1.

0 Wessex Patient Safety Collaborative – Sepsis Project

A network of Patient Safety Collaboratives (PSCs) was established across England in 2015 in response to the
Berwick review’s recommendations for the whole health and care system to foster a culture of continual
learning. As part of the PSC initiative, the Wessex region has focused on two key areas of concern for the
system:

• Sepsis, and
• Transfers of Care.

Four breakthrough sessions have been held over five days in 2015/16 by the Wessex Academic Health
Science Network facilitating work on quality improvement and measurement around these subjects.

NHS West Hampshire CCG Quality Team has been working within the Collaborative on the Sepsis work
stream and is the only CCG in Wessex to have participated in the PSC in its entirety.

The PSC work on sepsis links with the 2015/16 national CQUIN on sepsis recognition in secondary care and
continuing work with providers around the implementation of SEPSIS 6. Within this predominantly
secondary care focused framework, WHCCG has used the PSC to focus on engaging with Primary and
Community Care around screening and recognition of sepsis and establishing standardised pathways for
referring and transferring patients who need urgent acute care assessment or treatment.

2.0 What Is Sepsis?

Sepsis is a time-critical medical
emergency, which can occur as
part of the body’s response to
infection. Unless treated
quickly, sepsis can progress to
severe sepsis, multi-organ
failure, septic shock and
ultimately death. Sepsis affects
all age groups but has a higher
incidence in the elderly (95
patients per 100,000 population
<65 years versus 1,220 per 100,000 >65years).1 Over 70% of cases arise in the community2 so general
practice and community providers have an important role to play in diagnosis and rapid referral.

Sepsis affects 200-337 people per 100,000 population. For WHCCG that equals 1,092-1,840 people at a cost of
£19,656,000-£33,120,000 per year. This is equivalent (or greater) to cases of Myocardial Infarction or Stroke.
Improving the management of sepsis across the heath economy could save lives, reduce hospital length of stay
by 3.4 days per case and save WHCCG £3,146,400 per year.

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2.1 Key Principles of Managing Sepsis
• Prompt recognition before infection becomes sepsis or progresses to severe sepsis and organ
failure
• Early antimicrobial therapy (plus fluid management as appropriate)
• Severe Sepsis
• Rapid referral and transfer to secondary care
• Intravenous antimicrobials
• Lactate measurement
• Fluid bolus
• Oxygen
• Urine output monitoring
• Blood cultures

3.0 The Sepsis Project

The WHCCG Sepsis Project focused on the potential weaknesses or variability in the current system around
the recognition and management of sepsis and identified the following as key areas of focus:

• Standardised tools to assist diagnosis

• Establishing a common language across healthcare providers
• Standardising pathways for sepsis patients to ensure timely treatment.

Patients/Public Diagnosis Treatment

Communication Pathways
Low awareness of HP awareness & ED pressure
sepsis workload Common language Incorrect pathway
Lack of warning
Delayed Non-specific Safety-netting Delays
presentation presentations Time critical
Misinterpretation SCAS priorities
treatment
Incorrect place of Non-standardised between providers Patient transport
presentation assessment

The anticipated impact of the project is to:

• Reduce variation in the assessment of patients with potential sepsis

• Improve timely diagnosis of patients with sepsis to ensure early intervention with the aim of
avoiding hospital admissions (where appropriate) or reducing hospital length of stay, duration
of intensive care admission and improving mortality and morbidity outcomes.

A significant proportion of the initial Sepsis Project is as an enabler, setting up the systems and
processes to identify and manage sepsis and the deteriorating patient.

The current system of red and yellow flag sepsis (UK Sepsis Trust) is poorly integrated into Primary and
Community Care and the Systemic Inflammatory Response Syndrome (SIRS) criteria has recently been
shown to miss 15% of patients with SIRS negative sepsis and is inaccessible as a tool within Primary Care
as it requires White Cell Count measurement.

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The Sepsis Project, therefore, examined if the National Early Warning Score was suitable for use within
the Primary and Community Care setting and whether this could be used as a standardised and
validated assessment aid and a common language across providers which triggers a common set of
responses.

The National Early Warning Score is a validated acute care tool comprising of six biological
measurements which are accessible to community practitioners:

• Respiration Rate
• Oxygen Saturations
• Temperature
• Systolic BP
• Heart Rate
• Level of Consciousness (defined on the AVPU system)

When combined using a graded scoring system (0-20), these parameters shown to accurately predict
acute illness and the risk of death.

NEWS Score Mortality

0 0.5%
<5 5.5%
≥5 22%
≥7 27%
≥9 38%

All practices in the WHCCG boundaries were contacted via Business Week and asked if they would
be willing to assist with the Sepsis project. One practice responded and this has become the
pilot/resource practice for the CCG.

3.1 Sepsis Project Primary Care

Within the Primary Care element of the project, the CCG has collaborated with a local GP Practice
with an interest in Sepsis to conduct a retrospective audit into the potential use of the National Early
Warning Score (reported in Part 2 CGC Papers).

The purpose of the audit was to evaluate the feasibility and accuracy of the National Early Warning
Score in Primary Care.

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To do this, the audit retrospectively examined GP case notes of patients registered with the Practice
admitted to acute care with a diagnosis of sepsis to evaluate:

1). How many of the National Early Warning Score parameters were taken/recorded for these
patients

2). Whether the National Early Warning Score would have flagged these patients as requiring
admission

3). The anticipated workload for GP’s if the National Early Warning Score is implemented

4). The entry point for starting to record the National Early Warning Score

5). The pathway of admission for these patients.

This piece of work was completed following Information Governance approval over a period of
several GP sessions.

The audit demonstrated that:

• Many of the National Early Warning Score parameters are already being measured within
Primary Care for patients when there is a concern about potential infection or sepsis
• However, the parameters are often inconsistently documented and are being interpreted
using clinical judgement alone without the use of a quantitative tool
• Implementing the National Early Warning Score for this specific group of patients is unlikely
to significantly increase GP workload and can assist clinical judgement / reduce risk
• The audit showed that the National Early Warning Score does appear to correctly reflect
clinician diagnosis and level of concern but further work is required to validate this
• It was not possible to accurately determine an entry point for starting the National Early
Warning Score within Primary Care and a further prospective audit may be helpful.

Future Project Plans:

• Negotiate a prospective audit of the use of the National Early Warning Score in a triage
setting to determine the entry point of use of the tool
• Finalise the arrangements for embedding the National Early Warning Score on EMIS Web to
launch during relevant consultations
• Disseminate the learning from the audit across the CCG.

3.2 Sepsis Project Community Care

Many cases of sepsis arise within the Community Care (nursing and residential care homes) setting
due to the number of vulnerable residents with indwelling devices, wounds or multiple co-
morbidities. Recognising the deteriorating resident within Community Care can be problematic and
the Sepsis Project has been working with local homes and GP practices to:

• Define the ‘soft signs’ of sepsis or deterioration for non-registered healthcare workers

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 • Facilitate the use of the National Early Warning Score to establish quantifiable assessment of
potentially deteriorating patients
• Define a whole system escalation strategy/pathway based on the National Early Warning
Score with key stakeholders (GP’s, Out of Hours, South Central Ambulance Service
(facilitated through the Wessex Academic Health Science Network))
• Improve the quality of communication of concerns between healthcare providers and
establish a common language across healthcare
• Design and trial a tool to identify the deteriorating resident that is accessible to registered
and non-registered healthcare workers in community care and proportionate to the
community care setting.

Defining the ‘Soft Signs’ of sepsis or deterioration: The project has worked with a number of
nursing and care homes through training, focus groups and feedback to define suitable soft signs or
triggers which increase the index of suspicion of potential deterioration. Most importantly, these
triggers have been identified by non-registered carers who provide the majority of day-to-day care
for residents which is critical in order to achieve timely recognition and escalation of possible
deterioration.

Defining a whole system escalation strategy/pathway: The project has engaged with GP’s,
secondary care clinicians, the South Central Ambulance Service and academics who worked on the
original acute version of the National Early Warning Score to agree a standardised pathway in
response to specific scores. This differs from the acute version due to the level of support and
invasive monitoring available in the community and needs to be carefully calibrated to avoid the
unnecessary over-escalation of moderately unwell residents (e.g. hospital admissions) whilst
ensuring the tool adequately recognises and supports the deteriorating person. It is anticipated that
by using a quantitative National Early Warning Score, in addition to the normal narrative around

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clinical concern that a common language, recognised by all clinicians and workers can be established
across the healthcare system.

Improving the quality of communication of concerns between healthcare providers: The project
recognises that identifying the deteriorating resident is only one aspect of preventing and managing
sepsis. In order to improve outcomes, concerns need to be escalated in a timely, concise and
effective manner in order to gain the right intervention and the right time. As part of the Sepsis
Project, the SBAR (Situation, Background, Assessment, Recommendation) communication tool has
been incorporated into the National Early Warning Score tool to help registered and non-registered
staff effectively communicate their concerns and expectations to other healthcare professionals.

The Sepsis Project has designed a National Early Warning Score Observation and Escalation Tool
which is currently being sequentially piloted in four nursing homes (>150 beds), which includes
residents with dementia, long-term care needs and discharge-to-assess beds. The nursing homes are
supported by specific GP practices which the CCG are working with to obtain feedback on the
efficacy of the tool.

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 By staging the pilot sequentially, it is anticipated that feedback from one nursing home and GP can
be incorporated into the tool and quickly trialled in the next home in order to thoroughly evaluate
use and outcome.

The outcome measures for the National Early Warning Score Observation and Escalation Tool are:

Qualitative:

• Staff feedback via evaluation and focus groups on accessibility and use of the tool
• Case studies on use of the tool
• Feedback on system-wide escalation (efficacy and timeliness)
• Calibration of the tools (suggested actions versus actual action).

Quantitative:

• Baseline score for residents (stratified according to condition and type of bed)
• Number of potentially avoided admissions due to sepsis to Secondary Care over the pilot
period

It is anticipated that the pilots and evaluation will be concluded by June 2016 and that (if
appropriate) a wider system roll-out can be commenced after this time.

3.3 Future Activity

• A bid has been submitted to the Wessex Academic Health Science Network for funding to
support the trial of the National Early Warning Score in Community Care
• The Wessex Academic Health Science Network have expressed an interest in the CCG
contributing work from the sepsis project into the 2016/17 PSC work stream focused on the
deteriorating patient
• Provision of education and training on sepsis and the deteriorating patient to care/nursing
homes and GP’s through TARGET

4.0 Conclusion
The Sepsis Project and National Early Warning Score Observation and Escalation Tool is an enabler to
raise awareness on sepsis and the deteriorating patient/resident with the goal of improving
diagnosis and treatment and, therefore, outcomes for the population. The Sepsis Project has
completed a significant amount of the groundwork needed to establish the National Early Warning
Score in routine Primary and Community Care practice and the next phase of the project will be
around evaluation and spread.
1. Hall MJ, Williams SN, DeFrances CJ, Golosinskiy A. Inpatient care for septicemia or sepsis: A challenge for patients and hospitals.National Center for Health Statistics. 2011
2. Esteban A, Frutos-Vivar F, Ferguson N, et all. Sepsis incidence and outcome: Contrasting the intensive care unit with the hospital ward. Crit Care Med. 2007; 35(5):1284-1289

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