-PGN 05… · 6/3/2020 · AMPH-PGN-05 4 Cumbria, Northumberland Tyne and Wear NHS Foundation Trust AMPH-PGN-05-Sepsis Management-V03- June 2020 Part of CNTW(C) 29-Trust standards

Trust standard for the assessment and management of physical health policy Practice guidance note (PGN)

Sepsis Assessment Tool – V03

Date issued Issue 1 – June 2020

Planned review June 2023

AMPH-PGN-05 - part of CNTW(C)29 –

Trust standard for the assessment and management of physical health policy

Author/ Designation Kevin Crompton – Physical Health Projects and Skills Advisor

Responsible Officer / Designation

Rajesh Nadkarni-Executive Medical Director

Section Contents Page No:

1 Introduction and scope 1

2 Duties, responsibilities and Scope 2

3 Consent 4

4 Who is at risk 4

5 Implementation 5

6 Clinical indications and treatment 7

7 Post Sepsis risk factors 9

8 Post Sepsis Syndrome (PSS) 9

9 Training 10

10 Infection Prevention and Control 11

11 Record keeping and audit 11

12 Further reading with health education support material for care-staff and service users

12

Appendices – listed separate to the PGN

Document No:

Description

Appendix 1 Sepsis Assessment Tool

Appendix 1a Sepsis Assessment Tool Supporting Notes

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1 Cumbria, Northumberland Tyne and Wear NHS Foundation Trust AMPH-PGN-05-Sepsis Management-V03- June 2020 Part of CNTW(C) 29-Trust standards for assessment and management of Physical Health Policy

1. Introduction and scope 1.1 The Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust Sepsis

Assessment Tool is designed to act as an early indicator for identifying sepsis and subsequent prompt for intervention. More broadly it aims to promote greater awareness of the subject and provide a supporting framework for clinical evaluation of health status.

1.2 The sepsis assessment tool practice guidance note (PGN) has been designed

specifically for ‘non-acute’ hospital settings and environments which can’t reflect National initiatives such as the ‘Sepsis Six’. Organisations such as CNTW do not have the acute-infrastructure and expertise to manage acute care requirements. However, CNTW aims to implement a system that will identify sepsis at early presentation in order to facilitate prompt referral and admission to the acute-care environment.

1.3 The Sepsis Trust UK states sepsis kills at least 48,000 people a year in the UK with many thousands more are left with disabilities and life-changing consequences.

1.4 For many patients, if sepsis is caught early, it can be easy to treat and with early

diagnosis, we could save thousands more lives a year in the UK. 1.5 In recent years The Royal College of Nursing has been somewhat critical of the

fragmented and slow approach to sepsis recognition within children. CNTW Trust has re-designed the Sepsis Assessment Tool to be even more sensitive to identifying early indicators of sepsis in children.

1.6 One of the main problems in sepsis recognition is that the sepsis can have varied

presentations and can be confused with other conditions. 1.7 The symptoms of sepsis may develop after localised infection (infection limited to one

part of the body) and in some cases the primary infection cannot be identified and so a high index of suspicion is used.

1.8 The immune system will normally limit infection spread but in sepsis the body reacts

to the infection with an overwhelming life threatening inflammatory immune response. Initially the problem may present as mild and with the primary infection starting anywhere, from a cut to the finger to a chest or urinary tract infection. But when the immune system overreacts this can lead to systemic shock, organ failure and even death.

1.9 Therefore a system of ‘red-flag’ or warning indicators to recognise sepsis in its early

presentation is needed. The National Confidential Enquiry into Patient Outcome and Death (NCEPOD) enquiry says there has been poor recording of patient’s physical observations and vital signs in both primary and hospital settings. The report recommends more doctors and nurses use early warning systems and screening.

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1.10 CNTW Trust aims to continue the success of the sepsis initiative with the implementation of the revised Sepsis Assessment Tool. It also will share the success through Regional and National NHS organisations and patient safety groups.

1.11 Since the initial launch of the Sepsis Tool, CNTW has completed two clinical audits

on sepsis and which indicate progressive adoption and implementation. The sepsis tool has effectively identified sepsis, with CNTW staff facilitating prompt acute service transfer. All lessons learnt from the audits have been reflected in the new version.

1.12 NCEPOD recommends that all hospitals should have a formal protocol for early

identification for immediate management of sepsis. The sepsis assessment tool will act as an early ‘red flag’ indicator for symptoms but aims to be applicable in all care environments.

1.13 CNTW will continue to reflect following standards and recommendations:

• Surviving Sepsis Campaign UK • The UK Sepsis Trust • National Institute for health and care excellence (NICE) Guidance on Sepsis

updated Sept 2017 and Sepsis Pathways Feb 2020 • Recommendations from NCEPOD • NHS England • Ongoing collaborative work with Health Education North East

2. Duties and Responsibilities 2.1 The Chief Executive on behalf of the Trust retains ultimate accountability for the

health, safety and welfare of all service users, carers, staff and visitors; however key tasks and responsibilities will be delegated to individuals in accordance with the content of this policy.

2.2 Medical Director and Executive Director of Nursing and Operations are required to:

• Ensure that all Medical and Nursing staff are aware of this PGN and supporting Appendices

• Ensure that adequate training is given to allow medical and nursing staff to implement PGN safely

• To inform Senior Management if the PGN is not being implemented or adhered to in service areas / within the Trust

2.3 All staff are required to:

• Ensure that they are aware of the content of this PGN and supporting Appendices

• Ensure that they attend the appropriate level of training for their staff group • Ensure that they abide by their governing bodies professional code of practice

at all times

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2.4 The Resuscitation and Medical Emergencies and Physical Health and Wellbeing

groups will provide the clinical governance assurances for this PGN 2.5 In accordance with the code; standards of conduct, performance and ethics for

nurses and midwives (Nursing and midwifery council 2008), all nurses are accountable for their actions or omissions regardless of advice or guidance given by another professional. As such nurses are able to extend their scope of practice, within the healthcare legal framework, but must ensure that they have the knowledge and skills to do so in a competent manner. If competency levels are not adequate, support and supervision must be sought from a competent practitioner.

2.6 Other practitioners/disciplines will abide by their professional bodies codes, and

advice in undertaking this practice. 2.7 This Practice Guidance Note (PGN) should be read in conjunction with the Trust

Policies, CNTW(C)01- Consent to Examination or Treatment. 2.8 The Physical Health and Wellbeing Group (PHWG) will provide clinical governance

support for sepsis implementation. 2.9 This PGN document will sit within the Trust’s CNTW(C)29 – Trust standard for the

assessment and management of physical health policy. 3. Consent 3.1 The Department of Health states: “It is a general legal and ethical principle that valid

consent must be obtained before starting treatment, physical investigation or providing personal care” (DOH). All patients/clients have a right to receive accurate information about their condition and intended treatment. It is the responsibility of individual practitioner proposing to carry out the treatment to ensure that the patient/client understands what is proposed (NMC 2002).

3.2 This PGN also reflects principles under the Human Rights Act 1998

Article 5: The right to liberty and security of person

Article 8: The right to privacy

Article 10: Confidentiality

3.3 The term “consent” refers to the service user’s agreement for a health professional to provide care, or agreement to participate in education or research. Service users may indicate consent non-verbally, orally or in writing. Consent will need to be gained for the procedure, research and any educational/supervisory purpose.

3.4 For the consent to be valid the service user must have capacity to make that

particular decision. The Mental Capacity Act 2005 details assessment of capacity and best interest decisions. The service user should firstly be assumed as having capacity to make decisions if the person capacity is in question an assessment must

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be carried out and documented. A person is unable to make a decision for themselves if they are unable to:

Understand the information relevant to the decision

Retain that information

Use or weigh that information as part of the process of making the decision

Communicate their decision (whether by talking, using sign language or any other means)

3.5 If a person does not have the capacity to consent to this procedure a ‘best interests’ decision must be made by the person carrying out the procedure. This must consider any advanced decision or advanced statement made by the person. Any decision must be in the best interests of the service user and follow the principles of the least restrictive option possible. Best interest decision must also be documented. For further advice on consent/capacity please consult the Trust’s policy CNTW(C) 05 - Consent to Examination or Treatment.

3.6 At all times staff will make reference to the Mental Capacity Act and practice code in

relation to medical emergency situations and interventions. Pertinent paragraphs within the code are 3.6, 5.26, 6.35, 6.37 and 9.56 - 3.6 ‘Clearly, in emergency medical situations….urgent decisions will have to be made and immediate action taken in the persons best interest. In these situations, it may not be practical or appropriate to delay the treatment while trying to help the person make their own decisions, or to consult with any known attorneys or deputies. However, even in emergency situation, healthcare staff should try to communicate with the person and keep them informed of what is happening’.

4. Who is at risk? 4.1 Potentially anyone can develop sepsis after an injury or infection, although some

people are more vulnerable, such as:

People with medical condition or receiving medical treatment that weakens their immune system (people who have had a splenectomy, or people with sickle cell disease)

People that have Diabetes

People already in hospital with serious illness

Very young or old

People who have just had surgery

Those with wounds or injuries

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Immunosuppression/blood dyscrasia (e.g. Clozapine especially but other antipsychotics and anticonvulsants)

Treatments for other medical conditions that may lead to immunosuppressed state (e.g. chemotherapy, previous splenectomy, post-transplant patients)

Alcohol and substance misuse and risk of localised infection (self-harm, IV drug use) and long-term steroid use

Anyone that has been previously treated for sepsis has increased risk factors for reoccurrence and should be closely monitored with Multi-Disciplinary Team (MDT) awareness

Patients with low BMI secondary to eating disorders. Patients at low BMI often have a very different base line (low BP, low pulse rate, low core temperature) and therefore constantly trigger alerts when we use NEWS-2. It is also important to appreciate that patients with low BMI may react to sepsis by their observations becoming closer to normal, example: pulse rate may go from low to normal; temperature may go from low to normal) this can lead to early signs of sepsis not being detected. Therefore effective, dynamic care-planning is paramount to reflect individualised health presentations

Additional risk factors for women who are pregnant or who have been pregnant, given birth, had a termination or miscarriage within the past 6 weeks. Specific risk indicators include: gestational diabetes or diabetes or other comorbidities including invasive procedures such as caesarean section, forceps delivery, removal of retained products of conception

Other factors to consider are prolonged rupture of membranes, continued vaginal bleeding or discharge or have been in close contact with people with group A streptococcal infection, for example scarlet fever

5. Implementation 5.1 Sepsis assessment tool will be implemented collaboratively through following groups:

Nursing Directorate: Instigating sepsis tool within individual care planning

Medical Directorate: Instigate sepsis tool when treating infection/prescribing antibiotics

Pharmacy Department: Can act as a prompt for sepsis tool implementation through monitoring antibiotic use, drug audits and prescription systems

Infection, Prevention and Control (IPC) Department: Instigate sepsis tool through ward/department based IPC support and IPC training - mandatory

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Tissue Viability specialists: During any direct ward/department tissue viability support, advice/guidance and training

The sepsis tool will be highlighted within junior doctor’s rotational placement induction within CNTW, through Medical Education

All nursing staff must receive local ward/department induction that includes use of sepsis tool

Sepsis will be signposted in all CPR training sessions and training provided through Foundation Physical Skills and Advanced Physical Skills training programmes

CNTW intranet for independent reference and clinical support will have the Sepsis PGN, Assessment Tool and Guidance Notes

CNTW SharePoint reference material under Academy and Sepsis Icons

Sepsis will be cross reference with the National Early Warning Score NEWS-2, Paediatric Early Warning Score PEWS (currently going through CNTW clinical trial) and SBAR (Situation, Background, Assessment and Recommendation) communication Tool

5.2 The tool design is based upon initial paper versions but the format allows for adoption

within the E-Systems at a later stage. 5.3 Staff must complete a safeguard report when a patient has a known or suspected

infection, treated with antibiotics. 5.4 The standard ward review documented on RiO will be utilised using the standard

format on medications and this will act as a prompt in regards antibiotic use. Progress notes to identify improvement or monitor.

5.5 IPC matrons currently receive a weekly update from pharmacy listing all patients who

have received or receiving antibiotics. This is checked on RiO to gain further information relating to the circumstances of antibiotic use and the infection. Again this could serve as a prompt to implement the sepsis tool.

5.6 Nurse practitioners involved in physical health monitoring and prescribing can assist

implementation. 5.7 All Physical Health Link/Champions nurses have covered sepsis as part of their

physical health advanced training and therefore are in an ideal position to assist and support local ward/department implementation of the tool.

5.8 The current review and implantation of NICE guidance for urinary tract infection and

antimicrobial resistance will include sepsis reference.

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5.9 The Trust’s CNTW(C)18 - Tissue Viability Policy practice guidance notes will cross reference to sepsis.

6. Clinical indicators and Treatment 6.1 Treatment requires early recognition, assessment and treatment in specialist acute

clinical settings. 6.2 The sepsis tool will be instigated for all known, suspected and treated infections. 6.3 Any primary infection will be managed accordingly and care-planned with risk factors

discussed in conjunction to sepsis tool implementation. 6.4 When the sepsis tool is actioned this will be translated into care-planning within the

MDT. 6.5 The lead doctor will direct initial management and discuss any on-going changes in

presentation that will require further intervention and this will be documented and shared with the nursing team.

6.6 Frequency of on-going physical observations which may include: Temperature,

Pulse, Respiration, Blood Pressure, Oxygen Saturation and Blood Glucose levels will be identified and maintained, if requested by medical staff or the patient is a diabetic.

6.7 Sepsis can interfere with Blood Glucose regulation such as a resulting Transient

Hyperglycaemia. Look for any deviations from normal Blood Glucose range. If a person is diabetic this would require care-planning and be supported by the corresponding Blood Glucose Monitoring Chart: PGN 06 Guidelines for the Safe Prescribing, Administration and Monitoring (Appendix 1) of Insulin and oral anti-diabetic drugs (incorporating PPT PGN 02 - Treatment of acute hypoglycaemia in hospitals without an on-site Duty Doctor).

6.8 Sepsis can interfere with Fluid balance regulation and result in both poor intake and

reduced urine output. If a person has difficulties maintaining fluid balance, this should be care-planned and supported by the corresponding Fluid Balance Chart: CNTW’s Fluid Balance Monitoring Chart: PPT-PGN- CNTW 15 Appendix 4 Fluid Balance.

6.9 The CNTW Sepsis Assessment Tool uses a high index of suspicion and must be

actioned for all known, suspected and/or treated infections. It also works effectively in conjunction with the National Early Warning Score NEWS-2 within Adult Services & the Paediatric Early Warning Score PEWS within Children’s Service 5-16 years (PEWS currently going through and CNTW clinical trial).

6.10 Both the NEWS-2 and PEWS Observation Charts record normal base-line physical

parameters and then identify any deviations in subsequent observations that could suggest deteriorating health. They also include operational Clinical Guidance Notes to support the Observation Charts and accompanying Practice Guidance Notes (PGN).

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6.11 Underlying health conditions can be either chronic in nature or an acute presentation to a known or unknown health condition and in both cases individual care-planning would be expected.

6.12 Observations may already identify that a person has lower or elevated baseline

readings that are in fact normal for them or reflect their underlying health. Individuals may already score on the NEWS-2 and possibly show variations in the PEWS, so thresholds and sensitivity for response may need to be altered. Any change from baseline is still significant, even if not scoring on the NEWS-2 or PEWS and care must be escalated.

6.13 It is important to consider expected changes to observations (such as a possible

result of known or suspected infection) and those changes that would not be expected. For example low grade temperature due to minor viral infection would be expected but an accompanying fall in oxygen saturation and systolic blood pressure would not and would be a trigger for concern. Monitoring and escalate of car for any change in observation is expected, even if they don’t represent a scoring indicator within both the NEWS-2 or PEWS observation parameters.

6.14 When recording observations be aware that people may respond to infection differently, so older people with an infection may not develop an increased heart rate but may develop a new arrhythmia. Further heart rate response may be affected by medicines such as beta –blockers.

6.15 The Sepsis Assessment Tool, NEWS-2 and PEWS record a range of observations

but cannot describe the context, behaviour, specific individual medical conditions or background history and so must work in conjunction to effective care-planning and communication. The Sepsis Tool therefore looks for broader individual presentation other than just recordable physical observations.

6.16 Where the National Early Warning Score (NEWS-2) (See Trust’s CNTW(C)29 – Trust

standard for the assessment and management of physical health, practice guidance note – AMPH-PGN-03-NEWS-2) is operationally used this will still be maintained and will assist in on-going physical health assessment in support of the sepsis tool.

6.17 Where sepsis is identified or suspected, immediate 9-999 Medical Emergency

Services will be accessed and the known or suspected diagnosis of sepsis made clear.

6.18 The on-call doctor will be contacted for immediate response but this is secondary to

the 9-999 medical emergency response activation. 6.19 In all cases where escalation of care is required the CNTW SBAR Communication

Tool will be used. This identifies Situation, Background, Assessment and Recommendation. This proves ordered and structured framework for communication to assist in prioritizing and triaging appropriate response.

6.20 Staff will instigate continued physical observations including Airway, Breathing,

Circulation, Disability and Exposure (ABCDE) and on-going assessment of response

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using the ACVPU (Alert, sudden onset/acute Confusion, disorientation or delirium responds to Voice, responds to Pain stimuli and Unresponsive).

6.21 Nursing staff will follow principles in relation to Cardio-pulmonary Resuscitation

including emergency use of high flow oxygen. 7. Post Sepsis Risk factors 7.1 In some cases following sepsis, people can be more prone to developing further

infections, and therefore have an increased risk of readmission with infective complications (including sepsis). Therefore these could be at an increased risk if they acquire COVID-19. In 2012 in the journal Shock, researchers found that sepsis survivors may be more vulnerable to developing viral respiratory (lung) infections.

7.2 COVID-19 as an infection can in itself cause sepsis. 7.3 Using a broad definition of sepsis as a life-threatening condition that arises when the

body’s over-inflammatory response to infection injures its own tissues and organs. Clinical information form COVID-19 cases indicates a percentage of COVID-19 infections can result in such organ failure, meaning that some people develop kidney failure or shock rather than only respiratory failure.

8. Post-sepsis syndrome 8.1 Post-sepsis syndrome (PSS) is a condition that appears to affect up to 50% of people

following sepsis. It can include both physical and/or psychological impacts and can be long-term in nature. Such things as:

Decreased cognitive (mental) functioning

Loss of self-esteem

Depression

Difficulty with sleep

Concentration difficulties

Hallucinations

Panic attacks

Disabling muscle or joint pain/aches 8.2 PSS appears higher following admission to an intensive care units (ICU) and for

those who have been in the hospital for extended periods of time. 8.3 PSS can affect people of any age. 8.4 Causes of their PSS can be multiple, varied and individualised in nature. 8.5 Long lasting physical issues such as amputations, damaged organs can perhaps be

explained to an extent but PSS can present as disabling fatigue, chronic pain. And seemingly unrelated problems such as hair loss.

8.6 Many people that have that have had sepsis also report symptoms of post-traumatic

stress disorder (PTSD).

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8.7 Doctors, nurses and other healthcare professionals must recognise PSS syndrome in order to offer further emotional, psychological, physical therapy or neurorehabilitation support.

8.8 Due to the potential secondary complications and susceptibility, following sepsis

episode this will be logged as a Rio Alert. 9. Training 9.1 NICE Guidance indicates that all healthcare professionals involved in triage or early

management are given regular appropriate training which includes:

Early identification and assessment (managing of sepsis in appropriate clinical setting)

Local protocols for early treatments

Criteria and pathways for escalation in-line with their health care setting

9.2 Sepsis awareness, recognition and management are covered in all Advanced Physical Health (PH) Training session and are seen as a fundamental core scenario within PH simulation.

9.3 All qualified nurses in the role of ‘local’ Physical Health Link or Champions’ must

attend the Advanced PH two-day training programme. 9.4 IPC will include a specific section promoting sepsis awareness within the IPC training

presentation. This is a mandatory course and it is hoped this will facilitate Trust-wide promotion.

9.5 Sepsis will be covered in the wound assessment session that all Tissue Viability

Nurse links attend at induction. 9.6 The sepsis tool and use of physical observations can work in conjunction with the

National Early Warning Score system (NEWS-2) and CNTW aims to embed this with both ‘local’ training and clinical response (See Trust’s CNTW(C)29 – Trust standard for the assessment and management of physical health, practice guidance note – AMPH-PGN-03 – NEWS-2).

9.7 CNTW promotes the use of effective structured communication when escalating care

by use of the SBAR framework: Situation, Background, Assessment, Recommendation and Decision. The SBAR is covered in Cardio-Pulmonary Resuscitation (CPR) at Immediate Life Support (ILS) level, Foundation Physical Health Skills and Advanced Physical Health Skills.

9.8 Both the NEWS-2 PEWS and SBAR are presented to all junior doctors within their

CNTW placement and cross reference with Sepsis. 9.9 Sepsis will be signposted in all CPR sessions at both Basic Life Support and

Immediate Life Support levels.

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9.10 Sepsis will covered in all Foundation and Advanced Physical Health Skills Training course.

9.11 Sepsis will be highlighted within the junior doctor induction programme. 9.12 Sepsis will be highlighted through ‘local’ mentor check list’ for Junior doctor

placements. 9.13 Sepsis reference material will also be kept on CNTW intranet ‘SharePoint’ under

Academy and Sepsis icons. 10. Infection Prevention and Control 10.1 In all cases CNTW IPC guidance will be adhered to, reflecting the latest

Governmental and Public Health England Guidance on COVID-19, in relation to safe care delivery and use of personal protective equipment (PPE).

11. Record keeping/Audit 11.1 The sepsis tool will be completed and kept as hard copy and remain ‘live’ until the

individual is medically clear from infection and sepsis risk. 11.2 All observation will be recorded on CNTW NEWS-2 and PEWS observations charts 11.3 Within the web-based incident reporting system there will be a specific sub-cause for

sepsis (PI16) in order to identify all incidents. This information will help evaluate the impact of the sepsis assessment tool and provide data for the Physical Health and Wellbeing Trust group. The senior clinical trainer and document author will receive sepsis incident data in order to provide support and advice to the PHW group.

11.4 All post Sepsis incidents will be logged as a Rio Alert. 11.5 Any escalation of care, sepsis identification and subsequent actions, must be

communicated and recorded using the IR1 reporting form and logged on the Rio System.

11.6 All physical health evaluations will be recorded in both medical and nursing notes

and within MDT care-planning. 11.7 This PGN is also sited within the Trust’s CNTW(C)29 – Trust standard for the

assessment and management of physical health policy and health screening standards.

11.8 The PHW group and Patient Safety will review sepsis incidents within CNTW through

annual Sepsis Audit.

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12. Further Reading with health education support material for care-staff and service users

www.sepsistrust.org

www.survivingsepsis.org

https://www.sepsis.org/sepsis-basics/post-sepsis-syndrome/

https://campaignresources.phe.gov.uk/resources/campaigns/54-sepsis/overview

https://www.nhs.uk/conditions/sepsis

www.world-sepsis-day.org

www.ncepod.org.uk/sepsis

https://www.nice.org.uk/guidance

https://www.nice.org.uk/guidance/ng51

https://www.nice.org.uk/guidance/qs161

http://www.sepsistrust.org/

http://www.survivingsepsis.org/



https://www.nhs.uk/conditions/sepsis

http://www.world-sepsis-day.org/

http://www.ncepod.org.uk/sepsis

https://www.nice.org.uk/guidance

https://www.nice.org.uk/guidance/ng51

https://www.nice.org.uk/guidance/qs161

Documents

-PGN 05… · 6/3/2020 · AMPH-PGN-05 4 Cumbria, Northumberland Tyne and Wear NHS Foundation Trust AMPH-PGN-05-Sepsis Management-V03- June 2020 Part of CNTW(C) 29-Trust standards