“Sepsis is a life-threatening organ dysfunction caused by a dysregulated host response to infection.  Sepsis and septic shock are major healthcare problems, affecting millions of people around the world each year.  Early identification and appropriate management in the initial hours after sepsis develops improves outcomes,” (Rhodes, et al., 2017). According to the National Institute of Health Statistics, more than a million Americans develop severe sepsis every year.  Between 28 and 50 percent of these people die.  This high mortality rate creates a clinical problem and generates interest in improving the care of septic patients.The systemic inflammatory response syndrome (SIRS) criteria servedas the original definition of sepsis. SIRS definition contains two or more of the following: temperaturegreater than 38 degrees Celsius or less than 36 degrees Celsius, heart rategreater than 90 beats per minute, respiratory rate greater than 20 breaths perminutes or PaCO2 less than 32mmHg, and white blood cell count greater than12,000/mm3 or less than 4,000/mm3 or greater than 10%immature bands.  Another tool to identifyorgan dysfunction is the quick Sequential Organ Failure Assessment (qSOFA). Twopoints is a positive qSOFA, with increasing points patient outcomes areassociated with higher mortality rates (Bhattacharjee, Edelson, & Churpek,2017). Quick Sequential Organ Failure Assessment (qSOFA) criteria contains:respiratory rate greater than or equal to 22 breaths per minutes, alteredmentation, and systolic blood pressure less than 100mmHg. These two, SIRS andqSOFA, are sepsis recognition tools.Emergency departments play a vital role in identifying,treating, and managing septic patients. The problem with SIRS criteria as a screening tool for sepsis ispatients presenting to an emergency department do not have these laboratorytests, white blood cell and PaCO2, drawn hours prior to arrival.  This is one component that cannot beincorporated into a triage screening tool but updated throughout the stay in anemergency department.  Unless two othervital signs are abnormal there is potential to fail at recognizing a septicpatient initially presenting to an emergency department.  Similarly, the qSOFA criteria has shown highspecificity to sepsis and poorer outcomes (Bhattacharjee, Edelson, &Churpek, 2017).Sepsis recognition is not enough to decrease risk ofmortality in septic patients. Kumar, et al. (2006) discovered an associationbetween effective antimicrobial administration within the first hour ofdocumented hypotension increased survival in adults with septic shock. The 2016International Sepsis Guidelines strongly recommends administration of IVantimicrobials initiation within one hour of sepsis recognition. The best wayto improve patient outcomes for septic patients is to identify those withsepsis. The second way is to manage the septic patient, which includesinitiation of antibiotics. To assess this clinical problem, the PICO questionformulated is, in adult septicpatients, how does a sepsis triage screening tool based on qSOFA, compared tothe current 2+SIRS criteria, affect door to antibiotic time?MethodsAn electronic literature search was conducted using theCINAHL database. The search included 4 keywords: sepsis, antibioticadministration, SIRS, and qSOFA. All searches conducted were restricted toadults, 2010-2017-time frame, and articles in English. My first search resultedin 3,527 articles. A focus on articles that used SIRS or qSOFA foridentification took priority. These terms, SIRS and qSOFA, were searched titlespecific.  This resulted in a final 289articles. A secondary electronic literature search with the keyword of ‘nursingintervention and sepsis’ showed a few hundred articles. The research questionwas assessed using four journal articles that were peer reviewed. Theindependent variables were qSOFA and SIRS.Summary of EvidenceTromp, Hulscher, Bleeker-Rovers et al. (2010) researched the effects of a nurse driven implementation of a sepsis protocol care bundle. A prospective before and after intervention study at an emergency department of a university hospital in the Netherlands was conducted using three different five month increments. Period 1, July 1, 2006 – November 6, 2006, occurred before introducing the new care bundle based sepsis protocol. Period 2, November 6, 2006 – June 25, 2007, occurred after the sepsis protocol was put into place and before training. Period 3, June 25, 2007 – October 1, 2007, was after training and performance feedback. The sepsis care bundle consisted of seven elements. Six elements were required, the seventh was not required unless the patient was hypotensive or had an elevated serum lactate. The bundle included: measuring serum lactate concentration within six hours, obtaining two blood cultures before starting antibiotics, taking a chest radiograph, taking a urine sample for urinalysis and culture, starting antibiotics within three hours, hospitalize or discharge the patient within three hours, and volume resuscitation for serum lactate >4.0mmol/L or hypotension. The researchers used 2+ SIRS criteria to identify septic patients entering the emergency department. The sample size included 825 people, 16 years of age or older (Tromp, Hulscher, Bleeker-Rovers et al., 2010).The findings showed that implementing a nurse-drivensepsis care bundle provided an increase in early recognition of sepsis inpatients presenting to the emergency department. Additionally, when staff receivededucation and training on this intervention, compliance to the bundle improvedearly recognition and treatment of patients with sepsis. Compliance to thecomplete sepsis care bundle increased from 3.5% to 12.4%. This study measured antibioticsstarted within three hours after staff training. Antibiotic administrationincreased from which increased from 38% to 56%. These results are statisticallyand clinically significant. Evidence exists that delay in care for septicpatients leads to worse outcomes (Bhattacharjee, Edelson, & Churpek, 2017).This intervention study provides level IV (Melnyk & Fineout-Overhold, 2015)evidence for an increased compliance to implementing a sepsis care bundle aftertraining. Some limitations to the study include that is was an uncontrolled studyat a single center and only one year in length. Having a broader understandingof this disease across multiple countries and over extended periods of timewould improve the validity of the results. Strengths of this study include thelarge sample size, nurse driven implementation, and SIRS criteria for sepsisscreening. Another strength is that this study, like other studies, revealeducation improves sepsis recognition and sepsis care. From this study, it canbe determined that the training and implementation of a sepsis care bundleincreases sepsis recognition and improves adherence to the bundle, improvingpatient outcomes.Yousefi, Nahidian, and Sabouhi (2012) conducted a studyto review the effects of an educational program about sepsis care of intensivecare unit (ICU) nurses.  This study was aquasi-experimental interventional study with two groups over three timeperiods: before, immediately after, and three weeks after.  Nurses with a bachelor’s degree or higherlevel of education and one year ICU experience were included in the study.Infection control committee or members that participated in a similar studywere excluded.  The sample size included thirty-twonurses randomly enrolled into each of the test and control groups.  The data collection tool was a four-partquestionnaire to measure knowledge, attitude, and practice of ICU nurses.  The results obtained earn Level III evidence(Melnyk & Fineout-Overholt, 2015).The findings revealed there was no significantdifference between the control (c) and test (t) groups in terms of age, sex,education, experience, and employment status. Mean scores of knowledge (t=62.5,c=63.7), attitude (t=73, c=72.8), and practice (t=81.8, c=82.2) of ICU nursesin the test and control groups had no significant difference before theintervention. In the test group, attitude (t=79.7, c=73.3) and practice(t=90.5, c=82.2) increased immediately after and attitude (t=83.3, c=73.2) continuedto trend up at the three weeks later mark. Education was found to be effective andhave a positive impact on attitude, knowledge, and practice on sepsis care ofICU nurses, like other studies. Thestudy did have some limitations which included the ability of the nurses toutilize books, media, and articles on the subject which could influence thestudy.  This study is limited dueto the small sample size.  A largersample size in various departments and facilities would strengthen the evidenceand improve clinical significance. One important thing to consider with thisarticle is that the nurses observed were bachelor’s degree nurses.  Associate degree nurses are the majority ofthe nursing workforce.  This could be aweakness for the article in that they fail to capture the majority education ofnurses. The strength of this studyprovides evidence supporting training statistically improved levels of attitude,knowledge, and practice of ICU nurses in sepsis care.  Findings of this article are likeother studies. Tarrant, O’Donnell, Martin, Bion, Hunter, & Rooney(2016), conducted a qualitative design-grounded theory study using focusedethnography to gain an understanding of the barriers to implementing the sepsissix bundle components within an hour of recognition of sepsis.  Data collection occurred through various waysincluding: over three hundred hours of observations, 43 staff membersinterviewed, and shadowing multiple units and staff members across six pilothospitals in Scotland from March 2013 – May 2014. The results of this studyprovide Level VI evidence (Melnyk, & Fineout-Overholt, 2015). The main findings include that the Sepsis Six clinical bundle is notsix simple tasks but a series of complex processes. Gaining a betterunderstanding of the problems of interruptions and operational failures thatget in the way of task completion is ideal to improve compliance for Sepsis Sixwithin one hour. The researchers suggest focusing on individual behavior changeto improve compliance to Sepsis Six with a combination of reducing barriers andchallenges in the everyday workflow that are responsible for the delays inSepsis Six. The research hypothesizes that there would be greater compliance toSepsis Six within one hour window if the everyday barriers and challenges werereduced. This study is limited to one country, Scotland.  Additionally, the length of study could havemissed problems and barriers associated with night shift.  Night shift tends to run with fewer resourcesand less access to providers. Night shift is also associated with lessexperience providers. These barriers need to be assessed to gain a betterunderstanding of delays in compliance to sepsis six bundle.  The strengths of this study lie in thequalitative perspective to gain a better understanding of barriers toimplementing sepsis six bundle. The study highlights that a focus on educationand knowledge of sepsis is not enough, and emphasize the importance to reducingbarriers to promote ultimate compliance. Gunn, Haigh, andThomson (2016) conducted a retrospective study, over a six-month period, onpatients presenting to the ED who had a sepsis six form completed.  The emergency department currently uses SIRScriteria to identify septic patients. The purpose of the study was to determine if qSOFA would reliablyidentify septic patients within the emergency department population.  The sample size was two hundred patients withsepsis diagnosis.  One hundred and ninety-fivewere positive for SIRS.  Twenty-nine werepositive for qSOFA. SIRS and qSOFA were compared to determine specificity andsensitivity to identifying septic patients. This article is rated Level IVevidence (Melnyk & Fineout-Overhold, 2015).  SIRShad a higher sensitivity at 97%, and a 2.4% specificity. qSOFA showed a 90%specificity and a 48% sensitivity.  SIRSwas reliable in identifying sepsis and qSOFA was reliable with detecting thoserequired higher levels of care and mortality. These finding show clinical andstatistical significance.  Theresearchers conclude that SIRS criteria serves as a useful triage tool inidentifying septic patients.  Theresearchers further conclude that once positive SIRS criteria is establishedqSOFA should be conducted to assess severity and critical care need. Limitationsof this study include the sample size, location, and length of time where thestudy took place.   Increasing the sample size over a longer period of time to gain abroader population would increase the strength of this article.  This study would be strengthened if anobservation of a larger sample size took place, over a longer period, and overmultiple facilities.  The strength ofthis study is the results that provide evidence for SIRS criteria as the betterseptic recognition tool.  The resultsindicate SIRS is best at identifying sepsis. These results are statistically and clinically important.  If qSOFA was usedinstead of SIRS, many people would not have been included in a sepsis workupand could potentially have worse outcomes due to delay in recognition andsepsis care.  From this article, keepingSIRS criteria is vital for sepsis recognition. However, including a qSOFA could benefit those critically ill inidentifying those at higher risk for worse outcomes.  Raithet. al (2017) published a retrospective cohort analysis study on the prognosticaccuracy of the SOFA score, SIRS criteria, and a qSOFA within the first 24hours of admission in discriminating in-hospital mortality among patients withsuspected infection admitted to the ICUs. This study began in 2000 andcontinued to 2015. The sample size included 184,875 adults withinfection-related primary admission diagnosis. The study took place in 182 ICUsin Australia and New Zealand. This study was rate a Level IV using Melnyk & Fineout-Overhold, (2015) evidence appraisal guidelines.Theresults of this study showed SOFA had significantly greater discrimination forin-hospital mortality than SIRS criteria or qSOFA.  A SOFA of 2 or more points showed a 90.1%accuracy in mortality or ICU length of stay of three days or more.  The SIRS score of 2 or more points had a86.7% accuracy, while a qSOFA score of 2 or more points revealed 54.4%accuracy.  The overall results favored aSOFA score over qSOFA and SIRS, showing greater accuracy for in-hospitalmortality.  Thestrengths of this study include the duration, sample size, and location. Havingthis much diversity in the study decreases variables or outliers alteringresults. Additionally, the information gathered utilized a quality-surveillancedata collection process reducing bias. One limitation the researchers addressis the inability to apply this study to emergency department patients. Thisstudy used patients in the ICU. The statistical significance and clinicalsignificance could be applied to an ICU setting, but for the clinical problemstated earlier this would not hold clinical significance in an emergencydepartment setting.  Like the previousstudy, the use of SOFA in conjunction with SIRS criteria would be beneficial indetermining those with greater critical care needs for proper placement and toidentify those at higher mortality risk. Discussion and Conclusions Sepsis is a terrible disease with poor outcomes.  Understanding the best recognition tool and management are key to surviving sepsis.  The overall articles bring collective information on improving sepsis recognition and decreasing door-to-antibiotic time.  The studies described range from Level III to Level VI according to Melnyk and Fineout-Overholt’s (2015) level of evidence guide.  Having meta-analysis, randomized control trials, or even well-designed controlled trials without randomization would increase the validity of the results.  As previously stated, education is found effective in increasing knowledge and recognition on sepsis care.  Implementing an educational program on sepsis recognition and care is clinically significant to improve sepsis outcomes. Education should be incorporated into a sepsis care bundle to improve compliance and sepsis recognition. Additionally, if qSOFA or SOFA were used after SIRS criteria to determine critical care status this would increase results and provide knowledge on patient outcomes. The overall evidence in the studies is not enough tomake changes in clinical practice.  Thereis not enough collective strength of evidence to make a change in clinicalpractice. However, the articles did support SIRS criteria for greatestsensitivity to sepsis recognition with qSOFA showing higher sensitivity tomortality. The sources of evidence support the continuing use of SIRS criteriafor a sepsis triage screening tool. Recognizing sepsis and reducing barriersare key to improving antibiotic administration. The results of the study showedthe importance of education and reducing barriers to improving sepsisrecognition and management. According to the evidence, SIRS criteria isproviding better recognition for sepsis. The evidence leads to septic patients benefitingfrom an additional screening tool, the qSOFA, if they have 2+ SIRS criteria torule out higher mortality and critical care needs. Further evidence is neededon qSOFA replacing SIRS for sepsis identification prior to implementing in theclinical setting. It appears most evidence conducted is from retrospectivestudies. Randomized control trials or meta-analysis would strengthen this claimfor SIRS over qSOFA in emergency department triage screening tool for sepsisrecognition.  ReferencesBhattacharjee, P.,Edelson, D. P., & Churpek, M. M. (2017). Identifying Patients With Sepsison the Hospital Wards. Chest, 151(4), 898-907.doi:10.1016/j.chest.2016.06.020Gunn N, Haigh C, Thomson J.(2016) Triage of Sepsis Patients: SIRS or qSOFA – Which is best?Emergency Medicine Journal ;33:909-910.Kumar, A.,Roberts, D., Wood, K. E., Light, B., Parrillo, J. E., Sharma, S., . . . Cheang,M. (2006). Duration of hypotension before initiation of effectiveantimicrobial therapy is the critical determinant of survival in human septic shock. CriticalCare Medicine, 34(6), 1589-1596. doi:10.1097/01.ccm.0000217961.75225.e9Rhodes, A., Evans,L. E., Alhazzani, W., Levy, M. M., Antonelli, M., Ferrer, R., . . . Dellinger, R. P. (2017). Surviving Sepsis Campaign. Critical CareMedicine, 45(3), 486-552. doi:10.1097/ccm.0000000000002255Melnyk, B. M., & Fineout-Overholt, E. (2015). Evidence-based practice in nursing & healthcare: a guide to best practice. Philadelphia, PA: Wolters Kluwer. (n.d.). SepsisFact Sheet. Retrieved March 22, 2017, from https://www.nigms.nih.gov/education/pages/factsheet_sepsis.aspxRaith, E., Udy,A., Bailey, M., Mcgloughlin, S., Macisaac, C., Bellomo, R., & Pilcher, D.V. (2017). Prognostic Accuracy of the SOFA Score, SIRS Criteria, andqSOFA Score for In-Hospital Mortality Among Adults With Suspected Infection Admitted tothe Intensive Care Unit. Jama, 317(3), 290.doi:10.1001/jama.2016.20328Tarrant, C.,O’Donnell, B., Martin, G., Bion, J., Hunter, A., & Rooney, K. D. (2016). Acomplex endeavour: an ethnographic study of the implementation of the SepsisSix clinical care bundle. Implementation Science, 11(1).doi:10.1186/s13012-016-0518-zTromp, M.,Hulscher, M., Bleeker-Rovers, C. P., Peters, L., Berg, D. T., Borm, G. F.,Pickkers, P. (2010). The role of nurses in the recognition and treatment ofpatients with sepsis in the emergency department: A prospective before-and-afterintervention study. International Journal of Nursing Studies, 47(12),1464-1473. doi:10.1016/j.ijnurstu.2010.04.007YousefiH, Nahidian M, Sabouhi F. Reviewing the effects of an educational program aboutsepsis care on knowledge, attitude, and practice of nurses in intensivecare units. Iranian Journal of Nursing and Midwifery Research 2012; 17(2):S91-S95.Get Help With Your EssayIf you need assistance with writing your essay, our professional essay writing service is here to help!Find out more