Brighton and Sussex University Hospitals Sepsis: recognition, diagnosis and early management Policy Version: Category and number: Approved by: V1 C086 Date approved: August 2017 Name of originator/author: Name of responsible committee/individual: Date issued: October 2017 Review date: August 2020 Target audience: Accessibility Clinical Policy Steering Group Sepsis Clinical Nurse Specialist Sepsis Clinical Nurse specialist All medical and nursing staff responsible for caring for adults with sepsis or at risk of sepsis. This document is available in electronic format only. V1 Approved Clinical Policies Steering Group: 15 th October 2017 Page 1 of 13
Contents Section Page 1 Introduction 3 2 Purpose of this policy 3 3 Definitions 4 4 Responsibilities, Accountabilities and Duties 4 5 Policy 5 6 Monitoring Arrangements 8 7 Links to other Trust policies 9 8 Associated documentation 9 9 References 9 Appendices Appendix 1 Associated documentation: Sepsis screening tool 10 Appendix 2 Due regard assessment tool 12 V1 Approved Clinical Policies Steering Group: 15 th October 2017 Page 2 of 13
1 Introduction 1.1 This policy is for use by the multi-professional team in the acute hospital setting to provide guidelines around caring for a patient with suspected or confirmed sepsis. 2 Purpose of this policy 2.1 To support all health care providers in the early recognition, prompt response and appropriate management of all adult patients with suspected or confirmed sepsis, supported by best evidence and national directives. 2.2 To promote the use of the sepsis screening tool in the emergency department and all clinical settings to assist staff to consider sepsis and escalate rapidly if suspected. The sepsis screening tool has been developed with recommendations from NICE guidelines and utilising the UK Sepsis Trust toolkit. 2.3 Patients may appear well initially but if untreated could rapidly progress to septic shock / death. Early diagnosis and prompt treatment can prevent death. Symptoms may be vague and often there is no obvious focus of infection. 2.4 Sepsis can occur in anyone with an infection however some patients are higher at risk of sepsis and they include: Older patients (>75) or the very frail. Pregnant or recent pregnancy People who have impaired immune systems because of illness or drugs, including: o Patients receiving or recently received (<6 weeks) anticancer treatment. o Patients who have impaired immune function (for example, people with diabetes, people who have had a splenectomy, or people with sickle cell disease) o Patients taking long-term steroids o Patients taking immunosuppressant drugs to treat non-malignant disorders such as rheumatoid arthritis. V1 Approved Clinical Policies Steering Group: 15 th October 2017 Page 3 of 13
o Patients who have had surgery, or other invasive procedures, in the past 6 weeks o Patients with any breach of skin integrity (for example, cuts, burns, blisters or skin infections) o Patients who misuse drugs intravenously o Patients with indwelling lines or catheters. 3 Definitions 3.1 Sepsis is life-threatening organ dysfunction caused by a dysregulated host response to infection. (Singer, M, et al. 2016) 3.2 Septic shock is a subset of sepsis in which underlying circulatory and cellular/metabolic abnormalities are profound enough to substantially increase mortality. Patients with septic shock can be identified with a clinical construct of sepsis with persisting hypotension requiring vasopressors to maintain MAP greater than or equal to 65 mm Hg and having a serum lactate level above 2 mmol/l despite adequate volume resuscitation. With these criteria, hospital mortality is in excess of 40%. 3.3 Red Flag sepsis is defined as a patient with one or more Red Flag criteria as indicated on the sepsis screening tool with a probable infection and a diagnosis from a clinician. This is time critical and the patient will require antibiotics within one hour. 3.4 Amber Flag sepsis is defined as a patient with one or more Amber Flag criteria as indicated on the sepsis screening tool with a probable infection. Close monitoring is advised, a clinician has 3 hours to decide on antibiotic treatment and discussion with Microbiology is encouraged. 3.5 Sepsis 6 is a bundle of basic therapies, shown to improve outcomes in septic patients. If the 6 factors are completed within the first hour following recognition of sepsis, the associated mortality has been reported to reduce by as much as 50% (Daniels, R 2011) 4 4. Responsibilities, Accountabilities and Duties 4.1 The Chief Executive The Chief Executive is responsible for ensuring the requirements within this policy are fulfilled and operational responsibilities are in place when patients who are septic or at risk of sepsis are nursed on general wards and within the Emergency departments. 4.2 Chief Nurse and directorate lead nurses V1 Approved Clinical Policies Steering Group: 15 th October 2017 Page 4 of 13
The chief nurse is responsible for ensuring requirements within this policy are fulfilled and that this policy is disseminated to all the directorate lead nurses and matrons for appropriate action 4.3 Executive medical director The Executive Medical director is responsible for ensuring that this policy is disseminated to consultants who supervise medical staff in training and that education and training facilities are available. 4.4 Trust Board The Trust Board is responsible for the overall patient management within the Trust. Assurance for the implementation of this policy is delegated to the Directorate Quality and Safety Committees. 4.5 Directorate leads It is the responsibility of the leads to ensure that the policy is adhered to by medical staff. 4.6 Ward manager Ward managers should ensure sepsis screening tools are available on the ward and the criteria are adhered to by all staff. 4.7 Sepsis Clinical Nurse Specialist (CNS) It is the responsibility of the CNS to ensure that a training strategy is provided and the policy is adhered to by nursing staff. 4.8 All staff: Nursing & Medical Teams It is the responsibility of all medical and nursing staff to ensure that sepsis patients are cared for in accordance with this policy. 5 Policy All clinical staff in the Trust must be familiar with the significant morbidity and mortality associated with sepsis and possess the knowledge and skills to recognise and initiate early resuscitation and treatment. Sepsis is a time critical condition and therefore requires timely and accurate management and treatment. 5.1 Escalation plan/treatment: For immediate information refer directly to Sepsis Screening Tool A patient with a raised National Early Warning Score 4 greater than or equal to and suspected/confirmed infection will follow the sepsis pathway via the sepsis screening tool. The Healthcare professionals caring for their patient also have an option to use the sepsis screening tool when there is clinical concern/patient looks sick, though NEWS score may not trigger. The Escalation plan is shown through following the sepsis screening tool and the pathway support points of contact for escalation. Parent team, Critical Care Outreach RSCH (bleep 8495) PRH (bleep 6331) or site team overnight RSCH (bleep 8152 ) or HDU/ITU. Every patient who requires admission to hospital must be considered for sepsis. Within the single clerking documentation: V1 Approved Clinical Policies Steering Group: 15 th October 2017 Page 5 of 13
Implementing the sepsis pathway during patient assessment and escalation will support rapid, senior review and implementation of the sepsis 6, or review and reassessment within the appropriate time frame. The sepsis pathway will form part of the patient documentation and must be included within the patient s case notes. On-going review, reassessment and antimicrobial stewardship must be documented clearly. 5.3 Emergency Department (ED) All major patients attending the ED will be triaged and a full set of observations will be carried out (respiratory rate, oxygen saturations, pulse, blood pressure, AVPU/Glasgow coma scale (GCS), temperature and pain score) and assessed by the triage nurse for potential sepsis. The observations will be entered into National early warning score chart (NEWS) and a trigger score calculated. NEWS greater than or equal to 4 or 3 in one parameter and or patient looks sick/clinical concern the triage nurse completes the sepsis screening tool. They will identify the patient to the senior doctor in the ED who will then decide whether this patient could have sepsis, or this patient does not have sepsis. The reviewing doctor will then screen to identify if potential infection is present and for the severity of sepsis (Red Flag Sepsis / Septic shock). If the clinician confirms a differential diagnosis they can sign off/discontinue the sepsis screening tool and document plan in patient case notes. 5.4 Inpatients All inpatients must have a full set of observations (respiratory rate, oxygen saturations, pulse, blood pressure, AVPU/Glasgow coma scale, temperature and pain score) on presentation to the ward then at least 12 hourly. The observations will be entered into the NEWS chart and a trigger score calculated. NEWS greater than or equal to 4 or 3 in one parameter and/or patient looks sick/clinical concern the nurse then completes the sepsis screening tool. They will identify the patient to the senior doctor in the parent team (if out of hours the relevant on call team and/or night practitioner) who will then decide whether this patient could have sepsis, or this patient does not have sepsis The reviewing doctor will then screen to identify if potential infection is present and for the severity of sepsis (Red Flag Sepsis / Septic shock). If the clinician confirms a differential diagnosis they can sign off /discontinue the sepsis screening tool and document plan in patient case notes. 5.5 Treatment: V1 Approved Clinical Policies Steering Group: 15 th October 2017 Page 6 of 13
The patient will be treated according to the Sepsis Screening Tool; if they are diagnosed as probable/confirmed sepsis and have one or more red flags present they will receive the sepsis six care bundle as detailed below: 1. Oxygen to maintain SpO2 >94% (or 88-92% in CO2 retention) 2. Blood cultures (plus think source control for other potential samples) 3. Antibiotics as per trust guidelines for presumed source of infection (microguide link) 4. IV fluids - 500ml bolus crystalloid if normotensive and lactate 0-1.9mmol/l. if hypotensive or Lactate >2mmol/l then up to 30ml/kg. 5. Lactate (Arterial Blood Gas) (Plus FBC, U+E, LFT, CRP, calcium (in suspected neutropenic sepsis) & clotting screen) 6. Fluid balance (hourly) - this may require the insertion of a catheter. The above treatments must be administered within an hour of diagnosis. Once they have been administered then the patient should be evaluated at least hourly for response and appropriate escalation plan made. 5.7 Ongoing care 5.7.1 Monitoring of the patient should include physiological measures and clinical assessment, these should be clearly documented using the NEWS observation chart. Improvements in clinical parameters for example: If blood pressure, heart rate urine output and lactate return to normal levels then a management plan should be documented and referrals for further inpatient care organised. If the patient continues to have a haemodynamic deficit following fluid resuscitation of 30ml/kg then referrals for increased level of care should be made to the Critical Care team (outreach or ITU registrar/consultant). 5.7.2 Antimicrobial All inpatients must have a senior (ST3+)/specialist to input a final choice of antibiotic, route and duration at 24-72hrs with a view to de-escalating treatment as appropriate by 72hrs post initiation of antibiotics. This review must take account of information available from relevant cultures to switch to as narrow spectrum antibiotics as possible This review must be documented on the drug chart and within the clinical notes. 5.8 Patient safety All risk issues identified should be reported using the trust datix system and investigated. Lessons learnt should be shared with the relevant departments and ward areas caring for sepsis patients. 6. Training Implications Training on the new sepsis screening tool is covered in nursing induction and a roll out plan in place for existing staff. This is to ensure there is a V1 Approved Clinical Policies Steering Group: 15 th October 2017 Page 7 of 13
consistent practice and all staff has a baseline knowledge of sepsis, access to the screening tools and online resources to emphasise the importance of early recognition, prompt escalation and appropriate management of the septic patient. This training is being provided by the Sepsis CNS and Practice educators across the trust with resources available on IRIS. 6 Monitoring Arrangements Measurable Policy Objective Monitoring / Audit Method Frequency Responsibility for performing monitoring Where is monitoring reported and which groups / committees will be responsible for progressing and reviewing action plans Quarterly report to commissioners of audit findings. Updates to individual wards and units. Audit of a randomised sample of 50 from the total number of inpatients who meet the criteria for suspected sepsis NEWS 4> or 3 in one parameter. Monthly Sepsis Clinical Lead Sepsis Clinical Nurse Specialist Safety and Quality team. Sepsis team. Deteriorating patient group. Audit of a randomised sample of 50 from the total number of patients who present to ED and other units that directly admit emergencies who meet the criteria for suspected sepsis NEWS 4> or 3 in one parameter. Of these that receive a diagnosis of sepsis Timely treatment for sepsis in emergency departments and acute inpatient settings will be audited, namely antibiotics given within 1 hour. The effectiveness of this policy is also monitored by means of the ongoing Sepsis CQUIN audit. Reducing the impact of serious infections (Antimicrobial Resistance and Sepsis). V1 Approved Clinical Policies Steering Group: 15 th October 2017 Page 8 of 13
7. Link to other trust policies https://nww.bsuh.nhs.uk/clinical/teams-and-departments/critical-careoutreach-team-ccot/news-national-early-warning-score/clinical-response-andfurther-education Patient Observation policy 8. Associated documentation Intravenous Fluid Therapy Guidelines - Adults Sepsis screening tool Note: Brighton and Sussex University NHS Trust is using Red Flag High risk criteria to focus resources and urgent review. Consideration was given to qsofa prior to this decision by the sepsis working group. 9 References Singer, M, et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016;315(8):801-810. doi:10.1001/jama.2016.0287 Daniels, R. Surviving the first hours in sepsis: getting the basics right. Journal of Antimicrobial Chemotherapy. 2011;(66(s2)): ii11-ii13. Sepsis: recognition, diagnosis and early management, NICE guideline [NG51] Published date: July 2016 Last updated: September 2017 Levy MM, Dellinger RP, Townsend SR, et al. The Surviving Sepsis Campaign: results of an international guideline-based performance improvement program targeting severe sepsis. Crit Care Med. 2010;38:367-374. V1 Approved Clinical Policies Steering Group: 15 th October 2017 Page 9 of 13
Appendix one Sepsis screening tool V1 Approved Clinical Policies Steering Group: 15 th October 2017 Page 10 of 13
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Appendix 2 - Due Regard Assessment Tool To be completed and attached to any policy when submitted to the appropriate committee for consideration and approval. 1. Does the document/guidance affect one group less or more favourably than another on the basis of: Age No Disability No Gender No Gender identity No Marriage and civil partnership No Pregnancy and maternity No Race No Religion or belief No Sexual orientation, including lesbian, gay and bisexual people 2. Is there any evidence that some groups are affected differently and what is/are the evidence source(s)? 3. If you have identified potential discrimination, are there any exceptions valid, legal and/or justifiable? 4. Is the impact of the document/guidance likely to be negative? Yes/No No No NA No 5. If so, can the impact be avoided? NA 6. What alternative is there to achieving the document/guidance without the impact? 7. Can we reduce the impact by taking different action and, if not, what, if any, are the reasons why the policy should continue in its current form? 8. Has the policy/guidance been assessed in terms of Human Rights to ensure service users, carers and staff are treated in line with the NA NA Comments V1 Approved Clinical Policies Steering Group: 15 th October 2017 Page 12 of 13
FREDA principles (fairness, respect, equality, dignity and autonomy) If you have identified a potential discriminatory impact of this policy, please refer it to Sepsis Clinical Nurse Specialist, together with any suggestions as to the action required to avoid/reduce this impact. For advice in respect of answering the above questions, please contact Sepsis Clinical Nurse Specialist. V1 Approved Clinical Policies Steering Group: 15 th October 2017 Page 13 of 13