MSc Advanced Professional Practice: Sepsis Treatment Variation

This dissertation investigates the variations in early intervention and treatment of sepsis within primary and urgent care settings in the UK. It highlights sepsis as a life-threatening condition arising from the body's response to infection, leading to organ dysfunction. The research employs a secondary research methodology, analyzing articles from databases like CINAHL, MEDLINE, and BMJ to identify prevalent treatment modalities, primarily sepsis 3 and sepsis 6 bundles. The findings emphasize the importance of prompt antibiotic and intravenous fluid administration, alongside fluid replacement, mechanical ventilation, and catheter placement, for effective sepsis management. The study also addresses the global prevalence of sepsis, the role of awareness campaigns, and the challenges in balancing antimicrobial use with the fight against antibiotic resistance, while stressing the need for standardized guidelines and timely intervention to reduce mortality rates.

Running head: DISSERTATION
Masters Dissertation Module
MSc Advanced Professional Practice
Variation in the early intervention and treatment of sepsis in the primary and urgent care
setting in the UK
Student Name: Saber Jbara
Student Number: 15037062
Word Count:
Author Note

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Abstract
Background- Sepsis has been recognized as a possibly life-threatening health ailment that
generally manifests as response of the human body against invasion by pathogen. This leads
to the release of several chemicals in the body that trigger changes and lead to dysfunction of
multiple organs.
Methodology- Secondary research conducted by searching articles from three electronic
databases namely, CINAHL, MEDLINE, and BMJ, with the use of search terms.
Results- 12 articles were retrieved and critically analysed and suggested that sepsis 3 and
sepsis 6 bundles are the main treatment modalities employed across primary and urgent care
centres.
Conclusion- Sepsis management should primarily focus on administration of antibiotics and
intravenous fluids, as soon as possible, in addition, to fluid replacement, mechanical
ventilation, and catheter placement.
Keywords: sepsis, management, treatment, sepsis 6, sepsis 3

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Table of Contents
Chapter 1: Introduction..............................................................................................................3
Background........................................................................................................................3
Research aim......................................................................................................................9
Research objectives............................................................................................................9
Chapter 2: Methodology..........................................................................................................10
Research design................................................................................................................10
Search strategy.................................................................................................................12
Research philosophy........................................................................................................14
Chapter 3: Results....................................................................................................................18
Chapter 4: Discussion..............................................................................................................26
Chapter 5: Conclusion..............................................................................................................33
Chapter 6: Recommendations..................................................................................................38
References................................................................................................................................42
Appendix 1...............................................................................................................................53
Appendix 2...............................................................................................................................54

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Chapter 1: Introduction
This dissertation is written to support operational and strategic planning, for
promoting early intervention and treatment of sepsis in an Urgent Care Centre (UCC). Sepsis
is commonly referred to as a life threatening condition that typically arises under
circumstances when the response of the human host to different infections, leads to damage
of the organs and tissues of that host (Polat et al., 2017). The condition is a prevalent
inflammatory immune response that is triggered by the onset of infection, commonly caused
due to bacterial invasion. Under normal circumstances the human body releases several
chemicals in the bloodstream to fight infection. Hence, sepsis generally occurs due to
disruption of balance, in relation to the release of chemicals, thereby triggering variations that
bring about damage to numerous organ systems (Simonsen et al., 2014). NICE (2016) define
sepsis as a major form of organ dysfunction that IS a direct manifestation of deregulation of
the host response to different types of infection. Sepsis is responsible for millions of deaths
globally every year, and is one of the most common factors that lead to the death of patients
who have been hospitalised (Deutschman & Tracey, 2014). By contrast, Lyle et al. (2014)
suggested that the worldwide incidence of sepsis estimated AT 18 million cases/year.
Background
Research evidence also highlighted that roughly 123,000 cases of sepsis occurred in
England in the year 2014, of which there were as many as 37,000 deaths. In addition, 70% of
those cases were in community-based settings (RCGP, 2017). The WHO (2018) reported that
the global burden of sepsis is more common in middle and low income countries, and an
estimated 1.2 million children and 3 million new-borne also suffer from the condition each
year. Acosta et al. (2014) cited incidence rates of severe sepsis as 4.7 (95% CI 4.2–5.2) per
10,000 maternities. In addition, they found that roughly 71 women (19.5%) in maternity units
had developed septic shock, with deaths of five women (1.4%). This established certainty that

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failure to implement early intervention and management strategies, increases risk of septic
that leads to multiple organ failure, and subsequent death. Furthermore, research evidence so
highlighted that maternal mortality rates due to sepsis during 2006–2008 in the UK, were
approximately 1.13/100,000, which was significantly higher than to previous records (Acosta
and Knight 2013). This data identified the large proportion of women who suffer from the
life-threatening condition, and also recognized the need for implementing early management
strategies, in order to reduce the mortality rates.
Complex surgical procedures have been allied with sepsis, however, Shahin, Harrison
and Rowan (2012) were not able to draw any correlation between outcome and volume for all
patients suffering from severe sepsis in the UK. Other evidence has established a correlation
between sepsis among infants and neonates living in the UK, and an increased proportion of
parecho virus infections in their cerebrospinal fluid (CSF) (Tang et al., 2016). This further
established THAT if not treated in a timely and effective manner, sepsis can result in the
onset of a potentially threatening viral infection that subsequently increases the likelihood of
death among children and infants. Reinhart et al. (2017) reported evidence for the
effectiveness of high profile campaigns in increasing awareness about sepsis and its
prevention in the UK, the US and Germany by almost 62%, 55%, and 69%, respectively.
Therefore, there are variations across different countries in the steps that are adopted for
sepsis management and intervention.
The researchers reinforced (Reinhart et al., 2017) that approximately 70% cases of
sepsis are typically community acquired, and early intervention should focus on effective
administration of antibiotics. In addition, administration of antibiotics as early intervention
has also proved efficacious in increasing awareness among people on the necessity of seeking
treatment services, without making any delay, with the sole purpose to prevent avoidable
disability and death. Global prevalence of sepsis has gained attention in recent years,

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followed by conduction of case examinations that place due emphasis on different
management strategies (Pearson et al., 2011).
The resolution adopted by the World Health Organization and the World Health
Assembly has made sepsis an international health priority by recognizing the apparent
conflict between fast administration of antimicrobials for the effective management of sepsis
and efforts that should be adopted in order to fight antibiotic resistance (Kissoon et al., 2017).
Universal efforts to decrease the burden associated with sepsis must be concomitant with
different measures that help in minimizing antimicrobial resistance, and show alignment with
the WHO-approved Global Action Plan related to Antimicrobial Resistance (Wuijts et al.,
2017). In recent years, $4.6 million USD has also been allocated by the WHO for
implementing the aforementioned sepsis resolution (Global Sepsis Alliance, 2017).
Moreover, the sequelae of sepsis has been correlated with a plethora of clinically substantial
cognitive, physical, and psychological disabilities that are often unidentified and untreated
(Annane & Sharshar, 2015). Hence, researchers have provided adequate evidence to illustrate
the role of increasing awareness on sepsis management, and the need for presenting patients
early to healthcare facilities (Vincent et al., 2014) . In addition, continued adherence to use of
suitable antibiotics, and critical treatment based on the guidelines that have been locally
developed, can suggestively lessen death rate due to sepsis (Ferrer et al., 2014).
Inada-Kim et al. (2017) conducted a retrospective cohort analysis and reported that
there were roughly 47475 admissions of patients with suspicion of sepsis (SOS), which in
turn was comparable to 17 admissions/1000 adults in a single year. Information from the
Hospital Episode Statistics data for 2013–2014 also highlighted the occurrence of 7.2%
mortality for the group, at the time of hospital admission, thereby indicating that patients who
are suspected to suffer from sepsis can be easily identified by conducting an assessment of
routine administrative data. This facilitates the screening process for sepsis and enhances the

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procedure of sepsis detection and treatment. Fjalstad et al. (2016) conducted a nationwide
population-based study in the Norwegian Neonatal Network and found that most of the
culture-confirmed cases of EOS could be attributed to Gram-positives (83/91; 91%), and
showed a prevalence of group B streptococci (0.31 per 1000 LB). In addition, the incidence
rates of culture-confirmed reflected international reports, and highlighted the presence of low
rates of mortality. It WAS stated by AM (2015) that the NICE Guideline Development Group
(GDG) have worked towards the formulation of a guidelines (CG149), with the aim of
accomplishing consistency and standardization in the treatment and management of infants
screened with early onset sepsis, residing in the UK. However, the researchers recognized the
differences that exist in implementation of practice across diverse healthcare centers located
in the UK.
Risk of sepsis treatment delay was discussed by Eisenhut (2016) who based the
research on the sepsis guidelines formulated by NICE and stated that patients having one
moderate and/or high risk measure, without the presence of any conclusive condition do not
routinely obtain timely administration of antibiotics, within an hour of detection. However,
such patients are generally subjected to reviews and assessments by senior clinicians, within
three hours, in relation to consideration of antibiotic administration. It was further stated that
moderate to high risk criteria generally include poor peripheral perfusion in addition to
lengthy capillary refill, rigor, and cold feet and hands. However, late review by a senior
clinician subsequently brings about a delay in the management of gram negative bacteraemia,
thereby slowing down the recovery process of the patient, and worsening their health
situation.
Findings from the RCGP Sepsis Summit Consensus Report 2017 illustrated that
hospital care for sepsis is generally directed towards conducting a rapid assessment of all
patients diagnosed with infection, in addition to the swift administration of several

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intravenous fluids, antibiotics, and oxygen. The National Early Warning Scores (NEWS 2)
that are followed by healthcare professionals for diagnosing sepsis include conducting an
assessment of six biological parameters namely, temperature, oxygen saturation, respiration
rate, heart rate, systolic blood pressure, and level of unconsciousness. The report also
identified that Out-of-Hospital comprehensive and thorough observations are often absent.
Furthermore, blood pressure and respiratory rate that act as the greatest predictors of the
condition are the mostly poorly recorded by physicians, for patients who have been affected
by sepsis. This acts as an impediment in the process of care delivery, thereby risking a
deteriorating the health outcome.
Moran et al. (2017) stated that although the quality standards proposed by NICE are
creditable in principle, the actual reality of implementing the standards for sepsis
management and treatment are uncertain. antimicrobials stewardship (AMS) has also been
recognized as an effective strategy for early intervention of sepsis, in that AMS tries to lessen
exposure to an antibiotic, while enhancing the health outcomes among sepsis patients, and
may automatically contrast with the contemporary antibiotic prescription procedures. This
presents a significant challenge to critical care physicians who have the responsibility of
accurately diagnosing an infection, and improving the outcomes, while decreasing usage of
antimicrobials. In other words, effective management of sepsis can be accomplished by
showing adherence to local strategies for empirical therapy, enhanced antibiotic dosing,
improved risk for multidrug resistance determination, and incorporation of speedy diagnostic
practices in the clinical decision-making process (De Waele & Dhaese, 2019). Results from
evaluation research that focused on determination of the value, feasibility, and cost of
intravenous immunoglobulin provided the evidence for high uptake of bundles (> 70%), in
relation to the management and resuscitation of all patients who had been diagnosed with
severe sepsis, mostly those suggested by the SSC (Soares et al., 2012).

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In addition, it was stated by the researchers that low dose steroid administration, in
alignment with standard care protocols and IVIG were used for advanced sepsis management
of 56.9% patients (Soares et al., 2012). Freitag et al. (2016) opined that sepsis might often
present with the manifestation of non-specific signs and symptoms. People aged less than a
year or more than 75 years, immune) compromised, or pregnant are expected to display a
greater index of sepsis suspicion (Rhodes et al., 2015). The condition is also expected to
affect those who have been subjected to recent surgery, or device insertion (Prucha, Bellingan
& Zazula, 2015). The UK Parliamentary and Health Service Ombudsman inquiry “Time to
Act” also found significant failures in the identification, screening, diagnosis, and early
intervention of patients who died due to sepsis (Parliamentary and Health Service
Ombudsman, 2013).
Some of the major clinical issues that arise in relation to sepsis management and early
intervention were (i) failure of clinicians in taking timely patient history and assessment, (ii)
failure in conducting necessary tests for quick identification of the infection source, (iii)
regular monitoring, and (iv) failure to rapidly commence treatment. Furthermore, lack of
adequate staff training and education opportunities, absence of timely patient referral to
critical care centers, and failure to effectively handover clinical protocols also creates a
negative influence ON patient health outcomes (Parliamentary and Health Service
Ombudsman, 2013).
Mukherjee et al. (2015) found that prior to the implementation of NICE guidelines
that focus on treatment of early onset sepsis (EOS), 38.1% of screened infants stayed less
than 72 hours in the neonatal units. This percentage of infants considerably lessened to
18.4%, following adherence to the NICE guidance. In addition, prior to adherence to the
guidelines, 20.9% babies remained in the unit for more than five days; that substantially
augmented to 27.7%, after following the recommendations. Hence, it was suggested that

9DISSERTATION
timely management of sepsis helps in reducing the length of hospitalization of patients,
thereby reducing unnecessary health costs.
Hence, an analysis of the evidences presented in the scholarly articles discussed above
suggests that there exist clear variations across community settings, in the recognition, early
intervention and management of sepsis. In addition, these lead to differing health outcomes
among the affected patients. This led to the formulation of the research question that is
provided below:
What are the variations in the early interventions and treatment for sepsis in primary care and
urgent care setting?
Research aim
To explore the variations that exist in the early intervention and treatment of sepsis in
the primary and urgent care setting in the UK.
Research objectives
· To identify the range of the early intervention strategies for sepsis
· To explore the different practices adopted for sepsis management
· To determine the factors that underpin differences in the management strategies

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Chapter 2: Methodology
Research design
The research strategy forms an essential part of the review since it focuses on the
steps that must be followed, whilst addressing the phenomenon under investigation. The
method that was selected for conducting this research was a literature review, which was
preferred to empirical research design, given that a considerable amount of scientific
literature on the phenomenon of sepsis treatment strategies already exists. According to
Galvan and Galvan (2017) a narrative literature review is comprised of current knowledge,
which encompasses substantial findings, in addition to presenting methodological and
theoretical contributions to specific research topic. This is categorised as a secondary
research owing to the fact that it does not report any original or new experimental findings,
and most of the evidence presented in the literature review was collected from academic
oriented scientific literature, and academic journals (Ramdhani, Ramdhani & Amin, 2014). A
review of the literature is in clear contrast to primary empirical research where the
researchers themselves participate in collecting and presenting findings about a target
population. Nonetheless, it should be taken into consideration that literature reviews should
be robust and sufficient enough to meet similar quality standards to empirical research by
utilising procedures that reduce the chances of bias or errors in the findings.
The purpose of conducting a literature review was to gain a sound understanding
about the topic, which focused on variation in sepsis management, in addition to obtaining a
conceptual framework for future project or research planning that is build up on already
existing literature (Aveyard, 2014). The review was conducted with the aim of collecting
essential information from appropriate scientific sources, which would help in identification
of existing gaps, thereby enabling them to be addressed during future clinical development.

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Although evidence that currently exists, might not be relevant or fitting to the research
question, presence of a plethora of studies on similar topics made it necessary for evaluating
the obtainable information, in order to determine the strengths and limitations of the facts that
had been included.
Narrative reviews have been found to facilitate assessment of the contemporary state
of research related to a specific topic, and they also help in determining how extensively the
phenomenon has already been probed (Kumar, 2019). One of the complementary advantages
of conducting a narrative review is associated with the fact that it rapidly revealed the
domains that have been most focused on, hence acting as an important resource for
contemporary research consultation (Hewitt-Taylor, 2017). Although it provides an overview
or summary of the topic, the primary difference of a narrative literature review with a
systematic review is that the latter tries to derive answers to a well-focused clinical question
and comprises a high level synopsis, based on identification, selection, synthesis, and
appraisal of superior quality evidences that are relevant to the question. In addition, the
primary purpose of narrative reviews is to help the readers gain a comprehensive
understanding of contemporary knowledge, besides highlighting the implication of new
investigation. Owing to the fact that narrative reviews are based on subjectivity and
experience of authors of selected scholarly articles, and help demonstrating the importance of
a specific point of view, in relation to the topic being investigated, they have been selected
best, for this investigation. Furthermore, based on the fact that narrative reviews help in
identification of research gap, they will prove effective in investigating the variations that
exist, in relation to treatment and intervention of sepsis in urgent and primary care services.
However, some common limitations of narrative review are based on the fact that the
attention placed on particular studies often get limited or ignored by reviewers, while
attempting to draw a definite conclusion. In addition, the unsystematic approach also leads to