NICE algorithm (2016)

Patient 12 years and over with infection / fever / feeling unwell

Identifying the person developing sepsis is difficult as symptoms can initially be vague, but always ask the question, "Could this be sepsis?" Take into account that sepsis can present as someone feeling unwell and who has no fever with very non-specific symptoms.

Particular attention should be paid to the concerns expressed by the patient and especially changes in behaviour that are noted by the patient or often by relatives. Has this person a risk factor for developing sepsis? These include:

• Lowered immunity (including having chemotherapy or taking steroids or immunosuppressant medication)
• Recent surgery or an invasive procedure
• Breach of skin integrity
• Intravenous drug user
• Recent or current pregnancy
• The older person (over 75 years old)

Outside hospital:

Recognition of sepsis is dependent on assessing the general health of the patient, specifically including the feeling of being unwell, fever and signs or symptoms of infection. Sepsis should be considered when signs and symptoms suggest infection, even when the body temperature is not raised. People with sepsis can feel unwell initially with few other symptoms.

Groups where extra care needs to be taken in the assessment include:

• People > 75 years old
• People with co-morbidities / multiple other health issues, e.g. recent injuries, surgery or invasive procedures; people with a lowered immunity, e.g. following a cancer diagnosis or receiving steroids.
• Women who are pregnant or have recently given birth, miscarried or had a termination in the last 6 weeks).
• Where English is not the first language or it is difficult to get a good history, e.g. where there are communication issues
• Anyone unable to give a good explanation of their reason for accessing healthcare

In hospital:

Recognition of sepsis is dependent on assessing the general health of the patient, specifically including the feeling of being unwell, fever and signs or symptoms of infection. Sepsis should be considered when signs and symptoms suggest infection, even when the body temperature is not raised. People with sepsis can feel unwell initially with few other symptoms.

Carry out clinical assessment taking account of known baseline physiology, behaviour and mental state if possible. Measure respiratory rate, oxygen saturation, heart rate and blood pressure. Ask about frequency of urination. Assess behaviour and mental state. Examine skin.

Start with the high risk criteria and work down the risk ladder.

High (red) risk

One or more of the following criteria.

Objective, new evidence of altered mental state; assess any changes in the patient's current mental state (e.g. becoming confused, agitated or drowsy).
Increasing changes in vital signs to abnormal levels.

Breathing:

• High Respiratory rate ≥ 25 bpm
• FiO2 0.4 to maintain SaO2 > 92% or 88% in known COPD

Cardio-vascular:

• Tachycardia (fast heart rate) ≥ 130 bpm
• Blood Pressure (systolic) ≤ 90 mmHg or ≥ 40mmHg below normal for patient

Urine Output:

• Not passed urine in the previous 18 hours or for catheterised patients, passed < 0.5 mL/kg/hr

Colour/skin:

• Mottled, ashen or cyanosis of skin, lips or tongue
• Non-blanching rash

Raised lactate (> 2mmol/L) or new AKI in the presence of two or more moderate (amber) risk criteria.

Moderate (amber) risk

Either two or more of the following criteria or SBP of 91-100 mmHg.

History of recent change in behaviour and/or mental state.
Acute deterioration of functional ability.
History of rigors.
Impaired immune response (e.g. on oral steroids, chemotherapy, illness or other medicines).
Trauma, surgery or invasive procedure in last 6 weeks.

Breathing:

• Respiratory rate: 21-24 bpm; increased work of breathing

Cardio-vascular:

• Heart rate: 91-130 bpm (100-130 bpm if pregnant) or new onset arrhythmia

Blood Pressure (systolic):

• 91-100 mmHg

Urine Output:

• Not passed urine in previous 12-18 hours
• If catheterised: 0.5 to 1 mL/kg/hr

Wounds/skin:

• Tympanic temperature < 36 °C
• Signs of potential infection: swelling increased redness, discharge/breakdown at a wound (including surgical wounds)

Low (green) risk

Normal behaviour.
No high (red) risk or moderate (amber) risk criteria met.

Where sepsis is suspected, referral to hospital (if outside hospital) and/or immediate review is required.

Outside of hospital, if sepsis is assessed as moderate to high risk, then a definitive diagnosis needs to be made and the person assessed as to whether they can be safely treated. If these decisions are not made, the person should be referred urgently to emergency care.

In relation to low risk suspicions, support and guidance in relation to monitoring symptoms may be required.

High (red) risk

The review should include consideration of alternative diagnoses to sepsis and venous bloods to assess:

• Blood gas (including glucose and lactate levels)
• Blood cultures
• Full blood count
• C-reactive protein
• Urea and electrolyte measurements (including creatinine)
• Blood clotting screen

Administration of a broad spectrum antimicrobial medicine (within one hour of recognition of a high risk in an acute hospital setting), and discussion with a consultant (admitting consultant, consultant covering medicine or anaesthetics) is required.

In accordance with the NICE guidelines (2016), intravenous fluid boluses may need to be given immediately and the person referred to the critical care team for further review.

Observation of the person's mental state and vital signs should be started and recorded every 30 minutes.

Moderate (amber) risk

The review should include venous bloods to assess:

• Blood gas (including glucose and lactate levels)
• Blood cultures
• Full blood count
• C-reactive protein
• Urea and electrolyte measurements (including creatinine)

The person's condition needs to be reviewed within one hour (of meeting the criteria for moderate to high risk), by a doctor/clinical decision maker able to prescribe antimicrobial medication, and within 3 hours by a senior clinical decision maker (e.g. doctor or advanced nurse practitioner).

Observation of the person's mental state and vital signs should be started and recorded every 60 minutes unless the condition of the patient changes.

Low (green) risk

Management needs to proceed in line with the clinical judgement of the patient's situation and diagnosis.