by Zach Read - firstname.lastname@example.org
Early in her career, before UNC Hospitals became her professional home, Ila Mapp, RN, MSN, encountered a patient with acute pancreatitis. She was working in Florida at the time – in critical care, as she has throughout her decade as a nurse – and it was her first time caring for a person with the condition.
Her job? Ensure that the otherwise healthy young male maintain a stable blood pressure, even if it meant giving him boluses or blood to keep his range normal. A simple enough task, she thought, except for one fact: Mapp and her colleagues quickly discerned that acute pancreatitis wasn’t the patient’s only emergent health issue. Despite their efforts, his blood pressure was dropping, his heart rate was rising, and his temperature was elevating – clear signs, taken together, that he had developed shock, a life-threatening condition that can occur with infections, pancreatitis, heart failure, or trauma. One of the most common reasons a patient experiences shock is due to sepsis, a condition that arises when the body’s response to infection injures its own tissues.
The results of sepsis can be devastating: death, cognitive damage, and deterioration in physical functioning.
“I have seen what can happen with sepsis,” says Mapp, who serves as Nurse Manager of the Adult Specialty Care Team at UNC Hospitals, which includes the Adult Rapid Response Team (ARRT), Venous Access Team, and Intensive Care Unit Transport Team. “In a short period of time, a healthy young person can become totally weak with no will to fight. It is scary.”
Mapp can recall many cases of sepsis but one in particular stands out. A man had gone fishing with friends, gathered oysters, and eaten several of them.
“Within 12 hours,” remembers Mapp, “he was being eaten from the inside out by sepsis. From these experiences early in my career, I learned how common sepsis could be, what could cause it, and how important it is to recognize it early and treat it quickly.”
A Love of Critical Care
For seven years of her career, Mapp crisscrossed the country as a travel nurse, working in hospitals in Modesto and San Diego, California; Bradenton and Sarasota, Florida; Baltimore and College Park, Maryland; Chapel Hill, Durham, and Raleigh, North Carolina; and Cincinnati, Ohio.
“These experiences were fun and rewarding, professionally and personally,” she says. “I combined two of my loves: traveling and nursing. And I was able to develop my interest in critical care.”
During her travels, Mapp worked in different critical care settings, including surgical, medicine, cardiac, and neurosciences intensive care units and stepdown areas. She was drawn to these patients because they are often the sickest – they challenged her skills, knowledge, and judgment as a nurse.
“Some patients have no way of communicating to tell you what’s hurting them, so, as a health-care professional, you have to react based on what you see on the monitor – based on your full assessment,” she says. “You have to try to beat the body – to figure out what the body is going to do before the body does it. For me, that’s the most intriguing part about critical care – it makes you use your mind.”In addition to intellectual interest in critical care, the most rewarding aspect, for Mapp, was being there for patients in need.
“Sometimes, 24 hours later, based on your interventions and assessment, you could have that patient completely turned around to where the person is waking up and able to communicate with you, and within two days you see them going to stepdown or to a floor,” she continues. “The greatest thing is when they come back to say, ‘Thank you for being there for me.’”
Finding Home, Fighting Sepsis
In 2008, during her second travel nursing stop at Duke University Medical Center, Mapp learned of a position that was set to open in the Neurosciences Intensive Care Unit at UNC Hospitals. She had worked at UNC Hospitals previously, and after leaving she kept in touch with former colleagues such as Angela Overman and Ellenita Kornegay, among many others she considers friends. The possibility of returning to Chapel Hill intrigued her.
“I’d always loved being at UNC,” she recalls, “so I took the position. I knew right away I’d found where I wanted to be – I’d found the home I was looking for during my travel experiences.”
After one year she transitioned to the Cardiac Intensive Care Unit (CICU), under the direction of Jacci Harden, where she was for six months, and followed her CICU work by becoming an ICU transport nurse, ICU transport manager, and Adult Rapid Response Team manager. At the same time, she noticed that the experiences she’d had – working on so many different units in so many different hospitals – provided her with a unique perspective. She decided that pursuing her MSN at UNC-Greensboro, with a focus on education, would benefit her, her patients, her colleagues, and UNC Hospitals. Struck by her encounters with septic patients throughout her career, she made the focus of her thesis sepsis education.
“I felt that I could bring something back to UNC Hospitals,” she says.
After earning her Master’s, Mapp met with Dr. Tina Schade Willis, Associate Chief Medical Officer for Quality at UNC Hospitals and a physician in the Pediatric Intensive Care Unit at the North Carolina Children’s Hospital, and performance improvement project manager Meridith Pumphrey. Dr. Schade Willis and Pumphrey had begun preparing for UNC Hospitals’ sepsis reduction initiative, Code Sepsis. Mapp knew Dr. Schade Willis from their work on the development of the Adult Rapid Response Team – the Adult Rapid Response Team would play a critical role in early response to cases of sepsis through Code Sepsis, and Mapp, as nurse manager, would oversee it.
“Ila and I have a great shared interest in the importance of staff empowerment, patient advocacy, and teamwork in producing better patient outcomes,” says Dr. Schade Willis. “When we were brought together on Code Sepsis, as we had been in the development of the Adult Rapid Response Team, I knew that we would be committed to the same goals of educating staff, trusting nurses’ intuition, and reducing sepsis mortality.”
Last fall, Mapp became responsible for piloting the adult inpatient bundle with the Adult Rapid Response Team, ensuring that the team is able to respond to Code Sepsis cases quickly and to act decisively so that treatments are delivered and administered within one hour of the onset of sepsis. She also led the implementation of the Modified Early Warning Score (MEWS) at UNC Hospitals. MEWS is a tool that complements Code Sepsis’s emphasis on frontline staff empowerment, especially bedside nurse empowerment, in the early recognition of deteriorating patients.
“Code Sepsis emphasizes constant awareness, patient-centeredness, teamwork and communication, and critical care assessment and response among staff, with the goal of preventing patient deterioration and cardiac arrest,” says Mapp. “During my travel experiences, I’d come across MEWS at other health-care facilities. When I was pursuing my MSN I started doing literature reviews about MEWS. I saw that it could be a helpful tool for our nurses to use alongside the education and training that Dr. Schade Willis and Code Sepsis have implemented to help change the culture of sepsis recognition here. My goal was to bring it back to UNC Hospitals.”
Based on patients’ MEWS scores, which are determined by the patient’s vital signs and level of consciousness, health-care professionals decide which patients can safely transfer from units without concern of returning to those units due to onset of sepsis and which patients require a call to the Adult Rapid Response Team and potential treatment for sepsis. Mapp worked closely with Code Sepsis team members including ISD application analyst programmer Daniel Licatese, who worked tirelessly to include urine output as a factor within the MEWS in Epic@UNC. The importance of urine output in diagnosing sepsis was brought to the attention of the Code Sepsis team by Patient Advisor to the Code Sepsis Program and School of Nursing faculty member Carol Durham, whose tell-tale sign that she was septic was low urine output.
Over the past roughly two years, Dr. Schade Willis has seen Mapp as a vital leader to the success of the Code Sepsis program.
“She understands small tests of change and the larger goals and leads her team and others through progress with ease," says Dr. Schade Willis. "She is happy to share her expertise with others and try new things. We could not do the work of this project without her.”
Mapp, meanwhile, credits the Code Sepsis team and leaders throughout the medical center for helping improve the culture surrounding sepsis.
“Since launching this effort, there have been cases where patients have surgeries and two days later they’re still experiencing elevated heart rate and temperature,” says Mapp. “The Adult Rapid Response Team nurses are thinking about sepsis. The fact that they are doing the preliminary work – getting the lactate, the blood cultures, starting the fluids – has helped them start the antibiotics on time. In some cases, patients haven’t had to be transported to the ICU – sepsis has been caught in time. We see that type of thing on an everyday basis.”
Because of the prevalence, seriousness, and treatability of sepsis, UNC Hospitals has launched a sepsis initiative that aims to implement reliable screening for early detection of sepsis, educate multidisciplinary teams in evidence-based therapies, and standardize tools and treatment bundles for our specific patient populations. For more information about Code Sepsis, please visit http://news.unchealthcare.org/empnews/code-sepsis.