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NHS organisations in the Thames Valley are starting to build algorithms for severe sepsis into their electronic patient record systems, helping staff to treat those at high risk quickly.
Oxford University Hospitals NHS Foundation Trust now displays a purple-highlighted “S” on screens listing patients to indicate those in danger of sepsis shock, also known as blood poisoning or septicaemia.
“Severe sepsis kills, and it can kill extremely quickly,” Clare Dollery, deputy medical director of the trust, told an event run by the Oxford Academic Health Science Network in May 2017. The network has led work to introduce standard algorithms to assess patients’ risk of developing severe sepsis across all health and care providers in Berkshire, Buckinghamshire and Oxfordshire.
Research published by the journal Critical Care Medicine in 2006, based on 2,731 cases, showed a patient’s chance of surviving severe sepsis is linked to when treatment begins.
If cumulative effective antimicrobial treatment starts within 30 minutes of the onset of hypotension (abnormally low blood pressure) triggered by sepsis, a patient’s chance of survival was 82.7%. However, this rate dropped by an average of 7.6% each hour, falling to just 42% in the sixth hour after sepsis shock.
Oxford is among the first to introduce an electronic process based on current National Institute for Health and Care Excellence (Nice) guidelines for sepsis. Dollery said one problem with carrying out swift assessments is that there are many methods for doing so: “Everyone has their favourite, and achieving consensus and getting people to give up on the one they’ve always used in their trust is a difficult task.”
Dollery said standardisation across the Thames Valley should make life easier for junior doctors and other staff who move between organisations. The network involves health and care providers including the area’s seven acute NHS trusts, the private Manor Hospital, clinical commissioning groups, community hospitals and nurses, GP out of hours services, and care homes.
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The network has taken advice from patients and families who have suffered from severe sepsis, including Geoff, who was initially sent back from hospital after staff missed his symptoms meaning that treatment only started three days after onset. At one point, medics believed he would die within an hour, but he survived and has since recovered. He and his family made a video to highlight the importance of swift diagnosis. It also involved Sue Morrish, whose son Sam died of sepsis and who now campaigns for better awareness of the condition.
Andrew Brent, Oxford University Hospitals’ sepsis clinical lead, told the event that spotting it in children is harder than for adults as many children experience sepsis-like symptoms. “Finding the patients with sepsis really is like finding that needle in a haystack,” he said. As a result, there is an alternative algorithm for children.
While other trusts across the three counties are adopting the algorithms, many continue to work out the risk scores manually. “We’re privileged here to some electronic platforms that let us move away from paper,” said Brent. “We were able to convert it into an electronic algorithm that uses data from electronic observations of the patient and the electronic patient record.”
Making the agent available to other trusts
Oxford developed its Electronic Sepsis Agent to work with the trust’s Cerner Millennium electronic patient record software. Brent said this took a “not inconsiderable amount of work”, adding that it could make the agent available to other trusts that use Cerner.
Some other trusts have developed similar bespoke systems in their own software and there are commercial equivalents. “It is important that any such tool is tailored carefully around the clinical users and integrated into the clinical workflow to maximise impact,” he said.
South Central Ambulance Service NHS Trust, which covers the Thames Valley, is also introducing sepsis algorithms into its technology. Mark Ainsworth-Smith, a consultant pre-hospital care practitioner at the trust, told the event that sepsis can be present in any of the 560,000 999 calls and 1.25 million 111 calls received by the trust each year. Just over half of 999 calls lead to the trust taking the patient to hospital, with most of the rest involving ambulance medics providing treatment on-site.
The trust has already loaded a sepsis recognition tool with versions for adults and children onto the tablet computers used by its ambulance staff, allowing it to be used in patients’ homes and in ambulances. The tool digitises standard questions (also available on a printed flowchart, although the trust encourages staff to use the computer) and generates guidance on both treatment and whether to carry out a blue-light transfer.
“We can do better than that,” said Ainsworth-Smith. The trust is proposing all UK ambulance services use a standard tool, based on a second version of the National Early Warning Score (News2) for sepsis, which is currently awaiting approval. “That would ensure consistency of care and standardised training across all ambulance services,” he said. “There’s a huge benefit to us using just one score.”
Automatic score calculation
In readiness for News2 gaining approval, South Central has set the algorithm up in its electronic patient record system for it to automatically calculate a score, with five or above suggesting a blue-light transfer to a pre-alerted hospital. Blood pressures, pulse rates and oxygen levels are already transferred electronically from monitoring devices, although some will still need to be inputted by staff, such as temperature, blood sugar and level of consciousness.
News2 could also be used by GPs and residential care homes, with the results allowing ambulance services to decide what level of service they need to provide, with the option of alerting the hospital and rushing the patient there in the most serious cases. “We’re almost at that point where if you want to leave someone at home and they have a News score of seven, it will ask if you want to do that,” said Ainsworth-Smith.
As well as improving safety, he said the system will provide data for research. This will allow sepsis incidents to be mapped as South Central does for road traffic accidents, allowing the trust to focus resources and training on higher-risk areas.