Wright and colleagues1 discuss some interesting issues around blood cultures and sepsis outcome measurement. We agree that evaluating and tracking sepsis associated mortality over time is important. It would facilitate assessment of the impact of changes in practice, both intended effects of sepsis improvement interventions and unintended consequences of other initiatives, e.g. restrictive antibiotic policies, as well as epidemiological changes in populations. An ideal outcome measure would be "simple, objective, clinically meaningful, resistant to ascertainment bias, and, ideally, suitable for automation using data routinely stored in electronic health records"2. Unfortunately, there is no such perfect measure to track sepsis associated mortality.

Analysis of recorded International Classification of Diseases, Tenth Revision (ICD-10) codes is frequently utilised for tracking trends in healthcare, including mortality3. At first, this seems appealing as ICD- 10 codes should be simple and clinically meaningful and are available from routinely collected data. However, inconsistency in assignment of codes and changes in coding patterns make this susceptible to ascertainment bias thereby compromising the validity and reliability of applying this as a standalone measure2. Where remuneration and penalisation in healthcare is linked to coding, there is also potential for gaming and coding trends to emerge which do not reflect a real change in the population2,3. Additionally, due to the presence of a range of appropriate codes that could be applied to patients with sepsis, analysis of coding is complex4. Both primary and secondary discharge codes require interrogation and organ -specific infection codes, such as community-acquired pneumonia (ICD- 10 code J18.9), do not indicate whether the patient had sepsis, thereby reducing the sensitivity of this as a measure. All-cause mortality is also utilised within the literature. It is simple, objective and routinely collected, however, it lacks sensitivity to detect the impact of improvement interventions in clinical practice.

We agree with Wright et al that blood cultures should only be drawn where appropriate. As advocated as part of the Sepsis Six5, when patients fulfil two or more Systemic Inflammatory Response Syndrome (SIRS) criteria (see Box 1) and have a suspected or confirmed source of infection blood cultures should be obtained7.

Box 1: SIRS criteria6

SIRS present when two or more of the following measured:

* Temperature <36oC or >38oC

* Heart Rate >90 beats/min

* Respiratory Rate >20 breaths/min OR PaCO2 <4.3kPa

* White blood cell count <4000/?L or >12000/?L

One concern which we share with Wright et al is that blood cultures are often taken from patients who do not meet SIRS criteria, as found in an audit of patients with cellulitis presenting to an Acute Medical Unit8, but this is not encouraged if the Sepsis Six is implemented correctly. Such snapshot audits are limited to the clinical observations available at the time of data collection and this is likely to result in an underestimation of the prevalence of sepsis at any time during a hospital admission among patients who have a blood culture taken. With the exception of immunocompromised patients or those with suspected endocarditis, blood cultures should only be taken from patients who have two or more SIRS criteria otherwise there is potential to waste resources and cause patient harm7.

Wright et al reported a rise in blood culture sampling within NHS Forth Valley. This should not necessarily be interpreted as a negative development. The Scottish Trauma Audit Group9 reported that 39% (n=251) of patients fulfilling criteria for severe sepsis in the emergency department had no blood cultures sampled during the first 48 hours following presentation. From this baseline the number of blood cultures being drawn should rise initially if the Sepsis Six is being implemented reliably. Interestingly the beginning of NHS Forth Valley's rise in blood culture sampling appears to pre-date the beginning of the Scottish Patient Safety Programme (SPSP) national Sepsis Collaborative in January 2012. This apparently crude rate may reflect an already increasing awareness of sepsis but may also have been influenced by the increasing number of inpatient discharges in NHS Forth Valley in the period 2010-201310.

Wright et al suggest that the measurement of mortality among patients with a positive blood culture would be more useful than blood cultures alone. However, the proportion of patients with a positive blood culture is a small subset of the wider sepsis population with one cohort reporting that only 21% of patients with sepsis had a bacteraemia11. Therefore, to restrict the measurement of sepsis associated mortality to this population would significantly underestimate the true incidence of sepsis. Additionally, the presence of a positive blood culture has not been demonstrated to be independently associated with higher mortality once adjusted for age, sex and comorbidity11,12. These considerations limit the clinical meaningfulness of this as a measure, and negate Wright et al's concern about "treating culture-negative sepsis with broad spectrum antibiotics". This concern is not consistent with the objective of the Sepsis Six, which is to ensure that patients with clinical signs of sepsis receive prompt, appropriate and timely antibiotic treatment.

The proxy outcome measure for the SPSP national Sepsis Collaborative examines the thirty day mortality among adult inpatients in acute hospitals who have had a blood culture sampled. Utilising the existing Scottish Hospital Standardised Mortality Ratio (HSMR) model, the data will be adjusted for changes in clinical activity and acuity of care. However, even crudely adjusted (e.g. for age, sex and occupied bed days or admissions) blood culture mortality is a superior outcome measure compared to the other currently proposed options. We accept that it is not perfect, and are undertaking further work to validate its scope and applicability, including investigating combining blood culture sampling with other routinely available data. Improving the selection of patients for blood culture sampling, as discussed above, would improve the performance of this measure. However, even as it stands, it is simple, relatively objective, clinically meaningful and more resistant to ascertainment bias than most other options, and is suitable for automation using data routinely stored in electronic health records.

References

1. Wright DJ, Beckett DJ, Cooke B. Use of sepsis 6 raises some interesting questions. Emerg Med J Published Online First: 01.09.2014

2. Rhee C, Gohil S, Klompas M. Regulatory Mandates for Sepsis Care - Reasons for Caution. N Engl J Med 2014; 370: 1673-1676

3. Vaughan Sarrazin MS, Rosenthal GE. Finding Pure and Simple Truths with Administrative Data. JAMA 2012; 307(13):1433-1435

4. MacPherson D, Griffiths C, Williams M, Baker A, Klodawski E, Jacobson B, Donaldson L. Sepsis-associated mortality in England: an analysis of multiple cause of death data from 2001-2010. BMJ 2013; 3(8)e002586

5. Daniels R, Nutbeam T, McNamara G, Galvin C. The sepsis six and the severe sepsis resuscitation bundle: a prospective observational cohort study. Emerg Med J 2011; 28:507-512

6. Jones GR, Lowes JA. The systematic inflammatory response syndrome as a predictor of bacteremia and outcome from sepsis. Q J Med 1996; 89:7

7. Coburn B, Morris Am, Tomlinson G, Detsky AS. Does This Adult Patient With Suspected Bacteremia require blood cultures? JAMA 2012; 308:5

8. Marwick C, Rae N, Irvine N, Davey P. Prospective study of severity assessment and management of acute medical admissions with skin and soft tissue infection. J Antimicrob Chemother 2012; 67:1016-9.

9. The Scottish Trauma Audit Group. Sepsis Management in Scotland. 2010.

10. http://www.isdscotland.org/Health-Topics/Hospital-Care/Inpatient- and-Day-Case-Activity/ [last accessed 22.09.14]

11. Marwick CA, Guthrie B, Pringle JE. Identifying which septic patients have increased mortality risk using severity scores: a cohort study. BMC Anesthesiol 2014; 14:1

12. Phua J, Ngerng WJ, See KC, Tay CK, Kiong T, Lim HF, Chew MY, Yip HS, Tan A, Khalizah J, Capistrano R, Lee KH, Mukhopadhyay A. Characteristics and outcomes of culture-negative versus culture-positive severe sepsis. Critical Care 2014; 17:R202

Conflict of Interest:

None declared

The authors thank Dr Clayton for her comments.

However, they point out that her critique of their paper is largely inconsistent with what was actually written and can only assume a misunderstanding of the article.

The article does not state, nor even imply, that the GMC require students to provide expert or definitive care as she asserted in her response. Indeed the article talks about basic skills and basic prehospital care verbatim, and as such is not culpable for the points outlined in her comments.

Whilst BLS and first aid may be essential components of prehospital care, the authors disagree that it is 'the best any practitioner (or student) can offer'. As detailed in the article, other aspects of care (and not just treatment) will benefit both the injured and those assisting, not least in ensuring personal safety. Furthermore, whilst BLS may be taught in medical schools, such teaching has been reported as inadequate, and it is the authors' suggestion that its compulsory and regulated integration into the undergraduate curriculum would ensure that it is taught to the correct standard.

Finally, the authors thank Dr Clayton for pointing out the training that paramedics receive. Nonetheless, they feel they must again emphasise that the article has never once suggested that over-zealous students (and junior doctors) should interfere with and hinder these paramedics, which she wrongly implied in her response. Quite the opposite. As the article states that ambulance response times have been reported as substandard, i.e. are taking longer to reach an emergency than they should, its emphasis is thus that of care prior to the arrival of these paramedics, a time when a student is first on the scene and might improve patient outcome. The authors had hoped that this could be understood from the lines "transferring relevant and detailed information to a 999 operator" i.e. what to say when calling 999, and "on-scene handovers to emergency services" i.e. telling paramedics what has happened as they arrive and take over.

The authors therefore do not agree with Dr Clayton's suggestion that "everyone else should stand well back" as this implies that no care would be given, the injured may deteriorate and the GMC guidelines are disregarded.

Conflict of Interest:

None declared

In Yeovil District Hospital (YDH), o2 alert cards are currently issued by the respiratory nurse specialist. Patients are usually referred by a doctor or the ward nurses for a respiratory nurse review to optimise management of a respiratory disorder and arrange appropriate follow up in the community. If a patient has a documented episode of type II respiratory failure the respiratory nurse will issue an o2 alert card as recommended by BTS. A retrospective audit was carried in Yeovil District Hospital in 2013 to determine if oxygen alert cards are achieving their intended purpose. This included assessing whether alert cards were issued correctly to at-risk patients and to review the compliance of oxygen administration in both ambulances and hospital with BTS guidance. 79 patients were issued o2 alert cards over the 12 month period; 63 notes were available and audited. The results showed that all patients audited had a documented ABG confirming an episode of hypercapnoea; the majority of which had a diagnosis of COPD. Of those 63 patients audited, 19 patients were readmitted with a total of 38 admissions. Therefore the average number of re-admissions per patient was 2 (range: 1-5) During 33 of these episodes the patient was brought to hospital via ambulance. There were only 2 ( reports of alert cards being shown and appropriate venturi masks being issued to the ambulance staff. Furthermore on 76% of episodes, o2 administered in the ambulance was not appropriate and oxygen saturations exceeded the targeted 88-92%. On arrival to hospital there were no recordings of any alert cards being shown to staff and issued with the appropriate venturi mask. On first saturation measurement whilst in hospital only 29% were within the target range and in over 50% these were not acted on appropriately. During the admissions, there were 8 incidents where an ABG was not preformed. However, in the remaining 30 admission episodes in which an ABG was preformed, appropriate action and oxygen titration was carried out in 90% of the episodes. It is clear from this audit that currently, in Yeovil District Hospital, the o2 alert cards issued to patients are not being used. The audit has also demonstrated that oxygen administration in both ambulatory services and hospital setting are not following the current recommendations set by BTS in regards to the administration of oxygen to patients at risk of hypercapnoea. Patients are continuing to be inappropriately administered oxygen and are being put at high risk of the potentially dangerous side- effects of high-flow oxygen. It appears from the study that in the majority of patients it is only after an ABG that oxygen administration levels are appropriately titrated. However, worryingly not all patients have an ABG on admission. There are probably a number of reasons why the o2 alert cards are not currently working. The alert cards are a relatively new scheme in Yeovil District Hospital and therefore education will play a crucial role for improving the use of o2 alert cards. Patient and carers will be targeted as the main source of education and it is hoped that providing them with BTS leaflets on oxygen administration will increase understanding. Obviously education of health professionals will also be important to raise awareness of the scheme and guidelines. Communication between primary and secondary services is another area that could possibly develop; one idea is that the home address and ideal oxygen dose or target saturation ranges of at-risk patients could then be flagged in the ambulance control systems and communicated to ambulance crews when required. A further idea is that the name of the o2 alert cards could be changed to something which implies a more serious danger hopefully this would encourage the use by patients similar to the reporting of drug allergies.

Conflict of Interest:

None declared

Much has been written about the current difficulties of recruiting and retaining doctors in key specialities: most recently psychiatry (1) and emergency medicine (2).

Concurrently there has been a year-on-year decline in the number of doctors choosing to enter speciality training immediately upon finishing their FY2 year: in 2013 only 64% of FY2's chose to enter speciality training (3). Instead, many FY2's opt to work abroad, or to take trust grade positions.

Currently, going "off-program" allows junior doctors the flexibility to develop their own skills and interests, in a way that rigidly structured training programs don't. It gives them a chance to take ownership of their own training, and to see their personal and professional development as their own responsibility, rather than an exercise in "hoop-jumping". They have a chance to work abroad, pursue additional qualifications or research, and to choose where they live and how many hours they work. They can choose to work in specialities that they didn't get to experience during the foundation program.

As a "sessional" speciality which requires a broad portfolio of skills, and doesn't require continuity of care, emergency medicine could capitalise on juniors doctors' apparent desire to have greater flexibility and freedom in their training: trainees could be offered "half-time" contracts, which would leave them 6 months a year free to pursue other interests, degrees, or specialities.

Similarly, a more permissive approach to offering sabbaticals, and a greater variety of less-than-full-time-training rotas would offer FY2's the best of both worlds: the flexibility associated with trust-grade work, and the support and development opportunities afforded by training jobs. Emergency departments would benefit from having committed doctors on full- time contracts, who would be guaranteed to return the following year to continue training.

Svirko et al identified that one of the key factors repelling trainees from emergency medicine is the perceived lack of a "work-life- balance" (2): emergency departments can improve this by offering a wider variety of training contracts, to suit the different lifestyles and interests of the diverse group of doctors who are drawn to the emergency department.

(1) Mukherjee, Psychiatric Bulletin (2013) 37: 210-214 (2) Svirko, Lambert et al Emerg. Med. J. 2014 31:556-561 (3) Foundation Programme Annual Report http://www.foundationprogramme.nhs.uk/pages/home/keydocs

Conflict of Interest:

None declared