Quality statement 4: Escalation of care

Quality statement

People with suspected sepsis in acute hospital settings who receive intravenous antibiotics or fluid bolus are seen by a consultant if their condition fails to respond within 1 hour of initial treatment.

Rationale

Septic shock is associated with a high risk of death, so specialist input is important for people who have not had significant improvement after initial treatment. Being looked after by specialist healthcare staff, including a consultant, can improve clinical outcomes for these people.

Quality measures

Structure

Evidence of acute hospital settings having arrangements in place which ensure that people with suspected sepsis are seen by a consultant if their condition fails to respond within 1 hour of initial intravenous antibiotics or fluid bolus. This includes ensuring a consultant is available to attend promptly.

Data source: Local data collection.

Process

Proportion of people with suspected sepsis in acute hospital settings who are seen by a consultant if their condition fails to respond within 1 hour of initial intravenous antibiotics or fluid bolus.

Numerator – the number in the denominator who are seen by a consultant.

Denominator – the number of people with suspected sepsis in acute hospital settings whose condition fails to respond within 1 hour of initial intravenous antibiotics or fluid bolus.

Data source: Local data collection.

Outcome

Rates of 28-day all-cause mortality in 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 consultant is available to see people with suspected sepsis if their condition fails to respond within 1 hour of initial intravenous antibiotics or fluid bolus.

Healthcare professionals (such as healthcare professionals working in emergency departments) ask a consultant to see people with suspected sepsis if their condition fails to respond within 1 hour of initial intravenous antibiotics or fluid bolus. Consultants attend promptly when asked to see people with suspected sepsis in these circumstances.

Commissioners (such as clinical commissioning groups) ensure that they commission services in acute hospital settings in which consultants are available to see people with suspected sepsis if their condition fails to respond within 1 hour of initial intravenous antibiotics or fluid bolus.

People with symptoms that suggest life-threating illness and that fail to improve within 1 hour of treatment see a consultant. The consultant will be able to arrange specialist treatment to prevent septic shock.

Source guidance

Sepsis: recognition, diagnosis and early management (2016) NICE guideline NG51, recommendations 1.6.7, 1.6.22 and 1.6.37

Definitions of terms used in this quality statement

Failure to respond

In adults and young people aged 12 years and over, failure to respond is indicated by any of:

  • systolic blood pressure persistently below 90 mmHg

  • reduced level of consciousness despite resuscitation

  • respiratory rate of 25 breaths per minute or above, or a new need for mechanical ventilation

  • lactate not reduced by more than 20% of initial value within 1 hour.

[NICE's guideline on sepsis, recommendation 1.6.7]

In children aged 5 to 11 years, failure to respond is indicated by any of:

  • reduced level of consciousness despite resuscitation

  • respiratory rate:

    • 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

  • heart rate:

    • 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

  • lactate remains over 2 mmol/litre after 1 hour.

[NICE's guideline on sepsis, recommendation 1.6.22]

In a child under 5 years, failure to respond is indicated by any of:

  • reduced level of consciousness despite resuscitation

  • respiratory rate:

    • 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

  • heart rate:

    • 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

  • lactate over 2 mmol/litre after 1 hour.

[NICE's guideline on sepsis, recommendation 1.6.37]

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]