Quality statement 2 – Time-critical management

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.

Purpose

To ensure that appropriate clinical pathways are used effectively to ensure timely recognition and treatment of suspected sepsis, and escalation of assessment and management; and to enable consultation with, or transfer of care to, another healthcare setting from where the patient is located, if required.

For patients

Sepsis is a condition that needs urgent treatment. It can cause serious complications or death. If you are not in a hospital and think you or a family member could have sepsis, contact your general practitioner or call 000 for an ambulance.

If there is a chance you have sepsis, medical care should be started immediately and should follow a recognised clinical pathway, which guides doctors and nurses to ensure that you get the important care you need. Fast treatment can prevent complications from sepsis.

Your doctors and nurses will assess your symptoms, take your medical history, and perform tests and procedures to help with your diagnosis and treatment. Your doctor or nurse will make observations, such as measuring your blood pressure, pulse and the number of breaths you take per minute. They will order blood tests, and give medicines and fluids urgently.

Your doctors and nurses will continue to check how you are responding to treatment. They may consult with other doctors and nurses who are experienced in managing sepsis. If you are already in hospital, you may be transferred to a different ward or to the intensive care unit. If you are not in a hospital or are in a small hospital, you may need to be transferred somewhere that can provide the expertise and high-level care that are needed to manage sepsis.

If you or a person you care for is seriously ill and you are worried that the condition is getting worse, it is very important to tell a doctor or nurse in the facility where you are being treated.

If you are still concerned that help is not coming urgently, it is your right to seek help from someone else in the hospital. Hospitals must have systems in place so that you can immediately seek help from someone else, if you feel your concerns are not being addressed or taken seriously. Tell the staff that you think you or your family member has sepsis or ask ‘Could it be sepsis?’, that you want to escalate care, and ask what systems are in place for you or your carer to raise your concerns. Most hospitals will have a telephone number to call. You may have to say that you want to speak to somebody higher up (the next line of management).

Concerns for your wellbeing, or that of the person you are caring for, are valid, and all information is important. These services are available to help you to communicate your concerns so that they can be acted on. Recognising a worsening condition can prevent serious illness or death.

For clinicians

When sepsis is part of a differential diagnosis, expediting assessment and treatment is essential. Use a locally approved clinical pathway, appropriate to the patient’s age and clinical setting, to guide assessment, diagnosis and appropriate treatments within the recommended time frame. Follow all the required steps. Key actions and further information about the requirements for locally approved sepsis clinical pathways are in Box 1.

Box 1: Essential elements of a sepsis clinical pathway

Clinical pathways are designed to assist clinical judgement using the best available clinical evidence. Sepsis clinical pathways should include:

  • Criteria to support clinical decision-making to enable recognition of sepsis, including:
    • a clinical decision support tool with parameter thresholds for vital signs and blood lactate measurement
    • guidance on recognising clinically significant organ dysfunction that warrants starting time-sensitive interventions, such as fluid resuscitation, administration of appropriate antimicrobials, and timely surgical source control when required
  • Triggers and timeframes for escalation of care. This includes:
    • methods to communicate with a clinician who has experience in recognising and managing sepsis
    • processes to enable escalation to an appropriate clinician with experience in sepsis 24 hours a day, 7 days a week
    • escalation to higher levels of care
    • the ability for emergency transfer of patients to or from other health services
    • a way for the appropriate investigations and treatments to start before transfer
  • Guidance on the availability of appropriate interventions and timing of their use, including diagnostics, medicines and treatments. Guidance on the appropriate use of:
    • fluids and other time-critical treatment(s)
    • blood culture(s)
    • antimicrobial therapy
    • source control for the suspected infection
  • Timeframes for clinical review, which includes appropriate monitoring and review of investigation results, the patient’s response to treatment and the antimicrobial plan
  • Ways to consider the patient’s age, cultural needs, goals of care and advanced care plans in decision-making
  • Consideration of alternate diagnoses.

Any clinician can activate the sepsis clinical pathway at an early stage. The principles of recognise, resuscitate, refer and review should guide care. Recognise the signs of clinically significant organ dysfunction and, if sepsis is suspected, escalate immediately and activate the rapid response system. In smaller hospitals that do not always have doctors on site, follow relevant local procedures related to care of the deteriorating patient for the healthcare setting. On-call clinicians will need to be called into the hospital.

Ensure that the patient is promptly assessed by a clinician with expertise in recognising and managing sepsis or patient deterioration (for example, an emergency physician, infectious diseases physician, intensivist, paediatrician, advance practice nurse, nurse practitioner, paramedic, rural generalist or general medicine staff specialist). This assessment should occur directly (person to person). A clinician with expertise in sepsis should be involved in the care of the patient during the first 48 hours and beyond. Patients can deteriorate despite initial treatment, and the response to interventions should be monitored until the desired outcome is reached. Document the patient’s diagnosis, whether it is sepsis or an alternative diagnosis in line with Quality statement 6 – Transitions of care and clinical communication.

In smaller hospitals or remote healthcare services, the pathway should prioritise consultation with retrieval services when a higher level or acuity of care may be needed. The patient needs to be assessed by a clinician with expertise in managing sepsis. Seek review or advice from a more experienced clinician if required. In settings where 24‑hour critical care or infectious diseases support is unavailable, this review may occur by telehealth or in consultation with clinicians in an acute facility who have expertise in managing sepsis.

Consider transfer time needed if transferring the patient within the hospital or to another hospital. Consultation may be needed to decide which care or interventions should be delivered before or during transfer. Resuscitation may need to start and antimicrobials administered before transfer, including by the ambulance service if necessary. Notify the receiving facility of the suspected sepsis diagnosis and any sepsis screening or protocols that have been initiated.

If diagnosing or managing sepsis is outside your scope of clinical practice, the most appropriate action may be the immediate referral of the patient to hospital.

Do not alter calling criteria for acutely unwell patients, unless in line with local policy (such as for patients with a chronic condition such as chronic obstructive pulmonary disease or patients who may have type 2 respiratory failure and are at risk with high oxygen levels). In a patient being treated for probable or suspected sepsis, parameters for calling criteria should reflect the need for early and timely intervention, and be determined by a clinician with expertise in managing sepsis.

Talk with the patient and their carer about their goals of care. Ensure that treatment decisions align with the person’s needs and preferences, and are determined through shared decision making. Refer to advance care plans if available, including whether the patient is willing to be transferred to another facility if this is being considered.

Listen to all patient and family concerns, including those that may indicate deterioration or sepsis, and respond directly and promptly to these concerns. In paediatrics, parental concerns and observations are key to initiating an escalation of care.

Patients, families, carers and other support people should be able to escalate concerns and seek emergency assistance when they are concerned about deterioration. Cases of sepsis have been missed due to clinicians not listening to the concerns of patients, their families or carers. It has also been demonstrated that response systems for patients and families to trigger an alert for help are not misused, with a systematic review finding that all calls included were deemed to be appropriate.

Be aware that the NSQHS Recognising and Responding to Acute Deterioration Standard requires healthcare services to:

For healthcare services

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. In most cases, this will be a pathway that has been developed at the statewide or territory-wide level.

Box 1: Essential elements of a sepsis clinical pathway

Clinical pathways are designed to assist clinical judgement using the best available clinical evidence. Sepsis clinical pathways should include:

  • Criteria to support clinical decision-making to enable recognition of sepsis, including:
    • a clinical decision support tool with parameter thresholds for vital signs and blood lactate measurement
    • guidance on recognising clinically significant organ dysfunction that warrants starting time-sensitive interventions, such as fluid resuscitation, administration of appropriate antimicrobials, and timely surgical source control when required
  • Triggers and timeframes for escalation of care. This includes:
    • methods to communicate with a clinician who has experience in recognising and managing sepsis
    • processes to enable escalation to an appropriate clinician with experience in sepsis 24 hours a day, 7 days a week
    • escalation to higher levels of care
    • the ability for emergency transfer of patients to or from other health services
    • a way for the appropriate investigations and treatments to start before transfer
  • Guidance on the availability of appropriate interventions and timing of their use, including diagnostics, medicines and treatments. Guidance on the appropriate use of:
    • fluids and other time-critical treatment(s)
    • blood culture(s)
    • antimicrobial therapy
    • source control for the suspected infection
  • Timeframes for clinical review, which includes appropriate monitoring and review of investigation results, the patient’s response to treatment and the antimicrobial plan
  • Ways to consider the patient’s age, cultural needs, goals of care and advanced care plans in decision-making
  • Consideration of alternate diagnoses.

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.

For patients

Sepsis is a condition that needs urgent treatment. It can cause serious complications or death. If you are not in a hospital and think you or a family member could have sepsis, contact your general practitioner or call 000 for an ambulance.

If there is a chance you have sepsis, medical care should be started immediately and should follow a recognised clinical pathway, which guides doctors and nurses to ensure that you get the important care you need. Fast treatment can prevent complications from sepsis.

Your doctors and nurses will assess your symptoms, take your medical history, and perform tests and procedures to help with your diagnosis and treatment. Your doctor or nurse will make observations, such as measuring your blood pressure, pulse and the number of breaths you take per minute. They will order blood tests, and give medicines and fluids urgently.

Your doctors and nurses will continue to check how you are responding to treatment. They may consult with other doctors and nurses who are experienced in managing sepsis. If you are already in hospital, you may be transferred to a different ward or to the intensive care unit. If you are not in a hospital or are in a small hospital, you may need to be transferred somewhere that can provide the expertise and high-level care that are needed to manage sepsis.

If you or a person you care for is seriously ill and you are worried that the condition is getting worse, it is very important to tell a doctor or nurse in the facility where you are being treated.

If you are still concerned that help is not coming urgently, it is your right to seek help from someone else in the hospital. Hospitals must have systems in place so that you can immediately seek help from someone else, if you feel your concerns are not being addressed or taken seriously. Tell the staff that you think you or your family member has sepsis or ask ‘Could it be sepsis?’, that you want to escalate care, and ask what systems are in place for you or your carer to raise your concerns. Most hospitals will have a telephone number to call. You may have to say that you want to speak to somebody higher up (the next line of management).

Concerns for your wellbeing, or that of the person you are caring for, are valid, and all information is important. These services are available to help you to communicate your concerns so that they can be acted on. Recognising a worsening condition can prevent serious illness or death.

For clinicians

When sepsis is part of a differential diagnosis, expediting assessment and treatment is essential. Use a locally approved clinical pathway, appropriate to the patient’s age and clinical setting, to guide assessment, diagnosis and appropriate treatments within the recommended time frame. Follow all the required steps. Key actions and further information about the requirements for locally approved sepsis clinical pathways are in Box 1.

Box 1: Essential elements of a sepsis clinical pathway

Clinical pathways are designed to assist clinical judgement using the best available clinical evidence. Sepsis clinical pathways should include:

  • Criteria to support clinical decision-making to enable recognition of sepsis, including:
    • a clinical decision support tool with parameter thresholds for vital signs and blood lactate measurement
    • guidance on recognising clinically significant organ dysfunction that warrants starting time-sensitive interventions, such as fluid resuscitation, administration of appropriate antimicrobials, and timely surgical source control when required
  • Triggers and timeframes for escalation of care. This includes:
    • methods to communicate with a clinician who has experience in recognising and managing sepsis
    • processes to enable escalation to an appropriate clinician with experience in sepsis 24 hours a day, 7 days a week
    • escalation to higher levels of care
    • the ability for emergency transfer of patients to or from other health services
    • a way for the appropriate investigations and treatments to start before transfer
  • Guidance on the availability of appropriate interventions and timing of their use, including diagnostics, medicines and treatments. Guidance on the appropriate use of:
    • fluids and other time-critical treatment(s)
    • blood culture(s)
    • antimicrobial therapy
    • source control for the suspected infection
  • Timeframes for clinical review, which includes appropriate monitoring and review of investigation results, the patient’s response to treatment and the antimicrobial plan
  • Ways to consider the patient’s age, cultural needs, goals of care and advanced care plans in decision-making
  • Consideration of alternate diagnoses.

Any clinician can activate the sepsis clinical pathway at an early stage. The principles of recognise, resuscitate, refer and review should guide care. Recognise the signs of clinically significant organ dysfunction and, if sepsis is suspected, escalate immediately and activate the rapid response system. In smaller hospitals that do not always have doctors on site, follow relevant local procedures related to care of the deteriorating patient for the healthcare setting. On-call clinicians will need to be called into the hospital.

Ensure that the patient is promptly assessed by a clinician with expertise in recognising and managing sepsis or patient deterioration (for example, an emergency physician, infectious diseases physician, intensivist, paediatrician, advance practice nurse, nurse practitioner, paramedic, rural generalist or general medicine staff specialist). This assessment should occur directly (person to person). A clinician with expertise in sepsis should be involved in the care of the patient during the first 48 hours and beyond. Patients can deteriorate despite initial treatment, and the response to interventions should be monitored until the desired outcome is reached. Document the patient’s diagnosis, whether it is sepsis or an alternative diagnosis in line with Quality statement 6 – Transitions of care and clinical communication.

In smaller hospitals or remote healthcare services, the pathway should prioritise consultation with retrieval services when a higher level or acuity of care may be needed. The patient needs to be assessed by a clinician with expertise in managing sepsis. Seek review or advice from a more experienced clinician if required. In settings where 24‑hour critical care or infectious diseases support is unavailable, this review may occur by telehealth or in consultation with clinicians in an acute facility who have expertise in managing sepsis.

Consider transfer time needed if transferring the patient within the hospital or to another hospital. Consultation may be needed to decide which care or interventions should be delivered before or during transfer. Resuscitation may need to start and antimicrobials administered before transfer, including by the ambulance service if necessary. Notify the receiving facility of the suspected sepsis diagnosis and any sepsis screening or protocols that have been initiated.

If diagnosing or managing sepsis is outside your scope of clinical practice, the most appropriate action may be the immediate referral of the patient to hospital.

Do not alter calling criteria for acutely unwell patients, unless in line with local policy (such as for patients with a chronic condition such as chronic obstructive pulmonary disease or patients who may have type 2 respiratory failure and are at risk with high oxygen levels). In a patient being treated for probable or suspected sepsis, parameters for calling criteria should reflect the need for early and timely intervention, and be determined by a clinician with expertise in managing sepsis.

Talk with the patient and their carer about their goals of care. Ensure that treatment decisions align with the person’s needs and preferences, and are determined through shared decision making. Refer to advance care plans if available, including whether the patient is willing to be transferred to another facility if this is being considered.

Listen to all patient and family concerns, including those that may indicate deterioration or sepsis, and respond directly and promptly to these concerns. In paediatrics, parental concerns and observations are key to initiating an escalation of care.

Patients, families, carers and other support people should be able to escalate concerns and seek emergency assistance when they are concerned about deterioration. Cases of sepsis have been missed due to clinicians not listening to the concerns of patients, their families or carers. It has also been demonstrated that response systems for patients and families to trigger an alert for help are not misused, with a systematic review finding that all calls included were deemed to be appropriate.

Be aware that the NSQHS Recognising and Responding to Acute Deterioration Standard requires healthcare services to:

For healthcare services

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. In most cases, this will be a pathway that has been developed at the statewide or territory-wide level.

Box 1: Essential elements of a sepsis clinical pathway

Clinical pathways are designed to assist clinical judgement using the best available clinical evidence. Sepsis clinical pathways should include:

  • Criteria to support clinical decision-making to enable recognition of sepsis, including:
    • a clinical decision support tool with parameter thresholds for vital signs and blood lactate measurement
    • guidance on recognising clinically significant organ dysfunction that warrants starting time-sensitive interventions, such as fluid resuscitation, administration of appropriate antimicrobials, and timely surgical source control when required
  • Triggers and timeframes for escalation of care. This includes:
    • methods to communicate with a clinician who has experience in recognising and managing sepsis
    • processes to enable escalation to an appropriate clinician with experience in sepsis 24 hours a day, 7 days a week
    • escalation to higher levels of care
    • the ability for emergency transfer of patients to or from other health services
    • a way for the appropriate investigations and treatments to start before transfer
  • Guidance on the availability of appropriate interventions and timing of their use, including diagnostics, medicines and treatments. Guidance on the appropriate use of:
    • fluids and other time-critical treatment(s)
    • blood culture(s)
    • antimicrobial therapy
    • source control for the suspected infection
  • Timeframes for clinical review, which includes appropriate monitoring and review of investigation results, the patient’s response to treatment and the antimicrobial plan
  • Ways to consider the patient’s age, cultural needs, goals of care and advanced care plans in decision-making
  • Consideration of alternate diagnoses.

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.

Equity and cultural safety for clinicians

Ask about and record the patient’s Aboriginal and Torres Strait Islander identity with respect to evaluating risk (based on incidence), providing care which meets the needs of the person, and supporting transitions of care. For example, offer for an Aboriginal or Torres Strait Islander health worker or liaison officer to be involved. Ask about and document the patient’s preferred language and facilitate access to interpreters when required.

Resources

Related resources have been identified which are relevant to the quality statements, including:

  • Decision support tools and sepsis pathways and other guidance about sepsis - including state and territory resources
  • Guidelines and tools for recognising and responding to acute deterioration, including patient escalation pathways for each state and territory
  • Resources to support management of antimicrobial therapy
  • Education and information for patients and carers during hospitalisation for sepsis, on discharge and through survivorship.

A range of implementation resources have also been developed by the Commission including guidance, factsheets and tools for healthcare services and clinicians, and resources for consumers.