I read the article titled "The management of minor injuries- a personal view" and while I agree with the author on the title, I believe that the contents are very biased and unrealistic. Of course the author is entitled to give his views but in the era of evidence-based medicine nobody can deny the evidence and antagonise all the research results because simply he "does not like it".

Throughout the article the author states that "recently a number of some influential groups have suggested that minor injuries can be managed entirely by nurses and do not need to be seen in an A&E department, the purpose of his article was to question this proposal". The author moves on without providing any evidence from his or anybody else's research to contradict the success of the Emergency Nurse Practitioners in providing a high standard care for patients presenting with minor Injuries [1-7].

Research on the ENPs in the UK has indicated that the care provided by these trained nurses is equal and in some aspects better than typical SHOs during their normal six months post in A&E . Certainly this is the standard care for patients with minor injuries through the UK as most of these patients are cared for by SHOs. The ENPs in Minor Injuries Unit were also compared with the medical staff in the A&E department; the results indicated that the standard of care was the same in both groups (details of this study will be published soon).

The author states that a new generation of A&E specialist, characterised by many registrars in training see themselves as emergency physicians who are not interested in minor injuries. He also adds that those interested in intensive care should become intensivists. The correct state is that most, if not all, the registrars in training have chosen their speciality rationally, they are not in the wrong speciality but they are all aware of the balance between what is life threatening and what is common, between what is triage category 1, and what is triage category 4 or 5. It is worrying to see that seniors in some departments have no interest in multiple trauma and believe that minor trauma is more important, such departments might be better declared as Minor Injuries Units.

He also adds that "some older A&E consultants are not interested in minor injuries, and their position has weakened with the decline in major trauma". There is strong evidence that the work of these "older A&E consultants" has improved trauma care in this country and reduced mortality [8], these "older A&E consultants" are probably the ones who established our speciality and are the ones who plan ahead for the development of a speciality that care for all patients not just minor injuries patients.

M Sakr ( FRCS, FRCS A&E, MD) SpR

References

(1)Sakr M. Angus J. Perrin J. Nixon C. Nicholl J. Wardrope J. Care of minor injuries by emergency nurse practitioners or junior doctors: a randomised controlled trial Lancet. 354:1321-6,1999 Oct 16.
(2) Geolot D, Alongi S, And Richard E, Charlottesville V. Emergency nurse practitioner: an answer to an emergency care crisis in rural hospitals. JACEP 6:8 (Aug) 1977,354-357.
(3) Freij RM, Duffy T, Hackett D, Cunningham D, Fothergill J. Radiographic interpretation by nurse practitioners in a minor injuries unit. J Accid Emer Med 1996; 13:41-3
(4) Meek S, Kendall J, Porter J, Freij R. Can accident and emergency nurse practitioners interpret radiographs? A mu1ticentre study. J Accid Emerg Med 1998 Mar;15(2):105-7.
(5) Mabrook AF, Dale B. Can nurse practitioners offer a quality service? an evaluation of a year's work of a nurse led minor injury unit. J Accid Emerg Med 1998; 15:266-268.
(6) Powers M, Jalowiec A, Reichelt P. Nurse practitioner and physician care compared for non-urgent emergency room atients. Nurse Practitioner 1984; 9:39-52.
(7) Rhee K, Dermyer A. Patient satisfaction with a nurse practitioner in a university emergency service. Ann Emerg Med 1995; 26: 130-2.
(8) Lecky F. Woodford M. YatesDW. Trends in trauma care in England and Wales 1989-97. UK Trauma Audit and Research Network Lancet. 355(9217):1771-5, 2000 May 20.

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

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

Dear Editor,

The "Sepsis Six" resuscitation bundle is now common in UK hospitals, and endorsed by the College of Emergency Medicine, SIGN guidelines, and the Royal College of Physicians.1-3 However, the evidence behind it remains limited and must be re-evaluated as new data emerges - especially since the results of the PRoCESS and ARiSE trials on Early Goal Directed Therapy (EGDT) were published this year.4,5

The paper supporting Sepsis Six was originally published in 2010 in this Journal, and remains (as far as we are aware) the only published evidence on Sepsis Six.6 We believe this trial is internally flawed, and unable to provide convincing evidence of the benefit of Sepsis Six.

We have two main criticisms of this sepsis 6 trial - firstly, it is inconsistent. Given that two large randomised controlled trials this year have shown EGDT to have negligible effect on mortality, it is hard to interpret the results of this trial - which showed a relative risk reduction of 91% (mortality dropped from 90.3% without EGDT to 7.5% with it). Also, the subgroup of patients who were shocked shows internal inconsistencies. The worst performing group - with a staggering 97.1% mortality were the shocked patients who received Sepsis 6 - yet if they received EGDT alone, their mortality was 8%. However, the combination of Sepsis 6 and EGDT in shocked patients performed best of all - with a 4.7% mortality!

It seems inconceivable that in septic shock Sepsis 6 would increase mortality to 97.1% if performed alone, but reduce it to 4.7% if performed in combination with EGDT (which we know from RCT data has a negligible effect).

The only possible explanation is that of confounding effects - younger, fitter people were receiving EGDT and Sepsis 6- who had a low mortality rate and survived, and less fit people did not receive it This leads to our second criticism - lack of co-variate analysis. Although the authors comment on the difference in age between some of the cohorts, they did not perform a multivariate logistic regression (or similar) that could have included age, MEWS score, source of infection. Given the complexity and difference between the subgroups, it is impossible to compare them without covariate statistical analysis.

It is very hard to draw causality from observational trials (and the authors do not try here), but given the significant problems with this trial, we do not feel it can be interpreted as supporting evidence for Sepsis 6 either.

Although we do not aim to be unnecessary critical of what may be seen as 'common sense practice', we have three main concerns. Firstly, the claim that sepsis 6 in unlikely to be harmful is not a sufficient basis for it's continued use. 'Common sense' medicine has repeatedly been proven to be harmful on numerous occasions. Secondly, emergency departments and wards are busy and under huge time pressure, and protocols that might tie up staff for an hour or more must be scrutinised. Thirdly, sepsis 6 is likely to lead to the greater use of stat doses of antibiotics in any febrile patient, given the impetus to administer them within the first hour for any unconfirmed sepsis diagnosis. We do not know the long-term impact of this on antibiotic resistance - which is rapidly increasing.

Sepsis 6 means well, but is unproven, and should be treated as such.

Fergus Hamilton Bryony Lewis

1. SIGN. Care of deteriorating patients: Guideline 139. 2014. Available at: http://www.sign.ac.uk/pdf/SIGN139.pdf. Accessed October 14, 2014.

2. RCP. Acute Care Toolkit 9: Sepsis.; 2014.

3. College of Emergency Medicine. Clinical Standards for Emergency Departments. 2013. Available at: http://www.collemergencymed.ac.uk/Shop- Floor/Clinical Standards. Accessed October 14, 2014.

4. The ARISE Investigators and the ANZICS Clinical Trials Group. Goal-Directed Resuscitation for Patients with Early Septic Shock. N. Engl. J. Med. 2014:141001063014008. doi:10.1056/NEJMoa1404380.

5. Yealy DM, Kellum JA, Huang DT, et al. A randomized trial of protocol-based care for early septic shock. N. Engl. J. Med. 2014;370(18):1683-93. doi:10.1056/NEJMoa1401602.

6. 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(6):507-12. doi:10.1136/emj.2010.095067.

Conflict of Interest:

None declared