GP mythbuster 88: Identifying and responding to sepsis

GPs and practices providing in-hours services may not encounter sepsis frequently, but early detection is vital.

What is sepsis?

Sepsis is the body’s life-threatening response to infection. It can be catastrophic if undetected and untreated, leading to tissue damage, multiple organ failure and death. See the international definition of sepsis and the Sepsis Alliance definition.

It can affect anyone but is more common in people who have a weakened immune system, a long-term condition, and those who are very young or are frail. The incidence is particularly high in patients with a learning disability.

Identifying sepsis

Sepsis affects many different organs so it can be hard to spot.

A full history and set of physical observations can support clinical judgement to make this difficult diagnosis. These include trying to identify a possible source of infection and checking a person’s:

• pulse
• temperature
• oxygen saturations
• blood pressure
• respiratory rate
• altered mental state, consciousness, alertness and confusion
• risk factors
• deterioration in function
• rashes, mottling and cyanosis.

A raised respiratory rate, poor perfusion or low blood pressure, and new onset confusion are particularly important to record as they provide a better indication of sepsis than the other measures.

Practices must be aware of sepsis and be able to demonstrate how to identify and manage an acutely unwell or deteriorating patient before and during an appointment. This includes any ongoing referral or care.

The priority should be to arrange for an immediate review by a senior clinician. This may be face-to-face if the patient is in the practice, or remotely if the patient is off site.

The Royal College of GPs (RCGP) supports the use of physiological measurements in a general practice setting for all patients at risk of deterioration. However, the RCGP suggests further research into evidence on the use of NEWS2 in a primary care setting.

All patients who have any of the high-risk criteria for sepsis should be transferred to hospital immediately using the 999 response. Practitioners should make it clear at handover to the ambulance service they have high risk criteria for sepsis, in line with NICE guidance, alongside the patient’s physiological measurements to aid early identification and treatment.

The secondary care team should be informed in advance of the patient’s arrival to the emergency room. For patients who do not meet the criteria, there should be a low threshold for progressing to a face-to-face assessment.

Symptoms

Babies and young children

Symptoms of sepsis may include:

• abnormal temperature – low as well as high
• difficulty (or rapid) breathing
• lack of interest in eating and drinking, or have stopped feeding
• not passing urine for 12 hours or longer
• repeated vomiting
• being sleepier than usual or difficult to wake
• a high-pitched cry
• change in mental state including unresponsiveness or agitation
• irritability
• mottled pale or bluish skin, or a rash that does not fade when pressed

Parental concern is another key feature that needs to be considered.

Adults and older children

Symptoms may include:

• feeling extremely unwell
• abnormal temperature – low as well as high
• chills and shivering
• a fast heartbeat
• fast breathing or difficulty breathing
• feeling dizzy or faint
• decreased urine production
• a change in mental state, such as confusion, disorientation or agitation

See:

• Signs of Sepsis, the UK Sepsis Trust
• Symptoms of sepsis, NHS England
• Sepsis toolkit, Royal College of General Practitioners. This provides clinical resources and guidance for GP practices
• Recognition, diagnosis and early management of sepsis, NICE

When we inspect

GP practices should take measures to help manage the risks associated with sepsis. We may consider these as part of our inspections:

Regulation 12 (Safe care and treatment)

Regulation 18 (Staffing)

Areas we may look at:

• Does training enable staff to recognise and respond to acutely unwell or deteriorating patients who may have sepsis?
• Do all staff, including receptionists, know how to recognise what doesn’t sound right and to raise concerns? See the RCGP Sepsis Toolkit for training resources.
• Are patients able to access appointments and triage when needed?
• Do triage processes include identifying and rapidly responding to possible cases of sepsis?
• Is appropriate equipment available and accessible to assess patients with possible sepsis, including emergency equipment and medicines, and pulse oximeters for adults and children? See our guidance on Resuscitation in GP surgeries.
• Are oxygen cylinders accessible to provide oxygen therapy.
• Are staff aware of the Patient Safety Alert regarding the placement of pulse oximeter probes?
• How do you ensure there is a high uptake of vaccinations, particularly flu vaccinations in children and babies, people aged over 65, pregnant women, and those with underlying and long-term conditions, especially people with a learning disability?
• Do you have systems for ‘safety netting’ and follow up care?
• Do you use sepsis assessment and audit tools and consider auditing the management of patients referred to secondary care?
• Are incidents and any themes relating to sepsis used for learning and improvement?
• Do you record and share clear and accessible information about a patient’s condition, including accurate physiological measurements?
• Have you implemented effective infection control processes?
• Is information and advice about sepsis available on the practice website or in patient leaflets to raise awareness and promote early recognition in the local community? Do you give this to patients who are at a higher risk and their carers?