As NHS RightCare publishes its Sepsis Scenario, following a patient’s journey along a sub-optimal, difficult scenario versus an ideal pathway, an Acute Medicine consultant explains the unique opportunity and challenge of a standardised NHS language of sickness:
As a front line clinician who assesses undiagnosed, unwell patients, I can relate that it is not always easy to exactly fathom the reasons why a patient deteriorates.
As a consequence, I work on educated hunches, or suspicion, with possible causes being ruled in and out. The term ‘suspected sepsis’ sums this up well.
Awareness around sepsis has risen remarkably in the last few years. Both healthcare professionals and patients have become more vigilant and are applying the ‘Think Sepsis’ mantra in deterioration cases.
However, clinicians must be mindful that not all deteriorations are caused by sepsis. For this reason, it is crucial that there is no separation of the pathways of care within all cause deterioration and sepsis, and that the scoring systems to define and communicate risk within these conditions are identical and well understood.
Suspicion of Sepsis (SOS): those admitted with bacterial infections that can cause sepsis are responsible for one-third of emergency admissions in England – 1.8 million episodes per year – and cause two-thirds of deaths. Patients admitted with these diagnoses have five times the mortality of other causes.
Sepsis, which is the most severe category of SOS, is estimated to affect 123,000 patients a year in England and cause 37,000 deaths.
I don’t know of any dedicated clinical teams that directly and continuously look after patients with sepsis, and consequently, all healthcare staff should be ‘sepsis aware’ and competent at recognising and managing it. The NHS RightCare scenario demonstrates the difference between a ‘sepsis aware’ and ‘sepsis unaware’ system and the huge impact this can have on patient outcomes.
Sepsis can happen to anyone, and in any environment, and currently doesn’t have a diagnostic test. Until recently, it had a multitude of different definitions leading to confusion amongst healthcare professionals and huge variation in its reported numbers and mortality rates.
In patients with SOS, the Royal College of Physicians (RCP) National Early Warning Scores (NEWS2) is probably the best validated system for predicting risk of death and survival in the majority of cases. It can be tracked over time, easily communicated and, crucially, can be used by all healthcare professionals in all environments.
It is pleasing to see that there is national alignment and support from the key arm’s length bodies. NHS England, NHS Improvement, RCP, the National Quality Board and the National Confidential Enquiry into Patient Outcome and Death have all endorsed its use in acute and ambulance settings, and are encouraging its use across community settings.
The most critical step in sepsis care is the early review of patients with physiological risk – signified by a total NEWS of five or more – by a competent clinician and the use of clinical judgement to determine if a sick patient has suspected sepsis. Not all of these will have sepsis but ensuring it’s considered in all patients with these diagnoses is critical to improving outcomes. Whilst no clinician would delay antibiotic treatment in a patient with suspected sepsis, their decisions should always be balanced against the harms of antibiotic overtreatment e.g. rising resistance and side effects.
The NHS England Sepsis implementation guidance and revised Sepsis CQUIN reinforce the huge role played by clinical judgement in determining who, or who should not, receive expedient antibiotic treatment.
Healthcare professionals are understandably not always comfortable in determining if suspected infection is present, so a logical step, outlined in the guidance, is to get an urgent senior review to make that decision and determine appropriate treatment.
There is careful wording within the implementation guidance and CQUIN, stating that once sepsis is suspected there is a 60 minute timeframe between this point and the administration of effective antibiotic treatment.
I have seen first-hand that to achieve the best possible outcomes for a patient, teams must communicate well with each other. A common language that is understood by everyone involved, at every level throughout healthcare would enable all involved to express concern, communicate and understand risk and have a shared mental model for the delivery of optimal outcomes.
The NHS has a wonderful opportunity to radically improve outcomes for patients with sepsis and all cause deterioration, by collaborating across pathways of care in all environments – embracing NEWS2 as its standardised language of sickness and becoming a truly ‘sepsis aware’ system.
This will not be easy.
To those who are wedded to differing systems to describe sickness, please consider the bigger picture and the benefit of using NEWS2 for your patients, as well as the ‘system’, as they move from one environment and healthcare team to another and the improved outcomes this is likely to deliver.
The establishment of a standardised communication system is long overdue.
- For more on this see our NHS RightCare Scenario webpages.