Comment: Sepsis - barriers to treatment and solutions to overcome them

Sepsis is defined as the body’s response to an infection, which, if not treated promptly causes multi-organ failure and death in over one-third of sufferers. Infections causing sepsis are typically community-acquired conditions, such as pneumonia, with healthcare-associated infections making up a minority.

RON DANIELS

Almost unknown by the public, this killer condition accounts for 37,000 lives lost annually in the UK – more than breast cancer, bowel cancer and prostate cancer combined. Sepsis consumes an estimated £2.5 billion of our NHS expenditure each year.

We might expect, therefore, that sepsis would be a high priority and on the radar of health professionals and commissioners, and that robust system-wide protocols and solutions should exist; in reality, this is not the case. International guidelines govern recommendations for basic care, such as the administration of the right intravenous antibiotic within the first hour after taking samples to identify the infecting organism. In those hospitals prioritising urgent sepsis care in the UK, a simple care bundle known as the Sepsis 6 is used to ensure that all urgent interventions are delivered rapidly. This treatment is associated with a more than 50% reduction in death rate, yet in the UK we currently achieve care to these standards for only 1 in 7 patients with sepsis. If we can transform our system to care appropriately for patients with sepsis, cost savings to the NHS of over £170 million per annum are achievable.

Barriers

To better treat sepsis demands more timely identification and a coordinated response. This is hampered by its often subtle onset and an overwhelming lack of awareness among healthcare professionals (sepsis is not a formal component of most undergraduate or postgraduate curricula) and members of the public. The result is that patients present to healthcare late, early symptoms are frequently missed by GPs and other community-based staff, and hospitals respond unreliably. There is also a need for improved coding; sepsis is currently under-recognised and under-reported.

The Department of Health has responded robustly to issues of avoidable harm through the National Outcomes Framework but has focused primarily on harm due to commission – actions by healthcare staff or organisations that have brought about adverse consequence. Harm from omission, conversely, describes episodes where patients are failed through a lack of adequate response or a failure to recognise deterioration. Public sympathy lies with both scenarios, since both cause avoidable harm, and it is about time our attention was also given to both.

A third issue has been the interpretation of the Department of Health’s document Start smart – then focus. Addressing the very real problem of antimicrobial stewardship, this document has been misinterpreted as demanding a reduction in the use of antibiotics at all costs. Ministers have been under the impression that this document has resolved the issue of antibiotic management – it has not.

Solutions

Awareness must improve

Earl Howe has recently asked the Academy of Medical Royal Colleges to examine their training provision on sepsis. We need to ensure that this happens and that it is followed through.

Junior doctors, who are the eyes and ears of the medical profession, are exposed to college curricula only after 2–4 years of practise. Their training needs can be met through the national education programme Survive Sepsis but at present, undergraduate and early postgraduate training in sepsis is voluntary and unregulated. It is of equal importance that we address the training needs of nurses, paramedics and other healthcare professionals if we are to deliver transformational change together with heightened public awareness of the early signs of sepsis. Coding of sepsis can be improved upon. The recent development of the role of Medical Examiner and of the Professional Association of Clinical Coders allows opportunities to develop standard instruction sets in the coding of patients with infective illness, which should be explored.

Systems must change

Domain 5 of the National Outcomes Framework aims to improve safety. It is time that this is modernised to encompass avoidable harm arising from inaction. Sepsis is the ideal inclusion to initiate this high profile change, as it is of major impact in health and economic terms, cost-effective therapies significantly improve outcomes and it is measurable.

The UK Sepsis Trust has formed a coalition of professional and patient bodies to help drive change, including the Royal Colleges of Physicians, Surgeons and Nursing, the Intensive Care Society, the College of Paramedics and the Patients’ Association. This coalition is ideally placed to work with the NHS Commissioning Board to ensure that a system-wide change is implemented and embedded.

The public message around antibiotics must change

The current interpretation of Start smart – then focus is that healthcare-associated infections should be prevented and that people should avoid troubling healthcare services with symptoms of viral infection. While laudable, this is not the only message of the document.

Professional bodies, including the UK Sepsis Trust, the Infection Prevention Society, the British Society for Antimicrobial Chemotherapy and the Intensive Care Society, are now uniting to ensure a common, sustained message is delivered. We need to work with public bodies to ensure that the real messages of antimicrobial stewardship gets across: (1) no patient should suffer harm due to a preventable infection; (2) the preservation of effective antibiotics to treat patients with known or suspected bacterial infection is of the utmost importance; and (3) identifying and responding rapidly in cases of severe infection is of equal importance to reducing healthcare-associated infection rates.

If you would like to know more about the content of this article, or would like to help the UK Sepsis Trust with parliamentary or Ministerial questions or in a future All Party Parliamentary Group on sepsis, please contact DR RON DANIELS, Chief Executive, UK Sepsis Trust at [email protected]