Sepsis and septic shock: inching forwards
Editor – It was great to see the article by Jonathan Cohen and colleagues highlighting the large challenge that recognition and basic treatment of sepsis still brings (Clin Med June 2009 pp 256–7). I share their concerns that it is not part of the core competencies or syllabus for Modernising Medical Careers. Our sepsis audit, in keeping with a lot of national data, demonstrated the time to antimicrobials for patients with severe sepsis (any two of systemic inflammatory response syndrome (SIRS) criteria + one feature of end-organ dysfunction) was over seven hours in some cases. This prompted the production of a one-sided A4 document to be used as a pro forma and audit tool; a sepsis guidelines/antibiotic prescribing guidelines card that is attachable to the trust photo ID badge.
In view of this we set up two sepsis symposia to promote early recognition and delivery of a sepsis care bundle. The symposium each comprised of three training sessions of a total of 24 doctors over a two-hour period.
Introduction
The introduction covered the audit data and the evidence for a need to change.
Session A: sepsis simulation with ‘Sim man’
This session was based on a real scenario that had occurred a few weeks previously, when a patient with severe community-acquired pneumonia had not been treated with antibiotics or fluids for six hours and subsequently died. This was a 10-minute scenario for each team, culminating in improving observations/survival or a pulseless electrical activity (PEA) cardiac arrest depending on the group's ability to recognise and effectively treat the underlying sepsis. This was followed by structured feedback for each group.
Session B: the ‘box’
This was a 20-minute brainstorming session where the junior doctors were asked to plan, construct and populate a box with the components needed to investigate and promptly treat sepsis. This resulted in the production of a ‘suspicion of sepsis’ box containing intravenous (iv) Tazocin(r), 500 ml normal saline, a giving set, two cannulae, a blood culture phlebotomy pack, an arterial blood gas syringe, a tourniquet, water for injections and flushes. The juniors were also asked to formulate what should be written on the box with instructions, warnings and guidelines.
Session C: iv antimicrobial administration/blood culture phlebotomy/priming iv giving sets
This was a practical session involving a senior nurse teaching the juniors how to mix and administer iv antibiotics. It was our philosophy that, the more clinicians who can give iv therapy, the better the chances of prompt treatment. The second part of the session was taught by a medical assistant who gave a practical demonstration of the optimal methods to obtaining ‘clean’ blood cultures. The feedback from the junior doctors has been universally positive and it is certainly something that is missing from the current curriculum.
The preliminary re-audit data following the symposiums have seen more than a 50% reduction in time to antimicrobials. For every hour antimicrobial therapy is delayed in a patient with severe sepsis there is an 8% increase in mortality, every second really does count.1 Aside from the benefits of the more expensive and technical therapies and interventions that exist, the main priority remains, as it always has, early recognition and treatment.
Footnotes
Please submit letters for the Editor's consideration within three weeks of receipt of the Journal. Letters should ideally be limited to 350 words, and sent by email to: Clinicalmedicine{at}rcplondon.ac.uk
- © 2009 Royal College of Physicians
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