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Nurse-led team winning the race against sepsis

Sepsis kills more people in the UK each year than lung cancer, with persistent shortcomings in initial assessment and emergency treatment. But in one trust that has struggled with sepsis care, a nurse-led team based in the emergency department is demonstrating the dramatic impact of early intervention

Sepsis kills more people in the UK each year than lung cancer, with persistent shortcomings in initial assessment and emergency treatment. But in one trust that has struggled with sepsis care, a nurse-led team based in the emergency department is demonstrating the dramatic impact of early intervention


A scan showing bacteria among red blood cells. Picture: Science Photo Library

The first nurse-led team focusing on patients with sepsis in the emergency department (ED) has vastly improved care for those at risk of the life-threatening condition.

The team, whose members wear bright red uniforms, are on the lookout for patients arriving at the ED at University Hospitals of Leicester NHS Trust with any of the signs or symptoms of sepsis.

Over the past year the team has seen more than 4,000 patients and there has been a doubling in sepsis screening and a jump in the number of patients receiving antibiotics in the critical first hour. This has been accompanied by an increase in knowledge among staff about the condition, known as the ‘silent killer’.

‘If we get sepsis in time you can watch as the patient gets better’

Carrie Hayhurst, clinical lead for sepsis team

‘The majority, about 90%, of sepsis cases in a hospital arrive into the ED,’ says nurse Carrie Hayhurst, clinical lead for the team. ‘The aim is to strengthen our response and improve our figures on the time it takes for the patient to receive antibiotics.’

Annual toll

Sepsis, the body’s systemic inflammatory response to microbial infection, can cause organ damage, shock and eventual death. It is believed to affect more than 120,000 people a year in England. The UK Sepsis Trust says about 44,000 people a year die as a result of the condition – more than die as a result of lung cancer.

44,000

The number of deaths per year from sepsis in the UK.

Guidance from the National Institute for Health and Care Excellence says patients at risk of sepsis should receive antibiotics within an hour of reaching hospital. But at Leicester the rate was only around 60-70%.

The dedicated team was set up in February last year with funding from the NHS Litigation Authority after the trust had struggled with sepsis care for a number of years. The Care Quality Commission (CQC) raised concerns during an inspection in 2014, when it was found that not all patients were being screened or treated appropriately for the infection.

‘A sepsis clinical pathway was in place but we found this was not always completed for patients, despite there being evidence of escalating Early Warning Scores,’ the inspection report said.

At follow-up inspections in 2015 and 2016 these same concerns were found to persist in the ED. The trust is still rated as needing improvement by the CQC.

Missed chances to save lives

The failings were not unique to Leicester. A 2013 report from the Health Service Ombudsman for England, called Time to Act, highlighted ten cases across the country where shortcomings in initial assessment and delay in emergency treatment led to missed opportunities to save lives.

But after progress on sepsis improvements stalled, the Leicester trust decided to launch the first ED sepsis team. When fully staffed with six full-time professionals, which can include paramedics and operating department practitioners, the team will be able to provide round-the-clock sepsis care in the busy department at Leicester Royal Infirmary.

‘Just ask the question, could it be sepsis? That’s the main thing’

Clair Ripley, sepsis practitioner

The sepsis team member on duty attends shift handovers and checks the observations for all ED patients via the IT system. They visit any patient who scores three or more on the National Early Warning Score to look through their notes and see if they warrant screening using the trust’s sepsis tool.

Hotline

Team members also carry what they call the sepsis phone, which ED colleagues or paramedics heading for the department can call if they suspect a patient is at risk.

With at least two thirds of patients who come through the ED having signs that could suggest sepsis, there is plenty of work for team members, who also look out for deteriorating patients. On a busy day up to 130 patients in the ED will have these early signs of sepsis.

90%

The proportion of hospital sepsis cases that present via the emergency department.

For Ms Hayhurst, who has a background in intensive care and critical care outreach, seeing a patient improve rapidly is hugely satisfying. ‘If we get sepsis in time you can watch as the patient gets better. Having worked in ITU, I have seen patients where we have not got it right, who are not responding and have multiple organ failure.’

Screening tool

The screening tool helps staff to assess whether a patient has an early warning score of more than three, or if they look unwell or have had an acute change in mental state, combined with an indication that they could have an infection.

If the answer to these questions is yes, the clinician is prompted to perform a rapid assessment using set criteria, including respiratory rate, blood pressure, urine output, new onset delirium and whether the patient is neutropenic or has had chemotherapy in the past six weeks.

A single positive answer in this assessment is classed as a sepsis ‘red flag’, which should immediately trigger the sepsis care bundle. All six steps, including blood cultures, supplementary oxygen if required, intravenous antibiotics and measuring lactate and urine output, should take place within an hour. A plan is also set out for those without red flags but who are judged to be at moderate risk.

Mortality rates down

The year before the team was launched about 800-1,000 sepsis screenings were completed in the Leicester ED. Last year, that jumped to 2,500. Red flags are raised for an average of 15 patients a day, and they are being screened as high risk.

‘Since we started we have improved massively,’ says Ms Hayhurst. ‘Our antibiotics-in-an-hour rate is averaging about 90%, but we have also noticed a big knock-on effect. Our hospital mortality rate has gone down and our ITU mortality rate has gone down from about 28% to 12%, because patients never get sick enough to go there and just aren’t deteriorating on the wards, as we are catching them.’

The trust board has agreed to continue funding the team following its success. It will become part of the critical care outreach team, but the ED work, and the red uniforms, will not change.

£2 billion

The cost of sepsis to the NHS each year.

Another aspect of the team’s work is education. They help train staff in recognising and responding to sepsis. Ms Hayhurst and her colleagues have already seen that all staff, including more junior colleagues, feel able to speak up about sepsis. ‘Sepsis is a silent killer and we are really trying to raise its profile,’ she says.

Empowered by pathway

Clair Ripley, a sepsis practitioner on the team, says staff need to understand that sepsis can be difficult to pick up as its symptoms may be vague.

‘Sepsis is indiscriminate and it is quite non-specific,’ she says. ‘Patients describe feeling worse than they have before, but that is quite subjective. Health professionals have not really known what to look for, but the new sepsis pathway has really helped to empower people to treat patients.’

There is one thing that all staff can do to improve care, Ms Ripley says. ‘Just ask the question, could it be sepsis? That’s the main thing. If you think the patient could have sepsis go to the senior nurse. It is just about planting that seed. The answer might be no, which is fine. Staff are now a lot more empowered to have that conversation and the culture is slowly changing.’

Sepsis red flags

  • Responds only to voice or pain, or is unresponsive
  • Acute confusional state
  • Systolic BP ≤90 mmHg (or drop >40 from normal)
  • Heart rate >130 per minute
  • Respiratory rate ≥25 per minute
  • Needs oxygen to keep SpO2 ≥92%
  • Non-blanching rash, mottled/ashen/cyanotic
  • Not passed urine in past 18 hours/urine output <0.5 ml/kg/hr
  • Lactate ≥2 mmol/l
  • Recent chemotherapy

Source: UK Sepsis Trust

Tips on identifying sepsis

  • Think 'could this be sepsis?' if a person presents with signs or symptoms that indicate infection
  • People with sepsis may have non-specific, non-localised presentations, for example feeling very unwell, and may not have a high temperature
  • Pay particular attention to concerns expressed by the person and their family or carers, for example changes from usual behaviour
  • Assess people with suspected infection to identify possible source, factors that increase risk of sepsis and any indications of clinical concern, such as new onset abnormalities of behaviour, circulation or respiration
  • Use a structured set of observations to assess people in a face-to-face setting to stratify risk if sepsis is suspected

High risk patients

  • Those aged under one year, over 75, or who are very frail are at higher risk. Risk is also increased in people with impaired immune systems, who have had surgery or other invasive procedures in the past six weeks, people with breaches of skin integrity (cuts, blisters), people who misuse drugs intravenously, and people with indwelling lines or catheters
  • Women who are pregnant, have given birth or had a termination of pregnancy or miscarriage in the past six weeks are in a high-risk group for sepsis

Adapted from NICE guidance Sepsis: Recognition, Diagnosis and Early Management.


Erin Dean is a freelance health journalist

 

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