Quality statement 2: Senior review and antibiotic treatment | Sepsis | Quality standards

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 an immediate review by a senior clinical decision-maker and antibiotics given within 1 hour if indicated.

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

The following measures can be used to assess the quality of care or service provision specified in the statement. They are examples of how the statement can be measured, and can be adapted and used flexibly.

Structure

a) Evidence of local arrangements for immediate review by a senior clinical decision-maker 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: No routinely collected national data for this measure has been identified. Data can be collected from information recorded locally by healthcare professionals and provider organisations.

b) 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: No routinely collected national data for this measure has been identified. Data can be collected from information recorded locally by healthcare professionals and provider organisations.

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 have an immediate review by a senior clinical decision-maker.

Numerator – the number in the denominator who have an immediate review by a senior clinical decision-maker.

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: No routinely collected national data for this measure has been identified. Data can be collected from information recorded locally by healthcare professionals and provider organisations.

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 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: No routinely collected national data for this measure has been identified. Data can be collected from information recorded locally by healthcare professionals and provider organisations, for example, using local prescribing data.

Outcome

Rates of in-hospital mortality for people with sepsis.

Data source: No routinely collected national data for this measure has been identified. Data can be collected from information recorded locally by healthcare professionals and provider organisations, for example, using NHS Digital Hospital Episode Statistics and Office for National Statistics primary care mortality database.

What the quality statement means for different audiences

Service providers (secondary care services) ensure that a senior clinical decision-maker is available for immediate review of people with suspected sepsis and at least 1 of the criteria indicating high risk of severe illness or death. 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) seek an immediate review from a senior clinical decision-maker if they identify at least 1 of the criteria indicating high risk of severe illness or death from sepsis.

Commissioners ensure that acute hospital settings can demonstrate that there is immediate review by a senior clinical decision-maker and intravenous antibiotics are given if indicated 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-threatening illness from sepsis have a review by a senior healthcare professional and antibiotics started within 1 hour if needed 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. NICE guideline NG51 (2016), 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.'

**Table 1 Antibiotic treatment for suspected sepsis**
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 table 2 are at high risk of severe illness or death from sepsis.

**Table 2 Criteria indicating 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

Be aware that some pulse oximeters can underestimate or overestimate oxygen saturation levels, especially if the saturation level is borderline. Overestimation has been reported in people with dark skin. See also the NHS England Patient Safety Alert on the risk of harm from inappropriate placement of pulse oximeter probes. [NICE's guideline on sepsis, recommendations 1.4.2, 1.4.5 and 1.4.8]

Immediate review

Review by a senior clinical decision-maker for people with high risk of severe illness or death should take place as soon as possible and within a timeframe that enables provision of antibiotics within an hour if indicated. [Expert opinion]

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]