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