SUSPECT SEPSIS AND SAVE LIVES IT’S IN YOUR HANDS Professional Development Team 2018 Louise Rooney M.B.E., Cathryn Smith, Jane Brunsdon

AIMS To understand the physical presentation of Sepsis in Adults Recognition of Sepsis Be empowered to take appropriate action

OBJECTIVES To identify what Sepsis is To recognise the signs and symptoms of Sepsis To be aware of those at greatest risk How to use NEWS and SBAR

WHAT IS SEPSIS? 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 In sepsis the patient's immune system goes into overdrive setting off a series of reactions including widespread inflammation. This can cause a significant decrease in blood pressure reducing the blood supply to vital organs and starving them of oxygen Sepsis can lead to multiple organ failure and death especially if not recognised early and treated quickly (RCN online accessed 10/04/2018)

ePain Assist www. epainassit ePain Assist www.epainassit.com/infections/long-term-effects-of-sepis [accessed 01-5-2018]

SEPSIS CLAIMS MORE LIVES THAN LUNG CANCER, AND MORE THAN BOWEL, BREAST Sepsis affects an estimated 250,000 people per year in the UK Sepsis accounts for 44,000 deaths annually in the UK SEPSIS CLAIMS MORE LIVES THAN LUNG CANCER, AND MORE THAN BOWEL, BREAST AND PROSTATE CANCER COMBINED (UK Sepsis Trust, 2018)

Always consider “Could this be sepsis?” Sepsis is a MEDICAL EMERGENCY and patients with severe sepsis are 5 times more likely to die than patients with heart attack or stroke. (UK SEPSIS TRUST 2016) Caught early, the outlook is good for the vast majority of patients. Identification of sepsis in the elderly can be challenging as the symptoms can be similar to other chronic conditions that they may already have. For those who survive sepsis, many patients suffer long term physical and mental problems Always consider “Could this be sepsis?”

Signs of Sepsis Shivering fever or very cold Pale Or Mottled skin Extreme pain or general Discomfort “worse ever” Pale Or Mottled skin Sleepy difficult to wake up confused “I feel like I might die” Short of breath or rapid breathing

Possible other signs Sometimes signs of sepsis can be difficult to distinguish from other infections. Rapid Pulse Reduced urine output Anxiety Difficulty breathing Fatigue, malaise Nausea and vomiting Diarrhoea Sense of impending doom

SEVERE SEPSIS & SEPTIC SHOCK In some cases, symptoms can become more severe and lead to severe sepsis or septic shock.  These can include: Dangerously low blood pressure (Feeling dizzy or faint) Extreme changes in Pulse rate (bradycardic/tachycardic) A change in mental state – such as confusion or disorientation Difficult to rouse Respiratory distress Significant skin changes

How does your body react? blood pressure drops due to expansion of arteries and veins and the blood having a bigger space to fill. The heart tries to compensate by beating faster hence a rapid pulse As the blood pressure lowers the organs are starved of blood and oxygen leading to cell damage and organ failure and possibly a slow pulse. Due to the kidneys being affected urine output is decreased. Due to lack of oxygen going to the brain confusion and drowsiness will set in.

What can cause sepsis? Sepsis can be caused by a huge variety of different bacteria such as: E-coli MRSA C-difficile Streptococcus Most cases of sepsis are caused by common bacteria which we come into contact with every day without them making us ill. Sepsis occurs when the body responds abnormally to these.

What infections cause sepsis? Any infection can give rise to sepsis including: pneumonia urinary tract infections wound infections bites illnesses such as pancreatitis/cholecystitis/cellulitis/appendicitis

Who’s at risk of sepsis Anyone can develop sepsis after an injury or minor infection, although some people are at greater risk including: Those being treated for cancer with chemotherapy Those who have impaired immune function (for example, people with diabetes, people who have had a splenectomy, or people with sickle cell disease) Those taking long-term steroids Those taking immunosuppressant drugs to treat non-malignant disorders such as rheumatoid arthritis

Who’s at risk of sepsis people who have had surgery, or other invasive procedures, in the past 6 weeks people with any breach of skin integrity (for example, cuts, burns, blisters or skin infections) people who misuse drugs intravenously people with indwelling lines or catheters

Remember Think ‘could this be sepsis?’ Does the patient / resident look sick? Is the resident, the family or the carer / nurse worried? Is the NEWS triggering?(above 5 or more) Are there risk factors present e.g. age over 75, recent surgery, recent/ current infection, in-dwelling catheter, skin integrity breached? (UK Sepsis Trust 2018)

Possible long term physical effects of sepsis Reduced mobility Fatigue Loss of appetite Taste changes Dry skin/brittle nails Brittle teeth Hair loss Oedema Joint stiffness or pain Muscle wasting Neurological symptoms Decreased kidney function

Possible long term psychological effects of sepsis Reduce libido Anxiety Insomnia Panic attacks Nightmares Flashbacks Depression PTSD Lack of concentration Short term memory loss

VITAL SIGNS OBSERVATIONS CLINICAL OBSERVATIONAL 1. Respiratory rate 2. Oxygen saturation level 3. Pulse rate 4. Systolic Blood pressure 5. AVPU / GCS 6. Temperature 7. Urine output 1. Is their breathing normal 2. Are they pale/ grey/ blue tinge around lips 3. Any palpitations or pallor 4. Any dizziness / fainting 5. AVPU 6. Flushed/ hot/ cold/ sweaty/ clammy 7. Urine output

NEWS (National Early Warning Score) NEWS enables us to calculate the level of risk of a deteriorating patient using physiological parameters The score is calculated from these observations and determines a minimum level at which the patient may be said to be at low, medium or high risk of becoming acutely unwell. NEWS was developed by the RCP National Early Warning Score Development and Implementation Group (NEWSDIG) and has been demonstrated to be superior to any other score in prediction of patient deterioration.

National Early Warning Score ( NEWS) Wales Physiological Parameters (“Vital signs” or “Obs”) Full set required to calculate a Score 3 2 1 Airway & Breathing Respiratory Rate (Per min) < 8 9 - 11 12 - 20 21 - 24 > 25 Oxygen Saturations (%) < 91% 92 – 93% 94 – 95% > 96% Any Supplemental Oxygen? Yes None Circulation Systolic BP (mmhg) < 90 91 – 100 101 - 110 111 - 219 220 > Pulse (Heart rate) Beats per min < 40 41 - 50 51 – 90 91 - 110 111 - 130 > 131 Disability (Responds to...) Blood Glucose? AVPU Score: Alert? Voice? to Pain? Unresponsive? Alert V, P, or U Exposure Temperature (oC) < 35.0 35.1 – 36.0 36.1 – 38.0 38.1 – 39.0 > 39.1 *Consider alternative methods of assessment for patients in the “End of Life” phase. Concern about a Patient should lead to escalation regardless of Score/s

National Early Warning Score ( NEWS) Wales RISK SUSPECT SEPSIS ? 0 – 2 TWO OR MORE OF THESE: Temperature < 36 or > 38.3oC Heart Rate > 90 beats per min. Respiratory Rate > 20 per min. WCC > 12 or <4 x 109/l Acutely altered mental state Hyperglycaemia (>7.7mmol/L) PLUS: Suspicion of a new infection? = POSSIBLE SEPSIS! 3 – 5 3 = THREAT! Acute Illness or Unstable Chronic Disease? 6 - 8 6 = SICK! Likely to deteriorate rapidly 9 9 = NOW! Immediately Life Threatening critical illness. Are there any Advanced Directives documented? i.e. “Do Not Attempt CPR” or preferred place of care (such as “do not admit” or “preferred place of death”)? Frequency of observations can be increased at discretion of Clinical team Pain Scores: Use “Mild, Moderate or Severe (inc. Distressed)” or “1 – 10”

Scenario 1 – Mr Davies Mr Davies is normally a fit gentleman for his age (84), he is mobile with a walking stick and independent with all activities of daily living. Mr Davies has capacity and had no communication difficulties. Mr Davies’ past medical history is as follow: Arthritis Bilateral hip replacement Diabetic type 2 High blood pressure Occasional urinary tract infections

Scenario 1 Mr Davies has ‘not been himself’ for a few days, he is a little confused, needs more prompting than normal to take medication and to carry out daily activities. He has been less steady on his feet and has been off his food and drink for 2 days. On your assessment Mr Davies is very sleepy and has spent most of the afternoon in bed. On completing a set of observations the results are as follows:

Scenario 1 Respiratory rate: 11 breaths per minute Oxygen saturations: 96% on air Blood Pressure: 102/60 Pulse: 111 beats per minute AVPU: responding to voice only Temperature: 38.7 What is the NEWS score? 8 What do you think is wrong?

Scenario 2- Mrs jones Mrs Jones is 84 years old and has severe dementia. Mrs Jones is normally very confused and disorientated, however she is mobile and will respond to simple commands. Mrs Jones has a long term in-dwelling catheter and suffers from occasional UTI’s Mrs jones last had her catheter changed by the district nurses 2 weeks ago Mrs jones does not take any medications and has no significant past medical history

Scenario 2 Today the carers have noticed that Mrs Jones is very reluctant to eat her breakfast, she looks pale, but when asked if she is ok says “yes” Mrs jones appears sleepy and winces when moved, her catheter drainage has been 200mls in the last 12 hours. Mrs jones’ observations are:

Scenario 2 She is responding to voice only Her temperature is 38.2 Her respirations are 22 Her pulse is 89 bpm Her blood pressure is 104/60 Her oxygen saturations are 96% What is her NEWS score? 7 What do you think might be wrong?

SBAR Situation Background Assessment Recommendation

WHY USE SBAR? To reduce the barrier to effective communication across different disciplines and levels of staff. SBAR is a tool to aid multidisciplinary communication to be used for patient handovers and situations requiring escalation or critical exchange of information SBAR is memory prompt; its concise and easy to remember and encourages prior preparation for communication SBAR reduces the risk of critical information being missed

HOW CAN SBAR HELP ME? It’s easy to remember It clarifies what information needs communicating quickly It aids the instigation of an action plan Prevents “hinting, hoping and assumptions”

SITUATION Identify yourself, the establishment/location you are calling from. Identify the patient by name and the reason for your call confirm capacity and consent and describe your concerns, (especially if the patient is triggering over 6, as 6=SICK!)

SITUATION For example: "This is Lou, a registered nurse/carer from Thomas Care Home. The reason I'm calling is that Mrs Taylor from Happy Day Unit has become suddenly short of breath. Mrs Taylor is aware I am calling.

BACKGROUND Give the reason why the resident is with you i.e permanent/respite Explain brief significant medical history Overview of the patient's background including: admitting diagnosis recent procedures/treatments current medications, allergies DNACPR/ACP status For this, you need to have collected information from the patient's chart, flow sheets and progress notes. Please have notes to hand.

BACKGROUND For example: "Mrs. Taylor is a 79-year-old woman who has lived here for three years. She is a known COPD with Diabetes.” “Until now she is normally fit and well and independent with activities of daily living. Last seen GP one month ago for cold like symptoms.” “She has an Advanced Care Plan that states in the event of an acute illness she should be admitted” “She does have a DNACPR”.

ASSESSMENT Vital signs/visual observations Concerns You need to think critically when informing the call taker of your assessment of the situation. This means that you have considered what might be the underlying reason for your patient's condition i.e UTI/chest infection

ASSESSMENT For Example: “Her oxygen saturation has dropped to 92% per cent on room air, her respiration rate is 24 per minute, her heart rate is 111 and her blood pressure is 95/60. her temperature is 38.5°c, and she looks blue around the mouth. She is alert.” “She has a NEWS score of 9” “I don’t know what’s wrong but I am really worried”

RECOMMENDATIONS Explain what you need - be specific about request and time frame Make suggestions Clarify expectations Finally, what is your recommendation? That is, what would you like to happen by the end of the conversation i.e I need the doctor to ring me within the next hour Any order that is given on the phone needs to be repeated back to ensure accuracy Mutually agree further actions i.e repeat obs 2 hourly/commence fluid balance/ analgesics/ ring if worse

Scenario 3 – Mr Brown It is 7:00pm on a Thursday evening and you are on shift looking after Mr Brown. Mr Brown is a temporary resident on respite, he is known to have a “chronic chest” and he often gets chest infections. Mr Brown is 72 years of age and has suddenly become more confused than normal in the last 2 hours, he also seems hot and flushed. He is currently on antibiotics for another chest infection. Mr Brown has an active DNACPR and has capacity.

Scenario 3 Using SBAR to hand over Mr Brown to the OOH’S call handler as you are requesting a GP. Situation: My name is _____ and I am a registered nurse/carer at _______. Mr Brown has capacity and has consented to the call. Mr Brown has suddenly become more confused than normal in the last 2 hours, he also seems hot and flushed.

Scenario 3 Background: Mr Brown is known to have a “chronic chest” and he often gets chest infections. He takes the following medications: Aspirin 75mgs Ipratropium inhaler paracetamol He is currently on antibiotics for another chest infection. Mr Brown has an active DNACPR and has capacity.

Scenario 3 Your assessment of Mr Jones is: He is alert and talking His respirations are 20 His oxygen saturations (on air) are 94% (not on oxygen) His pulse is 120 His BP is 120/60 His temp is 38.4 What is the NEWS score? 4 What do you think is wrong?

Scenario 3 Recommendation: Could someone please contact me back with advice What do you want to happen? As I think he might need to go into hospital

Scenario 4 – Mrs Warburton Smyth You are on shift on a Monday morning mid winter and looking after Mrs Warburton Smyth. Mrs Warburton Smyth is 68 years of age and has been a permanent resident for a number of years. Mrs Warburton Smyth has woken up with a runny nose and slight cough. She has capacity and has insisted that you call the GP whilst she eats her breakfast.

Scenario 4 Using SBAR hand over Mrs Warburton Smyth to the GP. Situation: My name is _____ and I am a registered nurse/carer at _______. Mrs Warburton Smyth has insisted that I call. Mrs Warburton Smyth has woken up with a runny nose and slight cough.

Scenario 4 Background: Mrs Warburton Smyth has diabetes type 2. She has been a resident at some time with us. She is normally fit and well but has refused the flu jab this year as she said it ‘gave her flu last year’. Mrs Warburton Smyth says she needs antibiotics so her symptoms doesn’t go to her chest.

Scenario 4 My assessment of Mrs Warburton Smythe is: She is alert and vocal Her respirations are 12 Her oxygen saturations (on air) are 99% (not on oxygen) Her pulse is 78 Her BP is 120/60 Her temp is 36.5 What is the NEWS score? What do you think is wrong…???

Scenario 4 Would you call the GP? What would you ask the GP to do? Are there any other options?

Scenario 5- Mrs Green Mrs green is 75 years old, at your home for respite while her family are away. She is usually self caring and has capacity, she is mobile with a zimmer frame. Today Mrs green has not got out of bed, she looks very unwell, appears confused and is breathing very quickly

Scenario 5 Her observations are: Respiratory rate 27 BP 89/50 Pulse 125 O2 saturations 94% Responding to pain only Temp 34.7 What is her NEWS score? 15

Scenario 5 What Critical information should be included on the SBAR when you are contacting the OOH GP?

SUMMARY Use the tools alongside your own knowledge and skills Be confident and empowered Drive up standards of recognition of the deteriorating patient (especially sepsis) in your care home

ANY QUESTIONS?

References ABUHB (2016) World Sepsis Day http://howis.wales.nhs.uk/sitesplus/866/news/47109 accessed 25/11/16 Hancock, C(2013) The Good NEWS for Wales Implementation by NHS Wales of the National Early Warning Score (NEWS) Cardiff: 1000 Lives Plus / Welsh Government Institute for Healthcare Improvement http://www.ihi.org/resources/pages/tools/sbartoolkit.aspx Accessed 28/11/16 Parry, J (2011) Improving Clinical Communication Using SBAR. Cardiff: 1000 Lives Plus / Welsh Government The How to Guide for Reducing Harm from Deterioration, Patient Safety First, Version 1.1, September 2008. http://tinyurl.com/ptsafety1 Accessed 24/11/16 UK Sepsis Trust What is Sepsis? http://sepsistrust.org/public/what-is-sepsis/ Accessed 01/5/2018 Use of the national early warning score across wales 2013 http://www.1000livesplus.wales.nhs.uk/sitesplus/documents/1011/Rapid%20response%202%20page%20leaflet.pdf Accessed 24/11/16 Epain Assist www.epainassist.com/infections/long-term-effects-of-sepsis [accessed 01st May 2018]