National Confidential Enquiry into Patient Outcome and Death (NCEPOD)
Just Say Sepsis – An overview of the report
Sepsis is a leading cause of avoidable death in the UK, and kills more people than breast, bowel and prostate cancer combined. The condition occurs when the body is overwhelmed by an infection. In severe sepsis organs fail and in some cases this leads to septic shock (when blood pressure drops to a dangerously low level) and death. It is estimated that 65,000 people a year in the UK survive sepsis, but some suffer a long-term disability such as amputation and irreversible damage to lungs, heart and kidneys.
The NCEPOD report “Just Say Sepsis” was published on 24th November 2015. The study aimed to investigate avoidable and remedial factors affecting the care of patients with sepsis or suspected sepsis. A team of multi professional reviewers assessed 551 cases from throughout the UK using a retrospective case note review methodology.
The study collected organisational data, data regarding patient population and pre-hospital care, admission data to secondary care, data relating to hospital acquired infections, the first identification of sepsis and the initial management of septic patients. It also looked at complications of sepsis and discharge planning allowing advisors to comment on the overall quality of care. Overall quality of care was ranked either:-
Good practice (identified in 36.5% of cases)
Room for improvement (clinical) (identified in 27.4% of cases)
Room for improvement (organisational) (identified in 7.2% of cases)
Room for improvement (both) (identified in 22.7% of cases)
Less than satisfactory (identified in 6.3% of cases).
The study identifies huge variability in the recognition and response to septic patients. There was generally poor documentation of clinical observations by both primary and secondary care providers that could have improved the management and handover of patients. 40% of patients in the Emergency Department (ED) did not have a timely review by a senior clinician.
Only 46% of patients admitted via the ED has a possible source of infection recorded. For patients who were appropriate for source control this was delayed in 43% of cases with the outcome negatively affected in 26/41 patients.
20% of the patients included in the study did not have a consultant review within the recommended 14 hours. However, when a consultant review did take place, amendments to treatment occurred in over 60% of patients suggesting that early senior review is imperative
Only 43/73 patients has a surgical site bundle completed despite a quarter of the patients’ in the study contracting their infection in hospital and half of these following a surgical procedure. In 10/88 patients the reviewers felt that the infection was preventable.
There was a delay in diagnosis of sepsis in 36% of cases, severe sepsis in 51% of cases and septic shock in 32% of cases. Comprehensive documentation was associated with a timely diagnosis.
Despite evidence of sepsis protocols in use investigations essential to the diagnosis of sepsis were missing in 39% of patients and delayed in a further 39%. Less than 40% of patients were started on a sepsis care bundle despite evidence of reduced delays in treatment following commencement.
Only 25% of acute hospitals used standard proformas to identify and monitor septic patients.
A microbiologist was involved in the management of septic patients only 52% of the time. This is essential to aid the appropriateness of antimicrobial usage
22% of patients had complications following discharge but there was little evidence of patient information being given regarding sepsis and its consequences.
The reviewers felt that early recognition, improved documentation and prompt treatment would lead to better care for septic patients. It was felt that using the term “sepsis” specifically would also raise awareness amongst both healthcare professionals and patients
• All hospital should have a formal protocol for the early recognition and management of patients with sepsis
• An Early Warning Score should be used in both primary and secondary care for patients where a diagnosis of sepsis is suspected
• On arrival to the emergency department a full set of vital signs should be undertaken in line with the Royal College of Emergency Medicine standards for sepsis and septic shock
• All acutely ill patients should be seen within the national recommended timescales (max 14 hours after admission)
• There should be formal arrangements for handover
• There should be critical care facilities and a Critical Care Outreach service to facilitate escalation of care
• A sepsis care bundle would benefit all patients diagnosed with sepsis
Nicki Credland is a Lecturer in Critical Care at the University of Hull and also works clinically as a Critical Care Outreach Sister. She has led on the development and introduction of nurse led ICU follow up clinics and the implementation of the National Early Warning Score in a multi-site DGH. She is the programme lead for both the BSc (Hons) Critical Care and the MSc Advanced Practice and is the National Secretary for the British Association of Critical Care Nurses (BACCN). Nicki is undertaking her PhD looking at why we fail to recognise deteriorating patients and looking at strategies to improve current practices