By Debra Wood, RN, contributor
Fewer patients are dying of septic and hemorrhagic shock these days at Good Samaritan Hospital. Nurses at the San Jose, California, facility have learned to identify early signs and symptoms of impending shock and sound a Shock Alert.
“Our raw data shows we’ve had a reduction in mortality,” said Susan Scollan-Boring, RN, MS, CNS, nurse leader for the shock protocol team at Good Samaritan. “There are probably at least 25 or 30 patients, out of the 65 patients we had in the first year, who probably would not have survived if they had not been recognized early. These are relatively young people in their 40s with meningococcal meningitis or Strep pneumonia, pretty serious things.”
Good Samaritan began the program in January 2004, after intensive care nurses and intensivists recognized and called leadership attention to the fact that the shock process started six to 24 hours before most patients were transferred to the unit. They felt that earlier intervention would improve outcomes, and it has.
Clinicians reviewed research pioneered by Emanuel P. Rivers, M.D., at Henry Ford Hospital, in Detroit, Michigan and published in The New England Journal of Medicine in 2001. Rivers showed that patients receiving early, aggressive treatment of sepsis and septic shock had a lower incidence of organ failure, spent less time on a ventilator and survived more often than patients in the control group receiving standard care.
Scollan-Boring called Good Samaritan’s implementation of a similar protocol “classic evidence-based research put into practice.”
Before launching the shock team, Good Samaritan provided hospital-wide education to nurses and physicians. Leaders prepared physicians to expect, in the beginning, that nurses may call the alert more often than necessary, but said it rarely happened.
“We didn’t want any nurses to start second guessing when they needed to call it,” said Julie Clayton, RN, MSN, chief nursing officer at Good Samaritan. “When they jumped the gun or didn’t understand the criteria, it gave the team a good opportunity for some more education.”
Nurses at the 360-bed hospital use systemic inflammatory response syndrome criteria, developed by the American College of Chest Physicians, to identify patients in need of intervention. Without waiting for an order, nurses call an overhead Shock Alert page to mobilize the shock team, composed of two critical care nurses, an emergency room physician, two lab technicians, a respiratory therapist, a nursing supervisor, X-ray and electrocardiogram technicians and a shock cart.
The team draws on guidelines based on Rivers’ early goal-directed therapy, which are similar to the Society of Critical Care Medicine’s guidelines. Protocols include rapid fluid resuscitation, oxygenation, antibiotics within one hour for septic shock, vasopressors, stress-dose corticosteroids, tight glycemic control, and rapid transfer to the intensive-care unit, if appropriate.
“We know we have cut our rapid infusion time in half,” Clayton said.
Most of Good Samaritan’s cases are septic shock, but some are gastrointestinal or other bleeds. For the most part, the protocol remains the same.
“Shock is basically a lack of perfusion at the cellular level.” Scollan-Boring said. “It doesn’t really matter what causes the shock. If you have a lack of perfusion, it will set off an incredible inflammatory response.”
That lack of perfusion affects every body system. For instance, cellulitis left untreated can lead to necrotic bowel due to lack of perfusion in the intestines.
Good Samaritan adapted the protocol to manage labor and delivery patients experiencing rapid blood loss.
“We rarely have that happen, but when it happens, it’s a huge emergency,” Clayton said. “Even a few minutes can make a difference in patient outcomes.”
The shock cart in the maternity suite includes surgical instruments used to stop a postpartum hemorrhage. An operating room nurse also responds to pass surgical instruments to the physician.
Clayton considers modifying the protocol for labor and delivery a good example of how a facility can take one rapid-response process and tailor it to the special needs of different units.
“We’re looking now at where else we can [use] rapid-response teams,” Clayton said.
The hospital continues to investigate the shock team’s effect on mortality, length of stay and cost. It could not enroll a control group, but instead is using a retrospective chart review, comparing results from patients cared for before the program started who would have met the criteria for care by the shock team and those who received actual care from the shock team.
“The part I think has been most successful is it really empowers the nurses to use their critical thinking skills and really look at what their patients need,” Scollan-Boring said. “And if they feel their patient needs help, they have a way of getting it. It’s been well supported by the nursing staff and raised the bar.”
© 2005. AMN Healthcare, Inc. All Rights Reserved.
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