Recognition, diagnosis, and early management of suspected sepsis: summary of updated NICE guidance
BMJ 2024; 385 doi: https://doi.org/10.1136/bmj.q1173 (Published 18 June 2024) Cite this as: BMJ 2024;385:q1173
- 1National Institute for Health and Care Excellence, UK
- 2NHS Lothian, UK
- 3University College London, UK
- Correspondence to A Gildea Anthony.gildea{at}nice.org.uk
What you need to know
Calculate NEWS2 scores to determine an adult’s risk of severe illness or death from sepsis in acute hospital, mental health, and ambulance settings
Use the person’s risk level to help determine the time window in which to give antibiotics
Sepsis is defined as life threatening organ dysfunction caused by a dysregulated host response to infection.1 In 2016, the National Institute for Health and Care Excellence (NICE) first published guidance on recognising, diagnosing, and managing suspected sepsis. In May 2022, a statement published by the Academy of Medical Royal Colleges2 (and endorsed by NHS England) on use of the updated National Early Warning Score (NEWS2)3 sought to guide the urgency of antibiotic prescribing and source control. The statement was based on a narrative review of the literature and expert clinical consensus.
As a result, in January 2024, NICE guidance was updated to include NEWS2 for stratifying risk of severe illness or death from sepsis.4 The updated guideline aims to ensure that early recognition of patient deterioration and treatment for sepsis becomes standardised nationally, and includes recommendations on the timing of antibiotic prescribing based on a person’s risk level, while investigating the underlying infection source.
Recommendations
NICE recommendations are based on systematic reviews of best available evidence and explicit consideration of cost effectiveness. When minimal evidence is available, recommendations are based on the guideline committee’s expertise and opinion of what constitutes good practice. A subsequent consultation process with stakeholder bodies provides external confirmation. Evidence levels for the recommendations are given in italic in square brackets.
GRADE Working Group grades of evidence
High certainty—we are very confident that the true effect lies close to that of the estimate of the effect.
Moderate certainty—we are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different.
Low certainty—our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect.
Very low certainty—we have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect.
Evaluating risk level using NEWS2
A new recommendation was made that NEWS2 scores should be recorded for all patients aged 16 and over (excluding people who are or have recently been pregnant) in acute hospital, mental health, and ambulance settings to help stratify risk of severe illness or death from sepsis. Failing to recognise clinical deterioration promptly can be potentially life threatening. Using the NEWS2 score for initial assessment and repeat monitoring to gauge the response to treatment may mitigate this risk.
Figure 1 outlines the six physiological measurements that make up NEWS2, as defined by the Royal College of Physicians. Each measurement is scored to create an aggregate score which is combined with one of four risk categories to determine the frequency of monitoring and subsequent clinical response. These risk categories are based on consensus recommendation2 and determine further action and intervention, with urgency increasing with a higher band.
NEWS2 tool3 for managing suspected sepsis. SpO2 scale 2 adjusts target saturations to 88-92% for those with hypercapnic respiratory failure.
NEWS2 score interpretation and risk of severe illness or death from sepsis: 0 (very low), 1-4 (low), 5-6 (moderate), >7 (high). CVPU=confusion (new), response to voice, response to pain, unresponsive
A score of 3 in any single parameter may indicate an increased risk of organ dysfunction and clinical deterioration and that the person’s risk level should be considered potentially higher than their aggregate score suggests. This distinction of using a single parameter is based on the clinical experience of the guideline committee and in line with recommendations from the Royal College of Physicians.3 In people with a NEWS score of >5, the risks of admission to the intensive care unit and mortality increase.3
In people aged 16 or over, grade risk of severe illness or death from sepsis using the person’s:
History
Physical examination results (especially symptoms and signs of infection—in line with the recommendations on when to suspect sepsis4) and
NEWS2 score.
Interpret NEWS2 scores in the context of the person’s underlying physiology and comorbidities.
When evaluating the risk of severe illness or death from sepsis in people aged 16 or over with suspected or confirmed infection, use clinical judgment to interpret the NEWS2 score and recognise that:
A score of 7 or more suggests high risk of severe illness or death from sepsis
A score of 5 or 6 suggests a moderate risk of severe illness or death from sepsis
A score of 1 to 4 suggests a low risk of severe illness or death from sepsis
A score of 0 suggests a very low risk of severe illness or death from sepsis.
If a single parameter contributes 3 points to the NEWS2 score, request a high priority review by a clinician with core competencies in the care of acutely ill patients (FY2 or above), for a definite decision on the person’s level of risk of severe illness or death from sepsis.
Consider evaluating the person’s risk of severe illness or death from sepsis as being higher than suggested by their NEWS2 score alone if any of the following is present:
Mottled or ashen appearance
Non-blanching petechial or purpuric rash
Cyanosis of skin, lips, or tongue.
Consider evaluating the person’s risk of severe illness or death from sepsis as being higher than suggested by their NEWS2 score alone if their condition is deteriorating or has not improved since:
Any previous NEWS2 score was calculated
Any interventions that took place.
This evaluation should take into account any NEWS2 score calculated or intervention carried out before initial assessment in the emergency department.
Re-calculate a NEWS2 score and re-evaluate risk of sepsis periodically:
Every 30 minutes for those at a high risk of severe illness or death from sepsis
Every hour for those at moderate risk of severe illness or death from sepsis
Every four to six hours for those at a low risk of severe illness or death from sepsis
When standard observations are carried out, in line with local protocol, for those at very low risk of severe illness or death from sepsis.
[Based on low to moderate certainty evidence and expert clinical consensus from the guideline committee]
Antibiotic management
These updated recommendations on antibiotic management were based on review of the evidence and feedback from those working in clinical practice that the current target of antibiotic administration in one hour for all patients (regardless of their NEWS2 score) at risk of severe illness or death from sepsis was not always practical and could be potentially harmful. Owing to a lack of evidence, and based on consensus from the guideline committee,2 for people at high risk, antibiotics should be given within a one hour window; for people at moderate risk within three hours; and for people at low risk within six hours. This approach may reduce the risk of possible antibiotic related harm for people with suspected sepsis, and promotes antimicrobial stewardship. Clinical judgment should be used when considering the needs of the patient, and each timeframe is a maximum time until prescription rather than a target to work towards.
When the source of infection is confirmed or microbiological results are available:
Review the choice of antibiotic(s) and
Change the antibiotic(s) according to results, using a narrower spectrum antibiotic if appropriate.
Give people aged 16 or over who are at high risk of severe illness or death from sepsis broad spectrum intravenous antibiotic treatment, within one hour of calculating the person’s NEWS2 score on initial assessment in the emergency department or on deterioration when in the ward. Give antibiotics only if they have not been given before for this episode of sepsis.
For people at moderate risk of severe illness or death from sepsis, a clinician with core competencies in the care of acutely ill patients (FY2 level or above) should consider:
Deferring administration of a broad spectrum antibiotic treatment for up to three hours after calculating the person’s first NEWS2 score on initial assessment in the emergency department or deterioration in the ward, and
Using this time to gather information for a more specific diagnosis
Discussing the person’s condition with a senior clinical decision maker.
Once a decision is made to give antibiotics, do not delay administration any further.
For people at low risk of severe illness or death from sepsis, request assessment by a clinician with core competencies in the care of acutely ill patients (FY2 level or above) for them to consider:
Deferring administration of broad spectrum antibiotic treatment for up to six hours after calculating the person’s first NEWS2 score on initial assessment in the emergency department or on deterioration in the ward, and
Using this time to gather information for a more specific diagnosis.
Once a decision is made to give antibiotics, do not delay administration any further.
For someone with a NEWS2 score of 3 or 4 and a single parameter contributing three points to their total NEWS2 score, use clinical judgment to determine the likely cause of the three points in one parameter. If the likely cause is the current infection, manage as moderate or high risk and:
For moderate risk, give broad spectrum antibiotic treatment (ie, deferring administration of broad spectrum antibiotic treatment for up to three hours)
For high risk, give broad spectrum antibiotic treatment within one hour
For other circumstances (such as a pre-existing condition), manage as low risk (ie, deferring administration of broad spectrum antibiotic treatment for up to six hours).
[Based on very low certainty evidence and expert consensus]
Community and custodial settings
The recommendations on caring for acutely ill patients in community and custodial settings (eg, prison, young offender institutions, and border, court, and policy custody) were updated regarding administration of antibiotics while awaiting transfer. They include situations where a clinician with core competencies in the care of acutely ill patients may not be available, such as in some ambulances and mental health facilities, and in rural areas where transport to the acute setting might take longer than in urban areas. Different considerations were made depending on time to transfer to the acute setting, with the aim of avoiding a high volume of referrals that would put undue pressure on secondary care, while also avoiding geographical inequalities associated with transfer time.
In remote and rural locations, a person being assessed as at high risk of severe illness or death from sepsis should receive antibiotics outside of hospital in accordance with local guidelines. However, this recommendation is limited by the number of paramedics who are able to prescribe, and by substantial variation in how services are organised across the country.
In ambulances and acute hospital settings, on taking over care of a person whose risk of severe illness or death from sepsis has already been evaluated in the community or in a custodial setting, evaluate their risk of severe illness or death from sepsis using NEWS2.
In remote and rural locations where combined transfer and handover times to emergency department are greater than one hour:
Ambulance services should consider whether they need to put in place mechanisms to give antibiotics to people with high risk criteria (NEWS2 score of 7 or more) if antibiotics have not been given before by a GP
Paramedics who are thinking about giving antibiotics should follow local guidelines or seek advice from more senior colleagues, if needed.
Ambulance crews should consider a time critical transfer and alert the hospital for people aged 16 or over with suspected or confirmed infection who either have consecutive NEWS2 scores of 5 or above or show cause for significant clinical concern.
When deciding whether a time critical transfer and alert of the hospital is needed for a person aged 16 or over with consecutive NEWS2 scores of 5 or above and suspected or confirmed infection, take into account:
Local guidelines and protocols in relation to clinician scope of practice
Agreements on transfer to hospital
Advance care planning
End-of-life care planning.
For people at high risk of severe illness or death from sepsis (NEWS2 score of 7 or more) who are in an acute mental health setting, follow local emergency protocols on treatment and ambulance transfer.
[Based on very low certainty evidence and expert consensus]
Implementation
NEWS2 has seen widespread uptake across the NHS in England— at present, 100% of ambulance trusts and at least 76% of acute trusts use NEWS2—and other early warning scores are in place elsewhere. National standardisation through using only NEWS2 may reduce variation in practice and improve clinical outcomes, thereby offsetting any resource impact. Some specialised hospitals, such as those that care for patients with altered baseline physiology (eg, spinal injury, heart, and lung disease) may be unable to adopt NEWS2 because the scores may be less accurate in these patient cohorts. NEWS2 should be interpreted within the context of a person’s underlying physiology and comorbidities.
The diagnostic accuracy and cost effectiveness of NEWS2 remains unknown, but real world studies are ongoing.
Future research
The guideline committee identified the following key research questions:
In adults and young people (aged 16 and over) with suspected sepsis, what is the association between NEWS2 bands and risk of severe illness or death?
In adults and young people (aged 16 and over) with suspected sepsis, what is the association between the NEWS2 score of 3 in a single parameter and risk of severe illness or death?
Guidelines into practice
What steps do you take to ensure healthcare practitioners in your service are able to carry out a NEWS2 assessment on people with suspected sepsis?
How often do you defer antibiotics in patients with lower NEWS2 scores while investigating the presence of an infection and whether it requires treatment?
Further information on the guidance
This guidance was developed in accordance with NICE guideline methodology (www.nice.org.uk/media/default/about/what-we-do/our-programmes/developing-nice-guidelines-the-manual.pdf). A guideline committee was established by NICE, which incorporated healthcare professionals (one professor of intensive care medicine, one advanced critical care outreach lead, one consultant in infectious diseases and acute medicine, one consultant in haematology, one consultant in emergency medicine, one consultant in intensive care medicine, one consultant obstetrician and gynaecologist, one consultant in critical care and nephrology, one advanced paramedic practitioner, one consultant in infection, one recognise and rescue and sepsis matron, one general practitioner with a special interest in frailty, and two lay members.
The guideline is available at Overview | Suspected sepsis: recognition, diagnosis and early management | Guidance | NICE
The guideline committee identified relevant review questions and collected and appraised clinical and cost effectiveness evidence. Certainty ratings of the evidence were based on GRADE methodology (www.gradeworkinggroup.org). These relate to the quality of the available evidence for assessed outcomes or themes rather than the quality of the study. The guideline committee agreed recommendations for clinical practice based on the available evidence or, when evidence was not found, based on their experience and opinion using informal consensus methods.
The draft of the guideline went through a rigorous reviewing process, in which stakeholder organisations were invited to comment; the guideline committee took all comments into consideration when producing the final version of the guideline.
NICE will conduct regular reviews after publication of the guidance, to determine whether the evidence base has progressed significantly enough to alter the current guideline recommendations and require an update.
How patients were involved in the creation of this article
Committee members involved in this guideline update included lay members who contributed to the formulation of the recommendations summarised here.
Footnotes
Funding: No authors received specific funding to write this summary. This guidance was funded by NICE.
Contributorship and the guarantor: All authors contributed to the development of the guideline, the planning, drafting, and revision of this summary, approved the final version and take responsibility for its accuracy. The authors thank James Jagroo (senior technical analyst at NICE) for comments and suggestions. AG and EMF are guarantors.
The members of the guideline committee were (shown alphabetically): Alasdair Gray, Ann Hoskins (chair), Barry Murphy-Jones, Erum Khan, Giovanni Satta, Jeremy Henning, Louise Bradbury, Marlies Ostermann, Mervyn Singer, Peter Gosling, Sally Wood, Samina Begum, Savio Fernandes, Tessa Lewis, Tumena Corrah.
Competing interests: We declared the following interests based on NICE’s policy on conflicts of interests (https://www.nice.org.uk/Media/Default/About/Who-we-are/Policies-and-procedures/declaration-of-interests-policy.pdf):
The guideline authors’ full statements can be viewed at register-of-interests (nice.org.uk)
Provenance and peer review: commissioned; not externally peer reviewed.