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A&E nurses risk missing sepsis by not recording vital signs

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Accident and emergency nurses are failing to consistently record patient’s vital signs, risking a late diagnosis of sepsis and potentially avoidable deaths, a new report has claimed.

The investigation, by the National Confidential Enquiry into Patient Outcome and Death, found that a full set of vital signs were recorded by clinicians in just 40% of 369 sepsis cases across 200 A&E departments.

“Mandatory early recognition training for sepsis is a very straight forward way to save many lives”

Ron Daniels

In particular, 17% of patients had none of the six vital signs – temperature, blood pressure, heart rate, respiratory rate, blood glucose, mental status assessment – recorded at triage.

The Just Say Sepsis! report looked at avoidable factors in caring for patients with sepsis and noted that early identification of infection and administration of appropriate antimicrobials was “vital”.

In the 164 acute hospitals that had a policy for intravenous antimicrobials, 75% of them allowed staff nurses to administer the drugs, along with 85% for senior nurses.

But the report found avoidable delays in the administration of antimicrobials in just under a third of patients subsequently thought to have arrived at A&E with sepsis.

In addition, the likely source of infection was not documented at triage in more than 50% of patients, when around half of these should have been.

Meanwhile, 33% of the total of 544 hospitals in the study had no formal sepsis protocol. In hospitals that did have protocols, there was no formal education on sepsis for nurses working in general wards in 27% of hospitals, and none for those working in A&E in 16% of cases.

Experts behind the report said a full set of vital signs should be taken when patients arrived at A&E and suggested more nurses should be given prescribing responsibilities.

They added that triage nurses and nurse practitioners in acute medical units would be” ideally placed” to ensure sepsis patients received prompt antibiotics.

Dr Alex Goodwin, report author and consultant in anaesthesia and intensive care medicine, noted sepsis had a “number of faces” and its symptoms could be mistaken for flu.

“This is why it can be so difficult to diagnose, and why recording a patient’s vital signs at all stages and documenting sepsis is so important,” she added.

UK Sepsis Trust chief executive Dr Ron Daniels said: “Mandatory early recognition training for sepsis is a very straight forward way to save many lives.”

“I am not sure nurse prescribing is the answer – the diagnosis of sepsis or septic shock is the issue”

Catherine Plowright

Catherine Plowright, consultant nurse in critical care at Medway NHS Foundation Trust, who was involved in reviewing the sepsis cases in the report, said the failure to record vital signs was not only concerning for sepsis patients, but others coming to A&E too.

She suggested that in many cases observations were taken but not documented, noting A&E teams were understaffed and often filled with temporary nurses and doctors.

She noted delays to administering antibiotics were “not just to do with nurses” and questioned whether increasing nurse prescribers would solve the problem.

“I know from experience in many cases doctors may prescribe the antibiotics and then perhaps fail to inform a nurse who can administer,” said Ms Plowright.

She added: “I am not sure nurse prescribing is the answer – the diagnosis of sepsis or septic shock is the issue.

Catherine Plowright

Catherine Plowright

Catherine Plowright

“Also, whoever prescribes the antibiotics needs to be able to diagnosis what and where the source of infection is, so it is more than just having a nurse prescribe,” she said. “The nurse has to assess diagnosis and then prescribe and administer, which I’m sure many nurses can do but not all.”

 

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