When the pandemic created a need for healthcare professionals to consult remotely to prevent the spread of Covid-19 infection, the NHS soon saw the importance of good communications with the adult social care workforce. There have been calls for care home staff to be better trained in helping clinicians to monitor residents to improve the early detection and communication of certain health conditions, especially when the health of older people they care for rapidly deteriorates. One such example is how increased sepsis awareness in social care staff can support the early detection of the condition in the residents they care for.
NHS England's Improving Outcomes for Patients with Sepsis — A Cross-system Action Plan (2015) refers to sepsis as a “silent killer”, simply because it can be so difficult to identify, for both professionals, the public and carers alike, “with symptoms often suggesting less serious illnesses such as influenza”.
Over the past years the NHS made progress in improving the early recognition and treatment of sepsis. Now, the Royal College of General Practitioners (RCGP) is highlighting a need to go further and deliver a fully “sepsis aware system” across health and social care. The UK Sepsis Trust has joined the RCGP in calling for a standard approach across settings to detecting and managing sepsis.
What is sepsis?
The international definition of sepsis is “life-threatening organ dysfunction caused by a dysregulated host response to infection”. The effects are the body’s toxic response to the infection.
The UK Sepsis Trust has estimated that sepsis kills at least 48,000 people a year in the UK but believes with early diagnosis and timely referral to treatment, thousands more lives could be saved.
Why is the detection of sepsis relevant to social care settings?
Earlier detection of sepsis in older people in the social care system would clearly improve the health outcomes of some of the people who are at greatest risk of sepsis.
NHS England has said, whilst anyone can develop this potentially life-threatening condition, older people are at greater risk as they are often immune compromised, living with co-morbidities and prone to infections. The RCGP’s Sepsis Toolkit says in England, 70% of sepsis cases derived from an infection developed in the community; these were predominantly respiratory, urinary tract and lower GI infections, with these affecting the very young and older people disproportionately.
In a study published in NHS England’s Atlas of Shared Learning, care home staff across Lancashire were routinely reporting on numbers and types of infections experienced by care home residents, with local data showing urinary tract and respiratory tract infections as two of the most common types of infections in care home residents, and in turn often associated as a risk factor for sepsis and hospitalisation. This gave rise to a case for a plan to improve the early identification, timely referral to treatment and recording of outcomes for care home residents suspected of having sepsis.
Can social care settings help to improve the sepsis care pathway?
In its Shared Learning case study of Lancashire Care Homes, NHS England said extending training in sepsis awareness and sharing a national warning score across primary care, community services and care homes improved communications, reduced duplication and supported management across the sepsis pathway.
The shared approach allowed care homes to use standardised language and clinical evidence to communicate to their GPs and local ambulance services that sepsis was suspected, allowing more timely escalation for appropriate healthcare.
Care home staff felt that this use of a consistent method to detect, track and trigger suspected sepsis or cases of deterioration helped them to manage health concerns effectively and improve outcomes for their residents.
How did Lancashire Care Homes achieve this improvement?
After a great deal of engagement, the local community infection prevention nurse and Sepsis Lead were able to devise an integrated approach to implementation as they:
carried out a “needs analysis” of sepsis training for care homes and primary care to identify variation and gaps
drew up a Sepsis Strategy in consultation with many bodies including local clinical commissioning groups (CCGs), local care homes, the ambulance service and the NHS England National Sepsis Lead
developed sepsis training and development sessions for care homes
promoted sepsis awareness for community health and social care providers.
Face-to-face training was then rolled out for over 200 care staff, with support from a local critical care and sepsis team. The objectives of the training were to:
understand importance of infection prevention
increase knowledge of sepsis
be knowledgeable, confident and skilled to detect, manage and escalate residents for time critical healthcare
implement “infection and risk principles” with support of “NEWS2” system and associated escalation protocols
improve awareness of care needs of residents with post-sepsis syndrome.
How does early sepsis identification and NEWS2 work?
The use of a national early warning score (NEWS) allows for accurate early assessment, recording and sharing of clinical findings. The Royal College of Physicians (RCP) launched such a system in hospitals in 2017, with NEWS2 now being used by all hospitals and ambulance services in England to assess acute-illness severity as well as to “track and trigger” acute clinical deterioration and response.
Work is now taking place at NHS England to collect evidence on the use of NEWS2 in primary and community settings, including publishing case studies of best practice. The National Institute for Health and Care Excellence's (NICE’s) Guideline NG51 recommended this be done.
So NHS England is encouraging the use of NEWS2 for adults in community settings “as an adjunct to clinical assessment but not a replacement”, to support the assessment of their physical deterioration. Health and care professionals should use it to communicate vital signs data in a “single language of sickness across all conditions and settings”, according to National Clinical Advisor on Sepsis Matt Inada-Kim, here, with thresholds providing a guide to the severity of the illness.
NEWS2 comprises six biological measurements:
systolic blood pressure
level of consciousness (defined by AVPU).
The Lancashire Care Homes case study found that it can be very challenging taking all of the NEWS2 observations for residents who have certain conditions like dementia, but by using the soft signs of deterioration, and of infection, and using clinical judgment, earlier identification and appropriate escalation could still be achieved.
Care homes are increasingly encouraged, especially when there are limits on physical visits caused by the pandemic, to train care home staff to take biological measurements in residents. The British Geriatric Society (BGS) advised that it would be a positive move to train staff to check temperature and other vital signs such as heart rate, where possible, to enable external health practitioners to triage and support residents according to need. Introducing NEWS2 training for appropriate members of the workforce can be seen as a natural extension of this skills base.
Does sepsis training lead to measurable results?
After implementing approaches from the sepsis training and development sessions in the care homes, the Lancashire case study said the:
numbers of ambulance call-outs to care homes and hospital admissions reduced
infections were treated earlier within the care homes
suspected sepsis cases identified earlier and escalated appropriately
communication and support for sepsis residents to return from hospital improved.
The study concluded that building a “sepsis aware community across patient pathways” was essential to reduce unavoidable morbidity and mortality from sepsis.
Are there other areas to be aware of?
The RCGP and Care Quality Commission (CQC) have also stressed the importance of having improved awareness in health and care settings of the needs of patients with post-sepsis syndrome.
For help with staff training, see Croner-I Navigate-Care’s Sepsis Awareness Training Presentation.
The UK Sepsis Trust’s sepsis guide contains an introduction, with basic overview of the condition together with case studies and a care worker’s guide.
NICE, Sepsis: Recognition, Diagnosis and Early Management (NG51), updated April 2019.