Guidance
Rationale and impact
- People with neutropenia or immunosuppression
- Initial assessment and examination
- Evaluating risk level in people with suspected sepsis in acute hospital settings, acute mental health settings and ambulances
- Outside acute hospital settings
- Managing suspected sepsis in acute hospital settings
- Finding and controlling the source of infection
Rationale and impact
These sections briefly explain why the committee made the updated recommendations and how they might affect practice.
People with neutropenia or immunosuppression
Recommendations 1.1.10 and 1.1.12
Why the committee made the recommendations
The committee carefully thought about care for people with neutropenia or immunosuppression, such as those on anticancer treatment and immunosuppressant therapies, because sepsis shares many of the same signs and symptoms as neutropenic sepsis. The committee agreed that people with suspected neutropenic sepsis are at very high risk and should be treated in line with NICE's guideline on neutropenic sepsis in people with cancer.
Initial assessment and examination
Why the committee made the recommendation
The committee agreed that the initial assessment is an important opportunity to identify people who are most at risk of sepsis. They noted that sepsis is hard to recognise (particularly in the initial stages), because the signs and symptoms are not specific. So when people who are unwell present multiple times to a GP or hospital with non-specific signs and symptoms, they may not initially be identified as at risk of sepsis. However, the committee agreed that this group is more likely to have sepsis, and they highlighted the need to ask people if they have presented before.
How the recommendation might affect practice
Asking people about multiple presentations can be done as part of the existing initial assessment, so should not require additional resources to implement. This information could allow sepsis to be diagnosed and treatment started earlier. This could reduce costs, because fewer critical care interventions would be needed at a later point.
Evaluating risk level in people with suspected sepsis in acute hospital settings, acute mental health settings and ambulances
Recommendation 1.1.8 and recommendations 1.11.4 to 1.11.9
Why the committee made the recommendations
Using the NEWS2 to evaluate risk from sepsis
Evidence showed an increased risk of ICU admission and mortality in people with suspected sepsis aged 16 and over associated with a NEWS2 score of 5 or more. This supports the findings of the 2022 AoMRC statement on the initial antimicrobial treatment of sepsis. It is also in line with the clinical experience of the committee.
The committee agreed, based on their knowledge and experience, that:
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the 4 NEWS2 score bands outlined in the 2022 AoMRC statement should be used to determine the level of risk from sepsis for someone in any of the settings where NEWS2 has been endorsed by NHS England (acute hospital settings, acute mental health settings and ambulances) [2024]
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a person's risk level should be re-evaluated each time new observations are made, in line with observation frequencies in the AoMRC report [2024]
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a person's risk level should be re-evaluated when there is deterioration or an unexpected change. [2024]
Interpreting NEWS2 scores
The committee discussed the importance of clinical judgement when interpreting the NEWS2 scores. They agreed that the NEWS2 should be used as a tool to support clinical decision making, not to replace clinical judgement. A NEWS2 score should thus be interpreted within the context of the patient's history and physical examination results.
The committee also acknowledged that NEWS2 can be less accurate in people with certain conditions, such as people with spinal injury or heart or lung disease, because of their altered baseline physiology.
The committee also highlighted that mottled or ashen appearance, non-blanching rash or cyanosis of skin, lips or tongue can be signs of meningococcal disease. [2024]
NEWS2 score of 0
The committee discussed the care for someone with a NEWS2 score of 0. They were concerned that a score of 0 may be interpreted as indicating that there was no risk and no action was needed. They emphasised that people with a possible or confirmed infection and a NEWS2 score of 0 are still at risk of sepsis and should receive routine NEWS2 score monitoring in line with local practice.
They also agreed that acute illness is a dynamic state and treatment priorities must be adjusted over time. They agreed to highlight that deterioration or lack of improvement in the person's condition might indicate the need to take more urgent actions than suggested by their NEWS2 score alone, depending on any previous NEWS2 score or action already taken. [2024]
Single parameter contributing 3 points to a NEWS2 score
In the NEWS2 framework as defined by the Royal College of Physicians for the assessment of acute illness severity (that is, not specific to sepsis), specific attention is given to a NEWS2 score of 3 in a single parameter, which is classified as low-medium risk. The AoMRC report on the initial antimicrobial treatment of sepsis uses the NEWS2 to evaluate risk of severe illness or death from sepsis. It does not support systematic use of a single parameter contributing 3 points to a NEWS2 score to escalate care but does state that 'abnormal single parameters should be used to alert clinicians to the need for more detailed observation and investigation'.
The committee considered this issue at length. Despite the lack of evidence, and based on their clinical expertise, they agreed that:
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a single parameter contributing 3 points to a NEWS2 score is an important red flag suggesting an increased risk of organ dysfunction and further deterioration and
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in the presence of such a parameter, clinical judgement is key to carefully consider the likely cause of its extreme value and whether the person's condition needs to be managed as per a higher risk level than that suggested by their NEWS2 score alone. [2024]
How the recommendations might affect practice
The NEWS2 is already in use in most NHS acute care settings, emergency departments, ambulance services and mental health facilities in England. The committee agreed that recommending its use to evaluate risk of severe illness or death from sepsis in these settings would further improve consistency in the detection of and response to acute illness due to sepsis (for people for whom the NEWS2 can be used), at no further cost. [2024]
Outside acute hospital settings
Recommendation 1.12.3, recommendations 1.12.4 and 1.12.5, recommendations 1.12.6 and 1.12.8 and recommendation 1.12.11
Why the committee made the recommendations
When to transfer immediately: people in mental health settings
There was no evidence identified for acute mental health settings, so the committee recommended following local emergency protocols. [2024]
Transfer by ambulance for people with consecutive NEWS2 scores of 5 or above
The committee considered:
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settings and situations where a clinician with core competencies in the care of acutely ill patients may not be present, such as ambulances and mental health facilities
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important issues faced in rural areas, where transport to the nearest appropriate acute setting might take longer than in urban areas
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existing local and personal arrangements.
Because evidence shows a higher risk of acute deterioration in people with suspected sepsis and a persistent NEWS2 score of 5 or more, which would require timely management and treatment, they agreed that time-critical transfer and pre-alerting the hospital should be considered for these people. [2024]
Managing the condition while awaiting transfer
In remote and rural locations, there can be a long delay between a person initially being assessed as at high risk of severe illness or death from sepsis, and the assessment in the emergency department. To address this issue, the committee made recommendations on giving antibiotics outside of hospital. [2016, amended 2024] [2024]
In ambulance crews, only some paramedics are able to prescribe antibiotics. There is also variation in how services are organised across the country. Because of this, the committee did not think they could make detailed recommendations for all ambulance services, so they recommended following local guidelines. [2024]
The committee discussed the importance of antimicrobial stewardship and the potential for the recommendations to increase the use of broad-spectrum antibiotics. The committee did not think this would be an issue because:
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the recommendations only cover people at high risk of severe illness or death from sepsis, which narrows the group that could potentially receive broad-spectrum antibiotics
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this group will be narrowed further because broad-spectrum antibiotics will only be given to people if combined transfer and handover times to emergency departments are greater than 1 hour.
If immediate transfer is not required: people in mental health settings
No evidence was identified for acute mental health settings, so the committee made recommendations based on their expertise and experience.
The committee agreed that, in acute mental health settings, immediate transfer will not always be needed for people with a moderate, low or very low risk of severe illness and death from sepsis. [2024]
In people at moderate risk of severe illness or death from sepsis, the committee agreed that transfer to hospital may be needed, depending on the definitive diagnosis of the person's condition and whether it could be treated safely outside of hospital. The committee was aware that not all mental health settings would have the expertise to assess this, or to manage suspected sepsis or any other suspected or confirmed physical health conditions. Because of the variation in services, and the lack of evidence, the committee recommended following local emergency protocols on treatment and ambulance transfer. [2024].
People at low or very low risk of severe illness and death do not need immediate transfer, but their level of risk can still change rapidly. The committee recommended providing information to these people about which symptoms to monitor and how to access medical care if there are any causes for concern. [2024].
How the recommendations might affect practice
The committee carefully considered the threshold at which to prompt immediate transfer, to avoid an excessively high volume of referrals, that would put undue pressure on emergency departments and acute hospital wards, while also avoiding geographical inequalities associated with transfer time. The committee strived to create a better balance while avoiding a negative impact on current practice. [2024]
If not already in place, rural ambulance services may need to produce local guidance or put mechanisms in place to ensure antibiotics can be prescribed for people at high risk of severe illness or death from sepsis. This may involve:
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setting up processes for purchasing and storing broad-spectrum antibiotics
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collecting information from GPs, acute mental health settings or the emergency operator during a handover
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assessing existing resources within ambulance crews and how they are used across the service.
The recommendations may represent a big change in practice for some services, but once the relevant mechanisms are in place the resource impact on services would be minimal.
Managing suspected sepsis in acute hospital settings
Type and timing of antibiotics
Recommendations 1.13.3, 1.13.9, 1.13.10, 1.13.14, 1.13.15 and recommendation 1.14.1
Why the committee made the recommendations
Timing of antibiotics
Given the lack of direct evidence, the committee decided, by consensus, to recommend adopting the initial antimicrobial treatment of sepsis outlined in the 2022 AoMRC statement. That is, antibiotics should be offered to people with low, moderate and high risk of severe illness or death from sepsis, within a timeframe that depends on risk level. They should also be offered to people at very low risk, on a need for basis, in line with local practice.
The committee highlighted that:
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the purpose of deferring antibiotic delivery is not to delay treatment, but to have extra time to gather information for a more specific diagnosis, allowing for more targeted treatment
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the 1-, 3- and 6‑hour time limits are a maximum (rather than an aim) for each risk level
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clinical judgement is key when considering someone's specific care needs.
This explains why they also recommended that once a decision is made to give antimicrobials, administration should not be delayed any further.
The committee agreed that basing the risk evaluation and antibiotic delivery time on the NEWS2 would ensure due consideration is given to both patient safety and antimicrobial stewardship. [2024]
Single parameter contributing 3 points to a NEWS2 score
The committee agreed that a single parameter contributing 3 points to a person's NEWS2 score may be suggestive of organ dysfunction. The dysfunction may be caused either:
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by something other than the current infection or
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by the body's dysregulated response to the infection leading to organ failure (that is, by sepsis).
Based on their clinical expertise, the committee concluded that, if the likely cause of the 3 points in 1 parameter is the current infection, the person's risk of severe illness or death from sepsis is higher than that indicated by their NEWS2 score alone and the timeframe for antibiotic treatment should be adjusted accordingly. [2024, amended 2024]
When to count time from (time zero)
To guide the appropriate timing for delivering antibiotics, the committee discussed what constitutes time zero. After careful consideration, they agreed to define it as 'a first NEWS2 score calculated on initial assessment in the emergency department or on ward deterioration' and accompanied by suspected or confirmed infection. This is in line with the AoMRC report.
However, the committee raised concerns about possible inequalities and delays in clinical assessment and subsequent reviews that may be due to:
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geographical variability in transfer time and
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the high influx of patients and already strained NHS system. [2024]
They recognised that a long time might elapse between the moment a patient is first deemed to be at high risk and that of initial assessment in an emergency department, so they also agreed to make recommendations to address this issue. To this end, they wrote a new recommendation and amended, by consensus, an existing recommendation from the 2016 guideline to take account of situations where not only transfer time but also possible delays between arrival and initial assessment in the emergency department take more than 1 hour. For more information, see the explanation of the recommendations on managing the condition while awaiting transfer.
Type of antibiotics
As part of giving due consideration to both patient safety and antimicrobial stewardship, the committee agreed that:
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for people with suspected sepsis for whom the source of infection is unknown, broad-spectrum antibiotic treatment should be given within the recommended timeframe for the person's risk category
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once the source of infection is confirmed, source specific antibiotics should be used instead. [2024]
How the recommendations might affect practice
For ambulance services, mental health settings, and acute hospitals that are already using the NEWS2, the recommendations will not have a major impact on practice. Basing risk stratification and timing of antibiotics on NEWS2 score will balance patient safety, antimicrobial stewardship and resource capacity constraints. [2024]
Return to recommendations 1.13.3, 1.13.9, 1.13.10, 1.13.14, 1.13.15
High and moderate risk of severe illness or death from sepsis
Recommendations 1.13.2, 1.13.7, 1.13.8 and 1.13.11
Why the committee made the recommendations
The committee noted the importance of clear escalation pathways for care of people at high and moderate risk of severe illness or death from sepsis.
The committee recommended that clinicians with core competencies in the care of acutely ill patients (FY2 or above) conduct the initial assessment, because they have the competencies needed for this and should be able to assess people more urgently.
People at high risk are severely ill and may benefit from additional expertise in the management of their condition. Referral to the senior clinical decision maker is recommended because these senior doctors would be able to provide a more accurate diagnosis. Consultants can bring further expertise, but they may have limited availability, so the committee recommended that clinical judgement should be used when deciding if a discussion with a consultant is needed. [2024].
For people at high risk, the committee broadened the 2016 recommendation on escalation to cover lack of response within 1 hour of any intervention (the original recommendation only covered response to fluids and antibiotics). Given the level of risk for this group, the committee also felt it was appropriate to involve the senior clinical decision maker, the responsible consultant and the critical care specialist or team.
For people at moderate risk whose NEWS2 score remains the same or goes up following reassessment, there is a higher risk of poor outcomes and prompt intervention may be needed. Because of this, the committee recommended that care for this group should be escalated to a clinician with core competencies in the care of acutely ill patients.
How the recommendations might affect practice
The recommendation on initial assessment will ensure people are assessed quickly by a clinician with core competencies in the care of acutely ill patients and are able to start treatment without having to wait for a more senior doctor. This will allow treatment to start sooner and reduce pressure on more senior doctors.
The updated recommendation on escalation will reduce the number of referrals to critical care, as this is now only recommended for people who are not responding to interventions. The involvement of the senior clinical decision maker and responsible consultant is already current practice for people who are not responding to interventions, so this will not have a resource impact.
For people at moderate risk whose condition has not improved or deteriorated, escalation to a clinician with core competencies in the care of acutely ill patients is already current practice and so will not have a resource impact.
Discharge
Why the committee made the recommendation
By consensus, the committee removed recommendations on discharge for people at moderate and low risk of severe illness or death from sepsis. The committee did not think that the initial management period was the right time to consider discharge for people at these risk levels. The section of the 2016 recommendations on providing information and safety netting was retained, as this is applicable to everyone with suspected sepsis when they are eventually ready for discharge.
Low or very low risk of severe illness or death from sepsis
Recommendations 1.13.13 and 1.13.16, and recommendation 1.13.17
Why the committee made the recommendations
The committee agreed, based on their experience, that, all registered health practitioners would be capable of conducting the initial assessment for people at low or very low risk of suspected sepsis.
Antibiotics are more likely to be needed for people whose NEWS2 score remains the same or goes up following reassessment. Because of this, the committee recommended that care for this group should be escalated to a clinician with core competencies in the care of acutely ill patients.
Finding and controlling the source of infection
Recommendation 1.3.10 (amended), recommendation 1.13.1 and recommendation 1.17.4
Why the committee made the recommendations
The 2016 recommendation on involving surgical teams only covered intra-abdominal and pelvic infections. Infections at other sites can be treated surgically or radiologically, and the committee expanded the recommendation by consensus to address this.
The committee discussed the timing of interventions and agreed that this would vary depending on:
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the patient
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where the source of infection was
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if the intervention would be surgical or radiological
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if an interventional radiologist was available.
Because of this, the committee could not recommend a specific timeframe for interventions. However, they agreed that interventions should be carried out as soon as possible.
How the recommendations might affect practice
Prompt source control could mean fewer critical care interventions are needed at a later point, which would reduce costs.
Return to recommendation 1.3.10