Quality statement 2: Senior review and antibiotic treatment

Quality statement

People with suspected sepsis in acute hospital settings and at least 1 of the criteria indicating high risk of severe illness or death, have the first dose of intravenous antibiotics and a review by a senior clinical decision-maker within 1 hour of risk being stratified.

Rationale

Sepsis is a medical emergency and needs urgent senior review to identify the source of infection and ensure that people receive appropriate treatment. A senior decision-maker is also more likely to recognise if there is another potential cause for the person's severe illness. For people at high risk of severe illness or death from sepsis, the clinical benefits of having the first dose of intravenous antibiotics within an hour outweigh any risks associated with possible antimicrobial resistance.

Quality measures

Structure

a) Evidence of local arrangements to ensure urgent assessment mechanisms are in place to deliver antibiotics to people with suspected sepsis in acute hospital settings within 1 hour of any high risk criteria of severe illness or death from sepsis being identified.

Data source: Local data collection.

b) Evidence of local arrangements for a senior clinical decision-maker to be available within 1 hour for people with suspected sepsis in acute hospital settings and at least 1 of the criteria indicating high risk of severe illness or death from sepsis.

Data source: Local data collection.

Process

a) Proportion of people with suspected sepsis in acute hospital settings and at least 1 of the criteria indicating high risk of severe illness or death from sepsis who receive the first dose of intravenous antibiotics within 1 hour of risk being stratified.

Numerator – the number in the denominator who receive the first dose of intravenous antibiotics within 1 hour of risk being stratified.

Denominator – the number of people with suspected sepsis in acute hospital settings and at least 1 of the criteria indicating high risk of severe illness or death from sepsis.

Data source: Local data collection, for example, using local prescribing data.

b) Proportion of people with suspected sepsis in acute hospital settings and at least 1 of the criteria indicating high risk of severe illness or death from sepsis who have a review by a senior clinical decision-maker within 1 hour of risk being stratified.

Numerator – the number in the denominator who have a review by a senior clinical decision-maker within 1 hour of risk being stratified.

Denominator – the number of people with suspected sepsis in acute hospital settings and at least 1 of the criteria indicating high risk of severe illness or death from sepsis.

Data source: Local data collection.

c) The percentage of people who were diagnosed with sepsis in emergency departments and acute inpatient services and received intravenous antibiotics within 1 hour of diagnosis.

Numerator – the number in the denominator who received intravenous antibiotics within 1 hour of diagnosis.

Denominator – the number of people who were diagnosed with sepsis in emergency departments and acute inpatient services.

Data source: This is taken directly from NHS England's National 2017/19 CQUIN.

Outcome

Rates of in-hospital mortality for people with sepsis.

Data source: Local data collection, for example, using Hospital Episode Statistics and Office for National Statistics mortality database.

What the quality statement means for different audiences

Service providers (secondary care services) ensure that a senior clinical decision-maker is available to review the care of people with suspected sepsis and at least 1 of the criteria indicating high risk of severe illness or death within 1 hour of risk being stratified. Mechanisms should also be in place to give the first dose of intravenous antibiotics within 1 hour of any high-risk criteria being identified.

Healthcare professionals (such as healthcare professionals working in emergency departments) give intravenous antibiotics and seek a review from a senior clinical decision-maker within 1 hour of identifying at least 1 of the criteria indicating high risk of severe illness or death from sepsis.

Commissioners (such as clinical commissioning groups and NHS England) ensure that acute hospital settings can demonstrate that intravenous antibiotics are given and there is review by a senior clinical decision-maker within 1 hour of at least 1 of the criteria indicating high risk of severe illness or death due to sepsis being identified.

People with symptoms that suggest life-threating illness from sepsis have antibiotics and a review by a senior healthcare professional within 1 hour to make sure that they have the best treatment as soon as possible. If it will take more than an hour to get to hospital, the antibiotics may be given by healthcare professionals in primary care or by ambulance staff.

Source guidance

Sepsis: recognition, diagnosis and early management (2016) NICE guideline NG51, recommendations 1.6.1, 1.6.16, 1.6.31 and expert consensus

Definitions of terms used in this quality statement

Antibiotic treatment for suspected sepsis

The NICE quality standard on antimicrobial stewardship includes the statement: 'People in hospital who are prescribed an antimicrobial have a microbiological sample taken and their treatment reviewed when the results are available.'

Age

Symptoms

Antibiotics

NICE recommendation(s)

All

Clear source of infection

Local antimicrobial guidance

1.7.6

All

Fever and purpuric rash suggesting meningococcal disease

Parenteral benzyl penicillin in community settings
Intravenous ceftriaxone in hospital settings

1.7.5

18 years and over

No confirmed diagnosis but empirical intravenous antimicrobial needed

Local formulary

1.7.7

Up to 17 years (excluding neonates)

Suspected community acquired sepsis of any cause

80 mg/kg once a day ceftriaxone with maximum daily dose of 4 g

1.7.8

Up to 17 years

Suspected sepsis already in hospital, or known to have previous infection or colonisation with ceftriaxone-resistant bacteria

Local antimicrobial guidance

1.7.9

Under 3 months

Suspected sepsis

Additional antibiotic active against listeria (for example, ampicillin or amoxicillin)

1.7.10

Neonates

Presenting in hospital with suspected sepsis in their first 72 hours

Intravenous benzyl penicillin and gentamicin

1.7.11

Neonates over 40 weeks corrected gestational age

Community acquired sepsis

Ceftriaxone 50 mg/kg unless receiving i.v. calcium
Cefotaxime 50 mg/kg every 6 to 12 hours (depending on age) if receiving i.v. calcium

1.7.12

Neonates 40 weeks corrected gestational age or under

Community acquired sepsis

Cefotaxime 50 mg/kg every 6 to 12 hours (depending on age)

1.7.12

Criteria indicating high risk of severe illness or death from sepsis

People with any of the symptoms or signs in the table below are at high risk of severe illness or death from sepsis:

Symptoms or signs

Adults, children and young people aged 12 years and over

Children aged 5 to 11 years

Children under 5 years

Behaviour

Objective evidence of new altered mental state

  • Objective evidence of altered behaviour or mental state, or

  • Appears ill to healthcare professional, or

  • Does not wake (or if roused, does not stay awake)

  • No response to social cues, or

  • Appears ill to a healthcare professional, or

  • Does not wake, or if roused does not stay awake, or

  • Weak, high-pitched or continuous cry

Respiratory rate

  • 25 breaths per minute or above, or

  • New need for 40% oxygen or more to maintain oxygen saturation more than 92% (or more than 88% in known chronic obstructive pulmonary disease)

  • Aged 5 years, 29 breaths per minute or more

  • Aged 6 to 7 years, 27 breaths per minute or more

  • Aged 8 to 11 years, 25 breaths per minute or more

  • Oxygen saturation of less than 90% in air or increased oxygen requirement over baseline

  • Aged under 1 year, 60 breaths per minute or more

  • Aged 1 to 2 years, 50 breaths per minute or more

  • Aged 3 to 4 years, 40 breaths per minute or more

  • Grunting

  • Apnoea

  • Oxygen saturation of less than 90% in air or increased oxygen requirement over baseline

Heart rate

130 beats per minute or above

  • Aged 5 years, 130 beats per minute or more

  • Aged 6 to 7 years, 120 beats per minute or more

  • Aged 8 to 11 years, 115 beats per minute or more

  • Or heart rate less than 60 beats per minute at any age

  • Aged under 1 year, 160 beats per minute or more

  • Aged 1 to 2 years, 150 beats per minute or more

  • Aged 3 to 4 years, 140 beats per minute or more

  • Heart rate less than 60 beats per minute at any age

Blood pressure

Systolic blood pressure of 90 mmHg or less, or more than 40 mmHg below normal

Urine

Not passed urine in previous 18 hours (for catheterised patients, passed less than 0.5 ml/kg/hour)

Temperature

  • Less than 36ºC

  • Aged under 3 months and temperature 38ºC or more

Appearance

  • Mottled or ashen, or

  • Cyanosis of skin, lips or tongue, or

  • Non-blanching skin rash

  • Mottled or ashen, or

  • Cyanosis of skin, lips or tongue, or

  • Non-blanching skin rash

  • Mottled or ashen, or

  • Cyanosis of skin, lips or tongue, or

  • Non-blanching skin rash

[NICE's guideline on sepsis, recommendations 1.4.2, 1.4.5 and 1.4.8]

Senior clinical decision-maker

Depending on local arrangements the senior clinical decision-maker for people aged 18 years or over should be a doctor of grade CT3/ST3 or above or equivalent, or an advanced nurse practitioner with antibiotic prescribing responsibilities.

[NICE's guideline on sepsis, recommendation 1.6.1]

The senior decision-maker for people aged 5 to 17 years is a paediatric or emergency care qualified doctor of grade ST4 or above or equivalent.

[NICE's guideline on sepsis, recommendations 1.6.1 and 1.6.16]

The senior clinical decision-maker for children under 5 years is a paediatric qualified doctor of grade ST4 or above.

[NICE's guideline on sepsis, recommendation 1.6.31]

Suspected sepsis

Suspected sepsis is used to indicate people who might have sepsis and require face-to-face assessment to determine whether they need urgent intervention.

Symptoms of sepsis can include, but are not limited to:

  • high body temperature or low body temperature

  • fast heartbeat/breathing

  • feeling dizzy or faint/loss of consciousness

  • a change in mental state, for example, confusion or disorientation

  • diarrhoea/nausea and vomiting

  • slurred speech

  • severe muscle pain

  • breathlessness

  • reduced urine production

  • cold, clammy and pale or mottled skin.

People with sepsis may have non-specific, non-localised presentations, for example, they may feel very unwell, and may not have a high temperature.

[NICE's guideline on sepsis and expert opinion]