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NHS England’s Medical Director for Clinical Effectiveness looks at the progress made in recognising and treating sepsis, and the National Early Warning System that can support clinicians to spot the signs, standardise diagnosis and ultimately save lives:
I spent 10 years as a colorectal surgeon so I’m well aware of the impact that serious infections and sepsis can have on patients and their families, especially when the infection is resistant to antibiotics.
There is also a big impact on staff and a cost to healthcare organisations to limit the spread of these infections.
I Chair the Cross System Sepsis Programme Board, tasked with improving sepsis care across England in all care settings, and I led the call for the introduction of a CQUIN in 2015 to help acute trusts focus on better recognition and prompt treatment of sepsis.
The board wanted to support the use of the Sepsis Six, but needed very simple metrics, so after discussion with stakeholders we settled on assessment of high risk patients for sepsis, and time from recognition to first antibiotic administration. We asked that high-risk patients should be identified using some type of Early Warning Score.
Initially we introduced this CQUIN for patients arriving in emergency departments (ED), and then later spread to those on in-patient wards. We added the three-day review of antibiotics to reduce the risk that patients might be inappropriately put on long courses of antibiotics that they didn’t need. For 2017-2019 we linked the work on reducing anti-microbial resistance into a joint CQUIN – ‘Reducing the Impact of Serious Infections’.
The CQUIN has gone well. Headline figures show that since 2015, across England in the samples submitted, the assessment for sepsis has increased from 52 per cent to 89 per cent in ED, and from 62 per cent to 75 per cent for in-patients. Prompt antibiotic treatment – within an hour of recognition of sepsis – has increased from 49 per cent to 70 per cent in ED and from 60 per cent to 80 per cent for in-patients.
We estimate, based on these samples that at least 1,600 lives have been saved due to the sepsis CQUIN and frontline staff responsible for this should be proud of their achievements. I recently wrote to the chief executives of the 20 trusts that had shown the greatest improvement on the sepsis CQUIN to congratulate them and their staff.
There is, however, still more to do. Firstly, not all trusts are submitting data to the CQUIN, so we don’t have information about how well sepsis is being spotted and treated in every hospital. Secondly, the overall average figures hide variation in performance between trusts.
The burden of data collection for the sepsis CQUIN is quite high for trusts that do not yet use an electronic platform for recording vital signs and calculating National Early Warning Scores (NEWS).
Electronic platforms can help to improve the accuracy of the calculation of NEWS and some of them also provide alerts directly to an appropriate clinician to act on the deterioration more rapidly. The difference between trusts using electronic observations systems and those that are not is apparent when you find that the collective number of patients’ data submitted in the CQUIN by trusts not using such systems is 27,000 between 107 trusts. By contrast, the two trusts who submitted sepsis CQUIN data electronically sent data on 590,000 patients.
Since the sepsis CQUIN work started, it has become apparent that NEWS (most recently NEWS2, launched by the Royal College of Physicians in 2017) is the best validated tool, and is already being used in around 75 per cent of acute trusts. NHS England is asking all trusts to move to be using NEWS2 by March 2019 as part of their approach on sepsis and to qualify for the CQUIN payment.
NEWS2 is endorsed by the National Quality Board. Matt Inada-Kim, National Clinical Advisor on sepsis explains: “For clinicians to appropriately and reliably manage (detect, communicate and escalate) sepsis and all cause deterioration, the NHS should move to using NEWS2 as the single language of sickness across all conditions and settings.
“When patients are admitted as emergencies, the exact cause of deterioration is often unclear, and separating the pathways for sepsis from other causes of deterioration is harmful. We have a wonderful opportunity to standardise the management of sepsis and deterioration and radically improve the care of acutely unwell patients across England.”
For the future we are listening to people who are developing more data analysis to better define which patients need immediate antibiotics to save their life, and those for whom it’s ok to wait a few hours to find the infecting organism and its sensitivity profile so that antibiotics can be targeted better.
We welcome the close working relationship that we have with colleagues focussing on antimicrobial resistance and those focussing on better infection prevention, since a joined-up approach will help all of us realise our goals to improve the quality and outcomes for all our patients.