Page 106 Complete Your CE Test Online - Click Here Quick SOFA screening tool A screening tool, called the quick SOFA (qSOFA), was developed to be used at the bedside to quickly identify patients who may have infection. A positive qSOFA in a patient who otherwise was not believed to have infection should be a red flag to the clinician to suspect infection. This tool does not require the use of blood draws or other predictive measures, and it may be used at the bedside as often as necessary. The qSOFA criteria include presence of the following (Singer et al., 2016): ● ● Respiratory rate greater than or equal to 22 breaths per minute. ● ● Altered mentation: Changes in the Glasgow Coma Scale may be used here. ● ● Systolic blood pressure less than 100 mmHg. EBP alert! A recent study compared the qSOFA tool to the previously used SIRS tool in patients who entered the emergency department with suspected infection. The qSOFA tool was found to be have greater prognostic accuracy than the formerly used SIRS tool had (Freund et al., 2017). Key points ● ● The SOFA scoring system helps to predict mortality for patients with sepsis and other conditions that lead to multiple organ dysfunction syndrome. ● ● The SOFA scoring system takes into account abnormalities in the respiratory system, cardiovascular system, hepatic system, coagulation system, neurologic system, and renal system. ● ● The qSOFA scoring system is used as a quick screening tool that can be used frequently at the bedside and does not require invasive testing. ● ● The qSOFA takes into account the patient’s respiratory rate, cognitive status, and blood pressure. Nursing consideration: Nurses should utilize the qSOFA screening tool at regular intervals to evaluate patients. They should report a positive qSOFA score promptly in any patient! The qSOFA tool can be useful in identifying patients with an unknown infection or identifying those patients with suspected infection who may have a poor outcome. Self-evaluation: Question 4 Which of the following statements is false in regards to the SOFA scoring system? a. The lower the bilirubin level, the higher the SOFA score. b. Decreased urine output or an increased creatinine level correlates to a higher SOFA score. c. The SOFA score is considered to be 0 at baseline unless a patient has known organ dysfunction before infection. d. The SOFA score is used to predict the likelihood of death in the patient with sepsis. Surviving Sepsis Campaign recommendations for screening and management The Surviving Sepsis Campaign (SSC) was formed in 2002 in an effort to raise awareness and decrease mortality from sepsis. The focus of the SSC is to educate clinicians and to provide a set of recommended care guidelines to improve diagnosis and care for the patient with sepsis. The SSC recommends the following screening and management tools for sepsis (2016). Step 1: Screening and management of infection ● ● Identify infection: Look for signs and symptoms of infection. ● ● Manage infection: Obtain blood and other cultures as indicated. Administer antibiotics while simultaneously reviewing laboratory results to screen for infection-related organ dysfunction. Step 2: Screening for organ dysfunction and management of sepsis Identify organ dysfunction: Organ dysfunction should be identified using lactate levels > 2 mmol/L and the quick Sepsis-Related Organ Failure Assessment (qSOFA). Organ dysfunction may also be present if the following is present: ● ● Significantly decreased urine output. ● ● Abrupt change in mental status. ● ● Decrease in platelet count. ● ● Difficulty breathing. ● ● Abnormal heart function. ● ● Abdominal pain. Management: If organ dysfunction has been identified, begin the three-hour bundle recommendations (see below). Patients still need blood cultures if only nonblood cultures (sputum, urine, wound) were previously obtained. In addition, patients should be given a broad-spectrum antibiotic if previously given only narrow-spectrum antibiotics. Step 3: Identification and management of initial hypotension ● ● Identify patients with infection and hypotension: Patients with infection and hypotension (< 100 mmHg) or a lactate level > 4 mmol/L, should be provided an infusion of crystalloids at a dose of 30 mL/kg. ● ● Management of hypotension: The clinician should reassess volume responsiveness or tissue perfusion after infusion begins. The six- hour bundle should be implemented. Surviving Sepsis Campaign bundle recommendations (three and six hour) The SSC bundle recommendations as of 2015 are as follows. Three-hour bundle (To be completed within three hours of presentation). ● ● Measure lactate level. ● ● Obtain blood cultures before administration of antibiotics. ● ● Administer broad-spectrum antibiotics. ● ● Administer 30 ml/kg crystalloid for hypotension or lactate ≥ 4 mmol/L. Time of presentation is defined as the time of triage in the emergency department or, if presenting from another care venue, from the earliest chart annotation consistent with all elements of sepsis or septic shock ascertained through chart review. EBP alert! Serum lactate levels are measured in the first 3 hours of presentation. Higher serum lactate levels are associated with an increase in mortality, helping to identify patients at risk for a poor outcome (Mikkelsen et al., 2009). Six-hour bundle (to be completed within six hours). ● ● Administer vasopressors for hypotension that does not respond to initial fluid resuscitation to maintain a mean arterial pressure (MAP) ≥ 65 mmHg. ● ● In the event of persistent hypotension after initial fluid administration (mean arterial pressure (MAP) < 65 mmHg) or if initial lactate was ≥ 4 mmol/L, reassess volume status and tissue perfusion and document findings. ● ● Remeasure lactate if initial lactate is elevated. Document reassessment of volume status and tissue perfusion with either repeat focused exam (after initial fluid resuscitation), including vital signs, cardiopulmonary, capillary refill, pulse, and skin findings, or two of the following: ○ ○ Measure central venous pressure (CVP). ○ ○ Measure ScvO2. ○ ○ Bedside cardiovascular ultrasound. ○ ○ Dynamic assessment of fluid responsiveness with passive leg raise or fluid challenge.