process and
outcome variables and that the process affects the outcome variables. They supported the
propositions with empirical evidence synthesized from the literature, and with an empirical
validation of the proposed relationships in acute care settings (Doran et al., 2006, 2002).

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Myra Estrin Levine’s Conservation Model (1967).

According to Levine (1967), the conservation principles mean ‘keeping it together’; in

nursing, to keep together means to maintain a proper balance between active nursing
intervention coupled with patient participation on the one hand and the safe limits of the
patient’s ability on the other. Such a balance is struck only when the patient’s present needs,
as assessed by the nurse, are measured against the many variables that individualize his
predicament of illness. Then, since conservation takes place within a space-time continuum, in
planning nursing care the nurse must allow for progress and change and project into the future
the patient’s response to treatment.

The model of conservation utilizes four major concepts as the basis for theory.
Personal integrity is the sense of self-worth and identity being maintained or restored and
uniqueness acknowledged. As registered nurses, we maintain the desire to care for those who
are physically, medically, and emotionally in need of our assistance. Not only are we trying to
optimize a patient’s sense of self-worth, but also our own by utilizing our ability to assist with
the healing process of our patients. Our own uniqueness allows us to flourish in different areas
of patient care, particularly within the ED and the ICUs. Utilizing sepsis bundles will allow us a
greater sense of autonomy to participate in expedient nursing procedures for the septic
patient, and utilize our uniqueness in these specific areas of nursing. Personal integrity is an
important factor with nurses, and is what allows us to care for our patients to the level
required for optimum well-being for all involved. Social integrity notes that patients are social
beings & interact with others who are in their social realm, this awareness must be fostered.
As nurses, we are also in a position requiring fostered support from our peers, and using
Levine’s theory for implementation of sepsis protocols will nurture professional strength and
support from one another while giving exceptional nursing care to our patients. Structural
integrity is the prevention of physical breakdown and to promote healing, this must be
maintained or restored. Lastly, Energy is avoiding excessive fatigue by balancing energy levels
whether they are incoming or outgoing.

Based on Myra Levine’s Conservation Model, nursing interventions and the use of
bundles will provide a unified structure toward optimum care for septic patients. Levine (1966)

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explains, “when nursing intervention influences adaptation favorably, or toward renewed social
well-being, then the nurse is acting in a therapeutic sense. When nursing intervention cannot
alter the course of the adaptation-when her best efforts only maintain the status quo or fail to
halt a downhill course-then the nurse is acting in a supportive sense.”

For this specific case study, Levine’s Conservation Model (1967) is well-fit for
utilization for planning the care of a critically-ill adult patient with septic shock. Since the
patient is a whole being, a holistic nursing care must be rendered, and encompass not only the
physiologic but also the psychosocial aspects of the person. The four conservation parameters
of Levine’s model assure that utmost, holistic, and excellent nursing care will be rendered to a
critically-ill patient with septic shock. These four major concepts will be reflected on the
nursing care plan, especially on the diagnosis, intervention and evaluation parts of the case
study.

Early recognition and assessment of septic shock

Early identification of sepsis, severe sepsis or septic shock is the key to patient survival,
but remain the greatest challenging issue in effective management of adult patient with severe
sepsis and septic shock (Slade et al., 2003). Elapsed time from triage to delay in antibiotic
administration has been identified as the main leading cause of mortality in patients with
septic shock in intensive care settings (Rivers & Ahrens, 2008).

Multiple screening tools have been developed in order to increase the early
recognition of sepsis in clinical settings. Extensive research studies were also conducted in
recent years to assess the benefit of the screening tools for early identification of patients with
suspected severe sepsis or septic shock and, evidence indicated the effective value of
screening tool in early recognition and treatment of severe sepsis or septic shock that
significantly improve patient outcome (Moore et al., 2009; Mann-Salinas et al., 2013; Gyang et
al., 2014; Chamberlain et al., 2014).

The evaluation for severe sepsis screening tool was developed by surviving sepsis
campaign and institute for healthcare improvement in an attempt to improve the quality of

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care of patients with severe sepsis and septic shock (SSC & IHI, 2005). The screening tool
included three main components, such as patient’s history of new infection, signs and
symptoms of infection, and organ dysfunction criteria [Refer to Appendix 2.3].

Moore et al. (2009) also developed a three – step triage tool for sepsis patients. This
screening tool involved initial assessment of systemic inflammatory response syndrome (SIRS)
parameters, such heart rate, temperature, respiration rate and white blood cell count, and was
completed by the bedside nurses [Refer to Appendix 2.1]. Patients with positive results
proceed to second stage in which a nurse practitioner or resident physician attempts to
identify the possible infection that contribute to a patient’s condition and source of infection
involved [Refer to Appendix 2.2]. The final step involved evaluation of organ dysfunction
criteria by physician and if the patient met the criteria, the nurse and physicians would initiate
interventions promptly following sepsis protocol.

Moreover, Mann-Salinas et al. (2013) studied the impact of sepsis screening tool in
critically ill burn patients, since most of patients in burn unit are more likely to develop
hypermetabolic state. The sepsis triage tool that was developed reflected parameters further
from the normal values. The variables associated with sepsis in this burn population were
heart rate > 130 per min, temperature <36°C, mean arterial pressure <60 mm Hg, base deficit <
−6 mEq/L, glucose > 150 mg/dl, and use of vasoactive drugs. The sepsis criteria model was
validated within this burn population, giving a clear paradigm of the need to apply general
principles to a specific population group.

However, the sepsis validating tools that have been developed and advocated by many
studies are more similar than different. In common, three important variables must be
assessed and evaluated (Birriel, 2013), which include known or suggested infection, systemic
signs of infection (i.e. presence of high fever or hypothermia, tachycardia or tachypnea,
leukopenia or leukocytosis and mental status), and signs of new or worsened organ
dysfunction (i.e. hypotension, increasing in oxygen consumption, increased blood lactate
levels, bilirubin or creatinine level and coagulation).

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 To conclude, the patient met two or more SIRS criteria and suspected with source of
infection screened as a positive for sepsis and demand further screening for symptoms of
organ dysfunction (i.e. severe sepsis) and risk for death. Timely assessment, patient history
taking and systematic examination will help to promote early sepsis detection and timely
intervention. In this early assessment, the nursing staff plays a pivotal role in identifying sepsis
by implementing routine clinical screening of patients (McClelland & Moxon, 2014).

Early intervention (treatment and management) of septic shock

The cumulative data of 12 systematically-searched and reviewed articles revealed that

optimum treatment of sepsis is dynamic and an evolving process. The 2013 newly-released
evidenced-based guidelines for the management of sepsis is a product of multiple revisions
based on the most current and high scientific evidence available. These updated guidelines
represent the work of a committee of 68 international experts representing 30 international
organizations (Dellinger et al., 2013). The guidelines and their associated care bundles are
referred to as the Surviving Sepsis Campaign (SSC) [Refer to Figure 5]. The main purpose is to
create an international collaborative effort to improve the treatment of sepsis and reduce the
high mortality rate associated with the condition (Institute for Healthcare Improvement,
2013). The SSC is the first initiative of its kind to bring together three leading professional
organizations in the field of sepsis: the European Society of Intensive Care Medicine, the
Society of Critical Care Medicine, and the International Sepsis Forum (SSC, 2013).

Figure 5. Surviving Sepsis Campaign Bundles

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 The SSC recommendations are classified into 3 groups: 1) those directly targeting
severe sepsis; 2) those targeting general care of the critically ill patients and considered high
priority in severe sepsis; and 3) Pediatric considerations (SSC, 2013 in Dellinger et al., 2013).
The principles of the Grading of Recommendations Assessment, Development Evaluation
(GRADE) system was utilized to guide assessment quality of evidence from high (A) to very low
(D) and to determine the strength of recommendation as strong (1) or weak (2) (SSC, 2013 in
Dellinger et al., 2013) [Refer to Table 3]. Thus, it is safe to infer that the SSC guidelines which
represent the sepsis care bundles are intended to provide guidance for healthcare
professionals who are caring for a patient with sepsis or septic shock.

Table 3. Factors determining strong vs. weak recommendation on SCC Guidelines (2013)

With the exception of pediatric recommendations the detailed SSC recommendations

and guidelines are shown on the tables below. A summary of Evidenced-based Sepsis and
Severe Sepsis Protocol adapted from 2013 SSC guidelines is also discussed as follows:

● Therapeutic priorities for patients with sepsis and septic shock initiated within the first 3
hours are early source identification, measuring lactate level, correcting hypoxemia,
administering fluids and antibiotics [Refer to Table 4].

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● The adequacy of perfusion should be assessed in patients with suspected severe sepsis and
septic shock. Hypotension is the most common indicator of inadequate perfusion. However,
critical hypoperfusion can also occur in the absence of hypotension, especially during early
sepsis. Common signs of hypoperfusion include warm, vasodilated skin in early sepsis that
progresses to cool, vasoconstricted skin in late sepsis, tachycardia >90 per min, obtundation or
restlessness, oliguria or anuria, and lactic acidosis [Refer to Table 4].

● For patients with severe sepsis and septic shock, intravenous fluids, rather than
vasopressors, inotropes, or red blood cell transfusions as first-line therapy for the restoration
of tissue perfusion. Therapy should be initiated as early as possible, within six hours of
presentation [Refer to Table 4]. Fluid boluses are the preferred method of administration and
should be repeated until blood pressure and tissue perfusion are acceptable, pulmonary
edema ensues, or there is no further response. These parameters should be assessed before
and after each fluid boluses.

● For initial fluid replacement, using crystalloid solution rather than albumin-containing
solution and hyperoncotic starch solution not be administered. For patients who remain
hypotensive following intravascular volume repletion, norepinephrine is the preferred initial
vassopressing agent. For patients with severe sepsis and septic shock that are refractory to
intravenous fluid and vasopressor therapy, additional therapies, such as inotropic therapy and
blood transfusions, are administered based on individual assessment. Typically red blood cell
transfusion is reserved for patients with hemoglobin level <7 g per deciliter [Refer to Table 5].

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Table 4. Recommendations: Initial resuscitation and infection issues (SSC, 2013)

Page 28 of 46
● For most patients with sepsis and septic shock fluid management should be guided using
specific targets, rather than being managed without specific therapeutic targets. The optimal
target to guide fluid management is unknown. For most patients, the target mean arterial
pressure ≥65 mmHg and urine output ≥0.5 mL/kg/hour and integrate it with static measures of
determining adequacy of fluid administration (eg, central venous pressure [CVP] 8 to 12
mmHg), or dynamic predictors of fluid responsiveness (eg, respiratory changes in the radial
artery pulse pressure) or central venous oxygen saturation ≥70 percent [Refer to Tables 4 &5].
In addition, serial serum lactate (eg, every six hours), until there is a clear clinical response.

Table 5. Recommendations: Hemodynamic support and adjunctive therapy (SSC, 2013)

● Prompt identification and treatment of the site of infection are essential. Sputum and urine
should be collected for Gram stain and culture. Intra-abdominal fluid collections should be
percutaneously sampled. Blood should be taken from two distinct venipuncture sites and from
indwelling vascular access devices and cultured aerobically & anaerobically [Refer to Table 4].

● Antibiotics should be administered within the first three hour of presentation, preferably
after appropriate cultures have been obtained. Empiric broad spectrum antibiotics when a
definite source of infection cannot be identified [Refer to Table 4].

● Potentially infected vascular access devices should be removed (if possible), abscesses
should be drained, and extensive soft tissue infections should be debrided or amputated
[Refer to Table 4].

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● Patients requiring intubation and mechanical ventilation; the target tidal volume of 6ml/kg
of predicted body weight is recommended with head of the bed at 30-45 degrees angle to limit
aspiration risk and prevent ventilator-associated pneumonia. Sedation and analgesia either
continuous or intermittent are minimized, targeting a specific titration end points [Refer to
Table 6.1].

● Glucocorticoid therapy, nutritional support, glycemic control, DVT and stress prophylaxis
and setting goals of care with patient’s families are strongly recommended [Refer to Tables
6.1 and 6.2].

● Neuromuscular blocking agents (NMB’s), immunoglobulins, selenium and recombinant

human activated protein C (rhAPC) are not recommended and if possible be avoided [Refer to
Table 6.1]

● Rehabilitative and recuperative care is dependent on existing hospital policy and procedure
provided it is geared towards patient-and –family centered care [Refer to Table 6.2].

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Table 6.1 Recommendations: Other supportive therapy of severe sepsis (SSC, 2013)

Page 31 of 46
Table 6.2. Recommendations: Other supportive therapy of severe sepsis (SSC, 2013)

Page 32 of 46
Nursing interventions for septic shock

The nurse’s role in the afore mentioned, Surviving Sepsis Campaign, would be to remain
diligent with regard to being a patient advocate and supporting the bundle protocols which are
evidence-based best practice. Close nursing observation and monitoring of their patients while
in their care is also critical from presentation to the healthcare facility, to discharge. Nurses
must immediately report/communicate patient changes to the physician with respect to
laboratory values, signs and symptoms, vital signs and the overall status of the patient. Being
an intelligent observer of even the most subtle of changes is urgent with the septic patient. A
multidisciplinary collaboration and team approach is essential for improvement of clinical care
patient outcomes. Ahrens and Tuggle (2004) indicate that the nurses’ role is critical in the
prevention of progression in sepsis because their responsibility places them in a position to
identify patients at the very first sign of sepsis. Once identified early on, appropriate treatment
can be implemented immediately to reduce the progression of sepsis to involve multiple
organs.

According to Aitken et al. (2011), although the septic shock guidelines/protocols provide a
comprehensive review of the medical management of patients with sepsis and septic shock,
they are frequently silent on the nursing care that is essential for optimal outcome of these
patients. Research to identify the most appropriate nursing interventions for severe sepsis
patients is urgently required. Areas that are particularly needed include:

• Prevention recommendations related to education, accountability, surveillance of

nosocomial infections, hand hygiene, and prevention of respiratory, central line
related, surgical site, and urinary tract infections.
• Infection management recommendations related to both control of the infection
source and transmission-based precautions.
• Recommendations related to initial resuscitation include improved recognition of the
deteriorating patient, diagnosis of severe sepsis, seeking further assistance, and
initiating early resuscitation measures.
• Important elements of hemodynamic support related to improving both tissue
oxygenation and macro circulation.

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 • Recommendations related to supportive nursing care incorporate aspects of nutrition,
mouth and eye care, and pressure ulcer prevention and management.

Impact of sepsis protocol on outcome of septic shock

In the recent years, significant advances have been created to render better
healthcare delivery to patients with sepsis in the clinical setting, with newer promising
therapies, treatment and management that decrease or alleviate mortality, such as
implementation of sepsis protocols, guidelines, bundles or clinical pathway algorithms. A
number of research studies show that implementing such protocols may have a number of
various impact on the outcome of septic shock among critically-ill adult patients.

A two-year long prospective observational cohort study conducted by Girardis et al.

(2008) measured compliance to five (5) resuscitation and four (4) management sepsis
interventions following an educational program on sepsis for physician and nurses of all
hospital departments, and hospital implementation of a specific protocol for recognition and
management of patients with severe sepsis/septic shock, including an early consultation by a
skilled “sepsis team”. The study concluded that the “implementation of resuscitation and
management interventions was associated with a lower risk of in-hospital mortality (23% vs
68% and 27% vs 68%) [on the first phase] and after activation of the 'sepsis team', in-hospital
mortality of ICU septic shock patients decreased by about 40% compared with the previous
period (32% vs 79%)” (Girardis et al., 2008).

A multi-center study conducted in France by Lefrant et al. (2010), revealed that the
implementation of a care bundle adapted from the Surviving Sepsis Campaign guidelines
decreases the 28-day mortality rate in patients with severe sepsis and/or septic shock. The
research further noted that “increased adherence was observed mainly for hemodynamic
management and antibiotic timing, leading to a reduction in the mortality rate from 40 to
27%” (Lefrant et al., 2010). The authors recommended that efforts should be continued to
implement the international guidelines for the management of severe sepsis or septic shock.
On the other hand, a study conducted by Napoli et al. (2011) noted that a reduced accelerated
contractility index (ACI) is associated with mortality in critically-ill emergency department

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patients presenting with severe sepsis and septic shock meeting criteria for early goal-directed
therapy. Furthermore, the study revealed that “ACI did not correlate with amount of prior fluid
administration, central venous pressure, number of cardiac risk factors, or troponin I value”
(Napoli et al., 2011).

A collaborative research study between the Emergency Department (ED) and Medical
Intensive Care Unit (MICU) was performed by Casserly et al. (2010), and the authors’ data
suggest that the use of a collaborative protocol for sepsis intervention may decrease the time
to initiation of resuscitation for patients admitted to the ED with severe sepsis and decrease
the time to transfer to the MICU. It concluded that “there was a statistically significant
decrease in time to initial fluid administration and time to catheter insertion in the ED”
(Casserly et al., 2010). Furthermore, there were “trends toward decreased time for
administration of vasopressors and antibiotics and transfer time to the MICU” (Casserly et al.,
2010).

The importance of compliance to implementation of sepsis protocols were also studied

by a few researchers. An audit performed by Baldwin et al (2008) showed that compliance to
the sepsis resuscitation care bundle “did not meet the target of 100%.” Thus, the authors
recommended that training, education and increasing awareness of the care bundle across all
disciplines is imperative. On the other hand, a three-step sepsis screening tool was developed
in a Texas hospital’s Surgical Intensive Care Unit (SICU) by Moore et al. (2009), and they
concluded that the tool was valid for and has improved the early identification of sepsis which
enabled early therapeutic interventions. It concluded that “implementation of the tool and our
logic-based sepsis protocol has decreased sepsis-related mortality in our SICU by one third”
(Moore et al., 2009). The research also added that utilization of a multidisciplinary team with
escalating levels of expertise for each component of the screening process has resulted in a
screening tool that is both highly sensitive and highly specific (Moore et al., 2009).

In the geriatrics population, a research by El Solh et al. (2008) noted that

“implementation of a comprehensive sepsis bundle protocol in management of elderly patients
with septic shock had improved survival rate by 16%.” In the particular study, the treatment
group received a larger volume of fluid in the first 6 hours of presentation and had lower doses

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of vasopressors; however there were “no significant differences between the treatment and
control groups with respect to duration of mechanical ventilation or duration of hospital stay in
ICU” (El Solh et al., 2008). Another research that had a focus on the elderly patients noted that
the risk of dying from severe sepsis and septic shock are considerably higher in elderly patients
aged 60-80 years old and very elderly patients >80 years old, thus early aggressive treatment
to recognize and manage severe sepsis is required to improve outcome for elderly patients
(Nasa et al., 2012).

It is important to note that utilization of sepsis protocols does not only have impact on
the outcome of septic shock clinically, but also has benefits on the cost-effectiveness of care
given to patients. A very recent research study by Benson et al. (2014) noted that early
recognition of systemic inflammatory response syndrome (SIRS) can significantly alter
outcomes such as mortality, unplanned intensive care unit admissions, and cost. This particular
study concluded that “unplanned intensive care unit admissions were reduced by 3.25% after
intervention with a cost savings of approximately $250 000” (Benson et al., 2014).

All authors of the twelve articles included in the systematic review agree that
implementation of sepsis protocols has positive impact on patient outcomes. Collaborative
efforts and institutional acceptance of protocols lead to the successful utilization and/or
implementation such guidelines or bundles. A multidisciplinary sepsis team is also an
important part of the implementation. The need to provide education on the protocol in the
ICUs and emergency department’s staff members is also a significant aspect. With all these
factors inter-connected together, there will be improved survivability for patients with sepsis,
decrease related healthcare costs, and excellent nursing care, thus rendering a better
healthcare delivery to critically-ill patients.

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 DISCUSSION

Review of Findings

This systematic literature review aimed to identify the impact of sepsis protocol on the
outcome of adult patients with severe sepsis and septic shock. The results of literature review
were in general as anticipated. The findings of review suggest that screening tool to promote
early identification of patients with severe sepsis and septic shock and guidelines for
healthcare team responsiveness to standing for the implementation of sepsis protocol,
according to SSC guidelines and other international sepsis forums in intensive care settings
could improve outcome of patients with severe sepsis or septic shock.

Utilization of a systematic screening tool to recognize sepsis as early as possible has

been indicated in many studies as the most important key to improve patient outcomes
(Moore et al., 2009; Mann-Salinas et al., 2013; Gyang et al., 2014; Chamberlain et al., 2014).
However, the triage tools adopted in sepsis screening are still performed by using paper and
pen in intensive care settings. This probably gives critical care nurse an increased workload
since each item should be found from patient records and scores evaluated by hand. As most
of the healthcare organizations develop toward the electronic medical records (EMRs), there is
the great possibility to develop electronic sepsis screening tools in clinical settings. The
screening tools that searched the urgent required data from the patient electronic records
could significantly reduce the time demands and also foster real – time alerts to positive sepsis
screening results (McKinley et al., 2011; Herasevich et al., 2011). However, in either case, the
patient data should be verified and positive results must be communicated among team
members who are with patient continuously care and initiate the appropriate intervention.
The time commitment must be demand and individual responsibility should be accounted.
Educational program should also be conducted to improve nursing staff awareness of sepsis
screening tools since they are most often responsible for the initial assessment of patients
(Birriel, 2013).

Campbell (2008) has developed to assign nursing staff whose only duty is screening
and follow up on management of severe sepsis or septic shock. Adoption of this nurse

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champion has enhanced screening adherence, but did not always lead to improved
management of severe sepsis and septic shock. Therefore, recognition of patients with sepsis
alone does not guarantee that early intervention initiated.

As can be highlighted from the literature review, sepsis prevalence is increasing.

Identification of severe sepsis or septic shock as early as possible may not be enough. The
complete compliance to 6 hours and 24 hours intervention should be emphasized in intensive
care settings in order to decrease in – hospital mortality for adult patients with severe sepsis
and septic shock.

From the authors’ point of view, this systematic literature review presents impact of
using a sepsis protocol on the outcomes of critically ill adult patients with septic shock in
different countries, which including seven studies originated from USA, one from UK, Italy,
France, Australia and India. There was no Portugal study included in the review, which makes
the applicability of the results to Portugal healthcare system is difficult to assess. However,
three European studies included in the review and indicated the importance of implementing
sepsis protocol in management of septic shock patients and this suggestion is highly
applicable.

Reliability and Validity of the Research Studies

Since this paper is about systematic literature review, we are forced to depend on only
the previous studies about septic shock. Hence, ethical consideration of the study included
careful examination of the reliability and validity of the chosen articles. The database search
was conducted from reliable healthcare internet databases including EBSCO Academic Search
Premier, PubMed, OvidSP and ProQuest Health databases, which ensure that all the articles
had undertaken some extent of surveillance. Only peer-reviewed research articles about sepsis
and septic shock were selected into the review. Therefore, the reliability and validity of
literature review compromised with limitation of data search.

All selected research articles were read and analyzed by the authors and the results
were charted similarly in Appendix 1, which decreased the potential sources of bias. This

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systematic literature review was extensive, with 12 relevant evidences of septic shock in both
emergency and critical care. Massive amount of evidences regarding the effect of sepsis
protocol on outcome of critically ill adult patients with septic shock were identified from the
literatures within a short period of time. Thus, it is difficult to categorize and compare as many
of them overlapped with each other.

Since, none of the authors are not the native English speakers in five of the research
studies, the risk of misinterpreting the research evidence has to be considered. The different
concepts and terms used by different studies regarding septic shock management were
confusing at the same times. Moreover, whole process of the data analysis was done by the
four authors, communicating the results with each other. Therefore, it has to be acknowledged
that the findings of literature review might be affected by different personal perspective and
judgments. However, all the steps of data analysis process are described in details, which
enable the repetition of the data analysis.

Selected research articles included in the review were the recent studies that
conducted in both emergency and critical care units. Sample groups included both adult and
elderly patients with septic shock. Hence, findings of literature review present the
management of adult patients with septic shock in acute care settings.

Limitations of the Research Study

This systematic review has several limitations. The search was limited to the years
2000 to present. The limit of 14 years was chosen because acute and critical care nursing and
especially sepsis protocols change relatively quickly. On the other hand, this time span enabled
the authors to compare and contrast similarities and differences of such protocols. The search
was limited to studies published in English. The grey literature such as master’s theses were
not searched because the authors wanted to include the highest-quality studies. According to
Egger et al. (2003), major bibliographical databases will often produce results that are close to
those obtained from comprehensive searches including grey literature.

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 The search process and review were only done during the whole month of November
until the first two weeks of December 2014. The authors initially planned to specifically focus
on the impact of sepsis protocol in the ICU setting only, but because of limited number of
studies that have a research locale at the ICU, the inclusion criteria was modified to include
studies that were conducted in all areas of acute and critical care units.

All twelve studies comprise of critically-ill adult patients as population, however, in

three of the studies, the main focus was only on the geriatrics population in the critical care
situations. In this context, this may undermine some other types of impact of sepsis protocols
in a wider array of patients. Furthermore, only one of the research studies has discussed
impact other than physiological aspects of the patients. This may set some limitations to
conclusions made on the basis of the review summary.

Conclusion and Recommendations

The findings of the systematic review indicate that utilization of screening tool and
implementation of intervention based on evidence –based protocols are associated with
outcome benefits in patients with severe sepsis and septic shock.

Strong scientific evidence support the efficacy and cost effectiveness of the universal
implementation of SSC guidelines. This systematic review of 12 scientific articles revealed the
several translation of these guidelines into protocol in many different critical care settings to
suit the need of every unique patient population. Essentially, these protocolized guidelines
have provided healthcare professionals valuable guidance in caring for patients with severe
sepsis or septic shock. In turn, the utilization of this protocol simplifies the complex care and
treatment of patients in critical care setting. Early recognition of sepsis and the prompt
initiation of evidenced-based treatment bundles are two components of SSC guidelines that
have continued to reduce mortality rate since from the initial release of these guidelines in
2004 up to the present. This is the ultimate foundation of improved treatment outcomes in
which this systematic review has shown to accomplish.

The collaborative nursing team approach is important to developing a protocol for

early sepsis and septic shock identification and treatment in intensive care settings. Early

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recognition and management of sepsis and septic shock have been identified to improve
survival rates and quality of care for adult patients, however, this depends on the
implementation of the accurate sepsis screening tool for prompt recognition and
communication of the results among healthcare team members who is responsibility to initiate
appropriate interventions. It is quality of care provided by multidisciplinary healthcare team
that is effective in promoting better outcomes for adult patients with septic shock.

Sepsis protocols have direct implications for nursing care, as nurses are often
responsible for obtaining blood samples for measurement of lactate levels and for cultures, as
well as administering antibiotics and vasopressor therapy. The guidelines indicate the lack of
early recognition of sepsis as the major obstacle to initiation of treatment bundles and thereby
producing negative patient’s outcomes. The direct role of nurses in obtaining samples for
culture and administering antibiotic therapy have significant impact in maximizing the
identification of the source of infection as well as ensuring that patient’s received prompt
antibiotic therapy. Routine nursing care like bathing may reveal areas of redness and
inflammation have helped identify the presence of abscess, or drainage at the insertion site
from a vascular access catheter may suggest potential catheter-assocaited bloodstream
infections needing discontinuance of catheter. The use of careful infection control practices
including hand hygiene, catheter care, use of personal protective equipment are routine
nursing measures to prevent further complications. Head-of bed elevation at 35-40 degrees
angle, comprehensive oral care, and selective oral decontamination during suctioning by
nurses are methods to reduce the incidence of Ventilator Associated Pneumonia.

Although the SSC recommendations are intended to be the best practice but because
of some limitations involved, it cannot represent as a standard of care. Studies have shown in
countries with few limited healthcare resources have prevented healthcare personnel from
accomplishing particular recommendations. Furthermore, in the context of patient-and-family
centered care, these recommendations cannot replace the healthcare professional’s decision-
making capability when patient’s unique set of sign and symptoms are being presented.
Indeed, the optimum care and treatment of severe sepsis and septic shock are dynamic and an
evolving process. Everyone in the healthcare team especially critical care nurses are
confronted with the challenge to reduce the morbidity and mortality of sepsis worldwide. In
effect, several key points of recommendations are as follow;

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 1. Sepsis protocol requires multidisciplinary team (Physician, Nurses, Pharmacists,
Respiratory Therapists, Dietitians, and Administrators) and multispecialty
collaborations (Medicine, Surgery, ICU and Emergency) to promote achievements of
goals.
2. Performance improvement involves education, protocol development and
implementation, data collection, quality improvement staff and ongoing feedback to
members of the healthcare team.
3. Nurse-driven research is deemed significant in the continuous quality improvement of
nursing care to patients with sepsis. Further research and investigations should aim to
identify the most appropriate nursing interventions, impact of preventive measures
and the implementation of bundle strategies
4. Formal audit and feedback of performance improvement initiatives of sepsis
guidelines will influence the behavior of each member of healthcare team in the
implementation of valuable sepsis protocol, thereby reducing the burden of high
mortality and morbidity of sepsis.
5. Process change is recommended across the spectrum of acute care to adapt the
highest evidenced-based practice in the care and treatment of patients with severe
sepsis and septic shock.

In summary, sepsis screening tools/protocols and evidence–based intervention

protocols are available to support healthcare team members to assess and intervene early to
eliminate harm and significantly decrease mortality among critically-ill adult patients.
Therefore, better awareness and understanding of the screening tools and greater compliance
to sepsis protocols should be encouraged and improved among healthcare staff who are
involved in the direct care of adult patients with severe sepsis and septic shock. With all these,
the practice-research gap in the clinical setting will be lessened or eliminated, thus excellent
nursing care and the best possible quality of healthcare delivery will be rendered to all patients
in critical care settings.

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 REFERENCES
(*studies included in the systematic review)

Ahrens, T. & Tuggle, D. (2004). Surviving severe sepsis: Early recognition and treatment. Critical
Care Nurse, 2-15.

Aitken, L.M., Williams, G., Harvey, M., Blot, S., Kleinpell, R., Labeau, S., Marshall, A., Ray-
Barruel, G., Moloney-Harmon, P.A., Robson, W., Johnson, A.P., Lan, P.N. & Ahrens, T.
(2007). Nursing considerations to complement the Surviving Sepsis Campaign
guidelines. Critical Care Medicine, 39 (7), 1800-1818. doi:
10.1097/CCM.0b013e31821867cc

*Baldwin, L.N., Smith, S.A., Fender, V., Gisby, S. & Fraser, J. (2008). An audit of compliance with
the sepsis resuscitation care bundle in patients admitted to A&E with severe sepsis or
septic shock. International Emergency Nursing, (116), 250-256. doi:
10.1016/j.ienj.2008.05.008

*Benson, L., Hesenau, S., O’Connor, N. & Burgermeister, D. (2014). The impact of a nurse
practitioner rapid response team on systematic inflammatory response syndrome
outcomes. Dimensions of Critical Care Nursing, 33 (3), 108-115. doi:
10.1097/DCC.0000000000000046

Birriel, B. (2013). Rapid identification of sepsis: The value of screening tools. Society of Critical
Care Medicine. Retrieved from: http://www.sccm.org/Communications/Critical-
Connections/Archives/Pages/Rapid-Identification-of-Sepsis---The-Value-of-Screening-
Tools.aspx

Bridges, E.J. & Dukes, S. (2005). Cardiovascular aspects of septic shock: Pathophysiology,
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