Sepsis in primary care. Sarah Bailey, Emma Evans, Nicola Shoebridge, Fiona Wells

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1 Sepsis in primary care Sarah Bailey, Emma Evans, Nicola Shoebridge, Fiona Wells

2 Quiz!! OR Hands on your heads Hands on your hips

3 Definition. The Third International Consensus Definition for Sepsis A life-threatening organ dysfunction due to a dysregulated host response to infection.

4 Could this be Sepsis? Presumed source + SIRS criteria = infection Infection + life threatening organ dysfunction = sepsis Sepsis refractory to IV fluids = septic shock

5 Epidemiology Reported increase in Sepsis (UK) from 140K 260K per year, why?

6 Some facts. Responsible for 44,000 deaths annually in the U.K. 54% of patients with a hospital discharge diagnosis of sepsis had sepsis on arrival to hospital Essential that sepsis is recognised early for the patient to reach hospital soon enough to avoid complications or death. 42% of British public had not heard of the term sepsis Sepsis 6 care bundle - reduce death by 46.6% if delivered within 1 hour 70% of sepsis cases originated in the community. Only 1/3 of sepsis pts receive good quality care Reliable delivery of basic care can save per case in bed stays alone 48% sepsis case come from Respiratory tract 24% from UTIs (NHS England, 2015

7 NICE Guidelines (July 2016) Could this be sepsis? Signs/symptoms of infection +/- temp. Non- localising presentations general unwell concerns raised by family/friends/carers Taken particular care in those unable to give a good history Try to make a definitive diagnosis of their condition Decide whether they can be treated safely outside hospital. Safety netting

8 High risk criteria (Red Flag Sepsis) Objective evidence of new altered mental state Respiratory rate > 25 bpm or more OR new need for oxygen (more than 40% FiO2) to maintain saturation more than 92% (or more than 88% in known COPD) Heart rate: > 130 Systolic blood pressure <90 mmhg or SBP > 40mmhg below normal Not passed urine in previous 18 hours Mottled or ashen appearance Cyanosis of skin, lips or tongue Non blanching rash of skin SEND PATIENT URGENTLY FOR EMERGENCY CARE (with resuscitation facilities)

9 Moderate to high risk criteria Amber flags History from patient, friend or relative of new onset of altered behaviour or mental state History of acute deterioration of functional ability Impaired immune system (illness or drugs including oral steroids) Trauma, surgery or invasive procedures in the last 6 weeks Respiratory rate: breaths per minute Heart rate: beats per minute (for pregnant women beats per minute) OR new onset arrhythmia Systolic blood pressure mmhg Not passed urine in the past hours, Tympanic temperature less than 36 C Signs of potential infection, including redness, swelling or discharge at surgical site or breakdown of wound Can a definitive condition be diagnosed and treated in an out of hospital setting? Yes treat and provide information / safety net No Send patient urgently for emergency care (with resuscitation facilities)

10 Very young/ very old Hygiene Post natal If at risk of neutropenic sepsis refer to secondary care Risk Factors Recent trauma, surgery or invasive procedure (within last 6 weeks) Indwelling lines Impaired immunity

11 Assessment Who to assess? Look for Clinical evidence of systemic infection (recent history of fever) Patients whom you are considering antibiotic prescription Patients you suspect to have flu/ gastroenteritis Patients who are obviously unwell without a clear cause Patients who have deteriorated on antibiotic therapy Likely source of infection Risk factors Indicators of clinical concern (abnormal behaviour, circulation, respiratory problems) Use a structured set of observations to assess people

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14 Recognising Sepsis in primary care There are significant barriers to reliable sepsis identification in primary care. Sepsis is a complex condition and variable in it s presentation. Critically ill patients are likely to be identifiable without the need for new efforts However some patients with sepsis and less immediately obvious signs of critical illness maybe identified earlier with greater awareness and targeted clinical assessment.

15 National Confidential Enquiry into Patient Outcome and Death(NCEPOD) Improving the quality of healthcare. Just say Sepsis! A review of the process of care received by patients with sepsis (2015) 51.1% had pre-alert system for pts arriving with sepsis 9.4% pts seen by a GP were pre-alerted 12.5% self referred to hospital Less than half pts had their temp taken poor adherence to recording of vital signs 55% of GP referrals had a letter 38.9% of cases showed room for improvement in the primary care setting No EWS used by GPs in any of the case notes reviewed. Deficiencies in record keeping (primary and secondary care) 59.4% reason for delay in getting to hosp because delay seeing clinician

16 An early warning score (NEWS) Training in the recognition and management of sepsis in primary and secondary care Use safety netting Recommendations Use standard referral method from primary to secondary care Mention sepsis on referral document Training for staff clinical/ non-clinical

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18 UK sepsis trust tools for primary care

19 National Early Warning Score Launched in 2012 and estimates that 6000 lives per year could be saved.

20 Prevention

21 Any questions?

22 References National Confidential Enquiry into Patient Outcome and Death(NCEPOD) NHS England (2015) Improving outcomes for patients with sepsis, A cross system action plan The UK Sepsis Trust Sepsis Alliance: World Health Assembly World Health Organisation