Fever or body chills. An accelerated heart rate. Dizziness. Disorientation or confusion. Hyperventilation or shortness of breath.
These are some of the symptoms of sepsis, a life-threatening condition that kills five million people a year, worldwide. It is caused by an infection that usually starts in the lungs, urinary tract, skin or gastrointestinal tract.
Sepsis sets in when the body develops an extreme response to an infection, damaging its own tissues and causing organ dysfunction. If undetected and treated late, the infection may lead to severe sepsis and septic shock, increasing the death rate by up to 50 per cent.
While Singapore does not have a national sepsis registry to consolidate or track the numbers, care and outcomes for sepsis, 2020 data from the Singapore Ministry of Health indicates that sepsis has become more prevalent.
It is estimated that close to 5,000 deaths were attributed to sepsis from pneumonia and urinary tract infections in 2019. This is an approximate 13 per cent increase from cases reported in 2012.
In the healthcare system, nurses play a pivotal role in the early recognition and management of sepsis. Nurses are uniquely positioned to make the first crucial assessment in detecting the symptoms sepsis and implementing intervention to prevent deterioration.
With an eye on their professional, continuing education, Research Fellow Chua Wei Ling from the Alice Lee Centre of Nursing Studies, National University of Singapore, conducted several studies on the recognition and management of sepsis, tobetter equip nurses with the necessary skills.
EFFECTIVE LEARNING
Impact of sepsis education for healthcare professionals and students on learning and patient outcomes: A systematic review, published in the 2022 Journal of Hospital Infection, found that interventions delivered through an active learning approach such as game-based learning generally produced greater gains than didactic teaching. It led to the development of the Sepsis Interprofessional Education (IPE) programme for NUS undergraduate medical and nursing studies, adopting a blended learning approach involving virtual telesimulation.
Another study, The effect of a sepsis interprofessional education using virtual telesimulation on sepsis team care in clinical practice: A mixed-methods study, highlighted how medical and nursing students demonstrated a significant improvement in sepsis knowledge and team communication skills, post-intervention.
Students fostered a better understanding and appreciation of each other’s interprofessional role in sepsis care, and efforts are underway to complement virtual telesimulation with a mannequin-based simulation to enhance the long-term retention of sepsis knowledge and clinical skills performance.
Dr Chua says: “Mannequin-based simulation develops clinical skills performance in a realistic situation and consolidates sepsis care learning through face-to-face interactions and the opportunity for hands-on practice on clinical procedural skills.”
More recently, in collaboration with a team of nurses and doctors from the National University Hospital in Singapore, Dr Chua led a study to examine nurses’ knowledge and confidence in recognising and managing patients with sepsis.
Sepsis screening tools and sepsis bundles were identified to be useful in helping nurses recognise the onset of sepsis more quickly, and the study called for a stronger foundation in sepsis education and training programmes for nurses. It also stressed the need for systems to be put in place to improve nurses’ knowledge and enhance their sepsis care, along with a revamp of the hospital’s workplace sepsis training package for nurses.
Dr Chua says: “Incidences of sepsis will continue to rise with the interplay of multiple factors including an ageing population with more predisposing comorbidities, the use of immunosuppressive therapy, and the emergence of multi-drug antimicrobial resistance.
“With sepsis being a life-threatening medical emergency when the body has an extreme response to an infection, individuals with a weakened immune system, the elderly or infants, and those with underlying medical conditions such as heart or lung conditions, cancer, diabetes, liver or kidney diseases are at higher risk of developing it.”
IMPROVED CARE
Dr Chua’s efforts have culminated in an upcoming collaboration with the Emergency Department at Singapore’s Ng Teng Fong General Hospital, which she attributes to “a group of like-minded clinicians and academics who have invested interests in improving the care of patients with symptoms of sepsis and supporting nurses in their roles in this aspect”.
She explains: “At the Emergency Department, triage nurses are often the first point of contact patients have with the healthcare system. In the inpatient settings, nurses are able to identify hospital-onset sepsis at its earliest possible time because they have the most patient contact hours among other healthcare professionals and they are the ones responsible for routine bedside monitoring of patients.
“We conducted an exploratory study to explore their level of sepsis knowledge, and confidence in recognising and managing patients with symptoms of sepsis, as well as identify support needs of nurses in this area. This will help inform the design and learning content of our sepsis training programme for nurses.”
Efforts are underway to enhance the current IPE programme to achieve greater outcomes.
Currently, multiple users (i.e. medical and nursing students) must simultaneously log into the virtual platform to control and assume the various avatar roles. Dr Chua is working with her mentor, A/Prof Liaw Sok Ying, to develop a doctor-player avatar or 3D doctor virtual agent controlled by computer algorithms.
This would replace the existing doctor avatar controlled by humans in real-time with a computer-controlled version, so that nurses can practice in the virtual world without the actual presence of a doctor. It would also create interprofessional team-based learning opportunities for Nursing students and nurses across academic and healthcare institutions.
INDEPENDENT TRAINING
The new approach will also do away with Nursing students needing to pair up with medical students to form interprofessional teams for doctor-nurse training and improve the scalability of the program that is currently constrained by unequal medical-nursing cohort sizes.
“We have recently completed the pilot-testing of this single-player (nurse-player) virtual reality simulation for Nursing students’ training and will soon be testing this on a larger group of students,” shares Dr Chua.
“We are also in talks with our collaborator from Ng Teng Fong General Hospital to adapt this single-player virtual reality simulation for sepsis training for their Emergency Department nurses. We hope to eventually scale up this sepsis training for nurses in other clinical settings.”
Dr Chua suggests that even more can be done to support nurses in the care of sepsis patients and that digital technology can be leveraged to break new ground in ongoing educational efforts.
For instance, education and training through the use of mnemonics to guide nurses through the identification, assessment and initial management of patients with sepsis, and use of multimedia instructional materials including simulation and multimedia video can be considered.
Nurse-driven sepsis screening algorithms and sepsis care protocols or bundles can also be developed to facilitate the timely recognition and management of patients with sepsis.
“Nursing academics and researchers can work hand-in-hand with nurse educators and clinicians in designing interventions to support frontline nurses in their role in recognising and responding to symptoms of sepsis.
“They are also responsible to ensure that sepsis education content reflects the latest evidence-based knowledge and best practices.”
