[vc_row][vc_column width=”1/1″][vc_column_text]Defining Sepsis
Sepsis is complex and often challenging to diagnose. Sepsis begins with an uncontrolled, systemic inflammatory response (SIRS) to a variety of clinical insults such as infection, trauma and burns. SIRS develops into sepsis when a patient with two or more of the SIRS criteria also has a suspected or known accompanying infection. This rapidly overwhelms the body by creating a combination of an infective agent and a host response or over-response. This inappropriate response, without effective clinical management may result in associated organ dysfunction due to poor perfusion, known as severe sepsis. The final, pre terminal stage is septic shock, this is characterised by evidence of hypo-perfusion despite fluid challenges.
Incidence of Sepsis
Severe sepsis is a common condition with a high mortality rate of up to 30-35% of affected patients. Sepsis is currently said to account for 37,000 deaths annually in the UK and 150,000 people in Europe. Despite medical advances, the incidence of sepsis is set to increase due to the ageing population. Two thirds of people affected by sepsis are over sixty-five; this patient group also has the highest mortality rate. Cases of sepsis are five times more common than myocardial infarction and the mortality rate is higher than lung, breast and bowel cancer combined. Statistically an individual is ten times more likely to die from sepsis than be in a fatal road traffic collision. Research, shows that early recognition and intervention saves lives, which provides the rationale for this project.
A literature search revealed a wealth of relevant literature, with a substantial bank of evidence including established practices within hospitals. However, relatively little literature was found specific to prehospital sepsis management despite accepted knowledge that early recognition and aggressive management significantly reduces mortality. In particular there is a lack of research carried out by paramedics, an issue in all contexts not just sepsis.
Current Best Practice (Care bundles)
Broadly speaking, the procedure for managing adult sepsis in UK hospitals is well established. This is largely due to the Surviving Sepsis Campaign (2002), an international collaboration of experts with the aim of reducing mortality from sepsis by 25%. In 2004, (revised 2008 & 2012) the campaign produced evidence based guidelines known as care bundles, namely the ‘Sepsis Six’ and the ‘Resuscitation bundle’. These care bundles remain the internationally recognised gold standard of care. The foundation of these bundles is rapid diagnosis and management, which are integral to successful treatment.
Recognition & Current Compliance with Care Bundles
Despite having a higher mortality rate than myocardial infarctions and acute strokes, sepsis does not have the same priority in triage, possibly because of its challenging diagnosis. Sivayoham (2007) studied 107 UK emergency departments (ED) and found only 55 had a written sepsis protocol, 35 of which included end goal directed therapy (EGDT). Significantly, only 71% had even heard of the surviving sepsis campaign (Sivayoham, 2007). Another study by Cronshaw et al. (2011) reviewed 255 patients across three hospitals with severe sepsis or septic shock. The study found only 17% were diagnosed with sepsis in the ED and only 41% of patients diagnosed with severe sepsis received the recommended care.
Despite the introduction of the sepsis care bundles compliance is poor and the uptake of the care bundles still needs to be improved (Cronshaw et al. 2011; Small, 2011). Daniels et al. (2011) carried out a prospective observational cohort study assessing the delivery and impact of both the resuscitation bundle and the sepsis six. Notably, this study found a substantial improvement in patient outcome using the sepsis six in order to achieve the resuscitation bundle. Daniels et al. (2011) claimed that compliance with sepsis six reduced the relative risk of death by 46.6%. The major significance of this finding is the correlation between the two bundles; the use of the sepsis six lead to 84.6% of the 567 patients successfully completed the resuscitation bundle, compared to only 5.8% of patients without the use of the sepsis six. Daniels et al. (2011) also reported improved patient outcome when patients received care from specialist sepsis nurses. These nurses treated 34% of the patients, 72.9% of these patients compared to only 23.4% treated by non-speciality nurses fulfilled the resuscitation bundle. Consequently this group of patients had a lower mortality rate of 25.5% instead of 38.4%. These findings appear to demonstrate the benefit of the sepsis six and resuscitation bundle, although a large scale nationalised review would further substantiate these findings (Robson & Daniels, 2013).
Varpula et al. (2007) carried out a nationwide study in Finland. The study found emergency department personnel resisted using the Surviving Sepsis Campaign care bundles, stating that the problem was identifying patients who needed EGDT. Daniels et al. (2011) argues that specialist knowledge aids early recognition and therefore improves patient outcome. However, an evidence-based project by Kent et al. (2010) supplements specialist knowledge, instead advocating a sepsis screening tool. Kent et al. (2010:139) argues that algorithms facilitate the ‘consistent implementation of appropriate treatment’. In contrast, Vanzant & Scmelzer (2011) caution that by the time patients meet the screening criteria they have significantly decompensated and require rapid, aggressive resuscitation. Such measures are costly and risky; therefore clinicians are inclined to opt for less aggressive and consequently less effective measures (Vanzant & Schmelzer, 2011). This literature search found no conclusive findings that singularly champion algorithms or specialist knowledge.
Prehospital recognition of sepsis
Herlitz et al. (2012) performed a literature search reviewing the prehospital element of sepsis care. Herlitz et al. (2012) argue that the high mortality rate is partly due to poor recognition, attributed to defining symptoms at the onset. Interestingly, Herlitz et al. (2012) acknowledges an initial delay may lie with the patient and bystanders, commenting that medical complaints such as strokes or heart problems are commonly recognised by laypersons. However, infection and sepsis is often unrecognised and may be mirrored by misleading or subtle presentations. The issue of public recognition of sepsis is not well documented. However, if the majority of literature shows that early recognition is a key element in reducing mortality, perhaps this is an area that would benefit from further research and publicity.
Treatment of patients when sepsis has been identified
Once sepsis has been identified the treatment focuses on removing the infection with appropriate antibiotics (Porth, 2007). Varpula et al. (2007) concluded that the most important variable leading to the high mortality rate was the delay in antibiotics. A conclusion shared by Cronshaw et al. (2011) whose study recorded a 7.6% increase in mortality for every hour antibiotic administration was delayed.
A serum lactate measurement will identify those patients with poor tissue perfusion despite a normal blood pressure (Guerra et al. 2013). McClelland et al. (2012) & Herltiz et al. (2012) argue that lactate measurement is possible in the pre hospital environment, argue that lactate measurement should be done and should be part of the treatment algorithm. A mandate to accurately record urine output can avoid transfer of a patient with threatened renal failure to a ward, without appropriate ﬂuid resuscitation (Dellinger et al. 2004).
Seymour et al. (2010) performed a secondary data analysis of a retrospective cohort study, examining the association between the delivery of fluid administered in the pre-hospital setting and the achievement of the resuscitation end points (6 hour target). The study found that 48% of the patients with severe sepsis received fluids by ambulance clinicians. These patients ‘approached but did not achieve’ a statistical increase in the likeliness of achieving the desired mean arterial pressure (Seymour et al. 2010:149). A study of this size is unlikely to provide a robust foundation to detect a statistical difference (Parahoo, 2006). However the findings highlight a significant limitation in this treatment pathway. Interestingly, 37% of the patients in this study are reported to have failed IV access, therefore could not receive fluid therapy.
Furthermore, of those who did receive fluid out-of-hospital received a significantly larger volume in their first hour in-hospital. In a different context, studies regarding pain management have identified a similar finding, whereby patients who have not had analgesia administered in the prehospital environment experienced substantial delay in receiving analgesia once in the emergency department (McEachin et al. 2002; Vassiliadis et al. 2002; Brennan et al. 2007). Perhaps this emphasises the priority of IV fluids being initiated prior to arriving at hospital.
Seymour et al. (2010) concede that these are preliminary findings only, therefore have limited robustness and transferability. The small sample used (52 patients) limits generalisability (Parahoo, 2006), and it is doubtful these findings could be substantiated enough to affect practice without further large-scale research. The advantage of a retrospective study method is the sample could be widened and the study replicated to strengthen the findings (Kwan et al. 2009).
However, the findings have highlighted significant limitations, such as IV access. If fluid therapy is found to be beneficial the importance of gaining IV access perhaps should be prioritised. This literature search found no evidence of studies on this subject. In the prehospital setting in the UK IV access is a paramedic only skill, as paramedics do not attend all patients the chance of IV access being gained prior to arriving in hospital may further decrease.
Current Ambulance Procedure/Guidelines/Protocol
The sepsis guidelines were initially devised for ICU patients, the guidelines were then extended to ED (Small, 2012; McClelland & Younger, 2013). In 2012 McClelland & Younger, carried out a research study introducing a sepsis screening tool (SST) throughout North East Ambulance Service (NEAS). The study measured the impact of the SST, firstly baseline figures where established and the re-measured following the training and introduction of the SST. The study results showed a significant increase in pre-alerts, indicating recognition of sepsis had increased; however there was no measurable improvement in the treatment delivered once sepsis had been identified (McClelland & Younger, 2013). As a result NEAS staff now routinely pre-alert EDs of suspected sepsis patients, and a sepsis screening tool is in place.
Following this study the pre-hospital sepsis committee has produced the following recommendations to JRCALC:
‘All patients over 18 years with suspected sepsis should receive high-flow oxygen en route to hospital. Fluid challenges should be given in suspected sepsis to all patients over 18 years with low blood pressure, and with any one or more of prolonged capillary refill (> 2s), mottled skin, reduced conscious level, absent radial pulse or a characteristic purpuric rash’ (UK Sepsis Group, 2013). Furthermore, hospital pre-alerts for receiving units when sepsis is suspected should be clarified and appropriate response teams should be provided by the receiving ED. Finally, sepsis education and training must be reviewed for paramedics (UK Sepsis Group, 2013; McClelland & Younger, 2013).
In conclusion, despite the introduction of the surviving sepsis campaign, which has seen some improvement, sepsis has an unacceptably high mortality rate. Evidence shows that early recognition and aggressive treatment improves patient outcome, yet studies demonstrate that compliance with the care bundles is poor. There are no set protocols in place for ambulance clinicians despite having the skills and means to effectively treat septic patients. Instead ambulance clinicians appear to rely on historical practice rather than scientific precedence. A proposed prehospital pathway has been devised by Daniels et al. (2011) but further study is required and a standardised prehospital care pathway is yet to be established.
Since the introduction of stroke and myocardial infarction pathways, vast improvements have been documented in patient outcomes. Sepsis requires the same priority and clear treatment goals in order to see the same improvement. Simple, routine improvements in paramedic’s knowledge and practice could provide significant benefits. The lack of level one research in the pre hospital setting means the exact effect of paramedic interventions remains uncertain. This would certainly benefit from further study.[/vc_column_text][/vc_column][/vc_row][vc_row][vc_column width=”1/1″][vc_column_text]
Signs and Symptoms
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