Clinical Scorecard: Nurse-Activated Standing Orders for Sepsis in Diverse Hospital Care Settings
At a Glance
Category
Detail
Condition
Sepsis and sepsis-specific nurse-initiated standing orders (NISOs)
Key Mechanisms
NISOs allow nurses to initiate predefined diagnostic testing and treatment; surveyed sepsis-specific orders most often included lactate testing, while none included antibiotic orders.
Target Population
Hospitals and patients with sepsis in emergency department, inpatient ward, or rapid response team settings.
Care Setting
Michigan hospitals participating in the Hospital Medicine Safety Consortium; sepsis-specific NISOs were most commonly available in emergency departments.
Key Highlights
Among 68 surveyed hospitals, 48 (71%) reported at least one sepsis-specific NISO.
Of 84 setting-level sepsis-specific NISOs, 39 (57%) were in emergency departments, 22 (32%) inpatient, and 23 (34%) through rapid response teams.
Lactate measurement was included in 80 NISOs (95%); blood cultures in 63 (75%), complete blood count in 59 (70%), and comprehensive metabolic profile in 49 (58%).
Intravenous fluids were included in 27 NISOs (32%); antibiotic orders were absent from all 84.
Only 11 NISOs (13%) were reported as used in more than half of sepsis cases; usage data were unavailable for 30 (36%).
Guideline-Based Recommendations
Diagnosis
The surveyed NISOs most commonly included lactate measurement, blood cultures, complete blood count, and comprehensive metabolic profile.
The study did not establish a recommended core diagnostic component set for sepsis-specific NISOs.
Management
Intravenous fluid administration appeared in 27 of 84 NISOs (32%), most often as a 30 mL/kg or 1000 mL bolus.
No surveyed sepsis-specific NISO included antibiotic orders; the authors note this may reflect antimicrobial stewardship or scope-of-practice concerns requiring clinician assessment.
Monitoring & Follow-up
The authors report that hospital guidelines advise evaluating the use, usability, and effects of sepsis tools.
Usage frequency was unavailable for 30 of 84 NISOs (36%); the study did not assess effects on sepsis management or outcomes.
Risks
The study was limited to one state, relied on potentially inaccurate survey responses, included observations that were not independent across hospital settings, and could not evaluate effects on management or outcomes.
The authors identify possible explanations for limited NISO use, including inadequate awareness, ineffective design, hospital culture, or rapid physician assessment; these were not evaluated.
Patient & Prescribing Data
Patients with sepsis addressed by nurse-initiated protocols or orders in emergency department, inpatient, and rapid response settings at surveyed Michigan hospitals.
Among 84 sepsis-specific NISOs, 27 (32%) included intravenous fluids and none included antibiotics. The survey did not report patient-level treatment or outcome data.
Clinical Best Practices
The authors state that hospitals should evaluate the use, usability, and effects of sepsis tools.
Further research is needed to establish core diagnostic and therapeutic components for sepsis-specific NISOs and determine their effects on management and outcomes.
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