Leading change

The Community Infection Prevention Nurse (IPN) & Sepsis Lead at Lancashire County Council (LCC) led on a programme of work to implement a local community sepsis strategy and a sepsis training and development delivery programme. This has improved service provision for care homes across Lancashire.

Where to look

Sepsis is a life-threatening organ dysfunction caused by a dysregulated host response to infection (Singer et al., 2016). When people suffer from sepsis, the body’s immune system overcompensates causing widespread inflammation, swelling and blood clotting. These reactions can cause a significant reduction in blood pressure, which can decrease the blood supply to vital organs and starve them of oxygen. If not treated quickly, sepsis may lead to multiple organ failure and death. Whilst anyone is at risk of sepsis, older people are at greater risk of sepsis (NHS England, 2015), as they are often immune compromised, living with comorbidities and prone to infections.

Across Lancashire there are over 400 residential and nursing care homes. Care home staff routinely report on numbers and types of infections experienced by care home residents. However, no baseline data exists on the numbers of suspected sepsis cases. Local data indicated that urinary tract and respiratory tract infections are two of the most common types of infections experienced by care home residents. These infections are often associated as a risk factor for sepsis and hospitalisation.

With this evidence base, as well as drawing from post infection reviews for MRSA and C. difficile infections and discussions with district nursing teams, the Infection Prevention Nurse & Sepsis Lead identified opportunities to improve the early identification and timely referral to treatment for care home residents with suspected sepsis. The opportunities for improvement included:

• Unwarranted variation in consistent, best practice and evidence based approaches to screening care home residents for suspected sepsis;
• Unwarranted variation in the use of language and clinical evidence to communicate to GPs and the local ambulance service that sepsis was suspected;
• Unwarranted variation in the timely escalation for appropriate healthcare.

These variations in practice were deemed to be contributing to poor experiences for care home residents.

What to change

The Infection Prevention and Control Team (IPCT) provide advice, support, training and education, and quality improvement to health and social care providers, as well as advice, support and assurance to local commissioners. Prior to 2017, across Lancashire care homes, there was not standardised provision of:

• A local sepsis strategy,
• A sepsis training and development delivery programme; or,
• Specialist advice, support and resources on sepsis.

The IPN & Sepsis Lead saw an opportunity to address this unwarranted variation to improve experiences and outcomes, as well as the use of resources across the area.

How to change

Following engagement with key stakeholders the IPN & Sepsis Lead initially:

• Carried out a sepsis training needs analysis for care homes and primary care with local CCGs to identify variation and gaps;
• Developed a Sepsis Strategy for Lancashire Care Homes 2017-2020 in consultation with 6 local CCGs, local care homes, North West Ambulance Service (NWAS), Advancing Quality Alliance (AQuA), NHS England National Sepsis Lead and a sepsis survivor, UK Sepsis Trust. The strategy was launched in July 2017;
• Developed evidence based sepsis training and development sessions for care homes;
• Promoted awareness of sepsis amongst key health and social care providers in the community.

Face to face training was rolled out with the support from a local critical care/sepsis team. Key objectives of the training for care staff were to:

• Understand the importance of infection prevention;
• Have increased knowledge of sepsis;
• Be knowledgeable, confident and skilled to detect, manage and escalate residents for time critical healthcare;
• Implement infection and risk principles with the support of tools such as NEWS2 and associated escalation protocols and;
• Have improved awareness of the care needs of residents with post-sepsis syndrome.

The use of consistent methods to detect, track and trigger suspected sepsis and/or cases of deterioration helps care home staff to manage residents effectively and improve outcomes.

Adding value

Better outcomes – Between September 2017 and January 2019, over 200 care staff from residential and nursing care homes have attended the sepsis training and development sessions. Care home staff across Lancashire are now implementing the approaches from the training in their care homes to improve experiences and outcomes for residents. It has been noted that the number of ambulance call outs to the home(s) and hospital admissions have reduced, with infections being treated earlier within the care homes. Suspected sepsis cases are being identified earlier and escalated appropriately for time critical healthcare. Communication and support for care home residents to return home after treatment in hospital for sepsis has also improved.

Better experience – Care home staff have welcomed the training and new approaches within their homes as they help with care being provided “in the right place, at “the right time”. Feedback from care home staff includes:

‘This course is excellent and should be rolled out to all care homes’

‘I would recommend this training to all people involved in care’

‘Improved my knowledge and understanding of sepsis greatly’

‘I am looking forward to applying the methods from this course in my care home’

Residents and families have also responded positively, anecdotally reporting that they appreciate prompt assessment and awareness of deterioration.

Better use of resources – Care home staff are now able to communicate NEWS2 scores to GPs and ambulance services together with a detailed account of the resident’s signs and symptoms of deterioration. This helps with communication and management across the pathway and appropriate decisions about where the residents should best be cared for can be made. Consistency in using the NEWS2 tool across primary care, community services and care homes is making communication far more effective and reducing duplication.

Challenges and lessons learnt for implementation

There has been high demand and enthusiasm amongst care home staff (both residential and nursing) to attend sepsis training in order to better identify and manage deterioration and suspected sepsis for care home residents.

The presentation of sepsis can be variable and difficult to detect and diagnose. Building a sepsis aware community across patient pathways is essential to reduce unavoidable morbidity and mortality from sepsis.

Incorporating single systems, such as NEWS2, to manage deterioration and sepsis consistently across pathways is essential for improving patient outcomes.

It can sometimes be challenging to take all observations for NEWS2 for residents who have certain conditions i.e. Dementia and Learning Disabilities. Using soft signs of deterioration, signs of infection and clinical judgement can help with identification and appropriate escalation.

Multi-media approaches are helpful when trying to reach lots of people across lots of organisations. Consider how your offer is supported digitally as well.

During 2019-2020, the sepsis training and development sessions will be rolled-out to include Learning Disability providers.

For more information contact

Jane Mastin
Community Infection Prevention Nurse & Sepsis Lead
Lancashire County Council
jane.mastin@lancashire.gov.uk