Over the past decade, sepsis has risen to political, public and health professional attention as a major cause of avoidable death and morbidity. In September 2014, NHS England issued a Stage 2 Safety Alert on sepsis (NHS England, 2014), reinforced by an announcement of intent from the Secretary of State for Health in January 2015 (Department of Health, 2015).
Sepsis is conservatively estimated to affect over 100 000 adults and children in the UK annually, with 37 000 deaths resulting (Daniels, 2011) and long-term morbidity affecting around 20% of survivors (Iwashyna et al, 2010). Research has shown us how hospital-focused improvement programmes can significantly improve outcomes, with mortality rates reducing by almost one half in several studies (Daniels et al, 2011; Miller et al, 2013). It has been well described that paramedics can positively impact on hospital performance—thereby saving lives—by screening for sepsis and pre-alerting the receiving hospital (Gray et al, 2013), but the profession rightly intends to go a step further by initiating the lifesaving therapies detailed in care bundles such as the UK Sepsis Trust's Sepsis Six.
It is clear that paramedics have a key role to play in the management of patients with sepsis. A significant majority of patients arriving in emergency departments with sepsis are conveyed by pre-hospital services (Gray et al, 2013). It is well known, albeit from largely retrospective and exclusively observational data sets, that each hour's delay in initiating antimicrobial therapy in the most severely ill subgroup (those with septic shock) increases mortality (Kumar et al, 2006). Although recent studies bring the need for a ‘first hour’ rule into question (Sterling et al, 2015), what is clear is that early antibiotics are better than late antibiotics for the vast majority of patients provided adequate source control is also achieved. Significantly, none of these studies have examined time delays in presentation to healthcare services. Furthermore, wherever global outcome data have been reported with mortality rates at or below 20%, these have been in centres with rapid intervention strategies. As public awareness rises and the timing of presentations becomes more reliable, it might be that the outcome differences between prompt and delayed care becomes more marked.
‘Until now, efforts to initiate antimicrobial therapy in the pre-hospital setting have been thwarted by criticism of the lack of evidence supporting the applicability of the international definitions for sepsis in the pre-hospital setting’
In areas where transit times are frequently prolonged—for example, in excess of 1 hour—it is logical that pre-hospital recognition and intervention will save more lives than recognition and pre-alerting alone. Until now, efforts to initiate antimicrobial therapy in the pre-hospital setting have been thwarted by criticism of the lack of evidence supporting the applicability of the international definitions for sepsis in the pre-hospital setting. With antimicrobial resistance a very real threat to humankind, it is perhaps understandable that pre-hospital antibiotic therapy has not yet become the norm.
With the launch of the Clinical Toolkit for Pre-hospital Services by the UK Sepsis Trust and NHS England in September 2014, it became possible to tailor screening tools to detect Red Flag Sepsis. These screening tools are focused on bedside clinical signs rather than data from hospital laboratories. For the first time, a tool endorsed at national level empowered paramedics to deliver at least two elements of the Sepsis Six (fluid challenge and oxygen therapy), and to pre-alert receiving units.
In 2016, a new set of international consensus definitions for sepsis is likely to be announced. Though still hospital-derived, the new definitions are far more pragmatic than before, and Red Flag Sepsis will require only minimal tweaks to remain compatible. Out will go the current reliance on laboratory data, and in will come a set of criteria with which paramedics will be familiar, namely a search for shock, tachypnoea and altered mental state in the presence of suspected infection.
We would argue that this sea change in the international definitions validates existing efforts centering on Red Flag Sepsis. It may well be that this new focus is sufficient to stimulate the profession to act by adopting a common language, a national tool such as the Pre-hospital Toolkit, and a unified desire to reduce the impact of this hidden killer.