SEPSIS

GP trainees Anne Hunt

@SepsisSrLister

Plan

Sepsis: national and local figures

Audit feedback

Decision making resources

Safety netting

Learning from incidents & complaints

Post sepsis syndrome

Sepsis – in numbers

(UK Sepsis Trust, 2016)

150,000 hospital admissions / year

Incidence potentially 260,000 cases / year

80% of infections leading to sepsis originated in the community

44,000 deaths in UK attributed to sepsis

Estimated 13,000 could have been prevented

Records of prevalence and incidence of sepsis in the UK are not robust

Consider sepsis with discharge summaries pneumonia, pyelonephritis

Watford Football Stadium 21,500 seats

Sepsis at East and North Herts

64,000 patients seen in Majors / Resus over 12 months 2016 - 17

Over 2000 of these patients had red flag sepsis

52 patients admitted to ICU with sepsis in first 3 months 2017

5 of these patients required 4 or more organ support

Surviving Sepsis

Sepsis Six within 1 hour

IVABx ‘value added step’

Mortality increases by 7.6% for every hour antibiotics are delayed

CQUIN Targets

2a Every patient who should be screened for sepsis is screened for sepsis

2b Every patient who was found to have sepsis receives IV antibiotics within 1

hour of meeting high risk criteria

Clock starts at time of Red Flag

2c Antibiotics are reviewed by senior clinician between 24 – 72 hours

Narrowest spectrum according to diagnosis, culture & sensitivity

Switch to oral, Stop dates

2d Reducing antimicrobial consumption

Feedback: July audit

50 patients with Red Flag Sepsis audited

40 patients BIBA

16 Pre Alerted (15 Sepsis)

9 developed Red Flags >1 hour after arrival

15 Pre Alerts for Sepsis

Many were GP referrals

Thought Sepsis!

Oxygen

IV Access

All 15 received IVABs within 1 hour

14 survived & left hospital

Red Flags not pre alerted

4 High Resps / Low Sats in COPD

2 on Chemo

3 with confusion

Plus one confusion pre alert ?Stroke

NICE Guidelines

Pre-alert secondary care (through GP or ambulance service) when any high

risk criteria are met in a person with suspected sepsis outside of an acute

hospital, and transfer them immediately

Ensure urgent assessment mechanisms are in place to deliver antibiotics when

any high risk criteria are met in secondary care (within 1 hour of meeting a

high risk criterion in an acute hospital setting).

Take blood cultures before antibiotics are given

UK Sepsis Trust

RCGP Toolkit

http://www.rcgp.org.uk/clinical-and-research/toolkits/sepsis-toolkit.aspx

Produced by Drs Simon Stockley, Ron Daniels and Tim Nutbeam

Operational solutions to complexities of sepsis management in General

Practice

Compatible with

NICE guidelines for Sepsis

Antimicrobial Resistance Strategy

Sepsis Aware Consultation

History – consider taking observations; change from baseline

Pay particular attention to concerns expressed by the person and their family

or carers

changes from usual behaviour

Failure to improve

“I feel like I’m going to die”

Assess people who might have sepsis with extra care if they cannot give a

good history

people with communication problems

People who speak little / no English

Amber Flags: Safety netting

Amber Flags: Sepsis possible; safety netting

Clinical judgement

Deterioration from baseline

maybe manage in community setting

Consider:

Planned second assessment +/- blood results +/- urine culture

Specific safety netting advice

Practicalities: don’t assume

Can they take (antibiotic) tablets? Just ask

Swallowing – size, crush, suspension

Can they keep them down?

Vomiting

Social arrangements – living alone

Has the patient understood?

What to do if…

AKI: Think Kidneys!

Sick Day Rules (Medication)

Safety Netting: Say Sepsis Seek medical help urgently if you develop any of these…

Slurred speech or confusion

Extreme shivering or muscle pain

Passing no urine in a day

Severe breathlessness

It feels like you’re going to die

Skin mottled or discoloured

Issues at Hospital

Capacity

Pre Alerts diverted to majors

Medical expected - sent to AMUA, wait…

Improvement on journey

Oxygen +/- IVF en route

Handover crucial

Red Flag was present: IVABs within 1 hour

Use of NEWS prehospital

Incident’s & Complaints

Baby A – mottled

Mrs S – redirected GP referral

Mr D – repeated urosepsis

Mr F – repeated urosepsis

Mrs H – atypical meningococcal septicaemia

Miss N – LD; urosepsis; recent discharge

Baby A – Born @ 27 weeks

12 weeks old

17.26 s/b GP T-38.6 unknown origin; very young vulnerable parents

Referred to Paeds

Family left before letter was ready, faxed to ED ‘hope they attend’

no transport

19.22 booked in @ Lister

20.00 arrived in CAU: looks mottled; smiling & alert; T 37.7 after calpol

20.45 Sats <90% (76% when feeding); Mottled; irritable; low U/O

21.50 pH 7.24 Lactate 5.2

Septic screen, including LP => IV Ceftriaxone & IV fluids

Baby A: concerns

Ambulance transfer would have been appropriate

3 day admission

Negative blood cultures and LP

Mrs S – redirected GP referral

GP referral ?Sepsis (one of 31 referrals that day; 4 arrived within same ½ hr)

BIBA – pre alert: sats 88% on air – Red Flag

Sats rising to 98% with O2 – still Red Flag!

Redirected to majors as resus was full 15.23

Redirected to AMUA as Medical expected

Red Flag on arrival missed

Lack of capacity in AMUA

Long corridor / trolley wait

IVABs given at 20.15

Learning from Mrs S case

Training all receiving staff to recognise high risk criteria

Importance of handover

Red Flags

NEWS score

Empowering EEAST crews, common language

AMUA ring fencing assessment area

Work in progress

Mr D – repeated urosepsis

Multiple admissions with urosepsis 2’ dehydration

Resistant bacteria

Picked up on Meropenum Ward Round

Lived in residential home

Losing independence

Unwilling to accept help

Mr D – repeated urosepsis

Patient Education

Hydration

Regular voiding

Early symptoms

Residential home staff education

Offer regular drinks

Keep them close to him

Monitor intake

Ease of getting to toilet

Early signs to spot deterioration

Mr F – repeated urosepsis

59 years old, profound learning disability

Incontinent of urine, used pads

Supported living

Prolonged hospital admission following blocked PEG

Multiple courses of IVABs

Rebound sepsis

Mr F – repeated urosepsis

Dramatic decline from baseline over 6 months

Weight loss

Case conference

Breaking the cycle of sepsis

What were we missing

Imaging

Enlarged prostate

Too poorly to undergo surgery

Home with support from community nurses

Mrs H – 61 years old

Wrist pain after 4 day history of flu-like illness

1st ED attendance (ever); 05.15

NEWS 1: HR 105

Erythaemic bump on right wrist

Streamed to UCC

NEWS 2: HR 99; Sats 95%

Thorough consultation

Bloods taken

1 litre IVI

Mrs H – 61 years old

Blood results

WBC 5.2

Platelets 67

CRP 271

Creatinine 128

D/W Med Reg – too busy to see

Diagnosed Reactive Arthritis

NSAIDS

Follow Up in Ambulatory Care

Mrs H

Returned next day

Rising respiratory rate & heart rate

Rapid deterioration => ICU

Septic Shock

Source: atypical meningococcal septicaemia

3 months intensive care, 5 month length of stay

Bilateral leg amputations

Deaf

Miss N

19 years old

Learning disability

Urine infection

Early discharge ‘facilitated’

Miss N

‘Reasonable adjustments’

Missed doses of antibiotics

Unable to swallow

Vomiting

Paramedic – didn’t want to go back

OOH GP – do not disturb, anti-emetic

Wanting to please

Rapid deterioration

Septic shock

Questions & Comments

Post Sepsis Syndrome

Affects 50% of survivors

Psychological and physical symptoms

Hair and skin loss

Amputations and joint pains

Hallucinations and Cognitive difficulties

Similar to post ICU syndrome but present in patients

Financial worries

Fear of recurrence

PSS

Diet & Exercise advice

Talking therapies; psychologist

UK Sepsis Trust – support groups

Follow up bloods – renal function

Sepsis Nurses