Recommendations for research
- 1 Epidemiological study on presentation and management of sepsis in England
- 2 A complex service evaluation of implementation of NICE Sepsis guideline
- 3 Use of biomarkers to diagnose and initiate treatment
- 4 Validation of clinical early warning scores in pre-hospital and emergency care settings
- 5 Derivation of clinical decision rules in suspected sepsis
The guideline committee has made the following recommendations for research.
What is the incidence, presentation and management of sepsis in the United Kingdom?
The lack of robust UK based epidemiological studies on the incidence and outcomes from sepsis have been clear throughout the guideline development process. A large epidemiological study to collect information about where sepsis is being treated, patient interventions and patient outcomes would provide population based statistics on epidemiology of sepsis which are necessary to support evaluation of interventions, planning of services and service redesign. The mortality and morbidity and service complexity associated with severe infection and sepsis, and the need to use broad spectrum antimicrobials to treat sepsis, justifies the cost required to set up such a study.
What effect will the NICE sepsis guideline have on patient care processes and outcomes in the UK over the next 5 years?
Implementation of NICE's guideline on sepsis will be a challenge to the NHS. A robust evaluation of how NHS service providers adhere to the recommended care processes needs to be carried out over the next 5 years.
A complex evaluation is needed to understand the effect of guidelines on services and on patient outcomes. Evaluation should include assessment of costs and cost effectiveness, the use of a universal audit tool for sepsis patient care that includes evaluation of pre-hospital and secondary care and monitoring of broad spectrum antibiotic use, development of multi-resistant organisms and incidence of antibiotic-related infection such as C. difficile.
What is the clinical and cost effectiveness of procalcitonin (PCT) point-of-care tests at initial triage for diagnosis of serious infection and the initiation of appropriate antibiotic therapy?
There is an urgent clinical need for accurate biomarkers of serious bacterial infection (SBI) which provide early diagnosis of SBI, and prompt clinical interventions to improve outcomes. The current tests used in the NHS (white cell count and C-reactive protein) are non-specific and not sensitive enough. Biomarker-guided initiation and termination of antibiotic therapy might be an effective strategy to reduce unnecessary antibiotic use and help prevent further multidrug resistance. The NICE diagnostics guidance on procalcitonin for diagnosing and monitoring sepsis has shown there is not enough evidence in this area.
Can early warning scores, for example NEWS (national early warning scores for adults) and PEWS (paediatric early warning score), be used to improve the detection of sepsis and facilitate prompt and appropriate clinical response in pre-hospital settings and in emergency departments?
Delay in detecting and treating sepsis increases mortality. Early detection and appropriate management will reduce morbidity and mortality and will reduce NHS costs by reducing critical care admissions, inappropriate antimicrobial use and length of hospital stay. No high quality data exist on the validation or use of early warning scores in pre-hospital settings or in the emergency department settings. The use of scores might improve communication between pre-hospital settings and hospital settings and allow recognition of people who need more urgent assessment.
Is it possible to derive and validate a set of clinical decision rules or a predictive tool to rule out sepsis which can be applied to patients presenting to hospital; with suspected sepsis?
In primary care and emergency departments people with suspected sepsis are often seen by relatively inexperienced doctors. Many of these people will be in low and medium risk groups but evidence is lacking as to who can be sent home safely and who needs intravenous or oral antibiotics. The consequences of getting the decision making wrong can be catastrophic and therefore many patients are potentially over-investigated and admitted inappropriately. Current guidance is dependent on use of individual variables informed by low quality evidence.