Don't overlook sepsis, a bigger killer than cancer

Sepsis has garnered a lot of attention in the last year, but not nearly enough. The public is unlikely to know what sepsis is and what symptoms should cause concern. This would be understandable if sepsis was rare, but it isn’t.

The condition is indiscriminate and affects 100,000 patients in the UK every year, killing about 37,000. These figures are staggering. To put them into perspective, sepsis kills more patients each year than bowel, prostate and breast cancer combined.

It is no secret that sepsis is losing out to other conditions in the popularity poll. Despite causing about 25 million fatalities globally each year, clinicians are more aware of, and alert to, other conditions such as cancer or stroke.

‘The lack of awareness causes sepsis to often be missed and untreated’

This situation may be because of its vague symptoms, which often mimic other illnesses. Or it might be because, until recently, there was no single royal college to champion it. Whatever the case, the lack of awareness causes sepsis to often be missed and untreated.

Tools to treat

The UK Sepsis Trust seeks to support those affected, raise awareness and improve standards of care by pushing for political and healthcare changes.

Recognising the need for clear guidelines on this dangerous but often forgotten condition, the organisation has a produced toolkit for clinicians that seeks to assist different healthcare professionals with steps they should take for proper investigation and diagnosis.

‘Negligence most commonly occurs when sepsis is overlooked and mistaken for something else’

In September, the trust launched the Clinical Toolkit 6: Emergency Department Management of Paediatric Sepsis. This aims to help clinicians identify and manage sepsis in children who attend non-specialist emergency departments, as this will usually be their first port of call. The overall objective is to reduce preventable deaths and, in turn, avoid negligence.

The toolkit hopes to ensure that “all healthcare professionals, after appropriate training, are capable of recognising sepsis early and institute basic treatment in whatever setting the patient is initially seen”.

What to look for

So how does the toolkit change the expectations on healthcare professionals? When faced with a medical emergency, how do you find your way amid the noise?

The toolkit provides step by step advice on what to look for and what to do.

In using the toolkit, clinicians must be aware of the following:

• Early recognition: it is believed that this alone could reduce 1,000 paediatric deaths a year. It’s simply not good enough to wait until the child is ill; any suspicion of an infective cause should prompt screening and assessment for sepsis. Screening should be a two part process: for systemic inflammatory response syndrome (SIRS), which is prompted by physiological abnormality or suspicion of infection, and for red flag sepsis (RFS), which should be undertaken once sepsis is suspected. Sepsis should be assumed in any child with a confirmed or suspected infection and who meets two or more of the SIRS screening criteria. At this stage, red flag sepsis screening should be commenced. If RFS is identified, immediate treatment must be given under the Paediatric Sepsis 6 guidelines.
• Accurate diagnosis: it’s insufficient to limit a diagnosis to “sepsis”. Healthcare professionals must confirm and record the exact type, only using the terms “septic shock”, “severe sepsis”, “red flag sepsis”, “uncomplicated sepsis” or “no current evidence of sepsis”. Their definitions are listed in the toolkit.
• Treatment within 60 minutes: any diagnosis or suspicion of RFS, severe sepsis or septic shock requires treatment, as per the Paediatric Sepsis 6, within an hour. If in doubt, a clinician experienced in paediatric sepsis must be consulted.
• Clinical judgement: initial symptoms can be vague and not all children with an infection will have sepsis. The toolkit suggests review by a senior doctor (ST4 or above) for children with sepsis (within 60 minutes of diagnosis), severe or RFS (within 30 minutes of arrival) or septic shock (as soon as possible but within 30 minutes of arrival). Any deviation from the Paediatric Sepsis toolkit must be documented, to ensure that due diligence has been taken and risks excluded.
• Communication: while some organisations believe that standardised treatment should be provided to patients once severe sepsis (including septic shock) has developed, others believe that treatment should commence in all septic patients who are still high risk (very young children, those with chronic conditions, those where no fever focus can be found). Whatever procedures are adopted, these should be uniform, clear and communicated to all staff.

The consequences of inappropriate treatment are significant: the condition is life threatening and substandard care can result in death. Any worse outcome may also lead to a claim for medical negligence. Medical negligence occurs when a patient receives:

• unacceptable medical care, which no other responsible body of medical professionals would have provided; and
• care that causes the patient an injury they would not have otherwise suffered, ie, led to their condition becoming worse.

As the symptoms of sepsis are sometimes vague, negligence most commonly occurs when sepsis is overlooked and mistaken for something else. Crucial time is lost, which can lead to devastating injuries that could have been avoided. It can also occur when sepsis is identified, but the appropriate treatment is not provided.

The majority of cases of paediatric sepsis will start in the emergency department, where clinicians wouldn’t usually have specialist sepsis training. Until now, clinicians did not have definitive guidance on the condition.

The toolkit provides a comprehensive guide on what to look for and how to treat suspected sepsis in children. It provides straightforward guidance on a complex condition, from the screening process to diagnosis, through to treatment.

I anticipate it will be of real help to clinicians, and will ultimately improve the care that is provided.

Ipek Tugcu is a senior solicitor specialising in clinical negligence at Bolt Burdon Kemp