The following is evidence given to us by the College of Emergency Medicine.
The College was aware of the launch of the Surviving Sepsis Campaign and fully supported it, because the potential reduction in death, suffering and disability for patients is enormous. In 2008 an expert panel, including emergency physicians, consultants in intensive care and nurse consultants met on several occasions to develop a set of clinical standards, which were published and distributed to all consultants and emergency departments in May 2009. This is one of several initiatives the Clinical Effectiveness Committee is currently taking to focus on quality care and safety for sick patients presenting to emergency departments.
Following publication of these standards, one year was allowed for the implementation of these changes and the introduction of a care pathway for this important group of patients. This was followed in 2011 by a national audit against the College’s standards. 160 emergency departments (74%) participated and it was completed on 31 January 2012. On 18 May 2012 each participating trust was sent an individualised report containing their audit result, and direct comparisons with national results, so their performance could be clearly seen.
This audit covered key areas of quality of care:
- Recording of vital signs on arrival (temperature, pulse, blood pressure, and so on).
- Oxygen delivery on arrival.
- Taking of important blood tests, including culture for bacteria in the blood.
- Timely administration of powerful antibiotics.
- Starting intravenous fluids to restore or maintain blood pressure.
- Measuring the amount of urine to monitor response to treatment.
A detailed report with full findings is available at the College of Emergency Medicine website. www.collemergencymed.ac.uk
In summary, the results of the audit indicated that approximately 80% of patients receive good quality care, but that in the remaining 20% care is substandard. We are also aware, from previous smaller departmental audits and from the literature, that there are occasional catastrophes both within emergency departments and in hospital. This is a condition that can and does occur on the wards and is not exclusively an emergency department problem. Another striking feature was the variation between hospitals, and this is a common finding in our audits that we have been conducting for ten years. The development of the standard and the audit was the Clinical Effectiveness Committee addressing these very issues.
‘Once a septic patient has been identified, they should be managed as an urgent priority.’
The College of Emergency Medicine
It is also important to note that a septic patient is not like an accident victim or heart attack patient, where the diagnosis and the need for urgent treatment are usually immediately obvious. Septic patients present in many ways, with vague symptoms, and may be elderly with several illnesses (called co-morbidities) which disguise and complicate the diagnosis. Emergency departments are very busy, with ambulances and walk-in patients, arriving frequently, and it is not easy to identify this group of patients quickly in a complex environment. There are lots of pressures with chest-pain patients, strokes, severe pain, psychiatric conditions, distressed relatives, drunk or abusive patients, and so on. Frequently there are several patients requiring urgent treatment at the same time.
Following the audit, in July 2012 the following recommendations were made by the College and widely distributed to senior emergency department clinicians and trust clinical effectiveness/clinical audit teams.
It is clear from the audit results that some departments have successfully implemented a sepsis pathway, but other departments have not yet done so. If an emergency department has not put in place a system which identifies the potentially septic patient on arrival, this should be introduced at the earliest opportunity to prevent lives from being lost unnecessarily.
Once a septic patient has been identified, they should be managed as an urgent priority, ensuring early delivery of intravenous fluids and antibiotics. This should occur within one hour of arrival, wherever possible.
Prescription of oxygen and the initiation of urine output measurement are well below the required standard across emergency departments. This should be emphasised in training programmes and departmental protocols.
The College recommends that this audit is repeated in two years.
In addition to these recommendations, the College has had further discussions on how we can act upon the findings of the audit:
A fresh national awareness campaign on the importance of early diagnosis and treatment across the specialty before the repeat audit.
Communication with chief executives, trust boards and emerging clinical commissioning groups to make them aware and encourage support.
Early intervention of senior staff and extending the hours, especially in the evenings and weekends, where consultants are on the ‘shop floor’, which will require recruiting more consultants in some hospitals.
Renewed emphasis and frequency of training for nursing and medical staff in departmental and specialist training programmes.
Engaging more with nursing staff so that the departmental care pathways are jointly prepared and implemented.
Ensuring all emergency departments have a blood gas machine in the department that can measure lactate, so that results are available in minutes.