Page 135 Complete Your CE Test Online - Click Here ● ● Coagulation system: Platelet concentration is measured. A lower platelet level corresponds with a higher SOFA score. ● ● Neurologic system: The Glasgow Coma score is used to evaluate the neurologic system. The lower the Glasgow Coma score, the higher the SOFA score. ● ● Renal system: The serum creatinine or urine output is measured. An increased creatinine level correlates to a higher SOFA score. Decreased urine output correlates to a higher SOFA score. A patient with a SOFA score greater than or equal to 2 is considered to be in a life-threatening situation with a mortality rate of greater than or equal to 10% (Singer et al., 2016). A patient with a SOFA score greater than or equal to 2 and who requires vasopressor therapy and has an elevated lactate level > 2 mmol/L despite fluid resuscitation has a mortality rate of 40% (Singer et al., 2016). The patient’s baseline SOFA score should be 0 unless the patient has known organ dysfunction before the onset of infection (Singer et al., 2016). 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