One of the things I have always liked about Acute Medicine is that it gives me a chance to make a rapid and noticeable impact on a patient’s outcome. Nowhere is this more marked than in patients with severe sepsis. Every year about 100,000 people in the UK are admitted to hospital with sepsis. About 30,000 of these have severe sepsis or septic shock, which carries a mortality of nearly 40%. It is these people where the stakes are highest. If they are recognised early and get some very simple interventions within the first hour, their chances of getting out of hospital alive are hugely increased. One study found that survival falls by 7% for every hour’s delay in antibiotic treatment! This is where the ‘Sepsis Six’ comes in. It is a set of 6 simple interventions which should be done within an hour of a patient presenting with severe sepsis:
- Oxygen to a target of 94-98% saturation (88-92% if risk of CO2 retention)
- Blood cultures (and culture any other likely infection source)
- Measure lactate
- Intravenous fluids (give a 500ml bolus and reassess)
- Intravenous antibiotics
- Measure urine output (catheter or accurate fluid chart)
All of these steps can easily be delivered by junior doctors and nurses, and yet can make a huge difference. So why don’t we do it all the time? One problem seems to be the difficulty in recognising severe sepsis. Patients often don’t arrive with that label, and indeed may have another tag-line attached to them, such as ‘off legs’ or ‘confusion’. Sometimes the other label doesn’t sound very serious and no-one else seems overly concerned about the patient. Compared to other emergencies such as acute stroke or MI, sepsis can present with a much broader range of symptoms, so diagnosis can be challenging. The only solution is to be vigilant, and to consider sepsis as a possible cause in every patient with an elevated Early Warning Score (MEWS).
For the last few years, I have been involved with the Scottish Patient Safety Programme (SPSP) work on improving delivery of the sepsis 6. This group consists of nursing and medical staff from key wards, pharmacy, infection control, and SPSP improvement advisors. Initially we focussed on the Emergency Department and Acute Medical Unit, since most patients come into hospital through these routes. We encouraged staff to use our gold ‘Sepsis ICP’ forms for every patient who might have sepsis. The form takes the user through a list of ‘red flag’ signs, which are designed to identify those with severe sepsis. These are the people who need the sepsis 6, and the time for delivering each component of it is recorded on the form and filed in the patient’s notes. Recently we have spread the message to the Galloway Community Hospital in Stranraer and to the medical HDU. Parallel work is ongoing in Obstetrics. Since the project began, the median time to first antibiotic dose in DGRI has fallen to less than one hour, so we know we are on the right track. However there is still much to be done – when I am collecting the data each month, I still see one or two patients who go unrecognised for several hours or only get part of the sepsis 6.
So what are the next steps?
Firstly we need to raise awareness amongst medical and nursing staff that severe sepsis is a medical emergency. In a world where new doctors can rotate through a department every week, it is often experienced nursing staff who are best placed to take the lead in this, and to flag up the possibility of sepsis to the rest of the team. Next, we need to spread the sepsis work more widely, so we can be confident that a patient will get the same quality of care no matter where or when they become unwell. With this in mind, I would invite anyone who is interested in joining our team or contributing in any way (nursing, medical, or AHP) to get in touch and join our exciting project. And if you don’t have time to do this, but still want to help, just remember that if you encounter a patient with severe sepsis and deliver the sepsis 6 within an hour, you can go home that night knowing you have made a difference. It’s that simple.
If you would like to contribute and join our group please contact the Patient Safety & Improvement Team on dumf-uhb.PatientSafety@nhs.net
Dr Sian Finlay is an Acute Physician and Clinical Director for Medicine at NHS Dumfries and Galloway