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: