Information for healthcare services - Sepsis Clinical Care Standard

What the standard says

A diagnosis of sepsis is considered in any patient with an acute illness or clinical deterioration that may be due to infection. A clinical support tool that includes assessment of vital signs and lactate is used to help recognise sepsis early and escalate care when required.

What the quality statement means

For acute facilities, ensure that the implementation of protocols to support early recognition and escalation of care for sepsis is consistent with the NSQHS Standards, including actions from:

• Preventing and Controlling Infections Standard (Actions 3.18 and 3.19)
• Recognising and Responding to Acute Deterioration Standard (Actions 8.01 and 8.06)
• Comprehensive Care Standard (Action 5.10).

For primary and community healthcare services, including general practice, ensure that the implementation of triage protocols is consistent with the Primary and Community Healthcare Standards, including the ‘Recognising and responding to serious deterioration and minimising harm’ criterion from the Clinical Safety Standard.

Formalise and implement locally agreed clinical support tools to assist in structured screening and assessment for sepsis. The tools should include:

• Initial assessment and monitoring of vital signs
• Lactate measurement (in acute facilities)
• Other relevant observations and the clinical criteria for further evaluation to enable prompt recognition of sepsis.

In most cases, the relevant state or territory health department will have developed these for widespread implementation.

Implement protocols for using these tools, which should include:

• Regular education for all relevant staff in using the protocols and the criteria for sepsis recognition and management
• Universal and direct access to the clinical decision support tools
• Routine review of the use of the tools and measures, and evaluation of their effectiveness for detecting sepsis.

Support clinicians with accessing regular and ongoing training in sepsis recognition and management.

Provide access to point-of-care lactate testing and guidelines for its appropriate use in settings where sepsis may occur.

Consider embedding alert systems in electronic healthcare records, if system capacity allows.

Equity and cultural safety

Ensure that systems are in place so that patients can be assessed and cared for in a way that is free from racism, bias and assumption.

Educate and train staff in cultural awareness and cultural safety regularly.

Systemic barriers to presentation and taking a medical history may include language differences, communication issues, being from a vulnerable community (such as people with disabilities or people without housing) and a lack of cultural safety.

The incidence of sepsis is higher in Aboriginal and Torres Strait Islander peoples than in the non-Indigenous population. Address barriers to healthcare access by using Aboriginal and Torres Strait Islander health workers and liaison officers and translators who can help patients to navigate the service and their treatment options.

What the standard says

Sepsis is a time-critical medical emergency. Assessment and treatment of a patient with suspected sepsis are started urgently according to a locally approved clinical pathway, and their response to treatment is monitored and reviewed. The patient is reviewed by a clinician experienced in recognising and managing sepsis, and is escalated to a higher level of care when required.

What the quality statement means

In any setting where sepsis may occur, ensure that there is a policy or guideline for sepsis care that reflects the time-critical nature of treatment and provides parameters for evidence-based practice.

Ensure that there is a locally approved sepsis clinical pathway appropriate to the healthcare setting that includes the essential elements in Box 1 (below). In most cases, this will be a pathway that has been developed at the statewide or territory-wide level.

Policies, procedures and guidelines should support the delivery of care described in the locally approved sepsis clinical pathway regarding:

• Ensuring there are multidisciplinary clinical governance processes, including oversight by a governing body. These processes should include endorsement, implementation and ongoing use of the locally approved sepsis pathway, to assess adherence to the pathway and evaluate its outcomes. Outcomes may include its effectiveness and the impact on antimicrobial prescribing
• Providing timely access to the appropriate diagnostics, medicines and treatments that are required for implementation of the pathway
• Ensuring that all clinicians initiating and following the pathway complete competency-based training on how to use it
• Ensuring that processes and resource allocation allow timely escalation to an appropriate clinician with experience in recognising and managing sepsis available 24 hours a day, seven days a week. This may require:
  • local action to identify the most relevant clinician(s) to contact, either through telehealth or in consultation with clinicians in an acute facility
  • clear communication on the roles and responsibilities of team members when escalating care
• Supporting multidisciplinary collaboration and teamwork between critical care, medical, surgical and paediatric teams to optimise the timely management of patients
• Supporting and evaluating appropriate documentation within the pathway, and that this documentation forms part of the healthcare record. This includes documentation of the final diagnosis (whether it is sepsis or an alternative diagnosis) and considers the patient’s age and cultural needs
• Outlining the roles and responsibilities of lead clinicians
• Evaluating adherence to the pathway and its performance, including assessment of family and patient experience.

Ensure that rapid response systems are in place for deteriorating patients, including those with suspected sepsis. Ensure that patients have access to a clinician with expertise in sepsis who should be involved in their care during the first 48 hours and beyond.

Ensure that care escalation processes are accessible via both patient and clinician-led pathways, and that these are communicated to clinicians and monitored to ensure that they are adhered to. Ensure that information for consumers on how to escalate care is widely available, so that patients, carers and families can easily escalate care independently from clinicians.

Tertiary hospitals and referral centres should know which hospitals refer to their service, and be able to respond promptly when being consulted about, or accepting transfers of, patients with suspected or probable sepsis. Ensure that systems are in place so that healthcare services, including primary care services, can communicate in an organised way that reflects the patient’s care needs and escalation time frames.

Ensure that policies and protocols allow for appropriate time-critical treatment to start before or during transfer if transport to an acute care hospital is expected to take more than 60 minutes (such as in remote areas).

What the standard says

A patient with suspected sepsis has blood cultures taken immediately, ensuring that this does not delay the administration of appropriate antimicrobial therapy. When signs of infection-related organ dysfunction are present, appropriate antimicrobials are started within 60 minutes. Antimicrobial therapy is managed in line with the Antimicrobial Stewardship Clinical Care Standard, including a review within 48 hours from the first dose.

What the quality statement means

Ensure that patients with suspected sepsis will be assigned an adequate triage category when presenting to a hospital emergency department to allow timely antimicrobial administration.

Ensure that systems and resources are in place for the appropriate collection of blood cultures. Ensure prompt communication of critical test results, including positive blood cultures, from laboratories directly to the clinician to inform timely antimicrobial treatment decisions. Establish clear referral procedures to allow access to infectious diseases and microbiology consultation. Embedding alert systems and flags in local clinical information systems may be a viable option.

Ensure that systems are in place to allow prompt administration of appropriate antimicrobials for the treatment of sepsis, in any location where people with sepsis may present for acute treatment. Review antimicrobial formularies regularly to ensure they support best-practice prescribing. Ensure 24-hour access to antimicrobials that are required urgently as part of the sepsis clinical pathway.

Evaluate antimicrobial use and prescribing in line with the NSQHS Preventing and Controlling Infections Standard Actions 3.18 and 3.19. Ensure that effective antimicrobial stewardship systems are in place to ensure appropriate antimicrobial treatment and that service provision aligns with the Antimicrobial Stewardship Clinical Care Standard (Box 2 - see below).

Support multidisciplinary collaboration between critical care, medical and surgical teams to optimise the timely management of patients.

Purpose

Sepsis is a complex, multisystem disease requiring a multidisciplinary approach to treatment. A patient with sepsis has their treatment in hospital coordinated by a clinician with expertise in managing patients with sepsis.

What the quality statement means

Provide a policy and system framework that nominates and enables a central clinician to coordinate multidisciplinary care in collaboration with the patient with sepsis, or their family or carer, in line with the NSQHS Comprehensive Care Standard Action 5.05. Define the roles and responsibilities of each clinician working in the team.

Optimise communication between services, and ensure that there are processes in place to enable routine, structured collaboration between all clinicians. Support multidisciplinary meetings where there is an opportunity for all stakeholders to discuss care, as this provides a basis for shared care. This may mean providing logistical support for meetings or communication systems that allow multiple clinicians to communicate in a timely and effective way.

A different coordinator may be nominated for long-term management in the community; this is usually the patient’s general practitioner. Ensure that adequate communication processes are in place (see Quality statement 6 – Transitions of care and clinical communication and Quality statement 7 – Care after hospital and survivorship).

Equity and Cultural Safety

Ensure that clinicians have received cultural safety training, and that Aboriginal and Torres Strait Islander health workers and liaison officers, translators, social workers and others who can assist in the social aspects of care are involved whenever cultural differences may be a barrier to the patient’s experience of care.

What the standard says

A patient, their family or carer is informed about sepsis from the time that it is suspected in a way that they can understand. Information includes the expected treatment and potential health effects of sepsis. Information is provided verbally and in writing.

What the quality statement means

Ensure that there are resources and processes in place to provide patients, their families and carers with information on:

• Sepsis diagnosis, treatment and management
• Accessing services
• Health care that may be required after discharge.

Ensure that clinicians have access to interpreters and written information in multiple languages, based on patient demographics. Resources should be co-designed with consumers, including culturally and linguistically diverse communities.

Ensure that clinicians undergo sepsis education training.

Equity and Cultural Safety

Ensure that clinicians undergo cultural safety training.

What the standard says

A patient with known or suspected sepsis has a documented clinical handover at transitions of care. This includes the provisional sepsis diagnosis, comorbidities, and the management plan for medicines and medical conditions. This information is provided to the patient, their family and carer as appropriate.

What the quality statement means

Ensure that systems and supports are in place for clinicians to develop a comprehensive care plan with patients and that this is used during transitions of care. This documentation includes:

• The suspected or probable sepsis diagnosis
• The management plan, including infection control requirements
• Any underlying or additional diagnoses and medicines
• The contact details of the care coordinator.

Documentation needs to be accessible to all relevant clinicians and the patient, and should be captured in clinical information systems. Define the roles and responsibilities of clinicians involved in transitions of care, including a responsibility to complete and communicate discharge summaries. Where local clinical information systems allow, upload information into the patient’s My Health Record.

If the patient is transferred from a larger to a smaller hospital, the referring hospital should ensure that the smaller hospital has appropriate resources to manage the patient, including access to appropriate antimicrobials.

Ensure that clinicians maintain accurate and complete healthcare records (including discharge summaries and death certificates), consistent with the NSQHS Communicating for Safety Standard Actions 6.07, 6.08 and 6.11, and Primary and Community Healthcare Standards Action 1.11. Evaluate the effectiveness of the clinical communication process, in line with the NSQHS Communicating for Safety Standard Action 6.02.

Ensure that clinicians communicate infection control precautions to patients and their carers to ensure consistency with the NSQHS Preventing and Controlling Infections Standard Actions 3.07 and 3.09, or the Primary and Community Healthcare Clinical Safety Standard ‘Communicating for safety’ criterion.

Equity and Cultural Safety

Ensure that services are in place to enable effective communication with patients, taking into account their culture and location of care.

Aboriginal and Torres Strait Islander people who have completed acute treatment away from their community or Country may need structured support to ensure that they safely return to their place of residence. Establish appropriate networks – for example, with local Aboriginal medical services. Ensure adequate supports for patients who have been transferred from remote locations.

What the standard says

A patient who has survived sepsis receives individualised follow-up care to optimise functional outcomes, minimise recurrence, reduce rehospitalisation and manage the ongoing health effects of sepsis. This requires structured, holistic and coordinated post-discharge care and education that involves the patient, their family, carer, general practitioner and other clinicians.

Support and information are provided to the family or carer of a patient who has died from sepsis.

What the quality statement means

nsure that processes are in place to support patients, families and carers after hospital discharge for acute management of sepsis. This can include rehabilitation, access to emotional and social wellbeing supports, and allied health care. Consider using a centralised computer system to coordinate the patient’s post-acute care.

Before discharge, a patient should be referred to their general practitioner (GP), who can coordinate their care after hospital discharge. The GP and any other clinician to whom the patient is referred should be provided with:

• A comprehensive plan on follow-up requirements to optimise functional outcomes, minimise recurrence, reduce rehospitalisation and manage the ongoing health effects of sepsis
• Details of the hospital clinician with expertise in managing sepsis or care coordinator to support the transition of care and facilitate communication between the community and hospital care providers
• Education materials about sepsis and patient care needs.

Discharge summaries should include all the relevant information as described in Quality statement 6 – Transitions of care and clinical communication and the NSQHS Communicating for Safety Standard Action 6.11.

Healthcare services discharging patients on antimicrobial therapy should have systems in place to ensure that the patient can continue antimicrobial therapy post-discharge and address potential barriers to access, including cost. In some cases, antimicrobials may need to be supplied to the patient.

Review the death of any patient due to sepsis in the absence of a pre-existing life-limiting condition, or where death was unexpected. Offer the family an explanation, information and discussion in line with the principles of open disclosure. This may involve a follow‑up appointment at a later date and referral to bereavement care and support services as required. Ensure that all sepsis deaths are documented in a risk management system, reviewed, and reported to and monitored by a governing body (such as a patient safety or deteriorating patient committee, or similar) to identify opportunities for continued improvement.

Equity and Cultural Safety

Ensure that services are in place to support patients after discharge, such as access to Aboriginal medical services, Aboriginal and Torres Strait Islander health workers and liaison officers.

Ensure that information provided to patients is provided in a way that the patient understands and is culturally safe.