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GPs buried under trusts' workload dump

NHS forced to admit sepsis guidance is 'difficult' as GPs switch off alerts

NHS England has appeared to roll back on guidance for GPs to identify and treat sepsis following criticism that GPs were suffering from ‘alert fatigue’.

Commissioning guidance released in September conceded that ‘some front line staff have found it difficult to translate’ NICE guidance into practice.

It clarified that the application of the NICE guidelines is ‘not mandatory’, and that the ‘use of clinical judgement is a critical component’.

GP leaders said that GPs were suffering from ‘alert fatigue’, after the NICE guidance was embedded into IT systems, leading to repeated computer warnings.

The Government drive began two years ago with a string of measures designed to make GPs ‘think sepsis’, after a series of high-profile deaths, including asking GPs to conduct a ‘sepsis audit’.

The 2015 sepsis action plan suggested GPs have limited ability ‘to distinguish between sepsis, severe sepsis and septic shock’ and urged doctors to use screening tools to help differentiate simple infection from something more serious.

In 2016, NICE published guidelines urging GPs to treat signs of sepsis in the same way as chest pain and including large tables of symptoms and signs that were translated into electronic alerts embedded into GP systems.

However, BMA GP Committee prescribing lead Dr Andrew Green said these electronic alerts represented ‘a lesson in how not to use IT’.

Dr Green said: ‘The largest problem with it is the low threshold for sending an alert. The result is that these alerts are ignored. Should that “suspected UTI” patient go on to have sepsis, GPs may find themselves having to justify why they did not take action earlier.

‘Inquests where people have ignored warnings rarely look at the contribution of alert-fatigue.’

Dr Ron Daniels, chief executive of the Sepsis Trust, which helped drive the sepsis action plans, admitted the alerts were implemented ‘hastily’ and have backfired in some cases.

He said: ‘We’re aware of anecdotal cases where GPs have found the systems very helpful in clinical decision making, but we’ve also heard of cases where GPs decided to turn off the alerts.’

RCGP clinical champion for sepsis Dr Simon Stockley said there must be greater recognition of the importance of clinical judgement in assessing the risk of infection – mirroring the recent NHS England advice that he co-authored.

Dr Stockley said: ‘The numbers will not always give you the right answer, which is why the clinical systems tend to over trigger. You should always use your clinical judgement to weigh the risk.’

The latest NHS England guidance, released last month, says: ’NICE guidance on sepsis was published in 2016 and provides an evidence-based approach to recognising and initiating treatment for suspected sepsis. However, some front line staff have found it difficult to translate this guidance into practice.’

It adds: ‘The application of the recommendations in the NICE guideline NG51 is not mandatory and the use of clinical judgement is a critical component.’

In a separate piece of guidance issued last month, NHS England said it will ‘work with GP software providers to update their sepsis alert algorithms’.

Readers' comments (21)

  • AlanAlmond

    Stick your algorithms up your [this comment has been moderated]

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  • when I type the word deterioration get a sepsis alert.

    this tends to be a problem as I often type " warned about deterioration and emergency advice given"

    also hay fever triggers the alert

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  • David Banner

    So NHSE thinks GPs are creating bacterial Armageddon by overprescribing antibiotics, whilst at the same time killing patients with sepsis by underprescrbing antibiotics.

    Here's a thought, why not leave individual medical professionals to make individual prescribing decisions in individual patient consultations. It's so crazy it might just work.

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  • Vinci Ho

    Dr Stockley said: ‘The numbers will not always give you the right answer, which is why the clinical systems tend to over trigger. You should always use your clinical judgement to weigh the risk.’

    OMG , how long does it take for academics to realise the difference between textbook thinking (what computer systems are implementing) and clinical judgement and discretion exercised by experienced GPs in the frontline?
    The definition of insanity is doing the same thing over and over and expecting different results.
    But then again , NHSE and DoH simply want to kill off us(older GPs) because we are too f**king expensive.......

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  • Vinci Ho

    By the way , how much taxpayers’ money was paid to these ‘nice’ guys doing their guidelines every year ?

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  • Too much, Vinci, too much.
    And while we're at it how about those decent chaps down at CQC- even more value for money I shouldn't think....

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  • Vinci Ho

    You see
    I was teaching my GP registrars yesterday about the difference between the latest NICE recommendation of 1% 10Yrs fracture risk(FRAX or Qfracture calculator)threshold for initiating treatment of biphosphonates and the more logical approach of NOGG by using the assessment chart which adopts 6 to 10% fracture risks depending on age.
    You just wonder how these guidelines cannot converge and make common senses. Instead , every establishment wants to be territorial, worst of all , being ‘used’ by politicians and technocrats.

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  • Guys - you're missing the bigger picture.

    All these algorithms are too facilitate the non doctors doing our job wben we have all left. Cue risk averse, over investigations, over referral and over treatment.

    They'll miss us when we are gone

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  • Vinci Ho

    5 Oct 2017 1:45pm

    I haven’t written this sound bite for a while:
    ‘It is only a fine line between politically correct diplomacy and dangerously flawed hypocrisy.’

    Dangerously flawed particularly when some easily triggered artificial intelligence is increasing demand to an extremely overstretched NHS with inadequate resources provided by this government.

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  • I use it as a ruse to get patients admitted. In the last line of my admission covering letter I put - "insert your preliminary diagnosis here" +/- AKI +/- sepsis.

    All can only be discounted by doing some investigations. When the hospital don't bother to do any, they usually miss the AKI/sepsis.

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  • Glad someone mentioned "Hayfever" as a trigger for sepsis alert. Makes me smile every time!

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  • Agree Shaba, they have no idea. Medicine by numbers.
    Fever, deterioration , tachycardia all trigger and of course they are switched off - older GPs like me sadly type AFTER examining & agreeing treatment plan. Just slows down getting the next patient in specially if you look at your fingers while typing! So hurrah! Maybe they'll switch these off. And stop trying to direct our attention in only one diagnostic direction.

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  • ‘They’ know you ignore the alerts as it would be impossible to admit every patient where the alert flashes up. ‘They’ also know that if someon you see too quickly develops sepsis they will be an audit of you missing sepsis so you can be blamed.

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  • Healthy Cynic

    At last. Some software to hell me identify illness. Don't know how I've managed without it for the last 30 years.
    #dontdumbdowngeneralpractice

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  • Presumably all the above respondents have always immediately spotted life threatening sepsis whenever they have seen it or have never been aware of someone develop sepsis and die very quickly. As a GP on the planet earth who is moderately competent I very much welcome the recent focus on sepsis. The rest of you must be brilliant clinicians or dinosaurs.

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  • To Cedric
    Have you heard the story of the 'Little Boy That Cried Wolf'. After he kept sounding the alarm unnecessarily he eventually got ignored.
    So it is with the Sepsis alerts - very frequent false alarms are useless and irritating.

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  • re ' a gp for 25 years' needs fine tuning, but I have been a GP for longer than you! and sepsis still terrifies me.

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  • GP computer algorithms are An Adjunct to Clinical Acumen NOT a Substitute to allow Physician Assistants to behave as GPs! Politicians and NHS England should be encouraging Primary Care Physicians Not undermining them ! Measuring “the measurable “ because it can be “ managed” is Not The Solution it is alleged to be!

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  • Jmd

    I am baffled why the IT providers do not write an algorithm which behaves like an alert and cannot be turned off. The GP is obliged to fill in the appropriate data and look at its conclusion before being able to file the notes. I use EMIS and i am always alerted to use the template and it also allows me to print out PIL on sepsis which I discuss and give to the patient. There is no excuse not to practice good medicine.

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  • Jmd

    Please don't give them ideas !

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  • Protect yourself, admit everyone. Let NHSE deal with the a&e fallout

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