Sepsis – greater awareness can lead to better outcomes
News article published on: 3rd October 2019
I recently attended the Brain Injury Group’s Sepsis training event in the City of London together with my colleague, Gemma Salmon.
Throughout the day we heard from a number of distinguished speakers with experience of identifying and treating Sepsis in the community and in a hospital setting. We also learnt about the catastrophic and often fatal consequences that a delay in diagnosing Sepsis can have.
As lawyers, we were particularly interested to hear about the steps which responsible medical practitioners should be taking to identify Sepsis as early as possible and also to learn about how early identification and treatment can lead to better outcomes.
There is no accepted definition of sepsis, and the definitions which are used have changed many times over the years. However, Professor Klein of Great Ormond Street Hospital gave the most useful definition, and one which is most commonly used nowadays, as follows:
“Sepsis is an acute, non-specific, generalised, whole body, inflammatory response to infection”
It was interesting to learn that the infection itself is not the problem in patients with Sepsis (although the source of the infection does need to be controlled), but rather the body’s response to such infection. In the most severe cases, the body’s response can lead to multi-organ failure and even death.
Diagnosing Sepsis early on can be extremely difficult. Many of the symptoms which patients present with are similar to other frequently encountered conditions such as the common cold, particularly within the first four to six hours. It is GPs who are often the first port of call for sick people, and there are a number of steps that GPs should be taking in order to make sure that they do not miss a diagnosis of Sepsis. Firstly, Dr Mike Ingram informed us that GPs should be taking, and recording, observations from their patients. One of the common signs that a patient is suffering from Sepsis is a raised respiratory rate. Whilst observations alone will not enable the GP to arrive at a diagnosis, ensuring that they are recorded, and comparing the most recent observations with previous ones, will enable a GP to spot any deterioration in the patient’s condition and to act accordingly.
Dr Ingram informed us that the average sized GP practice will see only one case of Sepsis in a patient per year. The challenge for each GP is identifying that patient, and often the “gut feeling” that something is wrong is the most powerful predictor. However, there are also tools that a GP can use to help them make, or rule out, a Sepsis diagnosis. For example, the Sepsis Trust has developed guidance for GPs. Dr Ingram identified a number of risks that GPs will fail to diagnose Sepsis, which could lead them exposed to a future Clinical Negligence claim:
- Failing to record, or react to, vital signs – such as blood pressure, pulse, respiratory rates, temperature and oxygen saturation. GPs should record vital signs in writing, and relate these to each other, in order to spot any red flags.
- Diagnosing diarrhoea and vomiting as gastroenteritis – GPs often fall back on this diagnosis, but they should consider whether they can justify this diagnosis, and make sure that they are able to rule out Sepsis. If they are unsure, it is better to say so, rather than take the risk.
- Loss of continuity of care – often patients will return to the GP practice if their symptoms do not improve, but more commonly now will not be seen by the same person. The risk here is that the GP does now know the patient. Changes to GP’s working structures make this risk much more likely. If the GP does not know the patient, it will be much harder to pick up on uncharacteristic behaviour.
- Not listening to the patient – Dr Ingram made the point that listening to the patient is one of the most important things a GP can do. If the patient is telling the GP they have never felt this unwell before (which will often be the case in patients with Sepsis), then this should be a red flag and further investigation undertaken.
- Telephone advice – this is not as reliable as seeing the patient in consultation in person. It is easier to spot a severely unwell person in the flesh, than it is by speaking to them over the telephone. If a GP suspects a patient is becoming severely unwell, they should insist the patient come into the surgery.
- False diagnosis – similar to point 2 above, a GP should not make a diagnosis unless they are almost certain. It is important to ‘safety net’ the patient, telling them either to return or to attend A&E if their condition deteriorates. GPs should always bear in mind the expectation of the diagnosis they reach, and should take the appropriate action if the course of events does not follow what is expected (it could be Sepsis).
From a Claimant lawyer’s perspective and in light of the above, the client’s medical notes should be closely scrutinised to identify any instances where a GP’s care can be said to have fallen below that which can be reasonably expected.
The Effects of Sepsis
Following the talk from Dr Ingram, we listened to a useful presentation on causation in Sepsis cases from Dr James Stone, Consultant Medical Microbiologist.
Dr Stone made clear that Sepsis is a dynamic condition, with the progression being much more complex than simply inflammation or microbial replication. Sepsis can have a negative effect on a range of tissues and organs, and the progression will accelerate over time, again highlighting the vital importance of a timely diagnosis.
However whilst early treatment in the form of antibiotics and fluids is the most effective and leads to the best outcomes, Dr Stone was keen to point out that treatment late on can still positively effect outcomes for patients. One common causation argument used by Defendants in Clinical Negligence cases is that the condition was too far advanced for any medical intervention to have been effective.
US guidelines state:
“we recommend that administration of IV anti-microbials be initiated as soon as possible after recognition and within one hour for both sepsis and septic shock”.
With increasing delays in antimicrobial medication being administered, you also get increased morbidity and so there are long term effects as well as short term effects, the chance of which are increased by delay.
But, timing is of crucial significance in Sepsis cases and it is often possible to show that if intervention would have happened earlier than it did, outcomes would have been better for the patient .
Dr Stone said that it is helpful for lawyers to consider in respect of the timelines of events, both the infecting organism and the host response. In respect of the infecting organism, the innoculation time (entering the body), lag phase (where the bacteria acclimatises to the new environment), and the log phase (accelerating bacterial growth, enzyme and toxin production) should all be considered, with the help of expert medical evidence. Further, in respect of the host response, expert evidence should consider the innate inflammatory response (which will differ between patients), positive feedback leading to an exponential rise in toxic substances, collateral damage in the host tissues, and the overshoot of the inflammatory response which leads to further collateral damage to the host. In patients who present at hospital already in Septic shock, creating the timeline of events can be extremely difficult.
Dr Stone highlighted some common causation arguments he has encountered from Defendant lawyers:
- Late presentation – sepsis could have been established and prolonged at the time of first presentation to medical professionals. Defendants may argue that even if there has been a breach of duty, the outcome would have in any event been the same.
- Multiple previous and current co-morbid conditions – Defendants may argue that such conditions make survival of Sepsis unlikely, even with optimal therapy.
- Infection with very unusual, multi-resistant bacterium – Defendants will argue that in these cases, an initial inappropriate choice of antibiotic may be made by treating professionals, albeit unavoidably. As a result, there could be an unavoidable delay in commencing effective drug treatment.
In light of all of the above, and perhaps worryingly for claimant lawyers, Dr Stone made the observation that determining causation following any breach of duty can be extremely difficult in Sepsis cases, particularly those with non-fatal outcomes.
Almost all patients suffering from Sepsis will spend time in Intensive Care, and later in the afternoon an interesting talk was given by Dr Carl Waldmann, an Intensive Care Consultant at Royal Berkshire Hospital. He spoke about how intensive care is now a specialised area, one which used to be the reserve of anaesthetists.
Patients will be admitted to an ICU where they are in need of organ support (for example, a ventilator, kidney machine, or blood pressure drugs). Being in ICU is often a very distressing time for patients and their families, both physically and emotionally, and Dr Waldmann’s main point was that when patients leave intensive care, it is fundamentally important that they should receive rehabilitation.
The importance of that point is reflected in the fact that NICE Guidelines now mandate rehabilitation, and a plan for such rehabilitation, for every patient leaving ICU. In patients who have suffered from Sepsis, there is a high incidence of long term complications and so intensive care units should now focus on quality of life and rehabilitation.
Worryingly, Dr Waldmann said that there is a huge gap in society in the provision of rehabilitation, something which led him to set up the ICU follow-up clinic in Reading. He reported that some other hospitals have now followed his lead in setting up such clinics, which focus on supporting patients on the road to recovery following their discharge from ICU.
What became clear from my perspective, as a clinical negligence lawyer following all of these interesting talks – the complexity of Sepsis cases, and the importance of looking closely at the timeline of events in each case to determine whether things could have been done differently.
Additionally, whilst early treatment and a stay on the ICU ward are vitally important in ensuring that a patient makes the best possible recovery from Sepsis, lawyers should also be paying close attention to ensuring that their client is appropriately followed up after their discharge from ICU so that they can receive the appropriate rehabilitation and make the best possible recovery. Claimant and Defendant lawyers both have incentives to make sure that this is the case.
One of the final talks of the afternoon was given by Liz Truss, a survivor of Sepsis and a volunteer for the Sepsis Trust, which exists to raise awareness of Sepsis. Liz gave the frightening statistic that over 40,000 people die as a result of Sepsis every year in the UK, and stressed the importance of always asking the question to medical professionals if you or a loved one suddenly becomes very unwell, “could it be Sepsis”.
More information about the Sepsis Trust can be found on their website.
Blog by Nicholas Leahy.