We gratefully acknowledge a very detailed and most helpful briefing report from the UK Sepsis Trust.
Points of particular relevance to our concerns are:
1. Overview
Most cases of sepsis are caused by a community-acquired bacterial infection that is sensitive to antibiotic treatment. Less than 20% relate to healthcare-associated infections. Sepsis is common, with an incidence similar to heart attack, and mortality similar to lung cancer. It brings a substantial cost burden to the NHS, with each hospital admission costing about £20,000.
2. Shortcomings in the delivery of healthcare
Healthcare systems across the world have struggled to implement the Surviving Sepsis guidelines on resuscitation. In the UK in 2008, less than 20% of cases in 18 participating hospitals met the standards.
3. Key priorities for change in clinical practice
3.1 Recognition
Early diagnosis of sepsis reduces mortality. Screening tools and automated alerts are available but are not in widespread use. Where clinical information is stored electronically, software systems can detect sepsis before the clinical team has suspected it. A multidisciplinary and multispecialty approach to sepsis care improves outcomes, and needs to be supported by continuing education, implementation of protocols, data collection and audit, and feedback to facilitate continuous improvement.
3.2 Key therapeutic interventions
The reliable, early delivery of basic treatments like fluids and antibiotics has the greatest impact on improving outcomes. Identifying the causative organism by blood culture enables more focused antibiotics to be used, reducing complications and the risk of emerging antibiotic resistance. Each hour of delay in antibiotic administration increases the risk of death – delay also leads to longer hospital stays and thus greater cost. Compliance with current guidelines improves outcomes to the extent of saving one life for every four cases where it is implemented.
3.3 Systems (of care provision) change
Different systems are required to meet the needs of sepsis patients according to where they are being cared for. In the community, the issues concern recognition. In ambulances, there are opportunities for prehospital care. In emergency departments, where all necessary information is collected at about the same time, performance for sepsis contrasts unfavourably with that for other conditions such as myocardial infarction. In hospital wards, where the necessary information is collected at different times and in different formats, there are opportunities for automatic screening and end-of-shift review. There are ways to enhance the interfaces between all parts of the health system so as to reduce the time before treatment is started.
3.4 Communication and escalation
When there is no response to initial treatment, the involvement of senior staff and critical care specialists in decision making is needed. Delay in obtaining such support is common, and contributes to poor patient outcomes. No standards have yet been agreed to help manage these delays.
4. Priorities for strengthening the clinical evidence base
4.1 Administration of intravenous fluids
Restoring blood volume is a central tenet of sepsis treatment. The volume needed, and the rate of infusion, are not clear. The efficacy of fluid challenge is uncertain, and clarity on these matters will inform the design of prehospital care practice.
4.2 Prehospital recognition
The development of screening tools to detect sepsis reliably out of hospital would provide opportunities to shorten the period before antibiotics are administered.
4.3 Interface between primary and secondary care
There is no information available on the incidence of sepsis presenting to primary care and to the ambulance service. Such information is necessary to develop the collaborative clinical pathways that have been effective in improving outcomes for other critical conditions.
4.4 Biomarkers and rapid pathogen identification
The evaluation of measurement of substances in the blood to enable earlier confirmation of suspected sepsis and define its severity could reduce treatment delays. New technologies to identify the causative bacterium earlier would enable the cost and safety benefits of changing to more selective antibiotics to be achieved sooner.
5. Barriers to improving clinical outcomes
5.1 Public health data
Information on incidence and outcomes is limited to intensive care patients. Shortcomings in the international classification of disease codes for sepsis have resulted in under‑recording. Death certificates are often incomplete, illogical, or inaccurate. In turn, this confounds disease monitoring.
5.2 Awareness and training
Although the GMC provides general guidance on the undergraduate curriculum, detail is the prerogative of individual medical schools. Sepsis as a topic is covered variably, and tends to be a matter for postgraduate education. Its complexity requires reinforcement by a rolling programme of education for which time is difficult to identify.
5.3 Resources
While greater benefits may be achieved by improving basic care, providing the invasive aspects of the resuscitation bundle requires high dependency capacity and highly skilled staff, which are not always available.
5.4 Acceptance of guidelines
The ways that clinicians work, and the complexity of the evidence, explain why it always takes time to change clinical practice. Sepsis is still not always accepted as an emergency in the way that heart attack is. The benefits of first concentrating on non-contentious basic interventions are recognised.