Quality statement 1 - Could it be sepsis?

Sepsis can affect anyone. However, some people are at greater risk than others, such as:

• Newborns and young children
• Older people
• Aboriginal and Torres Strait Islander peoples
• People with complex health conditions
• People with COVID-19
• People with poor immune systems
• People who are pregnant or have just given birth
• People being treated for cancer with chemotherapy
• People with burns, wounds and injuries
• People who have been previously diagnosed with sepsis.

A clinician will consider the possibility of sepsis for someone who:

• Has an infection or might have one
• Is very sick
• Is getting sicker.

A doctor or nurse will perform physical checks such as taking temperature and blood pressure, doing blood tests and asking questions. This information will help them to quickly identify whether you or your family member could have sepsis.

The signs of sepsis in adults can include:

• Fast breathing or breathlessness
• Fever and chills
• Low body temperature
• Low or no urine output
• Fast heartbeat
• Nausea and vomiting
• Diarrhoea
• Fatigue, confusion or sleepiness
• A lot of pain or ‘feeling worse than ever’.

The signs of sepsis in children can include:

• Fast breathing or long pauses in breathing
• Blotchy or discoloured skin
• Skin abnormally cold to touch
• Rash that doesn’t fade when pressed
• Infrequent wet nappies or low urine output
• Drowsiness, difficulty waking up or confusion
• Restlessness or floppy limbs
• Vomiting
• Fits or convulsions
• A lot of unexplained pain.

For families, let a doctor or nurse know if you are worried that your child or family member is very sick or getting worse. Your concern is important and should be considered, as you know your child or family member best.

It’s important for you to ask ‘Could it be sepsis?’

For more information, refer to the National Sepsis Awareness Campaign

Recognising a patient with sepsis can be challenging. Consider sepsis in all patients with acute illness or deterioration who may have an infection.

Importantly, the presentation of sepsis in neonates and children may differ to adults. In children, hypotension is not necessary to diagnose septic shock. In older people, commonly recognised sepsis signs and symptoms are often absent. Older people are more likely to have relative immunosuppression. The presentation is less likely to include a fever, raised white cell count or raised C-reactive protein. In older people, hypothermia, delirium and falls (in frail people) are more likely.

Clinical support tools are available to help detect sepsis early and enable further assessment and escalation, although these tools do not replace clinical judgement. Identify possible sepsis using a structured approach that is consistent with an appropriate decision support tool for the setting, which has been agreed at the local level. Tools will vary according to the patient age, cultural needs and healthcare setting – no single tool will apply to everyone.

For situations where a decision support tool is not available (for example, for neonatal and maternity patients), early assessment and escalation to a clinician with expertise in recognising and managing sepsis are the priority. State or territory-endorsed age-specific observation charts and monitoring tools for children allow recognition of acute deterioration in children.

• See Related resources which includes resources for children

To determine whether a patient has signs or symptoms of organ dysfunction, take a full set of observations that includes vital signs and other relevant observations appropriate to the patient, including:

• Respiratory rate
• Oxygen saturation
• Heart rate
• Systolic blood pressure
• Temperature
• Altered mentation, behaviour change or delirium
• Poor peripheral perfusion, cool peripheries, delayed capillary refill time or mottled skin
• Blood lactate concentration
• In pregnant women, the vital signs of the fetus measured using cardiotocography (CTG).

Where this will not delay urgent care, test venous blood lactate levels. Capillary lactates may be useful in children. An increased lactate level may indicate a protective or a maladaptive response to shock and can play an important role in screening. Include blood lactate routinely in decision-making for an acutely deteriorating patient or for suspected sepsis. Although assessment of lactate levels is not sufficient for the purpose of diagnosis, it is a relatively simple investigation that can help recognise sepsis, while failure to recognise sepsis can lead to patient harm and potentially death. Point-of-care lactate testing is especially useful in rural or remote settings, including Aboriginal medical services, where critical care cannot be readily accessed.

Maintain a high index of suspicion for patients presenting with risk factors for sepsis or groups who experience higher rates of sepsis, including Aboriginal and Torres Strait Islander peoples. Red flags include:

• Family or carer concern. It is well demonstrated that a high level of family or carer concern warrants investigation – for example, concern for an older relative or for a child or an infant
• If a patient is presenting for acute medical care for a subsequent time, and has signs or symptoms of infection, or has an indwelling medical device
• Clinical deterioration despite treatment
• Recent history of surgery or burns
• Patients undergoing cancer treatment or who may be immunosuppressed.

In primary and community healthcare settings, be aware of the risk factors for sepsis as a time-critical emergency. If you suspect a patient has sepsis, refer the patient to an appropriate hospital as soon as possible.

For acute facilities, ensure that the implementation of protocols to support early recognition and escalation of care for sepsis is consistent with the NSQHS Standards, including actions from:

• Preventing and Controlling Infections Standard (Actions 3.18 and 3.19)
• Recognising and Responding to Acute Deterioration Standard (Actions 8.01 and 8.06)
• Comprehensive Care Standard (Action 5.10).

For primary and community healthcare services, including general practice, ensure that the implementation of triage protocols is consistent with the Primary and Community Healthcare Standards, including the ‘Recognising and responding to serious deterioration and minimising harm’ criterion from the Clinical Safety Standard.

Formalise and implement locally agreed clinical support tools to assist in structured screening and assessment for sepsis. The tools should include:

• Initial assessment and monitoring of vital signs
• Lactate measurement (in acute facilities)
• Other relevant observations and the clinical criteria for further evaluation to enable prompt recognition of sepsis.
• In most cases, the relevant state or territory health department will have developed these for widespread implementation.
• Implement protocols for using these tools, which should include:
• Regular education for all relevant staff in using the protocols and the criteria for sepsis recognition and management
• Universal and direct access to the clinical decision support tools
• Routine review of the use of the tools and measures, and evaluation of their effectiveness for detecting sepsis.

Support clinicians with accessing regular and ongoing training in sepsis recognition and management.

Provide access to point-of-care lactate testing and guidelines for its appropriate use in settings where sepsis may occur.

Consider embedding alert systems in electronic healthcare records, if system capacity allows.