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Sepsis Awareness

Jennifer Dickinson
 
Welcome to this evening's webinar on sepsis awareness.  My name is Jennifer, your RACGP representative for this evening.  We are joined by our presenter, Dr Helen Goodwin and Dr Melanie Berry, and our facilitator, Dr Rebekah Hoffman.
 
Before we get started, I would like to make an acknowledgement of Country.  We recognise the traditional custodians of the land and sea on which we live and work, and we pay our respects to elders past, present, and emerging.  I myself am joining from Dharawal Land this evening in South-Western Sydney, and I would like to acknowledge any Aboriginal and Torres Strait Islander colleagues that may have joined us online. 
 
I just wanted to introduce you to our presenters for this evening.  Dr Helen Goodwin is the current New South Wales Health Chief Paediatrician and is a General Paediatrician with extensive experience in regional and metropolitan paediatrics.  She worked in Tamworth for 16 years and has been a senior staff specialist at Royal North Shore Hospital since 2018.  Helen is also the current medical lead for the Paediatric Patient Safety Program at the New South Wales Clinical Excellence Commission, and was the chair of the Clinical Excellence Commission Paediatric Sepsis Pathway Working Group.  She has a special clinical interest in emergency paediatrics and chronic and complex healthcare in children and young people.  Helen has had a long-standing involvement in medical education and monitoring healthcare staff.  Welcome, Helen.
 
Dr Melanie Berry is an emergency physician and holds positions at Orange Hospital and is an emergency staff specialist and a VMO at Gosford Hospital, as well as working in virtual care at Royal Prince Alfred Virtual.  Melanie has a Masters in Clinical Epidemiology and is a lecturer and co-Director of Critical Care at the University of Sydney Rural Clinical School of Orange.  Melanie holds honorary positions with the New South Wales Clinical Excellence Commission as the co-chair of the Serious Incident Review Committee, chair of the Adult Sepsis Working Group, looking at how to improve the guidelines to identify sepsis, and a member of the Sepsis Pathway Expert Advisory Group, and a member to the New South Wales Urgent Sepsis Expert Working Group.  Welcome, Melanie.
 
And last but not least, Dr Rebekah Hoffman is a specialist GP, practice owner and the New South Wales and ACT faculty chair.  She has special interests in a broad range across women's and children's health, sports medicine, surgery, and business governance.  Further to this, she also enjoys teaching, being a senior lecturer at the University of Wollongong in medical education, and regularly monitors students studying medicine from a number of universities in New South Wales.  Welcome, Rebekah.
 
I just would also like to welcome, we have some representatives from the New South Wales Ministry of Health and the New South Wales Clinical Excellence Commission.  Welcome everyone.  I will now hand over to Rebekah just to look over our learning objectives for tonight.
 
Dr Rebekah Hoffman
 
Thank you and welcome to all of our attendees.  These learning objectives were circulated before this evening, so I am going to take them all as read so we can move on to the content of tonight.  If anyone had any questions, I am happy for you to pop them in the Q&A. I will be monitoring those questions as they come in and interrupting our facilitators or holding them off until the end of the session.  I am going to pass over to Dr Helen Goodwin.  Thank you.
 
Dr Helen Goodwin
 
Thanks very much.  Kind of sounds important when you read out all those things, but really, I am just another person doing this job, same as you guys.  I am meeting tonight from Cammeraygal Land, and I would like to acknowledge the traditional owners of the lands on which I am meeting, and the traditional owners of the lands on which everyone else is meeting as well, and also acknowledge the health gap of Aboriginal people.  Particularly with sepsis, Aboriginal children are three times more likely to die from sepsis than are non-Aboriginal children. Tonight's webinar is brought to you by the New South Wales Ministry of Health and the New South Wales CEC, and the College of GPs.  The New South Wales Ministry of Health, just for everyone's information, has developed a public-facing education campaign.  Could this be sepsis is the underlying theme behind it. You may find that people start coming into your practice asking that question, which is what we are hoping.  The aim is to raise the community's awareness and recognition of sepsis.  The reason for this webinar is to try and improve the early detection and treatment of potential sepsis cases in primary care.  The CEC, for those people who do not know, is the pillar that leads quality and safety improvement for all New South Wales health acute care facilities, and the Sepsis Program is just one of the programs that we run with the aim to support staff to provide safer and more reliable care for every patient every time.  We cannot really talk about sepsis.  without acknowledging the patients and carers families and clinicians involved in the care of patients with sepsis.  Sepsis is a devastating disease which has huge impacts on patients, families, carers, and clinicians, and the experiences and stories of the people on this slide have greatly influenced the Sepsis Improvement Program across Australia, but particularly in New South Wales.
 
Dr Melanie Berry
 
So why are we talking about sepsis? Because sepsis is still a wicked problem, and as we can see annually, we are seeing still 55,000 people affected by sepsis and 8700 of those are sepsis-related deaths, and sadly, even if you survive sepsis, you are going to have a significant disability in one out of two of those patients, and we all know when we have seen sepsis, it is like a train that comes and it can affect anyone from any part of our lives.  There are certainly some people who are more vulnerable, but it can affect what is previously a completely healthy person in the morning and by the evening they can be gravely unwell and heading into the intensive care.  This is why we really want to focus on how we can pick it up and pick it up early. 
 
We are just going to go a little bit into the science, but it will just be this particular slide, and then we are going to move on to the detail into the new guideline.  There is a consensus definition on sepsis and septic shock, and the last of those was done in 2016, and what happened at that point in time is that there was a move away from the word severe sepsis and just a focusing on what the definition of sepsis is, and just reminding everyone who has not looked at that recently that sepsis is the body's response to a life-threatening organ dysfunction caused by a dysregulated host response to infection.  Those are the things that are required to call someone having sepsis.  Now, septic shock is sepsis, in which the underlying circulatory system and does not respond to fluid resuscitation, and there is a need to give vasopressors in order to support that person's blood pressure.  There are existing markers that we can use and scoring systems to predict mortality associated with sepsis, and they can be used at the bedside and also using some clinical tests.  In our sepsis guideline, we have adapted some of those scoring systems, but we have not taken them on wholly and solely because the guideline that we are using is used across New South Wales Health from a multi-purpose surface in the Country to a quaternary health care service in the city, so what we are saying is we want a guideline that fits for all and we want something that does not require everyone to have 15 tests in order to calculate a scoring system.  We want common sense and a pragmatic approach for our guideline.  I do not know if you wanted to say anything further about the paediatric consensus criteria, Helen.
 
Dr Helen Goodwin
 
Sure.  The definition in children is the same, and that is a consensus definition that sepsis is suspected infection with organ dysfunction.  There was a new Phoenix criteria, which some of you may or may not have used which talks in a lot of detail around the dysfunction in the rest of the body, including respiratory, cardiovascular, coagulopathy, neurological deficit, etc.  Even though that is an important tool, we have not used that entirely for this pathway, and part of the reason is, is that exactly like Mel was saying, you will not get most of those results back until way into the treatment cycle, and so therefore it is more used for something retrospectively as a mortality indicator in the Phoenix school, so sepsis basically is still defined clinically as suspected infection with organ dysfunction and septic shock is sepsis with cardiovascular dysfunction.
 
Dr Melanie Berry
 
So I just wanted to now talk about the high-risk groups for sepsis.  As we said, sepsis can affect anyone, but there are some patients that are more vulnerable to sepsis than others, and the extremes of age obviously feature in this group, and there are a few groups that I just wanted to really focus on, and this is because of my work as the co-chair of the Serious Incident Review, so that is the unenviable task of we review all the serious incidents where there has been a death in New South Wales health in adults, and so what we can see is themes of when someone dies unexpectedly in hospital.  What are the themes that come under the reasons why that patient died unexpectedly? And one of the things we are seeing really consistently is if a patient is representing to a hospital or representing to a service, that is a risk in itself.  Another further risk is if the patient has had an infection and for example, they are thought to have a viral illness, but it is a number of days whilst that patient has been continuing to have what was thought to be a viral illness, then there often is anchoring bias and not the consideration of a secondary bacterial infection.  I just also wanted to just talk about vulnerable populations, and Aboriginal and Torres Strait Islander patients are more at risk of sepsis, but specifically, vulnerable patients are anyone who has difficulty in accessing care, and that can be for a variety of reasons.  It could be their experience with accessing care and not wanting to attend hospitals.  It could be related to a disability, which impairs their ability to communicate.  It could be because of their language and that the healthcare is run in English.  Anyone who is having difficulties in putting forward what is going on with them is definitely going to be a high-risk patient to actually identify sepsis in and as most people know, so anyone who is immune-compromised or has a device in situ that is not their own, so a plastic device such as a port for chemotherapy is more at risk of sepsis and also transplant patients and other immunocompromised patients. 
 
So the New South Wales sepsis KILLS program has three aims to it, and the first one is really important, and this is where general practice is integral, and that is about recognising the risk factors and signs and symptoms and recognising early.  Once we have recognised, then we want to resuscitate quickly with patients and refer onwards, and when I say refer, we are talking about referring to intensive care or retrieval services, depending on where you are working, but also further referring for source control.  There is also a National Sepsis Program, which is aiming to improve awareness, recognition, and support of sepsis, and other states are now developing their own Sepsis Review Programs and Sepsis KILLS programs. 
 
These are the four pathways that we have developed over the last 6 to 9 months, and it has certainly been a labour of love.  I am going to be focusing on the adult and maternal sepsis pathway, and Helen will be focusing on the paediatric and neonatal sepsis pathway.  For these pathways, if you do work in New South Wales Health within a hospital system, for example, if you are a GP who also has a VMO position within the hospital services, you will have access to these pathways, but you also have access to the silver book, if I have got that right, Rebekah, for guidelines around sepsis, and these can also be accessed through the CEC website. 
 
The first part of the pathway, it is just two pages, just ask the question, could it be sepsis, and that is a real focus for us is just having everyone think about it, because sepsis is common, and it just gives you again that reminder of what the definition is, sepsis is infection with organ dysfunction, and it is a medical emergency.  These pathways are not just for doctors, they are for everyone who works in a health service, so if the patient is showing signs or symptoms that the medical officer or the nurse or the allied health person considers, I am concerned about sepsis, they can pull this pathway out and they can use these as an aide memoire, and so these signs and symptoms, whereas we spoke about, it is broken down into the signs and symptoms and also the risk factors.  Just to discuss quickly about pregnant women, there are some specific risk factors that come with pregnancy.  Any woman who has breast wound or aligned redness who has got some flu-like symptoms, who has a family member who has been unwell, that is really pertaining to Group A strep throat or any household members who have been unwell, and then always you need to consider about the foetus.  If there has been a precipitous labour and the foetus is unwell with sepsis, then you should be considering about the mother and vice versa as the mother is unwell, then you should be considering about the baby.
 
Dr Rebekah Hoffman
 
Melanie, can I just ask, reason or requirement for when you would use one of these? So for instance, do you use these for every febrile patient or for every representation, and I guess I am going to throw you a double-barrelled question and follow up to that, when should a GP think about using these or when do you think it would be a good idea for us to go? I am going to pull up this website and specifically have a look at this and send this in with my patient, because I am worried about sepsis.
 
Dr Melanie Berry
 
So I think obviously like in general practice, you must see many, many febrile patients, but this is when you are thinking about the patient is looking slightly more unwell.  I think you can bring up this pathway whenever you want to because it is an aide memoire, so you might think, okay, the patient has a fever.  I am now going to have a look at the guideline and see if there are any other risk factors that are making me concerned.  I will do a blood pressure now, possibly be able to do a heart rate as well, and then you can decide, yes, I am going to continue this patient on the pathway and send them into hospital or no, actually, I think, I am more convinced this patient has a virus or I am more convinced that they do not fit within this pathway.  I think it is fine to use this pathway if you are even considering it, because it is just a helpful aide memoire.  What was the second part of your question, sorry, Rebekah.
 
Dr Rebekah Hoffman
 
It was when GP should be using them.
 
Dr Melanie Berry
 
I think, firstly I would say one of the things that we have got on the adult pathway is looks very unwell.  So if your gestalt is saying there is something not right about this patient, pull this pathway out.  We know that sepsis is common and we know that gestalt is really powerful in terms of diagnostics, so pull this pathway out.  If the patient has an infection or has a low temperature, pull this out and have a look, but you can use this pathway at any time with any patient that you consider has infection, and you are thinking about do they have organ dysfunction?
 
Dr Rebekah Hoffman
 
Okay, so it is really that gut feeling of I think it is more than just a tachycardic febrile patient who is a little bit dehydrated.  I am going to pull this out and decide or use it as a tool to decide ED or home.
 
Dr Melanie Berry
 
Correct, and I think the thing is it is a bit of a slippery slide because some patients will start a little bit dehydrated and they do have an infection, and then they are going to progress to sepsis, but it is great that if you pull it out and you can say, well, not at the moment, but if they are not getting better, I want to give them that advice, you need to go to hospital because you are getting a snapshot.  It is just the same as me.  When I see someone for a couple of hours in the ED and I say, look, this is what I think is going on now, but if later you are not improving, then this is what I want you to do.
 
Dr Rebekah Hoffman
 
Great.  Thank you.
 
Dr Helen Goodwin
 
I think that is me.  So for under 16s, there is two, there is a paediatric pathway and a neonatal pathway.  I might start on the neonatal pathway, and then I will talk about the paediatric pathway.  The old pathway for neonates used to be a newborn pathway.  It was babies just for that episode of care when they were born, and we made a decision based on a lot of feedback, but also in context of early discharge from hospital and the fact that neonates are their own patient group, that that should become a neonatal pathway and be used for all babies up to 28 days of corrected age, so that is 28 days from when they should have been born, in any clinical setting to support the recognition and management of sepsis.  Similar to the adult pathway, the recognition part is important, and then obviously moving on to assessment and treatment.  The big things for babies if it is in the first 24 hours of life, you can use a neonatal early onset sepsis calculator, so that is going to be really only babies who are transferred home in four hours, so probably people who are mainly working in primary care in the community would not likely to see those babies, but obviously if you were a GP in a remote or rural area, you may well be involved, in which case you can use the Neonatal Early Onset Sepsis calculator to help you decide whether or not it is likely that this baby has an infection.  Having said that, if you have any signs or symptoms of significant infection, then we would encourage escalation of care in that first four weeks.  Particularly in babies, not fading as a classic, so just not waking up for feeds, not interested in feeding, floppiness, poor tone, any signs of apnoea, fever or hypothermia, so babies can get cold and not be able to maintain their temperature, and the other one is temperature instability, which can be pretty tricky.  If you are not keeping a close eye on baby's fever, I guess the message is do not be reassured in a neonate by the absence of a fever, because it does not mean you do not have infection.
 
Dr Rebekah Hoffman
 
I am going to be interrupting again.  What would your range for hypothermia be?
 
Dr Helen Goodwin
 
The normal neonatal temperature is 36.5 to 37.4, but babies who are cold are often sitting around 36, 35.5 to 36.5, so if you cannot get a good temperature or you think the thermometer is not working properly, the baby is probably cold.
 
Dr Rebekah Hoffman
 
Fair.  Good point. and so previously we have been taught fever in the first 28 days of life means hospital, so does this change that or is this just an adjunct to that?
 
Dr Helen Goodwin
 
I think this is pretty much an adjunct.  Look, as you do, if you have a baby with a temperature of 37.5, snotty, looking incredibly well, you may not send them straight to hospital, but you would absolutely be safeguarding them to say, get a thermometer, take the baby's temperature.  If the temperature gets 38 is a definite septic workup in paediatrics in neonates or if there are any signs of unwellness then they need to be in hospital.  Mostly, they will actually have one and you will end up in hospital.  My message would be if in doubt, send them in.  If they look unwell, do not tell the parents to go straight to hospital.  The biggest issue we have is that people go home and they pack a bag.  They organise a childcare for the other kids.  They think it is okay, so really what the message we say is a baby looks unwell, has a fever, hypothermia, has any floppiness, poor feeding, any risk factors for sepsis, straight to hospital.  Do not go home.  Do not collect nappies, bottles, clothes.  We can do all of that in the emergency department.  Someone can bring all that in later, so yeah, basically, the message is still go straight to hospital if you have got a proper fever or if you look sick.  Particularly think about siblings who are unwell, so again, group A strep has been a bit of an epidemic this year.  If you have got a child in the family with tonsillitis, be particularly worried about newborns and mothers, because invasive group A strep is more likely in mums as well.  Even if you have got a viral infection, it does not mean that you cannot get a secondary bacterial infection, and most of the children with Group A strep this year have had a preceding viral illness, either RSV, influenza or cold or some other viral illness beforehand, so be very careful to say that a temperature that occurs on day 3 or 4 or 5 of other illness is still that virus because it may not be, and it probably is not.  In children, the big changes in the paediatric pathway are, we have got the same ones that were there before based on the Queensland Paediatric Sepsis mortality study and on the previous sepsis pathways, but we have also got some new ones that again, like Mel, unfortunately, I have the honour of chairing the Serious Incident Review Committee for Paediatrics, and what we have seen come through in a number of unrecognised cases of paediatric sepsis are children coming with unexplained pain out of proportion to for no good reason.  Beware a child, particularly an older child who refuses to walk, or if a child is being carried or pushed in a stroller and you think they are a bit old for that, or even if you think they are the right age, but they seem to be not wanting to move, please ask about pain, because unexplained pain is one of the things that is coming up as a red flag.  The other one is change in behaviour or reduced level of consciousness.  In similar to a geriatric patient, children can get a bit delirious with fever or just be not themselves, a bit floppy, a bit pale, a bit less responsive, that in itself is a red flag and I know Mel said respiratory rates are really important thing in adults for sepsis, but in children, it is tachycardia, particularly tachycardia that is persisting once the fever has gone away, so in a child who is tachycardic and cranky and hot, if they have had Panadol or Nurofen or whatever at home before they come, if they are still tachycardic, please do not put that down to fever.  If the tachycardia is what we call in the red zone above the normal range, which again, you can have a look at between the flags for red zone criteria or not responsive, then take it very, very seriously, and I am sure everyone remembers their physiology from medical school is that babies and children cannot increase their stroke volume.  The only way they can increase their cardiac output is by increasing their heart rate.  If a child with tachycardia, please pay attention.  I have already mentioned the recent increase in group A strep that frequently follows a viral illness.  Even if a child has a viral illness, they can still have sepsis because remember sepsis is an infection with organ dysfunction.  We have seen a number of neonates particularly and young children with enterovirus who have come in with significant collapse and shock.  And have needed to unfortunately go on ECMO and a couple have died, so sepsis can still occur from a viral illness.  Just because you have got a viral illness does not mean you do not have sepsis.  I am not trying to scare everybody, but if they look sick, if they are floppy, pale, grunting, poorly responsive, and particularly in babies who do not feed, do not smile, they do not have to do anything else, that is all they have got to do, then please send them to ED.
 
Dr Melanie Berry
 
Can I just interrupt quickly because, Helen, you reminded me of one thing really quickly, and that is, in kids, we really worry if parents/carers are concerned, in adults, it is the same thing, and in adults particularly, who, for whatever reason, can communicate for themselves, it is so important if the carer is saying there is something not right, like go with what they are saying, and that is really important in kids, but it is also in adults, and it is also really important if the patient is saying, I just feel terrible.  I just feel the worst I have ever felt, particularly in young, healthy people that often hold on to their vital statistics, their heart rate, their blood pressure until the very last minute, but if they are saying to you, I feel horrendous, be wary of those patients, and the only other thing I was going to say, Helen raising about respiratory rate, counting respiratory rate is something that none of us do very well, but if someone is really sick with sepsis, they will be huffing and puffing in front of you.  I am sure you will have seen it, and often again, it is that really young person who is just breathing super fast and you are like, why are they breathing so fast, but there is no clear focus here for this infection.  That could well be the beginning signs of sepsis. 
 
Dr Rebekah Hoffman
 
I am going to jump in again because we have talked on a previous session about a website where there were videos of sick children, and if people had not seen what huffing and grunting and tachypnoea in this age group was, I have also completely forgotten what the name of that website was.
 
Dr Helen Goodwin
 
The website that I love, it is actually a UK based website called www.spottingthesickchild.com.  It is run by the NHS and it is actually real children who have deteriorated in hospital, whose parents have given permission for them to be videoed and placed on online.  Now, all those children would probably be adults now because they have done a while ago, but it actually shows you what a grunting child looks like, what a child who is deteriorating with asthma looks like, what exhaustion looks like measles, overwhelming measles, encephalitis, etc.  When you go on to the website, it says you cannot come on here if you are not a doctor in the NHS, you actually can.  You just put your email address in and tell them you are a doctor and you get access.  It is not actually restricted.  I think that is just something to stop the world from jumping on.  It is a great resource.
 
Dr Rebekah Hoffman
 
I am going to agree, and I jumped on last week and nothing has happened to me yet.
 
Dr Helen Goodwin
 
You can definitely get on or you just got to say you are a doctor.
 
Signs of severe illness and organ dysfunction.  We have mentioned a few.  Floppy, grunting, mottled babies and children, change in mental state, increased respiratory rate or distress, and that is because of, well, it could be pneumonia or an underlying respiratory problem, but also acidosis particularly a high lactate which is what we see in sepsis will give you tachypnoea, and then in children, please try and take kids' blood pressures.  I try and take a blood pressure every time I see a child.  The manual cuff, it is very easy to do, and most children do not get distressed by blood pressure.  If you just pump it above the systolic pressure when you do it in the old fashioned way.  If you must use a machine, that is fine.  Just please put it on the neonatal or paediatric setting, because that is the biggest issue is that people forget to swap it from adult on the pump.  If you have got a fancy one, you can actually set children, so it does not go to 200 and make them scream their head off.  High lactate is over two, but particularly over five is associated with significant increase in mortality, and on our pathway, we have got lactate above 2 to 4 is a yellow zone criteria, so again, a lot of people will not have access to a lactate, but if you are a GP in a regional area or rural area, then it can be done for your point of care testing.  Very important.
 
The other big message that I really want to go into is taking on from what Mel said about carer concern.  In paediatrics, parental concern has always been something that we have talked about as being really important in understanding where the children are really sick.  Parents do know their children best, and we have actually been lucky enough to have been shared the results of a big study done in Victoria in Melbourne last year, led by Dr Erin Mills who is an emergency physician who did a study actually looking at we always say, parents know best, let us prove it, do they really?  They asked a 100,000 times "Are you worried your child is getting worse?" Simple as that.  Are you worried your child is getting worse? They asked over 14,000 families and 1 in 26 said yes.  Of those children where the parents said "yes, they are getting worse" they are 8x more likely in the inpatient setting to go to intensive care, 2.4x more likely to need admitting to hospital and 5.5x more likely to have a significant diagnosis.  Pretty powerful.  What they have also shown, which they have not published yet, is that of those parents who said, "yes, my child is getting worse" in the emergency department or inpatient setting, one-third of those picked up the deterioration before there was a change in the observations.  If you take away nothing else tonight, please take away to ask your patients and their families, "are you worried they are getting worse?" If you go home for any reason and you think you are getting worse, you need to go back and you need to be seen again, and you need to say, "I am getting worse, and my doctor told me that if I was getting worse, I needed to come and say, could this be sepsis?" Unfortunately, the recent Queensland sepsis study, which was published, many of you may have seen it on TV and on the news in the last few weeks, showed that sepsis is the commonest cause of preventable death in children under 16 and young people up to the age of 25 in Queensland, and that is worse than suicide, road traffic accidents.  Now, obviously not all children with sepsis.  It is preventable.  Some children die suddenly, and nothing we can do can make a difference, but some of those lives we can save if we give antibiotics early, we give fluids early.  If in doubt, if you are not sure, give antibiotics, give oral ceftriaxone, print out the sepsis pathway, tick off the bits that you need to tick off to say, "I am worried this patient has sepsis."  Call an ambulance if they have got observations in the red zone criteria.  If you are not sure what they are, you can download between the flags parameters.  If you think they are not very sick but you are worried they might get a bit worse, please give specific instructions about what to look for.  Particularly things like if you notice there is a change in their mental state, if they seem more floppy, if they seem more breathless, things like objective signs so that people know what to look for.  Telling families "I will come back if you are worried" does not help, because they are already worried, they would not be there if they were not worried.  Giving people specific objective information about what to worry about and to actually stand up and say, "I am worried they are getting worse because blah, blah, blah." It has actually now been proven to actually save lives, not just for us to think about it.  Do you want to just go to the next slide, please?  I keep talking and forgetting about going to the next picture.
 
Dr Melanie Berry
 
Helen, I just wanted to know two things.  Hypotension, relative in adults, just always remember, if you have got a previous blood pressure.  If you have got an elderly patient and their blood pressure is 190, that is really relevant.  I am sure all of you already know that, but just a quick reminder, if they are coming in and they have got a blood pressure of 120, but their normal blood pressure is 190, then that is relative hypotension and needs to be understood.  The other thing is really empowering patients, as you were saying, to speak up even if they are not heard the first time.  Empowering carers and patients, "I am not feeling well, I am not feeling better" and continually saying that because as an emergency physician, in the chaos of the emergency room with multiple others I guess, ball is in the air, I think it is really important for carers and patients to be able to say, "hey, I am not okay".  That can be, as Helen is saying lifesaving.
 
Dr Helen Goodwin
 
Remember, GPs can always speak with a senior doctor at an emergency department, and I know sometimes they give you grief and I apologise for that because it is not what we should be doing.  We are supposed to be a team, but please feel as though you can call.  If you do get grief from somebody, then feel as though you can call somebody else.  That is absolutely okay.  Ask to speak to the admitting officer or the person in charge and if it is a child, then you just ring the paediatrician.  If for whatever reason you feel as though they are not taking you seriously, call the on-call paediatrician and we will call the emergency department and tell them to expect the child.  It should not happen, but it does, unfortunately. 
 
We talked about antibiotics.  The time to antibiotics in definitive care is critical.  If there are any delays in transferring to the emergency department in a child or an adult that you think is unwell, consider giving a first dose of antibiotics before you come.  Refer to the relevant antimicrobial guidelines for GPs.  Often you can get onto therapeutic guidelines electronically.  If in doubt, if it is a child and they do not have any reason not to give ceftriaxone, if you have access to ceftriaxone intramuscularly, then I think that would be an appropriate choice of antibiotic.  If you do not and you only have penicillin, then it will still cover group A strep and a lot of other things.  Please do not feel as though you cannot give antibiotics intramuscularly or IV in a very sick child or adult before they leave your care.  If we cannot get cultures, it is not the end of the world.  The main thing is that we reduce preventable harm.  If we use more antibiotics than we should, then again, if we over triage more than we should, if we can reduce preventable harm, then that is okay. 
 
Dr Rebekah Hoffman
 
That was one of my questions coming into this webinar.  We only have Benpen in our doctor's bag.  If we had a magic wand and I do not, but if we did and we could have one other antibiotic that was available to all GPs, you would say it would be ceftriaxone.
 
Dr Melanie Berry
 
Ceftriaxone, yes.
 
Dr Rebekah Hoffman
 
Do you think that there is value and again it is going to be a cost for value to the doctors to be spending the money to have that if they are in certain populations or in certain groups to have that on hand or do you think, if in doubt, give Benpen.
 
Dr Melanie Berry
 
It is a pretty narrow spectrum for first-generation penicillin, whereas you are getting slightly broader cover with ceftriaxone and third-generation cephalosporin.  My preference would be ceftriaxone versus benzylpenicillin, but you have to use what you have got, it is okay.  I think it is also really dependent on where you live and where you are working.  If you are working really regionally, your closest hospital is actually an hour and a half away, then the onus on you to have broader spectrum antibiotics is probably higher than if you are 10 to 15 minutes away from your local hospital.
 
Dr Rebekah Hoffman
 
More than 20 minutes, half an hour away, have a good think about what you have got and what you are going to spend your money on.  If you are a little bit closer, then might be better off just to pack up and send.
 
Dr Helen Goodwin
 
If you are that worried, then you probably should ambulance them anyway with "I am worried about sepsis".  Please write the blood pressure that you know they normally have on the form because otherwise they will not trigger red zone when they hit triage.  The other thing is in neonates, it will come up that you should not use ceftriaxone in neonates.  That is because in neonates, it caused biliary sludging and can worsen jaundice, but for a single injection it is fine.  It is not that it is unsafe in newborns and neonates.  It is not unsafe at all.  It is just that we prefer not to use a full course of ceftriaxone in a newborn because you make them a bit more sludgy.  I would tend to use cefotaxime once they hit hospital, but it is quite safe to use ceftriaxone would be my message.  In terms of its cost, I cannot tell you how much it costs, but in the scheme of things, I would personally spend the money.  I cannot remember.  That was one of my jobs to look it up, how much it was, but it is less than $100 and lasts for ages. 
 
Dr Melanie Berry
 
This is at the other end of the spectrum when the patient has been in hospital and has come out, so it really cannot be denied the effect on the patient, but also the entire family of what happens when someone has sepsis because it affects every single organ.  We do know that anyone who spends over two weeks in intensive care has a 30% risk of having a post-intensive care syndrome and that can affect every part of their body.  Physically they are affected, psychologically they are affected, cognitively they are affected.  It can take years to recover if they ever recover.  Many of these patients who have been affected will not return back to work.  From their own perspective, that is horrific for their family.  That is horrific in terms of generation of income, but also in terms of the broader perspective of the community losing patients who are within those years where they are still sort of working and healthy is a huge burden on society.  For the individual, it is a really long road ahead, and a number of them will end up being readmitted to hospital.  They have an increased mortality risk in the five years after they have had sepsis. 
 
Dr Rebekah Hoffman
 
Do you mind just going through exactly what post-sepsis syndrome is.  Is it similar to what we would see for chronic fatigue patients, or is it a completely different entity altogether?
 
Dr Melanie Berry
 
It is dependent on what kind of sepsis they have and how it has affected them.  As you would know, some patients will have lost limbs, so that will be one of their disabilities.  Often your cognition can be really affected just by being in the intensive care, your cognition can be affected, but you get a septic encephalopathy that can be associated with sepsis.  It is a variety of different symptoms and signs as a result of sepsis and the post-intensive care syndrome is very similar.  It could be quite different depending on the patient, but it often will affect in terms of their muscles waste away.  They lose a lot of body fat.  They cannot make decisions.  A number of them have post-traumatic stress disorder from being in intensive care and really struggle to recover from that.  Often if you talk to patients who have had sepsis, they are very frightened and they are aware of how close they came to dying and that is really difficult for them to overcome.  It is not only that, so they have got to recover the physical ailments that they have or the disablement that they now have, but also psychologically recover from being so close to death and spending sometimes months in rehab and recovery from being away from family and supports and then also economically being really hit, the whole family and themselves.  It is multifaceted.
 
Dr Helen Goodwin
 
Similar in children, you will often see developmental impacts, significant developmental regression.  Obviously they can have physical disability, but just even loss of gross motor and fine motor skills that take some time to come back.  The impact of obviously a sepsis in a child, on the rest of the family.  You guys do great wraparound care, the effect on the parents.  The fact that their child nearly died.  They often have PTSD.  They will often have mood disorders afterwards after their child has been very sick.  Just keep an eye out for the dads, particularly because, as you know, they are less likely to come to the GP because they are not the ones bringing the child back all the time for follow up because that, again, can be a significant issue, as you know. 
 
Dr Melanie Berry
 
This really is a bit of onus on the hospital about giving good discharge summaries and calling up the GP for any patient who has gone through sepsis because there needs to be a really careful handover.  Dependent on the patient, it is going to be a very specific sort of goal stepping plan for each patient would be completely different patient to patient.  I think understanding what the patient has been through, then leading them through the journey of what they are going to be going through for the next year is really important and if possible close follow up with them, particularly in the first few months as they come out and they emerge out of being cocooned in the intensive care and the rehab facilities and then out back into the community because it can often be really jarring because they have not had to do anything like they have just been trying to survive and now they have to go back to what was their previous life.  That can be really absolutely shocking.  Often these patients need psychological input.  The other thing is they are often sent home on multiple drugs and are really clear and good at rationalisation of whether they need to be on any of these drugs is important, dietician review because they often will gain back their body mass fat first, but not their muscle mass.  Dietitians are often really helpful.  Speech pathology.  If they have had a tracheostomy, they may still need to have that.  There is a great program that is run.  If you are lucky enough to be close to Royal North Shore, which is a post-intensive care unit, and there is a plan to start those, but at this stage we do not have many of them across the state.  Yes, but it is just the beginning of their journey when they survive sepsis and it is not finished when they leave the hospital.
 
Dr Helen Goodwin
 
There are more details on the sepsis clinical care standard as well around post-sepsis care and also in the Australian Sepsis Network which we can share the links.  In the next 24 hours, I will come through to you. 
 
Patient resources.  Remember, there are a few different things that you can give families.  Obviously there is the post-sepsis stuff that we talked about.  If a patient comes in who you think "they are a bit sick, I am not sure" then helpful fact sheets for parents in recognising serious illness can be found on the Recognising Illness in Children Factsheet on the Children's Hospital website that you can give to families.  That is going to be updated, if it has not already, to include information around Health Direct and the new Virtual Kids service that Health Direct can refer to is also worth letting parents know.  If they are worried, they can ring the Health Direct number on 1800 022 222.  Kids' Virtual Care actually has paediatric nurses and doctors up until around midnight who can do a virtual triage of patients state-wide and then and do a warm referral either back to yourself, to urgent care services or into the emergency department.  There is a new website.
 
Dr Rebekah Hoffman
 
Talking about this.  This is where I thought that the service could be really utilised for the patients that you get to on a Friday afternoon or a Saturday morning, and you go, I am not convinced you need to be in ED, but I do not know what the next 24 hours looks like.  That is when we were discussing that using Health Direct and the Virtual Kids Care could be an additional resource for the parents to be able to say, if you are not sure and you just want to talk through with someone whether or not you need to be in ED, then using this resource is another option, just another tool that they might be able to utilize.
 
Dr Helen Goodwin
 
Yeah, correct.  Parents can advocate with Health Direct to be put through to Virtual Kids.  I mean, obviously Health Direct does not want to put every child through because some of them do not need to be, but I think particularly if they have been seen by a doctor and you said to the family, "My doctor said, if I am worried I am getting worse, then I need to be seen at Virtual Kids." and I think people would be comfortable with that.  Health.nsw.gov.au/sepsis, the new sepsis website. 
 
Do you want to just go to the next slide, please.  Resources for what is going to be in the community.  Just a heads up for everybody is messaging for families, patients, people in the community around "could it be sepsis?"  Getting people to start asking the question if they get very, very sick quickly, if they are not themselves for whatever reason.  The example messaging will include things like "this is the worst I have ever felt, fever, diarrhoea."  Diarrhoea that is in association with being really, really sick like you have never felt that sick before, things like that.  The public campaign will be starting on Easter Sunday, but correct me if I am wrong. 
 
Prevention.  How do you prevent sepsis?  Well, encourage up-to-date vaccination.  You guys are legends at this.  Remember that in children particularly, the majority of sepsis occurs after a viral illness, so encouraging influenza vaccine in those children who are eligible, encouraging children to be up-to-date with all the preventable illness vaccines that are currently available.  Likewise, in elderly people or immunocompromised people checking what vaccinations they can have to stay safe.  Considering how chronic conditions can influence the risk of sepsis and integrating that into the care plans, particularly with people with wound and indwelling devices and safety netting, as we have discussed ad nauseam tonight.  Specific instructions about what to look for.  How will I know you are getting worse?  What to say if you are getting worse. 
 
Next slide, please.  This is just a reminder.  The sepsis clinical care standard goes through the care standards required for healthcare services to provide coordinated best practice care to reduce the risk of death and morbidity and goes across all healthcare settings.  It is available online. 
 
Next slide.  Questions.
 
Dr Rebekah Hoffman
 
We have no open questions at the moment, and I have asked my two.  It is actually really lovely to hear you say that we are I think the word was legends at vaccination because I think we have had a bit of vaccination fatigue coming through COVID the last few years.  I would completely agree that GPs are legends at vaccination and we are really, really good at it.  We are all about to ramp up to get into our flu vax season for the coming winter.  Hearing that is a little bit more motivating to go home, get off the webinar and think about influenza vaccinations.
 
Dr Helen Goodwin
 
Thank you.  Does anyone in the audience have any questions?
 
Dr Rebekah Hoffman
 
When we were talking offline, we were talking about the value or when we could send a patient back to hospital.  Specifically, that was around someone who had potentially been seen in ED in the previous 24 or 48 hours, and then they had come back to their GP a couple of days later.  What it was that, I know we have talked through what we needed to look out for, but as a GP, when I am sending someone back to hospital, how do I make myself feel better about it because it is always anxiety inducing because you feel that they have been seen by one of your other non-GP specialist colleagues in the past 2 to 3 days, and you are then essentially disagreeing with them, even though the clinical picture has probably changed and saying, "No, I disagree.  I actually think they need to be reviewed again." What is your advice for getting through that imposter syndrome and advocating for your patient and going, "No, you definitely need to go back."
 
Dr Melanie Berry
 
I think the advice is that it is a snapshot in time that that person saw the patient, and you are seeing them now and you are a specialist as well.  I think what you say in your letter is that I reviewed at this time, and at this time they had this.  Now I have seen them today having the history of knowing these patient and knowing that patient well, and they are not right for whatever reason, and it could be they just look very unwell.  I have known them for a number of years, they are not themselves or it could be you pull out the sepsis pathway, these symptoms and signs that I am concerned about sepsis.  In the end, you can say, "I am concerned.  I would like a re-review."  We know that patients that represent are at a higher risk of having serious infection.  We actually rely on people sending back patients.  If you are in the unfortunate position where someone is unprofessional, frankly, really the importance is that you have advocated for your patient.  It does not stop the imposter syndrome, which I think we all have.  In the end, you have advocated for your patient, and that is the absolute best thing that we can all do and what other people think as well although it is really horrific, it does not really matter because I have advocated for my patient.  In the end, with this particular campaign, we do actually need people to be cautious and send in, and that is okay.  I cannot speak for every other ED position.  I hope that everyone is a professional person and speaks properly on the phone, accepts referrals.  I hope that happens.  I hope that everyone across the board does their best, but I know that that does not always happen.  In the end, we can only do what is right for our patients, and if we are concerned, then we have to do what is right.
 
Dr Rebekah Hoffman
 
We were talking before and saying that you would prefer to have a false positive than a missed negative, that if we sent someone in and it turned out they were fine, you would prefer that a million times over than someone not representing.
 
Dr Melanie Berry
 
I think we all would because the outcome for the patient, for the family, but also like we cannot underestimate what happens when you do miss sepsis and being in the ED, it has happened in my department.  You never forget it because it is horrific.  I think false positives are a relief, right?  When you miss it, you feel terrible about it yourself.  Even from a professional's perspective, this can really stop people in their tracks.  They can stop working as doctors when this kind of stuff happens, but from the personal perspective of the patient and the family, it is just horrendous because not only does the patient have sepsis, but also the diagnosis had been missed and we are that many more hours behind.  That really is hard for families to cope with and the grieving process becomes even more difficult.  So yes, 100%.
 
Dr Rebekah Hoffman
 
There is a question about that in the chat specifically around sepsis development and what we can do as GPs in the community to prevent sepsis development.  If we should be changing our threshold for antimicrobial cover.
 
Dr Melanie Berry
 
It is so hard because again it is about numerator and denominator and as you go further into the hospital, the ID physician would be like, rationalise the antibiotics, the ED, like we are always thinking with kids, it is viral.  Last year we always had this thought it is viral until it is not viral but you cannot tell sometimes.  Last year there was a whole lot more group A strep and that is probably still there at the moment.  I tell you what, I am giving more antibiotics.  I think if we are giving more antibiotics, which invariably we probably will, it is the lesser of two evils.  There is no perfect answer to this, really.  What would you say, Helen?  I do not know the answer to that because there is no perfect test yet to say this person has sepsis.  This person has a virus.  This person is going to get better tomorrow.  There is not a marker or a biomarker that has come up with.  I hope any of you maybe have some money or is trying to come up with a protein that we can test because I think if we did come up with it that person will be very wealthy, but also we can all just relax.  At the moment, we are trying to pull together some signs and symptoms, very much like we did when we did not have tests and say, okay, these are the ones that are more likely to have sepsis.
 
Dr Rebekah Hoffman
 
That also answers the next question, which is about differentiating between viral illness and sepsis in the setting of fever in a child, and that it is really, really tricky and it is really, really hard.  We have to use all of those other tools that are available to us, including if the parent is worried and if the parent thinks they are getting worse, but there is no magic wand, no magic answer.
 
Dr Melanie Berry
 
Helen to comment on that.  Sorry.
 
Dr Helen Goodwin
 
No.  That is okay.  It is a tricky one, is not it?  I have been at this for over 30 years now, and sometimes we do not get it right.  We are lucky in hospital that we can do bloods.  We can do a CRP, we can do a chest x-ray.  We can check a blood count a bit more easily when we are not sure.  If the child is unwell, then I am not going to shoot anyone for starting a kid on Amoxil, to be honest.  If they have got a bulging eardrum or they have got chest pain or they are febrile, then you still start the antibiotics.  Just please give them a decent-sized dose, not 125 mg for a 30 kg kid because it will not be enough.  Give them a decent-sized dose.  Safety net, if they are getting worse, you go to ED basically.  In terms of how do you get over your imposter syndrome is trying to think of it as you are doing us a favour.  A bit like Mel said, remember, they might have been seen by a resident or registrar or a consultant, but often a junior person in the emergency department who ran it by their consultant and said, "I am not that worried about this patient.  There are observations between the flags.  I think they are okay.  I think they can go home.  Yep.  Good."  They come to you 24 hours later because they are worse.  Then you are saving our bacon by sending them back before they are rotten.  If they give you grief, then you say, "Hey, look, mate, I am trying to help you.  If this patient has got sepsis and I do not send them in, you are on the line."  If people are unprofessional, then you just remind them that we are trying to help because as Mel said, patients go home from the emergency departments and re-present 24 hours later with sepsis, and we beat ourselves up.  Did we miss it?  We might not have missed it, but God, we beat ourselves up.  How much would we beat ourselves up if the GP had thought they should come, but they were too scared to send them in and they did not come for another 24 hours and we would really beat ourselves up.  Just if you are not sure that is what we are paid to do and that is what you have got to remind yourself, that is what the taxpayer pays us for.  It is to see people that you are worried are getting sicker.  Yes, you are right.  There are people that are unprofessional.  There are people who are tired.  There are people who do not behave well.  Do a full set of observations, make sure that the objective signs are there in the letter and then just everyone is doing their best.  Someone has written in the chat about seeing a 4-year-old with fever, runny nose, bulging TM with pain.  Mum carried her in, refused to take to the ED.  Except for convincing the parent to present to the emergency department, what else could I offer?  Well, I would say advice on the spotting a sick child stuff for the family, not the spotting a sick child website, the sick child handout from the Children's Hospital about warning signs, when to go to ED if they will not come.  Queensland has some really good information sheets for families about could this be sepsis and you can print those out and give them to families about when to go back to hospital.  Excellent resources.  Please use them and start them on antibiotics anyway.  That would be my answer to that question.
 
Dr Melanie Berry
 
Medico-legally make sure, which I am sure you all do, document what you said.  Having worked in clinical governance for two years, document exactly what you said to the patient, including the words you said and what the risks were of not presenting to hospital.  Specifically, the words.  Like I said, they could have sepsis that is life-threatening and I explained what that meant, and I got the patient to tell that back to me.  The words are really important and what you wrote, and specifically what you said to the patient is really important in those cases.
 
Dr Rebekah Hoffman
 
We have 1 or 2 really specific questions, but I am also a fan of finishing a webinar on time, so we might actually circulate them to you and get you to answer them and circulate them to everybody.  I did want to say a big thank you very much to both of you for making what could have been a very dull topic far more interesting and exciting.  I think everyone on here has learned an awful lot and we look forward to hopefully doing this again.
 
Dr Helen Goodwin
 
Thanks for having us.
 
Jennifer Dickinson
 
Thank you.  Thanks, Rebekah.  I would like to extend that thanks to Helen and Melanie for presenting and also Rebekah for facilitating this evening.  I also want to thank everyone who has joined us online and apologies, we did not get to all the questions.  We do hope you enjoy the session and of course, enjoy the rest of your evening.  That brings us to the end.  Thank you everyone, and good night.
 
Dr Helen Goodwin
 
Thanks.  See you.

Other RACGP online events

Originally recorded:

19 March 2024

Join us for this webinar to gain insights from leading experts and enhance your skills in identifying the early signs and red flag symptoms of sepsis.
 
Develop a comprehensive understanding of the pivotal role that GPs play in effectively managing this critical condition. Don't miss this opportunity to advance your knowledge and contribute to improved patient care!

Learning outcomes

  1. Identify clinical red flags and demonstrate the ability to quickly assess and prioritise patients at risk.
  2. Discuss the diagnostic criteria including the importance of early diagnosis, prompt initiation of treatment in sepsis management.
  3. Identify the key features in determining when to refer a suspected case to hospital.
  4. Summarise clear information on clinical deterioration, sepsis risks, symptoms, and when to seek urgent medical attention.
  5. Outline post sepsis care and the need for ongoing monitoring of patients for possible post sepsis sequelae.
Educational Activities
1.0
hours

Facilitator

Dr Rebekah Hoffman
Chair RACGP NSW&ACT Faculty

Dr Rebekah Hoffman is a specialist GP and a fellow of the Royal Australian College of General Practice. She has special interest in a broad range across Women’s and Children’s Health, Sport Medicine, Surgery and Business Governance. Further to this, she also enjoys teaching, being a Senior Lecturer at the University of Wollongong in Medical Education, and regularly mentors students studying medicine from a number of Universities in NSW.

Speakers

Dr Helen Goodwin
Senior Staff Specialist Paediatrician

Dr Helen Goodwin is the current NSW Health Chief Paediatrician and is a General Paediatrician with extensive experience in Regional and Metropolitan Paediatrics. She worked in Tamworth for 16 years and has been a senior staff specialist at RNSH at St Leonards since 2018. Helen is also the current Medical lead for the Paediatric patient safety program at the NSW CEC and was chair of the CEC paediatric sepsis pathway working group. She has a special clinical interest in emergency paediatrics and chronic and complex healthcare in children and young people. She is passionate about health equity and consumer and carer engagement in health services provision. She has had a longstanding involvement in medical education and mentoring healthcare staff.

Dr Melanie Berry
Emergency Physician

Dr Melanie Berry is an Emergency Physician and holds positions at Orange hospital as an Emergency Staff Specialist and a VMO position at Gosford Hospital. As well as working in virtual care at RPA Virtual. Melanie has a Master’s in clinical epidemiology and is a lecturer and co-director of Critical care at the University of Sydney Rural Clinical School Orange. Melanie holds honorary positions with the NSW Clinical Excellence Commission as the co-Chair of the Serious Incident Review Committee, Chair of the Adult Sepsis working group looking at how to improve the guideline to identify sepsis and a member of the Sepsis Pathway Expert Advisory Group and member to the NSW Urgent Sepsis Expert Working group.

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