Table 4 Functions from the Functional Resonance Analysis Method (FRAM) model

a) Process request for clinical assessment NHS24

• Capacity/demand mismatches (more requests from patients to speak to staff than number of staff available to meet this demand) may delay commencement of this function.

• Staff reported deviating from the algorithm (which may be considered a control) when necessary in an attempt to achieve success

We have got the algorithm but quickly you learn that it's only a guide. I mean, when I was new I used to stick to it but now I do not refer to it. I mean I know it in my head anyway, but I ask other things and get them to hold the phone next to them to hear the breathing, ask them if they feel warm and ask them about confusion. I think that is more helpful. NHS24

• Variability of assigned triage times was observed with no association between triage time and the likelihood of a patient subsequently being admitted with suspected sepsis.

NHS24 triage time, n (%), when admitted with infective cause from out-of-hours

 ○ 1 h = 12 (24)

 ○ 2 h = 18 (36)

 ○ 4 h = 20 (40)

NHS24 triage time, n (%), when sepsis suspected at out of hours

 ○ 1 h = 7 (24)

 ○ 2 h = 10 (34)

 ○ 4 h = 12 (41)

b) Process request for clinical assessment GP surgery

• There was a difference between work-as-done by administrative staff and work-as-imagined by the GPs.

 ○ In general, our staff are good at saying this person doesn’t sound well and they are concerned and they don’t call often and they let us know so they will put it onto the emergency doctor. GP3

 ○ I don’t know if I would necessarily recognise it in a patient coming in because a lot of it is like fever and sickness - it could be anything. Training or a checklist may help. Receptionist 2

 ○ I think it is easy for us to recognise someone that comes in with chest pains rather than someone who comes in with sepsis. Receptionist 1

• Capacity/demand issues influenced function output resulting in staff taking less time to assess potential urgency of the medical condition at busy periods.

 ○ It can be quite hard on a Monday morning when you have got lots of patients waiting for an on-the-day appointment and we just get a sea of people it would be quite hard to say then could you give me indication of the problem. Receptionist 2

• Resources such as training, experience and knowledge of the patient were also thought to influence function output.

• There were no guidelines or protocols in place for staff. These may act as potentially beneficial controls that help staff to decide actions such as the urgency of speaking to a GP—when to interrupt and when to wait.

 ○ I think it’s difficult I don’t think they have had adequate training on it I don’t think years of practice or as a Health Board have addressed training for admin reception type staff. GP3

c) Process request for clinical assessment by an out-of-hours clinician via the single point of contact

• Output was based on the information given by community healthcare workers and was thought to be variable.

• There was no guidance to direct the required urgency of clinical assessment.

d) Perform clinical assessment

• Resource availability to aid clinical assessment was thought to be adequate in both in-hours and out-of-hours care.

• In-hours electronic templates were thought to be more useful.

 ○ In the surgery we have a template we use that is easy and helpful. GPANP

 ○ The out-of-hours template makes it more difficult – you see it when you are back in the car writing up the case after you have made your decision – it’s too late. I think if it was quick, easy and straightforward you might get better recording (of observations). GP2

• Clinicians stated that patients with possible sepsis would take more time to assess and manage. This was not thought to influence actions with these patients, but would cause increased time pressure when consulting with subsequent patients.

 ○ Time is a major factor although when you are dealing it is not a factor because you blank everything else out and you deal with it - you have to suck it up after. GPANP

 ○ I think often these patients are unwell so you take the time anyway. GPANP

• It was felt that the lack of information available through the Key Information Summary (KIS), an electronic summary of important clinical and social information created by the patient’s GP practice and available to out-of-hours GPs and secondary care, could influence clinical assessment as usual physiological parameters were not available

e) Create and maintain KIS

• The information contained in KIS was noted to be variable by GPs and by hospital teams. This was thought to reflect both a lack of guidance on completion and lack of time to perform this task properly by in-hours clinical teams.

 ○ I think it is variable sometimes it is excellent (the KIS) and it makes such a difference - and then other times it is not - and I think that is probably one of the reasons why it is not being accessed strategically because it is not the easiest or quickest thing to get into and it is almost like it is a bit like a lottery if you get one that is going to help you or not. AE cons

 ○ I know it is hard to find the time during the day to complete these (KIS) but in OOH the most important things I have is background observation and base line observations. GP

 ○ In out of hours and you have a confused buddy you don’t have any background information. You have no carer to tell you why, there is no relative it is very tricky there is a good chance you are going to miss something. Then as you don’t know if they are confused normally - you don’t know anything - so that makes it tricky. GP2

f) Record patient observations in clinical record

• In May 2016, there were a total of 731 admissions via ADOC, of which 592 were patients aged 16 or over (Table 5). Of these, 270 were for a presumed infective cause (66.2%).

Out-of-hours

All physiological parameters present to calculate NEWS score.

 • Those with infective cause: 32 of 50 (64%)

 • Those with presumed sepsis: 10 of 29 (34%)

 • NEWS score never calculated

 • Electronic template used in 5 patients (10%)

In-hours

All physiological parameters present to calculate NEWS score.

 • Those with infective cause: 11 of 76 (14.5%)

 • Those with presumed sepsis: 2 of 11 (18.2%)

• Recording of observations in out-of-hours was higher than in-hours and varied between practices. Despite the out-of-hours templates being described as a less usable resource, clinicians described feeing more vulnerable in an out-of-hours setting and were more likely to record all values. Most clinicians discussed measuring and recording physiological parameters to aid diagnosis and to defend themselves if something went wrong, but were not aware if secondary care colleagues found this information useful.

 ○ I feel in out of hours you don’t know the patient so well so I am very precise in out of hours of recording observations and I think it would be a good idea if more people did that. GP

• All physiological parameters were recorded less frequently for patients admitted with presumed sepsis, as opposed to an infective cause where sepsis was not suspected. One GP reported that once the decision to admit a patient had been made, further observations were not made. This was felt to be a beneficial trade-off to deal with the competing goals of efficiency versus thoroughness.

 ○ I saw this man on a visit and from the moment I walked in I knew I was admitting him. We had the information that he was getting chemo and was a bit shaky. I did his temp and pulse and thought – right you are going in – so I did not do the other values. GP2

g) Decide to admit patient

• This function was thought to vary dependent on the clinical picture and also clinician experience.

 ○ I think it is variable I think it is probably clinician dependant. Experience dependant. Possibly patient dependant or practice dependant. GP1

• The lack of time to observe the trajectory of the patient condition was reported.

 ○ The fact so many other things could be going on and the rapidly changing clinical picture cause you have only 10–15 maybe 20 mins, if you are lucky, with the patients. GP1

• Some clinicians used early warning scoring systems to aid decision making. These involve assigning a value to each physiological value and calculating a composite score to stratify risk. Others felt such scores were not helpful as routinely recording early warning scores would make normal work more difficult to do (through extra time to calculate and record scores).

 ○ I do observations - I probably do a version of NEWS … and I make the clinical decision based on that. GP2

• The overall clinical picture was felt to be a more important indicator of the severity of illness.

 ○ You have got to put it together with other observations and clinical picture and the history it gives you more weight, it is all about picking up things that help you make your decision. GP4

• When a patient comes through SPOC we do not get KIS access – surely this could be changed. GP1

 ○ It would be good to have access to previous notes to help decision making. GP1

h) Transfer patient to secondary care

• One GP reported that specialty trainees, who he supervised, usually ordered an immediate ambulance if sepsis was considered whereas, if the patient was relatively stable, he may order an ambulance that would transfer the patient to hospital within one hour. Variability in this area was thought to relate to a lack of guidance on transfer urgency.

 ○ I dunno…I suppose we should get a blue light ambulance .. yeah that’s what the trainees I supervise do. Sometimes I have arranged a 1 h though... I mean not if they are like very ill but if some of their obs are off but they are still well enough. GP2

i) Communicate with secondary care

• Variability was seen in the output of this function. Secondary care clinicians reported that the number of physiological parameters communicated during admission was variable. In addition, the use of the word sepsis to alert secondary care colleagues that the patient being admitted may require immediate clinical assessment was variable.

 ○ In OOH there is a variation of what information we get a lot of times .em so the girls manning the phone will still ask the same questions it just that information isn’t always to hand it is person dependent. CAU

• So, the most important thing for us is the more warning we have - and clear communication comes is really helpful - because as soon as the word sepsis is used it will precipitate a certain response amongst our team. AE

 ○ I don’t think I have ever used the word sepsis I am admitting this patient with sepsis. GPANP

 ○ I would describe the situation rather than say sepsis maybe I should say sepsis. GP2

j) Assess in secondary care

• It was felt that the variability of information received in admission communication and in the KIS had the potential to influence this function and result in delayed assessment, treatment and possible poorer patient outcomes.

 ○ Right we know this patient is coming we are expecting him as soon as that ambulance arrives they are straight into our resus bay where the team are waiting. CAU

 ○ I think if there has been abnormal physiology it is useful to have that documented. AE

k) Perform assessment of patient by community healthcare staff

• The output of this function was influenced by lack of available resources (thermometers, oxygen saturation monitors) and absence of controls - guidance on how to assess patients, what information should be communicated to clinical colleagues and to guide urgency of clinical review.

 ○ I do not think we could record all these scores as we do not carry thermometers or sats monitors. I know that the chemo folk need admitted and we are able to call the surgery to get a GP to see them. At the weekend, we can use the SPOC [single point of contact] to directly request a GP visit but I am not sure how quickly that [visit] happens. Community nurse

l) Make guidelines available to clinical staff

• NHS24 had electronic versions of guidelines and two GPs reported having and using an electronic smart phone application for sepsis management. Others were not aware of new guidance or did not know where it could be accessed.

 ○ I have not seen the new guidelines. GP4

 ○ I mean if there were some guidelines - get guidelines out. GP2

 ○ I do carry the [sepsis] app. GP1

m) Educate clinicians on sepsis management

• Educational meetings were considered valuable in raising awareness of guidelines for sepsis management by those that attended them, but many had not attended any local learning events. Other forms of delivering targeted education were suggested.

 ○ Education sessions trying to get people to engage – different people like different things and meetings are not suitable for everyone so not everyone has attended before. GP2

n) Maintain and stock equipment

• Variable access to resources such as thermometers and saturation monitors was reported by community nurses. For both in-hours and out-of-ours GPs and ANPs, this was thought to be adequate.

 ○ Most of the time in ADOC you have the thermometer and stuff and have spare batteries - I have never had a problem with that. GP1

 ○ In the surgery there is everything you need but I suppose sometimes I have to go and find stuff. I mean like a thermometer or a sats monitor. GPANP

 ○ We do not carry thermometers or sats monitors. DNs