SEPSIS MANAGEMENT
comprise a triad of determinants of clinical outcome in people with acute illness.3 The early warning system (EWS) works by checking basic physiological signs, as above, at intervals, (tracking) and responding as necessary to abnormal physiological parameters (triggers). EWS was developed to enable clinicians to recognise patients with established or impending critical illness; and to empower then to obtain experienced help. A review of 33 EWS found that NEWS was the most effective in predicting patients at risk of cardiac arrest, unanticipated intensive care unit admission or death within 24 hours.4
A NEWS score of ≥5 has been found to be effective in identifying possible sepsis.5
National Early Warning Score 2 NEWS2 has been updated to align the measuring system with The Resuscitation Council (UK) sequence ABCDE. The range of boundaries for the physiological parameter scores has now been included onto the chart. In addition, the chart has a dedicated section (SpO2
Scale 2) for use in patients with hypercapnic respiratory failure (usually due to chronic obstructive pulmonary disease) who have clinically recommended oxygen saturation of 88-92%. There is a further section of the chart which enables the recording of the rate per minute and the device used for supplemental oxygen delivery. NEWS2 also has changed in colour on
the chart, as those with colour blindness had difficulty in reading the red and green sections. In addition, the part of the chart which records the level of consciousness has also been updated to reflect a ‘new confusion’. This is designed to record any disorientation, delirium or agitation to the score, which adds to the signs of clinical deterioration. If patients are accompanied to the A&E department, or carers are present at the initial assessment, they can be asked to supply information on whether there is new confusion. It can be difficult for clinicians assessing patients they do not know and some of the signs can be very subtle. NEWS2 seeks to standardise the system in use across different sectors ie: community, ambulance services and acute hospital staff all using the same system. Recent reports have suggested that staff in Nursing homes or ambulance responders have been asked for NEWS2 scores to enable them to
prioritise their response. This can only be good news for patients requiring emergency responses and needing the best care possible to patients with the most critical needs. NEWS2 is not designed to be used on children under 16 years or pregnant women. Using the same system across the NHS also helps when consistent standardised approaches are used from one NHS Trust to another, as staff move from one Trust to another during their training and working lives. NEWS2 has not yet had time to be rigorously evaluated in hospital settings and further studies are required. In addition to the dataset which will emerge from the dashboard data.
Suspicion of Sepsis Dashboard
A patient safety collaborative and Imperial College Health partners have jointly developed a dashboard which was launched to help the NHS to accurately measure the number of patients admitted to hospital who are at risk of sepsis. The dashboard has provided clinicians with a national consistent measure for hospital admissions with infections or a ‘suspicion of sepsis’ to identify their length of stay, discharge and associated mortality rate. The dashboard enables clinicians to monitor the impact of improvement measures and gain retrospective insight on the effectiveness of their interventions with accurate data, allowing them to better plan future treatment regimes. Many of the regional patient safety collaboratives around England, have committed to adoption and spread of the Dashboard.6
NICE guidance The NICE guidance is available and covers
The NEWS provides the basis for standardising the training of all staff engaged in the care of patients in hospitals and pre-hospital assessment of patients. The education of staff should also be extended to incorporate all undergraduate training for medical, nursing and allied healthcare professionals.
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the recognition, diagnosis and early management of sepsis for all populations. The guideline was reassessed in April 2019 to reflect the publication and use of NEWS2 and update the guidance as necessary. The guidance is intended for use by people with sepsis, their families and carers as well as by healthcare professionals in primary, secondary and tertiary care.7
International adoption of NEWS
NEWS has been widely adopted not only by many in the NHS across the UK but in developed healthcare systems around the world. The World Health Organization (WHO) is currently working on sepsis rates in the low and middle income world. For example, infection after caesarean section is an important element in the epidemiology of sepsis because caesarean section is the most common surgical procedure in the world. In Africa, 20% of caesarean sections lead to surgical site infections which may turn into sepsis, resulting in inability of the mother to take care of the newborn and death in some cases. Implementation strategies to minimise maternal sepsis are being developed. The epidemiology of sepsis is better known in adults than in children, yet neonatal and child mortality due to sepsis is a major problem. There are an estimated 2.9 million deaths worldwide from sepsis every year (44% of them in children under five years of age) and one quarter of these are due to neonatal sepsis.8 The World Health Organization expert meeting identified that there are many challenges related to sepsis across countries. It is therefore important to understand what capacity each country has - and how difficult issues such as antimicrobial resistance (AMR) should be dealt with. While there is an urgent need for new antibiotics, these alone are unlikely to overcome sepsis and AMR. The need for better diagnosis and infection control is paramount. It was reported to WHO by the Surviving Sepsis Campaign in UK that awareness about sepsis is still quite low in the United Kingdom because sepsis is often under- coded and underreported. Health professionals worldwide use a variety of scoring systems to diagnose sepsis. Researchers in the United Kingdom showed that the National Early Warning
OCTOBER 2019
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