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Nigel's surgery 88: Sepsis

Categories:
  • Organisations we regulate,
  • GP and GP out-of-hours services

GPs and practices providing in-hours services are not likely to encounter sepsis frequently, but early detection is vital.

Here we give guidance on good practice for identifying and responding to sepsis.

What is sepsis?

Sepsis is a term used to describe the body’s abnormal response to infection. The international definition of sepsis is 'life-threatening organ dysfunction caused by a dysregulated host response to infection'. The effects are from the body’s toxic response to the infection.

The Sepsis Alliance defines it as 'the body’s overwhelming and life-threatening response to infection that can lead to tissue damage, organ failure and death. In other words, it’s your body’s overactive and toxic response to an infection.' Sepsis affects many different organs so it can be hard to spot. A full set of physical observations can support clinical judgement to make this difficult diagnosis.

It can affect anyone but is more common in people who have a weakened immune system, a long-term condition, are very young or are frail. The incidence is particularly high in patients with a learning disability. It can be catastrophic if undetected and untreated; leading to multi-organ damage and The UK Sepsis Trust estimates it leads to 52,000 deaths each year in the UK.

Practices must be aware of sepsis and be able to demonstrate how an acutely unwell or deteriorating patient is managed before and during an appointment, including any ongoing referral or care.

Symptoms

Symptoms of sepsis for babies and young children may include:

  • abnormal temperature – low as well as high
  • difficulty breathing
  • lack of interest in eating and drinking, or have stopped feeding
  • not passing urine for 12 hours or longer
  • repeated vomiting
  • change in mental state including unresponsiveness or agitation
  • irritability
  • mottled pale or bluish skin, or a rash that does not fade when pressed

Parental concern is another key feature that needs to be considered.

Symptoms for adults and older children may include:

  • feeling extremely unwell
  • abnormal temperature – low as well as high
  • chills and shivering
  • a fast heartbeat
  • fast breathing
  • feeling dizzy or faint
  • decreased urine production
  • a change in mental state, such as confusion, disorientation or agitation

Early identification of sepsis

The 2015 National Confidential Enquiry into Patient Outcome and Death (NCEPOD) report Just Say Sepsis highlights the importance of accurate early assessment and recording and sharing clinical findings.

Physiological assessments

These are an important part of clinical assessment and include:

  • pulse
  • temperature
  • blood pressure*
  • respiratory rate*
  • oxygen saturations

Perform these when a patient presents with an acute illness, or a deteriorating preexisting condition, particularly where sepsis is suspected.

* A raised respiratory rate, poor perfusion or low blood pressure and new onset confusion offer a higher predictive value than the other measures. They are particularly important to record.

National Early Warning Score (NEWS2) is used by all hospitals and ambulance services in England as a tool for identifying patients with sepsis. If GPs score patients using NEWS2 it can form part of a common language to describe concern and track deterioration. Early indications are that mortality from sepsis falls at sites using scoring systems routinely at patient handover.

Use the term ‘suspected sepsis’ at handover alongside their NEWS2 score or physiological measurements.

Telephone or online consultation

It is difficult to assess unwell people with infection indirectly. There should be a low threshold for progressing to a face to face assessment. If sepsis is a significant possibility, consider bypassing a primary care face-to-face assessment and admit to hospital urgently.

Safety netting

If patients show signs of infection, but not sepsis, give clear and specific advice about what to do next. Ideally, give this in writing. This makes sure patients with unresolved or worsening symptoms know when and how to get further advice.

What we expect to see on inspection

GP practices should take measures to help manage the risks associated with sepsis. We may consider these as part of our inspections under key lines of enquiry (KLOE):

Areas to consider:

  • Training: recognizing and responding to acutely unwell or deteriorating patients who may have sepsis. Empower receptionists to recognize what doesn’t sound right and to raise concerns. The RCGP Sepsis Toolkit has training resources for reception staff.
  • Triage processes: designed to include identifying and rapidly responding to possible cases of sepsis
  • Equipment: readily available to assess patients with possible sepsis, for example to measure blood pressure, temperature and pulse oximetry for adults and children (see Nigel's Surgery 1: Resuscitation in GP surgeries). Practices need to be aware the Patient Safety Alert regarding the placement of pulse oximeter probes.
  • Flu vaccination: high coverage, particularly in the over 65s, pregnant women, and those with long-term conditions, especially those with learning disability. Good practice includes incorporating NEWS baselines in annual checks for at risk adults (for example people in care homes or with a learning disability.
  • Information: providing guidance on sepsis for higher-risk patients and their carers, for example people with long-term conditions or prescribed immunosuppressive drugs. Good practice would formally incorporate this into medication reviews.
  • ‘Safety netting’: giving written advice about sepsis to patients who have infections.
  • Tools: using sepsis assessment and audit tools, considering auditing whether physiology was recorded for patients admitted to secondary care
  • Recording and sharing information: include accurate physiological measurements about a patient’s condition and use a common language with other services when admitting patients
  • Practice meetings: discussing sepsis management
  • Infection control: effective hand hygiene and actively encourage staff influenza vaccination.
Last updated:
04 April 2019

 


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