Don't miss vital signs of sepsis

A new sepsis toolkit has been launched by the Royal College of General Practitioners (RCGP), in partnership with Health Education England and NHS England.

The toolkit follows the release of a new action plan developed by NHS England earlier this year in an effort to improve outcomes in cases of sepsis, most of which arise in the community.

The new toolkit includes:

  • Decision Support Tools developed by the Sepsis Trust to help GPs better identify possible sepsis.
  • Resources for patients, parents and carers including 'symptom checkers' and other leaflets.
  • Significant national reports, relevant legislation and guidance.
  • Educational resources.

A 2015 NCEPOD analysis, Just Say Sepsis, found there are around 200 000 cases of sepsis each year in the UK with a current mortality greater than that for myocardial infarction in the 1960s.

Sepsis is a life threatening condition and tragically, in about a third of the cases notified by MDU members, the patient later died. Nationally, it is estimated that the condition is associated with 37,000 deaths each year, more than the number of deaths from lung cancer. What's more, the number of people developing sepsis is increasing, with around 123,000 cases each year in England.

The NCEPOD analysis found that the diagnosis of sepsis was missed in over half of patients who, in hindsight, the reviewers considered should have been admitted sooner and that in one third of the 77 general practice cases reviewed, 'not one of the four basic vital signs of temperature, pulse, blood pressure and respiratory rate had been recorded.' In addition, there was no referral letter available in 43% of cases when the patient was sent to hospital.

Avoiding delayed diagnosis

For GPs here are a few points that really stand out from these recent publications and which might help to avoid a delayed or missed diagnosis:

  • severe sepsis is a major and often avoidable cause of death
  • most patients with sepsis are seen in the community before hospital
  • keep sepsis in mind and make sure you ask the right questions to diagnose sepsis
  • record vital signs consistently
  • keep good records of significant negatives as well as positive findings in the history and examination
  • ensure patients are provided with and understand when to seek further advice if their condition doesn't improve and record that this safety netting advice has been given.

Types of cases

Around 500 members have asked the MDU for advice or support with cases relating to patients with sepsis over the past five years, including complaints and coroners' inquiries. Just under half were GP members who it was alleged had delayed a diagnosis of sepsis, failed to send the patient to hospital or failed to manage another condition which triggered sepsis such as a UTI or an ulcer.

In a typical case highlighted in page 48 of the NCEPOD analysis, a young patient with a fever, pain down the left side and dysuria for four days saw a GP. The GP initially diagnosed flu but the patient returned two days later and was noted to be drowsy and have a fever. A urine test was performed which suggested a UTI.

The patient was transferred to hospital and recovered after antibiotic treatment, but the study reviewers felt that had a urine test been performed during the first appointment, it may have saved hospital admission. Drowsiness, an important indicator of sepsis, was picked up at the second visit and triggered the patient's transfer to hospital.

Five key recommendations

Although sepsis can be difficult to diagnose because the symptoms are similar to other conditions, it is treatable and NHS England's action plan (drawn up with the RCGP, the UK Sepsis Trust, NICE and others) focuses on five key areas.

These are:

1. Preventing avoidable cases of sepsis

  • Some cases may be preventable, particularly in at risk groups including older people, the immunosuppressed, pregnant women and children.
  • Preventative measures include vaccination, hand washing, and more specific measures such as the prevention and early treatment of UTIs for patients in care homes.

2. Increase awareness of sepsis amongst professionals and the public

  • It's important to take and record appropriate vital signs in cases of febrile illness. Provide and document safety netting advice, explaining to patients when and after how long to seek further medical advice if symptoms don't improve.
  • If you regularly visit care homes, ensure that care home staff are confident in, and able to discuss the signs of sepsis.
  • Your triage systems should be designed to identify potential sepsis cases.
  • Audit tools are available to enable you to assess treatment of febrile children under five against the NICE guideline.

3. Improve the identification and treatment of sepsis across the whole patient pathway

  • Taking and recording of vital signs is critical in enabling the detection of a deteriorating patient.
  • Lack of laboratory tests can make diagnosis of severe sepsis difficult however the action plan identifies screening tools available.
  • Communication between primary and secondary care can often be poor. Local alerting systems can help ensure hospitals are warned about the arrival of a potentially septic patient. GP practices should also keep a record of referral letters.

4. Improve consistency of standards and reporting

  • It's important to act immediately if you suspect severe sepsis. The action plan advocates using an approach to treatment called the Sepsis Six care bundle. This treatment, which includes giving oxygen and intravenous antibiotics and fluids, may not be accessible in primary care, although may be available to some out of hours providers. The treatment has been shown to reduce the relative risk of death by 46.6 percent when delivered to patients with severe sepsis within one hour.
  • NICE plans to publish a clinical guideline on sepsis in 2016 and a quality standard in 2017.

5. Ensuring appropriate antibiotic use

  • Clear and evidence-based guidance on the use of antibiotics must be followed.

This page was correct at publication on 19/09/2016. Any guidance is intended as general guidance for members only. If you are a member and need specific advice relating to your own circumstances, please contact one of our advisers.

Dr Catherine Wills

by Dr Catherine Wills Medico-legal adviser

MA(Oxon) MB BS LLM FRCP MFFLM

Catherine joined the MDU in 2004 and is deputy head of the advisory department. Previously, Catherine was a hospital consultant in general medicine, diabetes and endocrinology.

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