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

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

3. 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

4. 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)

5. ePain Assist www. epainassit
ePain Assist [accessed ]

6. 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)

7. 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?”

9. 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

10. 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

11. 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

12. 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.

13. 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.

14. 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

15. 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

16. 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

17. 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)

18. 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

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

20. 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

21. 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.

22. 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
> 25
Oxygen
Saturations (%)
< 91%
92 – 93%
94 – 95%
> 96%
Any Supplemental
Oxygen?
Yes
None
Circulation
Systolic BP (mmhg)
< 90
91 – 100
220 >
Pulse (Heart rate) Beats per min
< 40
51 – 90
> 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

23. 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 = 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”

24. 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

25. 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:

26. 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?

27. 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

28. 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:

29. 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?

30. SBAR
Situation
Background
Assessment
Recommendation

31. 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

32. 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”

33. 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!)

34. 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.

35. 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.

36. 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”.

37. 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

38. 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”

39. 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

40. 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.

41. 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.

42. 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.

43. 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?

44. 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

45. 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.

46. 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.

47. 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.

48. 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…???

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

50. 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

51. 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

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

53. 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

54. ANY QUESTIONS?

55. References
ABUHB (2016) World Sepsis Day 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 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 Accessed 24/11/16
UK Sepsis Trust What is Sepsis? Accessed 01/5/2018
Use of the national early warning score across wales Accessed 24/11/16
Epain Assist [accessed 01st May 2018]