sepsis case study uk

elearning for healthcare

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“ THINK SEPSIS ” is a Health Education England programme aimed at improving the diagnosis and management of those with sepsis.

A number of sepsis cases result in death every year.  Some of the deaths are preventable. Prompt recognition of sepsis and rapid intervention will help reduce the number of deaths occurring annually.

The learning materials that are available on this website support the early identification and management of sepsis.

This website has a film and a wide range of learning materials for primary care, secondary care and paediatrics.

For more information on HEE’s work on sepsis please visit our  website .

Identifying and managing sepsis in primary care is an important measure in reducing deaths.

70% of sepsis cases develop within primary care. This sepsis in primary care elearning module addresses the high risk areas for the early identification and management of sepsis.

The first session is aimed at all clinical staff that work in primary care, giving an overview of sepsis for all staff in primary care. The remaining sessions on diagnosing sepsis in adults, children, elderly and complex issues such as maternity and neutropenia are primarily aimed at General Practitioners.

The elearning  module , consists of the following five sessions:

• Session 1 – Overview of Sepsis
• Session 2 – Adult Sepsis
• Session 3 – Childhood Sepsis
• Session 4 – Complex Sepsis Issues and Future Development
• Session 5 – Sepsis, Care Homes and the Frail Elderly

The Royal College of General Practitioners (RCGP) has developed a  sepsis toolkit  to support GPs and healthcare professionals to identify and manage the condition in patients. This toolkit has been designed to help GPs and other healthcare professionals in primary care tackle this challenge with a series of educational materials, up-to-date guidance and training resources. This also includes  10 Top Tips  for GPs & Primary Healthcare Clinicians to support a sepsis aware consultation.

Reception staff are commonly the first point of contact for people with acute health needs. Receptionists are not expected to make clinical decisions but need to be aware of which symptoms or presentations might suggest the patient is acutely unwell and requires specific actions. This programme has been developed to support receptionists in recognising specific symptoms that may indicate a deteriorating patient, including sepsis, and how they would consider escalating this to a clinician within the service/practice in which they operate.

The Leadership in Primary Care module is designed for non-clinical and clinical leaders working in primary care and looks at the challenges in leadership roles, to ensure best practice, in identifying and managing acute deterioration and sepsis in Primary Care settings, including general practice.

Improving Early Detection & Treatment of Sepsis

Approving Quality Alliance (AQuA) in partnership with HEE has developed a series of case studies to support the education of sepsis and deterioration in adults.

These case studies have been written in support of the Second Cross-System Sepsis Board Action Plan theme ‘Celebrating achievements and good practice’. The collection is designed to provide healthcare staff with examples of initiatives to improve the recognition of, and response to, sepsis in a range of settings. These case studies promote a collaborative approach, to improve how quickly staff can recognise and treat people with sepsis.

Each case study includes sections on key learning and reflection points, with a clear statement of what the team learned during the course of the improvement project. Measurement data is also provided to help learners identify improvement opportunities in the treatment of people with sepsis and monitor the impact of interventions.

You can access all the case studies in one document – Patient Pathway & System Solutions on Sepsis – All case studies, or you can access specific areas – Primary Care, Secondary Care, Cross sectional network and Diagnostics. Screening tools and observation charts are provided, along with 3 films to support the training.

Project Transform

An innovative interactive film,  Project Transform , which helps all healthcare professionals understand the common factors that may delay or hinder the diagnosis and treatment of sepsis, and therefore spot and treat sepsis earlier is also available. Created by the Royal Surrey County Hospital NHS Foundation Trust in conjunction with The Health Foundation, the UK Sepsis Trust and HEE, the film explores the features that make the diagnosis of sepsis difficult, the use of safety netting and empowering the most junior members of the team. We hope that this film will increase awareness of sepsis and the signs, to help staff diagnose and treat sepsis earlier.

Getting it Right

HEE in its report ‘Getting it right – the current state of sepsis education and training for healthcare staff across England’ ( Exec Summary and Full Report ), highlights numerous examples of good practice in relation to sepsis education and training. This report lists a number of resources that would be beneficial to healthcare workers requiring training on sepsis, and the audience they are most applicable to. Examples of learning sessions that healthcare workers in secondary care will find useful to address their training needs can be found below:

• Assessment and Differential Diagnosis of Sepsis (03_17_01) E-learning for Doctors and nurses in secondary care
• Management of the Septic Patient (03_034) E-learning for Doctors in secondary care. Nursing and pharmacy staff in a critical care environment
• Managing Sepsis (08_09) E-learning for Foundation programme doctors.

The UK Sepsis Trust has developed learning resources that supports the training and education of all healthcare professionals on how to diagnose and treat sepsis effectively.

Sepsis for management and executive staff in acute care

A learning resource for executive, non-executive and management level staff in trusts on sepsis, incorporating antimicrobial resistance and stewardship.

This training programme gives specific context for boards to understand the clinical priorities within healthcare and how boards and clinical leaders can work together to deliver of high quality safe care.

The training consists of an elearning session to be taken independently, to be followed by a facilitated discussion with board members and clinical staff.

It encourages engagement and debate within a trust, to understand locally what appropriate care looks like and what a board should be doing to deal with specific issues within their trust to maintain good standards on the quick recognition, management and treatment of sepsis and in improving standards of antibiotic prescribing.

Sepsis can strike the very old and the very young and as a result children, particularly premature babies and infants, can be more susceptible to developing sepsis.

Everyday somewhere in the UK a child dies from sepsis and cases have shown that a significant number are preventable. Children who survive can be left with debilitating consequences.

Early recognition and intervention can improve outcomes for infants and children with conditions that lead to sepsis. These paediatric resources are designed to ensure that all of us who work with sick children on the front line know how to recognise the clinical features of sepsis at the earlier stages and what to do when we see it.

An introductory resource aimed at all healthcare workers

This film explores the key points to consider in diagnosing and managing sepsis and refers to a patient story, presented by the parents of Maude Watkins who died of sepsis aged three.

Maude’s parents Jason (who is an actor in real life) and Clara share their experience of the traumatic loss of their daughter to sepsis, and provide a useful point of reflection for healthcare professionals on how they can ensure the appropriate and prompt recognition and management of sepsis in children. Their story also provides an important insight and reflection on the impact on families from the death of a family member. The film is an entry point to resources that paediatricians and GPs are recommended to look at relating to sepsis in children.  

An extended resource aimed at all clinical workers

This case based guide is aimed at supporting clinicians in the recognition and treatment of sepsis in children and involves the stories of three children, their assessment, experiences and treatment.

The learning sessions provide important insights in the recognition and management of sepsis in children. The sessions include the general principles for the safe assessment of a sick child, components of the consultation and assessment, specific factors to be considered in primary and secondary care settings and interpretation of investigations amongst others.

The training materials can be used in face to face teaching sessions or independently as elearning, in bite sized chunks to allow you to go at your own pace. The training is supported by a course summary sheet and a workbook that can contribute to a learner’s continuous professional development (CPD).

Paediatric sepsis podcasts

We worked with RCPCH to produce paediatric sepsis podcasts, that are designed as educational resources for health and social care professionals.

They explore what sepsis is, the complexities of how to recognise and manage sepsis, what is different about sepsis in children with complex health conditions and offers real-world advice and guidance on how to manage paediatric sepsis.

Practical resources for clinicians to share with patients and carers (as part of safety-netting) – home setting

Nhs choices:.

• Looking after a sick child : aimed at parents (NHS Choices)
• Does your child have a serious illness?  Aimed at parents (NHS Choices)
• Patient UK – Symptom Checker
• Health Help Now app  (specific localities only) or for the App
• BabyCheck  (App)
• Wessex Parent information : aimed at parents with children aged 6 months to 5 years
• UKST Spotting sepsis in children leaflet – Sepsis Assessment and Management (SAM)
• NHS Choices Spotting sepsis in under 5’s

Practical resources for clinicians to share with patients and carers (as part of safety-netting) – hospital / secondary care

Recognition of early sepsis .

• UKST  – Sepsis card
• MRF : Algorithms for Management of Meningococcal Disease and Bacterial Meningitis in Children and Young People
• KSS Parent info sheets for sick children – elfh or  SESCN

Recognition of early sepsis – assessment of sick children

• SystemOne templates  – Dr David Gould and Cricketfield practice
• KSS Clinical Pathways for Sick Children – elfh or SESCN

Educational resources for healthcare workers – primary care

Consultation matters.

• Re-ACT  Talks : The Effect of Criticism on Parents with Sick Children by Dr Sarah Neill
• Re-ACT Talks : Deterioration: How to Spot the Sick Child by Dr Ffion Davis
• Spotting Sick Child toolkit
• NICE RAG  assessment tool / traffic light system for identifying the risk of serious illness in children
• RCGP  elearning feverish child
• KSS Deanery – elfh elearning resource (clinical pathways for sick children)
• Human Reliability in Primary Care  by Dr Dawda
• UKST G.P. Paediatric Sepsis Decision Support Tool
• UKST Prehospital Sepsis Screening and Action Tool

Safety-netting

• NICE  – feverish child templates
• NICE algorithm for managing suspected sepsis in children aged under 5 years outside an acute hospital setting
• NICE risk stratification table for under 5 years with suspected sepsis
• NICE combined algorithms and risk stratification tables for those with suspected sepsis (includes for those under 5 years)
• UKST GP Paediatric Sepsis Decision Support Tool

Recognition of early sepsis

• Re-ACT Talks : Spotting Sepsis in the Sick Child by Dr Jeremy Tong
• Northern Paediatrics  – Northern Paedatric Sepsis

Sepsis pathways

• RCPCH elearning  – meningitis and meningococcal septicaemia
• Spotting the Sick Child
• NICE algorithm for managing suspected sepsis in children aged under 5 years in an acute hospital setting
• UKST ED/AMU Paediatric Sepsis Screening & Action Tool
• UKST Inpatient Paediatric Sepsis Screening & Action Tool

The Learning Disabilities Mortality Review (LeDeR) report published in May 2018 highlighted sepsis as a key contributor to premature mortality, with 11% of deaths being recorded as sepsis related. In response NHS England have undertaken work to improve the sharing of information on people with a learning disability, across health and care settings and have published an ‘ action from learning ’ report that provides examples of the local changes that have been made to services in response to common themes raised through LeDeR reviews across the country.

A number of freely available resources have been developed for the system that includes:

• a sepsis song to raise awareness and improve vigilance to the signs of sepsis amongst people with a learning disability.
• a training film that supports health and care professionals, and carers, to spot the softer signs of deterioration in people with a learning disability.
• a training film aimed at those who care for people with a learning disability who may not be able to communicate or verbalise how they are feeling.
• a film aimed at people with a learning disability who may not be able to communicate or verbalise how they are feeling.
• a podcast on recognising deterioration and sepsis amongst people with a learning disability, which may also be useful for carers.

Antonio De Gregorio

Mohamed Sadak

Janet Flint

Dr Gary Wares

Dr Neil Ralph

Andi Blackmore

Simon Stockley

Alison Tavaré

James Larcombe

Dr Nelly Ninis

Dr Tim Fooks

Dr Matt Inada-Kim

Available to all.

The Sepsis  programme is freely available to access here . Please note your progress and completion of sessions will not be recorded and you will not be able to generate a record of completion. If you require evidence of learning, please register and then log in to access this programme on the elfh Hub.

If you already have an account with elfh, then you can enrol on to the Sepsis   programme by logging in to the elfh Hub, selecting My Account > Enrolment and selecting the programme. You can then access the programme immediately in the My elearning section.

Register >

To view the Sepsis   programme, select the View button below. If you already have an account with elfh, you will also be able to login and enrol on the programme from the View button.

NHS healthcare staff in England

The Sepsis  programme is also available to NHS healthcare staff via the Electronic Staff Record (ESR). Accessing this elearning via ESR means that your completions will transfer with you throughout your NHS career.

Further details are available here .

Not an NHS organisation?

If you are not an NHS health or care organisation and therefore do not qualify for free access elfh Hub, you may be able to access the service by creating an OpenAthens account.

To check whether or not you qualify for free access via OpenAthens, you can view the eligibility criteria and register on the ‘ OpenAthens ’ portal.

Care home or hospice staff

To register for the Sepsis  programme, select the ‘ Register ’ button above. Select the option ‘I am a care home or hospice worker’ then enter your care home / hospice name or postcode and select it from the options available in the drop down list. Finally enter your care home / hospice registration code and select ‘Register’. You may need to see your employer to get this code.

If your employer does not have a code, then they need to contact the  elfh Support Team . The Support Team can either give the employer the registration code or arrange a bulk upload of all staff.

Detailed instructions on how to gain access are available here .

Social care professionals

Access to elfh content is available to all social care professionals in England whose employers are registered with the Skills for Care National Minimum Data Set for Social Care (NMDS-SC). Every employer providing NMDS-SC workforce information to Skills for Care has been given a user registration code for their staff. This code enables you to self-register for access to the Care Certificate programme. Please contact your employer for more details about the registration code.

For information about registering your organisation with the NMDS-SC your employer should access  www.nmds-sc-online.org.uk  or contact the Skills for Care Support Service on 0845 8730129.

If you have a registration code, you can register by clicking  here

Registering large numbers of users

If you are a HR, IT or Practice Manager and would like to register and enrol large numbers of staff within your organisation for access onto the Sepsis   programme, please contact elfh directly.

Organisations wishing to use their own LMS

For HR departments wanting to know more about gaining access to courses using an existing Learning Management System please contact elfh directly to express interest.

More information

Please select the following link for more information on how to use the elfh Hub .

Case study: 'Think Sepsis, Save Lives' project

Amanda Harvey, Clinical Skills Facilitator and Rebecca McLaughlin, Staff Nurse ITU, University Hospitals of Morecambe Bay NHS Foundation Trust

Amanda and Rebecca led a project called Think Sepsis, Save Lives.

Sepsis affects 150,000 people and leads to around 44,000 deaths per year in the UK alone. Amanda and Rebecca's mission was to increase understanding and recognition of sepsis among staff and patients, and reduce harm.

The project involved a large scale training program for clinical staff, including the introduction of ward based champions. The team developed resources such as screening tools, posters and pocket sized reference cards.

Sepsis training was also introduced into other existing training courses with collaborative working taking place between Practice Educators. Public and staff awareness events were also held.

At the end of the project the team had trained around 1,200 clinical staff in the recognition and management of sepsis. Sepsis screening in emergency admissions had increased from 22% in March 2015 to 56% in March 2016 and administration of antibiotics within the hour, as per Sepsis Six recommendation had increased from 61% in July 2015 to 72% in March 2016.

Following the Think Sepsis, Save Lives Campaign University Hospitals of Morecambe Bay NHS Foundation Trust has continued to make improvements in sepsis care. As of March 2018:

• 100% of both emergency admissions and inpatients were screened for sepsis
• 91% of emergency admissions and 94% of inpatients received antibiotics within the hour

The Think Sepsis, Save Lives scheme provided a vehicle to initiate change, and the improvements have been sustained long after its completion, leading to significant improvements in patient safety.

Related key lines of enquiry

Staff skills and knowledge

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The Atlas of Shared Learning

Improvement in early detection and prompt treatment of sepsis across weston area health nhs trust.

• Nursing, midwifery and care

Leading change

The Lead Nurse for Deteriorating Patient and Sepsis at Weston Area Health Trust identified unwarranted variation in the rates of early detection and prompt treatment of sepsis at Weston Area Health Area Trust and addressed this through awareness raising campaigns, training and introduction of best practice sepsis alert practices. This has significantly improved patient outcomes and safety.

Where to look

Sepsis is a leading cause of death in the United Kingdom (UK) with a reported 44,000 cases every year (NICE, 2017). Sepsis causes more deaths every year than breast, prostate and bowel cancer combined (UK Sepsis Trust, 2016). Forty percent of cases relating to sepsis are severe and 50% of cases are related to septic shock (NICE, 2014). Sepsis is the biggest cause of maternal death in the UK (World Health Organisation, 2016) and costs the National Health Service (NHS) over an estimated £2.5 billion per year (Health Care Ombudsman, 2014). Successful management of sepsis requires prompt recognition, appropriate interventions to identify and control the micro-organisms and restore oxygen delivery to tissues, and appropriate escalation and decisive medical management within the first hour of red flag sepsis.

What to change

The Trust was making progress in providing sepsis care but identified an opportunity to strengthen the sepsis care pathway, to not only save lives but to sustain improvements by using quality improvement methodology and integrating clinical governance. This unwarranted variation was identified through an audit in 2017 identifying the need and opportunity for improvement in the compliance in the use of the sepsis screening and delivery of the Sepsis Six within one hour of red flag sepsis. The Sepsis Six consists of three diagnostic and three therapeutic steps – all to be delivered within one hour of the initial diagnosis of sepsis.

The Lead Nurse for Deteriorating Patient and Sepsis conducted a baseline survey to try to understand why the sepsis screening tool wasn’t being used; 91 out of 100 of the survey results that were returned identified an opportunity to train staff so that they were aware of sepsis, its signs and symptoms and treatments so that they could provide best practice within their clinical areas.

How to change

The Lead Nurse for Deteriorating Patient and Sepsis addressed the unwarranted variation through the following focused actions:

• Multidisciplinary staff training, developing and empowering staff to support the clinical recognition of sepsis and the requirements of prompt action at the signs of sepsis.
• Improving sepsis identification through national guidelines ( NICE NG51 )
• The creation of a sepsis multidisciplinary team (MDT) providing a more integrated approach across medical disciplines to sepsis care.
• An integrated nursing leadership programme empowering nurses to escalate patients through the sepsis pathway more effectively.
• The introduction of NEWS (National Early Warning Scoring) enabling staff to utilise a validated medical assessment tool which supports staff to identify any patient who may have sepsis and trigger the appropriate sepsis pathway which includes the ‘Sepsis Six’ stepped treatment model.
• The introducing of a standard operating procedure (SOP) utilising sepsis alert cards for immunocompromised patients.
• On-going sepsis awareness campaigns. For example, all lift doors now display full-height posters encouraging patients and visitors to ask themselves, and to question hospital staff, ‘Could it be sepsis?’ Sepsis awareness is also now part of the Trust staff induction.

Adding value

Better outcomes – There was a large increase in the use of the sepsis screening tool from 17% in September 2017 to 96% across the Trust by January 2018. In the emergency department screening for sepsis is over 90% and administration of IV antibiotics within 1 hour is at 89%. Sepsis screening and treatment for inpatients has reached 100%. The sepsis related incidents reduced from 4 in October 2017 to an average of 0 or 1 by May 2018.  Sepsis length of stay at Weston General Hospital reduced from an average of 8 days in October 2017 to 4 in May 2018, which is below the national average length of stay average of 12 days in May 2018.

Better experience – Staff experience has been positive with 100% of staff saying they would recommend the sepsis training to colleagues and they feel confident to use the training in practice. Between September 2017 and March 2018 458 members of staff had attended the sepsis training. The educational sessions gave nurses the knowledge to identify and pre-empt interventions and encouraged them to prompt doctors in decision-making. One member of staff set up study days on their ward for their specialty, which includes sepsis care.

• I enjoyed “all of it – felt my knowledge has improved hugely with regards to sepsis and feel that can confidently complete sepsis 6 pathway”.
• The ‘sepsis stars’ initiative has been introduced, where staff are praised for recognising, escalating and treating patients with sepsis within one hour. Staff and teams are presented with certificates and included within internal communications or on social media.
• Anecdotal evidence from patients and families has also been positive and where there was learning, this has been shared. Sepsis support groups have now been set up for patients post discharge.

Better use of resources – The initiatives used throughout the Trust have been low in cost, using simple solutions that provide a standardised measurable response to sepsis and increase the compliance with the delivery of the Sepsis Six by using NEWS and the sepsis screening tool. By recognising and treating sepsis early, intensive care admissions, treatment and length of stay costs are reduced.

Challenges and lessons learnt for implementation

• Solutions that are known to work were implemented without inventing anything new and a 90 day implementation plan broke the work down into 90 day segments, making it more manageable.
• There was some challenge around staff engagement but educating, supporting and guiding colleagues addressed this.
• A culture of reporting and learning within the hospital is promoted – so if errors occur staff feel supported, cared for and valued.

Improvements are continuing to be made with sepsis care and looking at sustainability across the hospital and the maternal sepsis screening tool is being reviewed.

Find out more

For more information contact:

• James Merrell, Lead Nurse Deteriorating Patient and Sepsis,  [email protected]
• Diagnostic or screening
• Hospital (acute)

Project Sepsis

Project Sepsis is a research collaboration across medicine and science disciplines that addresses an urgent medical need for recognising and accurately detecting infection underlying sepsis - “blood poisoning” - in extremely vulnerable populations of the very young and old.

Video of Professor Peter Ghazal talking through the work of Project Sepsis.

Symptoms can be subtle, yet if sepsis goes undetected, catastrophic loss of life can occur within hours if not prescribed antibiotics. Consequently there is an overuse of antibiotics that can lead to antimicrobial resistance, itself a global health threat. The sensitivity of current tests is poor with between 6 to 8 cases out of 10 being missed.

Project Sepsis uses computer-assisted genome, proteome, and metabolism approaches to decode the communication from the blood-immune system to more rapidly detect infection and identify innovative treatments.

Project Sepsis is part-funded by the European regional Development Fund through the Welsh Government.

If you would like to find out more about project sepsis please contact: [email protected]

Project Sepsis is part of a collaboration with Dr C Costello’s team at Imperial College which recently secured National Institute for Health Research (NIHR) funding for a project tilted: Digital alerting to improve sepsis detection and patient outcomes in NHS Trusts.

Through this collaboration, the Project Sepsis team facilitated that our research partner, Cardiff and Vale University local health board, become a member of the NIHR Health Informatics Collaborative (HIC) data sharing framework.

This will support the establishment of a sustainable clinical informatics infrastructure at the trust in line with those at other participating HIC centres, create a shared governance framework and enable collaborative clinical research projects across the HIC, with all centres involved in relevant collaborations and initiating expansion to future data collaborations.

Celebration of achievement

Project Sepsis was funded by the Welsh Government’s Sêr Cymru programme. Prof Peter Ghazal was appointed Sêr Cymru Chair in Systems Medicine, Systems Immunity Research Institute, and established Project Sepsis in December 2017 to strengthen sepsis and systems research within Cardiff University and Wales. The project has produced high quality and impactful research, with substantive progress being made in the fight against Sepsis and improving sepsis awareness with the Sepsis Trust UK, and management and diagnosis, while increasing research capacity and our understanding of what drives this condition.

Project Sepsis applied a community-in-action approach uniquely establishing a Sepsis Engagement Centre housing the “Goldilocks Ward” used for promoting public and patient involvement, training and research. We successfully appointed at an early stage a lay advisory group, and over 20 research staff and 8 research students including 2 new lectureships that actively contributed to the project, and have strengthened collaborations with existing partners while building national and international research networks and links with new strategic partners from multi-disciplinary teams across academy and industry. This includes: Introduction of a sepsis case study to the medical curriculum, working with industry to develop a 360 degree fully immersive virtual reality training resource for medical students and staff, mathematical models for understanding and predicting sepsis, validating and developing new diagnostic tools and tests. Across three of our clinical platforms (neonatal, maternal and paediatric sepsis studies) we gratefully received blood samples from approximately 1000 participants in our research at Cardiff and Vale University Hospital and almost similar contribution from our partnering centres. This was during very challenging circumstances during the pandemic, allowing us to establish a large biobank of samples for continued research, while building key relationships with our clinical teams across various specialities in the NHS.

We are now beginning to see an increase in scientific out puts and collaborations with other UK based and international institutions.  Our research and technical achievements of Project Sepsis, could not be accomplished without participation of public and patient involvement. Improved public awareness of sepsis is key and we are proud of our contributions to a variety of successful engagement events highlighting differing aspects of sepsis and including yearly seminars to mark World Sepsis Day.  As a whole community we have increased the development of excellence research capability in Wales within systems medicine, and although the European sponsored Ser Cymru programme ends in April 2023, Project Sepsis will continue with the next phase of decoding sepsis and continue to build on our achievements.

Prof Peter Ghazal was recognised in the New Year’s Honours 2023 and awarded an OBE for his services to systems immunology.

Key research themes

(see Figure 1)

• Maternal sepsis (mSEP)
• Neonatal sepsis (nSEP)
• Paediatric sepsis (pSEP)
• Adult sepsis (aSEP)

Areas of expertise

Core project sepsis team, prof peter ghazal (n,p,asep) - chief investigator and academic lead for n, psep.

I previously led the Division of Pathway Medicine at the University of Edinburgh.

Watch a video of me talking about the research I carried out into Neonatal Medicine whilst there .

My research interests are aimed towards understanding how host-gene networks control infection, especially with those host-pathways associated with sepsis and the immune-metabolic axis. My recent studies have pioneered the field of host genomics of early-life infection, mapping and deciphering gene metabolic signatures of systemic host response to infection in pre-term infants and neonates and understanding the molecular wiring and mechanisms for coupling lipid metabolism to immune (interferon) response.

These studies are specifically aimed at the development of new diagnostic and therapeutic strategies, including predictive modelling of host-defence against infection in sepsis, and the development of new computational and functional genomic methods for gaining a deeper understanding of complex dynamical biological systems of viral (cytomegaloviral) and microbial diseases.

Prof Valerie O’Donnell (n,p,aSEP) - Principle Investigator and academic lipid metabolism lead

Our current research is focused on understanding the role of lipids (fats) in vascular inflammation, a major complicating factor in sepsis and driver of multi-organ failure. Lipids are generated by circulating blood cells and platelets in response to blood infection. These stimulate clotting and cell damage, and dampening these processes while allowing the body to control the infection itself is a major goal of our research.

We have identified large numbers of new lipids made in blood cells and understanding their biological functions is a core research goal. Delineating how lipids and energy metabolites interface during sepsis to control inflammation and blood clotting is essential if we are to develop new prevention and treatment approaches.

Dr Robert Andrews (n,p,aSEP) - Informatics lead

My interests are in the information management and analysis of large biomedical datasets. As part of my role, I design and build compute infrastructure for handling high-throughput ‘big-data’. Specifically, project sepsis will deploy a biomedical informatics framework for the capturing, querying, retrieval and sample tracking of clinical and laboratory research information with which to automate and manage novel microfluidic approaches aimed toward advancing innovative precision diagnostic tests and treatments for sepsis.

I also teach chromatin informatics with the Wellcome Trust advanced courses and lead the omics module on the MSc in Bioinformatics at the University.

Sarah Edkins

Dr daniel white - senior innovation and technology scientist.

With over 20 years of experience in lipid biology and analytical chemistry, spanning scientific fields from environmental monitoring to biomedical research, my role role in Project Sepsis is to develop high-throughput lipidomic profiling strategies to determine robust biomarkers of sepsis in the systemic circulation of patients. These methods are part of integrative strategy for understanding the casual link between metabolism and the immune response in determining sepsis patient outcome and together with clinical team members will be translated to the clinical care pathway for improving precision in identifying and treating those patients presenting with suspected sepsis.

Dr James McLaren - Sêr Cymru Lecturer in Systems Immunity

My research interests focus on understanding how adaptive immune responses (T cell driven) are mobilised during viral (HIV, cytomegalovirus) and microbial infections, inflammation and disease. Furthermore, I have a keen interest in discovering how this type of cellular immunity is regulated by biological signals (cytokines) and how it can destabilise when global immune responses become imbalanced, such as in sepsis. As part of Project Sepsis, my aim is to deconvolute the immunological mechanisms that drive the suppression of adaptive immunity in sepsis with a view to help improve diagnosis and to inform the design of novel therapeutic interventions.

Dr. Nicos Angelopoulos - Sêr Cymru Lecturer in Computational Systems Immunity

I work on knowledge based systems for explainable AI in biology and medicine. A computer scientist by training, I worked on methodological aspects of probabilistic programming before developing a strong interest in knowledge-based data analytics in bio-medicine. Of particular interest is the representation of biological knowledge in the context of machine learning both in how prior knowledge can incorporated in the learning process, but also in how we can learn models of interpretable knowledge. Bayesian approaches to model learning are of particular interest, especially when combined with classical AI approaches of knowledge representation amalgamating logic and probability theory. I also have interests in open source software and the ethical use of AI, contributing a number of libraries to the SWI-Prolog, logic programming system.

Dr Luke Davies

I am a passionate scientist with a research background in innate immune cell biology and metabolism. Sepsis is a life-threatening condition driven by dysregulated immunity which results in organ failure and metabolic dysfunction. I am excited to work with Project Sepsis to investigate new diagnoses and treatments for sepsis.

Dr. Patricia Dos Santos Rodrigues

Dr jason twohig - lecturer in medical transcriptomics.

I utilise novel ‘OMICs’ approaches to facilitate the identification and stratification of patients with chronic disease for effective therapeutic treatment with biologics. I am particularly interested in identifying blood transcriptomic signatures which predict the presence of SEPSIS, its progress, its mechanism, and its resolution. More broadly, my research interests also include understanding the role of cytokines in inflammation and homeostasis in the immune and neurological system during development and infection.

Dr Widad Dantoft (n,p,aSEP) - Research Associate

My research interest lies in understanding the intricate interplay between immunity and metabolism in the presence of viral (CMV) and bacterial infections, and how this affects the infection process and outcome. I am in particularly interested in how this immune-metabolic interplay is regulated on a transcriptional level.

Dr Mallinath Chakraborty (nSEP) - Clinical lead

My interests are in neonatal respiratory medicine and sepsis. I am the local Principal Investigator for several multi-centre clinical trials and am developing my own research group. I also run the respiratory module of the Masters in Neonatal Medicine at Cardiff University.

Dr Summia Zaher (mSEP) - Clinical lead

Dr tamas szakmany (asep) - clinical lead.

In collaboration with Public Health England and industry (Randox and Atlas Genetics) I have led Innovate UK funded multicentre clinical trials on adult sepsis. These studies identified mRNA and protein biomarker panels that distinguish sepsis from non-infective origin of organ dysfunction for use with point-of-care devices.

I further designed and led an award winning (Cardiff University Excellence in teaching award 2017 and NHS Wales Award runner-up 2016) collaboration with the Cardiff University Research Society for medical students, establishing the burden of sepsis on the general wards and Emergency Departments in Wales. These multi-centre point-prevalence studies recruited over 1000 patients quantifying the incidence when using different clinical scores to define sepsis.

Dr Siva Oruganti (pSEP) - Clinical lead

My background is a Bachelor in Medical Biology and a Master in Biomedicine. What fascinates me most is how complex systems in the body are regulated and interact, especially the immune system and the gut microbiota. My PhD is focused on the G-Protein coupled receptor (GPR) 84. This receptor has only been discovered quite recently; it is present on various immune cells and binds medium chain fatty acids. These come (most likely) from breast milk in the neonatal context. The receptor thus connects metabolism and diet with immunity. Since its expression is upregulated during neonatal sepsis, we decided to investigate the role of GPR84-signalling during neonatal sepsis, the presence and effects of its ligands and their potential origins. Hopefully this project will further the understanding of sepsis leading to better diagnosis and treatment in the future.

Simran Sharma

I am very excited to be joining project sepsis as a clinician as I see the detrimental impact of sepsis on mothers and babies every day. An opportunity to learn more through research is something I am very much looking forward to.

Dr Fergus Hamilton

Freya shephard, other collaborators and affiliated team members, dr claire smith (nsep) - edinburgh.

My research interest is in neonatal infection with on-going involvement in studies in this area. I am actively involved in the local neonatal unit infection surveillance programme and have played a significant part in introducing a successful infection reduction programme to the neonatal unit.

Prof Timothy Walsh (n,pSEP) - Principle Investigator

I am director of BARNARDS, a BMFG funded project examining the burden of neonatal sepsis in Nigeria, Pakistan, Bangladesh, Rwanda and Ethiopia. I am also PI of DETER-XDR-China and CUT-SEC that examines the one health approach to studying AMR in China, Vietnam and Thailand.

I am an advisor on AMR to the United Nations, Médecins Sans Frontières and the Fleming Fund.

Prof B Paul Morgan - Principle Investigator

I am an expert in the complement system, a critical component of innate immunity and a powerful driver of inflammation. Dysregulation of the complement system has been implicated in sepsis and systemic inflammatory response syndromes; indeed, complement markers in blood have been used to predict and monitor these conditions. Critically, an emerging wave of anti-complement drugs may provide new ways of breaking the cycle of inflammation in patients with sepsis.

Dr Paul Morgan (aSEP) - Principal Investigator

As an Intensive Care consultant and the Lead Volunteer in Wales for the UK Sepsis Trust, sepsis makes up a substantial part of my work.

My interests in sepsis has led me to try to drive change in sepsis recognition and care outside the critical care environment, working with staff from primary and secondary care so that sepsis can be spotted early, enabling timely intervention and thereby reduce the need for critical care admission. Ultimately, my hope is that this will reduce not just mortality from sepsis but also the morbidity, which results in long-term health problems for sepsis survivors. I am a member of the steering committee and co-author of the papers that have been published from the Size of Sepsis in Wales and the Defining Sepsis in the Wards point prevalence studies.

Dr Matthias Eberl (aSEP) - Principle Investigator and Academic lead of aSEP

My interdisciplinary research aims to characterise early immune responses in acutely ill patients and define pathogen-specific signatures of cellular and soluble biomarkers ('immune fingerprints'). This work has direct implications for improved diagnosis and treatment of microbial infections including sepsis.

Dr Matthew Morgan (aSEP) - Clinical lead

Intensive care doctor, scientist, computer programmer, teacher and geek interested in machine learning, medical education and public engagement. My PhD used artificial intelligence to tease out “immune fingerprints” from different types of life-threatening infections.

I have spent time training in the UK, Australia and the military. Passionate about critical care medicine and intensive care research, I also work with the British Medical Journal to improve medical education, healthcare IT and research outcomes.

Rhian Thomas-Turner (n,p,aSEP) - R&D Operations Manager

I am the R&D Operations Manager for the Noah’s Ark Children’s Hospital for Wales. My role involves both the strategic and operational oversight of research within the Children’s Hospital and running the newly establish Children and Young Adults’ Research Unit.   The aim of the Unit is to act a hub for high quality Child Health research in Wales.

Dr Jenna Bowen - Lecturer, Cardiff School of Pharmacy and Pharmaceutical Sciences

My research interests lie in the field of sepsis and infection, with a particular focus on the development of bio-sensing systems to enable rapid diagnosis, patient stratification and personalisation of therapies. I enjoy working across disciplines and have established collaborations across life science and engineering / physical science disciplines as well as with end-users from the clinical, commercial and third sector in order to deliver fit-for-purpose technologies.

I am also a co-founder of a start-up company, Cotton Mouton Diagnostics (CMD), which is developing a diagnostic platform that can be deployed across a range of healthcare settings.

Dr Mario Labeta (aSEP) - Senior Lecturer

My current work focuses on the immunobiology of the Toll-like family of immune receptors (TLRs) as mediators of immune and inflammatory responses. Following our discovery of a soluble form of TLR2 (sTLR2) in blood that has anti-inflammatory capacity, we are evaluating whether plasma sTLR2 may be used as a biomarker for sepsis, as opposed to SIRS and other serious infections. In collaboration with a Welsh biotech company ( JRBiomedical, Glyndwr University ) we are developing a fast point-of-care test to determine plasma levels of sTLR2.

In further work we have identified TLR2-derived peptides capable of boosting the immune response of immunosuppressed sepsis patients ex vivo, and currently seeking to stratify sepsis patient subgroup(s) that may therapeutically benefit from our TLR-based peptide strategy.

Dr Philip Anyanwu - Lecturer in Public Health

I am an infectious disease epidemiologist with research interests in causal inferential analysis and investigating the mechanism of impact of interventions to address antimicrobial resistance and sepsis.

I have a specific interest in the development and evaluation of digital applications for the management of sepsis, especially in LMICs. I am a co-investigator of a project on maternal sepsis working with research partners from Imperial College London and the University of Ibadan Nigeria to develop a digital system for sepsis alert and monitoring ward movement in maternity patients in Nigeria.

Rebecca Milton - Research Associate - Trial Manager

My research interests lie within maternal and neonatal health and I have a strong interest in working in low- and middle income countries. I obtained my Masters in Public Health at Cardiff University whilst working within a microbiology research group in the Institute of Infection and Immunity, Cardiff University. To date, much of my research has been focused on neonatal sepsis in LMICs. I have been working with Project Sepsis looking immunological markers, risk factors and incidence of stillbirths in northern Nigeria with an additional focus on cultural belief and understanding around stillbirth. I am currently working on a PhD by publication focusing on maternal and neonatal health in LMICs.

A feasibility study of stillbirths in Kano, Northern Nigeria.

Stillbirth Feasibility Study - Video

Find out more about the study

Our international community

Professor tobias strunk (nsep) - clinical associate professor, centre for neonatal research and education (the university of western australia, perth, australia) and neonatal directorate, king edward memorial hospital (perth, australia).

My research interest is the immunological determinants of newborn
susceptibility to invasive bacterial infection and novel prophylactic
and therapeutic interventions to reduce disease burden, areas highly  relevant to the current proposal.

EU NeoVanc Project

Clinical trial assessing the dosage of vancomycin antibiotic in the treatment of late onset bacterial sepsis caused by vancomycin susceptible bacteria in neonates and infants aged under three months.

Breathing Together

A five year research and engagement programme exploring breathing and lung health in children.

The Theirworld Edinburgh Birth Cohort

A 25-year study to learn more about how being born too soon or too small affects people’s health in later life.

Digital Alerting for Sepsis (DiAlS)

The DiAlS study will investigate the impact of digital sepsis alerts on patient outcomes and staff activity in NHS hospital Trusts across England and Wales.

DISCOVER ( DI agnostic and S everity markers of COV ID-19 to E nable R apid triage) study

Focused on blood-based biomarkers and their ability to predict a patient’s disease course alongside demographic factors such as age, sex, frailty and other medical conditions.

Project members

• Prof Carlo Giaquinto (University of Padova, Head of Paediatrics AIDS centre, Italy)
• Profs Mike Sharland  (St. Georges, University of London, Head of Paediatrics, UK)
• Prof Paul Heath (St. Georges, University of London, Paediatric infectious diseases, UK)
• Prof EvelyneJacqz-Aigrain (Robert Debre Hospital, Head of Paediatric pharmacology, France)
• Prof Irji Lutsar (University of Tartu, Head of Department of clinical microbiology, Estonia)
• Prof. Baiardi (Consorzio per Valutazioni Biologiche e Farmacologiche, Director Biostatistics, Italy)
• Dr. Mark Turner (University of Liverpool, Consultant neonatologist, UK)
• Prof Peter Ghazal (University of Edinburgh & University of Cardiff medical schools, Chief investigator project-sepsis)

Publications

• Milton, R. et al. 2021. Establishing the safety of waterbirth for mothers and babies: a cohort study with nested qualitative component: The protocol for the POOL study.. BMJ Open 11 (1) e040684. ( 10.1136/bmjopen-2020-040684 )
• Milosevic, S. et al. 2020. Factors influencing water immersion during labour: qualitative case studies of six maternity units in the United Kingdom. BMC Pregnancy and Childbirth 20 (1) 719. ( 10.1186/s12884-020-03416-7 )
• Milosevic, S. et al. 2019. Factors influencing the use of birth pools in the United Kingdom: Perspectives of women, midwives and medical staff. Midwifery 79 102554. ( 10.1016/j.midw.2019.102554 )
• Dantoft, W. et al. 2017. Genomic programming of human neonatal dendritic cells in congenital systemic and in vitro cytomegalovirus infection reveal plastic and robust immune pathway biology responses. Frontiers in Immunology 8 1146. ( 10.3389/fimmu.2017.01146 )
• Zhang, J. et al. 2017. Machine-learning algorithms define pathogen-specific local immune fingerprints in peritoneal dialysis patients with bacterial infections. Kidney International 92 (1), pp.179-191. ( 10.1016/j.kint.2017.01.017 )
• Raby, A. et al. 2017. Toll-like receptors 2 and 4 are potential therapeutic targets in peritoneal dialysis-associated fibrosis. Journal of the American Society of Nephrology 28 (2), pp.461-478. ( 10.1681/ASN.2015080923 )
• Holst, B. et al., 2017. Soluble toll-like receptor 2 is a biomarker for sepsis in critically ill patients with multi-organ failure within 12 h of ICU admission. Intensive Care Medicine Experimental 5 (1)( 10.1186/s40635-016-0116-z )
• Hopkinson, J. B. et al. 2016. People with dementia: what is known about their experience of cancer treatment and cancer treatment outcomes? A systematic review. Psycho-Oncology 25 (10), pp.1137 -1146. ( 10.1002/pon.4185 )
• Liuzzi, A. R. et al. 2016. Unconventional human T cells accumulate at the site of infection in response to microbial ligands and induce local tissue remodeling. Journal of Immunology 197 (6), pp.2195-2207. ( 10.4049/jimmunol.1600990 )
• Courtier, N. et al. 2016. Cancer and dementia: an exploratory study of the experience of cancer treatment in people with dementia. Psycho-Oncology 25 (9), pp.1079-1084. ( 10.1002/pon.4212 )
• Raby, A. and Labeta, M. 2016. Therapeutic boosting of the immune response: turning to CD14 for help. Current Pharmaceutical Biotechnology 17 (5), pp.414-418. ( 10.2174/1389201017666160114095708 )
• Duffin, R. et al., 2016. Prostaglandin E2 constrains systemic inflammation through an innate lymphoid cell-IL-22 axis. Science 351 (6279), pp.1333-1338. ( 10.1126/science.aad9903 )
• Morgan, M. et al. 2016. Sepsis patients with first and second-hit infections show different outcomes depending on the causative organism. Frontiers in Microbiology 7 207. ( 10.3389/fmicb.2016.00207 )
• King, A. , Hopkinson, J. B. and Milton, R. 2016. Reflections of a team approach to involving people with dementia in research. International Journal of Palliative Nursing 22 (1), pp.372-377. ( 10.12968/ijpn.2016.22.1.22 )
• Dickinson, P. et al., 2014. Whole blood gene expression profiling of neonates with confirmed bacterial sepsis. Genomics Data 3 , pp.41-48. ( 10.1016/j.gdata.2014.11.003 )
• Eberl, M. et al. 2014. Pathogen-specific immune fingerprints during acute infection: The diagnostic potential of human γδ T-cells. Frontiers in Immunology 5 572. ( 10.3389/fimmu.2014.00572 )
• Davey, M. S. et al., 2014. Microbe-specific unconventional T cells induce human neutrophil differentiation into antigen cross-presenting cells. Journal of Immunology 193 (7), pp.3704-3716. ( 10.4049/jimmunol.1401018 )
• Smith, C. L. et al., 2014. Identification of a human neonatal immune-metabolic network associated with bacterial infection. Nature Communications 5 4649. ( 10.1038/ncomms5649 )
• Raby, A. et al. 2013. Targeting the TLR co-receptor CD14 with TLR2-derived peptides modulates immune responses to pathogens. Science Translational Medicine 5 (185) 185ra64. ( 10.1126/scitranslmed.3005544 )
• Cohen-Bendahan, C. C. C. et al., 2005. Is there an effect of prenatal testosterone on aggression and other behavioral traits? A study comparing same-sex and opposite-sex twin girls. Hormones and Behavior 47 (2), pp.230-237. ( 10.1016/j.yhbeh.2004.10.006 )

Dr James McLaren took part in an episode of the Discovery Matters podcast to discuss the role of single cell sequencing in detecting sepsis:

Discover Matters -  Detecting sepsis: the role of single-cell

Professor Peter Ghazal took part in an episode of the Lancet infectious disease series:

Combating Childhood Infections in LMICs: evaluating the contribution of Big Data

World Sepsis Day 2020 - webinar

Recording of our World Sepsis Day 2020 webinar.

Talking about Sepsis

This preview event took place on Wednesday 20 June 2018 in the 'Goldilocks Ward' of the new Sepsis Engagement Centre.

The event was very well attended with over 60 people from Cardiff University, Wales Gene Park, Cardiff & Vale UHB, Sêr Cymru, Welsh Government and The UK Sepsis Trust in attendance.

See more information about the Talking about Sepsis event.

View event Talking about Sepsis programme.

World Sepsis Day 2019

Sepsis: a spotlight on what can happen to mum and baby.

Sepsis is a life threatening condition from infection, that can affect anybody at any age.

However, it is more common in vulnerable populations such as the very young and the very old. What is often not recognised is the significance of sepsis in pregnancy.

At the event we told Amanda’s story about a mother and baby who were severely affected by sepsis.

This was a free event open to all and took place on Friday 13 September 2019 in the seminar room and Sepsis Engagement Centre at the Sir Geraint Evans Cardiovascular Research Building at the University Hospital of Wales.

Event feedback:

'Excellent microbiology talk - very good illustrative case with patient perspective'

'Excellent varied programme, particularly enjoyed the patient’s story'

'Wonderful clinical simulation'

'A privilege to join the discussion and an invaluable insight into the global challenges of tackling sepsis'

See more information about World Sepsis Day 2019.

View the World Sepsis Day 2019 programme.

Public engagement

Sepsis engagement centre.

We seek to promote interaction between patients, researchers, and clinical staff through the Sepsis Engagement Centre, physically located in the Sir Geraint Evans Cardiovascular Research Building, acting as an interaction and training hub. Planned audio-visual exhibitions include “The sepsis life cycle”, an exhibition of simulation wards with featured displays of neonatal intensive care unit (NICU), paediatric intensive care unit (PICU), adult intensive care unit (ICU), and an exhibit for scientific understanding of current and planned future medical tests and treatments for sepsis.

The Sepsis Engagement Centre aims to engage through outreach events and to promote patient and public involvement (PPI) for making a real difference in our research and the clinic for saving lives against sepsis.

Read more about the preview event that was held for the Sepsis Engagement Centre on 20 June 2018 .

Why the 'Golidlocks Ward' - The Goldilocks fairy tale

The Goldilocks fairy tale was first recorded in narrative form in 1837, in a collection of essays by Robert Southey titled “The Doctor.”

As in the house belonging to the three bears, the Goldilocks Ward has three beds, from our tiny neonatal cot to an adult hospital bed.  The distinct zones provide crucial opportunities for simulated training and research. They represent:

• Neonatal Intensive Care Unit (NICU)
• Paediatric Intensive Care Unit (PICU)
• Adult Intensive Care Unit (ICU)

The ‘Goldilocks principle’ means to strive for what is ‘just right’. Our interactive display explores the application of this principle to precision medicine and the antibiotic treatment of sepsis - getting just the right medicine to the right patient.

Sepsis is caused by an unbalanced immune reaction in our blood to fight infection. The main pathogens that can trigger sepsis range in size Fungal/Yeast, Bacterial, Viral.

A community action for getting involved to be involved in sepsis awareness and research

Central to helping us reach our goals are Lay Advisory groups for neonatal, paediatric, and adult sepsis, respectively. The role of our Lay Advisory groups is to help review research priorities, identify new lines of research, give input into research proposals (lay summaries in particular) and impact statements and website content, as well as contributes to the dissemination of research findings to relevant target groups.

Lay advisory involvement for project sepsis is underway with opportunities to join the pool of lay advisors in our community action against sepsis. We especially welcome those affected by sepsis either directly, as former patients, or indirectly as family members of former patients as well as those who wish to get involved out of general interest.

If you would like to find out more about patient and public engagement, please contact: [email protected]

Our lay advisory community

• Terence Canning (aSEP)
• Nicola Madoc-Jones (nSEP)
• David Madoc-Jones (nSEP)
• Holly Powell (nSEP)
• Tracey Laight (aSEP)
• Jacqueline Mason (aSEP)
• Alan Brown (aSEP)

Our funding

This project is part-funded by the European Regional Development Fund through the Welsh Government.

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School of Medicine

Project Sepsis involves studies of Neonatal, Paediatric, Maternal and Adult sepsis.

Diagram showing individual patients that either have blood culture positive sepsis (red dots) or are well babies (blue dots). The position indicates how the pattern of 10,000 most variable genes alters amongst the patients and if similar occupy a similar position, revealing a clear discrimination between healthy and sepsis babies.

Line graphs of pathway diagnostic markers of sepsis showing the values of gene expression activity associated with causal pathways of (a) innate immunity (in-born), (b) metabolism, (c) adaptive immunity (acquired) and (d) the integration of all three pathways in patients either having blood culture positive sepsis (red dots) or well babies (blue dots). A 100% accuracy in predicting sepsis is obtained when all three pathways are combined.

Project Sepsis team.

Medical professionals giving a demonstration in the sepsis engagement centre.

Project Sepsis team joined by fellow medical professionals in the engagement centre.

Research that matters

Our research makes a difference to people’s lives as we work across disciplines to tackle major challenges facing society, the economy and our environment.

Postgraduate research

Our research degrees give the opportunity to investigate a specific topic in depth among field-leading researchers.

Our research impact

Our research case studies highlight some of the areas where we deliver positive research impact.

A research project aiming to harness the immune system and its soft wiring to metabolism as a detector of infection.

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• GP Training

Sepsis case study

By Dr Sean Brink on the 27 July 2016

A case of a 39-year-old man who presented with swelling and pain in his scrotum and penis highlights the importance of remaining vigilant to the risk of sepsis, red flags for sepsis in adults and the Sepsis Six care bundle.

Sepsis causes 37,000 deaths annually in the UK, a five-fold higher mortality than STEMI or  stroke . 1  Sepsis is a medical emergency, for every hour antibiotic administration is delayed there is an 8% increase in mortality. 2   NICE has published new guidance on recognition, diagnosis and management of severe sepsis . 3

A 39-year-old man felt unwell overnight with swelling and pain in his scrotum and penis. In the morning he felt breathless and had blood-stained fluid oozing from his penis. He called 999 and the ambulance crew took him to accident and emergency. The patient admitted that he had not attended earlier because he was frightened and because he was sole guardian of his teenage son, who had to come with him.

The patient was cared for in a cubicle in A&E. As a general practice trainee my first contact with him was when a concerned nursing assistant showed me his ECG, which revealed a sinus tachycardia with a rate of 140bpm.

The patient had no significant medical or sexual history, regular medications or allergies, and his last sexual contact was over two years ago.

Initial investigations

Observations showed a respiratory rate of 39 per minute with BP 120/75, oxygen saturations of 97% in air and tympanic temperature of 37.9C. Capillary blood glucose was 13.4mmol/l with no history of diabetes.

The patient’s arterial blood gas showed a marked compensated alkalosis with a lactate 3.9mmol/l. Venous blood results showed a CRP of 535 mg/l, urea of 11 mmol/l and creatinine 200 µmol/l.

Box 1. Red flags for sepsis in adults
Act immediately if ANY ONE of the following are present:

The patient had Fournier’s gangrene. Treatment followed the Sepsis Six care bundle — an initial resuscitation bundle designed for secondary care to offer basic intervention within the first hour of identification (box 2). 1

Box 2. Sepsis Six care bundle

Oxygen therapy, IV fluid resuscitation with crystalloid fluid through large bore cannulae, and analgesia were given. Blood cultures were taken. After 95 minutes in A&E the patient was taken to theatre for penile shaft and scrotal skin debridement. After 24 hours he had lower abdominal and thigh incisions. He spent nine days in the high dependency unit.

Guidelines for the management of patients in primary care are shown in box 3.

Box 3. Guidelines for the management of patients in primary care
. Arrangements should be made for review within 24-48 hours.

Outcome and follow up

Beta-haemolytic group A streptococcus was identified from the patient’s blood cultures. Antibiotic therapy was guided by the sensitivities.

The patient was followed up in the local plastic surgery department six weeks after leaving hospital for consideration of split skin grafting of unhealed areas.

Learning points

Healthcare professionals must remain vigilant to the risk of sepsis. It can occur in patients who are expected to be least at risk. In this case, sepsis was only identified when an ECG showed a marked tachycardia in an unassuming young patient.

It is important to triage effectively and review channels of communication so that patients feel able to contact us.  The UK Sepsis Trust  have produced a useful symptom checker card for patients, which can be downloaded from:  sepsistrust.org/uk .

Important:  NICE recommends asking 'Could this be sepsis?’ if patients present with signs or symptoms that indicate infection, even if they do not have a high temperature. See NICE algorithm for assessing adults

In Fournier’s gangrene, the infection spreads along well-described fascial planes of the perineum, scrotum and penis, often with involvement of the thighs and lower abdomen.

Fournier’s gangrene fulfils the criteria for necrotising fasciitis; a bacterial infection rapidly spreading through cutaneous tissue planes. Necrotising fasciitis is uncommon, with only 24 patients diagnosed in six years in one tertiary centre (group A streptococcus was the principal organism in a third of these cases). 4  

The hospital where this patient presented had 17 cases in nine years, of which eight cases related to the pelvic region and thighs.

Since 2001 the  Surviving Sepsis Campaign  aimed to improve survival.  National guidance for hospitals was published in 2005 . 5  

In 2013, the UK Parliamentary and Health Service Ombudsman  highlighted shortcomings  in initial assessment of patients with sepsis and delay in emergency treatment, which led to missed opportunities to save lives. 6  

Improvements have been made since then. For example, IT desktop toolkits for GPs are being created by the  UK Sepsis Trust . 1  NHS England, the Academy of Royal Medical Colleges and the Department of Health are working to reduce avoidable mortality. 7

Take a test on this article and claim your certificate on MIMS Learning

• Dr Sean Brink, GP in East Sussex, United Kingdom
• The UK Sepsis Trust. Toolkit:  General Practice management of sepsis . Available from: sepsistrust.org/wp-content/uploads/2015/08/1409322498GPtoolkit2014.pdf
• Kumar A, Roberts D, Wood KE et al.  Crit Care Med 2006; 34:1589–96 .
• NICE.  Sepsis: recognition, diagnosis and early management . NG51. NICE, London, 2016.
• Glass G, Sheil F, Ruston JC, et al.  Ann R Coll Surg Engl 2015; 97: 46-51 .
• Dellinger RP, Carlet JM, Masur H, et al.  Crit Care Med 2004; 32(3):858–73 .
• Parliamentary and Health Service Ombudsman.  Time to act. Severe sepsis: rapid diagnosis and treatment saves lives . 2013.
• NHS England.  Cross-system sepsis programme board . 19 March 2015.

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• Volume 5, Issue 1
• Making the journey safe: recognising and responding to severe sepsis in accident and emergency
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• Sarah Pinnington ,
• Brigid Atterton ,
• Sarah Ingleby
• Central Manchester University Hospitals NHS Foundation Trust, UK
• Correspondence to Sarah Pinnington sarah.pinnington{at}cmft.nhs.uk

Severe sepsis is a clinical emergency. Despite the nationwide recognition of the sepsis six treatment bundle as the first line emergency treatment for this presentation, compliance in sepsis six provision remains inadequately low. The project goals were to improve compliance with the implementation of the Sepsis Six in patients with severe sepsis and/or septic shock. In improving timely care delivery it was anticipated improvements would be made in relation to patient safety and experience, and reductions in length of stay (LoS) and mortality. The project intended to make the pathway for those presenting with sepsis safe and consistent, where sepsis is recognised and treated in a timely manner according to best practice.

The aim of the project was to understand the what the barriers where to providing safe effective care for the patient presenting with severe sepsis in A&E. Using the Safer Clinical Systems (SCS) tools developed byte Health Foundation and Warwick University, the project team identified the hazards and associated risks in the septic patient pathway. The level of analysis employed enabled the project team to identify the major risks, themes, and factors of influence within this pathway. The analysis identified twenty nine possible interventions, of which six were chosen following option appraisal. Further interventions were recommended to the accident and emergency as part of a business case and further changes in process.

Audits identified all severely septic patients presenting to A&E in October 2014 (n=67) and post intervention in September 2015 (n=93). Compared analysis demonstrated an increase in compliance with the implementation of the sepsis six care bundle from 7% to 41%, a reduction in LoS by 1.9 days and a decrease in 30 day mortality by 50%. Additional audit reviewed the management of 10 septic patients per week for the duration of the project to assess the real time impact of the selected interventions.

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits use, distribution, and reproduction in any medium, provided the original work is properly cited, the use is non commercial and is otherwise in compliance with the license. See:

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Severe sepsis is a clinical emergency. Despite the nationwide recognition of the sepsis six treatment bundle as the first line emergency treatment for this presentation, compliance in sepsis six provision remains inadequately low. Clinical audits have shown low compliance with the sepsis six care bundle within the accident and emergency (A&E) department on a national and local scale highlighting an urgent need for improvement. 1 To understand the problem in detail an audit of all patients presenting to Central Manchester University Hospitals NHS Foundation Trust (CMFT) adult A&E department with severe sepsis in October 2014. This audit identified that 7% of patients presenting with severe sepsis received the full sepsis six within one hour of arriving to the department, highlighted an urgent requirement for improvement.

CMFT&s adult A&E department is located within Manchester's city centre and the hospital catchment area ensures a wide variety of presentations among a diverse population. Daily attendances often reach 300 patients, which can create a busy and highly pressured working environment. While the project team understood that the environment and some staffing issues were factors that may have compounded the problem of inadequate recognition and management of severely septic patients, it was believed that systems and processes could be improved for the benefit of this patient group. In order to understand these systems and processes the project team utilised tools that were designed for the Health Foundation and Warwick University Safer Clinical Systems (SCS) project. 2 The project aimed to increase compliance in the delivery of the Sepsis Six in A&E to 50% within six month intervention time period. As there were no previous data on LoS and 30 day mortality before the initial audit, the overall aim was to compare the data from the initial and end audits from this project to provide a baseline for these figures.

Severe sepsis is a major healthcare issue in the UK with 100 000 cases presenting to hospital in the UK per year. 3 The mortality rate for patients presenting with severe sepsis has been estimated as between 28% and 50% in the UK, with an estimated 37 000 patient deaths and a further 65 000 people left with serious long term complications. 4 The economic burden of this patient group upon the healthcare economy due to these failures is considerable, with an average cost of about £200 000 per admission. This means that improved care could lead to the potential savings of £196 million a year per annum. 3

The current Trust policy used at CMFT is based on systemic inflammatory response criteria (SIRS). The SIRS criteria was utilised by the team as the initial tool to identify the severely septic patients. The SIRS criteria were defined in 1992 as the clinical expression of the host response to inflammation. 4 SIRS remained the predominant approach to screening and classifying sepsis, with two or more SIRS criteria being an indicator of a systemic response to infection. 5 The Trust's pathway mirrors this approach to identify potentially septic patients.

Severe sepsis is a systemic response to infection leading to severe organ dysfunction which can ultimately lead to sepsis shock and death. 6 The gold standard treatment is the completion of the sepsis six bundle within one hour of presentation. 1 Research has shown that the timely completion of this treatment bundle improves patient outcomes, reduces LoS and mortality. 3 , 6 Despite the establishment of national campaigns to address this failure in care provision, national audits have highlighted severe deficiencies in delivery of care, 1 , 6 and the immediate requirement for improvement in the recognition and delivery of care for this patient group has been highlighted as a national priority. 6 , 7 , 8

Baseline measurement

For this project it was necessary to obtain a representational sample of patients presenting with sepsis at A&E. It was decided that capturing all patients presenting with signs and symptoms of severe sepsis over a one month period would provide a data sample capable of detailed data analysis. This would firstly ascertain the performance of the department in the management of severely septic patients and secondly gain an informed idea of the actual number of severely septic that presented over this time period.

For these baseline figures, the project team proposed to identify all of the patients presenting with severe sepsis and septic shock in A&E over the month of October 2014. The decision to use the Systemic Inflammatory Response Syndrome (SIRS) criteria as the first method of identifying the patient group was primarily lead by the Trust's sepsis guidelines, which applied SIRS as the first identifier of possible sepsis. SIRS data were collected from the Patientrack™ electronic clinical observation recording and alerting system currently used throughout the Trust. Laboratory results from the Trust's clinical work base system were used to collect details of blood glucose and white cell count results to complete the information required for the SIRS criteria. Together this generated a database which identified all patients that triggered SIRS in A&E.

There was an obvious oversight during initial analysis in the use of clinical observations only in the identification of severe sepsis. Patients who presented in a critical condition and treated in the resuscitation area of the department were not consistently included in the database. Initial electronic submission of clinical observations were not always priority in these critical situations, leading to missed patients who may not trigger the SIRS criteria following treatment or those who had been rapidly transferred to critical care or theatre. To resolve these issues and ensure capture of all eligible patients, it was necessary to use other data sources. Data were obtained from the arterial blood gas machines in the department to identify patients with a lactate measurement ≥ 2mmols/L. Elevated lactate levels are a marker of cellular dysfunction invariably seen in severe sepsis. 9 The use of elevated lactate measurements, alongside capturing all critical care admissions within 24 hours of A&E presentation allowed the project team to identify patients potentially missed from the initial SIRS data.

The resulting baseline data found 948 patients met the set criteria. Case notes, laboratory test results, and clinical observations were reviewed by the project team to identify severe sepsis cases. In total 67 patients were deemed to be severely septic. Analysis found that only 10% of the 67 patients received the Sepsis Six care bundle within one hour of presentation and compliance with each element of the sepsis six need improvement (see supplementary file “baseline audit data”)

Supplemental material

The quality improvement project team consisted of a lead nurse for acute care, two nurse project facilitators, and an A&E consultant. A number of tools were used to gain a greater understanding of the current process and areas of risk within the patient pathway. These tools were created and utilised in the SCS project in 2011 in conjunction with Warwick University and the Health Foundation. The tools enable the team to review the patient pathway and identify levels of risk. They have been successfully utilised before within CMFT and the agreement was these tools would enable effective analysis of the areas of risk that would ultimately lead to appropriate interventions. The initial tool utilised was the high level process map, to ensure the project team have an initial understanding of the process. The severely septic patient journey was documented in sequential order, from admission route to discharge. Areas of potential risk were identified throughout the journey; identifying barriers for the timely recognition and management of the severely septic patient. This high level of risk faced by the septic patient required further analysis to determine the necessary interventions to make the journey safe.

Following the high level mapping, we invited a wider team of nurses and medics from the department and undertook two swim lane maps were made of different patient journeys; one a timely and appropriate response to sepsis, with the second being not an ideal or timely response. These swim lane maps identify all those involved in the journey and the details of the pathway, identifying where the process has not been as it should have been and again identifying bottle necks or areas of risk. This process again uncovered clear issues with the present process and by having the wider team present, began the initial engagement of the staff.

Following the identification of areas of risk/concern, the project team employed Failure Modes and Effects Analysis (FMEA) approach, which enabled a proactive systematic analysis of where processes involved in the septic patient's journey could go wrong. By utilising the knowledge gained from the high level process map and swim lane maps (as well as involving various levels of the A&E team) it helped establish a shared understanding of risks, forming the basis for development of patient safety initiatives. This analysis was strengthened by undertaking Hierarchical Task Analysis (HTA). This human factors analysis allowed the identification of tasks and sub-tasks; each task and subtask was risk ranked, identifying where things go wrong, reviewing how they go wrong, and what influences what goes wrong. This examination of intrinsic and extrinsic influences allowed for the recognition of the necessary changes in process needed to improve the care of the septic patient in A&E. Present mitigations were identified as well as a number of areas that were not presently as they should be and could be seen as potential interventions to reduce the risks.

In total there were twenty-seven improvement interventions that were generated in response to the areas of risk. An options appraisal was completed including ease of implementation, cost effectiveness, acceptability, effect on patient safety and more, with staff from the department to ascertain which interventions would be the most beneficial and achievable. The chosen interventions were grouped together into three themes:

Theme 1: Improving time to treatment; Theme 2: Improving communication; Theme 3: Improving awareness of sepsis in recognition and timely response.

Plan, do, study, act (PDSA) cycles were used to trial the improvement interventions and assess the impact on the compliance with the Sepsis Six. Alongside the PDSA cycles there were a number of process and outcome measures identified to observe for impact of the interventions. The project team reviewed ten cases per week, allowing for continuous evaluation of the impact of interventions and the project to be reactive to any compliance issues identified.

PDSA 1: Identification of septic patient for was a time consuming task when first looking for the baseline data in October and it was obvious that a more effective way was required. Development of sepsis database was undertaken to identify all A&E patients triggering SIRS, linking a positive result with early warning scores (EWS), microbiology and laboratory results indicating organ dysfunction. This enabled an improved approach to identification of severely septic patients, rather than manually searching through case notes and various clinical systems. The initial development of the database required a number of changes in regard to the information needed to ensure all patients were captured. The addition of critical care admission data also ensured that patients who may have been taken directly to theatre or critical care were not missed from the database.

The database has evolved further, creating an inpatients option. This allows specialties within the Trust to have the means to understand of the prevalence of sepsis presentation in their patient groups, and simplifies the process of identification of patients to audit for compliance with sepsis management.

PDSA 2: Continuing review of ten patient cases per week for the duration of the project was undertaken by the project facilitators. The number of 10 patients was specifically chosen as it would identify approximately half of the severely septic patients presenting at A&E per week, based on the baseline data numbers and it was able to be managed by the project facilitators. These patients were chosen at random utilising the sepsis database. The process measures that we were recording were average time to the Sepsis Six elements from presentation at the A&E department and overall compliance to the Sepsis Six for the review group were calculated weekly. This gave the opportunity for timely assessment of the impact of interventions and also allowed the project team to modify certain interventions in response to themes/issues highlighted by the review data. This data was displayed on the project boards in the department and feedback to all staff individually via email.

PDSA 3: Education of the A&E team was a top priority to ensure that the staff were knowledgeable and up to date regarding sepsis recognition and management. To ensure the education programme was effective, a number of trial sessions were held with three groups of four staff members. Feedback helped to develop an effective and interactive teaching session, which demonstrated improved knowledge with the use of pre and post teaching multiple choice questions (MCQ). Weekly education sessions were held for all grades of staff in the department to attend. These included information on sepsis recognition and management but also looked at reasons why diagnosis of sepsis could be delayed or missed. This allowed staff discussion of their own experiences, helping to identify where potential new improvements could be made and also helped evolve the contents of the teaching session to meet the needs of the department. Real life cases from the department were used in the teaching to further highlight issues found and for the team to have a greater understanding of how the departmental human factors could influence care. MCQs were once again employed to appraise the impact of the teaching, allowing timely changes to the content/teaching style to ensure essential information was conveyed. The MCQ questions were based on recognition and treatment of sepsis, including patient case based scenario questions.The times for the sessions were displayed on the project information board and also communicated to the team on a regular basis. Again numbers of staff trained and MCQ scores were monitored as process measures. The MCQ data demonstrated an increase in correct answers in the post teaching answers by up to 47%.

PDSA 4: In the initial analysis period of the project it was identified that barriers to productive communication influenced the recognition and timely treatment in severe sepsis. These potential communication failures ranged from poor communication due to staff not knowing which nurse/doctor was looking after the patient, to delays in treatment due to staff not communicating that treatment had been prescribed. The project team through observations and feedback from all grades of staff found that there were times when the staff did not know the skills or grade of other staff and also which staff were assigned to which patients. This obviously could have impacted on staff and patient safety. To improve the communication between the team it was decided to look at the introduction of a safety huddle at the start of shifts. A number of styles were investigated and trialed using feedback from the staff to guide the project team to formulate a set standard for the department. The introduction of the ‘pre brief’ comprised of a huddle in each area of the department at the start of shifts, allowed nursing and medical teams to be introduced to the name, role and relevant skills of each member of the team, such as if nurse was able to do venepuncture or administer intravenous medications. To support the introduction of pre briefs, name boards were introduced in the individual patient rooms which displayed information of the named nurse and consultant in charge of the patients care. This ensured the doctor or allied health professional knew the named nurse who they should communicated with in regards to the management plan and treatment prescribed for the patient. Compliance with the number of completed pre briefs and name boards was undertaken, alongside qualitative data from staff feedback and questionnaires to understand the impact on team communication.

PDSA 5: Staff engagement was achieved through staff meetings, handovers, teaching sessions, and email contact with the A&E team to keep them informed and updated with the project and highlighting their hard work. Continued engagement with staff throughout the project empowered staff members to take the project on as their own and feel proud of their work. Regular contact with staff through various mediums was integral to maintain the high profile of the project and in doing so raising awareness and ownership of the interventions, thus reducing the risk of the hazards. Feedback from staff helped to guide the methods of utilised to ensure the all staff had access and understood the project aims and interventions.

PDSA 6: The Trust sepsis stickers were introduced into the A&E department (see supplementary information “sepsis sticker”). Audit of septic patients within the Trust had revealed improved compliance in the completion of the Sepsis Six within one hour when the stickers were used. The aim was to introduce the stickers in to the department, to improve documentation and Sepsis Six compliance. The stickers were placed with the sepsis assessment forms to ensure they were available if sepsis was suspected. The stickers act as a prompt to ensure the risk of not giving the correct treatment in a timely manner is reduced. The sepsis stickers list the Sepsis Six and the practitioner prompted to acknowledge the time zero of the severe sepsis diagnosis and to date and time when each component has been achieved. It also has a reminder to inform the senior nurse and senior doctor, ensuring senior expertise at the earliest opportunity in the management of the patient. The stickers are implemented by the first practitioner seeing the patient, and encourage clear documentation and compliance with the sepsis six. The uptake and impact on compliance was measured with the weekly patient audits as part of the process measures and the end of project audit.

The compliance and average time to the elements of the Sepsis Six were monitored throughout the project, reviewing ten septic patients per week. The purpose of this was to allow for the impact of the interventions to be measured and acknowledged and give an indication as to the present level of safety in the pathway. The data found average time and overall compliance significantly improved over the project time frame (see supplemental information “project results” ).

In September 2015 the project team repeated the initial audit, once again identifying all those patients attending A&E with severe sepsis/ septic shock. Ninety-three patients were identified as having severe sepsis using the same inclusion criteria as October 2014. There was variation in the audit group sizes in both audits (n=26). To ensure no patients had been overlooked in the October data before the sepsis database had been created, the October 2014 data was rechecked using the newly developed database to help identify any missed patients. However, there were no missed patients identified when using the same data collection points as the September 2015 audit, meaning both audits represented the actual severely septic patients attending A&E in the audited time frames.

Analysis demonstrated a positive impact on the recognition of the patient with severe sepsis and the compliance with the Sepsis Six care bundle, with a 34% increase of patients receiving the Sepsis Six treatment within one hour from time zero. For our outcome measures the comparison with the initial October 2014 data found a decrease in length of stay by 1.9 days and a 50% reduction in 30 day mortality in the September 2015 patient group. Our second outcome measure established that time from prescription to administration of antibiotics reduced from 45.5 minutes to 11.2 minutes following the project interventions.

Lessons and limitations

As stated previously the Trust current sepsis policy is based on the SIRS criteria. However, reliance on SIRS criteria has been under great scrutiny by the international research body and there has been pressure to develop an improved screening tool for sepsis. 5 The recent international consensus has replaced SIRS as the suggested screening criteria with the introduction of Sequential [Sepsis-related Organ Failure Assessment (SOFA) and qSOFA for use in out of hospital settings, emergency departments, or general hospital wards. 10 , 11 This is due to its low sensitivity and specificity in identifying septic patients, 12 with SIRS not being specific to infection, as indicated by the name it is a systemic inflammatory response which can be activated by a wide range of clinical presentations. 13 These concerns over the low sensitivity of SIRS were seen in the in the data collection of this project, where excessive numbers of patients were identified as SIRS positive yet less than 10% actually had severe sepsis.

Additionally, there are a number of groups that have been shown to not fit the criteria, exemplifying the complexities of identifying sepsis, which were also witnessed during this project. An example of this is in the elderly population, where pyrexia is often blunted or absent and the elderly patient may present with non-specific symptoms like recurrent falls, confusion or new incontinence rather than classic SIRS. 15 Other patient groups seen to have potential for atypical presentation of sepsis include the young population who have the reserve to compensate well for a period of time before declining rapidly, as well as immunocompromised patients where any presentation of feeling unwell should treated as a medical emergency due to potential neutropenic sepsis and high associated mortality due to delay in treatment. 16 , 17 In addition certain medications and pre-hospital treatment may also mask signs of sepsis, such as beta-blockers, paracetamol and fluid boluses, relaying on good clinical assessment and communication to ensure this is evidenced. Recent research has also indicated that there is a number of patients who have SIRS negative sepsis again adding to the debate, and requirement for more sensitive screening pathway. 10 The project team are awaiting the upcoming NICE guidance alongside recently published international guidance to support the development of an improved and safer screening process for the Trust.

There were notable issues with the collection of time to treatment data for the Sepsis Six for fluid balance and oxygen leading to difficulties in accurate timing of delivery. Oxygen is not commonly prescribed within A&E and the correct percentage/flow was not always documented correctly with the input of observations leading to potential inadequacies in the data. Improvements in documentation have been seen since the implementation of the education sessions and a Trust wide oxygen improvement project will further enforce these standards. Fluid balance documentation was also a concern with many patients having no fluid balance recorded whilst in the department. This lead to the overall compliance with the Sepsis Six mainly being reduced due to the failure to fluid balance. Discussions with the departmental leads acknowledged that improvement was necessary and nominated staff are conducting an A&E based improvement project. A substantial increase in compliance has been seen in the continued monthly audit of severely septic patient care with approximately 70% of patients having completed fluid balance charts compared to the end of project data of 45% completion. Both the improvements in documentation of fluid balance and oxygen have been further encouraged by the addition of the sepsis sticker documentation within the department.

Recent studies looking at the management of sepsis have found concerns regarding the effectiveness of the early goal directed treatment (EGDT) - Sepsis Six. The Protocolised Care for Early Septic Shock (ProCESS) and Australasian Resuscitation in Sepsis Evaluation (ARISE) trials did not detect a significant reduction in sepsis mortality with the use of EGDT compared with usual care, 18 , 19 leading to argument that this may be the end for EGDT role in the management of septic patients. However, there questions remain regarding the overall significance of the results, with all patients in ARISE receiving antibiotics before randomisation, and patients including the usual-care group received rapid fluid resuscitation during the first six hours after randomisation. Mortality rates in ProCESS and ARISE were all significantly lower than the rate in the control group of the original 2001 EGDT trial, 20 confirming that rapid recognition, early antibiotics, and aggressive fluid resuscitation are the essence to more effectively treating sepsis. While there is further research/discussion regarding which initial interventions are required for the best outcome, the use of the Sepsis Six will remain gold standard until further guidance.

The time limitations of the project meant that a number of recommendations the project had highlighted through risk analysis could not be fully implemented. These interventions, if they had been implemented in the project time frame, could have contributed to further improved results. However, these interventions have had to be supported through business cases which have been authorised within the project time frame due to the monetary requirements and multi-professional input. The first of the in-progress recommendations concerns staffing levels. Through observations of the severely septic patient journey through the department, the project identified the Rapid Assessment Unit (RAU) as a high risk area. The present process of RAU is as follows; ambulances arrive and patient is assessed in by a triage nurse. The patient is then booked in by the reception staff. Initial investigations are then carried out following which the patient is moved to an appropriate area in the department and care is handed over. Currently the staffing in the RAU is one registered nurse (RN) and two nursing assistants (NA). There is an office for a receptionist within RAU, although this role is not always filled due to staffing limitations. The original template for the staffing of RAU includes a consultant or senior doctor. This allows for a rapid assessment by a decision making clinician and facilitates the timely recognition of the sick patient and prescription of appropriate treatments. However, this is not always possible due to medical staffing numbers.

The project team believe that due to the high volume of ambulances and the pressures of operating this gateway, a second RN would be highly beneficial for the care of patients and flow of the department. This would provide additional advice support in managing the patients, enable immediate prescribed treatments to be carried out without causing delay in triage/holding ambulances unnecessarily, and allow nurse to nurse handover to be given on transfer of patient. Observations within RAU found that nurse handover was compromised when RAU is staffed with only one nurse due to the pressures of ambulance arrivals and managing the patient care. It was found that only 10% of patients from the RAU were handed over to the receiving nurse in the department when there was one RAU nurse, whilst this handover rate increased to 60% when there were two RAU nurses. The observations also found delays in test and investigations due to the time taken to admit a patient on to the electronic systems if there was not a receptionist in the RAU. To highlight these findings, data gathered were presented in a report to the senior management team. This report is currently being used as part of a larger business case to request for increased staffing and a review of the process.

The next in-progress recommendation looks at the provision of arterial blood gas analysers in the department. Currently there is only one arterial blood gas analyser in the department which is located in the resuscitation area. The project team has recommended that a second blood gas analyser would be beneficial due to the high volume of blood gases required, the pressure that this puts on the one current machine, and to support the layout of the department. Staff feedback and delays in lactate measurement highlight the risk of the current equipment, not only in the identification of sepsis but in the rapid identification of the sick patient. Data gathered by the project have been added to a business case for the purchase of a second blood gas analyser within the department.

Finally, the third in-progress recommendation concerns the introduction of needle free antibiotics, which allow for reconstitution of the antibiotic via an ampule of the drug pre-attached to the diluent bag. A pilot for needle free antibiotics had previously been conducted, demonstrating improved times of antibiotic administration which would be hugely beneficial in the A&E department. This is presently under review.

The impact of education saw significant benefits in the timely recognition and management of severely septic patients within the A&E department, with the average improvement of 93% in the correct answers in the pre and post training multiple choice questions. The project result process measure run charts, illustrate the positive impact the teaching had on the average time to elements of the Sepsis Six, with improvements seen after the implementation of teaching programmes. The delivery of standardised education sessions supported a consistent and knowledgeable approach to recognising, escalating, and delivering timely and appropriate management in severe sepsis. The sessions allowed the opportunity for further discussion and engagement with staff, embedding the project aims and allowing the project team to be responsive to any knowledge gaps or process issues. The fact that this increased sepsis based education had positively influenced compliance with the delivery of the Sepsis Six; the project team understood the importance to replicate the education throughout the Trust. Improved sepsis education is now received on induction for all grades of healthcare staff and is included on the yearly clinical mandatory training to ensure all clinical staff within the Trust are up to date and aware of the sepsis pathway. Simulation sessions have also been started and additional training is undertaken by sepsis champions that have been identified within the A & E department to ensure sustainability.

The project team was able to identify the hazards within the septic patient journey using the Safer Clinical Systems approach, developing interventions that addressed these hazards to reduce the risk. The project has enabled the risks to be reduced (as is evident from the September audit) but the project team acknowledge that continued work is required to ensure an improved level of safety is achieved. To sustain the continued improvement and prevent a drift into failure the project team has appointed sepsis champions in the team to continue to drive the project aims and develop a teaching rota to ensure this initiative continues. This is also supported by continuing audit of the management of twenty septic patients per month to ensure compliance with the standards continues and that the department can be proactive in its approach to addressing any issues in a timely manner.

Due the significant results gained by this project, it is necessary to ensure these improvement methodology and interventions are shared throughout the Trust and further afield as necessary. The project team have begun supporting sepsis improvement projects with the Trust obstetrics team and enabling divisions to understand their sepsis management through audit supported by the development of the sepsis database. Further work is underway with the development of educational videos for public and staff to enhance awareness within the hospital and community settings.

Acknowledgments

All the A&E staff for their involvement and contributions to this project.

• ↵ CEM clinical audits 2011–2012: severe sepsis and septic shock . London : College of Emergency Medicine ; 2012 .
• ↵ Heath Foundation ( 2009 ) Safer Clinical Systems . London : The Health Foundation . http://www.health.org.uk/programmes/safer-clinical-systems .
• ↵ Health Service Ombudsman for England ( 2013 ). Time to act – severe sepsis: rapid diagnosis and treatment saves lives . London : Parliamentary and Health Service Ombusdman .
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• ↵ NCEPOD ( 2015 ) Just Say Sepsis! A review of the process of care received by patients with sepsis . London : NCEPOD .
• ↵ NHS England ( 2014 ) Improving outcomes for patients with sepsis . London : NHS England .
• ↵ NHS England ( 2015 ) Commissioning for Quality and Innovation (CQUIN) . London : NHS England .
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• ↵ NICE guidelines [CG151] . Neutropenic sepsis: prevention and management in people with cancer . 2012 . https://www.nice.org.uk/guidance/cg151 (Accessed 16 November 2015) .
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Declaration of interests Nothing to declare.

Ethical approval This work is deemed to be an improvement study and not a study on human subjects, therefore local policy excludes this from requiring ethical approval.

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A 26-year-old female arrives with a companion to an urgent care at 0845 by personal vehicle for treatment of suspected foot infection. The patient’s companion (a female roommate) reports to the triage nurse that the patient cut her foot while wading in the ocean over the weekend. They did not initially notice the cut but discovered it while removing tar from the bottom of the right foot. Approximately 24 hours later, her foot became too painful for ambulation, and a “thick, yellowish” discharge began to drain from the cut. Vitals upon arrival at urgent care showed a temperature of 101.5F, heart rate of 130, respiratory rate of 24, and blood pressure of 86/40. Her pain was 9/10 in her right foot and described as throbbing. During a HTT assessment by the PA, the patient is reported to be arousable to voice, oriented to person and place only, and complaining of nausea. The patient reports she took Tylenol that morning to relieve pain and fever. Her skin is pale, diaphoretic, and hot.

The urgent care calls 911, and medics are dispatched to the center for transfer to the local hospital to treat the patient for suspected sepsis. Upon arrival, medics find the patient is still tachycardic, and that her blood pressure has dropped to 80/40. Her respiratory rate has increased to 30. During transport, medics insert a 20 gauge peripheral IVs in the patient’s left antecubital. They infuse a fluid bolus of 500 mL of normal saline to manage her patient’s hypotension, and administer oxygen by simple mask at 4L/min. During the primary assessment, the patient’s right foot reveals a two-inch laceration with no active bleeding that is erythematous, edematous (non-pitting), and radiating heat. Edema is covering the entire bottom of the right foot and extends to the patient’s ankle.

The patient arrives to the emergency room within 15 minutes and is admitted for treatment at 1000. On the unit, Code Sepsis is called, and the agency’s sepsis protocol based on the Surviving Sepsis campaign is implemented. The patient’s vitals are now a temperature of 102F, heart rate of 140, respiratory rate of 34, and blood pressure of 96/42. Lactate levels are immediately measured. A second 20 gauge peripheral IV is inserted into the right antecubital, blood cultures are drawn, and a swab sample is taken of the cut and submitted to the laboratory for a culture and sensitivity test. Broad spectrum antibiotic ceftriaxone (Rocephin) is administered, and patient is given Ibuprofen to manage her fever. The patient is diagnosed with septic shock, and because she is still hypotensive, 30mL/kg of normal saline is infused. The patient’s lactate levels come back as 2.4 mmol/L. Norepinephrine (Levophed) is also hung, and the patient is further monitored. With careful titration and vital monitoring, the use of vasopressors restores the patient’s blood pressure to 101/52. Although fluid resuscitation helps to bring the patient’s heart rate down to 104, Nicardipine (Cardene) was ordered in anticipation of further needs to manage tachycardia. The patient is transferred to the ICU at 1300 for further monitoring and management of her hemodynamic status.

In the ICU, the patient’s vitals stabilize. Her tachypneic state reduces, and respiratory rate is now 18. She no longer requires oxygen supplementation. Her pain is being managed with IV morphine and she rates the pain in her as 3/10. Her IV pump is running 125 mL an hour of normal saline along with piggybacked ceftriaxone (Rocephin), and labs return a lactate level of 1.5 mmol/L. The patient’s roommate arrives. She is tearful and explains to the ICU nurse that she wanted to tell the patient’s parents what happened, but the patient refused. The ICU nurse calls for the case manager and a social service consult to inquire further. The patient’s roommate explains to the interdisciplinary team that the patient does not have insurance because she is 26 and has been removed from her parents’ medical plan. The parents are also currently engaged in a divorce, do not speak to each other, and use their daughter to communicate. The patient is aware of their financial situation and her lack of medical coverage and does not want to worry her parents in spite of her critical medical state.

• What are the priority nursing interventions for this patient in the ICU setting?
• What signs and symptoms in this patient would indicate the need for mechanical ventilation?
• What is the nurse’s role in addressing the patient’s financial concerns?

References:

Gordon, A.C., Mason, A.J., Thirunavukkarasu, N., et al. (2016). Effect of early vasopressin vs norepinephrine on kidney failure in patient with septic shock: The VANISH randomized clinical trial. JAMA, 316 (5), 509–518. doi:10.1001/jama.2016.10485

Hinkle, J. L., & Cheever, K. H. (2014). Brunner & Suddarth’s textbook of medical-surgical nursing. Philadelphia: Lippincott Williams & Wilkins. PulmCCM. (2019, January 14). From the Surviving Sepsis Guidelines: Criteria for diagnosis of  sepsis. Retrieved from https://pulmccm.org/review-articles/surviving-sepsis-guidelines-criteria-diagnosis-sepsis/

Schmidt, G.A., & Mandel, J. (2019, March). Evaluation and management of suspected sepsis  and septic shock in adults. Retrieved from https://www.uptodate.com/contents/evaluation-and-management-of-suspected-sepsis-and-septic-shock-in-adults?search=sepsis treatmentadult&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1#H465649907

Society of Critical Care Medicine. (2019). Hour-1 bundle: Initial resuscitation for sepsis and  septic shock. Retrieved from http://www.survivingsepsis.org/SiteCollectionDocuments/Surviving-Sepsis-Campaign-Hour-1-Bundle.pdf

Zhang, M., Zheng, Z., & Ma, Y. (2014). Albumin versus other fluids for fluid resuscitation in patients with sepsis: A meta-analysis. PloS one , 9 (12), e114666.

Nursing Case Studies by and for Student Nurses Copyright © by jaimehannans is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License , except where otherwise noted.

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Case-based learning: recognising sepsis

Sepsis can lead to organ failure and death. However, early diagnosis and recognition may help prevent these potentially fatal consequences.

JL / Science Photo Library / Shutterstock.com

Several personal stories of sepsis survivors and deaths from sepsis have been published in the media, highlighting the importance of sepsis as a major cause of preventable deaths in the UK. This article will provide an overview of sepsis with particular focus on the role of pharmacy professionals in recognition and referral.

Pathophysiology

Sepsis is characterised by a systemic inflammatory response to an invasive infection that has become unregulated [1] . White blood cells and pro-inflammatory cytokines are released causing widespread vasodilation and an increase in capillary permeability, resulting in the loss of fluid from circulation. This results in hypovolaemia and a fall in systemic vascular resistance, which in turn leads to a fall in blood pressure and a decrease in organ perfusion, culminating in tissue hypoxia and organ failure [1] .

There are around 250,000 cases of sepsis annually in the UK, 20% of which are fatal [1], [2] . The UK Sepsis Trust estimates that early diagnosis of sepsis and the application of evidence-based treatment could save 14,000 lives per year [2] . Therefore, the timely identification of sepsis can lead to rapid treatment and potential mortality reduction.

Initial recognition of sepsis relies on identifying symptoms, which presents challenges for healthcare professionals as the common symptoms are not specific to sepsis and could be caused by non-infective pathology (e.g. trauma, pancreatitis, burns ) [3] .

The inflammatory-response-induced hypovolaemia affects the brain and can cause confusion, slurred speech and loss of consciousness. Similarly, as the kidneys are affected, there is a reduction in glomerular filtration resulting in a drop in urine output and development of acute kidney injury [1] , [3] .

Gas exchange across the alveoli is compromised as fluid and proteins leak into the lungs, causing a drop in systemic oxygen saturation and a rise in carbon dioxide levels. The body attempts to compensate by increasing its respiratory rate, but the problem is ultimately compounded as the drop in organ perfusion affects the lungs, meaning that even if oxygen-rich air is present, there is little blood flow with which gas exchange can take place [1] , [3] .

Initially, the heart rate increases in an attempt to compensate for the drop in blood pressure. However, the reduction in circulating volume and the fall in systemic vascular resistance ultimately undermine this action. This is because a reduction in venous return prevents the ventricles from properly filling before they contract, reducing the cardiac output [1] .

The typical signs and symptoms of sepsis may vary across different age groups, be general or may not all be present. Examples of moderate- and high-risk symptoms include:

• Reduced urine output (e.g. dry nappies in babies and toddlers);
• Feeling cold with shivering or chills;
• Rapid breathing (increased resting breaths per minute);
• Rapid heart rate (increased resting heart rate per minute);
• Mottled (see Photoguide A) or ashen appearance;
• Cyanosis (blue tint) of skin, lips or tongue (see Photoguide B);
• Non-blanching rash (see Photoguide C) [1] , [4] , [5] .

Additional signs in babies and young children (aged under five years)

• Not responding normally to social cues (e.g. does not smile);
• Visibly unwell (e.g. floppy or overly passive);
• Wakes only with prolonged stimulation or, if roused, does not stay awake;
• Weak high-pitched or continuous cry;
• Parent or carer is concerned that the child is behaving differently from normal;
• Has a seizure or convulsion;
• Pallor of the skin, lips or tongue;
• Cold extremities, but head and torso may be hot to the touch;
• Change in temperature (e.g. red flag temperatures are over 38 o C in those aged under 3 months, 39 o C in those aged 3–6 months and less than 36 o C for any age) [1] , [4] , [5] .

Additional signs that can affect patients aged over five years

• Evidence of new-onset confusion (history may be from a parent, carer, relative or friend);
• Slurred speech;
• Signs of potential infection (e.g. redness, swelling or discharge at surgical site, breakdown of the wound);
• Tympanic temperature less than 36 o C;
• New onset arrhythmia [1] , [4] , [5] .

If sepsis is suspected, the patient should be immediately referred for emergency medical assessment. 

Photoguide: symptoms of sepsis

Source: Science Photo Library / Shutterstock.com

At-risk groups

Sepsis can affect anyone, but there are some patient groups that should be considered to be more susceptible to the development of sepsis, including:

• Very young children (aged under 1 year);
• Frail or older people (aged over 75 years);
• Immunocompromised people (e.g. those being treated for cancer with or without chemotherapy, post-splenectomy, taking long-term steroids or other immunosuppressant drugs);
• People who have had surgery or other invasive procedures in the past six weeks;
• People with any breach of skin integrity (e.g. cuts, burns, blisters or skin infections);
• People who misuse drugs intravenously;
• People with indwelling lines or catheters;
• Pregnant women;
• Women who have given birth or who have had a termination of pregnancy or miscarriage in the past six weeks [4] .

Understanding the patient risk factors may help improve timely diagnosis of suspected sepsis.

Sepsis can occur in response to a wide range of infections, but is most commonly associated with bacterial infection of the lungs, urinary tract, abdomen, central nervous system, or skin and soft tissues [1] . It is primarily diagnosed by a clinical assessment. Any number or combination of signs and symptoms may be present on diagnosis.

The National Institute of Health and Care Excellence (NICE) and the UK Sepsis Trust have published risk stratification tools to facilitate appropriate recognition of sepsis and the level of risk to the patient. Most NHS organisations use these tools or a locally approved variation of them [1] , [4] . These tools cater to a wide range of patients of different ages and the recommended action differs depending on whether patients’ symptoms are recognised in the primary or secondary care setting.

Patients who meet the high-risk criteria (see Box for the criteria for children aged under five years) should be sent urgently for emergency care (at a setting with resuscitation facilities). These patients should receive intravenous antibiotics with an appropriate level of cover within one hour of recognition of sepsis, along with other treatments and investigations [1] , [4] .

Box: high-risk criteria for children aged under five years outside of the hospital setting

• No response to social cues;
• Appears ill to a healthcare professional;
• Does not wake, or if roused, does not stay awake;
• Weak high-pitched or continuous cry.
• Aged under one year: 160 beats per minute or more;
• Aged one to two years: 150 beats per minute or more;
• Aged three to four years: 140 beats per minute or more;
• Heart rate less than 60 beats per minute at any age.

Respiratory rate

• Aged under one year: 60 breaths per minute or more;
• Aged one to two years: 50 breaths per minute or more;
• Aged three to four years: 40 breaths per minute or more;
• Oxygen saturation of less than 90% in air or increased oxygen requirement over baseline.

Temperature

• Aged under three months: 38°C or more;
• Any age: less than 36°C.

To see examples of mottled skin or ashen appearance, non-blanching rash of the skin, and cyanosis of the skin, lips or tongue, see the Photoguide.

Source: National Institute for Health and Care Excellence [8]

Initial blood tests should be requested to aid diagnosis and further inform on the likelihood of infection and prognosis. These should include:

• C-reactive protein — to detect inflammatory response;
• Full blood count — to detect immune response;
• Lactate — to detect tissue hypoxia.

Other investigations, such as a chest X-ray or lumbar puncture, may also be indicated depending on the likely focus of the suspected infection.

Point-of-care testing and future diagnostics

In the future, point-of-care testing facilities for key biomarkers may have a greater role in both primary care and hospital emergency departments, aiding healthcare professionals in diagnosing infection and sepsis. Recently published research into the use of sensor technologies designed to rapidly report on raised levels of biomarkers closely associated with sepsis (notably interleukin-6) may have the potential to aid sepsis diagnosis in the future [6] , [7] .

Case studies

Case study 1: a 12-month-old baby with suspected sepsis.

A mother brings her 12-month-old daughter Alice* into the pharmacy and asks to speak to the pharmacist. The mother clearly appears concerned and expresses that Alice seems very poorly and is not her usual self.

Consultation

The mother explains that her daughter attended nursery today and the nursery staff phoned in the afternoon to report that Alice was not feeling well. As she had a temperature of 39 o C, they administered a dose of paracetamol. The nursery staff also said that Alice had not been eating or drinking well and her nappies were dry all day.

Alice takes no regular medicine and has no ongoing health problems. She seems withdrawn and is not smiling or engaging with anyone, which the mother insists is unusual behaviour.

When assessing the patient, Alice’s hands feel cold despite her body and head feeling hot. During the interaction with Alice, she is noticeably very passive and inactive, and seems floppy in her mother’s arms. Alice does not appear to have a rash, though her skin appears pale.

Alice’s breathing appears very rapid.

Information given in the consultation suggests that Alice may have sepsis. Use the  National Institute for Health and Care Excellence ‘Sepsis risk stratification tool’ for children aged under five years out of hospital and compare it to the information obtained during the consultation [8] . By doing so, it is apparent that the following moderate-to-high risk criteria were demonstrated by the patient:

• Behaviour: parent or carer concern that the child is behaving differently than usual; not responding normally to social cues; no smile; and decreased activity;
• Cold hands or feet;
• Reduced urine output;
• Between 40 and 49 breaths per minute (normal resting respiratory rate for a 12-month-old is typically 20–40 breaths per minute);
• Pallor of skin, lips or tongue.

Although her temperature was high (39 o C), this would only be a moderate-risk criterion if Alice was aged between 3–6 months of age outside the hospital setting.

Advice and recommendations

Alice’s symptoms clearly indicate moderate-to-high risk of sepsis. According to the risk stratification tool, Alice should be referred either for a definitive diagnosis for treatment outside the hospital (i.e. to the patient’s GP), or to hospital for further review.

Considering the risk of sepsis and the importance of timely management, referral to hospital is the best choice for this patient. Calmly and clearly explain to the mother that Alice may have a serious infection and that the best course is for her to go to the hospital immediately.

Case study 2: an 11-year-old child with a viral infection

An 11-year-old boy called Liam* is brought into the pharmacy by his parents. They explain that he has not been feeling well for the past few days. The parents want to know if Liam’s symptoms can be treated with an over-the-counter (OTC) product or whether they should take him to the GP.

Liam has been unwell for the past three or four days and his condition does not seem to be improving. He has not yet taken any medicine for this illness. His temperature was 37.8 o C when most recently checked using an ear thermometer at home.

Liam says that he has a sore throat, a cough and a blocked nose. Liam describes the severity of his throat pain as three out of ten. Liam has been eating and drinking normally, has no long-term medical conditions and takes no regular medicine.

Liam and his parents agree that his behaviour and function are normal and he appears alert and coherent through the consultation. Liam’s breathing rate does not appear to be raised and his skin and lips appear normal, with no signs of a rash.

Liam may have an infection, which is likely to be viral, but does not require medical attention at present. However, to rule out sepsis, use the  National Institute for Health and Care Excellence ‘Sepsis risk stratification tool’ for children aged 5–11 years out of hospital and compare this to the information obtained during the consultation [8] . By doing so, it is apparent that no moderate-to-high risk criteria were demonstrated by the patient.

Liam can be treated with OTC analgesics to alleviate his throat pain and his raised temperature. Liam’s parents should ensure he is taking plenty of fluids and continue to monitor his temperature. If they become concerned about his condition, his behaviour or general functional ability, they should return to or call the pharmacy. Particular symptoms you advise them to look out for include development of a rash, if his skin becomes pale or mottled, his urine output drops, his breathing rate increases, or any general concern that mental state or activity is not normal.

Case study 3: an adult with red flag sepsis

Rahul*, a 28-year-old man, comes into the pharmacy and asks to see the pharmacist as he has begun to feel very unwell.

Rahul works as a driver, and he fell and scraped his leg while getting out of his van the previous day. Rahul explains that at the time he did not think much about the cut, so he did not clean or dress the wound and has not yet taken any medicine for it. Although the wound began to swell and weep overnight, Rahul went into work this morning, but left when he suddenly started to feel seriously unwell — around an hour ago.

Rahul says the wound now looks much worse than it previously did. On examination you find the wound is very red and swollen, the tissue around the wound is blistering and weeping, and there are red track marks extending further up Rahul’s leg. It is clear that this wound is infected.

Rahul uses inhalers for mild asthma, but otherwise takes no regular medicine.

Rahul says he is feeling hot and sluggish, and is clearly struggling to maintain his train of thought. His condition appears to be worsening by the minute. He needs to be referred for further help, but more information is required to decide whether he is referred to his GP or to a hospital emergency department. 

Rahul’s temperature is 35.8 o C. His breathing appears to be rapid. His blood pressure is 92/58mmHg and his heart rate is 140 beats per minute. Rahul does not appear to have a skin rash, although his lips seem to have a blue tint.

Rahul is likely to have a serious infection, which requires urgent attention. Use the National Institute for Health and Care Excellence ‘Sepsis risk stratification tool’ for people aged 18 years and over outside of the hospital setting and compare this to the information obtained during the consultation [8] . The patient has moderate- to high-risk criteria, such as tympanic temperature less than 36 o C and signs of potential infection. He also has several high-risk criteria that require urgent referral to emergency care:

• Altered behaviour or mental state;
• Respiratory rate over 25 breaths per minute;
• Heart rate more than 130 beats per minute;
• Cyanosis of skin, lips or tongue.

Tell Rahul that it is likely that he has a serious infection, and ask him to sit and wait in the pharmacy while an ambulance is called. It is not safe for him to drive to hospital. Share his information with the 999 operator and make another note of the details gathered during the consultation to hand over to the ambulance team upon arrival.

*All cases are fictional

Useful additional resources

• The UK Sepsis Trust. The Sepsis Manual. 2017–2018: Available at:  https://sepsistrust.org/wp-content/uploads/2018/06/Sepsis_Manual_2017_web_download.pdf
• National Institute for Health and Care Excellence. Sepsis: risk stratification tools. Available at:  https://www.nice.org.uk/guidance/ng51/resources/algorithms-and-risk-stratification-tables-compiled-version-2551488301
• For patients who are interested in finding out more about sepsis you can direct them to the NHS website. Available at:  https://www.nhs.uk/conditions/sepsis/

[1] The UK Sepsis Trust. The Sepsis Manual. 2017–2018. 2017. Available at: https://sepsistrust.org/wp-content/uploads/2018/06/Sepsis_Manual_2017_web_download.pdf (accessed October 2019)

[2] The UK Sepsis Trust. Professional Resources. Available at: https://sepsistrust.org/professional-resources/ (accessed October 2019)

[3] Gotts JE & Matthay MA. Sepsis: pathophysiology and clinical management. BMJ 2016;353:i1585.  doi: 10.1136/bmj.i1585

[4] National Institute for Health and Care Excellence. Sepsis: recognition, diagnosis and early management. NICE guideline [NG51]. 2016. Available at: https://www.nice.org.uk/Guidance/NG51 (accessed October 2019)

[5] National Health Service: Overview — Sepsis. 2019. Available at: https://www.nhs.uk/conditions/sepsis/ (accessed October 2019)

[6] Russell C, Ward AC, Vezza V et al . Development of a needle shaped microelectrode for electrochemical detection of the sepsis biomarker interleukin-6 (IL-6) in real time. Biosens Bioelectron 2019;126:806–814. doi: 10.1016/j.bios.2018.11.053

[7] Dolin H, Papadimos T, Stepkowski S et al. A novel combination of biomarkers to herald the onset of sepsis prior to the manifestation of symptoms. Shock 2018;49(4):364–370. doi: 10.1097/SHK.0000000000001010

[8] National Institute for Health and Care Excellence. Sepsis: Risk stratification tools. 2017. Available at: https://www.nice.org.uk/guidance/ng51/resources/algorithms-and-risk-stratification-tables-compiled-version-2551488301 (accessed October 2019)

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Recognition and management of neonatal sepsis

Luke William Crocker

5th Year Medical Student, University of Bristol, Bristol

View articles

Ayesha White

Paul Anthony Heaton

Consultant Paediatricians, Yeovil District Hospital

Débora Pascoal Horta

Ward Manager, Special Care Baby Unit, Yeovil District Hospital, Yeovil

Siba Prosad Paul

Consultant Paediatrician, Torbay Hospital, Torquay

View articles · Email Siba Prosad

Neonatal sepsis results from acute bacterial or viral infection occurring in the first 28 days of life. It causes significant morbidity and mortality, although the outcome can be improved by early recognition and prompt treatment by health professionals. This article describes the most common causes of sepsis, and explains why neonates are particularly vulnerable to infection. It highlights the non-specific way in which an infant with a serious infection may present, indicating the crucial features to elicit during history taking and examination, and emphasising the ‘red-flag’ signs and symptoms that should increase suspicion of a serious illness. The authors have adapted National Institute for Health and Care Excellence guidelines to produce an evidence-based approach to the management of an infant with suspected sepsis, and describe the roles of nurses in ensuring effective treatment and best outcomes for these babies.

Neonatal sepsis occurs when there is a serious bacterial or viral infection manifesting in the first 28 days of life (National Institute for Health and Care Excellence ( NICE) 2012 ). A systematic review with meta-analysis by Fleischmann-Struzek et al (2018) involving 23 studies estimated that it carries a mortality rate of 11–19*. The same study estimated that, globally, 3 million neonates are affected each year; the non-specific and varied nature of presentation may result in late diagnosis and delayed treatment. It is important that health professionals are aware of the condition and suspect sepsis at an early stage. This article details the clinical features of neonatal sepsis and includes two illustrative case studies to provide context.

Neonatal infections are divided into early-onset sepsis (EOS) occurring within the first 48 hours of birth, and late-onset sepsis (LOS) occurring between 2 and 28 days after birth ( Cailes et al, 2018 ). The neonatal infection surveillance network (NeonIN) study involving 12 neonatal units in England over a 10-year period recorded a total of 541 bacterial infections in 443 infants; it recorded an infection rate of 8/1000 live births, and 71/1000 in those admitted to the neonatal unit; sepsis was most common among male infants (56*) born prematurely (<37 weeks) and/or had a low birth weight <2500 g ( Vergnano et al, 2011 ).

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• NICE Guidance
• Conditions and diseases
• Antimicrobial stewardship

Suspected sepsis: recognition, diagnosis and early management

NICE guideline [NG51] Published: 13 July 2016 Last updated: 19 March 2024

• Tools and resources
• Information for the public
• Could this be sepsis?
• Face to face assessment
• Under 16s: evaluating risk and managing suspected sepsis
• Pregnant or recently pregnant people: evaluating risk and managing suspected sepsis
• Over 16s (not pregnant or recently pregnant): evaluating risk and managing suspected sepsis
• Antibiotic therapy, intravenous fluid and oxygen
• Finding and controlling the source of infection
• Information and support for all people with suspected sepsis
• Training and education
• Terms used in this guideline
• Recommendations for research
• Rationale and impact
• Finding more information and committee details
• Update information

Sepsis is a clinical syndrome caused by the body's immune and coagulation systems being switched on by an infection. Sepsis with shock is a life-threatening condition that is characterised by low blood pressure despite adequate fluid replacement, and organ dysfunction or failure. Sepsis is an important cause of death in people of all ages. Both a UK Parliamentary and Health Service Ombudsman enquiry (2013) and a UK National Confidential Enquiry into Patient Outcome and Death (NCEPOD, 2015) highlighted sepsis as being a leading cause of avoidable death that kills more people than breast, bowel and prostate cancer combined.

Sepsis is difficult to diagnose with certainty. Although people with sepsis may have a history of infection, fever is not present in all cases. The signs and symptoms of sepsis can be very non-specific and can be missed if clinicians do not think 'could this be sepsis?'. In the same way that healthcare professionals consider 'could this pain be cardiac in origin?' when presented with someone of any age with chest pain this guideline aims to make 'could this be sepsis?' the first consideration for anyone presenting with a possible infection.

Detailed guidelines exist for the management of sepsis in adult and paediatric intensive care units, and by intensive care clinicians called to other settings. To reduce avoidable deaths, people with sepsis need to be recognised early and treatment initiated. This guideline aims to ensure healthcare systems in all clinical settings consider sepsis as an immediate life-threatening condition that should be recognised and treated as an emergency. The guideline outlines the immediate actions needed for those with suspicion of sepsis and who are at highest risk of morbidity and mortality from sepsis. It provides a framework for risk assessment, treatment and follow-up or 'safety netting' of people not needing immediate resuscitation. The intention of this guideline is to ensure that all people with sepsis due to any cause are recognised and initial treatment initiated before definitive treatment on other specific pathways is instituted.

Previous terminology included terms SIRS (systematic inflammatory response syndrome), severe sepsis and septic shock but more recent terminology suggests using terms sepsis and septic shock only. Sepsis is defined as a life-threatening organ dysfunction due to a dysregulated host response to infection and septic shock as persisting hypotension requiring vasopressors to maintain a mean arterial pressure (MAP) of 65 mmHg or more and having a serum lactate level of greater than 2 mmol/l despite adequate volume resuscitation. Neither of these definitions are useful in early identification of people at risk and the guideline recommends actions according to clinical parameters that stratify risk of severe illness or death from sepsis.

There is significant overlap between this guideline and other NICE guidance, in particular the care of acutely ill patients in hospital , the assessment and initial management of fever in under 5s , bacterial meningitis and meningococcal disease , neutropenic sepsis , antibiotics for prevention and treatment of neonatal infection , and pneumonia in adults .

Toggle Contents

• Aims and objectives
• Introducing case study
• Section 1: Sepsis information
• Section 2: Case study
• Supporting policies
• Identifying the priorities
• Reflections

Case Study: document.write(name);

Current situation.

• Heart rate: 115 beats per minute

Blood pressure

• SpO 2 : 94%
• Respiratory rate: 24 breaths per minute

History of the situation

General practitioner

Past medical history

She has arthritis in her knees which limits the distance she can walk and is on regular analgesia.

Ability to be independent

Treatment given in ed.

Emergency department

Urinalysis undertaken; nothing abnormal detected (NAD).

Sputum specimen sent to labs for analysis.

Effect of treatment in ED

Her systolic BP has increased and she is not as tachycardic now.

Temp 38.4°C - blood cultures have been taken. Tazocin is given. Nebulisers salbutamol and atrovent administered for a slight wheeze with good effect.

Blood Gas Result

Arterial Sample Time: 18:30

pH	7.2
pCO	3.5 kPa
pO	10 kPa
HCO	16 mmol/L
Lactate	1.8 mmol/L

Handover from Emergency Department

Case Study: document.write(name); arrives

Medicine Chart for document.write(name);

WARD Emergency Dept. WARD __________ WARD __________			CONSULTANT ____________________		DATE OF ADMISSION		NAME: AGE: HOSPITAL NUMBER: NHS NUMBER:
Card No 1 of 1		Chart rewritten By _____________ Date ________________________ Pharmacy check By _____________ Date ________________________			Weight _______(kg) Date ____________ Weight _______(kg) Date
DRUG ALLERGY or ADVERSE EFFECT Medicine/Other Signature				If none know tick box [✔] Effect Date    This section must be completed and signed by a prescriber or Pharmacist
ONCE ONLY MEDICINES
Date	Medicine	Dose	Route	Administration Instructions	Time Required	Prescriber's Sig, Print Name & Bleep	Time Given	Given By	Checked By	Pharm
	Tazocin	4.5g	I.V.	Give Immediately	18.00		18.15	JE	AM
	Salbutamol	2.5mg	neb		18.00		18.15	JE	AM
	Atrovent	500mg	neb		18.00		18.15	JE	AM

Observation Chart for document.write(name); (from 17:50)

Patient Name:

Hospital Number:

Date ( )

Time

17:50

19:00

20:00

20:15

20:30

21:15

21:30

22:00

23:00

00:00

01:00

02:00

03:00

04:00

05:00

06:00

07:00

08:00

09:00

Blood pressure (mmHg)

Temperature

38.4

38.0

Response ( scale ('Alert, Voice, Pain, Unresponsive') is used to measure a patient's level of conciousness. ">AVPU)

A

A

A

">RR (per min)

24

24

24

/ ">SaO

94

94

94

">O delivery (% or L)

Air

Air

Air

">CVP (mmHg)

Blood sugar (mmol/L)

11.5

Lactate (mmol/L)

1.8

1.8

Fluid Chart for document.write(name); (from 18:00)

Patient Name: Age: Hospital Number:				DATE:      WARD: Emergency Dept.
INPUT (mLs)						OUTPUT (mLs)
Time	Intravenous fluid	Other (write)	DRUG (write) Noradrenaline	Hourly total	Running total	Urine	Hourly total	Running total	Balance (+ve or -ve)
01:00
...
18:00	500					++ incontinent
19:00	500	30 (tazocin)		1030	1030				+ve 1030
20:00	500, 500			1000	2030				+ve 2030
21:00
22:00
23:00
24:00

Fluid Chart for document.write(name);

Patient Name: Age: Hospital Number:				|  Part Two DATE:      WARD: Emergency Dept. PREVIOUS DAY'S BALANCE: +ve 2533
INPUT (mLs)						OUTPUT (mLs)
Time	Intravenous fluid	Other (write)	DRUG (write) Noradrenaline	Hourly total	Running total	Urine	Hourly total	Running total	Balance (+ve or -ve)
01:00	250		10	260	260	30	30	30	+ve 230
02:00	250		10	260	520	35	35	65	+ve 455
03:00	250		10	260	780	40	40	105	+ve 675
04:00	250		10	260	1040	15	15	120	+ve 920
05:00	250	500 Hartman's	10	760	1800	25	25	145	+ve 1655
06:00	250		10	260	2060	30	30	175	+ve 1885
07:00	250		10	260	2320	30	30	205	+ve 2115
08:00	250		10	260	2580	20	20	225	+ve 2355
09:00	250		10	260	2840	10	10	235	+ve 2605
...

Blood Results for document.write(name); - Serial Results

Test	Normal Values	18:30	20:15	06:00
(Hb) identifies the amount of haemoglobin in the circulating red blood cells which helps to indicate the oxygen carrying capacity of the blood. ">HB	11.5 - 16.5 g/dL	10.0
(thrombocytes) are used in the clotting process clumping together to form a plug, helping to stop a bleed - homeostasis. Once activated in the clotting process, they release phospholipids which further activate elements of the coagulation cascade. ">Platelets	150 - 450 x 10 /L	120
(WBC) test counts the total number of white blood cells. However, there are different types which respond to different infections and inflammation - Neutrophils, Eosinophils, Basophils, Monocytes and Lymphocytes. ">WBC	4.0 - 11.0 x 10 /L	14.0
(MCV) measures the average volume of red blood cells in the sample. It is calculated by dividing the total volume of packed red blood cells (Haematocrit) by the total number of red blood cells and multiplied by 10. The packed RBC total is identified by spinning the cells in a centrifuge. ">MCV	84 - 102 fL	85
are a type of white blood cell (leucocytes) which are usually the first to arrive at a site of inflammation, they help to clear the area using phagocytosis - measured as part of the white blood cell differential together with the other types of leucocyte. ">Neutrophils	2.0 - 7.5 x 10 /L	9.0
(ESR) tests for inflammatory and necrotic conditions. It measures the rate of fall of red blood cells in the test tube. A quicker fall in the erythrocyte results in an increased ESR value. ">ESR	1 - 20
(APTTr) is a measure of how well blood is able to clot effectively. It is used to assess the effectiveness of anticoagulants e.g. heparin. ">APTT Ratio	0.85 - 1.14
(INR) standardises the prothrombin time results as different manufacturers of the equipment used mean that results can vary. It is used to measure the effectiveness of treatment for patients who are on anti-coagulant therapy. ">INR	0.8 - 1.2
(PT) is the time taken for blood plasma to clot after the addition of a tissue factor (in the lab). It measures the quality of the 'extrinsic and common clotting pathways' in the clotting cascade. ">Prothrombin Time	10.0 - 12.0 sec's	12
(APTT) investigates unexplained bleeding or clotting looking at the different levels of some of the clotting factors in the clotting cascade. Usually performed with a Prothrombin Time. ">APTT	21.0 - 29.0 sec's	32
(TT) is requested as part of the coagulation screen to investigate bleeding disorders. ">Thrombin Time	17.0 - 21.0 sec's	21
">D-Dimer	0 - 250 µg/L	200
is part of the wider coagulation screening and is usually a follow-up test following an abnormal Prothrombin Time or APTT result. ">Fibrinogen	1.8 - 4.0 g/L

NB: Always check the normal values used by the laboratory you send blood samples to as these can vary between laboratories. These 'normal values' are given for the purpose of analysing blood results in this resource only. Always check local policy and local normal values before treating your patient.

Test	Normal Values	18:30	20:15	06:00
(Na) helps regulate the acid-base balance within the body. It is part of the routine assessment undertaken in an electrolyte assessment. Low blood concentrations (hyponatraemia) can be due to decreased intake or increased loss e.g. in diarrhoea, vomiting or excessive use of diuretics. ">Sodium	134 - 145 mmol/L	140
(K) helps regulate the acid-base balance within the body. It is part of the routine assessment undertaken in an electrolyte assessment. ">Potassium	3.5 - 5.3 mmol/L	4.5
(also known as Blood Urea Nitrogen - BUN) is a test that investigates the kidney's ability to function effectively. It is undertaken as a part of the routine urea and electrolyte levels. ">Urea	2.9 - 7.5 mmol/L	10.0
is used to investigate the ability of the kidneys to filter urine. ">Creatinine	45 - 84 µmol/L	100
(calculated creatinine clearance) is a more accurate way of investigating changes in kidney functioning. ">GFR	(ml/min)
is part of the routine assessment undertaken in an electrolyte assessment. High glucose levels indicate diabetes but can also be caused by acute stress to the body (e.g. in a heart attack or stroke, in response to trauma, in Cushing's syndrome and pancreatitis). ">Glucose	4.0 - 8.0 mmol/L	9.9
is a test used to diagnose pancreatitis. ">Amylase	0 - 110 U/L
(CK) enzyme are released into the blood stream when there is muscle damage. ">CK	25 - 200 U/L
(ALT) or Serum glutamic-transaminase (SGPT) is an enzyme found mostly in the liver. Detecting the enzyme in the blood stream generally means there is some associated liver damage. ">ALT	0 - 35 U/L	30
(γGT) is assessed to investigate liver damage and bile duct problems. ">γGT	0 - 40 U/L	50
is a byproduct of breaking down the haem from haemoglobin when red bloods cells die helping to show how easily red blood cells break down, the liver converts bilirubin and how the body excretes it. High levels of bilirubin can collect in the blood stream and colour the patient's skin, and sclera in the eyes, yellow. ">Bilirubin	0 - 21 µmol/L	40
(ALK Phos or ALP) is an enzyme found in different body tissues. Usually measured to assess liver function and the effectiveness of bile. ">Alk Phosphate	40 - 130 U/L	180
is a protein made in the liver and is used in different ways in the body. It makes up around 60% of the total protein in blood and supports the transportation of vitamins, electolytes and hormones around the body. ">Albumin	30 - 50 g/L	24
(CRP) is a protein made in the liver that is released in response to infection and/or inflammation. ">CRP	0 - 10 mg/dL	110
is a group of proteins that support and regulate muscle contraction in skeletal and cardiac muscle. This is usually undertaken if cardiac damage is suspected. ">Troponin	up to 0.1 µg/L
helps regulate the acid-base balance within the body. It is part of the routine assessment undertaken in an electrolyte assessment. ">Bicarbonate	24 - 32 mmol/L
is a mineral that is essential for many body processes including blood clotting, cell signalling, muscle contactions and bone density. ">Calcium	2.2 - 2.6 mmol/L
is required for effective muscle contractions and nerve functioning, bone growth and producing energy. The phosphate buffering system helps to regulate acid-base balance. ">Phosphate	0.8 - 1.45 mmol/L
is a mineral that supports effective muscle contractions, nerve function, bone density and energy production. ">Magnesium	0.7 - 1.0 mmol/L

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NHS priorities

Whether it’s to prepare for the next Pharmacy Quality Scheme deadline, or to increase your confidence in helping people with a learning disability, this section provides topic-specific pages that link to current NHS priorities. This section will support you in keeping your knowledge and skills up to date in order to provide high-quality pharmacy services and be service-ready.

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Our clinical portfolio is expanding on a frequent basis, helping you to advance your knowledge and skills and deliver medicines optimisation in practice for all sectors of pharmacy. From two new focal points a year to our small group learning for hospital pharmacists – Optimise – this section focuses on clinical pharmacy, diseases and therapeutics.

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The public health agenda is embedded in pharmacy, yet topics such as emergency contraception or stop smoking support are as prevalent as ever. As well as our public health workshops, use this section to access a wide range of resources to assure and maintain your competence, all underpinned by the Declaration of Competence system.

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Introduction to Sepsis

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Sepsis (2024)

This e-assessment is linked with the six CPPE Sepsis case studies which can be found on the CPPE Sepsis gateway page. You will need to complete all six sepsis case studies before completing this assessment.

Why should I do this assessment?

Core and foundation learning

Early recognition of sepsis - community setting.

This case study will help you to apply your knowledge on sepsis, including how to identify and manage sepsis safely using the National Early Warning Score (NEWS2). It is set in the community but contains learning relevant to all areas of practice.

This case study forms part of the Sepsis learning gateway . Here, you will find a range of learning resources which aim to increase your knowledge, skills and confidence in recognising and managing sepsis.

1h:00m (for events this includes pre and post event learning)

Learning Outcomes:

On completion of all aspects of this learning programme you should be able to:

• describe how the National Early Warning Score (NEWS2) can be used as a tool to support your clinical judgement when assessing if someone potentially has sepsis
• recognise the early signs and symptoms of sepsis
• calculate and interpret a person’s NEWS2 aggregate score
• determine the most appropriate action to take based on a person’s NEWS2 and your own clinical judgement.

Early recognition of sepsis - hospital setting

This short case study will help you to apply your knowledge on sepsis, including the risk factors, signs and symptoms of sepsis. The case will also help you to determine how you can identify and manage sepsis safely. It is set in a hospital but contains learning relevant to all areas of practice.

On completion of all aspects of this learning programme, you should be able to:

• recognise the signs and symptoms of sepsis
• interpret a person’s NEWS2 aggregate score
• determine the most appropriate action to take based on a person’s NEWS2 and your own clinical judgement to manage the person safely. 

Early recognition of sepsis - general practice setting

This short case study will help you to apply your knowledge on sepsis and understand the importance of clinical judgement when determining how to identify and manage sepsis safely. It is set in a general practice but contains learning relevant to all areas of practice.

• determine the most appropriate action to take based on a person’s NEWS2 and your own clinical judgement. 

Early recognition of sepsis - children

This case study relates to a child. It will help you to apply your knowledge on sepsis, including how to identify and manage sepsis safely in children.

This case study forms part of the Sepsis learning gateway . Here, you will find a range of learning resources which aim to increase your knowledge, skills and confidence in recognising and managing sepsis.

• apply the NHS Think Sepsis programme when you see a child who is unwell in your practice
• list the questions you could ask a parent or carer to support a diagnosis of sepsis in a child
• determine the most appropriate course of action if you suspect sepsis.

Early recognition of sepsis - pregnancy

This short case study will help you to apply your knowledge on sepsis and support you in adopting a person-centred approach to discussions on risk factors to sepsis. This case relates to a person who is pregnant.

• describe why pregnant or recently pregnant women are in a higher risk group for developing sepsis
• explain why it is recommended that all pregnant women receive the seasonal influenza vaccine
• adopt a person-centred approach to conversations on the risks of flu and sepsis during pregnancy.

Early recognition of sepsis - care home setting

This short case study will help you to apply your knowledge on sepsis, including how to identify and manage sepsis safely using the National Early Warning Score (NEWS2). It is set in a care home but contains learning relevant to all areas of practice. 

National Confidential Enquiry into Patient Outcome and Death - Just say sepsis!

This National Confidential Enquiry into Patient Outcome and Death (NCEPOD) report highlights the process of care for patients aged 16 years or older with sepsis. It contains nine case studies that cover pre-hospital care through to the initial management of sepsis.

Royal College of Physicians - National Early Warning Score (NEWS) 2

The NEWS aims to improve the detection of and response to clinical deterioration in patients with acute illness. The Royal College of Physicians page contains a link to the NEWS2 final report and NEWS scoring system, thresholds and triggers and observation charts.

Advanced learning

News2 - national early warning score online training resource.

This website offers free registration with an NHS email address. When registered, you will have an opportunity to learn about the implementation and use of the National Early Warning Score system, which has been introduced across the NHS.

Knowlex presentation - An Hour on Sepsis by Dr. Matt Inada-Kim

This presentation, hosted on YouTube, is delivered by Matt Inada-Kim, a Consultant Acute Physician. More about Matt and his work can be found on the NHS England website.

Think Sepsis - identifying and managing sepsis

“THINK SEPSIS” is a Health Education England programme aimed at improving the diagnosis and management of those with sepsis.

World Sepsis Day website

Further reading, the surviving sepsis campaign bundle, the surviving sepsis campaign:international guidelines for management of sepsis and septic shock, the uk sepsis trust - clinical resources, further reading continued, nhs england - cross-system sepsis action plan, nhs england - improving outcomes for patients with sepsis, nhs england - useful tools and key resources, nice - sepsis: recognition, diagnosis and early management, nice - fever in under 5s: assessment and initial management.

This guideline covers the assessment and early management of fever with no obvious cause in children aged under five.

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Sepsis assessment and management in critically Ill adults: A systematic review

Mohammad rababa.

Adult Health Nursing Department, Faculty of Nursing, Jordan University of Science and Technology, Irbid, Jordan

Dania Bani Hamad

Audai a. hayajneh, associated data.

All relevant data are within the article and its files.

Early assessment and management of patients with sepsis can significantly reduce its high mortality rates and improve patient outcomes and quality of life.

The purposes of this review are to: (1) explore nurses’ knowledge, attitude, practice, and perceived barriers and facilitators related to early recognition and management of sepsis, (2) explore different interventions directed at nurses to improve sepsis management.

A systematic review method according to the PRISMA guidelines was used. An electronic search was conducted in March 2021 on several databases using combinations of keywords. Two researchers independently selected and screened the articles according to the eligibility criteria.

Nurses reported an adequate of knowledge in certain areas of sepsis assessment and management in critically ill adult patients. Also, nurses’ attitudes toward sepsis assessment and management were positive in general, but they reported some misconceptions regarding antibiotic use for patients with sepsis, and that sepsis was inevitable for critically ill adult patients. Furthermore, nurses reported they either were not well-prepared or confident enough to effectively recognize and promptly manage sepsis. Also, there are different kinds of nurses’ perceived barriers and facilitators related to sepsis assessment and management: nurse, patient, physician, and system-related. There are different interventions directed at nurses to help in improving nurses’ knowledge, attitudes, and practice of sepsis assessment and management. These interventions include education sessions, simulation, decision support or screening tools for sepsis, and evidence-based treatment protocols/guidelines.

Our findings could help hospital managers in developing continuous education and staff development training programs on assessing and managing sepsis in critical care patients.

Nurses have poor to good knowledge, practices, and attitudes toward sepsis as well as report many barriers related to sepsis management in adult critically ill patients. Despite all education interventions, no study has collectively targeted critical care nurses’ knowledge, attitudes, and practice of sepsis management.

Introduction

Sepsis is a global health problem that increases morbidity and mortality rates worldwide and which is one of the most common complications documented in intensive care units (ICUs) [ 1 ]. About 48.9 million cases of sepsis and 11 million sepsis-related deaths were documented in 2017 worldwide [ 2 ]. Sepsis is an emergency condition leading to several life-threatening complications, such as septic shock and multiple organ dysfunction and failure [ 3 ]. Sepsis has negative physiological, psychological, and economic consequences. Untreated sepsis can lead to septic shock; multiple organ failure, such as acute renal failure [ 4 ]; respiratory distress syndrome [ 5 ]; cardiac arrhythmia (e.g. Atrial Fibrillation) [ 6 ]; and disseminated intravascular coagulation (DIC) [ 7 ]. Also, sepsis is associated with anxiety, depression, and post-traumatic stress disorder [ 8 ]. As for the financial burden of sepsis on the healthcare system, the cost of healthcare services and supplies for ICU critical care patients with sepsis is high [ 1 ]. In 2017, the estimated annual cost of sepsis in the United States (US) was over $24 billion [ 2 ].

Previous studies have shown that among nurses, misunderstanding and misinterpretation of the early clinical manifestations of sepsis, poor knowledge, attitudes, and practices related to sepsis, and inadequate training might lead to delayed assessment and management of sepsis [ 9 – 11 ]. Moreover, the limited numbers of specific and sensitive assessment tools and standard protocols for the early identification and assessment of sepsis in critical care patients leads to delayed management, therefore increasing sepsis-related mortality rates [ 10 ].

Critical care nurses, as frontline providers of patient care, play a vital role in the decision-making process for the early identification and prompt management of sepsis [ 11 ]. Therefore, improving nurses’ knowledge, attitudes, and practices related to the early identification and management of sepsis is associated with improved patient outcomes [ 12 , 13 ]. To date, there remains a wide gap between the findings of previous research and sepsis-related clinical practice in critical care units (CCUs). Furthermore, there is no evidence in the nursing literature regarding nurses’ knowledge, attitudes, and practices related to the early identification and management of sepsis in adult critical care patients and the association of these factors with patient health outcomes. Therefore, summarizing and synthesizing the existing research on sepsis assessment and management among adult critical care patients is needed to guide future directions of sepsis-related clinical practice and research. Accordingly, this review aims to identify nurses’ knowledge, and attitudes, practices related to the early identification and management of sepsis in adult critical care patients.

Materials and methods

The present review used a systematic review design guided by structured questions constructed after reviewing the nursing literature relevant to sepsis assessment and management in adult critical care patients. The authors (MR, DB, AH) carefully reviewed and evaluated the selected articles and synthesized and analyzed their findings to reach a consensus. This review was guided by the following questions: (a) what are nurses’ knowledge, attitudes, and practices related to sepsis assessment and management in adult critical care patients?, (b) what are the perceived facilitators of and barriers to the early identification and effective management of sepsis in adult critical care units?, and (c) what are the interventions directed at improving nurses’ sepsis assessment and management?

Eligibility criteria

The review questions were developed according to the PICOS (Participants, Interventions, Comparisons, Outcome, and Study Design) framework, as displayed in Table 1 .

Item	Description
Participants	patients aged 19 years and older who were admitted to critical care settings with sepsis, septic shock, or septicemia
Intervention	Training/educational interventions (e.g., regular lectures, simulations, algorithms, decision support tools, and sepsis protocol)
Comparison	No restriction was applied on the number or type of comparison group as the impact of the intervention could be determined. Comparison groups could include no intervention, standard protocol, and other types of intervention which was educational
Outcome	The primary outcomes of interest in this review were the effective assessment and prompt management of sepsis and nurses’ knowledge, attitudes, practice, perceived barriers, and enablers related to sepsis assessment and management. sepsis assessment and management could be assessed using either patient or nurse objective measures. Sepsis assessment and management were quantified as mean times required for sepsis recognition and treatment initiation, sepsis protocol adherence, and decline in mortality rate in-hospital sepsis-related complications. nurses’ knowledge, attitudes, and practice related to sepsis could be assessed using either nurse-reported tools or performance-based tests, while nurses’ perceived barriers and enablers could be assessed using nurse-reported tools.
Study Design	Experimental, quasi-experimental, description. Cross-sectional, observational, prospective, qualitative, and mixed methods

Inclusion criteria

The articles were retrieved and assessed independently by two researchers (MR, DB) according to the following inclusion criteria: (1) being written in English, (2) having an abstract and reference list, (3) having been published during the past 10 years, (4) focusing on critical care nurses as a target population, (5) examining knowledge, attitudes, and practices related to the assessment and management of sepsis, and (6) having been conducted in adult critical care units.

Exclusion criteria

Studies were excluded if they were (1) written in languages other than English, and (2) conducted in pediatric critical care units or non-ICU. Dissertations, reports, reviews, editorials, and brief communications were also excluded.

Search strategy

An electronic search of the databases CINAHL, MEDLINE/PubMed, EBSCO, Embase, Cochrane, Scopus, Web of Science, and Google Scholar was conducted using combinations of the following keywords: critical care, intensive care, critically ill, critical illness, knowledge, awareness, perception, understanding, attitudes, opinion, beliefs, thoughts, views, practice, skills, strategies, approaches, barriers, obstacles, challenges, difficulties, issues, problems, limitations, facilitators, motivators, enablers, sepsis, septic, septic shock, and septicemia. The search terms used in this review were described in S1 File . The search was initially conducted in March 2021, and a search re-run was conducted in April 2022. The search was conducted in the selected databases from inception to 4/2022. The initial search, using the keywords independently, resulted in 1579 articles, and after using the keyword combinations, this number was reduced to 241 articles. Then, after applying the inclusion and exclusion criteria, the number of articles was reduced to 92. A manual search of the reference lists of the 92 articles was carried out to identify any relevant publications not identified through the search. The researcher (MR) used the function “cited by” on Google Scholar to explore these publications in more depth. The researchers (MR, DB) then screened the identified citations of these publications, applying the eligibility criteria. In case of discrepancies, the researchers (MR, DB) discussed their conflicting points of view until a consensus was reached. Then, after careful reading of the article abstracts, 61 irrelevant articles were excluded, and a total of 31 articles were included in this review. Fig 1 below shows the Preferred Reporting Items for Meta-Analysis (PRISMA) checklist and flow chart used as a method of screening and selecting the eligible studies.

Data extraction

The following data were extracted from each of the selected studies: (1) the general features of the article, including the authors and publication year; (2) the characteristics of the study setting (e.g., single vs. multisite); (3) the sociodemographic and clinical characteristics of the target population, including mean age, and medical diagnosis (e.g., sepsis, septic shock, and SIRS); (4) the name of the sepsis protocol used, if any; (5) the characteristics of the study methodology (e.g., sample size and measurements); (7) the main significant findings of the study; and (8) the study strengths and limitations. All extracted data were summarized in an evidence-based table ( Table 2 ). Data extraction was performed by two researchers (MR, DB). An expert third researcher (AH) was consulted to reach a consensus between the two researchers throughout the process of data extraction.

Study	Aim of the study	Design	LOE	Setting/Sample	Main findings	Strengths/Weaknesses
Delaney et al. (2015)	To determine the impact of an educational program on nurses’ assessment & management of sepsis	Quasi-experimental	III	82 ER nurses/ USA	There was a significant improvement in nurses’ knowledge & competency related to the early recognition & management of sepsis after the educational program.	: use of self-report tools, purposive sample, homogeneity of sample. : use of reliable and valid tool
Breen and Rees (2018)	To identify the barriers to the implementation of sepsis protocols	Cross-sectional	VI	108 nurses in ACS/UK	Nurses’ poor knowledge & poor ability to recognize sepsis during observation round were the main barriers to prompt sepsis management	: low response rate, heterogeneity of sample : several geographical areas
Roney et al. (2020)	To evaluate the implementation of MEW-S in ACS	Quasi-experimental	III	139 nurses in ACS/ USA	Implementation of MEW-S led to a significant improvement in sepsis assessment & management, thus decreasing mortality rate by 24%	: one geographical site : use reliable & valid tools
N. Roberts et al.(2017)	To identify the barriers to and facilitators of the implementation of the Sepsis Six at a case study hospital	Mixed method	VI	13 ER nurses /USA	The main barriers were insufficient audit & feedback, poor teamwork & communication, & insufficient training & resources. Main facilitators were good confidence in knowledge & skills & positive beliefs towards sepsis bundles	: one geographical site : used mix methods design
van den Hengel et al. (2016)	To examine the factors influencing the knowledge & recognition of SIRS criteria & sepsis by ER nurses	Prospective -observational	IV	216 ER nurses from 11 hospitals/ Netherlands	ER nurses aged over 50 had significantly lower scores in knowledge related to sepsis criteria than did younger nurses. Nurses working in hospitals with 3 level ICUs had more knowledge than did nurses working in hospitals with levels 1&2 ICUs. The educational program improved nurses’ knowledge of sepsis.	: potential bias because multiple visits were made conducted in multi- center sites
Long et al. (2018)	To gain insight into clinical decision support systems-based alert and nurses’ perceptions	Cross-sectional	VI	43 ER nurses/USA	Using clinical decision support systems-based alert improved nurses’ decision-making related to sepsis, thus leading to better outcomes	: not validated questionnaire, conducted in single center : used interactive survey to collect data
Jacobs (2020)	To determine if implementing the NDS protocol reduces ACT readmission among patients with sepsis	Quasi-experimental	III	238 patients with sepsis/ USA	Readmission rate among patients assessed & treated by NDS & who received early-goal directed therapy was reduced from 36.28% to 25% after 8 weeks. Nurses’ compliance with the intervention protocol was improved.	: the protocol used was not universally applied novelty of the study and use of protocol based on the golden criteria of the SSC
Amland et al. (2015)	To examine the diagnostic accuracy of two-stage clinical decision support systems for the early recognition & management of sepsis	Observational cohort study	IV	417 patients with sepsis/ USA	Nurses completed 75% of assessment and screening within one hour of notification. The decision support system led to the early identification and timely, quality, and safe sepsis care	: single center : used sepsis alert with high positive predictive values
Delawder and Hulton (2020)	To test the effectiveness of sepsis bundle guidelines in the early assessment & treatment of sepsis.	Quasi-experimental	III	214 ER patients /USA	There was an improvement in the time to implement sepsis guidelines, except for antibiotic administration & blood culture collection. Mortality rate decreased from 12.45% to 4.55% but no differences in mortality rate based on age or gender	: single center : used an interdisciplinary trained team & standard guidelines for sepsis
Manaktala & Claypool (2017)	To evaluate the impact of a computerized surveillance algorithm & decision support system on sepsis mortality rates	Quasi-experimental	III	58 patients in Huntsville hospital (tertiary care teaching hospital/ USA)	The system was sensitive & specific for sepsis identification & management & improved decision-making related to sepsis management. Mortality rate was reduced by 53% & readmission rate was reduced, with no effect on patient length of stay	: Small sample size : used different methods to detect mortality rate related to sepsis
Harley et al. (2019)	To explore and understand ER nurses’ knowledge of sepsis & identify gaps in clinical practice related to sepsis management.	Qualitative	VI	14 ER nurses/ Australia	Nurses had poor knowledge, attitudes, & practices related to sepsis assessment & management. Barriers to sepsis management included high number & severity of sepsis conditions, nurses’ poor knowledge of sepsis, heavy workloads, & inexperienced ER doctors	: fatigue was a threat to internal validity, single center, & use of self-report tools : used detailed face to face interviews
Yousefi et al. (2012)	To review the effect of an educational program on nurses’ knowledge, attitudes, & practices related to the identification & management of sepsis	Quasi-experimental	III	64 ICU nurses/ Iran	Nurses’ knowledge, attitudes, & practices were improved after the intervention	: Differences in ICU facilities and equipment made it difficult to generalize the findings : used of valid & reliable tool
Nucera et al. (2018)	To assess knowledge and attitudes related to sepsis among ICU and non-ICU nurses and physicians	Quasi- experimental	III	11 different wards (ICU and non-ICU) in Italy	Nurses’ attitudes towards blood culture technique were poor & their knowledge of blood culture procedures & sepsis risks was good (>75%). Nurses had poor knowledge (<50%) of methods for the early identification, diagnosis, & management of sepsis. Their knowledge of sepsis improved after the intervention educational program	: Heterogeneity of the sample : High response rate and zero attrition rate
Rahman et al. (2019)	To explore nurses’ knowledge & attitudes related to the early identification & management of sepsis	Cross-sectional	VI	120 ER in Malaysia	Nurses had poor knowledge of & neutral attitudes towards sepsis.	: single center & low validity : detailed description of instruments
Storozuk et al., (2019)	To assess ER nurses’ knowledge of sepsis & their perspectives towards caring for patients with sepsis	Cross-sectional	VI	758 ER nurses/ Canada	Most nurses had poor knowledge of sepsis & SIRS definition, general knowledge, & treatment. Nurses were aware of the need to update their knowledge related to the early identification & timely management of sepsis to reduce complications	: single site : the questionnaire used was based on the standard guidelines of the SSC
Gyang et al. (2015)	To evaluate the use of NDS for early sepsis identification	Observational pilot	IV	245 patients with sepsis in intermediate care settings/ USA	The NDS had 95% sensitivity and 92% specificity.	: used a highly sensitive screening tool : one geographical site
El Khuri et al. (2019)	To assess the effect of EGDT in the ER on mortality rates related to sepsis and septic shock	Retrospective cohort	IV	290 patients with sepsis from one large tertiary hospital in Lebanon	There were no differences between the two groups in time & duration of vasopressor, antibiotics, and length of stay. The implementation of EGDT in the ER decreased the mortality rate from 47.6% to 31.7%. The most common cause of infection leading to sepsis was LRTI.	: first study conducted in Lebanon : conducted in one site
Vanderzwan et al. (2020)	To apply a multimodel nursing pedagogy with medium fidelity simulation senarios for the early identification & management of sepsis	Quasi-experimental	III	All critical care nurses in an academic medical center/ USA	Nurses’ knowledge & competency related to the early identification & management of sepsis improved after simulation	: Only face validity was used to validate the questionnaire : used multimodal in intervention
R. J. Roberts et al. (2017)	To evaluate nurses’ knowledge, attitudes, & perceptions related to antibiotic innitiation for patients with sepsis	Cross-sectional	VI	122 critical care nurses/ USA	Nurses had good knowledge related to defining septic shock & were aware of Aware of when to administer antibiotics. Lack of awareness of the importance of antibiotics initiation, lack of IV access, & the need for multiple medications rather than antibiotics were major barriers to sepsis management	: Self-selection and single center : valid tools
McKinley et al. (2011)	To compare between paper protocols & computerized protocols for standarizing sepsis decision-making	Quasi- experimental	III	948 ICU nurses in an academic tertiery hospital in the USA	The computerized protocol led to quicker antibiotic administration, blood culture collection, and lactate level checking as compared to the paper-based protocol. The computerize protocol had 97% sensitivity & 97% specificity to the standardized & rapid implementation of evidence-based treatment guidelines of sepsis	: Technical issues in implementing the protocol the intervention was applied over a long period of time
Drahnak et al. (2016)	To assess the impact of an educational program on nurses’ knowledge, perceptions, & attitudes related to sepsis	Quasi-experimental	III	680 ICU & ER nurses/ Pennsylvania, USA	Knowledge of sepsis was improved after the educational program. There was significant improvement in nurses’ ability to identify patients with sepsis	: high attrition rates standard guidelines for sepsis assessment
Proffitt and Hooper (2020)	To assess nurses’ perceptions towards the implementation of the 106 q-sofa assessment tool for sepsis	Quasi-experimental	III	14 ER nurses/ USA	The use of this tool led nurses to become more autonomous in making decisions related to sepsis, thus leading to prompt management of sepsis. Nurses perceived the lack of time to be a barrier to the implementation of the evidence-based treatment guidelines	: small sample size, single center : employing a new sepsis screening tool
Rajan and Rodzevik (2021)	To explore the differences between ER nurses receiving an educational program on the early identification & management of sepsis & nurses not receiving the program	Quasi- experimental	III	22 ER nurses/ USA	Using sepsis standing orders combined with the educational program contributed to the early identification of sepsis and better quality of care provided.	: Small sample size & single center :
Oliver (2018)	To assess the impact of EGDT on the early detection of sepsis in an ED	Quasi-experimental	III	63 patients with sepsis /USA	Revealed no significant differences in lactate measurement and blood culture collection but a decrease in time until antibiotic administration	: Single center, screening tool implemented over a short time period : used valid and reliable tools
Burney et al. (2012)	To identify the barriers related to sepsis treatment	Descriptive-cross sectional	VI	101 ER nurses/ USA	Shortage of nurses, unavailability of ICU beds and limited physical space in were the most reported barriers to sepsis treatment	single center and used self-report questionnaire provide detailed explanation about the barriers
Edwards & Jones (2021)	To examine nurses’ levels of knowledge, attitude, and skills related to sepsis management	Descriptive-cross sectional	VI	98 acute medical-surgical nurses/ UK	Nurses incorrectly answered the questions related to knowledge of sepsis and demonstrated positive attitudes.	used self-report questionnaire : used multi-settings
Steinmo el al. (2015)	To explore the effect of using behavioral science tools to modify the existing quality improvement guidelines for “Sepsis Six” implementation	Qualitative	VI	19 ER nurses, 12 ER doctors, 2 midwives and 1 healthcare assistant/ UK	Using behavioral science tools was feasible to modify the existing quality improvement guidelines for “Sepsis Six” implementation. The tools are compatible with the currently used pragmatic approach.	: fatigue was a threat to internal validity. : used multi-settings and detailed face to face interviews
Giuliano et al. (2005)	to examine nurses’ understanding of clinical practice related to assessment of sepsis as well as their knowledge of diagnostic criteria for sepsis	Descriptive-cross sectional	VI	517 nurses& 100 physicians/ USA	The majority of participants routinely use the findings of PAP, Bp, O2 Sat, and ECG to assess and manage sepsis	used self-report questionnaire : large sample
Ferguson et al. (2019)	To assess the effectiveness of QI initiative in improving the early assessment and management of sepsis	Retrospective cohort	IV	106,220 patients with sepsis from a medical center in Seatle/USA	The implementation of QI improved ER sepsis bundle adherence by 33.2%, decreased sepsis-related RRT calls by 1.35% & in-hospital sepsis-related mortality rate by 4.1% (p<0.001)	: conducted in one site : very large sample size
Giuliano et al. (2010)	To examine the difference in mean times required for sepsis recognition and treatment initiation between nurses exposed to 2 different monitor displays in response to simulated case scenarios of sepsis	Quasi-experimental	III	75 critical care nurses/ USA	mean times required for sepsis recognition and treatment initiation were shorter nurses exposed to EBM.	: screening tool implemented over a short time period & pilot study. : used control group and random assignment
Kabil et al. (2021)	To explore ER nurses’ experiences of initiating early goal-directed fluid resuscitation in patients with sepsis	Qualitative	VI	10 ER nurses/ Australia	participating nurses identified different factors limiting the prompt initiation of early goal-directed fluid resuscitation, some challenges to the clinical practice of sepsis, and solutions to these challenges. Most nurses suggested incorporating nurse-initiated early goal-directed fluid resuscitation for patients with sepsis.	: limited generalizability of findings & interpretation bias : used detailed face to face interviews

USA: United States of America; UK; United Kingdom; ACS: acute care settings; ER: emergency room; ICU: intensive care units; SIRS: Systematic Inflammatory Response Syndrome; KAP: knowledge, attitudes, and practice; qSOFA: Quick Sequential Organ Failure Assessment; EGDT; Early Goal-Directed Therapy; NDS: Nurse Driven Sepsis Screening tool; SIRS: Sepsis Inflammatory Response; MEW-S: Modified Early Warning Score; LRTI: Lower respiratory tract infection; IQ: Quality Improvement; EBM: Enhanced Bedside Monitor; RRT: rapid response team.

Ethical considerations

There was no need to obtain ethical approval to conduct this systematic review since no human subjects were involved.

Quality assessment and data synthesis

A quality assessment of the selected studies was performed independently by two researchers based on the guidelines of Melnyk and Fineout-Overholt [ 14 ]. Disagreements between the two researchers (MR, DB) were identified and resolved through a detailed discussion held during a face-to-face meeting. For complicated cases, the researchers (MR, DB) requested a second opinion from a third researcher (AH). According to the guidelines of Melnyk and Fineout-Overholt [ 14 ], twelve of the studies were at level 3 in terms of quality, four studies at level 5, and nine studies at level 6.

A qualitative synthesis was performed to synthesize the findings of the reviewed studies. The following steps were applied throughout the process of data synthesis:

• The data in the selected studies were assessed, evaluated, contrasted, compared, and summarized in a table ( Table 2 ). This data included the design, purpose, sample, main findings, strengths/limitations, and level of evidence for each of the studies.
• The similarities and differences between the main findings of the selected studies were highlighted.
• The strengths and limitations of the reviewed studies were discussed.

Description of the selected studies

Most of the reviewed studies were conducted in Western countries [ 9 , 11 , 12 ], with only one study conducted in Eastern countries [ 1 ], and two in Middle-Eastern countries [ 15 , 16 ]. The detailed geographical distribution of the studies and other characteristics are described in Table 2 .

Nurses’ knowledge, attitudes, and practices

Nine of the selected studies assessed nurses’ knowledge and attitudes related to sepsis assessment and management in critically ill adult patients [ 1 , 9 , 12 , 15 , 17 – 21 ] ( Table 3 ) . Nucera et al. [ 18 ] found that ICU nurses had poor attitudes towards blood culture collection techniques and timing and poor levels of knowledge related to the early identification, diagnosis, and management of sepsis. For example, the majority of nurses reported that there is no need to sterilize the tops of culture bottles, and there is no specific time for specimen collection [ 18 ]. However, the participating nurses reported good levels of knowledge related to blood culture procedures and the risk factors for sepsis. Similarly, R. J. Roberts et al. [ 19 ] found the participating nurses to have good knowledge of septic shock and good attitudes toward the initiation of antibiotics for critically ill adult patients with sepsis. Only two studies assessed nurses’ practices related to sepsis assessment and management [ 15 , 19 ]. For example, in the study of R. J. Roberts et al. [ 19 ], 40% of the nurse participants reported that they were aware of the importance of initiating antibiotics and IV fluid within one hour of septic shock recognition [ 20 ]. Also, Yousefi et al. [ 15 ] found the participating nurses to have good practices related to sepsis assessment and management.

Study	Knowledge (Mean Score, interpretation)	Attitudes (Mean Score, interpretation)	Practices (Mean Score, interpretation)
Van den Hengel et al. (2016)	15.9±3.21, above average	N/A	N/A
Rahman et al. (2018)	MNR, Moderate	21–27, neutral	N/A
Storozuk et al. (2019)	51.8%, Poor	N/A	N/A
Harley et al. (2019)	MNR, Poor	N/A	N/A
Nucera et al. (2018)	MNR, Good	51–75, poor	N/A
R.J. Roberts et al. (2017)	MNR, Good	N/A, positive	MNR, good
Yousefi et al. (2012)	64.5±5.21, MNR	73±4.51, MNR	81±4.31, MNR
Edwards & Jones (2021)	40.8%, Poor	25±2.97, positive	N/A
Giuliano et al. (2005)	MNR	N/A	N/A

*A range of the score reported

¥ a percentage of correct answers reported; MNR: Measured but not reported; N/A: Not Applicable

Barriers to and facilitators of sepsis assessment and management

The reviewed studies identified three types of barriers to the early identification and management of sepsis, namely patient-, nurse-, and system-related barriers ( Table 4 ). Meanwhile, only nurse- and system-related facilitators were reported in the reviewed studies. The most-reported barriers and facilitators were system-related. The reported barriers included (a) the lack of written sepsis treatment protocols or guidelines adopted as hospital policy [ 22 , 23 ]; (b) the complexity and atypical presentation of the early symptoms of sepsis [ 19 ]; (c) nurses’ poor level of education and clinical experience [ 1 , 12 ]; (d) the lack of sepsis educational programs or training workshops for nurses [ 22 , 23 ]; (e) the high comorbid burden among patients with sepsis, which complicates the critical thinking process of sepsis management [ 19 ]; (f) nurses’ deficits in knowledge related to sepsis treatment protocols and guidelines [ 22 – 24 ]; (g) the lack of mentorship programs in which junior nurses’ actions/activities are strictly supervised by experienced nurses [ 17 , 23 ]; (h) heavy workloads or high patient-nurse ratios [ 22 ]; (i) the shortage of well-trained and experienced physicians, particularly in EDs [ 19 , 22 , 23 ]; (j) the lack of awareness related to antibiotic use for patients with sepsis [ 19 , 22 ]; (k) the lack of IV access and unavailability of ICU beds [ 25 ]; (l) the non-use of drug combinations for the treatment of sepsis [ 22 , 26 , 27 ], and (m) poor teamwork and communication skills among healthcare professionals [ 22 , 26 ]. Only three facilitators of sepsis assessment and management were identified in the reviewed studies. These facilitators were (1) nurses’ improved confidence in caring for patients with sepsis, (2) increased consistency in sepsis treatment, and (3) positive enforcement of successful stories of sepsis management [ 22 , 27 ].

Barriers
Patient-related barriers	Nurse-related barriers	System-related barriers
• Complexity and atypical presentation of the early symptoms of sepsis • High comorbid burden among patients with sepsis, which complicates the critical thinking of sepsis management	• Nurses’ poor level of education and clinical experience • Nurses’ knowledge deficits regarding the protocols and guidelines for the treatment of sepsis • Lack of awareness related to antibiotic use for patients with sepsis • Poor teamwork and communication skills among healthcare professionals	• Lack of written sepsis treatment protocols or guidelines adopted as hospital policies • Lack of sepsis educational programs or training workshops for nurses • Lack of mentorship programs in which junior nurses’ actions/activities are strictly supervised by experienced nurses • Heavy workloads or high patient-nurse ratios • Shortage of well-trained and experienced physicians, particularly in EDs • Lack of IV access and unavailability of ICU beds • Non-use of drug combinations for sepsis treatment
Nurse-related		System-related
• Nurses’ improved confidence in caring for patients with sepsis		• Enhanced consistency in sepsis treatment • Positive enforcement of successful stories of sepsis management

Measurement tools of sepsis-related knowledge, attitudes, and practices

One of the reviewed studies used a Knowledge, Attitudes, and Practice (KAP) questionnaire developed according to the Surviving Sepsis Campaign (SSC) guidelines [ 15 ] to measure nurses’ knowledge, attitudes, and practices related to sepsis assessment and management. Meanwhile, eight studies [ 1 , 9 , 12 , 17 – 21 ] used self-developed questionnaires based on the literature and SSC guidelines and validated by expert panels. Details of these measurement tools and their psychometric properties are summarized in Table 5 .

Study	Name of the tool	Measured variable(s)	Description of the tool	# of items	Total score	Validity	Reliability	Piloted
Van den Hengel et al. (2016)	Self-developed questionnaire	Knowledge of sepsis and SIRS criteria	General information about sepsis, SIRS, protocol, treatments, & case studies	35	29	Validated by expert panel	0.53	No
Oliver (2018)	Self-developed questionnaire	knowledge & practices related to antibiotic administration for sepsis	Information about sepsis management protocol & barriers to rapid antibiotic administration	NR	NR	NR	NR	Yes
Rahman et al. (2019)	Self-developed questionnaire	Knowledge & attitudes towards sepsis	Questions on the indicators of SIRS, sepsis criteria, case scenarios, and attitudes towards the early identification and management of sepsis	39	39	Face & content validity were assessed	0.86	Yes
Storozuk et al. (2019)	Self-developed questionnaire	Knowledge of sepsis	Questions about the signs & symptoms of sepsis, sepsis criteria, definition of sepsis, at- risk patients, & treatment	225	NR	NR	NR	Yes
Harley et al. (2019)	Self-developed questionnaire	Knowledge of sepsis	Questions on sepsis, sepsis criteria, SIRS, q SOFA, nursing role, & barriers to the early identification of sepsis	22	NR	Qualitative content analysis	N/A	No
Nucera et al. (2018)	Self-developed questionnaire	Knowledge & attitudes towards sepsis	Questions on the riskiest sepsis procedures, knowledge about the early identification of sepsis, & attitudes towards blood culture collection techniques	26	NR	NR	0.88	Yes
Edwards & Jones (2021)	Self-developed questionnaire	Knowledge, skills & attitudes towards sepsis	Closed & open-ended questions on nurses’ opinions and experiences regarding sepsis	24	NR	NR	NR	Yes
Yousefi et al. (2012)	KAP	Knowledge, attitudes, & practices related to sepsis	Questions about knowledge, attitudes, & practices related to sepsis	46	NR	Content validity was assessed	77–90.7	No
Giuliano et al. (2005)	Self-developed questionnaire	Knowledge of diagnostics criteria for sepsis	Questions about the physiologic parameters routinely used to assess for sepsis	20	NR	NR	Not measured	No

SIRS: Systematic Inflammatory Response Syndrome; KAP: knowledge, attitudes, and practice; NR: not reported; qSOFA: Quick Sequential Organ Failure Assessment

* Cronbach’s Alpha

Interventions directed at improving nurses’ sepsis assessment and management

Educational programs.

Only four of the selected studies examined the impact of educational programs on nurses’ knowledge, attitudes, and practices related to sepsis management and found significant improvements in nurses’ posttest scores ( Table 6 ) [ 11 , 15 , 28 , 29 ]. For example, Drahnak’s study [ 28 ] implemented an educational program developed by the authors and integrated with patients’ health electronic records (HER) and found significant improvements in nurses’ post-test nursing knowledge scores. Another educational program developed by the authors was implemented to improve ICU nurses’ knowledge, attitudes, and practices related to sepsis and found a significant improvement in posttest scores among the intervention group [ 15 ]. Another study was designed to examine the effectiveness of the Taming Sepsis Educational Program® (TSEP™) in improving nurses’ knowledge of sepsis [ 11 ]. A 15-minute structured educational session was developed to decrease the mean time needed to order a sepsis order set for critically ill patients through improving ER nurses’ knowledge about SSC guidelines and found that the mean time was reduced by 33 minutes among the intervention group [ 29 ].

Study	Intervention/Control	Assessment Times	Measured Variable(s)	Differences in Posttest Scores Between Groups
Delaney et al. (2015)	: received 2 educational sessions. The first session consisted of 4 hours of online learning. The second session consisted of active participation in videotapes, high fidelity simulation, case scenarios, and debriefing sessions focusing on early sepsis assessment, care of septic patients, IHI bundles stages of sepsis, case studies, HLCC, & bundles of sepsis.	Post intervention	IHI bundles, SST, STEPS communication, & HLCC Sepsis assessment Sepsis management EGDT initiation	+0.22 +0.32 +0.16 +0.02 +21.45 +24.16 +19.25
Yousefi et al. (2012)	I: received one PPT session (8 hour) about sepsis care, treatment, prevention, principles, nosocomial infections, and guidelines integrated with pamphlets. Assessed nurses’ knowledge, attitudes, and practices three times (pre-intervention, immediately post intervention, and three weeks post intervention). C: did not receive an educational program	Pre-intervention, immediately post intervention, & three weeks post intervention.	Knowledge: Attitudes: Practices: Knowledge Attitudes Practices	+21.0 +6.4 +7.6 +21.7 +10.1 +8.6
Drahnak (2016)	*I: received one session (30 minutes) with a voice-over slide presentation & role-play case study focusing on the pathophysiology of sepsis, risk factors for sepsis, SSC guidelines, case studies, and assessment of sepsis, integrated with HER	Before the educational program 1 month post intervention	Knowledge Attitudes *Non-adherence *Partial adherence *Adherence	+56.22 -18.25 -31.74 +28.5 +3.4
Rajan et al. (2021)	I: received a structured educational session (15 minutes) focused on SIRS criteria, sepsis criteria, policy, sepsis screening tools, and sepsis standing order. C: did not receive an educational session	Post intervention	Time for sepsis identification	-33 minutes
Vanderzwan et al. (2020)	*I: received medium fidility simulation for 15 minutes. Nurses also received educational session about CLMS.	LMS & one week post simulation	Knowledge retention & competency related to the early identification & management of sepsis	outcomes improved after simulation
Giuliano et al. (2010)	I: exposed to EBM display which is a continuous visual display of combinations of recent data trends & parameters to promote early recognition of sepsis in response to a computer-simulated scenarioC: exposed to SBM display of 5 parameters including BP, ECG, PAP, CO, and O2 Sat which need to be intereprted by clinicans to meaningful data in response to a computer-simulated scenario    • All partciapnts received educational program on sepsis assessment and management based on SSC guidelines	Immediately Pre-intervention & post intervention	Response time to the different monitor displays Time for sepsis recognition Times for SSC-recommended interventions initiation	Similar responses -1.32 minutes -1.33 minutes

*one group only; MNR: Measured but not reported, IHI bundles: Institute for Healthcare Improvement; HLCC; Health literacy and culture competency; EGDT; Early Goal Directed Therapy; SST: Staging sepsis Team; CLM: computerized Learning Management Systems; HER: Electronic Health Record; I: Intervention; C: Control; EBM: Enhanced Bedside Monitor; SBM: Standard Bedside Monitor; CDSS: Clinical Decision Support System

Only two studies examined the effect of using simulation in improving the early recognition and prompt treatment of sepsis by critical care nurses ( Table 6 ) [ 30 , 31 ]. Vanderzwan et al. [ 30 ] assessed the effect of a medium-fidelity simulation incorporated into a multimodel nursing pedagogy on nurses’ knowledge of sepsis and showed significant improvements in six of the nine questionnaire items. While Giuliano et al. examined the difference in mean times required for sepsis recognition and treatment initiation between nurses exposed to two different monitor displays in response to simulated case scenarios of sepsis and showed a significant reduction in the mean times required for sepsis recognition and treatment initiation by those nurses who were exposed to enhanced bedside monitor (EBM) display [ 31 ].

Decision support tools

Four of the selected studies examined the effectiveness of decision support tools, adapted based on the SSC guidelines and the “sepsis alert protocol”, on the early identification and management of sepsis and confirmed the effectiveness of these tools ( Table 7 ) [ 32 – 35 ]. The decision support tools used in three of the studies guided the nurses throughout their decision-making processes to reach effective assessment, high quality and timely management of sepsis, and, in turn, optimal patient outcomes [ 32 , 33 , 35 ]. However, no significant differences in the time of blood culture collection and antibiotic administration were reported between the intervention and control groups in the study of Delawder et al. [ 34 ].

Study	Decision tool/sepsis protocol or tool	Description of the tool or protocol	Main effects on patient outcomes
Manaktala et al. (2017)	Sepsis Survilence Algorithim	The screening tool assesses sepsis clinical parameters (physical exam & lab test) & sends alam signals to nurses about positive findings.	Sepsis mortality rate was reduced by 53% & 30 day readmission was reduced from 19.08% to 13.21%. The tool sensitivity & specificity were 95% and 82%, respectively.
Amland et al. (2015)	Sepsis alert (Binary alarm system)	The tool consists of two steps. The first step is the detection of actual or potential sepsis, and the second is screening & stratification conducted within 15 minutes	89% of septic patients were detected by the alert system, & screening and stratification was completed for 75% of the cases within an hour from notification. The tool sensitivity was 94%.
Long et al. (2018)	User interface alert	User interface alert was designed for medical systems to a provide computer support system for decision-making related to sepsis	The tool enhanced reliability & specificty of patient data for detecting sepsis & provided an effective clinical decision support system for nurses to innititate sepsis assessment & management
Delawder et al. (2019)	Sepsis alert algorithim	Sepsis alert algorithim was designed to initiate full screening of sepsis when the nurse receives an electronic notification. This alert depends on the SIRS criteria & SSC guidelines	The alert algorithm can improve the time taken to implement sepsis guidelines except for antibiotics administration & blood culture collection. Mortality rate was decreased from 12.45% to 4.55%.
Proffitt et al. (2020)	qSOFA	It includes 2 parts, the first part being the assessment of potential infection & the second part being the assessment of Q-SOFA score, which is calculated based on GCS, systolic BP & RR.	The use of qSOFA led nurses to become more autonomous in making decisions related to sepsis management. The median time from ER admission to triage evaluation was reduced by 9 minutes.
McKinley et al. (2011)	TMH	If the patient had MAP<65 mmHg, LL >4 mmol/L, or U.O <0.5 mg/kg/hr, diagnostic tests, broad spectrum antibiotics, & fluid were initiated, and the lactate test was repeated after 4 hours. If the patient met two or more of the previous criteria, central venous line application would be added to the management plan	Time taken to initiate antibiotic administration, blood culture collection, & lactate level assessment & nurses’ compliance to sepsis treatment guidelines were improved, and the mortality rate declined with the use of TMH. The sensitivity & specificity of the TMH were 97%.
Oliver et al. (2018)	EGDT & NDS	The protocols are based on the SSC guidelines, and focus on blood culture, lactate measurement, and antibiotic administration	No significant differences in lactate measurement & blood culture collection were identified, but the time taken for antibiotic administration was improved.
Roney et al. (2020)	MEW-S	This tool was used for the early identification of at-risk patients based on the early signs of status deterioration according to body temperature, BP, RR, LOC, WBC, U.O & L.L.	MEW-S facilitated the early identification of sepsis & provision of timely management. The mortality rate declined by 24%.
Jacobs et al. (2020)	NDS	This tool was developed based on the SSC guidelines & had 4 steps: (1) measure lactate level, (2) take blood culture, (3) provide broad spectrum antibiotics, (4) administer 30 ml/kg crystalloid fluid if hypotensive & LL > 4 mmol/L, & (5) measure bilirubin, creatinine, GCS, MAP, RR, PT, PTT & platelets account.	The readmission rate was reduced from 36.28% to 25% 8 weeks after the NDS protocol, and compliance to the sepsis intervention protocol improved but with no effect on mortality rate.
Gyang et al. (2015)	NDS	Developed based on the SSC guidelines: (1) if the patient met >2 of the SIRS criteria>>> suspected sepsis; (2) if the patient screened >2 SIRS criteria >>> confirmed sepsis and presence of infection; (3) document findings in EHR & call physician	The tool sensitivity and specificity were 95.5% and 91.9%, respectively.
El-khuri et al. (2019)	EGDT	Developed based on the SSC guidelines depending on the following measurements: SIRS criteria, vital signs, U.O, O2 level, cardiac index, & continuous monitoring	There were no differences between the two groups in time and duration of vasopressor, antibiotic administration, or length of stay. However, the mortality rate was decreased from 47.6% to 31.7% with the implementation of EGDT.
Ferguson et al. (2019)	QI	Developed based on the SSC guidelines with few modifications: (1) administer 2 L of fluid instead of 30 ml/kg (2) apply it on patients with suspected infection, and (3) with 2 or more SIRS criteria	ER sepsis bundle adherence was improved by 33.2%, sepsis-related RRT calls was decreased by 1.35% & in-hospital sepsis-related mortality rate by was decreased 4.1% (p<0.001)

qSOFA: Quick Sequential Organ Failure Assessment; TMH: The Methodist Hospital; NDS: Nurse Driven Sepsis Screening tool; EGDT: Early Goal-Directed Therapy; SSC: Surviving Sepsis Campaign; SIRS: Sepsis Inflammatory Response; HER: Electronic Health Records; UO: Urine Output; O2: oxygen; Map: Mean Arterial Pressure; GCS: Glasgow Coma Scale; RR: Respiratory Rate; PT: Prothrombin Time; PTT: Partial Thromboplastin Time; LL: Lactate level; QI: Quality Improvement; RRT: rapid response team.

Sepsis protocols

Eight of the selected studies examined the effectiveness of sepsis protocols [ 24 , 36 – 38 ] and sepsis screening tools [ 16 , 39 – 41 ] for the early assessment and management of sepsis ( Table 7 ). All of these articles revealed that the implementation of sepsis screening tools or protocols based on the SSC guidelines leads to the early identification and timely management of sepsis, as well as the improvement in nurses’ compliance to the SSC guidelines for the detection and management of sepsis. For example, in one study, patients who received Early Goal-Directed Therapy (EGDT) had a lower mortality rate as compared to patients who received usual care [ 16 ]. The sepsis screening tools and guidelines were also tested to examine their impact on some patient outcomes, and variabilities were identified. For example, the use of the Modified Early Warning Score (MEW-S) tool revealed no significant improvement in patient mortality rate [ 41 ]. In contrast, mortality rates were decreased by using the Nurse Driven Sepsis Protocol (NDS) [ 40 ], Quality Improvement (QI) initiative [ 38 ], and a computerized protocol [ 37 ]. In addition, nurses in the computerized protocol group had better compliance with the SSC guidelines than did nurses in the paper-based group [ 37 ]. One of the selected studies compared between a paper-based sepsis protocol and a computer-based protocol and found that antibiotic administration, blood cultures, and lactate level checks were conducted more often and sooner by nurses in the computerized protocol group [ 37 ]. Two of the selected studies used the EGDT as a screening tool for sepsis and found no significant differences in times of diagnosis, blood culture collection, or lactate measurements between the control and intervention groups [ 16 , 24 ]. However, significant differences were found in the time of antibiotic administration in the study of Oliver et al. [ 24 ]. Although El-khuri et al. [ 16 ] revealed no significant differences in the time of antibiotic administration, the mortality rate among patients in the intervention group declined significantly.

Most of the reviewed studies focused on assessing critical care nurses’ knowledge, attitudes, and practices related to sepsis assessment and management, revealing poor levels of knowledge, moderate attitude levels, and good practices. Also, this review revealed that the three most common barriers to effective sepsis assessment and management were nursing staff shortages, delayed initiation of antibiotics, and poor teamwork skills. Meanwhile, the three most common facilitators of sepsis assessment and management were the presence of standard sepsis management protocols, professional training and staff development, and positive enforcement of successful stories of sepsis treatment. Moreover, this review reported on a wide variety of interventions directed at improving sepsis management among nurses, including educational sessions, simulations, screening or decision support tools, and intervention protocols. The impacts of these interventions on patient outcomes were also explored.

The findings of our review are consistent with the findings of previous studies which have explored critical care nurses’ knowledge related to sepsis assessment and management [ 42 ]. Also, recent studies conducted in different clinical settings support the findings of our review regarding nurses’ knowledge of sepsis. For example, a recent study conducted in a medical-surgical unit revealed that nurses had good knowledge of early sepsis identification in non-ICU adult patients [ 43 ]. The variations in nurses’ levels of knowledge related to sepsis assessment were attributed to variations in educational level and work environment (i.e., ICU vs. non-ICU).

The evidence indicates that the successful treatment of critically ill patients with suspected or actual sepsis requires early identification or assessment [ 44 , 45 ]. Early assessment is a critical step for the initiation of antibiotics for patients with sepsis, leading to improved patient outcomes and a decline in mortality rates [ 44 ]. The current review also revealed the significant role of educational programs in improving nurses’ knowledge, attitudes, and practices related to the early recognition and management of sepsis. These findings are in line with the findings of another study, which tested the impact of e-learning educational modules on pediatric nurses’ retention of knowledge about sepsis [ 45 ]. The study revealed that the educational modules improved the nurses’ knowledge acquisition and retention and clinical performance related to sepsis management [ 45 ]. The findings of our review related to sepsis screening and decision support tools are in congruence with the findings of a previous clinical trial which assessed the impact of a prompt telephone call from a microbiologist upon a positive blood culture test on sepsis management [ 46 ]. The study revealed that this screening tool contributed to the prompt diagnosis of sepsis and antibiotic administration, improved patient outcomes, and reduced healthcare costs [ 46 ]. The findings of our review related to the effectiveness of educational programs in improving the assessment and management of sepsis were consistent with the findings of a recent quasi-experimental study. The study found that incorporating sepsis-related case scenarios in ongoing educational and professional training programs improved nurses’ self-efficacy and led to a prompt and accurate assessment of sepsis [ 47 ]. One of the interventions explored in this review was a simulation that facilitated decision-making related to sepsis management. The simulation was found to be effective in mimicking the real stories of patients with sepsis and proved to be a safe learning environment for inexperienced nurses before encountering real patients, increasing nurses’ competency, self-confidence, and critical thinking skills [ 48 ]. Also, a recent study showed that the combination of different interventions aimed at targeting sepsis assessment and management, including educational programs and simulation, may lead to optimal nurse and patient outcomes [ 49 ].

Limitations

The present review has several limitations. There is limited variability in the findings of the reviewed studies in terms of the main variable, sepsis. Moreover, the review excluded studies written in languages other than English and conducted among populations other than critical care nurses. However, there may be studies written in other languages which may have significant findings not considered in this review. Further, only eight databases were used to search for articles related to the topic of interest, which may have limited the number of retrieved studies. Finally, due to the heterogeneity between the selected studies, a meta-analysis was not performed.

Relevance to clinical practice

Our findings could help hospital managers in developing continuous education and staff development training programs on assessing and managing sepsis for critical care patients. Establishing continuous education, workshops, professional developmental lectures focusing on sepsis assessment and management for critical care nurses, as well as training courses on how to use evidence-based sepsis protocol and decision support and screening tools for sepsis, especially for critical care patients are highly recommended. Also, our findings could be used to development of an evidence-based standard sepsis management protocol tailored to the unmet healthcare need of patients with sepsis.

To date, nurses remain to have poor to good knowledge of and attitudes towards sepsis and report many barriers related to the early recognition and management of sepsis in adult critically ill patients. The most-reported barriers were system-related, pertaining to the implementation of evidence-based sepsis treatment protocols or guidelines. Our review indicated that despite all educational interventions, no study has collectively targeted nurses’ knowledge, attitudes, and practices related to the assessment and treatment of sepsis using a multicomponent interactive teaching method. Such a method would aim to guide nurses’ decision-making and critical thinking step by step until a prompt and effective treatment of sepsis is delivered. Also, despite all available protocols and guidelines, no study has used a multicomponent intervention to improve health outcomes in adult critically ill patients. Future research should focus on sepsis-related nurse and patient outcomes using a multilevel approach, which may include the provision of ongoing education and professional training for nurses and the implementation of a multidisciplinary sepsis treatment protocol.

Supporting information

S1 checklist, acknowledgments.

The authors want to thank the Liberian of Jordan University of Science and Technology for his help in conducting this review.

Funding Statement

This study was funded by The deanship of research at Jordan University of Science and Technology (grant number 20200668).

Data Availability

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An evidence-based approach to a patient with sepsis

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• Undergraduate 2:1

Introduction

This essay will focus on the evidence-based approach to a patient with sepsis. Sepsis is defined as a systemic inflammatory response to infection (Polat et al., 2017). The importance of an evidence-based approach in nursing practice cannot be overstated. Indeed, evidence-based practice has been demonstrated to improve clinical outcomes, increase patient safety and even reduce healthcare costs (Considine and McGillivray, 2010, Peterson et al., 2008, Fineout-Overholt et al., 2005). An evidence-based approach requires knowledge of the robustness of the various types of studies sourced from the literature, as well as an adoption of a critically analytical mindset (Burns et al., 2011). To that end, relevant and up-to-date references shall be cited throughout this essay which contends with Mr. K, a 55-year-old gentleman. Mr. K's name and patient identifiers have been redacted and anonymized. This is in keeping with the guidelines put forth by the Nursing and Midwifery Council (NMC); the NMC stipulates that patient privacy and confidentiality should be upheld by nurses (NMC, 2015).

Mr. K has a medical history of chronic hypertension, hyperlipidaemia, type 2 diabetes mellitus and chronic obstructive pulmonary disease (COPD). He is a chronic smoker and occasionally consumes alcohol socially. He has no relevant surgical history. Mr. K has been admitted twice in the past year for acute exacerbations of COPD. Although he has been prescribed with a short-acting beta agonist (SABA) , long-acting beta agonist (LABA), anti-cholinergic and inhaled corticosteroid, he is non-compliant with his prescribed pharmacotherapy and has defaulted on his pulmonology outpatient follow-up visits multiple times.

History & Physical Examination

History taking is a crucial component of clinical decision making (Kassirer et al., 2010). A targeted history in the emergency department reveals that Mr. K has experienced chest pain for the past three days that is associated with a purulent cough. The chest pain was sharp in nature and well-localized to the left lower thoracic region. There was no associated radiation. However, there was some nausea without vomiting. Although he has had a chronic cough for years, he verbalized (with difficulty) that the nature of his sputum had changed to become more viscous and purulent. He also described his cough as being more severe and frequent than usual, and had difficulty breathing as well. There was no associated haemoptysis. Mr. K reported that he had felt feverish and had experienced chills and rigors during the preceding night.

In the emergency department, Mr. K's vital signs were as follows:

• Temperature - 39.1 degrees Celsius
• Heart Rate: 140 beats per minute
• Blood Pressure: 90/50 mmHg
• Respiratory Rate: 28 breaths per minute
• Oxygen Saturation: 86% on room air
• Glasgow Coma Scale: 15

On inspection, Mr. K appeared to be toxic. He was in moderate respiratory distress as evidenced by his recruitment of accessory muscles of inspiration (e.g. sternocleidomastoid muscles) and the adoption of a seated tripod position. He could not complete full sentences during the history taking delineated above. He did not appear to be peripherally or centrally cyanosed. On auscultation, Mr. K's heart sounds were normal without any murmur or pericardial rub. There was reduced air-entry over the left middle-lower lung field which was associated with crepitations. The abdominal system and the systemic review of other organ systems was unremarkable. Based on the history and physical examination, Mr. K appeared to have an acute exacerbation of COPD secondary to pneumonia, which was further complicated by sepsis and impending septic shock.

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Pneumonia, Sepsis & Septic Shock

Based on his vital signs alone, Mr. K had an extremely high NEWS (National Early Warning Score) score of 14. This warranted an emergency assessment by a rapid response team with critical care competencies. Indeed, the NEWS score is a well-validated tool which replaced a plethora of early warning systems throughout the United Kingdom (Jones, 2012). The NEWS score is associated with clinical outcomes and mortality and can predict a patient's likelihood of being admitted into the intensive care unit (Abbott et al., 2015). Patients with a NEWS score exceeding 6 should be monitored on an hourly basis minimally (NEWS, 2017). To that end, Mr. K was transferred from the P2 (priority 2) area of the emergency department to the P1 (priority 1) area and worked up extensively. Although the main differential diagnosis was that of pneumonia, an acute coronary syndrome (ACS) still had to be excluded in view of Mr. K's chest pain. This is especially so as COPD is associated with an increased risk of cardiovascular disease; Mr. K also had other independent risk factors such as diabetes and hypertension (Rothnie and Quint, 2016). A 12-lead electrocardiogram was performed and revealed no signs of ACS (e.g. T-wave inversions, reciprocal changes, ST-elevations/depressions).

While this investigation was performed, several nursing interventions were undertaken in accordance with the ABCDE approach. This approach is a widely adopted framework in emergency medicine and rapidly assesses the patient's airway, breathing, circulation, disability and exposure (Smith and Bowden, 2017). First, Mr. K's airway was deemed to be patient as he was capable of verbalizing. Second, supplemental oxygen was administered to him in order to reduce his effort of breathing by means of improving his oxygen saturation. It was prudent to ensure that his oxygen saturation remained between 88% and 92% (NICE, 2016), in order to avoid blunting his hypoxic drive (Brill and Wedzicha, 2014). As his respiratory distress was observed to improve shortly after this, a decision was made not to intervene with invasive ventilation (i.e. rapid sequence intubation). Third, in view of Mr. K's borderline blood-pressure, two large-bore intravenous cannulae were set over his antecubital fossae. 500 ml of normal saline was rapidly infused in order to address Mr. K's circulatory decompensation.

Sepsis and septic shock have a mortality of 30% and 50% respectively (Song et al., 2016). Shock is defined as an acute physiological perturbance which results in systemic signs and symptoms secondary to hypoperfused organ systems (Bonanno, 2011). Septic shock is further defined as a systemic inflammatory response to infection (Polat et al., 2017). In view of this, the Surviving Sepsis Guidelines (SSG) were enacted. The SSG mandate that a specific bundle be implemented by healthcare workers within one hour. This bundle consists of the early recognition of sepsis, obtaining blood cultures, administering intravenous broad-spectrum antibiotics, obtaining serum lactate and administering vasopressors if indicated (Milano et al., 2018). To that end, the establishment of circulatory access via intravenous cannulae was paramount. The same access was used to administer intravenous antibiotics. Prior to that, blood cultures and serum lactate (together with other haematological tests that assessed end-organ perfusion and ischaemia) were obtained.

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Septic Workup

Once Mr. K was stabilized, a full septic workup was commenced. A plain chest radiograph revealed lobar pneumonia in the left lung. A point-of-care urinalysis did not reveal any nitrites or leukocytes to suggest a urinary tract infection. At the same time, an arterial blood gas was obtained in order to assess Mr. K's acid-base status. Patients with acute exacerbations of COPD typically present with respiratory acidosis secondary to hypercapnia (Bruno and Valenti, 2012). A further one litre of normal saline was administered to Mr. K intravenously as an infusion in order to maintain his mean arterial pressure above 60mmHg. Mr. K's capillary glucose was also checked to ensure that he was not hyperglycaemic nor hypoglycaemic. Severe hyperglycaemia at admission is associated with an increased 30-day mortality in both diabetics and non-diabetics (van Vught et al., 2016). Mr. K's anti-hypertensive medications were temporarily suspended in view of his septic shock, and his oral hypoglycaemic agents (e.g. metformin) were titrated according to his glycaemic state. An oral steroid (prednisolone) was prescribed as there is strong evidence for its utility in severe exacerbations of COPD (Wedzicha et al., 2017).

Mr. K was subsequently transferred to the high-dependency ward for frequent monitoring. His family was updated of his diagnosis and apprised of his progress throughout his high-dependency and subsequent general ward stay. Mr. K was managed by a multi-disciplinary team including a medical social worker, a pulmonologist, a dietician and a pharmacist. His intravenous antibiotics were eventually oralised to Augmentin (co-amoxiclav) as his blood cultures grew Streptococcus pneumoniae. In taking a patient-centred approach, Mr. K's financial situation was taken into consideration. Hence, a referral was made to a medical social worker in order to provide Mr. K and his family with the appropriate financial counselling.

Mr. K presented with an acute exacerbation of COPD which was secondary to lobar pneumonia and further complicated by sepsis and septic shock. He required an escalation to P1 within the emergency department in view of a severe NEWS score. He also required the institution of the SSG. Several evidence-based nursing interventions were undertaken. These include the obtaining intravenous access, delivering supplemental oxygen, obtaining blood cultures and other associated haematological tests as well as administering fluid resuscitation amongst others. Nurses should endeavour to practice evidence-based medicine throughout their daily clinical practice in order to achieve optimal patient outcomes. This case study has demonstrated the utility of an evidence-based practice in clinical decision making, as well as in rationalizing decisions undertaken by the medical team.

Abbott, T. E., Vaid, N., Ip, D., Cron, N., Wells, M., Torrance, H. D. and Emmanuel, J. (2015) 'A single-centre observational cohort study of admission National Early Warning Score (NEWS)', Resuscitation, 92, pp. 89-93.

Bonanno, F. G. (2011) 'Clinical pathology of the shock syndromes', J Emerg Trauma Shock, 4(2), pp. 233-43.

Brill, S. E. and Wedzicha, J. A. (2014) 'Oxygen therapy in acute exacerbations of chronic obstructive pulmonary disease', International journal of chronic obstructive pulmonary disease, 9, pp. 1241-1252.

Bruno, C. M. and Valenti, M. (2012) 'Acid-base disorders in patients with chronic obstructive pulmonary disease: a pathophysiological review', J Biomed Biotechnol, 2012, pp. 915150.

Burns, P. B., Rohrich, R. J. and Chung, K. C. (2011) 'The levels of evidence and their role in evidence-based medicine', Plastic and reconstructive surgery, 128(1), pp. 305-310.

Considine, J. and McGillivray, B. (2010) 'An evidence-based practice approach to improving nursing care of acute stroke in an Australian Emergency Department', J Clin Nurs, 19(1-2), pp. 138-44.

Fineout-Overholt, E., Melnyk, B. M. and Schultz, A. (2005) 'Transforming health care from the inside out: advancing evidence-based practice in the 21st century', J Prof Nurs, 21(6), pp. 335-44.

Jones, M. (2012) 'NEWSDIG: The National Early Warning Score Development and Implementation Group', Clinical medicine (London, England), 12(6), pp. 501-503.

Kassirer, J. P., Wong, J. B. and Kopelman, R. I. (2010) 'Learning clinical reasoning'.

Milano, P. K., Desai, S. A., Eiting, E. A., Hofmann, E. F., Lam, C. N. and Menchine, M. (2018) 'Sepsis Bundle Adherence Is Associated with Improved Survival in Severe Sepsis or Septic Shock', West J Emerg Med, 19(5), pp. 774-781.

National Early Warning Score (NEWS) ' Standardising the assessment of acute-illness severity in the NHS', Available Online: https://www.rcplondon.ac.uk/projects/outputs/national-early-warning-score-news-2 , Accessed On: 9 Nov 2019

National Institute for Health and Care Excellence (NICE) 'Chronic obstructive pulmonary disease in adults', Available Online: https://www.nice.org.uk/guidance/qs10/chapter/Quality-statement-6-Emergency-oxygen-during-an-exacerbation , [Accessed On: 9 Nov 2019]

Nursing and Midwifery Council (2015) 'The Code, Professional standards of practice and behaviour for nurses, midwives and nursing associates', Available Online: https://www.nmc.org.uk/globalassets/sitedocuments/nmc-publications/nmc-code.pdf , Accessed On: 9 Nov 2019

Peterson, E. D., Bynum, D. Z. and Roe, M. T. (2008) 'Association of evidence-based care processes and outcomes among patients with acute coronary syndromes: performance matters', J Cardiovasc Nurs, 23(1), pp. 50-5.

Polat, G., Ugan, R. A., Cadirci, E. and Halici, Z. (2017) 'Sepsis and Septic Shock: Current Treatment Strategies and New Approaches', The Eurasian journal of medicine, 49(1), pp. 53-58.

Rothnie, K. J. and Quint, J. K. (2016) 'Chronic obstructive pulmonary disease and acute myocardial infarction: effects on presentation, management, and outcomes', European heart journal. Quality of care & clinical outcomes, 2(2), pp. 81-90.

Smith, D. and Bowden, T. (2017) 'Using the ABCDE approach to assess the deteriorating patient', Nurs Stand, 32(14), pp. 51-63.

Song, J. E., Kim, M. H., Jeong, W. Y., Jung, I. Y., Oh, D. H., Kim, Y. C., Kim, E. J., Jeong, S. J., Ku, N. S., Kim, J. M. and Choi, J. Y. (2016) 'Mortality Risk Factors for Patients with Septic Shock after Implementation of the Surviving Sepsis Campaign Bundles', Infection & chemotherapy, 48(3), pp. 199-208.

van Vught, L. A., Wiewel, M. A., Klein Klouwenberg, P. M., Hoogendijk, A. J., Scicluna, B. P., Ong, D. S., Cremer, O. L., Horn, J., Bonten, M. M., Schultz, M. J. and van der Poll, T. (2016) 'Admission Hyperglycemia in Critically Ill Sepsis Patients: Association With Outcome and Host Response', Crit Care Med, 44(7), pp. 1338-46.

Wedzicha, J. A. E. C.-C., Miravitlles, M., Hurst, J. R., Calverley, P. M., Albert, R. K., Anzueto, A., Criner, G. J., Papi, A., Rabe, K. F., Rigau, D., Sliwinski, P., Tonia, T., Vestbo, J., Wilson, K. C. and Krishnan, J. A. A. C.-C. (2017) 'Management of COPD exacerbations: a European Respiratory Society/American Thoracic Society guideline', Eur Respir J, 49(3).

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Our Press Coverage

3 scenarios to train for diagnosis, treatment of sepsis

Use simulation education to teach ems providers to recognize and treat sepsis.

BLS providers practice capnography monitoring with a high-fidelity patient simulator.

Photo/Aaron Dix

By Aaron Dix

EMS is dispatched to a local residence for a 20-year-old female with foot pain. Medics find the patient sitting in a recliner with her left foot supported by a pillow.

She spent the weekend at the beach and cut her foot on a piece of glass while walking in the ocean. Over the past several days her foot has become increasingly painful, and this morning she developed a fever that hasn’t responded to acetaminophen. She is conscious and alert but weak. Skin is pale, dry and hot. Heart rate 110, respiratory rate 24, blood pressure 100/60. An oral thermometer is not available.

Focused assessment of the patient’s foot reveals a one-inch laceration with no active bleeding that is red, swollen and painful. Swelling is present throughout the bottom of her foot and ankle. Since the patient does not appear to be in any acute distress, the medics suggest that she go to the local urgent care center in the morning and a refusal is obtained.

The next morning, medics are dispatched to the urgent care center for a transfer to the local hospital for hypotension. Upon arrival, the same medics find the above-mentioned patient with a blood pressure of 86/40 and a heart rate of 140. Tympanic temperature of 101.5 was obtained by the urgent care staff. The patient is urgently transported to the local emergency department. During transport, medics infuse 500 mL of normal saline per protocol for the management of medical hypotension.

At the emergency department, blood cultures are drawn, ibuprofen is administered for her fever, and she is admitted to the hospitalist service. Antibiotics for cellulitis from an infected wound are started once she is admitted. Her blood pressure continues to worsen throughout the night, and she is intubated and moved to the ICU. Despite blood pressure support and aggressive antibiotic treatment, the patient dies 24 hours after arriving at the hospital. The young patient in the above description died from septic shock secondary to her foot wound.

Sepsis is manageable with early diagnosis and treatment

A leading cause of death in the United States, sepsis carries a significantly higher mortality rate than both stroke and STEMI [1]. But when identified and treated with antibiotics at the onset of symptoms, sepsis is manageable and survivable.

Early antibiotic treatment is associated with drastically improved outcomes, yet many EMS providers lack the training to readily recognize sepsis and septic shock. Mortality increases an estimated nine percent per hour when antibiotics are delayed after hypotension [2].

Unlike STEMI and stroke, sepsis recognition does not require a specific exam or new equipment. As a recent study demonstrated, effective EMS sepsis recognition only requires the provider to evaluate respiratory rate, heart rate, temperature and the possibility of an infection [3]. Measuring lactate, while useful in determining the severity of sepsis, is not necessary in the recognition phase.

Simulation education for sepsis recognition

Simulation education can be useful in educating EMS providers, both basic and advanced, in both sepsis recognition and treatment. Here are four learning objectives to use or modify for an EMS sepsis training:

1. Discuss the SIRS criteria and how it relates to sepsis recognition. 2. Demonstrate an appropriate sepsis assessment. 3. Identify patients who have a high probability of being septic. 4. Differentiate between the flu and pneumonia.

Simulation tip: Some simulators have limitations and certain vital signs such as temperature and glucose will not be obtainable utilizing standard EMS equipment. The facilitator will need to provide the correct information when promoted by the participant’s actions, either verbally or through the simulator’s patient monitor. However, all high-fidelity simulators have the ability to provide respiratory rate, heart rate, blood pressure and lung sounds. Providers should be prompted to assess the simulator as a real patient and gather vital signs and history in real time.

Here are three simulation scenarios to use or modify for your EMS training program.

Scenario 1: Standard Sepsis

Facilitators should begin with a non-complicated scenario that easily demonstrates the signs and symptoms of sepsis. The debriefing should concentrate on ensuring that a proper assessment will yield all the necessary information a provider needs to determine sepsis: two or more SIRS criteria and a known or suspected infection. Two common causes of sepsis EMS providers are likely to encounter are pneumonia and urinary tract infections.

Overview: Crew arrives to find a 68-year-old male complaining of shortness of breath. His shortness of breath began after waking six hours earlier and is progressively getting worse. Since lunch he has been unable to ambulate without becoming significantly short of breath. He hasn’t been feeling great over the past several days and has had a productive cough that has occasionally awoken him from sleep.

History: HTN, previous MI (2002), hypothyroid

Allergies: none

Medications: lisinopril, levothyroxine, warfarin

Patient weight/height: 180 pounds/5 feet, 11 inches

Vitals: HR is 130, BP is 106/60, RR is 26/min, SpO2 is 90 percent, glucose 250 mg/dl, temp 101.3 F, ETCO2 30 mm Hg with a normal waveform, and lung sounds are bilateral rhonchi.

Treatment should include oxygenation administration, fluid replacement, sepsis alert and antibiotic therapy if available.

Scenario 2: Differentiating sepsis/pneumonia from the flu

EMS providers must be capable of maintaining a high sensitivity for sepsis patients while limiting false positives. The flu can easily mimic pneumonia, making sepsis recognition more difficult. In this case, the rapid onset, non-productive cough and clear lung sounds make the argument for a flu diagnosis over pneumonia.

Overview: Crew arrives to find a 56-year-old female with sudden onset of high fever, general malaise and a non-productive cough. She woke this morning feeling normal. Her symptoms began suddenly right after lunch and worsened rapidly. She has a frequent non-productive cough, and her fever has not responded to acetaminophen.

History: hyperlipidemia and type 2 diabetes

Allergies: penicillin and naproxen

Medications: simvastatin and metformin

Patient weight/height: 120 pounds/5 feet, 6 inches

Vitals: HR is 100, BP is 118/70, RR is 20/min, SpO2 is 98 percent, glucose 140 mg/dl, temp 103.5 F, ETCO2 40 mm Hg with a normal waveform, and lung sounds are clear.

Scenario 3: Septic shock

Septic shock has a mortality rate near 50 percent and requires aggressive treatment. This case has two main objectives: aggressively treating septic shock and understanding that sepsis can occur in the presence of hypothermia. While approximately 80 percent of septic patients will show hyperthermia, temperature dysregulation, not fever, is the hallmark sign.

ETCO2 can also be discussed as an identifier of severe sepsis or septic shock . Decreases in ETCO2 correlate with elevated levels of lactate and increases in mortality.

Overview: EMS responds to a local nursing home for altered mental status. Patient is a 72-year-old male who was admitted to a skilled nursing facility for rehabilitation following a total hip replacement. Staff states he became altered this afternoon and was unable to ambulate this evening. He was admitted to the facility last night, and very little information is known.

History: hypertension, atrial-fibrillation, and type 2 diabetes

Medications: metformin, lisinopril, amiodarone and warfarin

Patient weight/height: 220 pounds and 5ft 9in

Vitals: HR is 150, BP is 84/50, RR is 22/min, O2 is 96 percent, glucose 280 mg/dl, temp 94.8 F, ETCO2 20 mm Hg with a normal waveform, and lung sounds are clear.

Additional info: Swollen and red surgical incision site on the right hip covered by the gown visible only if inspected.

Treatment: High volumes of normal saline, pressor support (norepinephrine preferred), sepsis alert and antibiotic therapy if available.

In conclusion, simulation training can improve the ability of both advanced and basic providers to diagnose and treat sepsis. Facilitators should concentrate on ensuring a comprehensive patient assessment to identify and treat patients who have a high probability of sepsis. Assess respiratory rate, heart rate, temperature and the possibility of an infection to make an accurate determination of sepsis. Faster recognition and treatment by EMS providers will lead to improved patient outcomes.

1. Cronshaw, 2011. Impact of surviving sepsis campaign on the recognition and management of severe sepsis in the emergency department: Are we failing? EMJ, Volume 12, pp. 296-327.

2. Kumar et al, 2006. Duration of hypotension before initiation of effective antimicrobial therapy is the determinant of survival in human septic shock. Critical Care Medicine, Volume 34, pp. 589-596.

3. Walchok et al, 2016. Paramedic-Initiated CMS Sepsis Core Measure Bundle Prior to Hospital Arrival: A Stepwise Approach, Prehospital Emergency Care, DOI: 10.1080/10903127.2016.1254694

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• Artificial intelligence

Robecca: AI ethics in action

She helps shape the defence and security landscape with her work on the ethics, law and governance of artificial intelligence (AI) capabilities.

Serving her country is literally in her DNA.

With multiple family connections to the military Robecca grew up with a strong sense of duty and a desire to serve her country.

She specialises in the ethics, law and governance of AI -enabled defence and security capabilities, and said she is proud to work for the Defence Science and Technology Laboratory ( Dstl ) with its focus on keeping our Armed Forces safe.

AI Ethics in Action

Robecca said:

“My family connections to the military have been a source of inspiration for me to come and work for Dstl .

“It is that sense of shared values…sense of duty and service is something we share in common even though I am not in uniform.

“I wanted to do something meaningful with my life and give back to my country. Working for Dstl is my way of doing that.”

Robecca’s career

After graduating with a first-class honours degree in forensic psychobiology Robecca worked at the Atomic Weapons Establishment.

Building on her experience in the defence industry, her Dstl career began at the organisations’s Salisbury headquarters 7 years ago, before she worked remotely for 18 months from a military base in New York, USA, as a military spouse.

After returning to the UK, Robecca joined the inaugural Newcastle team when the new site opened in 2022 and where her work helps shape the defence and security landscape.

“I work at the intersection of what technology can do and what technology should do.

“I make sure that the checks and balances - in terms of ethics, laws, international standards and regulations - are applied to the development and use of artificial intelligence.

“The most exciting thing about my role is working directly with development teams on novel AI capabilities.”

Robecca also says that the rapid evolution of both AI and its surrounding ethical, legal and regulatory landscape make this a complex but critical responsibility.

While on maternity leave, Robecca learned that she had been named one of the global 100 Brilliant Women in AI Ethics 2024 – an accolade recognising her dedication to this work.

“I work with a lot of really clever people that I admire. I have made a particular effort recently to try and find mentors from other organisations as well; people whose careers I may want to follow. It’s important to show, particularly younger women maybe just starting out in their careers or at secondary school, that there are opportunities like this for people like you.”

Her day in the office can range from leading international workshops to taking part in research trials in the field, with military personnel, and land, air and sea platforms.

Running a Five Eyes workshop

“I’m most proud of a workshop I ran with about 80 military lawyers and academics from across the Five Eyes - that’s the UK, the US, Australia, Canada and New Zealand.

“That was an opportunity for these lawyers to work together on legal reviews of AI -enabled weapons; exploring the similarities and differences of our approaches, in order to foresee challenges and opportunities to interoperability so that if we were deployed on allied missions, how we might use, share or transfer capabilities or where tensions and difficulties may emerge.

“I’m proud of that because I’m not a lawyer. I almost felt I didn’t deserve at the table but I ended up leading it.”

In her free time, Robecca likes to travel and writes poetry for her children. However, some of her most exciting challenges have come through work.

Highlight of working at Dstl

“The coolest thing I have done at Dstl was probably collecting data during a military exercise which was hosted in a fort, on a cliff edge. We had Blackhawk helicopters popping up out of nowhere, Chinooks flying overhead, and there was a ship at sea.

“In the pitch black we were standing at the top of this fort looking down on an ‘attack’ unfolding. The only way we could see what was going on was by the red of the flare in the sky.

“I remember thinking to myself ‘I can’t believe I’m getting paid to do this because this is something I would have paid to experience.’ It was extraordinary. And that’s exactly the kind of career I want!”

Learn more about Dstl ’s pioneering AI work.

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High rate of carbapenem resistance in bacteria that cause newborn sepsis in Africa

Nearly a third of gram-negative bacterial infections in newborns with suspected sepsis in Africa are resistant to carbapenem antibiotics, researchers reported late last week in BMC Infectious Diseases.

The  findings are from a review and meta-analysis conducted by researchers from Woldia University in Ethiopia who hoped to fill in knowledge gaps in the population-based epidemiology of neonatal sepsis in Africa and estimate carbapenem resistance in the gram-negative bacteria that can cause sepsis in newborns. They defined carbapenem resistance as resistance to meropenem, imipenem, or ertapenem.

Pooled prevalence of carbapenem resistance was 30%

Among the 36 studies that assessed carbapenem resistance in gram-negative bacteria isolated from newborns with suspected sepsis in Africa, there were 7,116 isolates. The most frequently isolated pathogen was Klebsiella pneumoniae, which accounted for 38.2% of all isolates. 

The pooled prevalence of carbapenem resistance in all isolates was 30.34% (95% confidence interval [CI], 22.03% to 38.64%). The pooled estimate of gram-negative bacteria resistant to imipenem, meropenem, and ertapenem was 35.57% (95% CI, 0.67% to 70.54%), 34.35% (95% CI, 20.04% to 48.67%), and 26.11% (95% CI, 15.82% to 36.40%), respectively. 

The highest prevalence of carbapenem resistance was found in Acinetobacter baumannii and Pseudomonas  spp., which had pooled prevalence of 45.9% (95% CI, 33.1% to 58.7%) and 43.0% (95% CI, 23.0% to 62.4%), respectively. 

The percentage of carbapenem-resistant isolates varied widely between countries, ranging from 0.5% in Sudan to 57.9% in Egypt.

Neonatal sepsis is a primary cause of neonatal mortality in low- and middle-income countries in Africa and elsewhere. The study authors say stronger microbiology laboratory capacity to diagnose drug resistance is needed in countries with a high burden of neonatal sepsis.

To address this global health threat, it is essential to implement robust infection prevention measures, antimicrobial stewardship, and strict surveillance.

"To address this global health threat, it is essential to implement robust infection prevention measures, antimicrobial stewardship, and strict surveillance of infections and antimicrobial resistance (AMR)," the authors wrote. "This is particularly crucial as third-line medications and carbapenems are increasingly losing their effectiveness."

Cambodia reports fatal H5N1 avian flu case

Cambodia's health ministry today reported another human H5N1 avian flu case, the country's tenth of the year, according to a statement translated and posted by  Avian Flu Diary , an infectious disease news blog.

The patient was a 15-year-old girl from Prey Veng province who died from her infection on August 20. An investigation found that chickens had died in the village 5 days before the girl became ill and that she had touched and held dead chickens.

Two earlier cases this summer

Cambodia reported two other H5N1 cases earlier this summer, both from Svay Rieng province. The patients—a  4-year-old boy and a  16-year-old girl —were both hospitalized for their infections and both had contact with dead poultry before they got sick.

The cases are part of an uptick in H5N1 cases in Cambodia, which has now reported 18 since early 2023. 

So far, the clade of the H5N1 virus that infected the most recent patient isn't known, but many earlier infections involved an older clade called 2.3.2.1c, which is known to circulate in poultry in some Asian countries, including Cambodia. The H5N1 clade is distinct from the 2.3.4.4b clade circulating globally, including in the United States, where the virus has also infected dairy cows, poultry, and a few farm workers.

Georgia reports another measles case as Oregon outbreak hits 30

The Georgia Department of Public Health (DPH) yesterday reported a measles infection in an Atlanta resident who wasn't fully vaccinated, marking the state's fifth case of the year, according to a statement .

The DPH said the patient was exposed to the virus during international travel, adding that it is working to identify people who had contact with the patient during the infectious period.

Oregon outbreak worst since 1991

In other developments, the Oregon Health Authority reported 4 more measles cases in its outbreak, raising the total to 30 in three counties. The outbreak is the state's largest since 1991. 

According to the latest data , all patients were unvaccinated and 2 were hospitalized. Twelve of the patients are younger than 10 years old, and 11 are ages 11 to 19.

Measles activity in the United States is at its highest level since 2019, part of a global rise in cases. In its latest update , the Centers for Disease Control and Prevention said it has received reports of 219 cases from 27 jurisdictions. Thirteen outbreaks have been reported, and 68% of cases this year were linked to outbreaks.

In case you missed it

This week's top reads, sweden reports first clade 1 mpox case outside of africa as nih shares disappointing tpoxx results.

The patient sought medical attention in Stockholm but had recently visited Africa.

New studies estimate long-COVID rates, identify risk factors

About 34% of infected postmenopausal women had symptoms for 8 weeks or more, while 61% of survivors in a second study had symptoms at 2 years.

COVID-related loss of smell tied to changes in the brain

An impaired sense of smell could serve as both a potential marker of virus-induced brain damage and a marker of patients susceptible to brain damage.

COVID activity shows signs of slowing in parts of US

Wastewater levels are at the very high level nationally, but show downward trends in the South and Midwest.

CDC pandemic review of US H5N1 virus on par with earlier assessments from same clade

Like two recent 2.3.4.4b viruses, the subtype from the Texas patient is of moderate risk for both future emergence and public health impact. 

WHO declares global public health emergency for mpox surge in Africa

As plans move forward to mobilize vaccine, health officials still better epi information to best target the supplies.

Study identifies risk groups for severe COVID-19 by patient age

Children were less commonly vaccinated compared to adults.

CDC alerts providers about spike in parvovirus B19 activity

CDC said it had received multiple reports of increased activity from multiple sources, including clusters of complications in vulnerable groups.

European officials say more imported clade 1 mpox cases likely

The ECDC said the risk is high for those who have close contact with affected communities and moderate for people who are contacts of imported clade 1 cases.

Routine lab tests can't reliably distinguish long COVID from other illnesses, NIH study suggests

The authors say that clinicians should continue to focus on symptoms and symptom relief rather than rely only on lab test results.

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How Did Mpox Become a Global Emergency? What’s Next?

The virus is evolving, and the newest version spreads more often through heterosexual populations. Sweden reported the first case outside Africa.

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By Apoorva Mandavilli

Apoorva Mandavilli covered the 2022 mpox outbreak and the Covid-19 pandemic.

Faced once again with a rapidly spreading epidemic of mpox, the World Health Organization on Wednesday declared a global health emergency. The last time the W.H.O. made that call was in 2022, when the disease was still called monkeypox.

Ultimately the outbreak affected nearly 100,000 people worldwide, primarily gay and bisexual men, including more than 32,000 in the United States.

The W.H.O.’s decision this time was prompted by an escalating crisis of mpox concentrated in the Democratic Republic of Congo. It recently spread to a dozen other African countries. If it is not contained, the virus again may rampage all over the world, experts warned.

On Thursday, Sweden reported the first case of a deadlier form of mpox outside Africa , in a person who had traveled to the continent. “Occasional imported cases like the current one may continue to occur,” the country’s public health agency warned.

“There’s a need for concerted effort by all stakeholders, not only in Africa, but everywhere else,” Dr. Dimie Ogoina, a Nigerian scientist and chair of the W.H.O.’s mpox emergency committee, said on Wednesday.

Congo alone has reported 15,600 mpox cases and 537 deaths, most of them among children under 15, indicating that the nature of the disease and its mode of spread may have changed.

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