• This clinical guideline covers all adults (above 16yrs).

• There are separate specific guidelines for Maternity and Paediatrics

• Treatment urgency for adults should initially be determined by severity of illness using NEWS2 as part of clinical assessment.

• Patients with a NEWS2 of 7 or above with a positive sepsis screen should trigger initiation of sepsis care bundle including IV antibiotics within 1 hour.

• This guideline should be utilised in conjunction with the Trust policy on Management of the Deteriorating Adult Patients.

This is a controlled document. If you are using a printed copy, check it against the guidelines site to ensure you are using the latest edition. Print copies must be destroyed after use.

Abbreviations

Sepsis is a life-threatening condition that arises when the body’s response to an infection causes it to attack its own tissues and organs. It is a serious infection which affects one or more of the body’s organs such as the lungs, heart and kidneys. Sepsis has a significant impact on individuals, their families and healthcare resources. Many of those who die in the UK have significant co-existing health conditions, for example connected with old age, but other people could potentially survive sepsis if they had the right treatment in a timely manner.

Sepsis is not always easy to diagnose, particularly in the initial stages. When it is at an advanced stage with multiple abnormal physiological parameters it is relatively straightforward. However, by this stage it is associated with a remarkably high mortality, so wherever possible healthcare professionals should aim to suspect sepsis at an early stage and initiate treatment promptly.

The NICE Guidance for Sepsis: recognition, diagnosis and early management https://www.nice.org.uk/guidance/ng51 (Published: 13 July 2016) provided an evidence-based approach to recognising and initiating treatment for suspected sepsis. However, some front-line staff have found it difficult to translate this guidance into practice. NHS England (2017) stated that survey by the National Patient Safety Collaborative Sepsis Cluster stated that ‘75% of organisations do not plan to use the NICE guidelines exactly as published and most plan to modify the guidelines. In light of this, the NHS England published an implementation advice as a unified framework to help improve adult sepsis identification and care in hospital settings working collaboratively with clinicians with expert knowledge of sepsis and representing the Royal College of Physicians, the Royal College of GPs, Royal College of Nursing, NICE, Health Education England, the UK Sepsis Trust, Patient Safety Collaboratives and front line clinicians have worked with NHS England. Our previous Trust policy on recognition and initial management of sepsis was based on the NHS England (2017) Sepsis guidance implementation advice for adults.

Having the right treatment in time is important when treating patients with sepsis and requires patients to be seen by appropriately trained and competent health care professionals. If an infection is thought to be the cause of the illness, or tests show that that this is the case, antibiotics must be given promptly and then changed or stopped later when more test results are available. However, at present, the diagnosis is often based on clinical judgement. There is lack of diagnostic tool and the test relied upon may not be ready quickly enough to confirm the diagnosis.

Although giving antibiotics within the hour is appropriate for the sickest patients with sepsis, the recent evidence shows that it does not have to be such a rush in less sick patients. Evidence that survival from sepsis is improved by administering antimicrobials within one hour of presentation, compared with three, four or six hours, is largely derived from observational studies with methodological weaknesses.

Outcomes can be worse for patients receiving inappropriate antimicrobials or when receiving them whilst not required. However, the propensity of prescribers to prescribe antimicrobials is increased when there is diagnostic uncertainty, by assuming equivalence between uncomplicated infection and sepsis, and by performance targets which prioritise potentially unnecessary or inappropriate prescribing over antimicrobial stewardship.

Antimicrobial resistance is recognised by the World Health Organisation as a major global threat (WHO, 2021). Therefore, the controlled use of antimicrobials is important as all antibiotics can in themselves cause potentially life- threatening side-effects to an individual patient. On a population level, antibiotic overuse increases the risk that the microbes become resistant, so antibiotics no longer work.

Focus should therefore be on clinical assessment including patient history and examination together with investigation to determine if infection is the cause of deterioration.

Considering the new evidence and following recommendations from the Academy of Medical Royal Colleges (AoMRC), the NICE guideline was updated in March 2024.

This Trust policy aims to reflect these recent guidelines together with our local policy on managing deteriorating patients.

• In patients aged 16 or over, grade risk of severe illness or death from sepsis using the person's:

  • Patient history (including concerns/collateral history from relatives/family)

  • Physical examination (especially symptoms and signs of infection)

  • FHFT Modified National Early Warning Score version 2 (NEWS2)

• NEWS2 should be used to supplement clinical judgement to identify adult patients with suspected sepsis who are critically ill and need treatment quickly.

• If the deterioration is due to infection, Interpret the NEWS2 scores within the context of the persons' underlying physiology and comorbidities:

• a NEWS2 of 7 or more suggests HIGH risk of severe illness or death from sepsis

• a NEWS2 of 5 or 6 suggests a MODERATE risk of severe illness or death from sepsis

• a NEWS2 of 1 to 4 suggests a LOW risk of severe illness or death from sepsis

• a NEWS2 of 0 suggests a very low risk of severe illness or death from sepsis

• if a single parameter contributes 3 points to their NEWS2 score, request a high-priority review by a clinician with core competencies in the care of acutely ill patients (FY2 or above), for a definite decision on the person's level of risk of severe illness or death from sepsis.

• Response to NEWS2 should be followed as per Trust policy.

• Recalculate the NEWS2 score and re-evaluate risk of sepsis periodically, in line with the AoMRC statement on the initial antimicrobial treatment of sepsis (2022):

  • every 30 minutes, for those at high risk of severe illness or death from sepsis

  • every hour, for those at moderate risk of severe illness or death from sepsis

  • every 4 to 6 hours, for those at low risk of severe illness or death from sepsis

  • when standard observations are carried out, in line with local protocol, for those at very low risk of severe illness or death from sepsis.

• If there is deterioration or an unexpected change in the person's condition, recalculate the NEWS2 score and re-evaluate their risk of sepsis.

Clinicians should consider the following when assessing a deteriorating patient:

Question 1: Is this patient sick and what is the NEWS2 score?

• Be guided but not limited by NEWS scores and

• NEWS2 clinical response as per Trust policy should be followed as per the aggregated score

Question 2: Are there any sign or suspicion of infection?

For example: pneumonia, intra-abdominal, cellulitis, infected wound, Urinary tract infection, on Chemotherapy, neutropenic, Post partum, device related infection, recent surgery/trauma/invasive procedure (within 6 weeks)

Activate NEWS CALL

1. Give oxygen to maintain SpO₂ above 94%

(SpO₂ 88-92%for patients with COPD at risk of CO₂ retention)

2. Start looking for the source of infection. Take blood cultures: Ideally before the administration of IV antimicrobial. Also consider additional cultures: urine, sputum, wound, blood cultures from IV devices.

3. Administer IV antimicrobials as per Trust Adult Antimicrobial guide (Micro guide) WITHIN an Hour

4. Measure serum lactate.

5. Administer IV fluids 250-500ml Crystalloid stat if SBP <90mmHg.

6. Monitor urine output (1-2 hourly)

7. Observations at least every 30 mins following the Trust *NEWS2 **protocol ***and treat other underlying medical problems as appropriate.

Antimicrobial therapy when used with appropriate stewardship is an essential part of sepsis management which should focus on time-dependent recognition and resuscitation pathways.

• All Antimicrobials must be reviewed within the first 48 hours.

• Always follow Trust Antimicrobial guidelines.

Nurse in charge to be informed immediately.

Urgent assessment by a clinician with core competencies to assess acutely ill patients

Contact Rapid Response Team

1. Give oxygen to maintain SpO₂ above 94%

(SpO₂ 88-92%for patients with COPD at risk of CO₂ retention)

2. Start looking for the source of infection. Take blood cultures: Ideally before the administration of IV antimicrobial. Also consider additional cultures: urine, sputum, wound.

3. Administer IV antimicrobials as per Trust Adult Antimicrobial guide (Micro guide) WITHIN 3 Hours

   • Give IV antimicrobial ASAP if Sepsis is definite

   • use this time to gather information for a more specific diagnosis

   • discuss with a senior clinical decision maker (ST3 and above).

   • Once a decision is made to give antibiotics, do not delay administration any further.

4. Measure serum lactate

5. Administer IV fluids 250-500ml Crystalloid stat if SBP <90mmHg.

6. Measure urine output (1-2 hourly)

7. Observations at least every 30 mins following the Trust *NEWS2 **protocol ***and treat other underlying medical problems as appropriate.

Antimicrobial therapy when used with appropriate stewardship is an essential part of sepsis management which should focus on time-dependent recognition and resuscitation pathways.

• All Antimicrobials must be reviewed within the first 48 hours.

• Always follow Trust Antimicrobial guidelines.

LOW risk of severe illness or death from sepsis (NEWS2 of 1 to 4)

Arrange for registered health practitioner review within 1 hour of the person being assessed as at low risk.

Arrange for review by a registered health practitioner and use clinical judgement to manage their condition and escalate if appropriate.