Sepsis care standard to improve recognition

Sepsisⁱ, a condition — triggered by an infection — that can turn into a deadly disease if undetected, leads to more than 8700 deaths a year. However, it can elude even the most astute doctors, according to Dr Carolyn Hullick, Clinical Director at the Commission and Emergency Physician in Hunter New England Health NSW.

“Sepsis is overwhelmingly a disease of older people, with patients over 65 years of age accounting for two-thirds of sepsis cases. With incidence rates increasing 20% faster than younger patients, older people account for the most rapid escalation of longitudinal incidence,” said a 2018 research paper by Ellen Burkett and colleagues, published in Emergency Medicines Australia.

As an emergency physician, Hullick understands the challenges in diagnosing sepsis, particularly when treating a high volume of critical patients in a busy emergency department.

Sepsis occurs when you have an overwhelming response from your body to an infection, so the challenge with diagnosis is that many patients have a lot of symptoms because the infection could be coming from anywhere and the organ dysfunction related to sepsis could also be causing symptoms, she explained. The signs and symptoms can also be subtle.

“Older patients may have delirium. They may be on medicines that impact on their body’s response to sepsis. Sepsis can also mimic other health conditions like gastro or heart disease,” Hullick said.

“Yet the consequences of missing sepsis are dire, leading to multiple organ failure, disability or death.”

With an aim to improve outcomes and halt the devastating impact of sepsis on Australian patients and their families, the Australian Commission on Safety and Quality in Health Care has released the national Sepsis Clinical Care Standard, in partnership with The George Institute for Global Health.

The standard outlines optimal care for patients in hospital with suspected sepsis — from the onset of signs and symptoms, through to discharge from hospital and follow-up care. Sepsis affects more than 55,000 Australians of all ages every yearⁱⁱ. It also has a tangible impact on our healthcare system, with $700 million in direct hospital costs and indirect costs of more than $4 billion each yearⁱⁱⁱ.

The national framework will help ensure standardised treatment across Australia, so from the time a patient arrives at the health service everyone involved is aware of the risk factors and knows what’s expected of them, Hullick said.

Hullick shared three key red flags or messages from sepsis survivors and people who treat sepsis: these patients can deteriorate very rapidly; the families of these patients are very concerned; and it’s the worst they (patients) have ever felt.

“The new standard requires healthcare services to implement systems that flag people who may have sepsis, assess them urgently, and if necessary, escalate to a higher level of care. Rapid treatment is vital. If we delay sepsis treatment even by a few hours, it can have deadly consequences.

“To deliver antimicrobials to someone who has sepsis within 60 minutes, we need systems in place so that everyone in the ED team knows what they need to do,” she explained.

Anyone can get sepsis, but Aboriginal and Torres Strait Islander people, those with autoimmune diseases or weakened immune system, babies, children and older people are some of the vulnerable groups.

The research paper referenced earlier suggested that “the identification of sepsis in the older person requires a high index of suspicion and careful history and physical examination. Early management with appropriate antibiotics and fluid resuscitation with vasopressor support where indicated, with a multidisciplinary team approach, is associated with marked improvement in morbidity and mortality. However, given the high associated morbidity, high rates of increased dependence and high mortality of sepsis in older adults, it is important for ED physicians to ensure that a shared decision-making approach is taken to ensure that ongoing management is consistent with individual patient goals of care.”

Hullick also emphasised the importance of shared as well as supported decision-making. Older people may have other illnesses, could be on multiple medications and some of them may not be able to advocate for themselves, she said.

However, aged care staff is generally well trained in infection prevention and control and they often know their residents well, she said, highlighting the importance of advance care planning and achieving a balance between time-critical treatment and what the person (patient) wants and their goals of care.

Evidence is growing that some sepsis survivors experience long-term health problems, which are poorly recognised and treated. To address this, another key focus of the standard is the planning for care after the patient leaves hospital, in recognition of the ongoing effects of sepsis and ‘post-sepsis syndrome’.

Professor Simon Finfer AO, intensivist and Professorial Fellow in the Critical Care Division at The George Institute for Global Health, described sepsis as the most common preventable cause of death and disability.

“The Sepsis Clinical Care Standard is a game changer that will ensure healthcare workers recognise sepsis as a medical emergency and provide coordinated high-quality care to all Australians.

“If a patient is acutely ill or deteriorating rapidly — and there is no other obvious cause — we must consider sepsis as a possible diagnosis,” Finfer said.

“If you suspect sepsis, either as a clinician or a patient, escalate your concerns to a healthcare professional who is skilled in managing sepsis. You must ask, ‘Could this be sepsis?’.”

Finfer is an avid supporter of having dedicated sepsis coordinators to oversee care for people with sepsis, in a similar way to trauma and cancer patients.

“Patients with sepsis are cared for by a range of specialist doctors and nurses with frequent transfers between teams. By recommending that hospitals need a dedicated sepsis care coordinator, the Sepsis Clinical Care Standard will help to ensure a comprehensive and holistic approach to this complex and devastating condition,” he explained.

“Up to 50% of people who suffer sepsis and survive have ongoing medical problems which affect their physical, psychological and cognitive wellbeing.^iv Unlike other conditions such as heart attack and stroke, there is no coordinated care or rehabilitation for sepsis survivors. The standard is a huge step forward.”

The Sepsis Clinical Care Standard was informed by leading clinical experts and consumers and translates evidence into clinical practice to reduce preventable death or disability caused by sepsis.

References:

^{[i] Rudd KE, Johnson SC, Agesa KM, Shackelford KA, Tsoi D, Kievlan DR, et al. Global, regional, and national sepsis incidence and mortality, 1990–2017: analysis for the Global Burden of Disease Study. Lancet 2020;395(10219):200–11.}

^{[ii] As above}

^{[iii] The George Institute for Global Health. Cost of sepsis in Australia report. Sydney: TGI; 2021.}

^{[iv] The George Institute for Global Health. Life after sepsis. A guide for survivors, carers and bereaved families. Sydney: TGI, 2020.}

^{[v] Cvetkovic M, Lutman D, Ramnarayan P, Pathan N, Inwald DP, Peters MJ. Timing of death in children referred for intensive care with severe sepsis: implications for interventional studies. Pediatr Crit Care Med. 2015 Jun;16(5):410-7. doi: 10.1097/PCC.0000000000000385. PMID: 25739013.}

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