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www.european-hospital.com INFECTION & HYGIENE New diagnostic tool for A&E teams m JIB 2014 Report: Mark Nicholls Accident and Emergency (A&E) teams play a key role in identifying patients with sepsis, followed by risk stratification for severe sepsis and septic shock, initiating resusci- tation and treatment, and ensuring the correct onward management of patients identified with sepsis. Now a new clinical toolkit, developed jointly by the College of Emergency Medicine (CEM) and the UK Sepsis Trust, aims to help A&E teams to become more aware of the signifi- cant morbidity and mortality due to sepsis and provide the knowledge and skills for early recognition of its presence. Designed to provide operational solutions for reliable sepsis identifi- cation and management the toolkit also complements clinical toolkits designed for other clinical areas and also offers guidance on screening and response to sepsis. Dr Jeff Keep, a consultant in Emergency Medicine and Major Trauma at King’s College Hospital in London and a member of the Quality in Emergency Care Committee at the CEM, hopes the kit will bring clar- ity for emergency doctors over the different definitions of the sever- ity of sepsis. ‘Time can be wasted diagnosing the severity of sepsis and by making the diagnosis sim- pler and having the confidence to treat sepsis before a definitive diag- nosis has been made, we should improve door-to-antibiotic times,’ he explains. ‘Recognising sepsis is often easy when the patient is very unwell, but we want to recognise sepsis early on and this can be very difficult; the toolkit contains useful ways to achieve this.’ With emergency departments (EDs) using Early Warning Scores (EWS), performed very soon in the patient’s journey in the ED, an EWS of three or four, or higher, should trigger a sepsis screen, he said. The toolkit also summarises some key recommendations for better organisation of the hospital and its sepsis management. Dr Keep: ‘Sepsis is a time-critical illness. Researchhas shown that early treatment with antibiotics has a significant impact on mortality, which increases by 8% for every hour’s delay. ‘Many patients with sepsis pre- sent to the ED and therefore the ED should manage sepsis patients as it does other time-critical illnesses, such as major trauma, myocardial infarction and acute stroke. In the UK, if managed properly, we esti- mate that we could save 12,500 lives from sepsis every year.’ At present some 37,000 people die from sepsis annually in the UK, but steps are being taken to cut tackle this in bringing together professional organisations such as the College of Emergency Medicine, the College of Paramedics and the Royal College of Physicians to joint- ly tackle sepsis and advise a group of members of parliament (APPG) on how to fix sepsis. The Parliamentary Health Service Ombudsman published a report on sepsis last year, the NCEPOD (National Confidential Enquiry into Patient Outcome and Death) is con- ducting a review of sepsis patients, and UK health guidance and advi- sory body NICE (National Institute for Health and Care Excellence) has fast-tracked sepsis through its sys- tem and will be issuing guidelines in the near future. ‘NHS England [The National Health Service] has also joined the fight against sepsis and the momen- tum is currently strong and very positive. Of course, it is ultimately down to the individual healthcare providers to recognise sepsis early and start treatment, but the broad support from within the UK health- care system is invaluable,’ Dr Keep stated. In 2009, CEM developed national criteria and standards for the man- agement of severe sepsis and sep- tic shock, and conducted the first national audit of these standards in 2011/12 and a second in 2013/14. ‘The results have improved, and more patients with severe sepsis or septic shock are receiving IV fluids and antibiotics within an hour of attendance,’ Dr Keep said. He stressed the importance of data coding as being critical in com- bating sepsis and added: ‘If every hospital collected accurate data on sepsis then it would be easier to monitor improvements and manage sepsis more effectively. ‘Diagnosing the source of infec- tion is also important and strategies for early investigations are crucial to patient survival. By identifying and treating sepsis earlier, costly treatments such as ITU admission can be avoided and these resourc- es should be invested in hospital ‘Sepsis Teams’ that can respond rapidly with the necessary skills to diagnose and treat sepsis and not allow the patient’s condition to deteriorate further.’ many false positives; therefore their use should always be complemented by culture. Likewise for Norovirus the rapid enzymatic tests available require fur- ther confirmation because sensitivity is relatively low. However, in the case of C. difficile commercial tests that detect gluta- mate dehydrogenase in the patient’s stool and have a turnaround time of 15-45 minutes, compatible with routine laboratory needs, are highly correlated with culture and can be used as a first screening step in a diagnostic algorithm. ELISA tests are also commercially available for some of these gastroin- testinal pathogens. H. pylori can be detected in a stool ELISA test (HpSA, Meridian, Italy) based on monoclo- nal antibodies, with high specificity, but poor sample storage can affect sensitivity. ELISA kits are much more reliable than ICT to diagnose Campylobacter. Available commercially are the Premier Campy (Meridian Biosciences) and RidaScreen Campylobacter test (R-Biopharm AG) and take about two hours to perform have high specificity and good PPV and PNV of 100%. They are recom- mended to screen before culture or when a patient is culture positive and also before faecal transplant is performed. Another technique introduced in some laboratories and reference cen- tres is to use mass-spectroscopy by MALDI-tof to identify causal agents. This is particularly effective for Campylobacter sp. enabling positive identification of more different spe- cies than is easily done by normal microbiological techniques. The most accurate and widely used non-invasive test for H. pylori the 13C breath test, 97.9% specificity, 96.7% sensitivity requires the meas- urement of 13C02 by mass spectrom- etry, placing it beyond use among routine laboratories. The lesson from this training ses- sion is that diagnosis of gastrointesti- nal infections is perhaps not as easy as it could be for routine biology laboratories and more could be done to provide the tools needed for rapid and efficient diagnosis for those at the forefront of infection. Toolkit for quicker sepsis identification ections 12,500 lives could be saved from sepsis every year Jeff Keep MD is a consultant in Emergency Medicine and Major Trauma at King’s College Hospital, London, and a member of the CEM’s Quality in Emergency Care Committee. With a particular interest in sepsis, he developed the national standards in 2009, and keeps the committee up to date with sepsis developments. 21

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