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News Focus: Sepsis: the silent killer

Primary care nurses have poweful potential to prevent death from sepsis, writes Alex Turnbull

It’s been called a ‘silent killer’, but public awareness of sepsis was raised when the Secretary of State for Health, Jeremy Hunt, took the step of speaking at the memorial of William Mead in March. ‘We didn’t spot his sepsis before it was too late,’ he said.

In 2014, 12-month-old William Mead lost his life after a crucial symptom of sepsis was not recognised. A member of staff on NHS 111 missed the sign of the blood infection, leading to the death of the child, with an investigation finding at least 15 failures in the boy’s case.

Sepsis is a common and potentially life-threatening condition triggered by an infection which causes the body’s immune system to go into overdrive, and if it not treated quickly, it can lead to multiple organ failure and death. It claims more lives in the UK than lung cancer, and is the second biggest killer after cardiovascular disease. According to the Sepsis Trust, every year in the UK there are 150,000 cases of Sepsis, resulting in 44,000 deaths. The condition also presents an immense financial burden on the NHS, with an estimated cost of £7 billion to the country presently, with direct costs to the NHS standing at £860 million.

‘Sepsis is a devastating condition that kills more than 80 people in England every day,’ said Jeremy Hunt. ‘It’s time to apply the lessons we’ve already learnt on patient safety and reduce the number of lives that are needlessly lost to this silent killer.’

Sepsis can be triggered by an infection in any part of the body. The most common sites of infection leading to sepsis are the lungs, urinary tract, abdomen and pelvis.

Sepsis awareness

According to the Sepsis Trust, in many cases sepsis is avoidable and treatable, with early identification key to successfully treatment. However, as a survey performed in September 2016 highlighted, awareness of the condition remains low in the UK, with 44% of people having never heard of it. Additionally, a quarter of people do not know that a case of sepsis is a medical emergency requiring urgent treatment.

‘I don’t think enough is being done to raise awareness,’ said Dr Ron Daniels, chief executive and founder of the Sepsis Trust. ‘What we need is the government to do more to raise awareness of sepsis in adults. Quite frankly sending out a few posters isn’t going to cut it, and the public need to be aware of it.’

‘Severe symptoms can develop in sepsis very quickly,’ said Professor Gillian Leng, National Institute of Health and Clinical Excellence (NICE) deputy chief executive. ‘If high-risk patients are not identified and treated promptly, people can be left with debilitating problems. In the worst cases, they may die.’

The time to full recovery varies, and the condition creates a host of potential challenges for a primary care clinician. Some patients experience long-term problems such as lethargy; muscle weakness; swollen limbs or joint pain; chest pain or breathlessness; insomnia; hair loss; dry/flaking skin and nails; changes in taste, vision and limb sensation; poor appetite; post-sepsis syndrome; and repeated infections. There are also potential psychological consequences, such as anxiety or fear, depression, flashbacks, nightmares, insomnia, post-traumatic stress disorder, and poor concentration or short-term memory loss.

‘Rapid access to healthcare, and reliable delivery of the most basic aspects of care, can save an extra 11,000 lives every year’ says Dr Daniels.

Primary care

According to Health Education England, 70% of sepsis cases develop within primary care. However, sepsis is a difficult condition to diagnose with the limited resources of general practice.

‘This is largely about safety netting,’ says Dr Daniels. ‘I think it’s unreasonable to expect a nurse in primary care to spot every episode of sepsis in one consultation. Its about tracking changes in the patient’s condition. It’s that alarm bell ringing, with the patient looking more unwell that you’d expect them to, and their relatives being concerned, particularly in relation to children.’

NICE guidelines state that staff in any setting, from general practice to paramedics, should check people for specific signs that will show if their symptoms are life-threatening. This includes taking their temperature or heart rate, or checking for rashes and skin discolouration.

The guidelines state that clinicians should take into account that people with sepsis may have non-specific, non-localised presentations (e.g. feeling very unwell) and may not have a high temperature. Additionally, nurses should pay particular attention to concerns expressed by the person and their family or carers (e.g. changes from usual behaviour).

Four groups are particularly at risk of developing the condition:

  • Pregnant women
  • The elderly (over 65, and especially over 85)
  • Immunosuppressed (those who have recently been severely unwell)
  • Those aged under one year.

Nurses should also assess people who might have sepsis with extra care if they cannot give a good history (e.g. people with English as a second language or people with communication problems). NICE also stresses that anyone found to be high-risk should be referred to hospital immediately.

‘In terms of the symptoms, we describe in adults in primary care, we use the SEPSIS acronym,’ says Dr Daniels (see Box 1). ‘This remains relevant to primary care, but I would say you haven’t got the resources in primary care to do a full set of physiological tests in a consultation. There are groups who are at an increased risk, however. It is sensible to take some observations if any red flags appear in a primary care setting.’

The Sepsis Trust has also created a toolkit for primary care clinicians to assist in the diagnosis of sepsis (see Box 3). It states that in many cases the lack of laboratory services or point-of-care tests limit the ability of clinicians to distinguish between sepsis, severe sepsis and septic shock (according to international definitions). The Trust has stated that looking for sepsis in general practice settings can be like trying to find a needle in a haystack.

Nurses also should consider the possibility of a patient not knowing or understanding the risk of sepsis. According to Dr Daniels, it is a common problem for patients to have not realised that sepsis was a medical emergency. ‘Often it is not the GP or the practice nurse who misses sepsis. In about 60% of cases the cause is waiting for too long to call for help,’ he says. ‘We have evidence that awareness is of paramount importance.’

With the general public’s knowledge of sepsis rising, as well as a greater awareness among medical staff, early intervention in cases of suspected sepsis should in future hopefully save the lives of patients such as William Mead. As Professor Paul Cosford, Director of Health Protection and Medical Director at Public Health England, comments: ‘We know that acting quickly in cases of sepsis can save a child’s life and it is important parents have the information to take action.’