A multicentre observational study to investigate feasibility of a direct oral penicillin challenge in de-labelling 'low risk' patients with penicillin allergy by non-allergy healthcare professionals (SPACE study): Implications for healthcare systems

OBJECTIVE

The huge burden of inaccurate penicillin allergy labels (PALs) is an important driver of antimicrobial resistance. This is magnified by insufficient allergy specialists and lack of 'point-of-care' tests. We investigated the feasibility of non-allergy healthcare professionals (HCPs) delivering direct oral penicillin challenges (DPCs) for penicillin allergy de-labelling.

METHODS

This prospective observational study was conducted in three hospitals in England across three settings (acute medical, pre-surgical and haematology-oncology). Patients with a PAL were screened and stratified as low risk/high risk. Low risk patients (non-immune mediated symptoms, benign rash, tolerated amoxicillin since and family history) underwent a DPC.

RESULTS

N = 2257 PALs were screened, 1054 were eligible; 643 were approached, 373 declined, 270 consented and 259 risk stratified (low risk = 155; high risk = 104). One hundred and twenty-six low risk patients underwent DPC, 122 (96.8%) were de-labelled with no serious allergic reactions. Conversion rate from screening-to-consent was 12% [3.3% and 17.9% in acute and elective settings respectively; odds ratios for consent were 3.42 (p < 0.001) and 5.53 (p < 0.001) in haematology-oncology and pre-surgical setting respectively. Common reasons for failure to progress in the study included difficulty in reaching patients, clinical instability/medical reasons, lacking capacity to consent and psychological factors.

INTERPRETATION

DPCs can be delivered by non-allergy HCPs. A high proportion of patients with PALs did not progress in the study pathway. Strategies to deliver DPC at optimal points of the care pathway are needed to enhance uptake. Elective settings offer greater opportunities than acute settings for DPC. The safety and simplicity of DPCs lends itself to adoption by healthcare systems beyond the UK, including in resource-limited settings.

Survey of adherence to sepsis care bundles in six European countries shows low adherence and possible patient risk

Sepsis is a life-threatening condition which globally claims more lives than cancer. A set of evidence-based clinical practices (sepsis bundles) have been developed to guide early diagnosis and rapid intervention, which are vital to patient survival; however, their use is not widely adopted. A cross-sectional survey was administered in June-July 2022 to understand healthcare practitioner (HCP) knowledge of and adherence to sepsis bundles and identify key barriers to adherence in the UK, France, Spain, Sweden, Denmark and Norway; a total of n=368 HCPs ultimately participated. The results showed that among HCPs, overall awareness of sepsis and the importance of early diagnosis and treatment is high. However, there are indications that adherence to sepsis bundles is well below the standard of care: when asked which steps providers carry out to treat sepsis, only 44% report carrying out all steps in the bundle; and 66% of providers agreed that delays in sepsis diagnosis occur sometimes where they work. This survey also highlighted the possible barriers which are impeding the implementation of optimal sepsis care: particularly high patient caseload and staff shortages. This research highlights important gaps and obstacles in reaching optimal care of sepsis in the surveyed countries. There is a need for healthcare leaders and policy-makers alike to advocate for increased funding for more staff and training to address existing knowledge gaps and improve patient outcomes.

How to improve aseptic technique to reduce bloodstream infection during vascular access procedures

Bloodstream infections associated with vascular access procedures pose a serious risk to patients that can be reduced by better standards of aseptic technique. The objectives of this roundtable of experts were to achieve a consensus on how to improve skin antisepsis in hospital, improve training, competency, compliance and consistency in skin antisepsis, review the role of devices in improving skin antisepsis, identify methods to improve skin antisepsis integrated with the Aseptic Non Touch Technique (ANTT®) approach, and identify challenges to the implementation of the panel's recommendations. Recommendations include using MHRA-licensed 2% chlorhexidine gluconate in 70% isopropyl alcohol solution with bidirectional strokes for up to 30 seconds, then leaving the skin to air dry for 30 seconds; using the ANTT Clinical Practice Framework and terminology as the standard for skin antisepsis training and practice; standardised ANTT and skin antisepsis education with 3-yearly competency assessments for all UK health professionals; and more research to address the evidence gap on transmission of infection after skin antisepsis.

An evaluation of sepsis in dentistry

Sepsis is a life-threatening organ dysfunction caused by a dysregulated host response to infection. It is a major health concern and causes substantial morbidity and mortality. It is imperative that the signs of sepsis are identified early in both adult and paediatric patients and appropriately escalated to initiate early treatment and improve prognosis. This paper aims to discuss the change in classification from the previous systemic inflammatory response syndrome (SIRS) criteria to the current definition in adults and also the unchanged definition in children. The hallmark signs of sepsis (both red and amber flags) are discussed in relation to their underlying cellular mechanisms to provide a comprehensive overview for clinicians in primary care, hospital and community settings. The rise of antimicrobial resistance is also an increasing global health concern with resistant bacteria from common infections likely to result in greater patient morbidity and worse outcomes.A literature search identified reported sepsis cases in dentistry through searches in Ovid Medline and Embase from January 1990 to December 2019. Only primary studies were included with no restrictions on languages. Four articles were identified which reported sepsis associated with tooth extractions, dental abscess and submental/submandibular cellulitis. It is well known that locoregional infections of dental origin have the potential to cause sepsis. Therefore, dental healthcare professionals need to be vigilant and understand the specific signs and escalation protocols to ensure patient safety.

Development of the FAST-M maternal sepsis bundle for use in low-resource settings: a modified Delphi process

Objective

To develop a sepsis care bundle for the initial management of maternal sepsis in low resource settings.

Design

Modified Delphi process.

Setting

Participants from 34 countries.

Population

Healthcare practitioners working in low resource settings (n = 143; 34 countries), members of an expert panel (n = 11) and consultation with the World Health Organization Global Maternal and Neonatal Sepsis Initiative technical working group.

Methods

We reviewed the literature to identify all potential interventions and practices around the initial management of sepsis that could be bundled together. A modified Delphi process, using an online questionnaire and in‐person meetings, was then undertaken to gain consensus on bundle items. Participants ranked potential bundle items in terms of perceived importance and feasibility, considering their use in both hospitals and health centres. Findings from the healthcare practitioners were then triangulated with those of the experts.

Main outcome measure

Consensus on bundle items.

Results

Consensus was reached after three consultation rounds, with the same items deemed most important and feasible by both the healthcare practitioners and expert panel. Final bundle items selected were: (1) Fluids, (2) Antibiotics, (3) Source identification and control, (4) Transfer (to appropriate higher‐level care) and (5) Monitoring (of both mother and neonate as appropriate). The bundle was given the acronym ‘FAST‐M’.

Conclusion

A clinically relevant maternal sepsis bundle for low resource settings has been developed by international consensus.

Tweetable abstract

A maternal sepsis bundle for low resource settings has been developed by international consensus.

A maternal sepsis bundle for low resource settings has been developed by international consensus.

Life after sepsis: an international survey of survivors to understand the post-sepsis syndrome

OBJECTIVE

In this study, we aim to describe the post-sepsis syndrome from the perspective of the sepsis survivors.

DESIGN AND SETTING

The study is a prospective, observational online international survey.

PARTICIPANTS

Sepsis survivors enrolled via social media from 13 September 2014 to 13 September 2016.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Physiologic, physical and psychological function post-sepsis; and patient satisfaction with sepsis-centered care.

RESULTS

1731 completed surveys from 41 countries were analyzed, with 79.9% female respondents, age 47.6 ± 14.4 years. The majority of respondents (47.8%) had sepsis within the last year. Survivors reported an increase in sensory, integumentary, digestive, breathing, chest pain, kidney and musculoskeletal problems after sepsis (all P-value <0.0001). Physical functions such as daily chores, running errands, spelling, reading and reduced libido posed increased difficulty (all P-value <0.0001). Within 7 days prior to completing the survey, the survivors reported varying degrees of anxiety, depression, fatigue and sleep disturbance. Sepsis survivors reported dissatisfaction with a number of hospital support services, with up to 29.3% of respondents stating no social services support was provided for their condition.

CONCLUSIONS

Sepsis survivors suffer from a myriad of physiologic, physical and psychological challenges. Survivors overall reveal dissatisfaction with sepsis-related care, suggesting areas for improvement both in-hospital and post-discharge.

Patient-reported outcome measurement compared with professional judgment of cosmetic results after breast-conserving therapy

Background

In the present study, we set out to compare patient-reported outcomes with professional judgment about cosmesis after breast-conserving therapy (bct) and to evaluate which items (position of the nipple, color, scar, size, shape, and firmness) correlate best with subjective outcome.

Methods

Dutch patients treated with bct between 2008 and 2009 were analyzed. Exclusion criteria were prior amputation or bct of the contralateral breast, metastatic disease, local recurrence, or any prior cosmetic breast surgery. Structured questionnaires and standardized six-view photographs were obtained with a minimum of 3 years' follow-up. Cosmetic outcome was judged by the patients and, based on photographs, by 5 different medical professionals using 3 different scoring systems: the Harvard scale, the Sneeuw questionnaire, and a numeric rating scale. Agreement was scored using the intraclass correlation coefficient (icc). The association between items of the Sneeuw questionnaire and a fair-poor Harvard score was estimated using logistic regression analysis.

Results

The study included 108 female patients (age: 40-91 years). Based on the Harvard scale, agreement on cosmetic outcome between the professionals was good (icc: 0.78). In contrast, agreement between professionals as a group compared with the patients was found to be fair to moderate (icc range: 0.38-0.50). The items "size" and "shape" were identified as the strongest determinants of cosmetic outcome.

Conclusions

Cosmetic outcome was scored differently by patients and professionals. Agreement was greater between the professionals than between the patients and the professionals as a group. In general, size and shape were the most prominent items on which cosmetic outcome was judged by patients and professionals alike.

Comprehensive phytochemical characterization of St. John's wort (Hypericum perforatum L.) oil macerates obtained by different extraction protocols via analytical tools applicable in routine control

The aim of the present study was to investigate the impact of crucial process parameters, i.e. of light and temperature conditions, during the preparation of St. John's wort (SJW, Hypericum perforatum L.) Arachis oil macerates. Extracts were prepared according to a standardized protocol over a period of 28 days. For this purpose, flowering tops of H. perforatum were macerated with Arachis oil (drug extract ratio, DERnative 1:4) under different light and temperature conditions. Spectrophotometric measurements were carried out to quantitate naphthodianthrones and to characterize extract color in the CIE L*C*h° system. Moreover, individual plant secondary metabolites were screened by UHPLC-DAD-MSn measurements following liquid-liquid extraction of the oil macerates with methanol. For quantitation purposes, the chromatographic method was validated using reference standards. This methodology allowed the separation of up to 25 constituents in oily and methanolic SJW extracts, covering hydroxycinnamic acids, flavanols, proanthocyanidins, flavonol glycosides, flavonol aglyca, biflavones, bisanthraquinone glycosides, naphthodianthrones and phloroglucinols. Lowest naphthodianthrone contents were determined in oil macerates recovered at 5 °C, whereas highest amounts were detected upon extraction at 50 °C (both under the exclusion of light). Color shades of the oil macerates differed markedly, revealing e. g. a*-values ranging from -4.6±0.3 to 42.5±0.3. The flavonoids quercetin, kaempferol and I3, II8-biapigenin as well as the phloroglucinols hyperforin and adhyperforin could be simultaneously detected and quantitated in all oil macerates. Contents of these constituents varied noticeably between macerates prepared under different conditions (quercetin 14.7±1.2 to 21.8±0.6 μg/g, kaempferol 3.0±0.1 to 5.4±0.4 μg/g, I3, II8-biapigenin 4.4±0.2 to 7.4±0.4 μg/g, hyperforin 52.6±46.0 to 451.4±24.9 μg/g, adhyperforin 6.9±5.7 to 74.5±7.1 μg/g). These results confirm that the quality of the resulting plant extracts is largely determined by the respective process parameters, i.e. especially temperature and light conditions, and thus must be thoroughly chosen and monitored to obtain tailor-made preparations.

Future directions for the European influenza reference laboratory network in influenza surveillance

By defining strategic objectives for the network of influenza laboratories that have national influenza centre status or national function within European Union Member States, Iceland and Norway, it is possible to align their priorities in undertaking virological surveillance of influenza. This will help maintain and develop the network to meet and adapt to new challenges over the next 3-5 years and underpin a longer-term strategy over 5-10 years. We analysed the key activities undertaken by influenza reference laboratories in Europe and categorised them into a framework of four key strategic objectives areas: enhancing laboratory capability, ensuring laboratory capacity, providing emergency response and translating laboratory data into information for public health action. We make recommendations on the priority areas for future development.

Recognizing and managing sepsis: what needs to be done?

Sepsis is associated with significant morbidity and mortality if not promptly recognized and treated. Since the development of early goal-directed therapy, mortality rates have decreased, but sepsis remains a major cause of death in patients arriving at the emergency department or staying in hospital. In this forum article, we asked clinicians and researchers with expertise in sepsis care to discuss the importance of rapid detection and treatment of the condition, as well as special considerations in different patient groups.

A multidisciplinary team approach minimises prophylactic mastectomy rates

BACKGROUND

Prophylactic mastectomy (PM) has become increasingly common but is not without complications especially if accompanied by reconstructive surgery. In patients with sporadic unilateral breast cancer, contralateral PM offers no survival advantage. Multidisciplinary team (MDT) communication and interaction may facilitate shared decision-making and curtail PM rates. The aim of this study was investigate the effect of a regional MDT meeting on PM decision-making.

METHODS

We conducted an observational study involving retrospective review of prospectively recorded MDT meeting records for a 151 patient requests for PM from 2011 to 2014. Final MDT decisions were recorded as PM 'accepted', 'declined' or 'pending'. For MDT sanctioned requests, the factors justifying PM were recorded. Where PM was declined, justification for MDT refusal was sought and recorded.

RESULTS

Approximately half of all requests for PM have been upheld (53.0%) and 1/3 of requests have been declined (32.5%). Of those declined, low risk of contralateral breast cancer versus relatively high risk of systemic relapse were commonly cited as justification for PM refusal (45.7%). A proportion of patients who initiated PM discussion subsequently changed their minds (19.6%), or failed to attend clinic appointments (6.5%). Some patients were deemed medically unfit for complex reconstructive surgery (13%), or were declined on the basis of an apparent cosmetic drive for surgery (6.5%), concerns regarding depression or anxiety (2.2%) and/or if family history could not be substantiated (6.5%).

DISCUSSION

MDT meetings facilitate cross-specialty interrogation of requests for PM, minimise unnecessary surgery and restrict PM to those likely to derive maximum benefit.

Cluster of influenza A cases in vaccinated population of adults in Virology Laboratory in Glasgow in December 2012

BACKGROUND AND AIMS

The majority of influenza infections during the 2012/2013 influenza season in Scotland have been due to influenza A H3N2. We report an outbreak of influenza A H3N2 in a vaccinated population of adults in the Regional Virology Laboratory in Glasgow. This investigation was carried out to confirm the epidemiological link between cases.

METHODS AND RESULTS

Staff with clinical symptoms of influenza-like illness were included. Samples were tested by real-time polymerase chain reaction and sequencing. Staff were interviewed to obtain information regarding symptom onset and vaccination status. Eight confirmed cases and six clinically diagnosed cases were reported, which all occurred within 4 days of a lunchtime Christmas quiz. The eight samples subtyped as H3 virus. The haemagglutinin gene in the confirmed cases was sequenced and shown to be identical. Most of the attendees had been immunised against influenza with the same vaccine batch at least 6 weeks earlier.

CONCLUSION

This outbreak appears to have been an isolated incident, which arose due to a social event that provided the ideal conditions for transmission of a respiratory disease. It may have been compounded by low-vaccine effectiveness this season. Sequence data supported the epidemiological link.

Laboratory preparedness in EU/EEA countries for detection of novel avian influenza A(H7N9) virus, May 2013

Following human infections with novel avian influenza A(H7N9) viruses in China, the European Centre for Disease Prevention and Control, the World Health Organization (WHO) Regional Office for Europe and the European Reference Laboratory Network for Human Influenza (ERLI-Net) rapidly posted relevant information, including real-time RT-PCR protocols. An influenza RNA sequence-based computational assessment of detection capabilities for this virus was conducted in 32 national influenza reference laboratories in 29 countries, mostly WHO National Influenza Centres participating in the WHO Global Influenza Surveillance and Response System (GISRS). Twenty-seven countries considered their generic influenza A virus detection assay to be appropriate for the novel A(H7N9) viruses. Twenty-two countries reported having containment facilities suitable for its isolation and propagation. Laboratories in 27 countries had applied specific H7 real-time RT-PCR assays and 20 countries had N9 assays in place. Positive control virus RNA was provided by the WHO Collaborating Centre in London to 34 laboratories in 22 countries to allow evaluation of their assays. Performance of the generic influenza A virus detection and H7 and N9 subtyping assays was good in 24 laboratories in 19 countries. The survey showed that ERLI-Net laboratories had rapidly developed and verified good capability to detect the novel A(H7N9) influenza viruses.

Evaluation of the mechanism of gelation of an oleogel based on a triterpene extract from the outer bark of birch

Oleogels are known for their high physical, chemical, and mechanical stability and good in vivo efficacy, which make them appropriate vehicles for dermal drug delivery and skin care for very dry skin. Modern formulation research focusses on well tolerated and sustainable formulation concepts. This paper deals with an innovative oleogel, which is based on a triterpene dry extract from the outer bark of birch (TE). In this formulation TE does not only act as an excipient but provides interesting pharmacological properties at the same time. The oleogel was formulated using solely Simmondsia Chinensis seed oil (jojoba oil) and TE. Fluorescence microscopy and confocal Raman microscopy showed that suspended TE particles arrange in a three-dimensional gel network. Infrared spectroscopy revealed that the formation of hydrogen bonds between TE particles is responsible for the self-assembly of TE in oil. Moreover, the influence of TE concentration and morphology of the TE particles on the viscoelasticity of the resulting oleogels was analyzed. Gel strength increased with TE concentration and was critical to the specific surface area of the TE particles.

In vitro skin permeation and penetration of nonivamide from novel film-forming emulsions

The purpose of this study was to develop film-forming emulsions (FFE) facilitating long-term treatment of chronic pruritus with capsaicinoids. To this end, oil-in-water emulsions, which comprise dispersions of sustained-release polymers, were examined. Such emulsions form a film when applied to the skin and encapsulate the oily drug solution in a dry polymeric matrix. Permeation of the antipruritic drug nonivamide (NVA) is controlled by the matrix. Permeation rates of NVA from FFE and its concentration in the skin are equivalent to those achieved with a conventional semisolid formulation, but can be maintained for a longer period of time. FFE may therefore improve the treatment of chronic pruritus with capsaicinoids by enhancing patient compliance by means of a sustained-release regimen.

Severe sepsis, social media and the #Sepsis 6: 'Tweeting' national innovations

The Surviving Sepsis Campaign (SSC) was launched in 2002 with guidelines created to help manage severe sepsis and septic shock. In response to poor compliance with the SSC guidelines in the UK, the 'Sepsis 6' model of delivery was created. We report some of the innovative methods hospitals from around the UK are using to help deliver the 'Sepsis 6' care bundle. The use of social media, such as Twitter, for disseminating these innovations is also explored.

Hypericin for visualization of high grade gliomas: first clinical experience

AIMS

We aimed to demonstrate that Hypericin, a component of St. Johns Wort, selectively visualizes malignant gliomas. Hypericin is known as one of the most powerful photosensitizers in nature with excellent fluorescent properties.

METHODS

In five patients with a recurrence of a malignant glioma a newly developed water soluble formulation of hypericin was given intravenously (0.1 mg/kg body weight) 6 h before the surgical procedure. Tumor resection was performed under white light and fluorescence mode. The intensity grade of the tissue fluorescence was categorisized by the surgeon in three grades, highly fluorescent, weakly fluorescent and not fluorescent. In these areas tissue samples were taken and investigated by two blinded independent neuropathologists. Tissue samples were histologically classified differentiating between tumor tissue, tumor necrosis, tissue with scattered tumor cells and normal brain tissue.

RESULTS

In all patients tumor tissue was clearly distinguishable by its typically red fluorescence color from normal brain tissue which was colored blue under a special fluorescent filter. Histological evaluation of the 110 tissue samples showed a specificity of 100% and sensitivity of 91% for one of the two neuropathologists, whereas specificity for second pathologist was 90% and sensitivity 94%. The i.v. application of Hypericin proofed to be safe in all cases and there were no side effects observed.

CONCLUSION

Hypericin in its water soluble form is a well tolerated drug. In addition to its high photosensitizing properties hypericin will open up interesting new therapeutic possibilities especially when used in combination with fluorescence detection and simultaneously photodynamic therapy.

[The psychometric properties of three self-report screening instruments for identifying frail older people in the community]

BACKGROUND

Frailty can lead towards serious adverse consequences, such as disability. With regard to prevention valid screening instruments are needed to identify frail older people. The aim was to evaluate and compare the psychometric properties of three screening instruments: the Groningen Frailty Indicator (GFI), the Tilburg Frailty Indicator (TFI) and the Sherbrooke Postal Questionnaire (SPQ). For validation purposes the Groningen Activity Restriction Scale (GARS) was added.

METHODS

A questionnaire was sent to 687 older people (> or = 70 years). (1) Agreement between instruments, (2) internal consistency, (3) cumulative scalability according to Mokken scale analysis and (4) construct validity were evaluated.

RESULTS

The response rate was 77%. Prevalence estimates of frailty ranged from 40% to 59%. The highest agreement was found between the GFI and TFI (Cohen's kappa = 0.74). Cronbach's alpha for the GFI, TFI and SPQ was 0.73, 0.79 and 0.26, respectively. The scalability of the three instruments was inadequate (Loevinger's H: 0.28, 0.30 and 0.09 for GFI, TFI and SPQ, respectively). Frailty scores correlated significantly with each other and with the GARS scores.

CONCLUSION

Especially the GFI and TFI seem to be useful to identify frail older people. Further research regarding their predictive validity is still needed.

Surviving the first hours in sepsis: getting the basics right (an intensivist's perspective)

Severe sepsis is a major cause of morbidity and mortality, claiming between 36 000 and 64 000 lives annually in the UK, with a mortality rate of 35%. International guidelines for the management of severe sepsis were published in 2004 by the Surviving Sepsis Campaign and condensed into two Care Bundles. In 2010, the Campaign published results from its improvement programme showing that, although an absolute mortality reduction of 5.4% was seen over a 2 year period in line with increasing compliance with the Bundles, reliability was not achieved and Bundle compliance reached only 31%. This article explores current challenges in sepsis care and opportunities for further improvements. Basic care tasks [microbiological sampling and antibiotic delivery within 1 h, fluid resuscitation, and risk stratification using serum lactate (or alternative)] are likely to benefit patients most, yet are unreliably performed. Barriers include lack of awareness and robust process, the lack of supporting controlled trials, and complex diagnostic criteria leading to recognition delays. Reliable, timely delivery of more complex life-saving tasks (such as early goal-directed therapy) demands greater awareness, faster recognition and initiation of basic care, and more effective collaboration between clinicians and nurses on the front line, in critical care and in specialist support services, such as microbiology and infectious diseases. Organizations such as Survive Sepsis, the Surviving Sepsis Campaign and the Global Sepsis Alliance are working to raise awareness and promote further improvement initiatives. Future developments will focus on sepsis biomarkers and microarray techniques to rapidly screen for pathogens, risk stratification using genetic profiling, and the development of novel therapeutic agents targeting immunomodulation.

Impact of the Surviving Sepsis Campaign on the recognition and management of severe sepsis in the emergency department: are we failing?

BACKGROUND

Severe sepsis/septic shock (SS/SS) has a high mortality. The past decade lays witness to a concerted international effort to tackle this problem through the Surviving Sepsis Campaign (SSC). However, bundle delivery remains problematic. In 2009, the College of Emergency Medicine (CEM) set out guidelines for the management of SS/SS. These set the standards for this audit.

OBJECTIVES

To assess the recognition and management of patients presenting with SS/SS across three emergency departments (EDs) within the West Midlands.

METHODS

Data were collected retrospectively over a 3-month period. Patients in the ED with a diagnostic code of, or presenting complaint suggestive of, sepsis, had their scanned notes assessed for evidence of SS/SS. Compliance with the CEM guidelines, and evidence of referral to the intensive care staff was evaluated.

RESULTS

255 patients with SS/SS were identified. Of these, 17% (44/255) were documented as septic by ED staff. The CEM standard of care was received in 41% of those with a documented diagnosis of severe sepsis in the ED, and 23% of patients with SS/SS overall. 89% of patients received the 'treatment' aspects of care: oxygen, IV antibiotics and IV fluids. Twelve patients with a raised lactate level and normal blood pressure (cryptic shock) failed to receive fluid resuscitation. 71% of patients with SS/SS had no documented discussion or consideration of referral to the intensive care unit.

CONCLUSIONS

The SSC has had some impact; however, there is still a long way to go. It is assumed that the picture is similar in EDs across the UK and recommendations are made based on these local findings.