Improving Identification and Management of Sepsis in Outpatient Settings

Laura M. Cascella, MA, CPHRM

Sepsis is a debilitating, life-threatening, and costly condition that represents a persistent challenge to healthcare providers in terms of early diagnosis and management. Although sepsis is a leading cause of death in the United States¹ and a significant burden on patients and healthcare organizations, knowledge about — and recognition of — the condition is still problematic among many healthcare professionals and the public.

Various factors may contribute to lack of sepsis awareness and delays in diagnosis. First, the terms and definitions associated with sepsis have changed over the years, and lack of standardization has led to multiple definitions in use at the same time. Additionally, identification criteria associated with the terminology and definitions also have varied.²

Second, the early signs and symptoms of sepsis are indicative of a variety of other illnesses and conditions, and the progression of the condition can vary based on the site of infection, the pathogen, and individual factors. In short, sepsis can look like many other conditions, and it can look different among individuals.

Third, clinicians cannot definitively diagnose sepsis based on lab results alone. Although lab tests and cultures play a role in diagnosing sepsis — for example, confirming an infection — clinicians must consider a combination of clinical and laboratory findings to make a diagnosis.⁴

Despite these barriers, early diagnosis and prompt treatment of sepsis are crucial for saving lives and preventing long-term morbidity. A treatment delay of even just 6 hours worsens the prognosis, and the risk of mortality increases 7.6 percent each hour that antimicrobial treatment is delayed.⁵ In a publication on the early detection of sepsis, the Patient Safety Movement states:

It has become increasingly apparent that there is a long delay in both the recognition of sepsis and the initiation of appropriate therapy in many patients. This translates into an increased incidence of progressive organ failure and a higher mortality. Healthcare providers, therefore, need to have a high index of suspicion for the presence of sepsis and must begin appropriate interventions quickly.⁶

Although sepsis often is first identified in the hospital setting, data suggest that about 8 in 10 patients have the condition before entering the emergency department or hospital — and an evaluation by the Centers for Disease Control and Prevention found that many of these patients had recently used healthcare services or have conditions that require frequent medical care.⁷ These statistics, in combination with the knowledge that sepsis is a medical emergency that requires quick action, point to the need for better identification of sepsis risk factors in outpatient settings.

Healthcare providers who work in healthcare practices, clinics, and other ambulatory care settings can implement various risk management strategies to increase understanding about sepsis and promote early recognition and action. Examples of these strategies include the following:⁸

• Educate clinical staff about common infections associated with sepsis, such as urinary tract infections, pneumonia, abdominal infections, skin/soft tissue infections, and postpartum endometritis.
• Raise awareness about patient populations that are at increased risk for sepsis, such as:
  • Geriatric patients
  • Patients who are immunocompromised
  • Patients who have cancer
  • Patient who have cirrhosis
  • Patients who have asplenia
  • Patients who have neutropenia
• Discuss the various pathogens associated with the common infections that can lead to sepsis as well as the potential signs and symptoms linked to each. Also, educate clinical staff about potential atypical symptoms in high-risk patients, such as altered mental state in geriatric patients.
• Make sure that patients, families, and caregivers are active partners in sepsis recognition and prevention by providing clear, easy-to-understand information that explains what sepsis is, the potential signs and symptoms of sepsis, and how to act quickly.
• Make sure that patients, families, and caregivers understand the importance of taking antibiotics exactly as prescribed and only when indicated to prevent issues related to antibiotic resistance.
• Implement an early warning tool or scoring system — such as the Quick Sequential Organ Failure Assessment (qSOFA) or Systemic Inflammatory Response Syndrome (SIRS) screening — to evaluate patients who have infections or suspected infections and identify which patients might be at risk for sepsis. Although both qSOFA and SIRS have limitations, they still can provide a useful framework for screening.
• Implement a protocol for providers to follow if screening criteria for sepsis are met (i.e., a sepsis bundle). The protocol should delineate next steps to take, including assessing for the source of infection; ordering blood cultures, lactate cultures, and other tests as needed (e.g., urine or wound cultures); and determining whether the patient needs to be admitted to a hospital. Ensure that providers receive training and education on the organization’s sepsis protocol.
• Consider whether sepsis screening tools that integrate with electronic health record systems might be beneficial, particularly in practices that see patients who are at increased risk for sepsis (e.g., oncology practices).

The significant toll of sepsis on patients and healthcare organizations signals the importance of continuing to increase awareness and understanding about the condition. With appropriate knowledge, tools, and protocols, providers in outpatient healthcare settings are in a unique position to increase early identification and management of sepsis, which can ultimately save lives and reduce the costly burden of this condition. For more resources and information, see MedPro’s Risk Resources: Sepsis, the Sepsis Alliance website, and the Surviving Sepsis Campaign® website.

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¹ MacDonald, A. (2019, December 4). Detecting sepsis early. Technology Networks. Retrieved from www.technologynetworks.com/diagnostics/blog/detecting-sepsis-early-327999

² Ibid.

³ Singer, M., Deutschman, C. S., Seymour, C. W., Shankar-Hari, M., Djillali, A., Bauer, M., . . . Angus, D. C. (2016). The third international consensus definitions for sepsis and septic shock (sepsis-3). Journal of the American Medical Association, 315(8), 801–810. doi:10.1001/jama.2016.0287

⁴ MacDonald, Detecting sepsis early.

⁵ Virkstis, K. (2018, April 18). The 3 keys to a best-in-class sepsis prevention strategy. Advisory Board. Retrieved from www.advisory.com/daily-briefing/2018/04/18/sepsis-prevention

⁶ Patient Safety Movement. (2016, April). Actionable Patient Safety Solution (APSS) #10: Early detection of sepsis. Retrieved from http://patientsafetymovement.org/wp-content/uploads/2016/02/10-Sepsis-April-2016.pdf

⁷ Virkstis, The 3 keys to a best-in-class sepsis prevention strategy; Centers for Disease Control and Prevention. (2016, August). Making health care safer: Think sepsis. Time matters. CDC Vital Signs. Retrieved from www.cdc.gov/vitalsigns/pdf/2016-08-vitalsigns.pdf

⁸ Virkstis, The 3 keys to a best-in-class sepsis prevention strategy; Sanders, A. (2016). Early recognition of sepsis: An opportunity in the outpatient setting. AQIN Community Based Sepsis Initiative. Retrieved from https://atlanticquality.org/download/AQIN_Community_Based_Sepsis_Webinar_06-16-16.pdf; Handzel, S. (2016, December 14). Early sepsis recognition in outpatient settings: Challenges and progress. Oncology Nursing News. Retrieved from www.oncnursingnews.com/publications/oncology-nurse/2016/december-2016/early-sepsis-recognition-in-outpatient-settings-challenges-and-progress; Patient Safety Movement, Actionable Patient Safety Solution (APSS) #10; MacDonald, Detecting sepsis early.

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