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Background information Sepsis is the overreaction of the immune system to an infection/injury, leading to multiple organ failure and death if not recognised early and treated immediately. Sepsis is:Triggered by an infection in any body part – most common sites are abdomen, lungs, pelvis and urinary tract Avoidable and treatable; early identification is key to successfully treating sepsis Signs and symptoms (list is not exhaustive):Breathlessness or loss of consciousness New onset confusion, disorientation or slurred speech Diarrhoea or nausea/vomiting Fast breathing or heart rateHigh or low body temperature Looks mottled, bluish or pale Reduced urine productionSevere muscle painVulnerable groupsBelow are groups of people that are at higher risk of developing sepsis as detailed in the National Institute for Health and Care Excellence (NICE) Clinical pathways:GroupFurther informationInfants under 1 year of ageInfants are at higher risk of early-onset sepsis in the presence of certain risk factors which include:Invasive group B streptococcal infection in a previous baby Maternal group B streptococcal infection, bacteria in the urine r infection in the current pregnancy Rupture of membranes before labour/suspected or confirmed rupture of membranes for longer than 18 hours in a pre-term birth An infant born before 37 weeks gestation following spontaneous labourMaternal fever of higher than38oC during labourAntibiotic treatment given to the mother at any time during labour, by injection for confirmed/suspected invasive bacterial infection at any time during labour/ within 24 hours before and after birth Elderly/very frailElderly includes patients over 75 years of ageElderly/very frail patients may not always develop a fever Patients with weak immune systemsDue to certain medicines or illness such as:People undergoing chemotherapy for treatment of cancer People with diabetes, sick cell disease and those who have had a splenectomy People taking long-term steroid medicines People taking immunosuppressant medicines for treatment of non-cancerous illnesses such as rheumatoid arthritis Recent surgery or other invasive procedures Within the previous six weeksPatients with any damage to the skin-This includes blisters, burns, cuts or skin infectionsPeople who misuse intravenous drugs or alcoholPeople with catheters or indwelling linesWomen of childbearing ageWomen are at higher risk of sepsis when they are pregnant/ have recently given birth/had a termination or a miscarriage in the past six weeks are also at higher risk of developing sepsis. This also includes:Women with weak immune systems due to certain medicines or illnessWomen with gestational diabetes/diabetes/other clinical conditions Women who have had an invasive procedures such as caesarean, forceps deliveryWomen who have had continued vaginal bleeding/vaginal discharge Women who have had or been in contact with people with streptococcal infection A, such as scarlet fever605663011996700Dealing with sepsis in community pharmacy Pharmacists and their teams should be aware of clinical features and management of sepsis to facilitate early diagnosis, referral and rapid treatmentConsider providing training to all patient-facing pharmacy team members Use posters to identify symptoms: these are available from the NPA website Pharmacy Quality Scheme (PQS) - part of risk management and safety composite bundle: CPPE Sepsis training to be completed by 80% of all pharmacists/pharmacy technicians, including locum staffThe tables in Appendix 1, 2 and 3 have been adapted from NICE Clinical pathways on sepsis and grade sepsis risk as low, moderate-high and high, as is applicable in a community pharmacy setting.All pharmacists should be aware of the National Early Warning Score (NEWS2), a tool, developed by the Royal College of Physicians, for use in acute care settings to help identify and respond to worsening of an adult patient’s clinical condition in. A NEWS2 resource pack has also been developed which this is designed for use in acute hospital and ambulance trusts caring for adult patients. It may support pharmacists in assessing whether a patient has sepsis and when communicating with other healthcare professionals about sepsis. Pharmacists and pharmacy teams should be aware that sepsis is not easy to identify and consider the following points:Patient symptoms may be non-specific and may not be localised to a particular area of the body – for example there may be a general feeling of being unwell/feeling agitated/behaviour changes Suspect sepsis when a carer/relative reports a change in appearance/behaviour Changes in behaviour/mental state are a moderate/high risk criteria for developing sepsis All types of infection can lead to sepsis Use a structured set of observations to assess people in a face-to-face setting The NICE risk stratification tool can be used Only measure blood pressure/heart rate if there are appropriate facilities in place so assessment/treatment is not delayed, such as a correctly-sized blood pressure cuff Language barriers may pose communication issues and affect pharmacy teams from being able to obtain accurate information Both fever and low body temperature can be a symptom of sepsis Refer all of the following patients for emergency medical care (usually 999 ambulance):Someone who meets any of the high risk criteriaSomeone aged under 17 years of age with a weak immune system (either through use of certain medicines/illness) who meets any of the moderate/high risk criteria Further reading NICE: Quality standard and clinical pathways UK Sepsis Trust: The Specialist Pharmacy Service: NHS: National Early Warning Score (NEWS): reading for EnglandNHS.UK: Health England campaign 2016/17: Centre for Pharmacy Postgraduate Education (CCPE): reading for Northern Ireland NI Direct: Additional reading for ScotlandNHS Education for Scotland: Early Warning Score & Sepsis Screening Tool App: Scottish Patient Safety Programme (SPSP): highlighting the importance of early recognition and effective communication and featuring clinicians who currently practice within NHS Scotland: SPSP screening tool: Paediatric Sepsis 6 handy guide: Additional reading for WalesNHS Wales: Disclaimer: The information published is, to the best of our knowledge, correct at the time of publication. However, no responsibility will be accepted for any consequences of decisions made using this information.Appendix 1: Children under 5 – suspected sepsisCategoryAgeHigh riskModerate-high riskLow riskBehaviourAnyAppears ill to healthcare professional Continuous, high-pitched or weak cry Does not wake, or stay awake when roused No response to social cuesConcern behaviour is different to parent/carer No smile Not responding normally to social cues Wakes only with prolonged stimulation Decreased activity Responds normally to social cues Content or smilesStays awake or awakens quickly Strong normal cry or not crying RespiratoryAnyApnoea GruntingNasal flaringUnder 1 year Taking 60 breaths per minute or more Taking 50-59 breaths per minute 1-2 yearsTaking 50 breaths per minute or moreTaking 40-49 breaths per minute 3-4 yearsTaking 40 breaths per minute or moreTaking 35-39 breaths per minute Circulation and hydrationAnyHeart rate less than 60 beats per minuteReduced urine output For catheterised patients, passed less than 1ml/kg of urine per hour Under 1 yearRapid heart rate of 160 beats per minute or moreRapid heart rate of 150-159 beats per minute 1-2 yearsRapid heart rate of 150 beats per minute or moreRapid heart rate of 140-149 beats per minute3-4 yearsRapid heart rate of 140 beats per minute or moreRapid heart rate of 130-139 beats per minute SkinAnyCyanosis of skin, lips or tongue Mottled or ashen appearanceNon-blanching rash of skin Pallor of skin, lips or tongueNormal colour TemperatureAnyTemperature less than 36oCUnder 3 monthsTemperature 38oC or more 3-6 monthsTemperature 39oC or moreOtherAnyLeg painCold hands and feetAppendix 2: Children aged 5-11 – suspected sepsisCategoryAgeHigh riskModerate-high riskLow riskBehaviourAnyAppears ill Does not wake, or stay awake when rousedObjective evidence of altered behaviour or mental state Concern child is behaving differently to parent/carer Not behaving normally Decreased activity Behaving normally RespiratoryAged 5 years Taking 29 breaths per minute or more Taking 24-28 breaths per minuteAged 6-7 yearsTaking 27 breaths per minute or moreTaking 24-26 breaths per minute Aged 8-11 yearsTaking 25 breaths per minute or moreTaking 22-24 breaths per minute Circulation and hydrationAnyHeart rate less than 60 beats per minuteReduced urine output For catheterised patients, passed less than 1ml/kg of urine per hour Aged 5 years Rapid heart rate of 130 beats per minute or moreRapid heart rate of 120-129 beats per minute Aged 6-7 yearsRapid heart rate of 120 beats per minute or moreRapid heart rate of 110-119 beats per minuteAged 8-11 yearsRapid heart rate of 115 beats per minute or moreRapid heart rate of 105-114 beats per minuteSkinAnyCyanosis of skin, lips or tongue Mottled or ashen appearanceNon-blanching rash of skinTemperatureAnyEar temperature less than 36oCOtherAnyLeg painCold hands and feetAppendix 3: Children and adults over 12 – suspected sepsis CategoryHigh riskModerate-high riskLow riskHistoryObjective evidence of new altered mental stateHistory from patient, friend or relative of new onset of altered behaviour or mental stateHistory of acute deterioration of functional ability Impaired immune system (illness or drugs including oral steroids)Trauma, surgery or invasive procedures in the last six weeks Normal behaviour Respiratory Taking 25 breaths per minute or more Taking 21-24 breaths per minuteBlood pressure Systolic blood pressure 90mmHg or less or systolic blood pressure more than 40mmHg below normalSystolic blood pressure 91-100mmHgCirculation and hydration Raised heart rate of more than 130 beats per minuteNot passed urine in previous 18 hoursFor catheterised patients, passed less than 0.5ml/kg of urine per hour Raised heart rate of 91-130 beats per minute (for pregnant women 100-130 beats/min) or new onset of arrhythmia Not passed urine in the past 12-18 hours For catheterised patients, passed less than 0.5-1ml/kg of urine per hour Temperature Ear temperature less than 36oCSkin Cyanosis of skin, lips or tongue Mottled or ashen appearanceNon-blanching rash of skinSigns of potential infection, including redness, swelling or discharge at surgical site or breakdown of woundNo non-blanching rash ................
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