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Sepsis: the impact of A&E waiting times on detection and treatment

Posted: 28/11/2023

What is sepsis?

Sepsis develops where there is an overreaction within the body to an infection. It is a serious condition that progresses rapidly, causing organ failure and in severe cases, sadly, death. It is essential that sepsis is diagnosed early because of the time sensitive nature of the immune system’s overreaction. Unfortunately, the symptoms of sepsis are non-specific, and it can therefore be difficult to diagnose. Where suspected, urgent assessment is vital to ensure the correct diagnosis.

Timing of sepsis treatment

For adults in emergency care, the National Early Warning Score (NEWS) should be followed. This method allows for the assessment of the severity of acute illness by allocating a score to the six physiological measurements of respiration rate, oxygen saturation, systolic blood pressure, pulse rate, level of consciousness or new confusion, and temperature.

In line with NHS guidance, where a patient receives a NEWS of five or more, they are to be considered severely ill, and require urgent assessment. Where this is accompanied by suspicion of sepsis, the clinical decision-maker should start appropriate treatment, such as IV antibiotics and supplemental oxygen, within the hour.

This urgency is reflected in current NICE guidance on the early management of sepsis, which reiterates that NEWS should be followed in acute hospital settings. For those who have suspected sepsis or are high risk, an immediate review by a senior clinician should be undertaken, along with blood testing and broad-spectrum antimicrobials without delay. The patient should be monitored continuously, or a minimum of once every 30 minutes. It should be noted that this guidance is currently being updated and a revised version is expected in January 2024.

A&E waiting times and the effect on early diagnosis

A recent BBC article has highlighted the Royal College of Emergency Medicine’s (RCEM) claims that thousands of hours are missed from Wales’ monthly A&E figures. In an analysis of data obtained under the Freedom of Information Act, the RCEM states that patients classified as ‘breach exemptions’ have not been included in Wales’ official A&E performance data.

The term ‘breach exemption’ refers to the policy implemented in 2011 by Wales’ Department for Health, Social Services and Children. The guidance outlines that when a clinician decides the safest place for a patient is the emergency department, they should remain there until safe to move them.

On this basis, these patients are excluded from the ‘waits of more than four-hour’ category of data. For example, in the first six months of 2023, there were 45,757 patients classified as breach exemptions, which the RCEM suggests means that their true length of stay in A&E had not been recorded. Their waits and stays in A&E are officially recorded in the ‘less than four hours’ category of data, but in reality, their stay could be much longer. Since January 2012, the RCEM suggests 673,787 patients in Wales have been misrepresented in this way.

Those patients who fall under the breach exemption include clinically unstable patients that require more input from the emergency team, as well as those whose tests results are awaited before a decision can be made whether to admit or discharge them. This is significant in relation to suspected sepsis patients, who are more likely than not to fall into either of these categories.

RCEM notes that long delays in receiving emergency care are harmful to patients, and associated with increased mortality. This is particularly the case for suspected sepsis sufferers, where there is a mortality rate of 20%, and those presenting early are half as likely to die as those presenting late. The under-reporting of the extent of A&E waiting times in Wales is therefore particularly worrying in relation to sepsis sufferers.  

Further calls for transparency

Whilst there are no comparable breach exemption policies or practice in England, A&E doctors there have called out NHS bosses for using ‘misleading figures’ to hide poor performance by A&E units, which often includes data for walk-in centres or minor injuries units. The RCEM has called for NHS England to start publishing data that shows the true performance of every individual emergency department. This data is currently not in the public domain, as NHS England publishes its data for NHS trusts overall rather than individual hospitals.

This article was co-written with Ellen Banks, trainee solicitor in the personal injury and clinical negligence team. 

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