Responding Quickly and Effectively to the Deterioration of Sepsis Patients

Conservative estimates suggest there are at least 200,000 cases of Sepsis in the UK each year, with over 50,000 lives lost annually.[1]

The cost of sepsis to the NHS is roughly £1.5 billion per year. Part of the reason for this is that it is hard to detect and monitor the deterioration of sepsis patients.

Siân Annakin, Trust Sepsis Nurse Practitioner & Resuscitation Officer at Dudley Group NHS Foundation Trust, is educating trusts on how to spot the soft signs and triggers, and how best to escalate a patient’s treatment.

This case study explores Siân’s work on patient monitoring, trusting instincts, and knowing when and how to treat a patient.

NEWS2

The National Institute for Health and Care Excellence lists the symptoms of Sepsis as including but not limited to:

A patient experiencing these symptoms will be monitored once admitted to hospital.

The frequency a medical professional takes their vital signs should be individualised according to the patient’s National Early Warning Score (NEWS2).

The NEWS2 consists of six simple parameters:

These then inform the score, which is used to inform the level of response required.

If the score is 3 in any single parameter, then vital signs should be checked hourly. Alongside this, a registered nurse should inform the medical team of the score of the patient.

The medical team will then review and decide whether to escalate the level of care.

If the score has a total of 5, hourly checks on vital signs are carried out, however there are more precautionary steps taken.

There will be an urgent assessment by a clinical or team with core competencies in the care of acutely ill patients as to whether the patient needs a higher level of care.

At this stage, clinical care will be given in an environment with monitoring facilities.

If the NEWS2 score is a total of 7 or more, this places the patient in the emergency response threshold. This dictates continuous monitoring of vital signs.

The registered nurse will immediately inform the medical team, and this should take place at the specialist registrar level.

The next step is to complete an emergency assessment by a team that includes practitioners with advanced airway management skills.

Care may need to be transferred to a level 2 or 3 facility at this stage. Throughout this process, the time that a patient should be screened for Sepsis is when the NEWS2 score is at level 5 or above and there is a suspected infection.[4]

Spotting Deterioration

The structured approach for assessing a deteriorating patient is the ABCDE process.

Airways

The purpose of checking the airway is to establish the airway patency, assess the patient’s ability to protect their own airway.

Once the above has been established, it’s important to immobilise the spine using a backboard and rigid cervical collar.

Some causes of airway comprise include:

• Traumatic injury
• Patient’s tongue
• Foreign body
• Vomit, blood, other secretions
• Swelling due to infection or anaphylaxis[5]

If the airway is compromised, special manoeuvres are required. This could be a chin lift and jaw thrust, an oral or nasal tube insertion, and if those fail then a definitive airway has to be established in a more direct manner.

An endotracheal intubation, cricothyrotomy, or tracheostomy will be carried out if the airway continues to be blocked.

Breathing

Checking the patient’s breathing helps to determine whether there are signs of any respiratory diseases.

To assess breathing, a medical professional will count the respiratory rate. Between 12-20 per minute is considered a normal breathing rate.

Ways of managing breathing can vary from calming a patient down, to carrying out the manoeuvres outlined the in ‘airways’ section.

Circulation

Checking circulation is carried out to determine the effectiveness of the cardiac output, secure adequate tissue perfusion, and begin to treat external bleeding.

Causes of poor circulation include shock, traumatic injuries to arteries, and heart failure.

Circulation management includes:

• Placing direct pressure to control external hemorrhages
• Embedding two large-bore IV lines
• If situation is critical, a mass transfusion protocol will be implemented

Disability and Exposure

The goal of disability assessments is to determine and manage the presence of neurological injury.[5]

This entails examining the pupils, a motor and sensory examination, and an assessment of consciousness level through the Glasgow Coma Scale (GCS).

Exposure refers to managing potentially negative environmental effects, such as keeping the patient warm while undressing them to carry out the full physical examination.

Better Deterioration Detection

Siân explained that the ABCDE assessment can often be carried out incorrectly, leading to incorrect levels of treatment being given, resulting in deterioration going unmonitored.

To better detect and monitor the state of a patient, Siân advised the Stop and Watch method, which focuses more on soft signs.

Soft signs are appetite and mobility, skin colour, and the AVCPU scale. This stands for alert, confusion, voice, pain, unresponsive.

The Stop and Watch process is as follows:

This is a more comprehensive way of monitoring a patient’s progress.

Another point Siân stressed is that even if a patient’s NEWS2 is below 4, it is important to take a broader view and trust your instinct.

If concerned about a patient with a score of lower than 4, repeat the vital signs, express concern as a patient’s advocate, and inform the nurse in charge.

[1]CPPE.ac.uk. 2021. Fact Sheet: Sepsis.

[2]nice.org.uk. 2017. Guidance: Sepsis.

[3]firstresponse.org.uk. 2021. NEWS2: The National Early Warning Score.

[4]Annakin, Siân. 2021. Trust Sepsis Nurse Practitioner. Responding quickly and effectively to the deterioration of Sepsis patients.

[5]Lecturio.com. 2021. Concepts: ABCDE assessment.