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Sepsis in the community

Health campaigns are finally raising awareness of the life-threatening infection, sepsis. Independent nurse and health visitor Dorothy Karikari-Boateng takes a closer look, including how to spot and advise families on the infection.

Where is the place for sepsis as a discussion topic or technical subject in community health? Someone dies from sepsis globally every 3.5 seconds (UK Sepsis Trust, 2017) and it accounts for the majority of pregnancy-related deaths in the UK (Acosta et al, 2013). The WHO estimates that six million lives are lost to sepsis annually. Around 44,000 of these are in the UK (UK Sepsis Trust, 2017). 

It’s hard to overemphasise the importance of awareness of sepsis, its symptoms, and the steps to take in the event of a suspected case of sepsis in any health setting, in this case community health. Yet many people have either never heard of sepsis, or only in passing, until its devastating effects come knocking at their doors.

England and Wales had recent public health campaigns, and Northern Ireland is working with the UK Sepsis Trust to get a plan in place. Meanwhile, a campaign to raise awareness of sepsis in Scotland was announced at the end of September, albeit three weeks after the Scottish Government said it didn’t think such a campaign was ‘necessary at this time’ (BBC, 2017). 

These campaigns come after a number of medical and health organisations have been working for years to raise awareness and reduce mortality, with WHO making sepsis a global health priority in May this year (Reinhart et al, 2017).  

In this article we take a closer look at sepsis, its definition, causes, symptoms and treatments, and what a community practitioner can do when confronted with a suspected case of sepsis in the community, as well as resources for support.


Signs and symptoms

Children under five

If this age group show any sign of sepsis, immediate attention must be given. Symptoms in this age group include:

  • Altered mental state – drowsiness or lethargy
  • lBehavioural changes – refusal to feed, frequent/incessant crying, clinginess
  • Skin changes – mottled or ashen appearance, cyanosis of skin/mucous membranes, non-blanching rashes
  • Physiological changes – fewer wet nappies, infrequent passing of or lack of urine for 12 hours
  • Noisy breathing
  • Muscle pain and refusal to move (not their usual active self)
  • Extremely cold to the touch
  • Has a fit or convulsion.
  • Older children and adults
  • A change in mental state – such as confusion or disorientation
  • Nausea and vomiting
  • Slurred speech
  • Severe muscle pain
  • Severe breathlessness
  • Reduced urine production compared to normal Cold, clammy and pale or mottled skin
  • Loss of consciousness
  • Localised symptoms such as redness, swelling, heat and pain in an area of suspected infection. 

 

For all ages 

Using age-appropriate criteria, a community practitioner should stratify the severity of risk of sepsis based on: 

  • Temperature – above 38°C or below 36°C 
  • Breathing rate, as well as assessing breath sounds
  • Heart rate.

 

(Sources: NHS Choices, 2017; PHE, 2017; The UK Sepsis Trust, 2017) 


 

What is sepsis, exactly?

Sepsis is a life-threatening infection in the body that overwhelms the immune system so that the immune response causes damage to tissues and organs. It is often referred to as septicaemia or blood-poisoning, but these terms refer to the infection’s invasion of the bloodstream (the sequential step before sepsis, which may or may not occur) rather than the tissues and organs. It is also mistaken for septic shock, which is sepsis that causes dangerously low blood pressure (shock) – as a result, internal organs typically receive too little blood, causing them to fail. Septic shock is a possibility if sepsis goes untreated (NHS Choices, 2017; Singer et al, 2016).

Although bacterial infections are by far the most common cause of sepsis, viral and fungal infections can also be implicated. Sepsis can be triggered by an infection anywhere in the body, from something as small as a scratch on the skin right through to abdominal infections, lung infections, urinary tract infections, and post surgery. Sometimes the source of infection or site of origin are never found, so it’s important not to get bogged down in trying to locate the source.

 

Who is at risk?

Anyone can develop sepsis after an injury or minor infection, although some people are more susceptible. The groups at higher risk of sepsis (NICE, 2017; 2016) are:

  • The very young (under one year) and very old (over 75 years) or very frail older persons
  • Those who have just had surgery or an invasive procedure in the past six weeks 
  • Those with a weakened immune system, either because of  a medical condition (such as diabetes or sickle cell disease) or ongoing drug treatment (cancer patients, steroid users)
  • People with any skin breach (such as cuts, burns, blisters or skin infections)
  • People with in-dwelling lines, such as long-term catheters or feeding tubes
  • Women who are pregnant, postpartum or have had a termination or miscarriage within the past six weeks
  • People who are genetically prone to infections – for example, cystic fibrosis and lung infections
  • Anybody on a long inpatient stay with a serious condition, and anybody who has recently returned home from a long hospital stay.

 

What to look out for

Sepsis is difficult to identify with certainty even in the presence of a history of infection. The signs and symptoms at the early stages are often non-specific, resulting in missed diagnosis. Community practitioners must be tuned in and adopt a ‘could this be sepsis?’ attitude, especially when dealing with an unwell patient with an infection, and particularly in the higher risk groups. This way, you can help to reduce avoidable deaths. 

Having adopted this way of thinking, you need to make a face-to-face assessment of the person suspected of having sepsis, followed by stratifying the risks and putting into place a plan of action. 

Early symptoms of sepsis often resemble a viral illness. This makes sepsis difficult to diagnose (Journal of Family Health Care, 2016). However, if a child develops any of the ‘red flag’ symptoms (mottled, blue or pale skin; lethargic or difficult to wake; feels cold; fast breathing; non-blanching rash; fit or convulsion – see ‘Signs and symptoms’ on the previous page for an expanded list) then parents, carers and community practitioners must take immediate action.

 

What’s Next? Your role

Services provided by community practitioners are not intended to be a treatment or diagnostic service for the acutely unwell. However, when attending somebody who is unwell, the practitioner must have the knowledge to help parents and carers make a decision about the most appropriate course of action, and direct them to the most appropriate help, based on the presenting symptoms.

If you suspect sepsis, acting quickly is important. With consent, report your concerns to a GP as soon as possible. If a GP is not accessible, call NHS 111 (in Wales, NHS Direct 0845 46 47; In NI, GP out of hours).  and tell them you suspect sepsis. Using the national early warning score* is a great aid to help with decision-making. NICE sepsis guidance algorithms can also be a great help. 

If the patient has recently had an infection or injury, get urgent medical advice from a GP or NHS 111. This will help to stratify it into either medium or high risk. Severe sepsis and septic shock are medical emergencies. 

In fact, community practitioners should have direct access to their aligned GP surgery or local A&E department and should be able to get a doctor to see the patient within 30 minutes if possible (for red flag symptoms or all cases involving under ones and over 75s). 

Be alert if the patient has any additional factors that put them at higher risk. So for instance, if they are under one year old, over 75, have impaired immunity, just had a baby, or are not acting themselves (NICE, 2013). 

Computer templates such as Sick Patient EMIS, Sepsis SystemOne, which aids in recording and prompting, can help see what is abnormal for the age of your patient/client.


Professional resources

Sepsis in children: information for health visitors and school nurses (PHE, 2017) gov.uk/government/publications/sepsis-in-children-advice-for-health-visitors-and-school-nurses

Sepsis: recognition, diagnosis and early management: NICE guidelines QS161 (2017) nice.org.uk/guidance/qs161/history

Sepsis: recognition, diagnosis and early management: NICE guidelines NG51 (2016) nice.org.uk/guidance/ng51/chapter/Recommendations

Clinical tools (The UK Sepsis Trust in collaboration with NICE, NHS England and other experts) sepsistrust.org/education/clinical-tools/ 

Care of deteriorating patients. Consensus recommendations. SIGN 139 (Scottish Intercollegiate Guidelines Network, 2014) sign.ac.uk/assets/sign139.pdf

Sepsis toolKit (RCGP) rcgp.org.uk/clinical-and-research/toolkits/sepsis-toolkit.aspx

 

These can be highlighted to parents:

NHS Choices. Sepsis nhs.uk/Conditions/Blood-poisoning/Pages/Introduction.aspx

The UK Sepsis Trust. Spotting sepsis in children sepsistrust.org/wpcontent/uploads/2015/08/UST602_DL_6pp_SpottingSepsis_Leaflet_070716.pdf

The UK Sepsis Trust. What every parent needs to know about sepsis sepsistrust.org/wp-content/uploads/2015/07/Sepsissymptoms-leaflet.pdf


 

Advising parents and carers 

Make parents and carers aware of the signs and symptoms of sepsis, and when they should seek immediate medical attention. Give them information on local healthcare services, including the GP’s contact details, when to call 999 or attend the nearest A&E (for red flag symptoms), and when to call NHS 111 (Public Health England (PHE), 2017).

Parents and carers need to know that prevention is the best course of action to avoid the development of sepsis. For example, good hand hygiene can help, especially when handling food and caring for wounds. Children should be fully vaccinated according to the national immunisation schedule, against preventable infections. At-risk adults should have their pneumococcal vaccination and flu vaccines when advised. This will help to protect them from developing respiratory infections, which
can lead to sepsis.

About one in 10 sepsis cases follows a skin infection (Novosad et al, 2016). Wounds should be washed with soap and water, cleaning out any dirt or debris, and then covered. Good foot-care practices are vital for people with diabetes, since wounds can often develop dangerous infections.

A quarter of all sepsis cases are estimated to be a result of urinary tract infections (National Confidential Enquiry into Patient Outcome and Death, 2015), so these infections should be treated promptly. 

Also, patients should check with their GPs immediately about any infection that is not improving or seems to be getting worse with symptoms such as redness, swelling, discomfort and pain, localised heat in the affected area, or fever and chills. 

As well as these alerts, reassurance is important. Many people, especially children, recover from sepsis completely and their lives return to normal (PHE, 2017). 

In conclusion, the majority of sepsis cases are caused by community-acquired bacterial infections (rather than those that start in hospital) that are sensitive to antibiotic treatment. Less than 20% relate to healthcare-associated infections (Friedman, 2012). To put this in context, sepsis has the same frequency of occurrence as heart attacks, and a death rate close to that of lung cancer (NHS England, 2015). So awareness of sepsis and its symptoms as well as prompt management is imperative in community practice (McCarthy, 2016).

Picture credit | iStock


References 

Acosta CD, Knight M, Lee HC, Kurinczuk JJ, Gould JB, Lyndon A. (2013) The continuum of maternal sepsis severity: incidence and risk factors in a population-based cohort study. PLoS One 8(7): e67175. 

BBC News. (2017) Government announces u-turn on sepsis awareness campaign. See: bbc.co.uk/news/uk-scotland-41415560 (accessed 26 October 2017).

Friedman ND et al. (2002) Healthcare-associated bloodstream infections in adults: a reason to change the accepted definition of community-acquired infections. Ann Intern Med 137(10): 791-7.

Journal of Family Health. (2016) Think sepsis. See: jfhc.co.uk/think-sepsis (accessed 26 October 2017).

McCarthy K. (2016) How to avoid sepsis, a deadly medical emergency. See: consumerreports.org/doctors-hospitals/how-to-avoid-sepsis-deadly-medical-emergency/ (accessed 26 October 2017).

National Confidential Enquiry into Patient Outcome and Death. (2015) Sepsis: just say sepsis! See: www.ncepod.org.uk/2015sepsis.html (accessed 26 October 2017).

NHS Choices. (2016) Sepsis. See: nhs.uk/Conditions/Blood-poisoning/Pages/Introduction.aspx (accessed 26 October 2017).

NHS England. (2015) Improving outcomes for patients with sepsis: a cross-system action plan. See: england.nhs.uk/wp-content/uploads/2015/08/Sepsis-Action-Plan-23.12.15-v1.pdf (accessed 26 October 2017).

NICE. (2017) Sepsis: recognition, diagnosis and early management. NICE guidelines QS161. NICE: London.

NICE. (2016) Sepsis: recognition, diagnosis and early management. NICE guidelines NG51. NICE: London.

NICE. (2013) Fever in under 5s: assessment and initial management. NICE CG160. NICE: London.

Novosad SA et al. (2016) Vital signs: epidemiology of sepsis: prevalence of healthcare factors and opportunity for prevention. Morbidity and Mortality Weekly Report. 65(33): 864-9. 

Public Health England (2017). Sepsis in children – information for health visitors and school nurses. See: gov.uk/government/publications/sepsis-in-children-advice-for-health-visitors-and-school-nurses (accessed 26 October 2017).

Reinhart K, Daniels R, Kissoon N, Machado FR, Schachter RD, Finfer S. (2017) Recognizing sepsis as a global health priority – a WHO resolution. New England Journal of Medicine 377: 414-7.

Singer M et al. (2016) The third International consensus definitions for sepsis and sepsis shock (sepsis-3). JAMA 315(8): 801-10.

The UK Sepsis Trust. (2017) What is sepsis? See: sepsistrust.org/news/what-is-sepsis/ (accessed 26 October 2017).

The UK Sepsis Trust. (2017) Clinical tools. See: sepsistrust.org/education/clinical-tools/ (accessed 26 October 2017).

 

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