Standard 39: Sepsis, Clinical Deterioration and Venous Thromboembolism (Version 11)

Why it matters. A patient who is getting worse often shows it in the vital signs first. Recording them with a recognised early-warning score, at set times, flags the patient before the arrest.

Sample. Review observation sets and early-warning scores for a sample of admitted patients on every ward, for the last 3 months.

1. Vital signs are recorded and scored with a recognised early-warning tool at the defined intervals.

Method. Check each sampled observation set for the score and its time against the interval set for the ward.

Evidence to show. Early warning score audit record (DET-FRM-001).

Pass when. Every sampled observation set was scored at the defined interval.

2. Staff know how to score and respond.

Method. Ask a sample of staff to calculate a score from a set of observations and to state the response.

Evidence to show. Early warning score audit record (DET-FRM-001).

Pass when. Staff in each sampled ward score correctly and state the response.

Immediate fail (any one means the criterion is not met). A patient with a rising score is not escalated for six hours because the score was never calculated.

Why it matters. Sepsis kills quickly when it is not treated. Recognising it with a defined screen and giving antibiotics and fluid within a set time saves lives.

Sample. Review every suspected sepsis case in the sepsis time register for the last 12 months, with the patient record.

1. Antibiotics and fluids are given within the defined time of recognition.

Method. Compare the recorded times of recognition, antibiotics and fluids for each sampled case.

Evidence to show. Sepsis time-to-antibiotic register (SEP-REG-001).

Pass when. Every sampled case had antibiotics and fluids within the defined time, or a recorded reason.

2. The time is recorded for each case.

Method. Check the register for complete times for every sampled case.

Evidence to show. Sepsis time-to-antibiotic register (SEP-REG-001).

Pass when. Every sampled case has complete recognition, antibiotic and fluid times.

Immediate fail (any one means the criterion is not met). A febrile patient with low blood pressure waits 6 hours for antibiotics, and the delay is not recorded.

Why it matters. Blood clots are a common and preventable cause of death in hospital. Assessing every admitted patient for clot risk on admission, and giving prevention to those at risk, prevents them.

Sample. Review admission VTE risk assessments for a random sample of admitted patients in the last 3 months, and any patient with a significant change in condition.

Immediate fail (any one means the criterion is not met). A patient immobile after surgery is not assessed, and develops a pulmonary embolism.

Why it matters. Anticoagulants prevent clots but cause bleeding if they are not dosed carefully. Checking the dose, and having a written plan to reverse them, keeps patients safe.

Sample. Review every patient on an anticoagulant in the last 12 months, with the register and the reversal plan.

1. Anticoagulant use is recorded at admission and at each change.

Method. Check the register against the medication records for the sample.

Evidence to show. Anticoagulant use and reversal register (ANT-REG-001).

Pass when. Every sampled anticoagulant use is recorded, including each change.

2. Dosing is checked at the interval set for each drug.

Method. Check the dose checks recorded against the interval for each drug.

Evidence to show. Anticoagulant use and reversal register (ANT-REG-001).

Pass when. Every sampled dose was checked within its interval.

3. A written reversal plan exists for each anticoagulant, and the reversal agent is available.

Method. Check the written plan for each drug and the stock record for the reversal agent.

Evidence to show. Anticoagulant monitoring and reversal (ANT-POL-001).

Pass when. Every drug in use has a written reversal plan, and the reversal agent is in stock.

Immediate fail (any one means the criterion is not met). A patient on an anticoagulant has a major bleed, and no reversal plan or agent is available on the ward.

Why it matters. Unexpected deterioration, sepsis and clots in hospital are events that show where care is failing. Reviewing them regularly is how the hospital learns.

Sample. Review every unexpected deterioration, sepsis case and hospital-associated VTE in the last 12 months, and the quarterly review records.

1. Cases of unexpected deterioration, sepsis and hospital-associated VTE are reviewed at a defined interval.

Method. Compare the review dates with the defined interval.

Evidence to show. Review of deterioration, sepsis and VTE events (DET-SOP-002).

Pass when. Each quarter has a recorded review.

2. Each review looks for a pattern across the events.

Method. Check the review records for the pattern analysis.

Evidence to show. Review of deterioration, sepsis and VTE events (DET-SOP-002).

Pass when. Every review records the pattern analysis.

3. A pattern found leads to a written change to practice.

Method. Check each pattern for the written change, its owner and its date.

Evidence to show. Review of deterioration, sepsis and VTE events (DET-SOP-002).

Pass when. Every pattern found has a written change to practice with an owner and a date.

Immediate fail (any one means the criterion is not met). Three sepsis deaths on one ward in a year are reviewed separately, and no pattern is ever identified.