Sepsis remains a significant cause of morbidity and mortality across all high-, middle- and low-income countries despite increasing education for healthcare professionals and growing awareness from the public (Hantrakun et al, 2018; Jabaley et al, 2018; Dondorp et al, 2019; Rudd et al, 2020). Sepsis is defined as a dysregulated host response to an infection, which is mediated by the immune system, causing a physiological cascade that results in organ dysfunction, multi-organ failure and potential death (Singer et al, 2016; Feist, 2019; Kim and Park, 2019). Septic shock is a term that describes a later stage in this physiological cascade, whereby there is profound circulatory, cellular and metabolic abnormality, which is associated with increased subsequent mortality rates. Patients with sepsis often have acute and critical care needs and, therefore, require definite treatment and monitoring within the acute secondary care setting (Singer et al, 2016; Hunt, 2019; Lin, 2021).
In the UK, approximately 250 000 people are diagnosed with sepsis each year, resulting in around 52 000 deaths directly attributed to sepsis (Rudd et al, 2020). Of those who survive, it is estimated that approximately 60 000 people have residual and often permanent sequela after discharge from acute care (Iwashyna et al, 2010; 2012). It is estimated that around £15.6 billion is spent on the diagnosis and treatment of this illness (Prescott and Angus, 2018).
In 2015, the National Confidential Enquiry into Patient Outcome and Deaths (NCEPOD) highlighted the need for earlier detection of signs of sepsis across the healthcare system as the single most effective way of improving patient outcomes and avoiding sepsis-related deaths in the UK (NCEPOD, 2015). Furthermore, there is a growing body of evidence emphasising the association between early identification of sepsis in patients with an infective source in the acute setting and improvements in outcomes, including mortality, intensive care requirement and length of stay in hospital (Torsvik et al, 2016; Kim and Park, 2019; Burdick et al, 2020; Husabø et al, 2021). The NCEPOD report also identified that around 70% of sepsis cases originated in the community setting. In a healthcare model where increasing numbers of acutely unwell patients are managed in the community setting, there is a need for specific early detection skills among healthcare professionals (NCEPOD, 2015).
Despite this, there is a paucity of evidence surrounding current community nursing practices relating to the identification of sepsis. The Sepsis Trust's community nursing sepsis screening tool provides one method of identifying patients at risk of developing sepsis (Nutbeam and Daniels, 2020). This article aims to demonstrate how the community nursing sepsis screening tool can be used by healthcare professionals to improve identification of signs and symptoms of sepsis and facilitate consistent decision-making processes around escalation of care needs.
The Sepsis Trust
The Sepsis Trust is a UK-based charity, created in 2012 in an effort to raise awareness of sepsis and the high levels of mortality associated with sepsis. The charity has an overriding long-term aim of stopping preventable deaths from sepsis and providing support to all affected by this condition. The organisation works to raise awareness of sepsis among members of the public and healthcare professionals by providing education, research, and support to increase the chance of early diagnosis. The Trust also lobbies politicians to raise awareness and improve standards of care, while providing greater support for sepsis survivors. Since the Sepsis Trust's inception, there has been a steady increase in sepsis awareness at both national and international levels, highlighting the substantial work that needs to be done to improve the immediate survival and long-term outcomes of patients with sepsis. The Sepsis Trust plays an important role in sepsis education for both patients and clinicians alike, and has a wide range of useful resources for both patients and healthcare professionals. The charity's website can be accessed at: https://sepsistrust.org/.
Recognising sepsis in the community setting
It is essential for all healthcare professionals to have an underpinning baseline knowledge of sepsis, as this equips a clinician with the tools to recognise the signs of sepsis, which can occasionally be vague and non-specific. Unrecognised sepsis in the community is associated with high levels of mortality and morbidity, and delayed identification of sepsis has been demonstrated to increase the acute and critical care needs of patients (Scott et al, 2018). The Sepsis Trust has published a community nursing sepsis recognition tool to aid healthcare professionals in the community in identifying potential sepsis and providing a pathway to escalating increasing care needs to ensure timely transfer of patients to hospital. Figure 1 presents the Sepsis Trust Community nursing sepsis screening tool, which can be applied to any patient over 12 years of age.
To effectively identify sepsis, healthcare professionals should possess assessment skills, which enable them to take an accurate and focused patient history and physical assessment. Community clinicians are unable to easily access investigations and, therefore, need to rely on judgement to detect clinical signs that may help in the identification of the symptoms of sepsis (Olander et al, 2021). All patients should have a full set of vital signs completed and documented as part of the assessment process, and a NEWS2 score should be calculated and documented for all vital signs recorded (Inada-Kim et al, 2020; Baker et al, 2021). The NEWS2 score is a simple risk stratification score that measures the potential for deterioration and critical illness, calculated from the culmination of scores associated with each vital sign (respiratory rate, oxygen saturations, pulse, blood pressure, temperature and level of consciousness). The NEWS2 score itself is strongly associated with in-hospital mortality, and there is growing evidence to support the use of NEWS2 in the community setting (Brangan et al, 2018; Pullyblank et al, 2020). However, it is important for clinicians to recognise that the use of NEWS2 in isolation is not sufficient for the identification of patients with sepsis; where possible, this risk stratification score should be used alongside a sepsis screening tool in the clinical setting.
It is recommended that all clinical areas employ a sepsis screening tool to facilitate earlier identification of sepsis risk (Mulders et al, 2021). The tool is simple to follow and encourages the clinician to ask four questions to help elicit pertinent information from patient history and physical assessment. The specific questions are as follows:
- Does the patient look unwell, or do they have abnormal physiological signs?
- Could this be due to an infection?
- Are any Sepsis Red Flags present in this patient?
- Are any Sepsis Amber Flags present in this patient? (Nutbeam and Daniels, 2020).
For patients who appear to be unwell or have abnormal physiological signs on examination, it is vital that clinicians are aware of certain factors that are recognised to increase the patient's risk of developing sepsis in the presence of an underlying infection. The patients at greatest risk of developing sepsis are as follows (Hunt, 2019):
- Older adults aged over 75 years
- Infants and young children
- People with learning disabilities
- Recent trauma, surgery, pregnancy, childbirth, or miscarriage
- Patients with an acute or chronic wound or skin breach
- Patients with an indwelling line or catheter
- Illicit intravenous drug use
- Patients with compromised immunity (post splenectomy, diabetes, long-ter m steroid or immunotherapy medications, or cancer and cancer treatment).
What does sepsis look like?
Sepsis can present in many different ways, and presentation depends on specific characteristics of the patient, including their comorbidities and effects of any medications they are taking (Vincent, 2016). Patients who present with sepsis may have one or more of the following clinical signs or symptoms (Hunt, 2019):
- Pyrexia
- Rigors
- Hypothermia
- Decreased urine outcome
- Sustained tachycardia (heart rate >90 per minute)
- Nausea and/or vomiting
- Diarrhoea
- Fatigue/lethargy/weakness
- Abnormal skin discolouration
- Sweating and/or feeling clammy
- Severe pain.
Clinicians should be aware that some indicators of infection, like the presence of a pyrexia, are not a good indicator of infection or sepsis in isolation, particularly in patients who are immunocompromised (Hunt, 2019). A proportion of patients with sepsis will present with hypothermia rather than a pyrexia, and there is evidence to show that outcomes for patient with sepsis presenting with a low temperature have worse outcomes, particularly in relation to mortality (Wiewel et al, 2016; Rumbus et al, 2017). For this reason, any patient who is presenting with a new-onset undifferentiated illness, or who has vital signs that are abnormally deviated from baseline, should trigger an assessment for sepsis. It is also important for any healthcare professional to carefully consider whether the patient meets one of the high-risk criteria and ask themselves whether there is a potential source of infection, which remains a crucial step in the recognition process for sepsis (Kabi et al, 2020).
If, after taking a comprehensive history and completing a full physical examination of the patient, sepsis is unlikely, and a source for infection is not identified, it is essential for the clinician to consider an alternative diagnosis. This is likely to involve further examination and history-taking; if a cause is not identified, this should be escalated to a decision-making clinician, which might be a GP, advanced clinical practitioner or team leader. Where an infective source is likely, the next stage of the sepsis assessment is to consider whether the patient has any red or amber Flag signs.
Management of a ‘red flag’ sepsis
Red flags in healthcare are potentially alarming warning symptoms, signs and patient diagnostic tests that highlight possibly serious underlying disease processes to healthcare professionals (Schroeder et al, 2011). Table 1 presents key ‘red flags’ for sepsis in adults. To assess for the presence of red flags, a face-to-face physical assessment is required, including a full set of patient vital signs. The presence of one or more sepsis red flags indicates a time-critical medical emergency, and healthcare professionals in the community setting should implement the community nursing red flag care bundle without delay, as the patient is likely to have sepsis or septic shock (Kopczynska et al, 2018). The primary action within this care bundle is to activate a response from the local emergency ambulance service (ie by calling 999 in the UK) (Nutbeam and Daniels, 2020). Within this process, the importance of effective communication and information transfer between healthcare professionals is key to preventing delays and enabling optimised treatment outcomes for the patient. Healthcare professionals should make sure that the correct terminology is used when communicating with both control-room call handers and clinicians from the emergency services. It is important that community nurses state, where appropriate, that it is a red-flag sepsis to ensure that the emergency call is categorised correctly to get the most appropriate response time (Floer et al, 2021).
Table 1. Red and amber flags for sepsis
| Red flags for sepsis | Amber flags for sepsis |
|---|---|
| New confusion/altered mental state | Relatives are concerned about a change in mental status |
| Systolic blood pressure ≤90mmHg (or a drop of >40 mmHg from baseline blood pressure) | Systolic blood pressure of 91–100 mmHg |
| Heart rate of ≥130 per minute | Heart rate of 91–130 or new dysrhythmia |
| Respiratory rate of ≥ 25 per minute | Respiratory rate of 21–24 per minute |
| Not passed urine in 18 hours (if catheterised <0.5ml/kg/hr) | Acute deterioration of functional ability |
| New oxygen demand (needs supplemental oxygen to keep SpO2 ≥92%—or 88% in chronic obstructive pulmonary disease) | Immunosuppressed |
| Non-blanching rash/skin mottling/ashen skin tone/or cyanosis | Trauma/surgery/interventional procedure in the last 8 weeks |
| Recent chemotherapy | Temperature of <36.0°C |
| Clinical signs of an infected wound |
The overall aim of the community nursing red flag care bundle is to enable a rapid patient transfer to the acute secondary care setting. Management of sepsis in the acute secondary care setting follows an evidence-based approach, using the ‘Sepsis Six’ care bundle approach to patient management (Lin, 2021). Table 2 presents any overview of the Sepsis Six components. Early treatment following this protocol has been shown to reduce levels of mortality, critical care requirement and length of hospital stay, alongside improving long-term determinants of health-related quality of life (Nutbeam and Daniels, 2020).
Table 2. An overview of the Sepsis Six care bundle
| Sepsis Six care bundle | Clinical reasoning | Why this is important |
|---|---|---|
| Commence oxygen therapy (high-flow oxygen using a non-rebreathe mask) | Aim to keep saturations >94%If chronic obstructive pulmonary disease (COPD) and at risk of CO2 retention, aim for oxygen saturations of 88–92%) | In sepsis, oxygen supply and demand is not matched, causing a critical imbalance. Correcting low oxygen saturations can help to reduce tissue hypoxia |
| Take and send blood cultures | Think about potential source of the underlying infection–consider sending urine/sputum/wound samples for microscopy, culture, and sensitivity (MC&S)The patient should have a minimum septic screen, including peripheral blood cultures, urine and a chest X-ray | Tests help clinicians to understand the severity of the problem and stratify risk. This involves identifying the causative pathogen to enable effective treatments to be commenced |
| Initiate intravenous antibiotics | Follow local anti-microbial guidelinesConsider allergies prior to administration | Giving antibiotics helps to control the source of the infection, which reduces the stimulus to the immune system |
| Initiate intravenous fluids | If hypotensive/lactate >2 mmol/l or acute kidney injury (AKI), commence fluids up to 30 ml/kg in 10 ml/kg aliquotsGive 500 mls stat if no AKI, the patient is not hypotensive and lactate is normal | Hypovolaemia contributes to shock in sepsis. Temporarily restoring fluid volumes can help correct until additional treatments can be established |
| Measurement of lactate | If lactate is >4 mmol/l, monitor after administration of each 10 ml/kg fluid challengeLactate of >4mmol/l is indicative of early admission to intensive care. Re-measure any lactate in the presence of any sign of deterioration | Lactate is a product of anaerobic metabolism and, therefore, represents the extent of poor oxygen delivery to the cells in the patient |
| Measurement of urine output | Hourly urine measurement is required, and catheterisation is requiredEnsure that fluid balance chart is commenced and completed hourly | Urine output provides an important measure of physiological status and often is an early indicator of deterioration. Aim for a urine output of 0.573 ml/kg/hour |
It is commonly acknowledged that healthcare professionals in the community are unlikely to be able to complete all (or sometimes any) of the Sepsis Six care bundle, which is why the priority in the community is to call for emergency help to facilitate treatment and transfer to secondary care (Lin, 2021). Despite this, it is recognised that, in many areas of the UK, where the emergency ambulance trusts are under increasing pressure, there are delays in response times. In this situation, after the emergency call has been made, there may be opportunities for practitioners with extended skills and scope of practice, carrying appropriate equipment, to commence treatment (Raleigh and Allan, 2017; Bain and Moggach, 2019). This is likely to be limited to oxygen therapy, intravenous fluid therapy and intravenous antibiotic therapies, but it is important to recognise that the commencement of any treatment is secondary to calling for support from the emergency services.
Assessing for amber flags for sepsis
Where a patient has a clear infective source, but does not have any sepsis red flags, the clinician is required to move onto stage 4 of the community nursing sepsis screening tool, which focuses on the identification of the amber flags for sepsis (Nutbeam and Daniels, 2020). Amber flags in sepsis are less specific and indicate potentially sub-acute symptoms, as opposed to the red flag signs, but highlight that a patient could deteriorate and develop red flag signs if urgent care and treatment are not provided (Allen, 2018). If a clinician is assessing for amber flags in a patient between 12–17 years of age and the patient is immunocompromised, they should then be treated immediately, as a red-flag sepsis and the community red-flag sepsis care bundle are designed for rapid implementation (Nutbeam and Daniels, 2020). The amber-flag signs are presented in Table 1; if one or more sign is present during assessment, a pre-defined escalation plan is then included with the community nursing sepsis screening tool. The healthcare professional must select the most appropriate escalation option based on the findings of the physical assessment process and in agreement with the patient or their primary carer. Escalation will be initiated after one of the following questions:
- Is the patient well enough to have a same-day review by a decision-making clinician (eg GP)?
- Is an urgent referral for review by the acute secondary care team required (eg transfer to the emergency department for the acute medical team to review the patient's care needs)?
- Does the patient meet the essential criteria for review by the Hospital in the Home team?
If there is any doubt as to whether the patient can wait for assessment and treatment, it is critical to call the emergency services, as they will provide a decision-making clinician who is trained to choose whether the patient requires immediate transfer to acute secondary care. Where possible, it is important to integrate the patient and/or primary carer in the process of making decisions relating to treatment, including transfer to hospital (Abrashkin et al, 2019). If a patient is refusing transfer to hospital, it is essential for the healthcare professional to make a formal assessment of mental capacity of the patient, recognising that sepsis could potentially impact a patient's capacity and ability to make decisions while potentially critically unwell (Marshall and Sprung, 2016).
Where no amber flags are identified, the assessing clinician can be confident that there are no current signs of sepsis, even when an underpinning source of infection has been identified. In this instance, it is important that the clinician can undertake further investigation through physical assessment with history-taking and potentially the use of secondary data (ie blood tests) to identify a diagnosis for the patient. In the presence of an infection, this is likely to result in commencing antibiotic treatment (if not already started). Where commencing treatment is not within the scope of practice of a community healthcare professional, timely escalation to a decision-making clinician is required.
It is important for any community healthcare professional using the sepsis screening tool to recognise that assessment for signs of sepsis needs to occur longitudinally because, although the patient may not display any red flag signs during an initial assessment, it does not mean that they will not deteriorate and develop these in the future. As there are likely to be extended periods of time when patients are not under observation for deterioration (ie inbetween visits from a healthcare professional), effective safety netting and patient education is key to protecting both patients and clinicians alike (Massey et al, 2017; Tucker and Lusher, 2018).
Safety-netting advice in those at risk of developing sepsis
The sepsis screening tool provides community healthcare professionals with a method of supporting the decision-making process to identify sepsis and those patients likely to require escalation and urgent treatment in both primary and secondary care settings (Edwards et al, 2019). For any patient who is not transferred to a definitive care setting at the time of initial screening, it is important to consider what education and support these patients require at home. At a minimum, each patient will require both written and verbal safety netting (Edwards et al, 2021). The Sepsis Trust has produced several patient resources that can be useful in ensuring patients and carers have sufficient information to identify potential signs of deterioration. These resources can be accessed at the Sepsis Trust website: https://sepsistrust.org/get-support/support/resources/.
In relation to effective case management, all safety-netting advice should be documented in the patient's case notes, alongside any treatment that has been offered or commenced at the time of assessment. It is important for patients to understand when they will next be reviewed by a healthcare professional, and community nurses must advise on how to contact the emergency service if the patient or carer is concerned about deterioration (Edwards et al, 2021).
Conclusion
As there is evidence showing that a substantial proportion of patients develop sepsis within the community setting, there is a clear need for clinicians to have support in the decision-making process around sepsis identification. There is a continuing need for more research into clinical practices in the community, to understand how the specific complexities of managing potentially acutely unwell patients within their home environment affects education and learning needs for community healthcare professionals. The Sepsis Trust's community nursing sepsis screening tool provides an evidence-informed approach to the identification and early recognition of patients with signs and symptoms of sepsis. Implementation of this screening tool is likely to improve the consistent approach to early identification of both red and amber flags in a patient with an underlying infective process. There is evidence to demonstrate the improved clinical outcomes and reduced mortality rates in patients with sepsis.
Key points
- Sepsis is associated with high levels of mortality and morbidity globally. Early recognition of sepsis is key to treatment and is associated with improved clinical outcomes
- Identification of sepsis in the community setting can be challenging due to complexities in the patient population. Healthcare professionals in the community setting need to have a foundation knowledge of the red and amber flags for sepsis to facilitate identification
- The Sepsis Trust recommends that healthcare professionals in the community setting use a sepsis screening tool to aid decision-making around sepsis identification and management.
- Embedding a sepsis screening tool into daily practice can improve the consistency in the sepsis identification process which may be associated with improved patient outcomes.
CPD reflective questions
- Initially, consider what specific learning needs you might have in relation to understanding the pathway of developing sepsis and septic shock. From your experience, what factors increase the patient's risk of developing sepsis in the community setting?
- Consider whether there are patients in your own practice who may have had sepsis. What signs and symptoms did these patients have? How would using a sepsis screening tool change the way you might manage a patient with signs and symptoms of sepsis?
- Consider the Sepsis Trust screening tool. What are some of the challenges to implementing and embedding it in your daily clinical practice?