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Sepsis

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What is covered

This NICE Pathway covers the identification, early assessment, risk stratification and management of sepsis. It also covers the identification of the source of infection.

Updates

Updates to this NICE Pathway

27 February 2020 Intrapartum care: existing medical conditions and obstetric complications (NICE quality standard 192) added.
18 February 2020 SepsiTest assay for rapidly identifying bloodstream bacteria and fungi (NICE diagnostics guidance 20) added to identifying the source of infection and treating with antibiotics, fluids and oxygen in people aged 12 and over.
12 September 2017 Sepsis (NICE quality standard 161) added. Recommendations updated in evaluate the level of risk for a child under 5 years, evaluate the level of risk for child aged 5 to 11 and evaluate the level of risk for person aged 12 or over to reflect changes to NICE guideline NG51.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Short Text

Everything NICE has said on the recognition, diagnosis and early management of sepsis in an interactive flowchart

What is covered

This NICE Pathway covers the identification, early assessment, risk stratification and management of sepsis. It also covers the identification of the source of infection.

Updates

Updates to this NICE Pathway

27 February 2020 Intrapartum care: existing medical conditions and obstetric complications (NICE quality standard 192) added.
18 February 2020 SepsiTest assay for rapidly identifying bloodstream bacteria and fungi (NICE diagnostics guidance 20) added to identifying the source of infection and treating with antibiotics, fluids and oxygen in people aged 12 and over.
12 September 2017 Sepsis (NICE quality standard 161) added. Recommendations updated in evaluate the level of risk for a child under 5 years, evaluate the level of risk for child aged 5 to 11 and evaluate the level of risk for person aged 12 or over to reflect changes to NICE guideline NG51.

Quality standards

Intrapartum care: existing medical conditions and obstetric complications

These quality statements are taken from the intrapartum care: existing medical conditions and obstetric complications quality standard. The quality standard defines clinical best practice in the intrapartum care of women existing medical conditions and obstetric complications and should be read in full.

Sepsis

These quality statements are taken from the sepsis quality standard. The quality standard defines clinical best practice for sepsis and should be read in full.

Quality statements

Heart disease – risk assessment

This quality statement is taken from the intrapartum care: existing medical conditions and obstetric complications quality standard. The quality standard defines best clinical practice in the intrapartum care of women with existing medical conditions and obstetric complications and should be read in full.

Quality statement

Pregnant women with heart disease have their cardiovascular risk regularly assessed during pregnancy and the intrapartum period.

Rationale

Changes to the heart and circulation occur during pregnancy. Regular risk assessment allows planning for any additional management needed for women with heart disease who are at risk of adverse cardiovascular outcomes during labour and birth. Cardiovascular risk assessment is based on a combination of clinical, diagnostic and functional assessment. It is carried out by a multidisciplinary team that includes a cardiologist with expertise in managing the condition in pregnancy. The content and timing of risk assessment are tailored to the severity of the condition and the findings of previous assessment.

Quality measures

Structure
a) Evidence of local arrangements for pregnant women with heart disease to have their cardiovascular risk regularly assessed during pregnancy and the intrapartum period by a multidisciplinary team that includes a cardiologist with expertise in managing heart disease in pregnant women.
Data source: Local data collection, for example, service protocols, local network agreements for referral and core multidisciplinary team membership records.
b) Evidence of local arrangements for pregnant women with heart disease to have their cardiovascular risk regularly assessed during pregnancy and the intrapartum period.
Data source: Local data collection, for example, service protocols and local network agreements for referral.
Process
Proportion of pregnant women with heart disease who have their cardiovascular risk regularly assessed during pregnancy and the intrapartum period.
Numerator – the number in the denominator who have their cardiovascular risk regularly assessed during pregnancy and the intrapartum period.
Denominator – the number of pregnant women with heart disease.
Data source: Local data collection, for example, an audit of maternity records.
Outcomes
Rates of mortality during labour, birth and the early postnatal period for women with heart disease.
Data source: Local data collection. The MBRRACE-UK Confidential Enquiries into Maternal Deaths and Morbidity reports on the number of maternal deaths attributed to heart disease.

What the quality statement means for different audiences

Service providers (NHS hospital trusts) ensure that local protocols and referral pathways are in place so that pregnant women with heart disease have their cardiovascular risk regularly assessed during pregnancy and the intrapartum period by a multidisciplinary team that includes a cardiologist with expertise in managing heart disease in pregnancy. They ensure that staff have capacity to perform the assessments regularly and that there are rotas and systems in place for a cardiologist to be available to take part in team discussions.
Healthcare professionals (such as midwives, obstetricians, obstetric anaesthetists and cardiologists with experience of managing heart disease in pregnancy) regularly assess cardiovascular risk for pregnant women with heart disease during pregnancy and the intrapartum period through clinical, diagnostic and functional assessment. Cardiologists use their knowledge and experience to advise the multidisciplinary team on specialist aspects of intrapartum care for pregnant women with heart disease that is tailored to the woman’s individual level of risk.
Commissioners (clinical commissioning groups) ensure that they commission services that have local protocols and referral pathways in place, and the capacity for pregnant women with heart disease to have their cardiovascular risk regularly assessed during pregnancy and the intrapartum period by a multidisciplinary team that includes a cardiologist with expertise in managing heart disease in pregnancy. They ensure that services have rotas and systems in place for the cardiologist to be involved in team discussions.
Pregnant women with heart disease have regular tests to check their heart condition during pregnancy and up to 24 hours after birth by a team that includes a specialist in managing heart disease in pregnancy. This will help them and the team to plan the care needed during labour and birth.

Source guidance

Definitions of terms used in this quality statement

Pregnant women with heart disease
Relevant populations and heart conditions within the scope of this quality standard include:
  • women with mechanical heart valves
  • disease of the aorta
  • pulmonary arterial hypertension
  • heart failure
  • severe left-sided stenotic lesions (for example, aortic stenosis and mitral stenosis)
  • hypertrophic cardiomyopathy
  • cardiomyopathy with systolic ventricular dysfunction
  • Fontan circulation and other univentricular circulations
  • moderately severe and severe cardiovascular disease, as classified by New York Heart Association (NYHA) functional class.
Some women with heart disease are at low risk of complications and their care should be in line with NICE’s guideline on intrapartum care for healthy women and babies, whereas others need individualised specialist care.
Cardiovascular risk regularly assessed
The timing of risk assessment is tailored to the severity of the condition and the findings of previous assessment. The following should be used for the initial and ongoing assessments:

Equality and diversity considerations

Pregnant women with heart disease should be able to communicate effectively with the multidisciplinary team as part of their risk assessments. Women should have access to an interpreter, link worker or advocate if needed. The interpreter, link worker or advocate should not be a member of the woman’s family, her legal guardian or her partner, and they should communicate with the woman in her preferred language.

Involving women in care planning

This quality statement is taken from the intrapartum care: existing medical conditions and obstetric complications quality standard. The quality standard defines best clinical practice for the intrapartum care of women with existing medical conditions and obstetric complications and should be read in full.

Quality statement

Pregnant women with existing medical conditions or obstetric complications are involved in developing and reviewing their individualised intrapartum care plan.

Rationale

Involving a woman in developing and reviewing her intrapartum care plan enables her to discuss and make choices about her care. It allows her to be given information and opportunities for discussion to support shared decision making. Involvement of the woman allows the care plan to be tailored to her conditions or obstetric complications, her experience of these, and her preferences for labour and birth. The woman should be involved in updating the plan during pregnancy and on admission for birth to reflect changes in her conditions or obstetric complications.

Quality measures

Structure
a) Evidence of local processes to provide opportunities for pregnant women with existing medical conditions or obstetric complications to discuss and make decisions on the intrapartum management of their medical conditions or obstetric complications.
Data source: Local data collection, for example, documented procedures, service specifications and staff training on communication skills.
b) Evidence of local processes to ensure that pregnant women with existing medical conditions or obstetric complications are supported to develop an intrapartum care plan.
Data source: Local data collection, for example, service protocols and records for training in communication skills, multidisciplinary working and shared decision making.
c) Evidence of local arrangements to ensure that pregnant women with existing medical conditions or obstetric complications are supported to review their intrapartum care plan throughout pregnancy, including when their conditions change, and on admission for birth.
Data source: Local data collection, for example, service protocols and records for training in communication skills and shared decision making.
Process
a) Proportion of pregnant women with existing medical conditions or obstetric complications with an individualised intrapartum care plan who reported that they were involved as much as they wanted to be in discussing and making decisions about their care when developing the plan.
Numerator – the number in the denominator who reported that they were involved as much as they wanted to be in discussing and making decisions about their care when developing the plan.
Denominator – the number of pregnant women with existing medical conditions or obstetric complications with an individualised intrapartum care plan.
Data source: Local data collection, for example, patient surveys.
b) Proportion of pregnant women with existing medical conditions or obstetric complications with an individualised intrapartum care plan, who reported that they were involved as much as they wanted to be in discussing and making decisions about their care when reviewing the plan on admission for birth.
Numerator – the number in the denominator who reported that they were involved as much as they wanted to be in discussing and making decisions about their care when reviewing the plan on admission for birth.
Denominator – the number of pregnant women with existing medical conditions or obstetric complications with an individualised intrapartum care plan.
Data source: Local data collection, for example, patient surveys.
c) Proportion of pregnant women with existing medical conditions or obstetric complications with an individualised intrapartum care plan, who reported that they were involved as much as they wanted to be in discussing and making decisions about their care when updating the plan when their medical condition changed.
Numerator – the number in the denominator who reported that they were involved as much as they wanted to be in discussing and making decisions about their care when updating the plan when their medical condition changed.
Denominator – the number of pregnant women with existing medical conditions or obstetric complications with an individualised intrapartum care plan.
Data source: Local data collection, for example, patient surveys.
Outcome
Proportion of pregnant women with existing medical conditions or obstetric complications who felt that they were involved in preparing and reviewing their intrapartum care plan.
Numerator – the number in the denominator who were satisfied with their involvement in preparing and reviewing their intrapartum care plan.
Denominator – the number of pregnant women with existing medical conditions or obstetric complications and an intrapartum care plan.
Data source: Local data collection, for example, a patient (maternity) experience survey.

What the quality statement means for different audiences

Service providers (NHS hospital trusts) ensure that systems are in place for pregnant women with existing medical conditions or obstetric complications to take part in shared decision making and be involved in developing and reviewing individualised plans for their intrapartum care. They also ensure that staff are trained in how to involve pregnant women in developing the plan and shared decision making.
Healthcare professionals (such as obstetric physicians, clinicians with expertise in managing medical conditions during pregnancy and midwives) ensure that during pregnancy women with existing medical conditions or obstetric complications are involved in developing and reviewing their intrapartum care plan. To help support involvement, healthcare professionals should provide the woman with information about, and opportunities to discuss, her medical conditions or obstetric complications, and discuss how they might affect intrapartum care for her and her baby.
Commissioners (clinical commissioning groups) ensure they commission services that involve pregnant women with existing medical conditions or obstetric complications in developing and reviewing their intrapartum care plan during pregnancy. Women should be provided with opportunities for discussion to support their involvement.
Pregnant women with medical conditions or complications during pregnancy or birth are cared for by staff who give them opportunities to discuss how their medical conditions or complications may affect their care and the care of their baby. Women can make choices about their care.

Source guidance

Definitions of terms used in this quality statement

Involved in developing and reviewing the individualised intrapartum care plan
This can include:
  • providing tailored information in a way that can be understood
  • discussion of different care options, including risks and benefits
  • providing opportunities to ask questions
  • discussing preferences and expectations for labour and birth
  • discussing the woman’s experience and knowledge of her existing condition
  • taking into account previous discussions, planning, decisions and choices
  • making decisions together about the woman’s care.
Existing medical conditions
Medical conditions within the scope of this quality standard include:
  • heart disease
  • asthma (dependent on severity)
  • bleeding disorders
  • neurological conditions
  • obesity (BMI [kg/m2] 30 or over)
  • acute kidney injury or chronic kidney disease.
Obstetric complications
A complication arising during pregnancy, including complications relating to a previous pregnancy. Obstetric complications within the scope of this quality standard include:
  • pyrexia (high temperature or fever)
  • sepsis
  • intrapartum haemorrhage
  • breech presentation
  • suspected small-for-gestational-age baby
  • suspected large-for-gestational-age baby
  • previous caesarean section
  • labour after 42 weeks of pregnancy.

Equality and diversity considerations

Pregnant women with existing medical conditions or obstetric complications should be provided with information to support intrapartum care planning that they can easily read and understand themselves, or with support, so they can communicate effectively with healthcare professionals. The information should be accessible to women who do not speak or read English and it should be culturally appropriate. Women should have access to an interpreter, link worker or advocate if needed. The interpreter, link worker or advocate should not be a member of the woman’s family, her legal guardian or her partner, and they should communicate with the woman in her preferred language.
For women with additional needs related to a disability, impairment or sensory loss, information should be provided as set out in NHS England's Accessible Information Standard.

Composition of the multidisciplinary team

This quality statement is taken from the intrapartum care: existing medical conditions and obstetric complications quality standard. The quality standard defines best clinical practice in the intrapartum care of women with existing medical conditions and obstetric complications and should be read in full.

Quality statement

Pregnant women with existing medical conditions are cared for by a multidisciplinary team that can access expertise in managing the medical conditions in pregnancy and is led by a named healthcare professional.

Rationale

Specialist advice is important to ensure the best intrapartum care for a pregnant woman with existing medical conditions. Having a multidisciplinary team that can access expertise in managing the medical conditions during pregnancy means this advice is readily available when needed. More than 1 expert may be involved if a woman has more than 1 medical condition. Designating a named healthcare professional to lead the team supports coordination of expertise and continuity of care. This promotes planning of personalised, holistic care during labour and birth to help reduce the risk of adverse outcomes for the woman and her baby.

Quality measures

Structure
a) Evidence that multidisciplinary teams caring for pregnant women with existing medical conditions can access expertise in managing the medical conditions in pregnancy.
Data source: Local data collection, for example, service protocols and local network agreements.
b) Evidence that a named healthcare professional is available to lead the multidisciplinary team caring for pregnant women with existing medical conditions.
Data source: Local data collection, for example, service protocols, local network agreements, maternity records and staff rotas.
Process
a) Proportion of pregnant women with existing medical conditions cared for by a multidisciplinary team that can access expertise in managing the medical conditions in pregnancy.
Numerator – the number in the denominator with a multidisciplinary team that can access expertise in managing the medical conditions in pregnancy.
Denominator – the number of pregnant women with existing medical conditions.
Data source: Local data collection, for example, audit of maternity records, emails and records of phone calls demonstrating that expertise in managing the existing medical conditions during pregnancy was accessed by the multidisciplinary team.
b) Proportion of pregnant women with existing medical conditions who were cared for by a multidisciplinary team that was led by a named healthcare professional.
Numerator – the number in the denominator who had a multidisciplinary team that was led by a named healthcare professional.
Denominator – the number of pregnant women with existing medical conditions who were cared for by a multidisciplinary team.
Data source: Local data collection, for example, audit of maternity records, emails and records of phone calls demonstrating leadership of a multidisciplinary team by a named healthcare professional.
Outcome
a) Incidence of maternal morbidity associated with an existing medical condition.
Data source: Local data collection, for example, audit of maternity records. The MBRRACE-UK Confidential Enquiries into Maternal Deaths and Morbidity reports on maternal morbidity.
b) Incidence of maternal mortality associated with an existing medical condition.
Data source: Local data collection, for example, audit of maternity records. The MBRRACE-UK Confidential Enquiries into Maternal Deaths and Morbidity reports on maternal mortality.
c) Incidence of neonatal mortality in babies of women with existing medical conditions.
Data source: Local data collection, for example, audit of maternity records. The MBRRACE-UK perinatal mortality surveillance report presents data on perinatal deaths of babies.

What the quality statement means for different audiences

Service providers (NHS hospital trusts) ensure that protocols are in place for pregnant women with existing medical conditions to be cared for by a multidisciplinary team that can access expertise in managing the medical conditions in pregnancy. They ensure that there are rotas and systems in place for the staff with expertise to be available to give advice when needed, and for a named healthcare professional to be available to lead the team.
Healthcare professionals (such as midwives, obstetricians and obstetric anaesthetists) take part in multidisciplinary meetings to plan intrapartum care for pregnant women with existing medical conditions. They ask for input from an obstetric physician or clinician with expertise in caring for pregnant women with the medical condition by phone or email if expertise is needed. A named healthcare professional takes responsibility for leading the multidisciplinary team.
Commissioners (clinical commissioning groups) ensure that services have protocols in place for multidisciplinary teams planning intrapartum care for pregnant women with existing medical conditions to access input from obstetric physicians or clinicians with expertise in managing the medical conditions during pregnancy. They also ensure that services have arrangements so that the staff with expertise are available to give advice when needed, and for a named healthcare professional to lead the multidisciplinary team.
Pregnant women with medical conditions are cared for by a team that can get advice from healthcare professionals who are experts in the medical conditions during pregnancy. The team is led by a named healthcare professional.

Source guidance

Definitions of terms used in this quality statement

Existing medical conditions
Medical conditions within the scope of this quality standard include:
  • heart disease
  • asthma (dependent on severity)
  • bleeding disorders
  • neurological conditions
  • obesity (BMI [kg/m2] 30 or over)
  • acute kidney injury or chronic kidney disease.
Multidisciplinary team
For pregnant women with existing medical conditions, the multidisciplinary team may include, as appropriate:
  • a midwife
  • an obstetrician
  • an obstetric anaesthetist
  • an obstetric physician or clinician with expertise in caring for pregnant women with the medical condition
  • a clinician with expertise in the medical condition
  • a specialty surgeon
  • a neonatologist
  • a critical care specialist
  • the woman’s GP
  • allied health professionals.
The team is led by a named healthcare professional who is responsible for facilitating communication and coordinating care.

Equality and diversity considerations

Pregnant women with existing medical conditions should be provided with information to support intrapartum care planning that they can easily read and understand themselves, or with support, so they can communicate effectively with the multidisciplinary team. The information should be accessible to women who do not speak or read English and it should be culturally appropriate. Women should have access to an interpreter, link worker or advocate if needed. The interpreter, link worker or advocate should not be a member of the woman’s family, her legal guardian or her partner, and they should communicate with the woman in her preferred language.
For women with additional needs related to a disability, impairment or sensory loss, information should be provided as set out in NHS England's Accessible Information Standard.

Recognising and treating sepsis

This quality statement is taken from the intrapartum care: existing medical conditions and obstetric complications quality standard. The quality standard defines best clinical practice in the intrapartum care of women with existing medical conditions and obstetric complications and should be read in full.

Quality statement

Pregnant women in labour with sepsis have an immediate review by a senior clinical decision maker and antibiotics given within 1 hour if indicated.

Rationale

Physiological changes during labour may mask the early signs of sepsis. Sepsis is a medical emergency and needs urgent review from a senior clinical decision maker. The team determines whether antibiotics are needed as part of initial management, and they should be given within 1 hour of the signs of sepsis being recognised, if needed. Sepsis is associated with maternal and neonatal mortality. Unwarranted antibiotic treatment may, however, pose an unnecessary risk to the unborn baby, so senior review before prescribing is important.

Quality measures

Structure
a) Evidence of local arrangements to support escalation protocols to ensure that pregnant women in labour with sepsis are transferred from home birth and midwifery-led units to an acute setting for review and start antibiotic treatment (if indicated) within 1 hour.
Data source: Local data collection, for example, local network agreements and transfer protocols.
b) Evidence of local arrangements to ensure availability of, or access to, a senior clinical decision maker for pregnant women in labour with sepsis to have an immediate review.
Data source: Local data collection, for example, local network agreements, transfer protocols and staff rotas.
c) Evidence of local arrangements to start antibiotic treatment, if indicated, for pregnant women in labour with sepsis within 1 hour.
Data source: Local data collection, for example, system specifications and maternity record systems.
d) Evidence of local arrangements to document the decision to start antibiotic treatment for pregnant women in labour with sepsis.
Data source: Local data collection, for example, system specifications and maternity records.
Process
a) Proportion of pregnant women in labour with sepsis who have an immediate review by a senior clinical decision maker.
Numerator – the number in the denominator who have an immediate review by a senior clinical decision maker.
Denominator – the number of pregnant women in labour with sepsis.
Data source: Local data collection, for example, an audit of maternity records.
b) Proportion of pregnant women in labour with sepsis who started antibiotics within 1 hour.
Numerator – the number in the denominator who started antibiotics within 1 hour.
Denominator – the number of pregnant women in labour with sepsis who needed antibiotics.
Data source: Local data collection, for example, an audit of maternity records.
c) Proportion of pregnant women in labour with sepsis who had the rationale for the decision to start antibiotics documented.
Numerator – the number in the denominator who had the rationale for the decision to start antibiotics documented.
Denominator – the number of pregnant women in labour with sepsis who had antibiotics.
Data source: Local data collection, for example, an audit of maternity records.

What the quality statement means for different audiences

Service providers (NHS hospital trusts) ensure that protocols, systems and pathways are in place for pregnant women in labour with sepsis to have an immediate review by a senior clinical decision maker and receive the first dose of antibiotics, if indicated, within a 1-hour timeframe. They also ensure that a senior clinical decision maker is available to perform the review and protocols are in place to document the rationale for the decision to start antibiotics.
Healthcare professionals (such as a doctor of grade core trainee 3 [CT3] or above, specialty trainee 3 [ST3] or above or an advanced nurse practitioner with antibiotic prescribing responsibilities in discussion with the consultant under whose care the woman is admitted, or a consultant covering acute medicine or anaesthetics) review pregnant women in labour with sepsis immediately. They decide whether to give antibiotics (or not) based on this review, and administer the first dose of antibiotics, if indicated, within the 1-hour timeframe. They also document the rationale for the decision to start antibiotics.
Commissioners (clinical commissioning groups) ensure that they commission services that have protocols, systems and pathways for pregnant women in labour with sepsis to have an immediate review by a senior clinical decision maker and antibiotics given within 1 hour, if indicated. They also ensure that services have capacity to perform the review and have protocols in place to document the rationale for the decision to start antibiotics
Pregnant women with sepsis are assessed by a senior healthcare professional as soon as the early signs of sepsis are recognised. As part of this assessment, a decision is made about whether antibiotics are needed, and if they are, they are started within an hour.

Source guidance

Definitions of terms used in this quality statement

Senior clinical decision maker
A healthcare professional who is authorised to prescribe antibiotics, such as a doctor of grade core trainee 3 (CT3) or above, or a specialty trainee 3 (ST3) or above. Equivalent roles include an advanced nurse practitioner with antibiotic prescribing responsibilities, depending on local arrangements. The senior clinical review should involve discussion with a consultant. This is the consultant under whose care the woman is admitted, or a consultant covering acute medicine or anaesthetics. [NICE's guideline on sepsis recommendation 1.6.1, footnotes]

Women with no antenatal care

This quality statement is taken from the intrapartum care: existing medical conditions and obstetric complications quality standard. The quality standard defines best clinical practice in the intrapartum care of women with existing medical conditions and obstetric complications and should be read in full.

Quality statement

Pregnant women who present in labour with no antenatal care have an obstetric assessment and medical examination, and assessment of their medical, psychological, and social history.

Rationale

Women in labour with no antenatal care are at increased risk of serious obstetric and medical complications for themselves and their babies because there is no baseline information and no birth plan. Assessment of the woman’s medical, psychological and social history, as far as possible, as well obstetric assessment and medical examination, is likely to establish the reason she has not accessed antenatal care. It also indicates the likelihood of complications during labour and birth and identifies the woman’s preferences and needs. A complete assessment helps reduce the risk of adverse outcomes during labour and birth, recognise potential vulnerability and safeguarding concerns, and allows planning of further support, such as postnatal care and continuity of midwifery care.

Quality measures

Structure
a) Evidence of local processes to ensure that pregnant women who present in labour with no antenatal care have an obstetric assessment and medical examination by an obstetrician.
Data source: Local data collection, for example, written protocols, service specifications, and staff rotas.
b) Evidence of local processes to ensure that pregnant women who present in labour with no antenatal care have an assessment of their medical, psychological and social history.
Data source: Local data collection, for example, written protocols, service specifications, staff training records.
c) Evidence of training for healthcare professionals on understanding multiple disadvantage, supporting women with complex social factors and trauma-informed care.
Data source: Local data collection, for example, staff training records.
Process
a) Proportion of pregnant women who present in labour with no antenatal care who have an obstetric assessment and medical examination.
Numerator – the number in the denominator who had an obstetric assessment and medical examination.
Denominator – the number of pregnant women who present in labour with no antenatal care.
Data source: Local data collection, for example, audit of maternity records.
b) Proportion of pregnant women who present in labour with no antenatal care who have an assessment of their medical, psychological and social history.
Numerator – the number in the denominator who have an assessment of their medical, psychological and social history.
Denominator – the number of pregnant women who present in labour with no antenatal care.
Data source: Local data collection, for example, audit of maternity records.
Outcomes
a) Incidence of maternal mortality associated with no antenatal care on presentation in labour.
Data source: Local data collection, for example, audit of maternity records. The MBRRACE-UK Confidential Enquiries into Maternal Deaths and Morbidity reports on the number of women who died and had received no antenatal care.
b) Incidence of neonatal mortality associated with no antenatal care for the mother on presentation in labour.
Data source: Local data collection, for example, audit of maternity records. The MBRRACE-UK Confidential Enquiries into Maternal Deaths and Morbidity reports on the number of neonatal deaths for women who received no antenatal care.

What the quality statement means for different audiences

Service providers (NHS hospital trusts) ensure that they have written protocols and service specifications in place so that pregnant women presenting in labour with no antenatal care have an obstetric assessment and medical examination by an obstetrician. They also ensure that staff are trained in understanding multiple disadvantage, supporting women with complex social factors and trauma-informed care.
Obstetricians lead an obstetric assessment and medical examination of pregnant women who present in labour with no antenatal care so that they can plan further testing and management. Midwives or obstetricians sensitively and respectfully assess the woman’s medical, psychological and social history. This enables care for labour and birth to be planned, in line with the risk of adverse outcomes and the woman’s preferences. Midwives and obstetricians also look for signs of potential vulnerability and safeguarding concerns, identify the need for further support, such as postnatal care, and offer referral to other services as needed.
Commissioners (clinical commissioning groups) ensure that they commission services that provide an obstetric assessment and medical examination by an obstetrician for pregnant women who present in labour with no antenatal care. They also ensure that services train staff in understanding multiple disadvantage, supporting women with complex social factors and trauma-informed care.
Pregnant women in labour who have not had care during pregnancy have a range of assessments, led by healthcare professionals specialising in childbirth, so that they can discuss their preferences and be supported to plan their care during labour and birth. Any potential concerns about the woman’s welfare and her baby’s can be identified and further support after birth planned.

Source guidance

Definitions of terms used in this quality statement

Obstetric assessment and medical examination
Assessments in line with those described in NICE’s guideline on intrapartum care for healthy women and babies, section 1.4, and assessment of the unborn baby as described in NICE’s guideline on intrapartum care for women with existing medical conditions and obstetric complications and their babies, recommendation 1.18.6. This includes listening to the woman’s story and taking into account her preferences and her emotional and psychological needs when performing an initial assessment. [NICE’s guideline on intrapartum care for healthy women and babies]
Assessment of medical, psychological and social history
This should be undertaken as fully as possible to establish the woman’s life situation and, if possible, to find out why she has not accessed antenatal care. This, in combination with medical and obstetric assessments, indicates her risk of complications during labour and birth. She should also be asked who (if anyone) she would like to support her as her birth companion(s) during labour.
Potential vulnerability and safeguarding concerns should be sensitively explored.

Equality and diversity considerations

A woman’s language needs should be established and women with difficulty understanding, speaking and reading English should have access to an interpreter, link worker or advocate. The interpreter, link worker or advocate should not be a member of the woman’s family, her legal guardian or her partner, and they should communicate with the woman in her preferred language. This enables women who have difficulty speaking and reading English to give their own account of their situation.
Women with no antenatal care should also be provided with information that they can easily read and understand themselves, or with support, so they can communicate effectively with healthcare professionals during assessments. Information should be accessible to women who do not speak or read English and it should be culturally appropriate.
For women with no antenatal care who have additional needs related to a disability, impairment or sensory loss, information should be provided as set out in NHS England's Accessible Information Standard.

Assessment

This quality statement is taken from the sepsis quality standard. The quality standard defines clinical best practice for sepsis and should be read in full.

Quality statement

People with suspected sepsis are assessed using a structured set of observations to stratify risk of severe illness or death.

Rationale

People with suspected sepsis require face-to-face assessment to determine whether they need urgent intervention. Using a structured set of observations for assessing physiological symptoms should ensure that people at risk of severe illness or death from sepsis receive timely and appropriate treatment.

Quality measures

Structure
Evidence of local arrangements to ensure that a structured set of observations are used to stratify risk of severe illness or death from sepsis.
Data source: Local data collection. Services can consider using an early warning score (such as NEWS) to inform local arrangements and written clinical protocols.
Process
a) Proportion of people with sepsis in acute hospital settings who were assessed using a structured set of observations to stratify risk of severe illness or death from sepsis.
Numerator – the number in the denominator who were assessed using a structured set of observations to stratify risk of severe illness or death from sepsis.
Denominator – the number of people diagnosed with sepsis in acute hospital settings.
Data source: Local data collection, for example, using Hospital Episode Statistics.
b) Proportion of people with sepsis who were referred to an acute hospital setting from primary or ambulatory care settings who were assessed using a structured set of observations to stratify risk of severe illness or death from sepsis.
Numerator – the number in the denominator who were assessed using a structured set of observations to stratify risk of severe illness or death from sepsis.
Denominator – the number of people with sepsis referred to an acute hospital setting from primary or ambulatory care settings.
Data source: Local data collection.
Outcome
a) Rates of admission to critical care for people with sepsis.
Data source: Local data collection, for example, using Hospital Episode Statistics.
b) Rates of in-hospital mortality for people with sepsis.
Data source: Local data collection, for example, using Hospital Episode Statistics and Office for National Statistics mortality database.

What the quality statement means for different audiences

Service providers (such as primary, ambulatory and secondary care services) ensure that written protocols are in place on the use of structured sets of observations to stratify risk of severe illness or death (such as an early warning score) when people are suspected to have sepsis.
Healthcare professionals (such as GPs, paramedics and healthcare professionals working in emergency departments) consider sepsis if a person presents with signs or symptoms that indicate possible infection. They should use a structured set of observations to stratify risk of severe illness or death in people with suspected sepsis. Healthcare professionals outside acute healthcare settings should also be aware of the criteria that indicate when to refer people for emergency medical care.
Commissioners (such as clinical commissioning groups and NHS England) ensure that primary, ambulatory and secondary care services demonstrate the use of structured sets of observations for people presenting with symptoms that suggest sepsis. They should also monitor performance against the national CQUIN on the timely identification of sepsis.
People with symptoms that suggest sepsis are assessed to see whether they have a high risk of life-threatening illness from sepsis, and if urgent treatment or more checks are needed.

Source guidance

Sepsis: recognition, diagnosis and early management (2016) NICE guideline NG51, recommendation 1.1.7

Definitions of terms used in this quality statement

Structured set of observations
Everyone with suspected sepsis should have the following assessed:
  • temperature
  • heart rate
  • respiratory rate
  • level of consciousness
  • oxygen saturation.
Everyone with suspected sepsis should also be examined for:
  • mottled or ashen appearance
  • cyanosis of the skin, lips or tongue
  • non-blanching rash of the skin
  • any breach of skin integrity (for example, cuts, burns or skin infections)
  • any rash indicating potential infection.
The person, parent or carer should also be asked about the frequency of urination in the past 18 hours.
[NICE’s guideline on sepsis, recommendations 1.3.7 and 1.3.8]
Children under 12 years should have capillary refill assessed.
[NICE’s guideline on sepsis, 1.3.1 and 1.3.2]
Blood pressure should be measured:
  • in adults and young people over 12 years
  • in children aged 5 to 11 years if facilities, including a cuff of correct size, are available
  • in children under 5 years if heart rate or capillary refill time are abnormal and facilities to measure blood pressure, including a cuff of correct size, are available.
[NICE’s guideline on sepsis, recommendations 1.3.1, 1.3.3 and 1.3.4]
Suspected sepsis
Suspected sepsis is used to indicate people who might have sepsis and require face-to-face assessment to determine whether they need urgent intervention.
Symptoms of sepsis can include, but are not limited to:
  • high body temperature or low body temperature
  • fast heartbeat/breathing
  • feeling dizzy or faint/loss of consciousness
  • a change in mental state, for example, confusion or disorientation
  • diarrhoea/nausea and vomiting
  • slurred speech
  • severe muscle pain
  • breathlessness
  • reduced urine production
  • cold, clammy and pale or mottled skin.
People with sepsis may have non-specific, non-localised presentations, for example, they may feel very unwell, and may not have a high temperature.
[NICE’s guideline on sepsis and expert opinion]

Equality and diversity considerations

People with suspected sepsis should be assessed with extra care if they or their families or carers cannot give a good history of their signs and symptoms (for example, people with English as a second language or people with communication problems). People should have access to an interpreter or advocate if needed.

Senior review and antibiotic treatment

This quality statement is taken from the sepsis quality standard. The quality standard defines clinical best practice for sepsis and should be read in full.

Quality statement

People with suspected sepsis in acute hospital settings and at least 1 of the criteria indicating high risk of severe illness or death, have the first dose of intravenous antibiotics and a review by a senior clinical decision-maker within 1 hour of risk being stratified.

Rationale

Sepsis is a medical emergency and needs urgent senior review to identify the source of infection and ensure that people receive appropriate treatment. A senior decision-maker is also more likely to recognise if there is another potential cause for the person’s severe illness. For people at high risk of severe illness or death from sepsis, the clinical benefits of having the first dose of intravenous antibiotics within an hour outweigh any risks associated with possible antimicrobial resistance.

Quality measures

Structure
a) Evidence of local arrangements to ensure urgent assessment mechanisms are in place to deliver antibiotics to people with suspected sepsis in acute hospital settings within 1 hour of any high risk criteria of severe illness or death from sepsis being identified.
Data source: Local data collection.
b) Evidence of local arrangements for a senior clinical decision-maker to be available within 1 hour for people with suspected sepsis in acute hospital settings and at least 1 of the criteria indicating high risk of severe illness or death from sepsis.
Data source: Local data collection.
Process
a) Proportion of people with suspected sepsis in acute hospital settings and at least 1 of the criteria indicating high risk of severe illness or death from sepsis who receive the first dose of intravenous antibiotics within 1 hour of risk being stratified.
Numerator – the number in the denominator who receive the first dose of intravenous antibiotics within 1 hour of risk being stratified.
Denominator – the number of people with suspected sepsis in acute hospital settings and at least 1 of the criteria indicating high risk of severe illness or death from sepsis.
Data source: Local data collection, for example, using local prescribing data.
b) Proportion of people with suspected sepsis in acute hospital settings and at least 1 of the criteria indicating high risk of severe illness or death from sepsis who have a review by a senior clinical decision-maker within 1 hour of risk being stratified.
Numerator – the number in the denominator who have a review by a senior clinical decision-maker within 1 hour of risk being stratified.
Denominator – the number of people with suspected sepsis in acute hospital settings and at least 1 of the criteria indicating high risk of severe illness or death from sepsis.
Data source: Local data collection.
c) The percentage of people who were diagnosed with sepsis in emergency departments and acute inpatient services and received intravenous antibiotics within 1 hour of diagnosis.
Numerator – the number in the denominator who received intravenous antibiotics within 1 hour of diagnosis.
Denominator – the number of people who were diagnosed with sepsis in emergency departments and acute inpatient services.
Data source: This is taken directly from NHS England’s National 2017/19 CQUIN.
Outcome
Rates of in-hospital mortality for people with sepsis.
Data source: Local data collection, for example, using Hospital Episode Statistics and Office for National Statistics mortality database.

What the quality statement means for different audiences

Service providers (secondary care services) ensure that a senior clinical decision-maker is available to review the care of people with suspected sepsis and at least 1 of the criteria indicating high risk of severe illness or death within 1 hour of risk being stratified. Mechanisms should also be in place to give the first dose of intravenous antibiotics within 1 hour of any high-risk criteria being identified.
Healthcare professionals (such as healthcare professionals working in emergency departments) give intravenous antibiotics and seek a review from a senior clinical decision-maker within 1 hour of identifying at least 1 of the criteria indicating high risk of severe illness or death from sepsis.
Commissioners (such as clinical commissioning groups and NHS England) ensure that acute hospital settings can demonstrate that intravenous antibiotics are given and there is review by a senior clinical decision-maker within 1 hour of at least 1 of the criteria indicating high risk of severe illness or death due to sepsis being identified.
People with symptoms that suggest life-threating illness from sepsis have antibiotics and a review by a senior healthcare professional within 1 hour to make sure that they have the best treatment as soon as possible. If it will take more than an hour to get to hospital, the antibiotics may be given by healthcare professionals in primary care or by ambulance staff.

Source guidance

Sepsis: recognition, diagnosis and early management (2016) NICE guideline NG51, recommendations 1.6.1, 1.6.16, 1.6.31 and expert consensus

Definitions of terms used in this quality statement

Antibiotic treatment for suspected sepsis
The NICE quality standard on antimicrobial stewardship includes the statement: ‘People in hospital who are prescribed an antimicrobial have a microbiological sample taken and their treatment reviewed when the results are available.’
Age
Symptoms
Antibiotics
NICE recommendations
All
Clear source of infection
Local antimicrobial guidance
1.7.6
All
Fever and purpuric rash suggesting meningococcal disease
Parenteral benzyl penicillin in community settings
Intravenous ceftriaxone in hospital settings
1.7.5
18 years and over
No confirmed diagnosis but empirical intravenous antimicrobial needed
Local formulary
1.7.7
Up to 17 years (excluding neonates)
Suspected community acquired sepsis of any cause
80 mg/kg once a day ceftriaxone with maximum daily dose of 4 g
1.7.8
Up to 17 years
Suspected sepsis already in hospital, or known to have previous infection or colonisation with ceftriaxone-resistant bacteria
Local antimicrobial guidance
1.7.9
Under 3 months
Suspected sepsis
Additional antibiotic active against listeria (for example, ampicillin or amoxicillin)
1.7.10
Neonates
Presenting in hospital with suspected sepsis in their first 72 hours
Intravenous benzyl penicillin and gentamicin
1.7.11
Neonates over 40 weeks corrected gestational age
Community acquired sepsis
Ceftriaxone 50 mg/kg unless receiving i.v. calcium
Cefotaxime 50 mg/kg every 6 to 12 hours (depending on age) if receiving i.v. calcium
1.7.12
Neonates 40 weeks corrected gestational age or under
Community acquired sepsis
Cefotaxime 50 mg/kg every 6 to 12 hours (depending on age)
1.7.12
Criteria indicating high risk of severe illness or death from sepsis
People with any of the symptoms or signs in the table below are at high risk of severe illness or death from sepsis:
Symptoms or signs
Adults, children and young people aged 12 years and over
Children aged 5 to 11 years
Children under 5 years
Behaviour
Objective evidence of new altered mental state
  • Objective evidence of altered behaviour or mental state, or
  • Appears ill to healthcare professional, or
  • Does not wake (or if roused, does not stay awake)
  • No response to social cues, or
  • Appears ill to a healthcare professional, or
  • Does not wake, or if roused does not stay awake, or
  • Weak, high-pitched or continuous cry
Respiratory rate
  • 25 breaths per minute or above, or
  • New need for 40% oxygen or more to maintain oxygen saturation more than 92% (or more than 88% in known chronic obstructive pulmonary disease)
  • Aged 5 years, 29 breaths per minute or more
  • Aged 6 to 7 years, 27 breaths per minute or more
  • Aged 8 to 11 years, 25 breaths per minute or more
  • Oxygen saturation of less than 90% in air or increased oxygen requirement over baseline
  • Aged under 1 year, 60 breaths per minute or more
  • Aged 1 to 2 years, 50 breaths per minute or more
  • Aged 3 to 4 years, 40 breaths per minute or more
  • Grunting
  • Apnoea
  • Oxygen saturation of less than 90% in air or increased oxygen requirement over baseline
Heart rate
130 beats per minute or above
  • Aged 5 years, 130 beats per minute or more
  • Aged 6 to 7 years, 120 beats per minute or more
  • Aged 8 to 11 years, 115 beats per minute or more
  • Or heart rate less than 60 beats per minute at any age
  • Aged under 1 year, 160 beats per minute or more
  • Aged 1 to 2 years, 150 beats per minute or more
  • Aged 3 to 4 years, 140 beats per minute or more
  • Heart rate less than 60 beats per minute at any age
Blood pressure
Systolic blood pressure of 90 mmHg or less, or more than 40 mmHg below normal
Urine
Not passed urine in previous 18 hours (for catheterised patients, passed less than 0.5 ml/kg/hour)
Temperature
  • Less than 36ºC
  • Aged under 3 months and temperature 38ºC or more
Appearance
  • Mottled or ashen, or
  • Cyanosis of skin, lips or tongue, or
  • Non-blanching skin rash
  • Mottled or ashen, or
  • Cyanosis of skin, lips or tongue, or
  • Non-blanching skin rash
  • Mottled or ashen, or
  • Cyanosis of skin, lips or tongue, or
  • Non-blanching skin rash
[NICE’s guideline on sepsis, recommendations 1.4.2, 1.4.5 and 1.4.8]
Senior clinical decision-maker
Depending on local arrangements the senior clinical decision-maker for people aged 18 years or over should be a doctor of grade CT3/ST3 or above or equivalent, or an advanced nurse practitioner with antibiotic prescribing responsibilities.
[NICE’s guideline on sepsis, recommendation 1.6.1]
The senior decision-maker for people aged 5 to 17 years is a paediatric or emergency care qualified doctor of grade ST4 or above or equivalent.
[NICE’s guideline on sepsis, recommendations 1.6.1 and 1.6.16]
The senior clinical decision-maker for children under 5 years is a paediatric qualified doctor of grade ST4 or above.
[NICE’s guideline on sepsis, recommendation 1.6.31]
Suspected sepsis
Suspected sepsis is used to indicate people who might have sepsis and require face-to-face assessment to determine whether they need urgent intervention.
Symptoms of sepsis can include, but are not limited to:
  • high body temperature or low body temperature
  • fast heartbeat/breathing
  • feeling dizzy or faint/loss of consciousness
  • a change in mental state, for example, confusion or disorientation
  • diarrhoea/nausea and vomiting
  • slurred speech
  • severe muscle pain
  • breathlessness
  • reduced urine production
  • cold, clammy and pale or mottled skin.
People with sepsis may have non-specific, non-localised presentations, for example, they may feel very unwell, and may not have a high temperature.
[NICE’s guideline on sepsis and expert opinion]

Intravenous fluids

This quality statement is taken from the sepsis quality standard. The quality standard defines clinical best practice for sepsis and should be read in full.

Quality statement

People with suspected sepsis in acute hospital settings who need treatment to restore cardiovascular stability have an intravenous fluid bolus within 1 hour of risk being stratified.

Rationale

Early intervention with intravenous fluids is vital for managing sepsis. It can help to reverse septic shock and to restore cardiovascular stability for people who are at high risk of severe illness or death. Intravenous fluids improve oxygen delivery to organs and so reduce long-term disability associated with poor tissue perfusion.

Quality measures

Structure
a) Evidence of local arrangements and written clinical protocols to ensure that people with suspected sepsis in acute hospital settings who need treatment to restore cardiovascular stability have an intravenous fluid bolus within 1 hour of risk being stratified.
Data source: Local data collection, for example, using hospital board reports.
b) Evidence of local arrangements and written clinical protocols to ensure that people with suspected sepsis in acute hospital settings have their lactate levels recorded.
Data source: Local data collection, for example, healthcare records.
Process
a) Proportion of adults and young people age 12 years and over with suspected sepsis in acute hospital settings and systolic blood pressure less than 90 mmHg who receive an intravenous fluid bolus within 1 hour of blood pressure being measured as less than 90 mmHg.
Numerator – the number in the denominator who receive an intravenous fluid bolus within 1 hour of blood pressure being measured as less than 90 mmHg.
Denominator – the number of adults and young people age 12 years and over with suspected sepsis in acute hospital settings and systolic blood pressure less than 90 mmHg.
Data source: Local data collection.
b) Proportion of people with suspected sepsis in acute hospital settings, at least 1 criteria indicating high risk of severe illness or death from sepsis, and with lactate over 2 mmol/litre, who receive an intravenous fluid bolus within 1 hour of risk being stratified.
Numerator – the number in the denominator who receive an intravenous fluid bolus within 1 hour of risk being stratified.
Denominator – the number of people with suspected sepsis in acute hospital settings, at least 1 criteria indicating high risk of severe illness or death from sepsis, and with lactate over 2 mmol/litre.
Data source: Local data collection.
Outcome
a) Rates of cardiovascular stability in people with suspected sepsis.
Data source: Local data collection, for example, using Hospital Episode Statistics.
b) Rates of 28-day all-cause mortality in people with sepsis.
Data source: Local data collection, for example, using Hospital Episode Statistics and Office for National Statistics mortality database.

What the quality statement means for different audiences

Service providers (secondary care services) ensure that systems are in place for people with suspected sepsis who need treatment to restore cardiovascular stability, to have an intravenous fluid bolus within 1 hour of need for treatment being identified. They should also ensure that there are systems in place for people with suspected sepsis to have lactate levels taken and recorded.
Healthcare professionals (such as healthcare professionals working in emergency departments) give an intravenous fluid bolus to people who need treatment to restore cardiovascular stability, within 1 hour of need for treatment being identified. They measure and record lactate levels of people who have suspected sepsis.
Commissioners (such as clinical commissioning groups) ensure that they commission services in which people who need treatment to restore cardiovascular stability have an intravenous fluid bolus within 1 hour of need for treatment being identified. The services they commission should take and record lactate levels in people with suspected sepsis.
People with symptoms that suggest life-threating illness from sepsis have extra fluids in hospital through a drip or injection, no more than an hour after they have been diagnosed as being at high risk.

Source guidance

Sepsis: recognition, diagnosis and early management (2016) NICE guideline NG51, recommendations 1.6.2, 1.6.3, 1.6.17, 1.6.18, 1.6.32 and 1.6.33

Definitions of terms used in this quality statement

People with suspected sepsis who need treatment to restore cardiovascular stability
This includes the following groups:
  • people with suspected sepsis and at least 1 of the criteria indicating high risk of severe illness or death, and with lactate over 2 mmol/litre
  • adults and young people 12 years and over with suspected sepsis and systolic blood pressure less than 90 mmHg.
[Adapted from NICE’s guideline on sepsis, recommendation 1.6.2, 1.6.3, 1.6.17, 1.6.18, 1.6.32 and 1.6.33]
Suspected sepsis
Suspected sepsis is used to indicate people who might have sepsis and require face-to-face assessment to determine whether they need urgent intervention.
Symptoms of sepsis can include, but are not limited to:
  • high body temperature or low body temperature
  • fast heartbeat/breathing
  • feeling dizzy or faint/loss of consciousness
  • a change in mental state, for example, confusion or disorientation
  • diarrhoea/nausea and vomiting
  • slurred speech
  • severe muscle pain
  • breathlessness
  • reduced urine production
  • cold, clammy and pale or mottled skin.
People with sepsis may have non-specific, non-localised presentations, for example, they may feel very unwell, and may not have a high temperature.
[NICE’s guideline on sepsis and expert opinion]

Escalation of care

This quality statement is taken from the sepsis quality standard. The quality standard defines clinical best practice for sepsis and should be read in full.

Quality statement

People with suspected sepsis in acute hospital settings who receive intravenous antibiotics or fluid bolus are seen by a consultant if their condition fails to respond within 1 hour of initial treatment.

Rationale

Septic shock is associated with a high risk of death, so specialist input is important for people who have not had significant improvement after initial treatment. Being looked after by specialist healthcare staff, including a consultant, can improve clinical outcomes for these people.

Quality measures

Structure
Evidence of acute hospital settings having arrangements in place which ensure that people with suspected sepsis are seen by a consultant if their condition fails to respond within 1 hour of initial intravenous antibiotics or fluid bolus. This includes ensuring a consultant is available to attend promptly.
Data source: Local data collection.
Process
Proportion of people with suspected sepsis in acute hospital settings who are seen by a consultant if their condition fails to respond within 1 hour of initial intravenous antibiotics or fluid bolus.
Numerator – the number in the denominator who are seen by a consultant.
Denominator – the number of people with suspected sepsis in acute hospital settings whose condition fails to respond within 1 hour of initial intravenous antibiotics or fluid bolus.
Data source: Local data collection.
Outcome
Rates of 28-day all-cause mortality in people with sepsis.
Data source: Local data collection, for example, using Hospital Episode Statistics and Office for National Statistics mortality database.

What the quality statement means for different audiences

Service providers (secondary care services) ensure that a consultant is available to see people with suspected sepsis if their condition fails to respond within 1 hour of initial intravenous antibiotics or fluid bolus.
Healthcare professionals (such as healthcare professionals working in emergency departments) ask a consultant to see people with suspected sepsis if their condition fails to respond within 1 hour of initial intravenous antibiotics or fluid bolus. Consultants attend promptly when asked to see people with suspected sepsis in these circumstances.
Commissioners (such as clinical commissioning groups) ensure that they commission services in acute hospital settings in which consultants are available to see people with suspected sepsis if their condition fails to respond within 1 hour of initial intravenous antibiotics or fluid bolus.
People with symptoms that suggest life-threating illness and that fail to improve within 1 hour of treatment see a consultant. The consultant will be able to arrange specialist treatment to prevent septic shock.

Source guidance

Sepsis: recognition, diagnosis and early management (2016) NICE guideline NG51, recommendations 1.6.7, 1.6.22 and 1.6.37

Definitions of terms used in this quality statement

Failure to respond
In adults and young people aged 12 years and over, failure to respond is indicated by any of:
  • systolic blood pressure persistently below 90 mmHg
  • reduced level of consciousness despite resuscitation
  • respiratory rate of 25 breaths per minute or above, or a new need for mechanical ventilation
  • lactate not reduced by more than 20% of initial value within 1 hour.
[NICE’s guideline on sepsis, recommendation 1.6.7]
In children aged 5 to 11 years, failure to respond is indicated by any of:
  • reduced level of consciousness despite resuscitation
  • respiratory rate:
    • aged 5 years, 29 breaths per minute or more
    • aged 6 to 7 years, 27 breaths per minute or more
    • aged 8 to 11 years, 25 breaths per minute or more
    • oxygen saturation of less than 90% in air or increased oxygen requirement over baseline
  • heart rate:
    • aged 5 years, 130 beats per minute or more
    • aged 6 to 7 years, 120 beats per minute or more
    • aged 8 to 11 years, 115 beats per minute or more
    • or heart rate less than 60 beats per minute at any age
  • lactate remains over 2 mmol/litre after 1 hour.
[NICE’s guideline on sepsis, recommendation 1.6.22]
In a child under 5 years, failure to respond is indicated by any of:
  • reduced level of consciousness despite resuscitation
  • respiratory rate:
    • aged under 1 year, 60 breaths per minute or more
    • aged 1 to 2 years, 50 breaths per minute or more
    • aged 3 to 4 years, 40 breaths per minute or more
  • heart rate:
    • aged under 1 year, 160 beats per minute or more
    • aged 1 to 2 years, 150 beats per minute or more
    • aged 3 to 4 years, 140 beats per minute or more
    • heart rate less than 60 beats per minute at any age
  • lactate over 2 mmol/litre after 1 hour.
[NICE’s guideline on sepsis, recommendation 1.6.37]
Suspected sepsis
Suspected sepsis is used to indicate people who might have sepsis and require face-to-face assessment to determine whether they need urgent intervention.
Symptoms of sepsis can include, but are not limited to:
  • high body temperature or low body temperature
  • fast heartbeat/breathing
  • feeling dizzy or faint/loss of consciousness
  • a change in mental state, for example, confusion or disorientation
  • diarrhoea/nausea and vomiting
  • slurred speech
  • severe muscle pain
  • breathlessness
  • reduced urine production
  • cold, clammy and pale or mottled skin.
People with sepsis may have non-specific, non-localised presentations, for example, they may feel very unwell, and may not have a high temperature.
[NICE’s guideline on sepsis and expert opinion]

Information for people at low risk of severe illness or death

This quality statement is taken from the sepsis quality standard. The quality standard defines clinical best practice for sepsis and should be read in full.

Quality statement

People with suspected sepsis who have been stratified as at low risk of severe illness or death are given information about symptoms to monitor and how to access medical care.

Rationale

Sepsis cannot always be ruled out for people who have been assessed as being at low risk of severe illness or death from sepsis. They need to know which symptoms to look out for and how to access medical care urgently if these symptoms develop. This awareness will mean rapid management if symptoms become worse.

Quality measures

Structure
Evidence of local arrangements to ensure that information about symptoms to monitor and how to access medical care if needed is available to people with suspected sepsis who have been stratified as being at low risk of severe illness or death.
Data source: Local data collection, for example, using electronic hospital records and local primary care systems.
Process
Proportion of people with suspected sepsis who have been stratified as being at low risk of severe illness or death who are given information about symptoms to monitor and how to access medical care.
Numerator – the number in the denominator who are given information about symptoms to monitor and how to access medical care.
Denominator – the number of people with suspected sepsis who have been stratified as being at low risk of severe illness or death.
Data source: Local data collection, for example, using electronic hospital records and local primary care systems.
Outcome
Levels of awareness of symptoms in people with suspected sepsis.
Data source: Local data collection, for example, using local patient surveys.

What the quality statement means for different audiences

Service providers (such as primary and secondary care services) ensure that information is available about symptoms to monitor and how and when to access medical care for people with suspected sepsis who have been stratified as being at low risk of severe illness or death from sepsis.
Healthcare professionals (such as GPs and healthcare professionals working in emergency departments) give information about which symptoms to monitor and how and when to access medical care to people stratified as being at low risk of severe illness or death from sepsis; they also discuss this information with them.
Commissioners (such as clinical commissioning groups and NHS England) ensure that they commission services with protocols in place to provide information about symptoms to monitor and how to access medical care for people who have been stratified as being at low risk of severe illness or death from sepsis. They also ensure that services have healthcare professionals who can stratify and treat symptoms of sepsis when people are concerned about these.
People with symptoms that suggest they have a low risk of life-threating illness from sepsis are given information about what to do if they still feel unwell, important signs to look out for and when and where to get urgent help if they are worried about their condition.

Source guidance

Sepsis: recognition, diagnosis and early management (2016) NICE guideline NG51, recommendation 1.5.3 and 1.11.5

Definitions of terms used in this quality statement

Suspected sepsis
Suspected sepsis is used to indicate people who might have sepsis and require face-to-face assessment to determine whether they need urgent intervention.
Symptoms of sepsis can include, but are not limited to:
  • high body temperature or low body temperature
  • fast heartbeat/breathing
  • feeling dizzy or faint/loss of consciousness
  • a change in mental state, for example, confusion or disorientation
  • diarrhoea/nausea and vomiting
  • slurred speech
  • severe muscle pain
  • breathlessness
  • reduced urine production
  • cold, clammy and pale or mottled skin.
People with sepsis may have non-specific, non-localised presentations, for example, they may feel very unwell, and may not have a high temperature.
[NICE’s guideline on sepsis and expert opinion]
Low risk of severe illness or death from sepsis
People with suspected sepsis who do not currently meet any high or moderate to high risk criteria of severe illness or death from sepsis.
[NICE’s guideline on sepsis recommendations 1.4.4, 1.4.7 and 1.4.10]

Equality and diversity considerations

Information about symptoms to monitor and how to access medical care should be accessible to people with additional needs such as physical, sensory or learning disabilities, and to people (including families and carers) who do not speak or read English. People should have access to an interpreter or advocate if needed.

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

Information for the public

NICE has written information for the public on each of the following topics.

Pathway information

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Supporting information

Information at discharge for people assessed for possible sepsis, but not diagnosed with sepsis

Give people who have been assessed for sepsis but have been discharged without a diagnosis of sepsis (and their family or carers, if appropriate) verbal and written information about:
  • what sepsis is, and why it was suspected
  • what tests and investigations have been done
  • instructions about which symptoms to monitor
  • when to get medical attention if their illness continues
  • how to get medical attention if they need to seek help urgently.
Confirm that people understand the information they have been given, and what actions they should take to get help if they need it.
NICE has written information for the public on sepsis: recognition, diagnosis and early management

Signs and symptoms of sepsis by risk level for people aged 12 and over

Category
High risk criteria
Moderate to high risk criteria
Low risk criteria
History
Objective evidence of new altered mental state
History from patient, friend or relative of new onset of altered behaviour or mental state
History of acute deterioration of functional ability
Impaired immune system (illness or drugs including oral steroids)
Trauma, surgery or invasive procedures in the last 6 weeks
Normal behaviour
Respiratory
Raised respiratory rate 25 breaths per minute or more
New need for oxygen (40% FiO2 or more) to maintain saturation more than 92% (or more than 88% in known chronic obstructive pulmonary disease)
Raised respiratory rate 21–24 breaths per minute
No high risk or moderate to high risk criteria met
Blood pressure
Systolic blood pressure 90 mmHg or less or systolic blood pressure more than 40 mmHg below normal
Systolic blood pressure 91–100 mmHg
No high risk or moderate to high risk criteria met
Circulation and hydration
Raised heart rate: more than 130 beats per minute
Not passed urine in previous 18 hours.
For catheterised patients, passed less than 0.5 ml/kg of urine per hour
Raised heart rate: 91–130 beats per minute (for pregnant women 100 -130 beats per minute) or new onset arrhythmia
Not passed urine in the past 12–18 hours
For catheterised patients, passed 0.5–1 ml/kg of urine per hour
No high risk or moderate to high risk criteria met
Temperature
-
Tympanic temperature less than 36ºC
-
Skin
Mottled or ashen appearance
Cyanosis of skin, lips or tongue
Non-blanching rash of skin
Signs of potential infection, including redness, swelling or discharge at surgical site or breakdown of wound
No non-blanching rash
Carry out a thorough clinical examination to look for sources of infection, including sources that might need surgical drainage, as part of the initial assessment.
Tailor investigations of the sources of infection to the person's clinical history and findings on examination.
Consider urine analysis and chest X-ray to identify the source of infection in all people with suspected sepsis.
Consider imaging of the abdomen and pelvis if no likely source of infection is identified after clinical examination and initial tests.
Involve the adult or paediatric surgical and gynaecological teams early on if intra-abdominal or pelvic infection is suspected in case surgical treatment is needed.
Do not perform a lumbar puncture without consultant instruction if any of the following contraindications are present:
  • signs suggesting raised intracranial pressure or reduced or fluctuating level of consciousness (Glasgow Coma Scale score less than 9 or a drop of 3 points or more)
  • relative bradycardia and hypertension
  • focal neurological signs
  • abnormal posture or posturing
  • unequal, dilated or poorly responsive pupils
  • papilloedema
  • abnormal 'doll's eye' movements
  • shock
  • extensive or spreading purpura
  • after convulsions until stabilised
  • coagulation abnormalities or coagulation results outside the normal range or platelet count below 100x109/litre or receiving anticoagulant therapy
  • local superficial infection at the lumbar puncture site
  • respiratory insufficiency in children.
Perform lumbar puncture in the following children with suspected sepsis (unless contraindicated, please see contraindications in the above recommendation):
  • infants younger than 1 month
  • all infants aged 1–3 months who appear unwell
  • infants aged 1–3 months with a white blood cell count less than 5×109/litre or greater than 15×109/litre.
Investigate for acute kidney injury, by measuring serum creatinine and comparing with baseline, in adults and young people with acute illness if sepsis is likely or present. (For more information see what NICE says on person aged 17 or under with acute illness and person aged 18 or over with acute illness in terms of identifying acute kidney injury.)
Ensure urgent assessment mechanisms are in place to deliver antibiotics when high risk criteria are met in secondary care (within 1 hour of meeting a high risk criterion in an acute hospital setting).
Ensure GPs and ambulance services have mechanisms in place to give antibiotics for people with high risk criteria in pre-hospital settings in location where transfer time is more than 1 hour.
For patients in hospital who have suspected infections, take microbiological samples before prescribing an antimicrobial and review the prescription when the results are available. For people with suspected sepsis take blood cultures before antibiotics are given.
If meningococcal disease is specifically suspected (fever and purpuric rash) give appropriate doses of parenteral benzyl penicillin in community settings and intravenous ceftriaxone in hospital settings.
For all people with suspected sepsis where the source of infection is clear use existing local antimicrobial guidance.
Investigate for acute kidney injury, by measuring serum creatinine and comparing with baseline, in children with acute illness if sepsis is likely or present. (For more information see what NICE says on person aged 17 or under with acute illness in terms of identifying acute kidney injury.)

Information and support for people with sepsis, their families and carers

Ensure a care team member is nominated to give information to families and carers, particularly in emergency situations such as in the emergency department. This should include:
  • an explanation that the person has sepsis, and what this means
  • an explanation of any investigations and the management plan
  • regular and timely updates on treatment, care and progress.
Ensure information is given without using medical jargon. Check regularly that people understand the information and explanations they are given.
Give people with sepsis and their family members and carers opportunities to ask questions about diagnosis, treatment options, prognosis and complications. Be willing to repeat any information as needed.
Give people with sepsis and their families and carers information about national charities and support groups that provide information about sepsis and the causes of sepsis.
NICE has written information for the public on sepsis: recognition, diagnosis and early management
For people aged up to 17 years (except neonates) with suspected community acquired sepsis of any cause give ceftriaxone 80 mg/kg once a day with a maximum dose of 4g daily at any age.
For people aged up to 17 years with suspected sepsis who are already in hospital, or who are known to have previously been infected with or colonised with ceftriaxone-resistant bacteria, consult local guidelines for choice of antibiotic.
Follow NICE's recommendations on antimicrobial stewardship when prescribing and using antibiotics to treat people with suspected or confirmed sepsis.

Discharge information

Ensure people and their families and carers if appropriate have been informed that they have had sepsis.
Ensure discharge notifications to GPs include the diagnosis of sepsis.
Give people who have had sepsis (and their families and carers, when appropriate) opportunities to discuss their concerns. These may include:
  • why they developed sepsis
  • whether they are likely to develop sepsis again
  • if more investigations are necessary
  • details of any community care needed, for example, related to peripherally inserted central venous catheters (PICC) lines or other intravenous catheters
  • what they should expect during recovery
  • arrangements for follow-up including specific critical care follow-up if appropriate
  • possible short-term and long-term problems.
Give people who have had sepsis and their families and carers information about national charities and support groups that provide information about sepsis and causes of sepsis.
Advise carers they have a legal right to have a carer's assessment of their needs, and give them information on how they can get this.

Signs and symptoms of sepsis by risk level for children aged 5 to 11

Category
Age
High risk criteria
Moderate to high risk criteria
Low risk criteria
Behaviour
Any
Objective evidence of altered behaviour or mental state
Appears ill to a healthcare professional
Does not wake or if roused does not stay awake
Not behaving normally
Decreased activity
Parent or carer concern that the child is behaving differently from usual
Behaving normally
Respiratory
Any
Oxygen saturation of less than 90% in air or increased oxygen requirement over baseline
Oxygen saturation of less than 92% in air or increased oxygen requirement over baseline
No high risk or moderate to high risk criteria met
Aged 5 years
Raised respiratory rate: 29 breaths per minute or more
Raised respiratory rate: 24–28 breaths per minute
Aged 6–7 years
Raised respiratory rate: 27 breaths per minute or more
Raised respiratory rate: 24–26 breaths per minute
Aged 8–11 years
Raised respiratory rate: 25 breaths per minute or more
Raised respiratory rate: Aged 8–11 years, 22–24 breaths per minute
Circulation and hydration
Any
Heart rate less than 60 beats per minute
Capillary refill time of 3 seconds or more
Reduced urine output
For catheterised patients, passed less than 1ml/kg of urine per hour
Oxygen saturation of less than 92% in air or increased oxygen requirement over baseline
No high risk or moderate to high risk criteria met
Aged 5 years
Raised heart rate: 130 beats per minute or more
Raised heart rate: Aged 5 years, 120–129 beats per minute
Aged 6–7 years
Raised heart rate: 120 beats per minute or more
Raised heart rate: 110–119 beats per minute
Aged 8–11 years
Raised heart rate: 115 beats per minute or more
Raised heart rate: 105–114 beats per minute
Temperature
Any
Tympanic temperature less than 36°C
Skin
Any
Mottled or ashen appearance
Cyanosis of skin, lips or tongue
Non-blanching rash of skin
Other
Any
Leg pain
Cold hands or feet
No high or moderate to high risk criteria met
The following recommendation is from NICE diagnostics guidance on SepsiTest assay for rapidly identifying bloodstream bacteria and fungi.
There is currently insufficient evidence to recommend the routine adoption in the NHS of the SepsiTest assay for rapidly identifying bloodstream bacteria and fungi. The tests show promise and further research to provide robust evidence is encouraged, particularly to demonstrate the value of using the test results in clinical decision making see sections 5.18 to 5.22 of NICE diagnostics guidance 20).
NICE has published a medtech innovation briefing on Fungitell for antifungal treatment stratification.
The following recommendation is from NICE diagnostics guidance on procalcitonin testing for diagnosing and monitoring sepsis.
The procalcitonin tests (ADVIA Centaur BRAHMS PCT assay, BRAHMS PCT Sensitive Kryptor assay, Elecsys BRAHMS PCT assay, LIAISON BRAHMS PCT assay and VIDAS BRAHMS PCT assay) show promise but there is currently insufficient evidence to recommend their routine adoption in the NHS. Further research on procalcitonin tests is recommended for guiding decisions to:
  • stop antibiotic treatment in people with confirmed or highly suspected sepsis in the intensive care unit or
  • start and stop antibiotic treatment in people with suspected bacterial infection presenting to the emergency department.
Centres currently using procalcitonin tests to guide these decisions are encouraged to participate in research and data collection (see section 6.25 of NICE diagnostics guidance 18).
Pre-alert secondary care (through GP or ambulance service) when high risk criteria are met in a person with suspected sepsis outside of an acute hospital, and transfer them immediately.
Reassess the patient after completion of the intravenous fluid bolus, and if no improvement give a second bolus. If there is no improvement after a second bolus alert a consultant to attend.
Do not use starch-based solutions or hydroxyethyl starches for fluid resuscitation for people with sepsis.
Consider human albumin solution 4–5% for fluid resuscitation only in patients with sepsis and shock.

Manage the condition while awaiting transfer

Ensure GPs and ambulance services have mechanisms in place to give antibiotics for people with high risk criteria in pre-hospital settings in locations where transfer time is more than 1 hour.
If meningococcal disease is specifically suspected (fever and purpuric rash) give appropriate doses of parenteral benzyl penicillin in community settings and intravenous ceftriaxone in hospital settings.
Use a pump, or syringe if no pump is available, to deliver intravenous fluids for resuscitation to children under 12 years with suspected sepsis who need fluids in bolus form.
Assess all people with suspected sepsis outside acute hospital settings with any moderate to high risk criteria to:
  • make a definitive diagnosis of their condition
  • decide whether they can be treated safely outside hospital.
If a definitive diagnosis is not reached or the person cannot be treated safely outside an acute hospital setting, refer them urgently for emergency care.
If children and young people up to 16 years need intravenous fluid resuscitation, use glucose-free crystalloids that contain sodium in the range 130–154 mmol/litre, with a bolus of 20 ml/kg over less than 10 minutes. Take into account pre-existing conditions (for example, cardiac disease or kidney disease), because smaller fluid volumes may be needed.

Signs and symptoms of sepsis by risk level for under 5s

Category
Age
High risk criteria
Moderate to high risk criteria
Low risk criteria
Behaviour
Any
No response to social cues
Appears ill to a healthcare professional
Does not wake, or if roused does not stay awake
Weak high-pitched or continuous cry
Not responding normally to social cues
No smile
Wakes only with prolonged stimulation
Decreased activity
Parent or carer concern that child is behaving differently from usual
Responds normally to social cues
Content or smiles
Stays awake or awakens quickly
Strong normal cry or not crying
Respiratory
Any
Grunting
Apnoea
Oxygen saturation of less than 90% in air or increased oxygen requirement over baseline
Oxygen saturation of less than 92% in air or increased oxygen requirement over baseline
Nasal flaring
No high risk or moderate to high risk criteria met
Under 1 year
Raised respiratory rate: 60 breaths per minute or more
Raised respiratory rate: 50–59 breaths per minute
1–2 years
Raised respiratory rate: 50 breaths per minute or more
Raised respiratory rate: 40–49 breaths per minute
3–4 years
Raised respiratory rate: 40 breaths per minute or more
Raised respiratory rate: 35–39 breaths per minute
Circulation and hydration
Any
Bradycardia: heart rate less than 60 beats per minute
Capillary refill time of 3 seconds or more
Reduced urine output
For catheterised patients, passed less than 1 ml/kg of urine per hour
No high risk or moderate to high risk criteria met
Under 1 year
Rapid heart rate: 160 beats per minute or more
Rapid heart rate: 150–159 beats per minute
1–2 years
Rapid heart rate: 150 beats per minute or more
Rapid heart rate: 140–149 beats per minute
3–4 years
Rapid heart rate: 140 beats per minute or more
Rapid heart rate: 130–139 beats per minute
Skin
Any
Mottled or ashen appearance
Cyanosis of skin, lips or tongue
Non-blanching rash of skin
Pallor of skin, lips or tongue
Normal colour
Temperature
Any
Temperature less than 36ºC
Under 3 months
Temperature 38ºC or more
3–6 months
Temperature 39ºC or more
Other
Any
Leg pain
Cold hands or feet
No high risk or high to moderate risk criteria met
Provide people with suspected sepsis who do not have any high or moderate to high risk criteria information about symptoms to monitor and how to access medical care if they are concerned.
If sepsis is definitely excluded, see other NICE guidance.
Oxygen should be given to children with suspected sepsis who have signs of shock or oxygen saturation (SpO2) of less than 92% when breathing air. Treatment with oxygen should also be considered for children with an SpO2 of greater than 92%, as clinically indicated.

Glossary

for a definition of acute kidney injury, see what NICE says on acute kidney injury)
a medically qualified practitioner who has antibiotic prescribing responsibilities
an intensivist or intensive care outreach team, or specialist in intensive care or paediatric intensive care
emergency care requires facilities for resuscitation to be available and depending on local services may be emergency department, medical admissions unit and for children may be paediatric ambulatory unit or paediatric medical admissions unit
a senior decision maker for people aged 18 years or over should be someone who is authorised to prescribe antibiotics, such as a doctor of grade CT3/ST3 or above or equivalent, such as an advanced nurse practitioner with antibiotic prescribing responsibilities, depending on local arrangements; a senior clinical decision maker for people aged under 17 years is a paediatric or emergency care qualified doctor of grade ST4 or above or equivalent
(a senior clinical decision maker for people aged under 17 years is a paediatric qualified doctor of grade ST4 or above or equivalent)
sepsis is a life-threatening organ dysfunction due to a dysregulated host response to infection; 'suspected sepsis' is used to indicate people who might have sepsis and require face to face assessment and consideration of urgent intervention

Paths in this pathway

Pathway created: July 2016 Last updated: February 2020

© NICE 2020. All rights reserved. Subject to Notice of rights.

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