Literature review for college level nursing 

title Early detection and prevention of Sepsis

focusing on screening, detection and prevention

1) Overview of disease process

2) How to assess signs and symptoms 

3) Treatment and prevention of sepsis

METHODOLOGY

LITERATURE REVIEW

CONCLUSION

REFERENCES

Please use the attached references   

4-5 pages in length

Ask the Experts

QAre there time frames related to the sepsis
screening criteria? For
example, what window
of time would qualify
to meet criteria for
systemic inflammatory
response syndrome?
Would you expect
increases in heart
rate, respiratory rate,
and body tempera-
ture measurements to
occur simultaneously
or within 2 to 4 hours?
Would the change in

2 groups of patients in general
care areas; one group was automat-
ically screened with the prediction
tool and one group was not. The
tool algorithm incorporated hemo-
dynamic parameters that included
the shock index (heart rate/systolic
pressure) and the mean arterial
pressure. Laboratory values moni-
tored were white blood cell count;
neutrophil count; bilirubin, albu-
min, sodium, and hemoglobin lev-
els; and international normalized
ratio. This computerized prediction
tool would gather the data from
the electronic medical record and
the laboratory interface. The sam-
ple size was small, but the study
did show an increase in the number
of interventions and earlier transfer
to a higher level of care for patients
in whom the computerized predic-
tion tool was used. Length of stay
and hospital mortality were the
same in the 2 groups.

Croft et al3 compared a com-
puter versus a paper system for
recognizing and managing sepsis.
The hospital mortality rate was
significantly lower in the group
screened with the computer-based
system than in the group screened
with the paper system. Their com-
puter sepsis application provided
continuous recognition of sepsis
onset based on the electronic medi-
cal record. The scoring system used

white blood cell count be
within 12 to 24 hours of
elevated heart rate, respi-
ratory rate, and body tem-
perature? We are looking
at using the electronic
record to capture an alert
for clinicians and won-
dered if there were any
standards for this.

A Rosemary Lee, DNP, ARNP-BC, CCNS, CCRN,
replies:

In the 2012 Surviving Sepsis
Guidelines,1 it is recommended
to routinely screen potentially
infected patients for sepsis. The
sooner sepsis is diagnosed, the
sooner the 3-hour bundle can be
initiated. The guidelines further
recommend the administration of
appropriate antibiotics within the
first hour of recognition of severe
sepsis or septic shock. With the
diagnosis of septic shock, each hour
of delay in administering antibiot-
ics increases the mortality rate.

Sawyer et al2 used a real-time
prediction tool to detect sepsis
in patients who were not in the
intensive care unit. In that pro-
spective pilot study, they compared

Time Frames for Sepsis Screening Criteria

Author
Rosemary Lee is a clinical nurse specialist
in the critical care unit at Homestead
Hospital, Homestead, Florida, part of
Baptist Health of South Florida. She is also
adjunct faculty at the Nova South Eastern
University College of Nursing.
Corresponding author: Rosemary Lee, DNP, ARNP-BC,
CCNS, CCRN, Critical Care Unit, Homestead Hospital,
975 Baptist Way, Homestead, FL 33033 (e-mail:
rosemarl@baptisthealth.net).

To purchase electronic and print reprints, contact
the American Association of Critical-Care Nurses,
101 Columbia, Aliso Viejo, CA 92656. Phone, (800)
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©2015 American Association of Critical-Care
Nurses doi: http://dx.doi.org/10.4037/ccn2015989

74 CriticalCareNurse Vol 35, No. 3, JUNE 2015 www.ccnonline.org

for this application was the Mod-
ified Early Warning System–Sepsis
Recognition Score (MEWS-SRS).
The application was surveillance
followed by diagnosis of sepsis
and protocol orders. This sys-
tem was used in a surgical inten-
sive care unit.

Both of these studies mention
“real time” and continuous surveil-
lance, but not the time frames you
asked for. The Sawyer study states

patients present with a con-
stellation of abnormal vital
signs and laboratory find-
ings (fever, hypothermia,
tachycardia, tachypnea,
abnormal white blood cell
count, creatinine, liver func-
tion studies) and progres-
sion from a syndrome of
abnormal vital signs and
laboratory values to organ
dysfunction and shock.

The inference here is that sepsis
can be manifested in myriad ways
and as yet no standard has been set
for the time frames you seek.

The frequency of screening
varies by each accepted hospi-
tal practice. When nurses need
to manually input criteria into
a computer screening tool, the
screening is done anywhere from
every 4 hours to every 12 hours.
This screening and data entry
increase the workload for the nurse.
Early warning systems that are
automated, continuously survey-
ing the electronic medical record
and laboratory interface, and pro-
vide an alert via e-mail, beeper
page, text, or phone call would
be the most advantageous for

early identification of sepsis. Cur-
rently no set standards have been
reported in publications or by the
Surviving Sepsis Campaign.4

Not to be deterred, I did con-
sult with Donna Lee Armaignac,
PhD, RN-CNS, CCNS, CCRN, Director
of Best Practices for our Telehealth
Department (written communica-
tion, March 9, 2015). She is active
in our hospital system–wide sepsis
team. She stated,

We are testing independent
and combined contributions
of various variables’ sensi-
tivity, specificity, positive
predictive value, and nega-
tive predictive value in real
time. Answering her pre-
cise question of the time win-
dows is what we are testing,
the sweep is every 6 to 7 min-
utes, the vital signs (all that
are available, including SpO2
[oxygen saturation shown
by pulse oximetry] etc) will
always bring the most recent
in a live feed, also live data
from lab, WBC/diff [white
blood cell count/differential
count], lactate, procalcitonin
as it becomes available. The
organ dysfunction criteria
[are] almost useless, as the
horse is out of the barn, so
to speak. So we are focusing
more on the signs and symp-
toms of infection with SIRS
[systemic inflammatory
response syndrome]. We
are writing natural language
processing for infection cri-
teria, CXR [chest radiogra-
phy], cultures, orders for
antibiotics, and so on.

As you can see, more research
is needed in this area so that stan-
dards can be developed. Perhaps
your project could be developed into
a research study and you could add
to this body of knowledge.

Financial Disclosures
None reported.

References
1. Dellinger RP, Levy MM, Rhodes A, et al.

Surviving Sepsis Campaign: international
guidelines for management of severe sepsis
and septic shock, 2012. Crit Care Med. 2013;
41(2):580-637.

2. Sawyer AM, Deal EN, Labelle AJ, et al.
Implementation of a real-time computer-
ized sepsis alert in nonintensive care unit
patients. Crit Care Med. 2011;39(3):469-473.

3. Croft CA, Moore FA, Efron PA, et al. Com-
puter versus paper system for recognition
and management of sepsis in surgical
intensive care. J Trauma Acute Care Surg.
2014;76(2):311-319.

4. Surviving Sepsis Campaign. http://www
.survivingsepsis.org/Guidelines/Pages
/default.aspx. Accessed March 23, 2015.

Ask the Experts
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or legal question you’d like to have

answered? Send it to us and we’ll

pass it on to our Ask the Experts

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www.ccnonline.org CriticalCareNurse Vol 35, No. 3, JUNE 2015 75

Copyright of Critical Care Nurse is the property of American Association of Critical-Care
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without the copyright holder’s express written permission. However, users may print,
download, or email articles for individual use.

S
epsis is a serious condition that is a major cause of
avoidable death (National Confidential Enquiry into
Patient Outcome and Death (NCEPOD,) 2015). It
is estimated that there are about 123 000 episodes
of sepsis per year, with resulting mortality estimated

at 37 000 (NHS England, 2015), with an estimated total cost
to the NHS of £1.5 billion per year (Daniels and Nutbeam,
2017). Improvements in addressing sepsis within hospital trusts
has the potential to save £1.25 million annually (NHS England,
2015). Therefore, prompt identification and management are
essential in reducing the sepsis-related morbidity, mortality and
financial burden on the NHS.

Pathophysiology of sepsis
Sepsis can be caused by any pathogenic microbe and may
arise from pneumonia, urinary tract infection and infection
in the skin and soft tissue (Brent, 2017). Pneumonia is the
most common cause of sepsis, with bacter ia being the
most common causative organism (Gaieski et al, 2010).
Determining the causative microbe through blood cultures
will help ensure that the patient receives targeted antibiotic
therapy. Although sepsis can affect anyone, some individuals
may be at higher risk, including those with chronic illness,
the very young or old, people who have had recent surgery
and those who are immunosuppressed (Table 1).

Understanding sepsis
Karen Nagalingam

ABSTRACT
This article provides information on sepsis, which can be life threatening
and is often difficult to identify due to subtle signs and symptoms. It is the
body’s response to infection resulting in injury to the tissues and organs.
Assessment tools can be used to assess risk of sepsis and include
considering a source of infection along with a NEWS 2 or qSOFA score.
However, it is important to be aware of other subtle changes including cold or
clammy skin and changes in the patient’s behaviour such as new confusion.
Within 1 hour from diagnosis supportive treatments need to be administered,
including the most appropriate antibiotic for the source of infection, fluid and
oxygen. Blood cultures, bloods including lactate and urine measurement are
all needed to support management of the patient.

Key words: Sepsis ■ Acute illness ■ National Early Warning Score 2
■ Sepsis Six ■ quick Sepsis-related Organ Failure Assessment

Karen Nagalingam, Senior Lecturer in Adult Nursing, University of
Hertfordshire, k.l.nagalingam@herts.ac.uk

Accepted for publication: October 2018

Sepsis has been defined as follows:

‘A life-threatening condition that arises when
the body’s response to an infection injures its
own tissues and organs.’

Singer, 2016

This means that the signs and symptoms a patient may be
presenting with are as a result of physiological responses to
an infection.

When an infection occurs, an inflammatory response is
initiated, which should lead to recovery from the infection.
This involves a complex process that sets off a cascade of
reactions involving the immune system and the coagulation
cascade (Daniels and Nutbeam, 2017). Inflammation involves the
release of mediator molecules, causing vasodilation and capillary
permeability. This enables the infiltration of neutrophils and
monocytes (white blood cells), fibrinogen and platelets into
the area. The area will be red, hot and swollen as a result of
this process. When the defensive responses are overwhelmed by
infection or the inflammatory response is excessive, the patient
is at an increased risk of death. Septic shock can occur as a
result of this response. Therefore, identifying patients at risk or
at an early stage of sepsis can improve the chances of survival.

Signs and symptoms
A patient who is deteriorating, regardless of the cause, requires
immediate interventions to support them. In clinical practice
it can be difficult to determine whether sepsis is occurring
because the signs and symptoms vary and can be subtle in
certain patient groups (Brent, 2017).

In sepsis, a raised respiratory rate in a patient is a key
indicator of deterioration. Decreased oxygen transfer across
the alveoli occurs as a result of proteins and fluids leaking into
the tissues of the lungs. This leads to an increased breathing
rate to compensate for the reduced surface area available for
oxygenation. The circulatory system is also affected in sepsis,
with the release of nitric oxide and interleukins causing
vasodilation (Daniels and Nutbeam, 2017). This results in
hypotension in patients, leading to inadequate perfusion of
tissues (Gauer, 2013). The body attempts to compensate for
the low blood pressure by increasing the work of the heart,
which is known as compensatory tachycardia. In early stages
of sepsis, the patient may present with warm peripheries
and normal capillary refill time (Daniels and Nutbeam,
2017). They may have non-specific symptoms and subtle
changes in behaviour, such as withdrawal and agitation and
therefore concerns raised by the patient, family or carer need
to be considered. As sepsis progresses, the clinical signs and

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symptoms will include cold or clammy skin, reduced urine
output, lactic acidosis and altered mental status.

Although it has been stated that identification of sepsis can
be difficult, an awareness of the physiological processes that
occur and the presenting features will help aid diagnosis. In
a study by Gaieski et al (2010) it was found that delays in
treatment directly influenced mortality in patients with sepsis.
Various methods for determining sepsis have been used in the
past, with track and trigger systems, such as the National Early
Warning Score (NEWS) 2 (Royal College of Physicians, 2017),
being more accurate at identifying sepsis than tools such as
the quick Sepsis-related Organ Failure Assessment (qSOFA)
(Churpek et al, 2017). However, where infection is suspected,
qSOFA is a quick, easy and valid way to identify a patient at
risk of sepsis (Lamontagne et al, 2017), which can be easily
used in settings where a track and trigger system has not been
introduced (Table 2).

Management
Rapid clinical assessment and prompt management is required
if a deteriorating patient presents with a risk factor for sepsis,
a NEWS 2 score of 5 or more (or local equivalent), and a
clinical suspicion of infection (Daniels and Nutbeam, 2017).
The Sepsis Six is a care bundle designed to be delivered within
the first hour of diagnosis (Brent, 2017) (Box 1). This includes
supplementing oxygen to improve oxygenation to maintain
saturations between 94% and 98%. If the patient is critically
ill, this can be given as high-flow oxygen using a mask with a
reservoir at 15 L (Resuscitation Council, 2014).

It has been found that patients in septic shock had improved
outcome if antibiotics were administered within the first hour
of diagnosis (Sherwin et al, 2017). Although there is disputed
evidence around the precise time from diagnosis to treatment,
there is consensus that this should be as soon as possible (Gotts
and Matthay, 2016). Antibiotic choice should be guided by local
hospital guidelines and the suspected focus of infection. To aid
correct and targeted administration of antibiotics, it is essential
to take blood cultures peripherally and from any intravenous
devices such as lines and cannulas. Blood cultures should be
taken before antibiotics are administered where possible, so
that the organism causing sepsis can be identified and the most
appropriate antibiotic prescribed.

Supportive management of a patients with sepsis includes
administration of fluid. This improves the delivery of oxygen
and nutrients to tissues by improving circulation. Initial fluid
resuscitation is 500 ml of saline over less than 15 minutes, and
this is repeated if there is no improvement (National Institute
for Health and Care Excellence (NICE), 2017a). The need
for further fluids will be determined by the patient’s response
to fluids and escalation may be required. NICE (2017b)
recommends that, if within 1 hour the patient has not responded
to either the antibiotics or fluid resuscitation, a consultant review
is required. Failure to respond is indicated in Table 3.

Although evidence is sketchy surrounding the amount
of fluid required, expert consensus is that fluid resuscitation
has reduced mortality from septic shock (Gotts and Matthay,
2016). Any delay in receiving fluid can lead to prolonged tissue

Table 1. Risk factors for sepsis

Age ■ Younger than 1 year
■ Older than 75 years

Impaired immune
system

■ Drugs: chemotherapy, immunosuppressant medication
or steroids

■ Illness: diabetes, sickle cell or patients who have had
a splenectomy

Invasive procedures ■ Surgery
■ Indwelling lines or catheters
■ Misuse of intravenous drugs

Breach of skin integrity ■ Burns, blisters, cuts or skin infections

Pregnancy ■ Miscarriage, given birth, pregnant or termination in the
past 6 weeks

Source: National Institute for Health and Care Excellence, 2017b

Table 3. Indication for escalation after initial
resuscitation (fluid and antibiotics)

Systolic blood pressure <90 mmHg

Consciousness level ■ Reduced consciousness
level (<15 Glasgow Coma Scale)

■ VPU the AVPU [Alert, Voice,
Pain, Unresponsive] scale

Respiratory rate >25 breaths per minute

Lactate Reduced by 20% in first hour

Source: National Institute for Health and Care Excellence, 2017b

Box 1. Sepsis Six care bundle

■ Deliver oxygen to achieve saturations of 94–98% or 88–92%
in patients who retain CO2

■ Take blood cultures and other cultures

■ Administer intravenous (IV) antibiotics within 1 hour of
diagnosis

■ Commence crystalloid IV infusion 500 ml in 15 minutes and
reassess

■ Measure venous bloods: glucose, lactate and full blood
count. Urea and electrolytes, creatinine, C-reactive protein and
clotting screen

■ Measure urine output

Source: National Institute for Health and Care Excellence, 2017b;
Daniels and Nutbeam, 2017

Table 2. quick Sepsis Related Organ Failure
Assessment (qSOFA)

Fast respiratory
rate

Low blood
pressure

Altered mental
state

≥ 22 breaths per
minute

≤100 mmHg <15 Glasgow Coma Scale

Source: University of Pittsburgh, 2018

British Journal of Nursing, 2018, Vol 27, No 20 1169

AT A GLANCE
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hypoxia, resulting in multiple organ failure (Gauer, 2013), so it is
important that patients with sepsis receive timely intervention to
prevent further deterioration. Evidence has indicated that fluid
overload leads to worse outcome (Kelm et al, 2015), and this
means that a robust approach to assessment and management
of fluid is required to optimise patient outcomes.

Lactate is a marker of anaerobic respiration, and this is
produced when tissue hypoxia occurs. Oxygen is required for
the production of energy in the form of adenosine triphosphate
(ATP), but when there is a lack of oxygen, lactate is produced.
Lactate represents ischaemia and therefore its measurement
helps to identify whether treatment is working. An elevated
lactate of greater than 2 mmol/l predicts mortality, while a fall
in lactate from the previous measurement may indicate that
fluid resuscitation is working (Daniels and Nutbeam, 2017).

Measurement of urine output and any fluids administered
provides a clear record of fluid status. Prolonged poor perfusion
of the kidneys as a result of hypotension can lead to a reduction
in urine output, which is an indicator of acute kidney injury
(AKI). Sepsis and AKI frequently occur together and this is
associated with worse outcomes, including increased length
of hospital stay and mortality (Godin et al, 2015). Robust
measurement of fluid input and output should ensure clearer
patient management.

Conclusion
Sepsis can be difficult to identify because the signs and symptoms
can be variable and subtle. Assessment tools, such as NEWS 2 and
qSOFA, can aid health practitioners in determining a patient’s
risk of sepsis with the management of sepsis guided by NICE
(2017b) and the Sepsis Trust (Daniels and Nutbeam, 2017).
Oxygen, fluid and antibiotics are aimed to be delivered within
the first hour of diagnosis, with blood cultures, measurement of
lactate and urine output all guiding management. BJN

Declaration of interest: none

Brent A. Sepsis. Medicine. 2017; 45(10): 649-653. https://doi.org/10.1016/j.
mpmed.2017.07.010

Churpek M, Snyder A, Han X et al. Quick Sepsis-related Organ Failure
Assessment, systemic inflammatory response syndrome, and early warning
scores for detecting clinical deterioration in infected patients outside the
intensive care unit. Am J Respir Crit Care Med. 2017; 195(7): 906-911.
https://doi.org/10.1164/rccm.201604-0854OC

Daniels R, Nutbeam T, eds. The sepsis manual: responsible management of
sepsis, severe infection and antimicrobial stewardship. 4th edn. Birmingham:
The UK Sepsis Trust; 2017. https://tinyurl.com/ya7wplm6 (accessed 16
October 2018)

Gaieski D, Mikkelsen M, Band R et al. Impact of time to antibiotics on
survival in patients with severe sepsis or septic shock in whom early
goal-directed therapy was initiated in the emergency department.
Crit Care Med 2010; 38(4): 1045-1053. https://doi.org/10.1097/
CCM.0b013e3181cc4824

Gauer R. Early recognition and management of sepsis in adults: the first
six hours. Am Fam Physician 2013; 88(1): 44-53. https://tinyurl.com/
y9mow8m6 (accessed 16 October 2018)

Godin M, Murray P, Mehta RL. Clinical approach to the patient with AKI
and sepsis. Semin Nephrol. 2015; 35(1), 12-22. https://doi.org/10.1016/j.
semnephrol.2015.01.003

Gotts J E, Matthay MA. Sepsis: pathophysiology and clinical management.
BMJ 2016;353:i1585. https://doi.org/10.1136/bmj.i1585

Kelm DJ, Perrin JT, Cartin-Ceba R, Gajic O, Schenck L, Kennedy CC. Fluid
overload in patients with severe sepsis and septic shock treated with early-
goal directed therapy is associated with increased acute need for fluid-
related medical interventions and hospital death. Shock 2015; 43(1): 68-73.
https://doi.org/10.1097/shk.0000000000000268

Lamontagne F, Harrison DA, Rowan KM. qSOFA for identifying sepsis
among patients with infection. JAMA 2017; 317(3): 267-268. https://doi.
org/10.1001/jama.2016.19684

National Confidential Enquiry into Patient Outcome and Death. Just say
sepsis! A review of the process of care received by patients with sepsis.
London: NCEPOD; 2015. https://tinyurl.com/y8bfer88 (accessed 16
October 2018)

NHS England. Improving outcomes for patients with sepsis. A cross-system
action plan. London: NHS England; 2015. https://tinyurl.com/gm4zkps
(accessed 16 October 2018)

National Institute for Health and Care Excellence. Intravenous fluid therapy
in adults in hospital. Clinical guideline 174. 2017a (updated guideline,
first published 2013). https://tinyurl.com/mach6kv (accessed 16 October
2018)

National Institute for Health and Care Excellence. Sepsis: recognition,
diagnosis and early management. NICE guideline 51. 2017b (updated
guideline, first published 2016). https://tinyurl.com/zss9cg4 (accessed 16
October 2018)

Resuscitation Council (UK). Guidelines and guidance. The ABCDE approach.
Underlying principles. London: Resuscitation Council (UK); 2014.
https://tinyurl.com/hoaesdh (accessed 19 October 2018)

Royal College of Physicians. National Early Warning Score (NEWS) 2:
standardising the assessment of acute-illness severity in the NHS. 2017.
https://tinyurl.com/ycodbu85 (accessed 19 October 2018)

Sherwin R, Winters ME, Vilke GM, Wardi G. Does early and appropriate
antibiotic administration improve mortality in emergency department
patients with severe sepsis or septic shock? J Emerg Med 2017; 53(4): 588-
595. https://doi.org/10.1016/j.jemermed.2016.12.009

Singer M. The Third International Consensus Definitions for Sepsis and Septic
Shock (Sepsis-3). JAMA 2016; 315(8): 801-810. https://doi.org/10.1001/
jama.2016.0287

University of Pittsburgh. Quick Sepsis-related Organ Failure Assessment.
(qSOFA). https://www.qsofa.org/ (accessed 19 October 2018)

Vincent J, Sakr Y, Sprung C et al. Sepsis in European intensive care units:
results of the SOAP study. Crit Care Med 2006; 34(2): 344-353. https://
doi./org/10.1097/01.CCM.0000194725.48928.3A

CPD reflective questions
■ Consider how you could improve recognition of sepsis in your clinical area

■ What support would you need to ensure that the 1-hour target of management is met in the septic patient?

■ Consider in which patient groups it may be harder to identify sepsis. How could this be improved?

■ Which patients are at a higher risk of sepsis and what can be done to improve this?

LEARNING OUTCOMES
■ Understand how to identify whether a patient is at a high risk of sepsis

■ Understand the signs and symptoms of sepsis

■ Identify the management strategy for a patient with a high risk of sepsis

■ Be aware of the importance of subtle signs of sepsis, such as new
confusion and changes in behaviour

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Copyright of British Journal of Nursing is the property of Mark Allen Publishing Ltd and its
content may not be copied or emailed to multiple sites or posted to a listserv without the
copyright holder’s express written permission. However, users may print, download, or email
articles for individual use.

Ask the Experts

©2018 American Association of Critical-Care Nurses
doi:https://doi.org/10.4037/ccn2018245

QGiven all the changes
in sepsis definitions,

what is the best way

to know if a patient is

at risk for sepsis?

be used in the ICU as part of the

diagnostic criteria for sepsis.1

The key clinical point is the need

for ongoing monitoring of patients

for indications of organ dysfunction.

If a patient has indications of organ

dysfunction (regardless of the cause

or which screening tool is used), fur-

ther assessment is required.

The challenge is that there is no

consensus on how to screen for or

diagnose sepsis. The 2016 Surviving

Sepsis guidelines,5 which were

based on evidence using the old

sepsis definitions, did not include

the Sepsis-3 criteria. Rather, those

guidelines recommend ongoing

screening, without specifying the

criteria. Because the debate about

the appropriate screening criteria

for sepsis is ongoing,6-10 it is import-

ant to know what each score does

and does not tell you (Table 3).

An important consideration is

that a normal qSOFA or SOFA score

does not rule out sepsis,9 because

no screening tool is “perfect” (ie,

has 100% diagnostic accuracy).

Additionally, the accuracy of each

score varies depending on whether

the patient is in the emergency

department, the ICU, or a non-ICU

setting.1,13,14 Several excellent

review papers address this challeng-

ing question, including the use of

AElizabeth Bridges, PhD, RN, CCNS, FCCM, FAAN,
and Sheryl Greco, MN, RN, reply:

This is an important question, as

the early recognition and treatment

of patients with sepsis and septic

shock are associated with improved

outcomes. Unfortunately, there is

no clear answer to this question.

In 2016, the Third International

Consensus Definition for Sepsis

and Septic Shock (Sepsis-3) was

published.1-3 As part of Sepsis-3,

the definition of sepsis was revised

from an inflammatory process in

response to an infection to “life-

threatening organ dysfunction due

to a dysregulated host response to

infection.”3 One outcome of this

revision was that systemic inflam-

matory response syndrome, as an

indicator of sepsis in combination

with concern for infection, was

replaced with the quick Sequential

(Sepsis-Related) Organ Failure

Assessment (qSOFA; Table 1) or

the SOFA score (Table 2) as an

indicator of organ dysfunction.

The Sepsis-3 committee recom-

mended that qSOFA be used in set-

tings other than the intensive care

unit (ICU) to identify patients at

risk for sepsis and the SOFA score

Identifying Patients at Risk for Sepsis

Authors
Elizabeth Bridges is a clinical nurse
researcher at the University of Washington
Medical Center and a professor at the
University of Washington School of Nurs-
ing, Seattle, Washington.

Sheryl Greco is a clinical nurse specialist in
critical care and cardiology at the University
of Washington Medical Center.

Corresponding author: Elizabeth Bridges, PhD, RN, CCNS,
FCCM, FAAN, University of Washington School of Nurs-
ing, 1959 NE Pacific, Box 357266, Seattle, WA 98195
(email: ebridges@uw.edu).

To purchase electronic and print reprints, contact the
American Association of Critical-Care Nurses, 101
Columbia, Aliso Viejo, CA 92656. Phone, (800) 809-
2273 or (949) 362-2050 (ext 532); fax, (949) 362-
2049; email, reprints@aacn.org.

BRIDGES GRECO

72 CriticalCareNurse Vol 38, No. 6, DECEMBER 2018 www.ccnonline.org

www.ccnonline.org CriticalCareNurse Vol 38, No. 6, DECEMBER 2018 73

manual versus automated screen-

ing.5,15-17 A recent review paper,18

which summarized the literature

on the identifi cation of patients with

sepsis on hospital wards, noted

that although automated screening

decreases time to diagnosis and

intervention for sepsis, the mortal-

ity benefi t has been mixed and the

most accurate screening tools (sin-

gle time or automated) remain to

be identifi ed.

Case Study
A 48-year-old woman was trans-

ferred to the acute care surgical unit

after gastric conduit surgery on post-

operative day 2. She experienced

multiple minor regurgitation events

and aspiration of gastric contents.

Assessment on postoperative day 5

showed disorientation, anxiety, pull-

ing at catheters, heart rate 110/min,

respiratory rate 30/min, blood pres-

sure 86/60 mm Hg (mean 65 mm Hg

via noninvasive blood pressure

measurement), and normal body

temperature. The cause for these

symptoms was thought to be delir-

ium from receiving a combination

of benzodiazepines and opioids.

Yellow fl uid draining from the jeju-

nostomy site was attributed to bili-

ary drainage. Blood and surgical

site samples were cultured; no

other laboratory samples were col-

lected and antibiotics were not

administered. The patient’s condi-

tion deteriorated and the rapid

response team was called, after

which the patient was transferred

to the ICU. Sepsis was then recog-

nized, and the bundle elements

were initiated. Unfortunately, these

actions had been delayed, and the

patient could not be resuscitated

from septic shock.

Discussion
The case study illustrates the

challenge in differentiating sepsis

from other disorders, resulting in a

delay in implementing potentially

lifesaving interventions. Examine

the data gathered on postoperative

day 5—did the patient have indica-

tions of end-organ dysfunction? Yes

(mental status change, tachypnea,

hypotension: qSOFA score = 3). Did

the patient have indications (or risk)

for infection? Yes, aspiration and

possible wound infection or leak-

age. At this point (positive qSOFA

with risk of infection), further

assessment of the patient for sepsis

Table 1 Quick Sequential Organ Failure Assessment (qSOFA) score1,2

Systolic blood pressure ≤ 100 mm Hg
Respiratory rate ≥ 22/min
Any change in mental status

Each parameter is scored as 1 point, for a total of 0-3. For patients outside the
intensive care unit with a suspected infection, a score of ≥ 2 indicates an increased
risk for a prolonged stay in the intensive care unit or death.

Table 2 Sequential Organ Failure Assessment (SOFA) score4

Respiration: PaO2/FIO2 (P/F)

Coagulation: Platelet count, 103/μL

Liver: Bilirubin, mg/dL

Cardiovascular: Blood pressure and vasopressor use

Central nervous system: Score on Glasgow Coma Scale

Renal: Creatinine, mg/dL, or urine output < 500 mL/d

Points are assigned based on abnormality of each parameter. For example, a P/F
ratio of 400 is scored as a 0, < 300 as a 2, and < 100 as a 4. An online SOFA score calculator is available at www.mdcalc.com/sequential-organ-failure-assessment -sofa-score.

Table 3 General considerations for SIRS, qSOFA, and SOFA scores

SIRS

q

SOFA

SOFA

Indication of infl ammation
Not a specifi c indicator of sepsis—other causes of infl ammation1

47% of non-ICU patients were SIRS positive during hospitalization11

Sole dependence on SIRS criteria may miss 1 in 8 patients with sepsis12

The presence of SIRS should alert the clinician to the need for additional
assessment, as these signs may precede clinical deterioration.

Recommended for use in non-ICU patients as indicator of risk for prolonged
ICU stay and mortality1-3

Not a diagnostic tool to rule out sepsis
Positive qSOFA suggests the presence of organ dysfunction that requires

additional evaluation

Used in ICU to evaluate end-organ dysfunction4

Accurate predictor of in-hospital mortality in ICU patients1

In the presence of infection, an increase in SOFA score by > 2 points
(indicating worsening end-organ function) is diagnostic of sepsis

Abbreviations: ICU, intensive care unit; SIRS, systemic infl ammatory response syndrome; qSOFA, Quick
Sequential Organ Failure Assessment; SOFA, Sequential Organ Failure Assessment.

www.ccnonline.org

should have been undertaken,

including evaluating for other

causes of end-organ dysfunction.

This case demonstrates the need

to maintain constant vigilance for

sepsis and the potentially beneficial

use of a systematic process to iden-

tify patients at risk for sepsis. In the

absence of a single test or tool to

detect sepsis definitively, patients at

risk depend on the astute assessment

of the bedside nurse to recognize

the significance of a change in their

condition. For further information,

access the AACN website19 for

Resources for Sepsis. ���

Financial Disclosures
None reported.

References
1. Seymour CW, Liu VX, Iwashyna TJ, et al.

Assessment of clinical criteria for sepsis:
for the Third International Consensus Defi-
nitions for Sepsis and Septic Shock (Sepsis-3).
JAMA. 2016;315(8):762-774.

2. Shankar-Hari M, Phillips GS, Levy ML, et al.
Developing a new definition and assessing
new clinical criteria for septic shock: for the
Third International Consensus Definitions
for Sepsis and Septic Shock (Sepsis-3).
JAMA. 2016;315(8):775-787.

3. Singer M, Deutschman CS, Seymour CW,
et al. The Third International Consensus
Definitions for Sepsis and Septic Shock
(Sepsis-3). JAMA. 2016;315(8):801-810.

4. Vincent JL, Moreno R, Takala J, et al. The SOFA
(Sepsis-related Organ Failure Assessment)
score to describe organ dysfunction/failure.
Intensive Care Med. 1996;(11)22:707-710.

5. Rhodes A, Evans LE, Alhazzani W, et al.
Surviving Sepsis Campaign: international
guidelines for management of sepsis and
septic shock: 2016. Crit Care Med. 2017;45(3):
486-552.

6. Vincent JL, Martin GS, Levy MM. qSOFA
does not replace SIRS in the definition of
sepsis. Crit Care. 2016;20(1):210.

7. Franchini S, Duca A. qSOFA should replace
SIRS as the screening tool for sepsis [com-
ment]. Crit Care. 2016;20(1):409.

8. Sprung CL, Schein RM, Balk RA. To SIRS
with love—an open letter. Crit Care Med.
2017;45(4):736-738.

9. Singer M, Shankar-Hari M. qSOFA, cue con-
fusion. Ann Intern Med. 2018;168(4):293-295.

10. Sartelli M, Kluger Y, Ansaloni L, et al. Rais-
ing concerns about the Sepsis-3 definitions.
World J Emerg Surg. 2018;13:6.

11. Churpek MM, Zadravecz FJ, Winslow C,
Howell MD, Edelson DP. Incidence and
prognostic value of the systemic inflamma-
tory response syndrome and organ dysfunc-
tions in ward patients. Am J Respir Crit Care
Med. 2015;192(8):958-964.

12. Kaukonen KM, Bailey M, Pilcher D, Cooper
DJ, Bellomo R. Systemic inflammatory
response syndrome criteria in defining severe
sepsis. N Engl J Med. 2015;372(17):1629-1638.

13. Haydar S, Spanier M, Weems P, Wood S,
Strout T. Comparison of qSOFA score and
SIRS criteria as screening mechanisms for
emergency department sepsis. Am J Emerg
Med. 2017;35(11):1730-1733.

14. Freund Y, Lemachatti N, Krastinova E, et al.
Prognostic accuracy of Sepsis-3 criteria for
in-hospital mortality among patients with
suspected infection presenting to the emer-
gency department. JAMA. 2017;317(3):
301-308.

15. Scott MC. Defining and diagnosing sepsis.
Emerg Med Clin North Am. 2017;35(1):1-9.

16. Makic MB, Bridges E. Managing sepsis and
septic shock: current guidelines and defini-
tions. Am J Nurs. 2018;18(2):34-39.

17. Napolitano LM. Sepsis 2018: definitions
and guideline changes. Surg Infect. 2018;
19(2):117-125.

18. Bhattacharjee P, Edelson DP, Churpek MM.
Identifying patients with sepsis on the hos-
pital wards. Chest. 2017;151(4):898-907.

19. AACN website. Resources for Sepsis. 2018.
https://www.aacn.org/clinical-resources
/sepsis?page=1. Accessed August 6, 2018.

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American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author.

Degelman, D. (2009). APA style essentials. Retrieved from http://www.vanguard.edu/faculty/ddegelman/index.aspx?doc_id=796

Garrity, K., & Degelman, D. (1990). Effect of server introduction on restaurant tipping. Journal of Applied Social Psychology, 20, 168-172. doi:10.1111/j.1559-1816.1990.tb00405.x 

Hien, D., & Honeyman, T. (2000). A closer look at the drug abuse-maternal aggression link. Journal of Interpersonal Violence, 15, 503-522. Retrieved from http://jiv.sagepub.com/

Murzynski, J., & Degelman, D. (1996). Body language of women and judgments of vulnerability to sexual assault. Journal of Applied Social Psychology, 26, 1617-1626. doi:10.1111/j.1559-1816.1996.tb00088.x 

Nielsen, M. E. (n.d.). Notable people in psychology of religion. Retrieved from http://www.psywww.com/psyrelig/psyrelpr.htm

Paloutzian, R. F. (1996). Invitation to the psychology of religion (2nd ed.). Boston: Allyn and Bacon.

Shea, J. D. (1992). Religion and sexual adjustment. In J. F. Schumaker (Ed.), Religion and mental health (pp. 70-84). New York: Oxford University Press.

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