Sepsis Protocol for Nurses

by | Jul 27, 2023 | Critical Care | 0 comments

When you’re a fresh face in the ICU, understanding sepsis and knowing how to respond quickly can truly be a game-changer for our patients. As someone who’s been around the block in critical care, I’m excited to share some valuable insights and practical tips that will help you navigate the challenges of sepsis like a pro. So, grab your coffee ☕️ take a seat 🪑and let’s dive into a sepsis protocol for nurses. We’ll begin with some definitions, go through a sample protocol peppered with additional context, and even outline a theoretical patient example. Let’s get started! 🌟

gloved hand hand holding IV bag, sepsis protocol for nurses

Important disclaimer ➡️ The best evidence for sepsis changes rapidly. I highly, highly encourage you to view your hospital’s latest policy and protocols as it relates to the care of sepsis. Look closely at their references for the policy to learn more. This post is a general explanation and sample and it does not necessarily reflect the latest most appropriate clinical pathways for the treatment of sepsis. The information contained in this post should be not utilized to guide patient care.

Another important point ➡️ This is all about the care of adults. This is not applicable to children or infants.

Definition of Sepsis

Let’s begin with getting on the same page with what I mean when I use the word, “sepsis”.

Sepsis is a life-threatening medical condition that arises when the body’s response to infection causes widespread inflammation. The body is exposed to a pathogen, and for some reason, the immune response is WAY MORE than it needs to be. It’s as if instead of lightly stepping on the gas pedal to move forward at a predictable and safe pace, there has been a concrete block thrown on the gas pedal – and we can’t stop it.

It can lead to organ dysfunction or failure and, if not promptly treated, can progress to septic shock, a severe form of sepsis with low blood pressure and poor tissue perfusion. Sepsis can affect people of all ages and can be caused by various infections, including bacterial, viral, fungal, or parasitic.

It can be difficult to predict who will develop this or figure our why. The key is early recognition and treatment.

Definition of a Sepsis Protocol for Nurses

A sepsis protocol for nurses is a standardized set of guidelines and procedures developed by healthcare institutions to help nurses and other medical professionals recognize, diagnose, and manage sepsis effectively and promptly in a standardized way. The goal of a sepsis protocol is to initiate appropriate interventions promptly to improve patient outcomes and reduce mortality rates associated with sepsis.

This means that if a septic patient gets admitted at 0400 by Dr. Smith, and another patient gets admitted at 1600 by Dr. Jones, both will receive similar care that is based on evidence to give both patients the best possible chance at a positive outcome. The physicians order it, but the nurses administer it. That’s why we’re calling it a sepsis protocol for nurses!

Sample Sepsis Protocol

Let’s say you’re a new nurse working in an intensive care unit and you hear your preceptor and the intensivist say they’re concerned that the patient is septic. The next thing you know, the doc has put in in an order for the sepsis protocol. Let’s walk through what steps could be on that protocol.

Note: Throughout the entire time, we should be communicating with the patient and their loved one about what we’re doing and why.

Step 1: Suspect Sepsis

  • Look for signs of infection (e.g., fever, elevated white blood cell count, purulent discharge).
  • Identify any underlying risk factors (e.g., immunosuppression, chronic illnesses, recent surgery).

Step 2: Recognize Sepsis

Use qSOFA criteria:

  • Altered mental status?
  • Low blood pressure (SBP ≤ 100 mmHg)?
  • Rapid respiratory rate (≥ 22 breaths per minute)?

Step 3: Alert the Medical Team

  • Let the physician know immediately, or if appropriate, the rapid response team

Sometimes this situation unfolds slowly as the nursing and medical team are realizing certain criteria are met. The patient may be a bit more lethargic, a lower blood pressure than normal, and steadily increasing their respiratory rate. Other times, it’s a sudden change and the patient is now unresponsive with a MAP of 50.

Step 4: Obtain Key Samples

  • Draw blood cultures before administering antibiotics.
    • Drawn from a two peripheral blood sticks
    • Aerobic and anaerobic cultures
  • Obtain other relevant cultures (urine, wound, sputum) as indicated.
  • You likely will also need to get a complete blood count, liver function tests, chemistry, lactic acid, coagulation studies, D-Dimer, procalcitonin, ABG, and possibly imaging (like a chest x-ray, CT, etc. if necessary to assess a possible infection site).
    • These will let you know how severe it is and how much it is impacting the patient’s various body systems and support the diagnosis.
    • The specific ones you will be required to get will be on your protocol, and the ordering physician may add more.

It is imperative to obtain these samples prior to starting antibiotic therapy so that we know what pathogen we’re dealing with and can therefore give the correct antibiotic.

Step 5: Start Empiric Antibiotic Therapy

Arguably the most important step of this protocol is starting antibiotic therapy. In a perfect world, we would know exactly what pathogen is hurting our patient, but that’s not reality.

The blood cultures we chatted about in Step 4 are key here. We need to draw those immediately, but they need time to grow. The time varies depending upon laboratory’s processing time, the type of organism being tested for, the growth rate of the microorganism, and the specific blood culture system used. On average, it typically takes around 24 to 48 hours to obtain preliminary results from blood cultures. Some organisms take longer to grow, and in some cases take up to 72 hours to to be finalized!

We simply cannot wait three days to start antibiotics on these patients, so the physicians and pharmacists need to make a solid guess based upon the clinical picture to get them started immediately, and then change it up if needed.

Broad Spectrum vs. Empiric

You possibly have heard the term “broad-spectrum antibiotics” and are thinking that’s what should be indicated here. Not so much. Rather, we will use something called “empiric antibiotic therapy”. While they seem like they’d be interchangeable and mean the same thing – they don’t.

Empiric antibiotic therapy is an antibiotic that is effective against the most common bacteria responsible for the type of infection the patient likely has. This is common in situations where a quick response is crucial, such as in severe infections or when diagnostic results may take some time to be available.

On the other hand, broad-spectrum antibiotics are a specific class of antibiotics that are effective against a wide variety of bacteria, including both Gram-positive and Gram-negative bacteria. These antibiotics have a broader range of activity compared to narrow-spectrum antibiotics which are effective against a more limited group of bacteria.

In many cases, empiric antibiotic therapy involves the use of broad-spectrum antibiotics because they cover a wide range of potential pathogens until more specific information is available about the causative agent. However, not all broad-spectrum antibiotics are used exclusively for empiric therapy, as they may also be chosen for targeted therapy in certain situations.

Give Those Antibiotics STAT!

“The cornerstone of initial resuscitation is the rapid restoration of perfusion and the early administration of antibiotics.” [SOURCE]

Your goal is to get your antibiotic therapy initiated with one hour after this protocol has been enacted.

Step 6: Supportive Care

We need to get oxygen to those tissues! To so do, you will:

  • Administer IV fluids to maintain adequate blood pressure and tissue perfusion.
  • Provide respiratory support if needed (e.g., supplemental oxygen, mechanical ventilation).
  • For septic shock, initiate vasopressor therapy to maintain blood pressure.

Your goal will be to keep their hemodynamic status stable. This may include measuring their cardiac output, SCVo2, central venous pressure, mean arterial pressure, and/or urinary output. To do this, you may need fluids, vasopressors, or both.

Intravascular hypovolemia is common and might require rapid fluid resuscitation. The evidence on which to do first (blood pressure drips vs. fluid resuscitation) and what type of fluid (crystalloid vs. albumin, hydroxyethyl, salt solutions, pentastarch) varies quite a bit and is constantly evolving.

Step 7: Monitor and Reassess

  • Continuously monitor vital signs, including blood pressure, heart rate, respiratory rate, and oxygen saturation.
    • Your facility may have more advanced monitoring options (like cardiac output) that are part of your sepsis algorithm
  • Monitor urine output and kidney function.
  • Monitor mental status.
  • Monitor intravenous access sites, as large fluid resuscitation and vasoactive drips are hard on blood vessels (and may require placement of a central line)
  • Reassess the patient’s response to treatment and adjust interventions accordingly.

If you want me to break down ICU drips in a more digestible and understandable way, check out my free mini-course, ICU Drips for Beginners.

Depending on the situation and how the patient responds, you may also have to administer blood products, inotropic therapy (dobutamine, epinephrine), glucocorticoids, initiate stress ulcer prophylaxis, antipyretics, intensive insulin therapy, and more.

Your hospital’s sepsis protocol likely has indicators for starting any of the previously mentioned interventions. For example, for a blood sugar over 300, they may require an insulin drip. Often, blood sugar levels do increase when the body is stressed, so therefore it is not uncommon for this to happen!

Step 8: De-escalate Therapy When Appropriate

If the patient has responded to interventions, then we focus more on controlling that specific infection and back-off of all of the fluids and vasopressors.

  • Once infection source is identified, adjust antibiotics accordingly
    • A consult to Infectious Disease (ID) may be warranted to ensure the appropriate regimen is selected, that we are decreasing the likelihood for antibiotic resistance, and optimizing the duration of therapy for this unique patient
  • If hemodynamic status is stable, wean drips and decrease fluid

We don’t want to send patients into fluid overload. Some may even require diuretics therapy due to the volume of fluids that are often administered. If you push forward on intense fluid and administration, patients can develop cardiogenic shock and noncardiogenic pulmonary edema.

Sepsis Protocol For Nurses – Patient Example

Let’s consider a theoretical patient named Mr. Smith, a 65-year-old male with diabetes who was admitted to the ICU with pneumonia. Mr. Smith develops a high fever, increased heart rate, and low blood pressure. Erika, the nurse, suspects sepsis due to his infection and underlying risk factors. Erika immediately informs Dr. Jones, who assesses the patient himself and agrees. He orders the sepsis protocol to be initiated.

Erika lets her charge nurse, Marc, know that this has been ordered and he begins gathering supplies. She first communicates with Mr. Smith and his wife about what they suspect is happening, and that a lot of things are about to happen very quickly.

Erika draws blood cultures before she does anything else because, well, she’s amazing.

While she’s doing that, Marc draws many other labs (CBC, LFTs, CMP, lactic acid, PTT, PT, D-Dimer, and procalcitonin). The respiratory therapist comes into the room to draw an ABG. Soon, radiology is in the room for an x-ray.

Once Erika draws those labs and sends them off, she runs to the med room to get the antibiotics that just arrived from the pharmacy. She gets that started, and while she’s doing that, Marc gets another IV (for fluids and just to have another point of access).

Upon the physician’s assessment, sepsis is confirmed, and antibiotics are ordered promptly. Mr. Smith is given IV fluids to maintain his blood pressure, and oxygen supplementation is initiated to support his respiratory function. The nurse closely monitors Mr. Smith’s response to treatment and adjusts interventions as needed.

As the treatment progresses, Mr. Smith’s blood sugar levels start to rise significantly due to the stress response caused by the infection. Erika notices this during her regular monitoring and immediately informs Dr. Jones. To address the hyperglycemia, Dr. Jones orders the initiation of an insulin drip to help control Mr. Smith’s blood sugar levels.

After Erika has started his insulin drip, she notices his blood pressure is continuing to decrease despite fluids being given. Part of the protocol is to start a noreepinephrine (Levophed) drip if his mean arterial pressure went below 65. Erika pulls a bag of “Levo” from the med room and initiates the drip.

She then notifies Dr. Jones, who decides to insert a central line. Erika assists him during that procedure (Marc is checking on her other patient for her) and then uses sterile technique to apply a central line dressing. She then gets brand new tubing for all of her IV medications and connects them to his central line.

(She keeps the other two functioning IVs in place for now, just in case.)

For the rest of her shift, Erika is busy charting, titrating drips, and reassessing Mr. Smith.

Over the next 24 hours, his blood pressure stabilizes and mental status improves dramatically. He is switched from an insulin drip to sliding scale, and weaned off of his levophed drip. The blood cultures come back and his antibiotics are changed to be more targeted.

Thanks to the quick response from Erika and his improvement, he is stable enough to be transferred out of ICU and to the med-surg unit.

Resources For Nurses on Sepsis Care

To stay up-to-date with the latest guidelines and advancements in sepsis management, ICU nurses can refer to the Society of Critical Care Medicine (SCCM) website. SCCM provides valuable resources, educational materials, webinars, and updates on sepsis protocols and best practices.

Additionally, the American Association of Critical Care Nurses (AACN) is a phenomenal resource specifically for critical care nurses. They have journal articles, case studies, CE activities, books, and more that discuss nursing care of septic patients.

I also highly encourage all critical care nurses to check out the Walking Home From the ICU Podcast by Kaley Dayton, DNP AGACNP who is a critical care nurse practitioner with a passion for educating and inspiring ICU nurses to provide the best care possible. (And I really recommend starting with Episode 1.)

If you’re a brand new ICU nurse and need a more comprehensive brush-up on pathophysiology, diagnostics, meds, interventions, and more. Check out my crash course for new ICU nurses.

Remember, sepsis management is a dynamic field, and it’s essential to stay informed about the latest evidence-based practices to provide the best care for septic patients.

Resources For Sepsis Survivors and Families

If you’re reading this and are someone who experienced sepsis, there are amazing groups out there to support you.

Sepsis Alliance: Sepsis Alliance is a nonprofit organization that raises awareness about sepsis. They provide information, support, and resources for sepsis survivors and their families. They offer educational materials, webinars, and online support groups.

Surviving Sepsis Campaign: The Surviving Sepsis Campaign, run by the Society of Critical Care Medicine (SCCM) and the European Society of Intensive Care Medicine (ESICM), provides guidelines for the management of sepsis and septic shock. It can be a valuable resource for both patients and healthcare professionals.

Post-Sepsis Syndrome Support Groups: Many online communities and support groups exist where sepsis survivors can connect with others who have experienced similar challenges. These groups can provide a sense of community, understanding, and advice for coping with the after-effects of sepsis.

Local Support Groups and Hospital Programs: Some hospitals or healthcare facilities may offer specific support programs or groups for sepsis survivors. Inquire with your local hospital or healthcare provider to see if they have any resources available.

FreshRN Resources for ICU Nurses

Trying to build your confidence as a new ICU nurse?

Computer With Course Cover1

Breakthrough ICU from FreshRN is a 6-week, online course specifically crafted for brand new ICU nurses who want to get ahead of the game. So that instead of merely surviving orientation, they’re confidently thriving all the way through. With Breakthrough ICU, it’s like we took all of the highlighted info from the nursing textbooks, mixed in our own experience, wisdom, and expertise, and packaged it in a way that it’s tangible, easy to digest and understand, and can be applied to your very next shift. You can start your ICU journey with your head held high (but not too high!) and your heart calm. 

Picture of Kati Kleber, founder of FRESHRN

Hi, I’m Kati.

Kati Kleber, MSN RN is a nurse educator, author, national speaker, host of the FreshRN® Podcast, and owner of FreshRN® – an online platform created to educate, encourage, and motivate newly licensed nurses in innovative ways.

Connect with her on YouTube, Pinterest, TikTok, Instagram, and Facebook, and sign-up for her free email newsletter for new nurses.


Submit a Comment

Your email address will not be published. Required fields are marked *

This site uses Akismet to reduce spam. Learn how your comment data is processed.