Recognition and management of sepsis in General Practice

Jun 16, 2021

Although sepsis is rare, it is a life-threatening condition and patients can deteriorate rapidly. GPs must be vigilant for signs and symptoms, and know what to do when they encounter it. When sepsis is suspected in a patient at high risk, they must be referred to hospital as a time-critical medical emergency.

Cases of sepsis are rising. According to The UK Sepsis Trust, recent estimates put the annual UK caseload at ~245,000 and, with a mortality of around 20%, deaths have reached nearly 50,000 each year.

Sepsis is difficult to spot – even for the most experienced clinicians – and it may have devastating outcomes despite all reasonable care. However, delays in recognition and treatment of sepsis can lead to avoidable deaths and clinical negligence claims. When best practice is implemented, NHS England estimates that 10,000 lives could be saved each year.

NICE guideline and tools for sepsis

GPs should be familiar with the NICE guideline [NG51], ‘Sepsis: recognition, diagnosis and early management’, together with NICE’s algorithms and risk stratification tools. These are organised by patient age group and location (‘in hospital’ or ‘out of hospital’).

NICE recommends:

1. Think ‘could this be sepsis?’ if a person presents with signs or symptoms that indicate possible infection – the flowchart will help you decide.
2. If sepsis is suspected, use the appropriate algorithm and tools to stratify the patient’s risk and see what care NICE recommends.
3. Always refer back to the NICE guideline for recommendation details.

NICE recommendations can also be viewed in an interactive flow chart.

Assessing a person for sepsis

Assess a person with any suspected infection to identify the possible source of infection, risk factors for sepsis, and indications of clinical concern (such as abnormalities in behaviour, circulation or respiration). Pay heed to concerns raised by relatives or carers.

• For the appropriate physiological assessments and guidance on interpretation of findings, refer to NICE’s algorithms and risk stratification tools and the NICE guideline.

Be particularly alert for signs of sepsis during a remote consultation, and have a low threshold for offering a face-to-face assessment.

The Royal College of General Practitioners’ (RCGP) Top Tips advises GPs to consider using the templates in GP clinical systems to record findings. Not only is this useful for ongoing care of patients with sepsis, but also for documenting when signs of sepsis were absent.

When to escalate care

Refer any person presenting to primary care with suspected sepsis “for emergency medical care by the most appropriate means of transport (usually 999 ambulance) if:

• they meet any high risk criteria, or
• they are aged under 17 years, and their immunity is impaired by drug or illness and they have any moderate to high risk criteria.”

Assess people with suspected sepsis with moderate to high risk criteria; if a definitive diagnosis cannot be reached or they cannot be treated safely outside of hospital, refer them urgently for emergency care.

Handover to ambulance services

Given the urgency of sepsis treatment, clear communication with the ambulance service is crucial.

Convey concern using the words “SUSPECTED SEPSIS” and share the findings of your physiological assessment and any scoring system (such as NEWS2). The Care Quality Commission (CQC)  says: “Early indications are that mortality from sepsis falls at sites using scoring systems routinely at patient handover”.

While awaiting transfer to hospital, be aware that septic shock has a mortality of 7.6% for every hour that antibiotic therapy is delayed. Where transfer time to hospital is >1 hour, NICE recommends that GP practices have mechanisms in place to start antibiotic treatment.

Safety netting

Provide adequate safety netting advice for patients assessed for sepsis who are discharged home, even if they do not have a diagnosis of sepsis.

This means providing verbal and written information about sepsis, the tests and investigations that were done, which symptoms to monitor, and when and how to get medical attention if their illness continues or they need help urgently.

Additional resources

• RCGP’s Sepsis toolkit is designed for GPs and other healthcare professionals assessing people in the community. It includes resources for training and education, creation of sepsis aware communities and practices, as well as patient support.
• The Sepsis Trust offers a wealth of information for clinicians as well as decision support tools for GPs, based upon the NICE Sepsis Guidance:
• GP Paediatric Sepsis Decision Support Tool (Under 5)
• GP Paediatric Sepsis Decision Support Tool (Aged 5-11)
• GP toolkit for Adults and young people aged 12 and over.
• In GP mythbuster 88: Sepsis, CQC provides guidance on good practice in management of sepsis and what is expected upon inspection.

If you need advice or support as a result of a sepsis-related incident or claim, please speak to a member of our expert team today: contact us at Medical Defense Society.

Telephone triage systems: how to avoid the pitfalls

Jun 2, 2021

Telephone triage has been defined as ‘prioritising client’s health problems according to their urgency, educating and advising clients and making safe, effective and appropriate decisions’. It is a complex clinical skill. As GP practices moved rapidly to a ‘total triage’ model, driven by the pandemic, clinicians and other staff may have been thrown into telephone triage without specific training.

Without visual cues and opportunity for physical examination, telephone triage presents a risk of inappropriate management and adverse outcomes, potentially leading to complaints and claims. However, GPs and practices can take steps to avoid the pitfalls and use telephone triage systems with confidence.

Effective telephone triage brings benefits

Telephone triage systems can benefit patients and healthcare providers alike, if they are used well. A majority of GPs surveyed across the UK reported that they increased efficiency. They may be cost-effective and lighten workload, reducing the need for face-to-face appointments and home visits.

For patients, telephone triage may enhance access, facilitating immediate access for urgent care or allowing flexibility for non-urgent care. It may even provide opportunities for patient education on self-care, reducing dependency on face-to-face appointments.

What are the risks and pitfalls?

In ‘Telephone Triage and Consultation – Are We Really Listening?’, published by RCGP, Sally-Anne Pygall provides a ‘how to’ manual for GPs and nurses in primary care. She emphasises: “If it is not performed correctly, it will not yield the benefits, will increase the risks and could significantly increase workload.” One of the biggest risks is delaying or denying a face-to-face consultation when one is needed, but offering an inappropriate face-to-face appointment also risks increasing dependency and using resources needed by another patient.

The manual explains common reasons that telephone triage fails:

• Making assumptions without checking understanding.
• Lack of visual cues causing uncertainty and mistriage.
• Communication barriers – caller difficulties in accurately describing or recalling the history, poorly phrased questioning from the triager, and other communication or language barriers.
• Triage with a third party, especially when they are not with the patient.
• Poor communication due to lack of engagement with the patient.
• Time constraints – this may lead to an untimely conclusion; lack of information gathering; inappropriate outcomes; and poor interaction.
• Patient perception that telephone triage reduces their access to care.
• Patients not liking telephone triage – so they complain or feel dissatisfied as a result.
• Lack of clinician satisfaction and burnout – reducing the motivation to perform triage well.
• Poor documentation. This opens up the risk of legal liability.

If triage does lead to a claim or complaint, Medical Defense Society can provide expert advice.

Tips for effective telephone triage

GP practices can reduce the risk of failures by providing specific guidance and training. The Royal College of GPs (RCGP) offers an online course on Telephone Consultation and Triage Skills and guidance in ‘Remote versus face-to-face: which to use and when?’.

Triagers should guide a caller through a well-defined triage system. Pre-agreed scripts can help staff explain how to access services and what to expect, with reassurance that face-to-face care is available when clinically appropriate. Clear protocols are needed for recognising red-flag symptoms.

Staff performing telephone triage can follow these key points:

• Understand the limitations of telephone triage.
• Know who you are speaking to and check contact details.
• Consider safeguarding, capacity and confidentiality issues.
• Prioritise calls based on urgency.
• Take enough time to gather information and actively listen to the callers’ concerns.
• Recognise patient needs – for clinical advice over the phone or with a face-to-face appointment, or any other mode of consultation.
  • GMC provides a flow chart to help decide when it’s usually safe to treat remotely.
  • When a patient calls repeatedly about the same problem, have a low threshold for a face-to-face appointment or onward referral.
• Jointly agree on an acceptable consultation method with the patient, taking into consideration their needs and preferences, the circumstance, local risks of COVID-19 and national guidance (see updated NHS England standard operating procedures for general practice).
• Direct patients to the appropriate member of the clinical team or other service.
• Set clear expectations for patients: explain the triage process, timescales for call-backs, and what to do if symptoms get worse.
• Provide safety nets: explain when to contact the practice again if a healthcare professional has not been in touch.
• Check understanding of the patient’s concerns. Check the patient has understood advice.
• Keep adequate documentation.

Remember…

GMC’s remote consultation ethical hub reminds clinicians providing services remotely to:

• Follow guidance on consent and good practice in prescribing
• Work within your competence
• Check you have adequate indemnity cover for your remote consultation activities
• Discuss this element of your practice with your responsible officer at appraisal.

Please contact our expert medico-legal team at Medical Defense Society if you need advice or support with legal matters related to tria