Article in HSJ News, 6th July 2016
Sepsis Faces a New Front
Daloni Carlisle looks at how technology is helping clinicians to detect sepsis earlier, something which is key to combating this often undetected killer.
With 150,000 cases a year and 44,000 deaths – many of them preventable – sepsis has to be a critical safety issue for all NHS providers.
The challenge is to recognise sepsis in its early stages, before multiple organ failure sets in and to implement rapid treatment. Left untreated even for an hour and the chances of death rise rapidly.
Neither is easy. Sepsis in its early stages is easily dismissed as something less sinister and many hospital systems for alerting doctors – such as bleeps – are prone to delays.
That’s why there is so much attention on sepsis right now. With a focus on timely intervention, the National Institute for Health and Care Excellence has developed some very clear guidelines for health professionals on how to spot sepsis from vital signs and routine blood tests. Due out this month the guidance aims to help speed up diagnosis so that treatment can start quickly.
According to Paul Volkaerts, chief executive and founder of healthcare technology company Nervecentre, this is welcome and provides a stepping stone to a safe, reliable solution. Preventing sepsis deaths, he says, is an area where technology really can play a part by automating the recognition of affected patients and rapidly escalating their treatment.
Right now two large acute trusts – University Hospitals Leicester (UHL) and Nottingham University Hospitals (NUH) – are testing a tool developed with Nervecentre that does just this. The evidence so far is that the tool recognises sepsis accurately in individual patients. The next step is building a safety case to support automated alerts.
Nervecentre is known for two types of technology. One is e-observations, in which nurses record patients’ vital signs on handheld devices. In this electronic format and with the ability to import lab results, software can apply the NICE rules for spotting sepsis automatically in the background and alert the nurse if a patient shows features consistent with sepsis.
“We have developed algorithms based on the NICE draft guidance that can be rapidly updated should the guidance change,” says Mr Volkaerts. “It works in the background and it takes into account the realistic perspective that not all clinicians will have the exact details of NICE guidance instantly to hand.”
The other is e-alerts that replace bleeps with an automated system for alerting doctors and nurses to issues that require immediate attention. It is a technology that has been proven to reduce delays and improve safety in hospital at night systems.
Recognise and rescue
Applying this to sepsis enables staff nurses to spot the patient whose vital signs indicate sepsis via an alert on their hand-held device. They can then alert a senior nurse for a rapid screening before escalating as required to doctors to implement treatment.
That’s the theory, at any rate. Right now, clinicians are putting it to the test.
At NUH, the algorithm is running in the background against a selection of the 7,500-plus daily observations to measure the accuracy of identification of sepsis, ensuring both that patients with sepsis are not missed and that there are not too many false alarms.
Mark Simmonds, consultant in acute and critical care and the trust’s “recognise and rescue” lead is in charge of this work. He helped write the NICE guidelines and he says: “Screening patients for sepsis is incredibly complicated. For us to expect all 16,000 staff to be able to understand this in detail and apply it every day – well, it’s just not going to happen. We need the support of electronic tools.”
NUH has been working hard to crack the sepsis nut for several years, he says, and the challenge has always been making sure systems are reliable. Now with 5,500 mobile devices at ward level already running Nervecentre’s systems, he hopes this trial might be the breakthrough he needs.
“It’s not that clinicians do not know what to do, it is that they do not always do it,” he says. “We do not want patients to slip through the cracks. This tool makes it easier to do the right thing every time. The cracks get smaller.”
Dr Simmonds runs through the work at NUH in brief: “We are screening patients in real time now [May 2016] to test the system. We need to be sure it will not raise too many false alarms as we know from human factors work that too many false alarms risks alerts being ignored.”
Assuming this goes well – and he expects it will – it will be on to phase two. “The next step will be bringing in nursing and doctor alerts and because we already have 5,500 devices on our hospital floor that is not a big deal – we can upgrade the devices remotely and they will start to get the functionality within a couple of months.
”Phase three will be bringing in the lab data that will help us to refine the screening. The tool supports all of this today but it is important that we implement this following a safe and controlled process.”
Using the electronic tool does not do away with the need for training and education on the new NICE guidance. Nor will it replace the clinical judgement of senior clinicians – the tool is simply ensuring that clinicians are alerted quickly and are presented with the current guidelines.
UHL is also helping to develop Nervecentre’s sepsis tool, with go-live planned for this month. The technology is already well embedded – in 2014, the trust won an HSJ award for work with
Nervecentre developing e-handover; e-observations are now routine and work is under way to roll out e-alerts.
Julia Ball, assistant chief nurse, says all three electronic components contribute to the sepsis tool. E-observations flag up potential sepsis patients; e-alerts make sure the right clinician is brought in quickly; e-handover makes sure all the right information moves with the patient along the sepsis treatment pathway.
Sarah Odams is lead sepsis nurse at the trust and would be one of those receiving alerts. “The beauty of this is it’s all on mobile devices,” she says. “I could be anywhere in the hospital or on another site and I can receive an alert to look at a patient’s observations and I can do it there and then, give the ward nurse advice and alert the next set of people on the pathway.”
Ms Ball says there are two more benefits to the electronic system – and ones that are particularly important to clinicians and senior managers.
First is the ability to have a real time overview of the sickest patients in the hospital. This can support senior clinicians’ daily conference to manage these patients and help identify training needs – or indeed areas of excellence.
Second is the ability to generate Commissioning for Quality and Innovation reports automatically. A new national CQUIN is due to be released this year that will reward hospitals for starting IV antibiotics within an hour of identifying sepsis.
“Reporting this is one of the real strengths of the system,” says Ms Ball. “Currently we have to do this manually by going round the wards to highlight which patients are red flag for the CQUIN. In future, we will be able to do it automatically. The quality of the reports from the Nervecentre system is exceptionally good.”
At both sites, developing the sepsis tool is a work in progress and evaluating the impact will be a key part of that work – including measures of speed of treatment after diagnosis, reducing the number of patients transferred to ICU with sepsis, length of stay overall and length of stay in intensive care.
Mr Volkaerts is keen to let clinicians at the test sites speak for themselves. After all, the tool was developed collaboratively with them. And in both Nottingham and Leicester, hopes are high that this is technology that will make clinicians’ lives easier and help them to do the right thing every day.
As Ms Ball points out, the sepsis tool does not replace clinical judgement – but should make it easier for clinicians to exercise it. “It’s technology,” she says. “It does not take away professional judgement and accountability and we are emphasising that.”