Expert Insights

Theory of Sepsis

My sepsis project and theory of sepsis

Lucy Lopez

Introduction

Sepsis remains one of the leading causes of death worldwide. Early recognition and intervention are critical to improving patient outcomes and reducing mortality. Unfortunately, in clinical settings, sepsis is frequently misclassified during its early stages. This is particularly true for patients with comorbidities such as congestive heart failure, chronic kidney disease, chronic obstructive pulmonary disease (COPD), or those undergoing dialysis—populations in which providers often hesitate to intervene aggressively due to concerns over fluid overload. This paper explores how nursing theories, evidence-based practice (EBP), and emerging technologies can be integrated to improve sepsis care. It also examines organizational strategies that support early detection, rapid intervention, and sustained system-wide improvement. to improve sepsis care, emphasizing early detection and multidisciplinary collaboration.

Professional Bacl<ground & Initiative

My experience as an infection control practitioner and sepsis coordinator in both a 300-bed hospital and a 188-bed nursing home which I provided firsthand insight into the complexities of sepsis care. Following guidelines from the Centers for Medicare & Medicaid Services (CMS, 2006) and the World Health Organization (WHO), I led a facility-wide initiative to enhance sepsis management. This included educational campaigns on CMS sepsis bundles, staff engagement across all shifts, and the integration of real-time sepsis alerts using SIRS criteria 111 collaboration with our Cerner informatics team. I tailored education according to the needs of our staff and customized my schedule to accommodate theirs—ranging from teaching sessions as early as 5:00 AM to sessions held as late as 7:00 PM

Early Detection Through Nursing Theory

Applying Dorothea Orem's Self-Care Deficit Nursing Theory, sepsis can be conceptualized as a breakdown 111 a patient's ability to maintain physiological equilibrium. Nurses serve as critical agents in identifying and addressing these deficits. Implementing an Early Warning System (EWS) based on vital signs and laboratory values (e.g., heart rate >90 bpm, temperature > 100.90F, white blood cell count > 12,000 or <4,000) standardized the detection of early sepsis indicators. These interventions fulfill Orem's model by filling self-care gaps through timely, nurse-led responses.

Psychosocial Dimensions and Systems Theory

Sepsis extends beyond physical symptoms, often resulting in long-term psychosocial sequelae such as cognitive impairment, anxiety, depression, and post-traumatic stress disorder (PTSD), collectively known as post-sepsis syndrome (PSS). Using Betty Neuman's Systems Model, sepsis is seen as a complex stressor affecting physiological, emotional, and social systems. The model also supports addressing provider well-being, particularly in high-acuity environments like the ICU, where compassion fatigue and burnout are prevalent. Strategies such as structured debriefings, mental health support, and interdisciplinary teamwork are crucial to system-wide resilience.

Managing Vulnerable Populations with Holistic Nursing Theory

Patients with heart failure or renal dysfunction present a particular challenge due to the risks associated with fluid resuscitation. Martha Rogers' Science of Unitary Human Beings informs a more holistic, patient-centered approach by emphasizing the interconnectedness of the human system and environment. This perspective supports individualized fluid resuscitation by encouraging clinicians to consider the patient's entire physiological and psychosocial context rather than applying uniform protocols—especially vital when managing complex conditions like sepsis in patients with cardiac or renal vulnerabilities. In our protocol, patients were assessed with dynamic monitoring tools (e.g., passive leg raise, stroke volume variation), and individualized plans including proactive diuresis were implemented. This approach respected the patient's physiological and psychosocial wholeness, avoiding rigid adherence to generic resuscitation volumes.

Evidence-Based Practice in Sepsis Care

Integrating evidence-based practice (EBP) into sepsis management enhances patient outcomes, standardizes clinical decision-making, and ensures that interventions are driven by current research. Key components include:

1. Sepsis Screening and Care Bundles

The Surviving Sepsis Campaign (SSC) and CMS SEP-I bundle recommend systematic screening and standardized protocols. These bundles have been associated with improved mortality rates when implemented consistently (Rhodes et al., 2017). Studies in ICU settings have shown that structured sepsis bundles reduce ICU length of stay and overall mortality (Damiani et al., 2015).

2. Early Goal-Directed Therapy (EGDT) and Hour-I Bundles

EGDT introduced early hemodynamic optimization for septic patients. Although subsequent trials such as ProCESS and ARISE found no superiority over modern usual care, the emphasis on rapid recognition and intervention remains foundational (Peake et al., 2014; The ProCESS Investigators, 2014). The 2018 SSC update recommends the Hour-I Bundle, which includes lactate measurement, obtaining blood cultures, administering broad-spectrum antibiotics, fluid resuscitation, and initiating vasopressors as needed—critical steps that have been associated with improved outcomes when performed quickly.

Lactate measurement is a required component of the CMS SEP-I bundle. Elevated lactate levels serve as a marker of tissue hypoperfusion and metabolic stress. According to CMS, initial lactate must be measured within the first 3 hours, and if elevated (>2 mmol/L), a repeat measurement is necessary within 6 hours. Monitoring lactate helps guide fluid resuscitation and assess treatment response.

3. Fluid Resuscitation Guided by Dynamic Monitoring

CMS guidelines recommend the administration of 30 mL/kg of crystalloids within 3 hours In patients with sepsis-induced hypoperfusion. However, Individualized care using dynamic indicators (e.g., passive leg raise, stroke volume variation) is increasingly emphasized over static measures like central venous pressure. This approach is particularly important in patients with heart failure or renal impairment, where fluid overload can be dangerous.

4. Antibiotic Administration and Stewardship

Timely administration of broad-spectrum antibiotics is a core component of the CMS SEP-I bundle. For severe sepsis, antibiotics must be initiated within three hours of presentation; for septic shock, within one hour. Studies consistently show that each hour of delay increases mortality risk.

While procalcitomn is not part of the CMS bundle, it serves as a valuable adjunct in antibiotic stewardship. When integrated with clinical judgment, procalcitonin-guided protocols can help guide decisions about the duration of antibiotic therapy. This approach has demonstrated reductions 111 unnecessary antibiotic exposure and helps mitigate the development of antimicrobial resistance and Clostridioides difficile infection—without compromising patient safety (Schuetz et al., 2017).

5. Supportive Care and Multidisciplinary Protocols

Evidence supports key adjunct therapies:

VTE prophylaxis using low molecular weight heparin is strongly recommended. Stress ulcer prophylaxis is advised in patients with risk factors such as mechanical ventilation or coagulopathy.

Enteral nutrition within 24—72 hours is encouraged, although supported by low-quality evidence.

Palliative care integration, based on clinical judgment and patient preferences, is essential for aligning care with long-term goals.

6. Performance Monitoring and Continuous Improvement

Sustainable improvement in sepsis care requires real-time performance feedback. This includes appointing sepsis champions, auditing compliance, and using feedback loops to drive practice refinement. These steps align with Kotter's Change Model, promoting sustained adoption of evidence-based care pathways.

Technology, Data, & Sepsis Detection

Our collaboration with Cerner enabled real-time surveillance using algorithm-driven alerts based on SIRS criteria. The creation of "Sepsis Codes" in the emergency department included overhead announcements and team-based responses, streamlining interventions and improving time-totreatment metrics. These innovations exemplify how data and technology can optimize workflow, communication, and outcomes.

Sustaining Change Through Organizational Culture

Using Kotter's 8-Step Change Model (Kotter, 1996), we addressed cultural transformation:

I Established urgency using infection data

Formed a guiding coalition across departments

Developed a clear vision through education and alerts

Communicated the vision hospital-wide

Empowered broad action through interdisciplinary engagement

Celebrated early wins, like 92% compliance rates

Consolidated gains via ongoing education

Anchored new processes into the culture

Departmental champions identified via CliftonStrengths helped me sustain enthusiasm, while infection data and HAI tracking were reported at board meetings to maintain accountability and visibility.

Outcome Tracking & Future Directions

The initiative led to a 92% compliance rate, a significant reduction in infection-related complications, and increased early treatment adoption in long-term care. Future goals include tracking long-term outcomes such as post-sepsis syndrome (PSS), sepsis-related mortality, and provider wellness. We aim to expand predictive analytics, refine protocols for fluid-sensitive populations, and integrate further patient-reported outcomes into quality metrics.

Conclusion

This theory-based analysis underscores how nursing frameworks (Orem, Neuman, Rogers), evidence-based practice, technology, and organizational change models can be harmonized to create a comprehensive, proactive, and compassionate approach to sepsis care. Empowering staff, engaging patients, and institutionalizing best practices transforms the landscape of critical care—moving from crisis-driven response to sustainable, preventive systems.

References

Centers for Medicare & Medicaid Services. (2006). Sepsis core measure specifications.

Damiani, E. , Donati, A. , Serafini, G. , et al. (2015). Effect of performance improvement programs on compliance with sepsis bundles and mortality: A systematic review and meta-analysis of observational studies. PLOSONE, 10(5), e0125827. https://doi.org/l().1371/journal.pone.0125827

Evans, L. , Rhodes, A. , Alhazzani, W. , et al. (2021). Surviving Sepsis Campaign: International guidelines for management of sepsis and septic shock 2021. Intensive Care Medicine, 47, 1 181— 1247. https://doi.org/l O. 1007/00134-021-06506-y

Kotter, J. P. (1996). Leading change. Harvard Business School Press.

Peake, S. L. , Delaney, A. , Bailey, M. , et al. (2014). Goal-directed resuscitation for patients with early septic shock. New England Journal ofMedicine, 37/(16), 1496—1506. https://d0i.org/10.1056/NEJMoa1404380

Rhodes, A. , Evans, L. E. , Alhazzani, W. , et al. (2017). Surviving Sepsis Campaign: International guidelines for management of sepsis and septic shock: 2016. Intensive Care Medicine, 43(3), 304-377. https://doi.org/l O. 1007/00134-017-4683-6

Schuetz, P. , Wirz, Y. , Sager, R. , et al. (2017). Procalcitonin to initiate or discontinue antibiotics in acute respiratory tract infections. Cochrane Database ofSystematic Reviews, 10, CD007498 https://d0i.org/10.1002/14651858.CD007498.pub3

The ProCESS Investigators. (2014). A randomized trial of protocol-based care for early septic shock. New England Journal ofMedicine, 370, 1683—1693. https://d0i.org/10.1056/NEJMoa1401602