New Guidance for Spotting the Signs of Sepsis in Sick Children

ABSTRACT

Emeritus Professor Alan Glasper, from the University of Southampton, discusses a new publication from the English National Institute for Health and Care Excellence (NICE) that gives guidance to nurses on the recognition and management of the early signs of sepsis in sick children.

Introduction

In July 2016 the English National Institute for Health and Care Excellence (NICE) published a new guideline entitled “Sepsis: recognition, diagnosis and early management.”

Here at the Journal of Comprehensive Child and Adolescent Nursing we are committed to giving our world-wide readers up to date information on matters pertinent to their realm of nursing. We know that the one aspect of care management that all children’s nurses dread is undiagnosed sepsis in a child under their jurisdiction.

Newspaper headlines in England have been filled in recent years with stories of children who have died from unrecognised sepsis and this new NICE guideline comes in the wake of a series of high profile child deaths from sepsis. For example in 2014 one-year-old William Mead died of septicaemia and at the subsequent inquest into his death the roles of the family doctor and the out of hours medical services were criticised for being unable to recognise that the child was developing systemic sepsis precipitated, as later revealed, by an underlying chest infection (“William Mead Death,” 2016).

Similarly a baby Charlie Jermyn, died of sepsis in May 2015 aged only 30 hours, and at the inquest into his death the coroner was critical of the series of catastrophic failures in care delivered by the midwives who likewise failed to recognise the emerging signs of sepsis (“Sepsis Baby,” 2016).

Background

In the UK sepsis is known to be the cause of death of at least 37,000 people annually (Daniels, Nutbeam, McNamara, & Galvin, 2011). The populations most at risk are the very young and the elderly and with this number of deaths attributed to sepsis every year in many countries it is hardly surprising that the fear of sepsis continues to haunt the parents and carers of young children in many societies.

Such fears are not unjustified as the whole of medical history has been beleaguered with the stories of biblical plagues, pandemics, and pestilences, some of which have caused massive levels of mortality. Perhaps the most feared infection was that attributed to the Black Death in the 14^th century with Zeigler (2013) describing how this plague was responsible for the deaths of almost a third of the European population. In our own contemporary societies children have died from new plagues such as Ebola, and hospital acquired infection has likewise caused fear among the carers of children in hospital almost akin to the situation described by Semmelweis in in 19^th century Vienna (Semmelweis Society International, n.d.). History tells us that such was the fear of infection that some mothers chose to deliver their babies on the sidewalks of the streets rather than in the city’s lying in hospital where hospital-acquired puerperal sepsis was rampant. This was attributed to medical staff and obstetricians who carried out autopsies on dead mothers and then proceeded to deliver babies without first washing their hands. Boyce (1999) describes how Semmelweis introduced the simple measure of making the medical staff wash their hands in chlorinated lime solution prior to attending the women and this simple act led to significant reductions in mortality.

In many countries regulators for health and social care put significant effort into collecting data from the hospitals they inspect that infection control meets their own stringent standards. For example the English Care Quality Commission (for whom, incidentally, I work for periodically as a specialist advisor) will routinely conduct an assessment of cleanliness and hygiene and assess how reliable hospital systems are in protecting children from acquiring health care associated infections. As part of these in depth hospital inspections specialist advisors such as myself seek assurances from the health care staff that they interview that comprehensive risk assessments are carried out on service users in line with national and international guidance. In this context specialist advisors endeavour to identify how nurses take steps to recognise and respond appropriately to changing risk among sick children and ascertain if these nurses have an appropriate skill set to recognise deteriorating health in a sick child and the ability to put measures in place to initiate emergency interventions.

Hence specialist advisers will seek evidence of the use of early warning tools such as the Paediatric Early Warning Scores (PEWS) or the New-born Early Warning Scores (NEWS). New born early warning assessment tools for example have been shown to be helpful in delivering effective optimum care to babies at potential risk of deterioration (Roland, Madar, & Connolly, 2010).

Importantly, the use of paediatric care bundles or algorithms such as Sepsis Six which have been designed to reduce patient mortality from sepsis have been shown to improve patient outcomes (Daniels et al., 2011). Researchers such as Gao and colleagues (2005) have shown that successful sepsis algorithm implementation is predicated on staff training to ensure their effective use in optimizing the management of severely ill patients.

Children’s nurses have been routinely using clinical assessment tools such as Sepsis Six and PEWS as they are principally designed to detect signs of deterioration in sick children, and these tools alert them to the early signs of impending collapse. Importantly such tools, if used appropriately, can predict which children are likely to deteriorate and require more intensive care facilities.

To give these assessments greater efficacy some children’s nurses (for example those who work at Great Ormond Street Hospital in London) use the SBAR framework (i.e., Situation, Background, Assessment, and Recommendation) as this facilitates precise communication between members of the multi-disciplinary care team about the appropriate management of deteriorating sick children. However children’s nurses need more than simple diagnostic tools when caring for sick children and as an adjunct it is important for any nurse to think outside of the box and listen and respond to the almost extrasensory perceptions of parents and carers who uncannily can often see the early signs of deterioration before anyone else. This was shown to be true in the tragic case of William Mead whose mother desperately sought help, in vain, from health care professionals (“I Touched His Arm,” 2016).

The New Sepsis Guideline

Although many children’s nurses are adept at using measures of patient acuity where deterioration in a sick child can be detected early and appropriate interventions delivered in a timely fashion, in too many cases sepsis goes unrecognised. This has prompted the English NICE to publish its own guideline for health care workers to better detect and mange sepsis among vulnerable children and adults.

It is beyond the scope of this editorial to give anything more than a simple précis of this complex NICE guideline which has many algorithm subdivisions but which primarily seeks to help nurses and others identify service users with suspected sepsis. Many of these recommendations are pertinent to sick babies and children in all clinical settings.

The guideline identifies a number of risk factors associated with sepsis and these include among others young babies and children, young people who have suppressed immunity as in cancer treatment, children who are recovering from recent surgical interventions, and children with breached skin conditions, and those with indwelling catheters or intravenous lines.

Undertaking a Face-To-Face Assessment of Children at Risk and Stratifying the Risk of Severe Illness or Death from Sepsis

This new NICE guideline recommends that any child patient at risk of developing sepsis should be comprehensively physiologically assessed by health care staff. This assessment includes ascertaining such parameters as temperature, blood pressure, and level of consciousness among others. In young children other parameters such as oxygen saturation levels and capillary refill time are mandatory. Other aspects such as examining children for urinary functioning—and in small babies this will involve the weighing of nappies or diapers—skin mottling, cyanosis, and examining the skin for breach of integrity such as rashes are also part of the NICE reconditions. Importantly the guideline gives health care professionals a range of risk stratification tools for children and young people aged 12 years and over with suspected sepsis, children aged 5 to 11 and children under 5 with suspected sepsis. This allows children’s nurses to use the child’s history and physical examination results to grade the risk of severe illness or death from sepsis using criteria based on age (NICE, 2016).

Managing Sepsis in Children

The NICE guideline gives specific management guidelines for differing child age groups who have suspected sepsis and meet high risk criteria. Children’s nurses will want to consider using as appropriate assessment tools such as PEWs, the Modified Glasgow coma scale or the AVPU (Alert, Voice, Pain, Unresponsive) scale. In suspected child sepsis situations an immediate review by a senior clinician and the monitoring of children who meet any high risk criteria continuously, or a minimum of once every 30 minutes depending on the clinical setting. The guideline recommends a range of differing antibiotics and intravenous resuscitation fluids for each of the specific age groups including neonates. The NICE guideline also recommends a range of oxygen administration strategies including administering oxygen to sick children whose saturations fall below 91%.

The NICE guidance offers a range of caveats such as avoiding the performance of a lumbar puncture in children when contraindications are present as in raised intracranial pressure or in cases where there are fluctuating levels of consciousness as measured using the Modified Glasgow coma scale

Training for Sepsis Management

The NICE sepsis guideline is a complex and detailed document designed to save children’s lives. Despite its length I recommend that children’s nurses read and digest this information for the benefit of those children they deliver care to. However, NICE recognises that the continuing education departments within hospitals and community institutions will need to embed within their training and development plans, strategies to ensure that all staff including students are enabled to access training which will allow them to identify and manage sick children at risk of developing sepsis. Importantly children’s nurses involved with triage or the early management of sick children in departments such as accident and emergency, paediatric emergency assessment units, or those delivering peripatetic care such as site practitioners should be given regular clinical updating on the assessment and management of child sepsis including being enabled to access local protocols and escalation pathways. This NICE guideline is an essential read for many children’s nurses.

Key Points

• In July 2016 the English National Institute for Health and Care Excellence published a new guideline entitled “Sepsis: recognition, diagnosis and early management.”

• This new NICE guideline comes in the wake of a series of high profile child deaths from undiagnosed sepsis.

• Care bundles or algorithms such as Sepsis Six and the use of early warning score tools can improve sepsis outcomes among sick children.

Declaration of Interest

The author reports no conflict of interest. The author alone is responsible for the content and writing of this paper.