Deaths from sepsis recorded in England’s hospitals have risen by more than a third in two years, according to data collected by a leading safety expert.
According to Sir Brian Jarman, the director of the Dr Foster research unit at Imperial College London, the number of recorded deaths where the primary cause was sepsis was 11,328 in 2014-15. By 2016-17 there were 15,722 deaths in hospital or within 30 days of discharge where sepsis was the leading cause, an increase of 38.8%.
Jarman, whose unit sends real-time alerts to hospitals that fall behind the expected mortality rate, blamed the increase partially on the consequences of real-terms funding cuts.
“The biggest thing that’s important seems to be the number of staff – doctors per bed,” he told BBC Radio 4’s Today programme in August. “One of the secondary important things is the overcrowding of hospitals. The level of overcrowding shouldn’t be more than 85% [bed occupancy], and it’s been going over 90% in recent years.”
Jarman, a former president of the British Medical Association, said the number of beds available had halved and the number of admissions had roughly doubled over the past 30 years – an “amazing change of provision of healthcare”.
In 2015, an inquiry found that 40% of patients with sepsis who arrived in A&E had not been reviewed by senior doctors quickly enough. There were also avoidable delays in giving patients intravenous antibiotics in nearly a third of cases (29%).
Every death from sepsis is a tragedy, yet too often the warning signs are missed – there is a need to get far better at spotting sepsis across the NHS and this advice shows how vital it is for clinicians to treat life-threatening symptoms as soon as possible.
Last year, Jeremy Hunt, then the health secretary, told a private memorial service for a one-year-old boy who died from sepsis that the child was let down by the NHS and the government.
Speaking at the service in Cornwall, Hunt said he had “come here to say sorry” to the family of William Mead, who died after the emergency services failed to diagnose a fatal case of sepsis. Hunt told those gathered at Truro Cathedral: “I as health secretary, the government, and the NHS, let down William.
“I’ve come here to say sorry. This weekend William should have been enjoying beautiful Cornish sunshine with his parents.
“We didn’t spot his sepsis before it was too late.”
William’s mother, Melissa Mead, has become a prominent campaigner for better diagnostics of sepsis, saying that the NHS system was “broken”.
She has also described her son’s final hours, his symptoms and her repeated pleas to health services in painstaking detail on her blog site.
In February 2017, I developed sepsis, which is caused by an overly aggressive immune response to an infection. In my case, it happened because I had developed pneumonia while I had ‘flu. In sepsis (sometimes called septicaemia) the immune response causes widespread and severe inflammation and a drop in blood pressure (‘shock’), which leads to organ damage and other life threatening complications. The problem is that people often feel unwell when they have an infection, and sepsis is insidious. It can advance very rapidly. I developed pneumonia and sepsis within four days of starting with influenza symptoms, by the fourth evening, my symptoms had become life threatening.
I thought my symptoms were simply because I had a severe strain of influenza, and hadn’t realised I had developed pneumonia. My sons had both been very poorly the week before, while they had the ‘flu, too. By the time I knew something was very wrong, I was already in septic shock, and despite having an almost overwhelming urge to crawl back to my warm bed and just sleep, a sudden weird sense of impending doom kept me from doing so. Had I gone back to bed, I would never have woken again.
Although Jarman believes that staff shortages and overcrowding on wards are partly to blame for the rise in sepsis, NHS England have said more conditions were being classed as sepsis than before, and a spokesperson added that efforts had also been made to improve diagnosis. However, it’s not quite true that more deaths from sepsis are being recorded as being caused by sepsis.
Dr Ron Daniels, chief executive of the UK Sepsis Trust and an intensive care consultant, said sepsis was one of the most common causes of death in the UK, it’s responsible for killing up to 44,000 people a year – in hospital and in the community.
He said that hospital records made it almost impossible to keep track of the true number of deaths through sepsis, because, he added: “It’s very common that if someone dies of sepsis that it’s coded or reported as simply being the underlying infection.
“So they might die of sepsis in an intensive care unit with multiple organ failure – but they’re recorded as a death from pneumonia. We need to fix that problem before we can truly understand the scale of sepsis.
“The best way for us to do that is to develop a prospective data system like a registry that exists for other conditions, so that we can really get a national picture of what’s going on.”
He added: “The treatment for sepsis, if it’s caught early enough, involves very basic interventions – looking for the source of the infection, giving antibiotics.
“For every hour we delay in giving antibiotics, the patient’s risk of dying increases by a few per cent, so it’s essential that we spot it early and deliver the basics of care quickly.”
Jarman hopes his research data can be used to improve the survival chances of hospital patients who developed sepsis, via alerts that he sends to hospitals that are falling behind.
He said “Some of those hospitals with a lower death rate have got particular ways of reducing mortality from septicaemia, which the others we hope might learn from, and also we hope that by giving them this alert, within a month or two of the actual happening, they can actually get in there and do something quickly.”
There has been more of a focus on screening for sepsis in the NHS in recent years, led by the UK Sepsis Trust, which was formed by a group of clinicians at the Good Hope Hospital near Birmingham.
However, the fact that deaths from sepsis are commonly recorded as being caused by an underlying infection, rather than abnormal immune response to it – sepsis – means that gathering mortality data about hospital practices in diagnosis and management of sepsis is likely to lead to inaccurate results and cannot be relied on to improve recognition and diagnostic practices, or treatment.
Some reasons why sepsis is increasing
Vulnerability to sepsis is becoming more widespread. This is thought to be for a number of reasons:
- More opportunities for infections to become complicated – more people are having invasive procedures and organ transplants, and more of us are taking immunosuppressive drugs and chemotherapies
- Rising antibiotic resistance – microbes are becoming immune to drugs that would otherwise control infections
People more likely to get sepsis include:
- Those with underlying lung disease, such as COPD and asthma
- Those with illnesses that affect their immune response, such as HIV, leukaemia, chronic illness such as diabetes, lupus, and some other connective tissue /autoimmune diseases
- Those taking immunosuppressant therapies, such as people who have had organ transplants, those with autoimmune illnesses, those with cancer having chemotherapy, or those on long-term steroid treatment
- Those who have had their spleen removed
Other predictors of higher severe sepsis incidence rates include socioeconomic status (those in poverty and destitution are at greater risk), and urbanicity.
In a context of austerity and cuts to basic social security and the NHS, it seems almost inevitable that cases of sepsis will increase.
Any infection can trigger sepsis, including minor accidental cuts and insect bites that have become infected, but the following types of infections are more likely to cause sepsis:
- Abdominal infection
- Kidney/ urinary tract infection
- Infection of the gallbladder
- Some cases of ‘flu
Symptoms of sepsis include:
- Fever above 101ºF or a temperature below 96.8ºF (above 38.3º Celsius or below 36º C)
- Heart rate higher than 90 beats per minute (tachycardia)
- Fast, shallow breathing – rate higher than 20 breaths per minute (tachypnea)
Other symptoms may be:
- Dizziness or feelings of faintness
- Confusion or a drop in alertness, or any other unusual change in mental state, including a feeling of doom or a real fear of death
- Slurred speech
- Diarrhoea, nausea, or vomiting
- Severe muscle pain and extreme general discomfort
- Difficulty breathing – shortness of breath
- Low urine output (not needing to urinate for a whole day, for example)
- Skin that is cold, clammy, and pale, blue, discolored or mottled
- Skin that is cool and pale at the extremities, signaling poor blood supply (poor perfusion)
- Loss of consciousness
It’s crucial to seek immediate medical attention if someone has more than one or two those symptoms, though loss of consciousness and severe breathing difficulty always need urgent medical attention.
The earlier you seek treatment, the greater are the chances of survival.
Sepsis medical criteria
There are two tools or sets of criteria that doctors use to determine the severity of your condition. One is the systemic inflammatory response syndrome (SIRS). SIRS is defined when you meet two or more of the following criteria:
- Fever of more than 38°C (100.4°F) or less than 36°C (96.8°F), often with chills and shivering
- Heart rate of more than 90 beats per minute (tachycardia)
- Respiratory rate of more than 20 breaths per minute or arterial carbon dioxide tension (PaCO 2) of less than 32 mm Hg
- Abnormal white blood cell count
Another tool is the “quick sequential organ failure assessment” (qSOFA). It uses the results of three criteria:
- Low blood pressure
- High respiratory rate (greater than 22 breaths per minute)
- Glasgow coma scale score of less than 15. (This scale is used to determine your level of consciousness.)
A positive qSOFA is determined if two or more of the above measurements are abnormal. Some doctors prefer using qSOFA because unlike the SIRS criteria, qSOFA does not require laboratory tests and so may be used to make a prompt assessment. This means it can also be used by paramedics – as it was in my case. The results of either or both of these assessments will help doctors determine care promptly.
Tests, diagnosis and treatment of sepsis
The first step that doctors and paramedics take in diagnosing sepsis is to observe the symptoms. Sepsis is a major challenge to diagnose, and in Intensive Care Units it’s one of the leading causes of death. It is also a leading cause of people being readmitted to hospital. Sepsis arises unpredictably and can progress very rapidly.
When doctors observe the typical signs and symptoms of sepsis, they will also consider the patient’s medical history and be alerted to possible sepsis if there has been a recent infection, a surgical or catheter procedure, or if the patient is particularly vulnerable to infection – because of compromised immunity, for example.
The main treatment for sepsis and septic shock is antibiotics, as most cases are caused by a bacterial infection, though viral and fungal agents less commonly may also cause sepsis. If someone has severe sepsis and septic shock, antibiotics will be given directly into a vein (intravenously). Often other support is provided, such as oxygen, ventilation, or dialysis, is also given to support organ function, depending on how well a person’s organs are coping. Methods to stabilise blood pressure are often used, along with administered anticoagulants to prevent blood clots.
Ideally, antibiotic treatment should start within an hour of diagnosis to reduce the risk of serious complications or death. Intravenous antibiotics are usually replaced by tablets after two to four days (though sometimes longer). Antibiotics may have to take them for 7 to 10 days or longer, and often for a while after someone leaves hospital, depending on the severity of their condition.
Doctors may have to make a quick “best guess” at the type of infection and, therefore, the type of antibiotics needed, because speed in treating the infection is of the greatest importance; waiting for laboratory sample tests would hold up a potentially lifesaving intervention. Treatment may be adjusted once the causative microbe has been identified.
Antibiotics alone may be sufficient at a very early stage of sepsis, but treatment needs to be given very promptly.
For later stages of sepsis and septic shock, emergency hospital treatment will be needed (often in the intensive care unit); additional to the IV antibiotics, it may include:
- Intravenous fluids (especially during the first 24 to 48 hours after admission, if you have severe sepsis or septic shock.
- Vasopressors (to raise blood pressure)
- Central lines
- Anticoagulants (to prevent blood clots)
- Other means of organ support as necessary, such as oxygen therapy, mechanical ventilation or dialysis
Severe sepsis is associated with a drop in blood pressure. Low blood pressure reduces the amount of oxygen and nutrients going to the body’s organs. This drop causes damage to the body’s major organs.
Septic shock advances when adequate blood pressure cannot be restored despite treatment with IV fluids. Septic shock may progress very quickly to multiple organ failure and death.
Complications from septic shock may cause symptoms of:
- Kidney failure
- Lung failure
- Heart failure
- Blood clots
Prompt medical attention, diagnosis and treatment are key to surviving sepsis.
Often, paramedics may test for a rise in blood sugar as hyperglycemia is very common in people who are critically ill with sepsis, regardless of whether they have diabetes. Mine had risen despite the fact I had been unable to keep food down for four days. Mine is usually on the low side generally, but it had risen while I was ill. No one really knows why this happens.
Laboratory tests at the hospital include a blood test to measure C-reactive protein (CRP), which is a substance in the blood that is produced by the liver, and it is used to measure levels of inflammation in the body. It’s used often to test for some types of autoimmune illness flares, too.
A CRP level of more than 10 milligrams per litre (10mg/L) indicates clinically significant inflammation. However, when someone has a severe infection such as pneumonia, it is usually very high – often between 100-200, and sometimes higher. A high CRP is generally linked with infection severity, and a CRP of 200 + is fairly common in sepsis. A CRP above 300 is associated with a poorer prognosis. Mine was 396 by the time I got to hospital.
CRP tests are very clever science and extremely useful. It’s not possible to make a diagnosis from the test result alone, but used in conjunction with other tests, CRP results can support a diagnosis. And the CRP level may also be used to judge how effective treatments are. The CRP “resolves” – comes down quite quickly, often before a patient starts to feel better – when their treatment, such as antibiotics, is successful. Two or three days into the IV antibiotic treatment, my CRP was down to 193.
Other biochemical tests include blood clotting assessments, a white cell count, measurements of serum lactate, procalcitonin and something called alkaline phosphatase, all of which collectively may helpt to diagnose a severe infection and a severe systemic inflammatory response syndrome (SIRS), which is the key feature of sepsis
Testing is usually done to determine which family of bacteria has caused the infection so that antibiotic treatment may be tailored to treat it.
It’s important that doctors maintain a high suspicion of sepsis when someone hasan infection and symptoms, which is necessary to help prevent deaths.
In my case, the paramedics were highly suspicious of sepsis because I was tachycardic, my breathing was rapid, and I had an impeding sense of doom. My temperature was very raised and my blood glucose was raised. My blood pressure had plummeted to 70/40. There were no oxygen exchange noises in my lower lungs, so pneumonia was quickly diagnosed. An x ray later confirmed the pneumonia. I was given IV fluids to help raise my blood pressure and an antibiotic in the ambulance. I have no doubt these measures helped save my life.
Early suspicion of sepsis helps save lives.
I wrote about my own experience of sepsis here, which includes more detailed information. The most shocking part ofthis experience was the fact I had not realised I was so gravely ill. So I wanted to raise awareness of this insidious and often fatal condition: Surviving sepsis: awareness raising and a case study
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