PATIENT SAFETY
deteriorating on the ward, sepsis is not commonly an obvious or end-of-bed diagnosis. Compare this with other time- critical conditions, such as acute coronary syndrome and stroke, in which sufferers typically present with classical signs and symptoms. Furthermore, the diagnosis of sepsis is complex, requiring analysis of a battery of clinical information incorporating both physiological and laboratory data and relies on an index of suspicion.
Nurturing improvement This index of suspicion, coupled with the necessary knowledge and awareness, is key to recognising sepsis early and reliably delivering optimal care. Education will provide the foundations, but to change the culture to one of sepsis as a medical emergency through undergraduate education alone will take decades to achieve.We need to focus on strategies to improve process and structure. Process is an easier fix. Many, if not
most, hospitals now use examples of sepsis screening tools and care pathways based upon the Surviving Sepsis Campaign care bundles. As stand-alone documents, these will serve only to highlight the lack of awareness and will achieve little, but incorporated into a modified early warning score (MEWS), or another track-and-trigger system, they will begin to identify patients at an earlier stage. A triggering MEWS is between 50% and 68% specific for sepsis, so it is reasonable to recommend a sepsis screen in any patient triggering.18
Its sensitivity,
however, is lower, and ways to identify patients missed by MEWS need to be
‘If we can nurture a health system where just 80% of our patients receive optimal care using operational bundles such as the Sepsis Six, we estimate that 10,000 lives will be saved annually in the UK.’
considered – screening all patients with an elevated white blood cell count has been shown to be of utility.19
A number of
commercial bodies are currently developing strategies to automate sepsis recognition, but this will be hindered by cost. The UK Sepsis Group, in collaboration with the Global Sepsis Alliance, is currently developing an ‘App’ across major platforms to assist junior health workers with sepsis recognition. Operational difficulties in presenting
the Surviving Sepsis Campaign Bundle in its entirety across health systems (with its inclusion of complex peri-Critical Care tasks) have led many organisations to implement simplified sub-bundles, one of the more widely used of which is the Sepsis Six (
www.survivesepsis.org).20 Such operational solutions help to ‘front- road’ care, facilitating delivery of the basic aspects, the most important of which are antibiotics and fluids, by relatively junior staff immediately following identification. The Sepsis Six (Fig. 2) has been shown to be associated with a 50% reduction in mortality.18
Moreover, unpublished data
from this study showed that patients receiving the Sepsis Six were likely to stay two fewer days in Critical Care and overall 3.4 fewer days in hospital,
meaning an estimated £3,500 cost reduction for each survivor. Structure is more complex. Sepsis is
not ‘owned’ by a particular specialty, although a common destination for many is Critical Care. Patients present with sepsis at arrival in the Emergency Department, but also develop sepsis at a varying time following admission, either as a result of their primary diagnosis (the majority) or due to healthcare-associated infection. Unless the role of ‘generalist’ returns to our hospitals, this lack of ownership is unlikely to change. Sepsis remains, therefore, a whole-system problem: but the system is not engineered to accommodate this. Local solutions tend to focus on the use of Critical Care Outreach or Hospital at Night teams to bridge the gap between wards, the Emergency Department and Critical Care, but to create truly seamless care for these seriously ill patients requires a more co- ordinated approach. The ProMISe study has begun to address this gap through a linking of Acute Medicine, Emergency Medicine and Critical Care, and the College of Emergency Medicine audit for 2012 of performance against standards of care will raise awareness, but these strategies still do not offer seamless care.
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Schülke & Mayr UK Ltd Phone: 0114 254 3500 | Fax: 0114 254 3501 |
www.schulke.co.uk |
mail.uk@
schuelke.com
MARCH 2012
THE CLINICAL SERVICES JOURNAL
47
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