Dr CS Leung
Consultant, PMH, A&E
It was to my surprise when I saw the “HAT” flyer posted in many locations of a private radiology center, where I accompanied my family to have PET scan recently. My surprise came from that even a radiology center has the awareness on sepsis, which is not apparently a disease modality of radiology, and that being an emergency physician in Hong Kong, I do not see we have put enough attention and adequate resources in early treatment of sepsis.
HAT is the acronym of Hypotension, Altered mental status, and Tachypnea in the qSOFA (Quick Sequential Organ Failure Assessment) score to identify sepsis, a life-threatening organ dysfunction due to a dysregulated host response to infection (SEPSIS-3). This definition of sepsis is well known to emergency physicians. The qSOFA is a score developed by emergency physicians and has gained wide acceptance as a screening tool for sepsis. The great puzzle, however, is why we still do not have a territory-wide implementation of sepsis bundle in Hong Kong. Based on my recent survey by personal contacts, there are only about half of emergency departments in HK having guidelines or sort for fast-tracking those presented with suspected sepsis. Many A&Es have guidelines on “neutropenic fever” but not those on sepsis. My personal survey echoes the study by Hung et al (1) a few years ago, which showed less than half of HK emergency departments having departmental guidelines on sepsis care. In the same study, respondents did agree that sepsis is a leading cause of in-hospital mortality among other time-sensitive medical emergencies.
Sepsis has long been recognised as a time-sensitive emergency just like the “time is brain” and “time is muscle” concepts of acute stroke and acute myocardial infarction. (2,3) The “1-Hour Bundle” suggested by the Surviving Sepsis Campaign (www.survivingsepsis.org) is a completely feasible protocol for emergency departments in HK, all of which have overnight stocks of various antibiotics and the necessary monitoring devices. The major barriers to implementation of a sepsis protocol, based on the local study (1), were human resources, knowledge and the ability to identify sepsis. The latter two factors can be overcome by adequate training and usage of screening tools such as qSOFA. Furthermore, point-of-care machines are widely used in most if not all A&Es in HK, where the measurement of lactate level can further confirm the diagnosis of sepsis. What is left seems to be the manpower issue, which is in fact the single most popular and universal “barrier” for all kinds of new ideas and initiatives in clinical settings. Behind this is in fact an issue of attitude, which is the actual driving force for all sorts of change. Recognising the time-sensitive nature of sepsis, we should all adjust our minds to add one more “time is critical” item and start managing sepsis as soon as we can.
Hung KCH et al. Hong Kong Med J. 2018 Dec;24(6):571-578.
Seymour CW et al. N Engl J Med. 2017 Jun 8;376(23):2235-2244.
Kumar A. et al. Crit Care Med. 2006 Jun;34(6):1589-96.