Sepsis and documentation of vital signs: A retrospective study in GP 'Out-of-Hours'

Diarmuid Quinlan, Ellen Hayes

Keywords: Sepsis GP Out of Hours

Introduction:

Sepsis is increasing in incidence. To enhance early detection of sepsis, UK guidelines recommend GP assessment of vital signs. This study assessed GP documentation of clinical vital signs in patient records of non-pregnant adults with Lower Respiratory Tract Infection (LRTI) and/or Urinary Tract Infection (UTI) attending a GP Out-of-Hours (GP-OOH) service.

Method:

Retrospective study of 4,872 patient records, from four days in one GP-OOH service in Ireland, in 2016.

Results:

447 (9%) of patient files met the inclusion criteria relevant to the study. The temperature was documented in 31% (n=139), heart rate in 25% (n=112) and respiratory rate in 11% (n=47) of these patient files. The mental state of the patient was obvious in 100% of files. All four vital signs (mental state, temperature, heart rate, respiratory rate) were recorded in 7% (n=31) of patient files.

Conclusions:

Clinical records of 93% of adult patients presenting with LRTI/UTI to GP-OOH did not have all four vital signs documented. Development and implementation of sepsis guidelines in GP may improve detection, referral and outcomes in patients with possible sepsis.

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