Joint Committee on Public Petitions and the Ombudsmen díospóireacht -
Thursday, 20 Apr 2023

Public Petition on Lil Reds Legacy Sepsis Awareness Campaign: Engagement with the HSE

An Cathaoirleach

First today is Petition No. 52 of 2022, Lil Reds Legacy Sepsis Awareness Campaign. Our next business is engagement with Dr. Colm Henry and his colleagues from the HSE in respect of Lil Reds Legacy Sepsis Awareness Campaign. Before we start, I will explain some limitations to parliamentary privilege and the practice of the Houses as regards references witnesses may make to other persons in their evidence. The evidence of witnesses physically present or who give evidence from within the parliamentary precincts is protected pursuant to both the Constitution and statute by absolute privilege. Witnesses are reminded of the long-standing parliamentary practice that they should not criticise or make charges against any person or entity by name or in such a way as to make him, her or it identifiable, or to otherwise engage in speech that might be regarded as damaging to the good name of the person or entity. Therefore, if their statements are potentially defamatory in regard to an identifiable person or entity, they will be directed to discontinue their remarks. It is imperative that they comply with any such direction.

Before we hear from our witnesses, I propose that we publish the opening statement on the committee's website. Is that agreed?

Deputy Pat Buckley

Agreed.

An Cathaoirleach

On behalf of the committee, I extend a warm welcome to Dr. Colm Henry, chief clinical officer; Dr. Orla Healy, national clinical director of quality and patient safety; Dr. Michael O'Dwyer, national clinical lead for the sepsis programme; and Dr. Ciara Martin, national clinical adviser and group lead for young people, HSE.

I extend a welcome to Mr. Joe Hughes and Karen Phoenix who are seated in the Public Gallery. They are all very welcome back. I thank Deputy McAuliffe for joining us again. He has worked hard on this issue in his constituency.

Dr. Henry will now make his opening statement. I suggest he do so for about ten minutes. We will then have questions and comments from Members. I ask Members to limit their contribution to ten minutes as that will allow people to comment more than once. I invite Dr. Henry to make his opening statement.

Dr. Colm Henry

I thank the Chairman for the invitation to meet the committee to discuss Lil Reds Legacy Sepsis Awareness Campaign. I am joined by my colleagues: Dr. Orla Healy, national clinical director for quality and patient safety, HSE; Dr. Michael O'Dwyer, national clinical lead for the sepsis programme, HSE; and Dr. Ciara Martin, national clinical adviser and group lead for children and young people, HSE.

In the first instance, on behalf of the HSE, we would like to acknowledge the sad loss for the Hughes family of their son, Sean. We recognise the Hughes family's contribution in the intervening years to raise awareness of sepsis and the importance of early presentation to the acute setting if symptoms develop.

Before I begin, and as the focus of this meeting is on public awareness campaigns, I will briefly outline the international evidence on the effectiveness of public awareness campaigns as well as the techniques used to reach the target audience. While there is limited evidence of best practice guidelines on public awareness campaigns specifically focused on sepsis, the literature indicates that public awareness campaigns in general can lead to heightened information-seeking around the time of the public awareness campaign, as indicated by peaks in Internet search engine hits. Evidence on improved quality of care due to sepsis awareness campaigns and the impact on healthcare setting presentations is currently limited.

A number of studies noted the importance of undertaking public awareness campaigns in a targeted manner. This involves taking into account the difficulties in reaching certain audiences, the need to target those most at risk, and exploring family and patient barriers to taking action and promoting changes in behaviour. It is important we consider public awareness campaigns within national and international best practice for the management of sepsis and in the context of the national clinical programme for sepsis and its activities.

Today I will present the following: the context and background of the HSE's national clinical programme for sepsis; progress to date by the HSE's national clinical programme for sepsis; and key priorities for the HSE's national clinical programme for sepsis for 2023. In terms of context and background, the HSE's patient safety strategy 2019-2024 calls for the embedding of patient safety into everything we do. Commitment No. 4 of the strategy outlines 13 common causes of harm. These are high-impact patient safety risks that, if tackled effectively, can result in improving safety in healthcare organisations. Reducing and managing sepsis addresses one of these common causes of harm.

Sepsis is a time-dependent medical emergency where early recognition and prompt treatment is fundamental to increased survival rates, and optimal outcome for survivors of sepsis and septic shock. Sepsis causes significant morbidity and mortality. There were 11,294 cases of sepsis documented in Ireland in 2020 with an average hospital sepsis-associated mortality rate of 20.1%, 26.5% of which were admitted to a critical care area. The average crude mortality rate of these patients admitted to a critical care area was 30.8%. Prevention, awareness of symptoms and appropriate management are all crucial to improving outcomes in terms of sepsis.

In 2014, the HSE established the national clinical programme for sepsis and the first national clinical effectiveness committee, NCEC, national clinical guideline for sepsis was published. The focus of the programme is sepsis awareness to promote early recognition and evidence-based management. The programme aims to align its work with all relevant clinical programmes and national clinical guidelines as they relate to sepsis. Implementation of the NCEC national clinical guideline on sepsis management, which was published in September 2021, is advanced through audit, data collection, education and awareness-raising. The national clinical guideline standardises management of sepsis in the acute hospital setting with use of a screening form to assess risk and the use of a care bundle, called the sepsis 6 bundle, to optimise management of sepsis. Much work has been progressed on staff education to help to recognise the signs and symptoms of sepsis to allow early management and the provision of the sepsis 6 bundle.

The HSE's national clinical programme for sepsis has a 0.2 whole-time equivalent clinical lead and one whole-time equivalent programme manager. Each of the seven hospital groups has an assistant director of nursing with operational responsibilities for delivering on the programme's objectives. In February 2023, the HSE's national clinical programme for sepsis became part of the HSE's national quality and patient safety directorate. There are currently ongoing discussions with the Department of Health to request further resources to enhance the programme's ability to deliver fully on all aspects of the 2023 operational plan and to progress the development and implementation of a five-year strategic action plan for sepsis in Ireland.

A wide range of public awareness techniques have been utilised by the programme and local hospital teams, along with the HSE's communications, over recent years on sepsis awareness for the public, for example, planned communications using media relations to publicise sepsis risk, symptoms and what action people should take to respond to signs of this time sensitive medical emergency; HSE clinicians and patients taking part in media interviews on radio and television; the development of good quality information on the hse.ie website about sepsis, which is the primary route that the public take to learn about health topics; the utilisation of social media to share promotional videos and messaging; the production of a range of printed information materials for the public, which were made available through hospitals and health facilities, including World Sepsis Day in September; the display of the signs and symptoms of sepsis on the HSE's national ambulance service fleet; and the attendance at public events on several occasions to share materials and for expert nursing teams to engage with and educate the public about sepsis. The HSE has not undertaken a specific paid radio or television advertising campaign on sepsis awareness.

The national sepsis report for Ireland is published annually by the programme. The report highlights the burden of sepsis in the acute setting and its associated mortality rates. The first National Sepsis Report 2011-2015 was published in December 2016. In September 2021, the 2019 report was published and is the fifth report in this suite of reports. The key finding in that report was a 26.5% reduction in age-adjusted mortality from sepsis or septic shock since 2011 in Ireland, providing reassurance about our approach to sepsis. The overall reduction has been achieved by development and implementation of the national clinical effectiveness guidelines in adult, maternal and paediatric sepsis, which has seen a standardised approach to the management of sepsis.

The programme, working with colleagues in communications, has developed a targeted national communication plan for awareness, including World Sepsis Day in September. This utilises a variety of methods such as posters, social media content that involves high-profile personalities, and displaying the signs and symptoms of sepsis on the ambulance fleet. The programme has hosted national conferences and study days on sepsis awareness and training. This year, there was a focus on pharmacists with an article on sepsis awareness and guidance for community pharmacists published in the community pharmacists' magazine in March. Guidance on ways in which hospital pharmacists can assist in the management of sepsis in the hospital setting was also included in the article. There has been the development of educational programmes to support implementation of the national sepsis guideline and sepsis awareness, incorporating a maternal sepsis scenario and paediatric animated videos, to support parents to recognise sepsis in children and seek medical assistance and advice. Electronic learning or e-learning modules on adult and paediatric sepsis are also available on HSE-land. There has been the initiation of a project that examines the integration of software to GP clinics to aid with sepsis awareness and management.

Annual retrospective audits against the guideline have been undertaken. No audits were undertaken during 2020 or 2021. During 2022, these audits were delayed due to redeployment and vacancies but they are expected to be completed by May 2023. The 2023 audits will also commence in the coming weeks, with the audit methodology amended to allow more timely feedback and education opportunities.

There are a number of key priorities for the programme for 2023. They are to address sepsis awareness in paediatric services, including promotion of paediatric e-learning module on HSE-land; to address women's health sepsis awareness in pregnancy and post-pregnancy, including the development of a public awareness campaign; to commence the integration of software to GP clinics to aid with sepsis awareness and management as a pilot; to introduce new metrics regarding sepsis governance, audit and education in acute hospitals; to conduct regular education sessions on the signs and symptoms of sepsis and on what is called the sepsis 6 bundle throughout the year, with audits to assess adherence to recommendations, and this includes delivery of a webinar through Sláintecare, which will be publicly available; to undertake stakeholder engagement to progress with a view to developing a five-year strategic action plan for sepsis; to continue to provide national oversight and governance for sepsis through the national steering committee and working group and establish additional subgroups for priority areas; to publish a sepsis outcome report for 2022; to co-host a two-day international sepsis summit in Dublin Castle on 19 and 20 September with the HSE's national quality and patient safety directorate and the Department of Health; to conduct a qualitative survey on sepsis awareness and management in acute settings to ensure confidence in current management; agree an action plan with the HSE's communications team to assess and evaluate current public awareness campaigns and develop the most effective awareness campaign, taking into account the various platforms available and different patient groups who need to be targeted; to continue to engage in public awareness in acute hospital settings and other identified opportunities such as the National Ploughing Championships; to continue to update and maintain the programme for sepsis website to ensure information is relevant for healthcare professionals and the public; to progress the annual schedule of audit, including retrospective audits of paediatric and maternity services, and a prospective audit of adult in-hospital services; to continue to provide and encourage participation in the sepsis e-learning module for relevant healthcare professionals that will be continually reviewed and updated as required; and to undertake an assessment of training needs for national and regional teams and provision of learning programmes, for example, clinical hand-over, human factors, quality improvement and leadership training, change management and team ways of working, development and audit of metrics, integration across different healthcare settings, and bespoke clinical education, as required.

There is a need for a strategic and multidisciplinary approach to sepsis prevention, recognition and management. Many other countries, such as Australia, the UK and New Zealand, have recognised the need to develop a strategy to try to reduce the burden of sepsis on their economies. Having reviewed international best practice, the HSE's quality and patient safety directorate and the programme for sepsis have identified the priority areas for inclusion in a five-year sepsis strategic plan for the HSE. This plan will build on and enhance the existing priorities and work of the programme.

An Cathaoirleach

Before I let in others, I want to make a few points. Can we get to the issue of public awareness? It appears that the focus is on informing the medical community, which is highly important as well but which is not matched by a public awareness campaign. The targeted health programme is fine but there are another 11 months in the year besides September, which is sepsis month; sepsis is a year-long problem. In 2020, there were 11,294 documented cases of sepsis in Ireland. That works out at 31 cases per day. Surely that should ring alarm bells that there needs to be way more of a public awareness campaign outside of just September. We have had campaigns encouraging the public to quit smoking and wear seat belts and every one of those issues is important in its own right but some of the figures we heard here the day Mr. Hughes was before the committee include one in five deaths worldwide being linked to sepsis. Those kind of figures make it unbelievable that there is no campaign, and it is small money to run a campaign over a 12-month period in the overall scheme of things. Why has a year-round campaign, on television and radio especially, not been taken up? I know one of the points made in the opening statement related to social media but with social media I can sit on my phone, scroll through it and most of us will not even look at something like that, whereas if it is on the radio there is probably a family sitting around listening to it and if it is on television then people are looking at it. Why have we not had a nationwide campaign on sepsis on radio and television?

Dr. Colm Henry

I will involve my colleagues in this but before I pass over to them I will give the Cathaoirleach an initial response. Early recognition and treatment are critical and healthcare professionals such as GPs see a great number of people with infectious illness that is not sepsis. It is critically important to identify the relatively small number of people who have sepsis and to implement the sepsis 6 bundle, which has been shown to improve outcomes. The critical measure is to increase awareness among healthcare professionals, including in the community, where 70% of cases arise, or in hospitals. Public awareness campaigns are not mutually exclusive to that; it is about working hand in hand with the direction and benefits that we have demonstrated since the establishment of the sepsis programme or through raising awareness among healthcare professionals for the early recognition and treatment of sepsis, rather than leaving people undiagnosed and untreated. I will ask Dr. Healy to come in on this briefly as well.

Dr. Orla Healy

Heretofore we have focused on where the evidence pointed for where the campaigns and interventions would be most effective and that is in the early detection, intervention and management of cases presenting in the healthcare setting. We started with the acute setting, then we moved on to maternity and paediatrics and now we have moved to general practice. General practice takes in a level of public awareness as well and also there are public awareness elements to the use of the website, having posters on ambulances and distributing materials to GP practices, public health facilities and so on and so forth, all of which we will be undertaking in the coming weeks and months. That is the published material that we would distribute. As we have said in our strategic plan, we are open to having public awareness campaigns; it is just that this was not the initial focus because the initial focus had to be where the need was greatest.

The other point about sepsis is that the illness does not start as sepsis; it starts as in infection and the sepsis is the body's abnormal response to that infection. Not all infections progress to sepsis, therefore, and it is important to recognise the sepsis at the early stage. You have to target the awareness at where it is most effective and, as I said, that is why we focused on the acute setting, then paediatrics and maternity and now general practice. We will look at the most effective way of communicating to the public and because the evidence is limited in how you do that we are looking at that and progressing it. We are committed to doing it.

An Cathaoirleach

I have no problem with the HSE going into the healthcare setting and making them aware but the committee spoke with Mr. Hughes the other day and the Hughes family did not know about sepsis up until that time. The public must be made aware of it and they may pick up on some of those signs before it gets to hospital stage. The Hughes family is going around voluntarily trying to make other families aware of what is going on. The HSE should do that; it should not be up to individual families to carry out a nationwide campaign to make the public aware. It should also be up to the healthcare settings and we all know the healthcare staff need to be trained and made aware of the symptoms. However, if the public knows about some of those symptoms, it may save a lot of lives. Like I said, in the overall scheme of things it would be small money to run a campaign like that and if that only saves one life then as far as I am concerned it should be done.

Deputy Pat Buckley

I thank the witnesses for coming in. When this petition came to me, I did not realise how serious sepsis was and I welcome the fact that the witnesses said there has been a 26% reduction in mortality rates. Going back to the what the Cathaoirleach said, I totally get what the HSE is doing within the medical structure but when I heard this first I wondered how I had never heard about sepsis. I did not know it was this serious or how fast it can happen.

Coming from the HSE's side of it, it was about having an awareness campaign. I know Dr. Henry mentioned social media and so on but I was thinking to myself that the majority of this is in medical settings and this is about just getting the news out. I know the HSE does not want to panic people either but it has the tools to raise awareness of this. I was asking myself if it is possible for the HSE to go into the likes of schools and stuff. It is like a lot of things; education is key. Education and information are vital tools because in the HSE's side of work it comes across so many different cases and it thinks to itself that it was not aware of a case or it did not know.

I am delighted we are discussing this in the committee. However, as I listened to the opening statement I thought that was all spot on but I wondered where the big surprise I was waiting for was. I was thinking it would be the schools or youth clubs. We should get it out and try to normalise the information. Is there a fear that the public would be panicked? Is there a fear that a young teenager in school might get a cut and think they could end up getting sepsis? Is there a way of getting the information out in little simple bullet points that do not panic people and that make people aware? My wife would kill me for saying this and she will kill me but I always say that prevention is better than cure. I know there is a lot in that but that is what was going through my head.

Dr. Colm Henry

I will ask Dr. O'Dwyer to respond in a second but I will give an initial response. We do public awareness campaigns, some of which are quite simple. For example, the vaccination campaign sent a message to get vaccinated as it protects you against Covid. That was a simple message and people got it quickly, as can be seen from the number of people who took it up in Ireland. Other issues can lend themselves to public awareness campaigns. With stroke, for example, there is the face, arm, speech, time, FAST, campaign. Each facet of that is a symptom of stroke and again that is a simple message. In this area, finding a constellation that is simple, that people can lock into and that differentiates it from other conditions is more challenging than in stroke but nevertheless, it is possible.

The work we do with healthcare professionals does not at all exclude the work we wish to do raising awareness with the public. I wish to make that clear to the Deputy and to reassure him and the Hughes family. In tandem, we have messages to convey to the public about antibiotics. For many years, we have fought hard to encourage and foster a climate of appropriate use of antibiotics going from a time when antibiotics were overprescribed, leading to antimicrobial resistance. We have to integrate all this public messaging and these public campaigns into something the public gets, in that we do not want inappropriate, widespread use of antibiotics, because that encourages resistance and hospital-acquired infections such as Clostridium difficile, MRSA and all of those. We wish to twin that with a message of there being some people whose cases begin as infection, but culminate in a much more serious and common condition called sepsis. Early recognition and treatment is critical. I ask Dr. O'Dwyer to come in on this.

Dr. Michael O'Dwyer

One talks about the risks involved in the public awareness campaign. We would love the public to be aware of the signs and symptoms of sepsis and present early. It is a very complicated disease to pick up and it is very difficult to give somebody a simple message about the disease. It is not about creating fear in the community as such. That might drive lots of unnecessary additional emergency department visits. It may be about an expectation that patients need antibiotics for things they do not get antibiotics for. We have to link in with our colleagues throughout the HSE that take a more wide view of this, especially the antimicrobial resistance and infection control, AMRIC, group. We have regular meetings with the group and we are talking about how to move forward to get that message out and across in a sensible manner. With moving, we have focused on the hospital and acute settings, because that may be where the easy gains might have been able to be made in the first couple of years. Now, we are trying to reach out to the community and GPs and within that, there is a public-awareness element. We appointed our first GP lead for sepsis at the start of March and our intention is to work with that person, along with the AMRIC group, to bring the GPs into the fold of early awareness, detection and treatment. Through their interaction with the public in the GP surgeries and furthermore, through the pharmacies for patients who go on to purchase other medications perhaps for the early start of an infection, the aim will be to work on how to best assess whether it is getting better and when the right time to approach to the hospital is. The message is a difficult one to get across, but we are working on trying to find the best way to do so.

Deputy Pat Buckley

It is about having this topical discussion and trying to see if we can all move forward together. I am glad Dr. O'Dwyer mentioned pharmacies as well because even in the past few years we have seen a considerable culture change within the pharmacy industry, which is for the betterment of the community and about which I am glad.

Deputy Paul McAuliffe

I will start by saying a few "thank-you's" to the committee, because Karen and Joe made the petition directly. I was not aware of the Committee on Public Petitions and the Ombudsmen until they made the petition directly. The committee has been really strong in taking this up and pursuing it. I thank the witnesses for being here. For people at such a senior level to be here acknowledges how the HSE is responding to this issue, but also points to its determination to continue to respond to it. When I see the senior nature of people here, I hear that. As well as the words they are saying, their presence here is important. I acknowledge Dr. Healy and the Minister, Deputy Donnelly, met with the Hughes family and me. There were some discussions in this area as well. We should probably acknowledge the Minister, Deputy Harris, who at the very early stages of all of this, prior to Covid, gave a commitment to try to undertake some work in this space.

I do not think I ever got a chance - I was on the Special Committee on Covid-19 Response, when there were plenty of times I asked Dr. Henry very hard and difficult questions which were probably impossible to answer - to thank Dr. Henry for the work he did during the Covid period. It gets to the nub of what we are talking about here today. Covid was a period where we had national focus. Everybody was listening to everything Dr. Henry and many others were saying. They had an opportunity to explain behaviour methods, infection control and social distancing. These were concepts with which many people were not familiar. They had lots of attention and ability to explain those concepts. It had a crucial impact in Ireland's having an exceptional response to Covid. We do not often give ourselves credit for the response we had. In some ways, all of that took a bit of the steam out of what we had hoped would happen with a sepsis-awareness campaign, because Covid was happening and nothing else was happening in the country. Now that it passed, we are in a different space. No one's attention is on anything anymore. We are back to normal life, thank God, and in that competing space we wish to punch through public health messages.

I will focus on two things. Dr. Healy said to me at the meeting with Mr. Donnelly that they had focused on the GPs. I had not thought of that and was persuaded by it as strategy, because the Hughes family always talk about the phrase "Could it be sepsis?". There is no point in the public saying that if the doctor is not thinking it. If the witnesses are saying they are training and increasing awareness for GPs and perhaps for pharmacists as well - I agree with Deputy Buckley on that - and if the GP is asking if it might be sepsis, that is an investment worth making. I hear that and with regard to the money the witnesses have outlined, I am persuaded they have followed that strategy. It is harder for us to see sepsis though. That is the difficulty. I suppose the magic solution would be if the GP or the doctor in an accident and emergency department was asking whether it could be sepsis. If that was prompted by a patient asking whether it could be sepsis, that is the magic solution, in that both sides are thinking they should be considering this common, but rare, disease. I do not know how doctors do infection control. It is such a difficult area to diagnose and to predict where an infection will go. I understand it is not an exact science and is very difficult to communicate.

I think the witnesses are kind of part way through the process, which is the internal process with GPs and other stakeholders. In the process of looking outside, have they looked at how sepsis might be treated in other countries; how it is communicated; what the tools are with which one might persuade and the value for money for different offerings? If the witnesses tell me €500,000 on our TV advertising campaign could be better spent by double that impact on a radio campaign, I could be persuaded that would be a better thing to do. We do not need to be micromanaging how it is done, but we wish to see public awareness. We want all of us, in our day-to-day lives, to be seeing the word sepsis and asking ourselves "Could it be sepsis?". That is a helpful space in which to direct us.

Dr. Colm Henry

I thank the Deputy for his kind comments and I will return the acknowledgement of his own role in asking those difficult questions which are essential in any functioning democracy, even through a crisis such as Covid-19. The seniority of the presence here reflects the priority this has for clinicians of the HSE. It is a serious issue. The Deputy referenced the Covid-19 pandemic. We had a luxury for two years, even though it was a pandemic, in diagnostic tunnel vision in a sense, of looking for one condition only and testing the population multiple times for one condition. We know what has happened here and in other countries. The price of that was a reduced awareness of the impact of other serious conditions such as cancer and, of course, sepsis. We wish to rebalance and correct that and do better than we are now, notwithstanding the improvements this programme has brought over the past few years and we wish to address the expectation of the Hughes family here in making this a more responsive system.

The Deputy referenced money. The biggest bang for buck here, not just in monetary terms, but in impact, is on healthcare professionals, because they are the first point of contact for somebody who is feeling unwell. If they do not have a heightened sense of awareness, even if it is an unusual condition for them, the chance for early intervention is much reduced. It is often said that any consultation is a meeting of two experts, that is, the patient and the healthcare practitioners. Thus, the Deputy's comments about an informed and educated public asking whether this sepsis is possible is something we would certainly welcome, as we do with the stroke programme.

I ask Dr. Healy or Dr. O'Dwyer to comment on how we match the international evidence and the cost-effectiveness of media campaigns, which we are not at all excluding.

What we want is something that is sustainable and gets a singular message across. It should not trip us up with other messages we are giving out and should highlight the impact of a time-critical condition over a period.

Dr. Orla Healy

I will comment on the wider evidence base. Everything the programme does is evidence-based. Going back to the previous point, starting with healthcare professionals and working sequentially through them, as we have done, is based on the international evidence. We look to other countries and the types of campaigns they are undertaking. Dr. O'Dwyer will probably comment a bit more on the evidence base. As regards the campaign, we have already looked at the literature. Members will see from the opening statement that the evidence there is quite limited but as I said when we met in the Department, absence of evidence is not evidence of absence of an effect. We have started to look with our communications colleagues at what is in the first instance the most effective and the secondary consideration would be what is most cost-effective. We do not want to waste money on something that is not going to work. The initial indications are that TV campaigns are probably less effective than something like radio or social media but I am not prejudging the outcome of that work. It is work we would be involving the Hughes family in, and the programme will be meeting with Mr. and Mrs Hughes in May. They have already developed some material with the HSE and we will continue that work. If it comes down to something like radio, that can be achieved quite quickly. Other campaigns will take a bit longer. I am not prejudging the outcome but we have committed to it. We are open to it. We will look at the evidence and we will implement best practice.

Dr. Michael O'Dwyer

Things change over time. We only had television and radio until a couple of years ago so there is not great evidence out there for how social media compares with that. The evidence for TV and radio in terms of an outcome benefit has been extremely limited. We are conscious of that. We are also conscious that this is specific to Ireland. What is internationally applicable may not be applicable here. Sepsis involves different subgroups, namely, paediatric, adult and maternity. We have secured some funds to begin with maternal sepsis and we have funds to appoint a project manager with the express intention of a public awareness campaign in maternal health. We intend to use that experience to see what works and what does not work, which messages stick and which do not, and then try to apply them across the board to the other subtypes of sepsis. In terms of international comparisons, our 2020 report was just released. It shows that our mortality is very comparable globally. We compare with what other countries are doing and how they are treating sepsis internationally.

Deputy Paul McAuliffe

I have a final question. I thank the Cathaoirleach for his discretion. What the witnesses said is really useful. Every time we say the word "sepsis" in here it is a few hundred more times than it was said before. It is great to just be having the conversation and to hear the witnesses' insights. It is interesting in terms of research. There are communities where sepsis has become more high-profile, like Finglas where I am from, because of this tragic circumstances that happened with Seán and the campaign that came out of that. Lots of people are really aware of that word, and of the signs and so on. It would be interesting to see if that kind of short and ad hoc campaign, which it was, has had an impact on the awareness of sepsis in a community. I imagine there are places other than Finglas where those types of tragedies or local campaigns have happened. Could we examine how we can be informed by those experiences? Even with that experience in my local area of Finglas, and people being acutely aware of the signs of sepsis and all the rest, a member of my family passed away from sepsis a year or so after Seán. The signs and symptoms are just so tricky and difficult. We accept that even with all the awareness in the world it can still be difficult to identify and is a very tricky area of infection control. I ask the witnesses to keep pressing as much as they can to try to secure funding. However, I accept that it is not necessarily only about funding; it is about those other issues too. I thank the witnesses. I particularly the witnesses for indicating that they are going to continuously include families like the Hughes family. It is not just them. There are many others. One of the other members of the committee said to me the last time he was here that he had met four or five people since the previous meeting who raised the issue of sepsis with him and he had not heard about it before. It is all part of that bigger picture.

An Cathaoirleach

I want to ask one question before I let Deputy Devlin in. Are there certain symptoms that could be picked up easily enough by members of the public, if there was an awareness campaign, before going into a hospital setting? If someone was at home sick, are there obvious symptoms that people need to watch out for?

Dr. Colm Henry

I might ask Dr. Martin, who is our lead for paediatrics, to comment on that. Maybe Dr. O'Dwyer could come in after. Dr. Martin might highlight how we try to translate what can be a complex presentation into something simple.

Dr. Ciara Martin

For the symptoms of a person with an infection who is developing sepsis, it is hard to unpick one from the other. Some of the key signs of sepsis include a very high heart rate that is not settling or a very high temperature but you can have a very high heart rate and temperature with other illnesses as well. Some patients may have shortness of breath. On the campaign we are running with GPs, paediatricians and emergency staff we are telling them to look at patients with high heart rates, fever, shortness of breath or altered mental status and confusion which can be seen particularly in teenagers. A lot of our emphasis is on how to recognise a sick baby but we also need to know that sick teenagers will have slightly different signs. Pains in the arms and legs would be another sign of sepsis and just that overall feeling of being totally unwell and clammy. Heart rate, breathing and mental confusion would be the main ones and people should look for those signs.

Deputy Cormac Devlin

I thank the members of the HSE for coming in, particularly Dr. Henry. It is good to see him again and engage with him. I acknowledge, as the Cathaoirleach did, the presence in the Public Gallery of Joe and Karen Hughes. It is good to have the HSE respond so promptly to the request of the committee to discuss the issue of sepsis. I am very pleased with what I have heard this afternoon from Dr. Henry and his colleagues about the plans for raising awareness of sepsis.

Our previous engagement with Mr. Hughes was in early March. Concerns were raised at that time about the money that had been extended already to date by the HSE, as outlined in response to parliamentary questions raised by my colleague Deputy McAuliffe. From what is being said today, I am heartened because certain steps have been taken in the last little while by the HSE, particularly around the suggestion for the new clinical programme. I also heard the witnesses mention a GP lead, which is very encouraging. Is the sepsis information leaflet that is on the HSE website out in every GP surgery in the country? How is that disseminated? I note that in the figures that were given to us previously there was funding for conferences and display stands and all sorts of other paraphernalia, which is important. The key thing, and Dr. Henry said it, is the campaign and raising awareness, be that by means of TV, radio or social media. I ask him to elaborate on the dissemination of information currently and on the next stage of getting information out to the public to raise awareness.

Dr. Colm Henry

I thank the Deputy and will ask Dr. Healy to come in on that answer.

Dr. Orla Healy

I thank the Deputy for his question. The focus was on developing that material. It is on the website in the first instance and now we are printing the hard copies and distributing the material. That is something that was interrupted by the pandemic and we are now doing. There is a redoubled effort on accessibility to the website and to the videos and material on it, and on the making of hard copies of the material that my colleagues have developed available online. This will then be distributed to sites, general practice, pharmacies and so on.

Deputy Cormac Devlin

That is very heartening because at the most recent engagement we had with Mr. Hughes, his impression was there was more information on sepsis in his own home than there was anywhere else. Everybody will be aware that there were interruptions during the pandemic but the clinical lead is very important because that will put an emphasis on raising the awareness of sepsis. The information on the leaflet is wonderful. It is a checklist of symptoms, as Dr. Henry mentioned. The FAST campaign has raised awareness exponentially across the State and is important.

On sepsis, do the witnesses have figures for the percentage of patients who contract sepsis in clinical settings - I am conscious that some may have sepsis when they come into the clinical setting - or those who have contracted sepsis, having perhaps come in to this setting with other issues? Do the witnesses have any data as to how prevalent the condition is in clinical settings?

Dr. Colm Henry

I will hand that question over to Dr. O'Dwyer in a second. As we outlined earlier, infection is very common but sepsis is a dysfunction or a response, to put in those terms, to infection that is life-threatening. As the Deputy may know, infection in primary care is very common where, in the course of a day, a GP might see many people with acute viral illnesses, but in the course of a lifetime would see very few people with full-blown sepsis. I ask Dr. O'Dwyer to elaborate on that point.

Dr. Michael O'Dwyer

The headline figure is that approximately 80% of patients who are treated for sepsis in hospital have had contact with primary care or have come through the emergency department, and approximately 20% of cases of sepsis are acquired within the hospital. This is those patients who have acquired the condition within the hospital, who are there for other reasons and illnesses, are predisposed to this and have immune systems that do not function properly. They suffer very severe reactions to it. The ratio in percentage terms is about 80% to 20%. These which are the headline figures.

Deputy Cormac Devlin

Chair, I suggest that we might follow up with the HSE perhaps this time next year to track progress on this.

Again, like my colleagues, I thank Dr. Henry and his colleagues for giving the committee the time and talking us through the new and very welcome initiatives the HSE is taking. I commend the work of Lil Reds Legacy Sepsis Awareness Campaign and all the work it has done to date because that has brought about this conversation today with the HSE, which is very important and very much appreciated by all of the committee. I thank the Chair.

Dr. Colm Henry

We would welcome an invitation to come back and we also welcome the committee members’ own interest in this area because it is in our common interest to highlight this condition and to raise awareness of it. We share that goal with the committee.

Deputy Cormac Devlin

I thank Dr. Henry.

An Cathaoirleach

I agree with Deputy Devlin in that we should maintain contact with the HSE. We are still in the process of trying to organise an awareness day in the audiovisual room, which we discussed at the previous meeting. We are all present in the complex and perhaps we will sort that out before the summer. I call Deputy Higgins.

Deputy Emer Higgins

I thank the Chair and the HSE officials not just for being here with us to discuss this very important issue, but also for their leadership and everything they did during the Covid-19 period which saved so many lives.

My apologies for having missed the start of the meeting but I had to attend a meeting of the Joint Committee on Housing, Local Government and Heritage, which ran late. I have, however, read through the witnesses' opening statements and I am very impressed by the proactive nature of everything the HSE is doing in this area, including the five-year action plan; the fact that it is committed to publishing the sepsis outcome report from past year, the two-day international summit being hosted in Dublin, which is a significant opportunity to spread the word about this issue, and, of course, the communications plan which the HSE is working so strategically on with so many different stakeholders.

Sepsis was a word and not much more than a word for me for a long time but one that meant very serious complications. The more people know about this condition, the more they can understand how serious these complications can be. Sepsis, in many instances, is fatal and it can also lead to life-changing conditions for people.

Caroline Brady is a friend of mine in Lucan who is known for all of her advocacy and community work there and she is a cousin of Sophie Lanigan, who many people in her area would know. She is a 12-year-old girl who in December was admitted to hospital with streptococcus A. There has been significant publicity around streptococcus A, which is very welcome because that very much highlighted how serious a condition it is, how action is needed and how to respond when there are any concerns about it. Sepsis brought about the life-changing conditions for Sophie Lanigan. She is 12 years of age and has been very courageous through a very difficult time. She fought for her life for two weeks and when she woke, it was to the news that what she was losing her limbs. These are the very serious consequences for a 12-year-old whose life has just changed irreversibly forever. I commend her, her family, and everybody who rallied around her through a fantastic online fundraising campaign.

The reality is that while Sophie and her family found themselves in a completely horrific situation, it could, unfortunately, be worse and sometimes it is. I commend Mr. Hughes and Ms Phoenix on bringing this petition, and for their bravery, conviction and determination to build awareness around this issue to save other people’s lives. The updates the HSE officials have given us are very informative and have very much shown how proactive the HSE has been in this area.

The Chair is completely right in that we, as an Oireachtas, should be having awareness days also for ourselves. It is up to all of us to ensure that we are linking in with the HSE’s communications plan and that we are filtering this down to our constituents in helping to spread the word. My question, therefore, is in respect of the HSE’s action plan, the report, the summit that is coming up and the communications plan is what we, as Oireachtas Members and public representatives, can do to help spread awareness in this area and to help promote Lil Reds Legacy Sepsis Awareness Campaign.

Dr. Colm Henry

I will ask one of my colleagues to comment on the Deputy’s question. I thank her for her kind comments and encouragement. This is an important part of not just holding us to account but is also part of the common mission we have to highlight the importance of early awareness here. As some of my colleagues have referred to in the past hour or so, we see this as part of a continuum of messages about infection, the use of antibiotics and the identification of sepsis. One of the difficulties we get into in healthcare is that we give messaging that appears to be in conflict. It is about getting an integrated message across so that we can have prudent use of antibiotics, cut inappropriate use of them and heighten awareness of that small proportion of people with infection who go on to develop sepsis through education and the continuous training of healthcare professionals, and, of course, through raising awareness in the general public.

Dr. Michael O'Dwyer

Any way in which we can amplify the message can be useful as long as the message which is amplified is coming from trusted sources which take note of the delicacies between appropriately treating people and the inappropriate use of antibiotics in emergency department admissions and presentations. That is a very delicate balance to strike.

This week is Paediatric Sepsis Week. The HSE will put out our paediatric sepsis video and it is those sorts of things being amplified through the committee’s members to their constituents, which can only be helpful.

Deputy Emer Higgins

I probably just missed that section on the antibiotics and my apologies. What was Dr.Henry saying about that?

Dr. Colm Henry

One of the core risks in healthcare globally is the inappropriate, excessive use of antibiotics.

It is not just inappropriate but it causes harm through the evolution of resistance to antibiotics. Then we see the emergence of bugs, we sometimes call them hospital-acquired infections, that cause great harm and disruption in hospitals because of closure of beds, the need to isolate patients etc. The Deputy might have heard of MRSA, Clostridium difficile, and carbapenemase-producing Enterobacterales, CPE, and other bugs with acronyms like that. They have evolved because of antibiotic use, and sometimes excessive antibiotic use. The messaging we have through one arm of the HSE which works in tandem with the sepsis campaign - it is called AMRIC, antimicrobial resistance and infection control, and is led by Dr. Eimear Brannigan - is to try to harmonise messages that might seem to be in conflict. It is a delicate balance that we have to try to achieve and to say to the population at large that we do not need to give antibiotics for every single illness and doing so causes harm but at the same time, we need to make sure that for those cases that need antibiotics, there is a heightened sense of awareness of the deteriorating symptoms and signs among healthcare professionals and among the general public of which people have to filter through to get early treatment and recognition. I hope that conveys the somewhat complex nature of the message. It is not quite as simple as trying to reduce it down to something like the acronym that we have in the stroke campaign, FAST: face, arms, speech, time, for example.

Deputy Emer Higgins

That is an interesting message. It is probably worth all of us here clipping that and putting it on our social media too. I come across people all the time who feel they have gone to the doctor or hospital and did not get an antibiotic so it was not worth their while going but if they do not need an antibiotic, that is worth knowing and it is worth getting the message out there as loudly as we can that you have to trust in your doctor. Obviously, people have to trust their own instincts and if someone feels he or she needs a second opinion, then he or she should do so but if people are not given an antibiotic, that does not mean that something is not wrong with them but rather they might be able to fight it without over-prescription. I thank Dr. Henry for that. I thank everyone for all their work, not just on this issue but in all their day jobs.

An Cathaoirleach

Did Dr. O’Dwyer say there is an awareness video?

Dr. Michael O'Dwyer

We have made two paediatric sepsis awareness videos. Given that it is paediatric sepsis week, we got onto the HSE communications section and it said it would tweet that video this week. That is the sort of public awareness that we try to do on an intermittent basis.

An Cathaoirleach

Could that be sent to the committee and we will circulate it to all members in the complex and ask them to share it on their social media and so on to help raise awareness?

Dr. Michael O'Dwyer

Of course, yes.

Deputy Paul McAuliffe

Before Senator Murphy comes in, I have a short question to Dr. Henry to follow on from Deputy Higgins's comments. What I am hearing is that if too many people are asking if something could be sepsis, they could also be asking for antibiotics in a case where it would not be appropriate and then we could have a situation where those antibiotics would not be effective on the people who would need them because antibiotics become less effective if they are used too often and we could end up defeating ourselves by creating an expectation. Is that what the doctors are saying?

Dr. Colm Henry

The WHO has identified that one of the threats to population health is antimicrobial resistance, which is a resistance to antibiotics. At a society level, and a level of population health, it is not good for us to overuse antibiotics. That is a campaign that we have had here and internationally with GPs and hospitals that they should not prescribe antibiotics all the time. What happens then is that they become less effective and resistant bugs emerge. Sorry, Dr. Healy -----

Dr. Orla Healy

I was going to make the same point. I cannot help myself because my background is public health. It is the prevention element. There is a huge prevention element that people should take the vaccines that are available to them to prevent infections. They should observe hand hygiene to stop the spread of infections and observe respiratory etiquette. That has been drilled into us during Covid but it is very important in the healthcare setting as well. Then there is there is the early detection part and then the bit about antimicrobial resistance. There is no point treating a viral illness with an antibiotic for a bacterial infection, yet there are certain bacterial infections that critically require treatment with antibiotics. If you overuse antibiotics then you breed that resistance. If you suffer from an infection caused by one of those resistant organisms, then you are at risk of sepsis and we have less in our armoury to treat because we are breeding that resistance as well. That is what we mean about the complexity of the message. One of the critical messages to get across is that it is about having the right treatment when you need it and if you are not getting better on an existing treatment, then the awareness is there that if you are not getting better, to consider that it might be something like sepsis.

Dr. Colm Henry

That said, as Dr. Martin pointed out, there are certain symptoms and clinical red flags that we have to drum again and again into health professionals who are sometimes seeing people at high volume. We are telling them that in all the volume of people they are seeing in any one day in a GP surgery or an emergency department, there are certain red flags that they must be alert to that involve people where it is not just a viral illness but something much more sinister that needs early intervention. Balancing that message for healthcare professionals is challenging enough and then conveying that to the public is another challenge again.

Deputy Paul McAuliffe

I saw Dr. Henry do it with Covid so he is up to the challenge.

Senator Eugene Murphy

Unfortunately, I was called out during the last hour so I missed quite a lot of the presentation. It is nice to see Dr. Henry there and his team. We got to know him very well during Covid. I want to say thanks to him for all the messaging he got across to us morning, noon and night at a very worrying time for us all in communities. That is appreciated and I thank all the team that was involved.

This is a very important debate. It is very important that this awareness campaign be spread into every county, region and parish. Since we started speaking about this in the committee in recent weeks, I have found that a lot of families have been affected by loss of life from sepsis. What we are doing here is very important and I congratulate Mr. Hughes for bringing this to our attention. I will not ask any questions because my colleagues have done quite a lot of that over the past hour and unfortunately I missed most of it. I will engage with the Chairman on the debate. I thank everyone for being here today and for getting this very important message across.

Deputy Pat Buckley

It is great to have this conversation. It is about everybody talking and raising awareness here. I am delighted there is something on social media that we can all share. It is about sharing that information. It makes the point about how powerful some of these committees can be. I am lucky enough to sit on the Joint Committee on Autism and to learn a lot more from witnesses and so on, through conversation and even in such a short period. I do not think that committee has been operating for very long. Next month, we will be the first parliament in the world to be autism-friendly. This committee is also very different. It is a mix of all parties but it is very level; there is no real politics played here because we are here to try to promote things and to work with people.

Those sitting here across from me today is testament to how seriously they are taking it too. Our job is normally to question them and give them a hard time but not all the time. I wanted to put that on record and acknowledge it. If any of us from this side of the House can assist in any way, that is what we are here for. It is to try to move things forward and help people so that people do not have to go through the same thing as we had described to us. Whether it is cancer or suicide, sepsis or other things, it can be a niche thing, although you would not use that word. Often the people who try to get these campaigns going do so because they were personally affected by it. Sometimes it turns people into activists on specific subjects. It is not about normalising it but when you can get a team together where everyone is working together and on the same hymn sheet, then the advertising and the explanation gets out much easier.

I am very happy that we are talking about it. As I said, if we can help in any way by promoting this and making the witness's jobs a bit easier for a change, we are on board.

An Cathaoirleach

I apologise that I have not recognised the importance of all the HSE representatives coming before the committee today. I acknowledge Mr. Joe Hughes and the Hughes family. I said it before the committee on the day Joe was in, I was pure ignorant of how serious sepsis is until we got the presentation and heard the human side of it, namely, whereby the family had lost someone. As others have stated, the committee will do anything it can. We have agreed to do the viewing in the audiovisual room in order to try to raise awareness within the complex, but, even on a wider scale, if we can help in any way, I encourage the representatives from the HSE and Joe and anybody else to communicate with us. It was not until the matter was raised at the committee that people realised how serious sepsis can be and the life-changing effect it has on families.

I have a couple of minor questions before we finish. If anybody else wants to come in, they may do so. Is sepsis covered as part of the curriculum at third level? Is there significant training for medical students as part of that or is recognising the symptoms built into their training?

Dr. Colm Henry

I will ask my colleague to answer that.

Dr. Michael O'Dwyer

It is largely built in to the curriculum. We wrote to all the universities at the start of last year offering our services to come to give specific teaching around sepsis. I did not get responses from the universities, which led me to believe that they are happy that what they have on their curriculums is sufficient. The matter is front and centre when it comes to the junior doctor's job. The role of the latter in hospitals is to be familiar with it. The programme has spent a great deal of time and effort getting sepsis-specific education tools for junior doctors and nurses online. The hospitals have agreed that it would be a mandatory requirement that they complete the relevant module during their training and time in hospitals.

An Cathaoirleach

Is there a breakdown of the ages of the nearly 12,000 people affected by sepsis in 2020? Are we saying that sepsis affects people right across the board or is there an indication that it is affecting certain age groups more than others?

Dr. Michael O'Dwyer

The spectrum goes from birth right up to death, obviously, and peaks at both slightly higher mortality in the very young and higher mortality then as a person gets older. This is likely down to immune system immaturity in the very young and then the immune system not working very well in the elderly. It peaks on both sides; much more so in the older group, but it can affect absolutely anybody.

An Cathaoirleach

Is there an indication of what the main causes may be for sepsis in hospital settings? Do overcrowding or staff shortages have an impact?

Dr. Michael O'Dwyer

There are so many elements that go into it. There are patient-specific factors, such as their immune systems, comorbidities and genetics. There are also factors specific to the organism. Some strains are more virulent than others, like the group A streptococci. We have brought this matter up with the committee before. Then there are the institutional factors that we have talked about time and time again, such as antimicrobial resistance. If a person is in hospital, he or she is more likely to be affected by a resistant organism. That lulls people into a false sense of security because they are on an antibiotic. If, however, the organism is resistant to the antibiotic or if the antibiotic is inappropriate, it is the same as not having an antibiotic for a couple of days. There are many different factors that play into the severity of illness for patients within hospitals.

An Cathaoirleach

A commitment was given in late 2019 in respect of awareness training. Was it on the advice of the HSE or that of the Department that it was decided this would not be followed through on? I appreciate what the witnesses have told us for the past hour or more about the campaigns the HSE is running, but there seems to have been a change since 2019 - it seemed to occur after a couple months - which meant that the campaign in this regard did not go ahead. Was it on the advice of the HSE that - I will not say it was pulled - that it did not go ahead or was it the Department's call?

Dr. Colm Henry

I will answer that. Dr. Healy will also comment. Much of what we had planned, as the Cathaoirleach has heard from our testimony, which we have relayed to the committee honestly, was as a result of the disruptive effect of the pandemic and how things were paused.

Dr. Orla Healy

The Department and ourselves are at one on this. There is no difference of opinion. We work collaboratively and make our submissions to the Department for funding and so forth. As will have been seen from our meeting, we are at one. There was that small matter of the pandemic in the meantime.

I will pick up on an earlier point because the Cathaoirleach asked about the undergraduate and postgraduate education, and my colleague, Dr. O'Dwyer, mentioned the online training. That training is accompanied by a governance structure for sepsis in all of our acute hospitals and bearing in mind that most healthcare professionals go through the hospital system, every hospital group in the country has an assistant director of nursing dedicated to sepsis. That includes the paediatric hospitals, of which there are seven throughout the country. Their job is specifically geared towards training and audit. All of our hospitals also have both sepsis and deteriorating patient committees. There is a governance structure there to oversee that education, training and audit. We have both the proactive education and training, and also the assurance piece in that setting.

An Cathaoirleach

I again thank Dr. Henry for showing us respect by bringing such a high-profile team with him. We all sit on committees, and it is hard to get people in to answer questions at times. I also extend a big thank you to Joe and Karen Hughes. It was under sad circumstances that this matter had to be highlighted, but they have, through this committee, really raised the awareness of sepsis both in this committee and in the complex, but even on a wider scale, all around the country from where people are looking in. I thank them.

Does Dr. Henry wish to make any final statement?

Dr. Colm Henry

I thank the Cathaoirleach for his kind comments and his interest in this matter. Again, my thanks go to the Hughes family for raising the matter to this level. While it is one thing to suffer a tragedy, it is quite another to build upon it and want something good to come out of it. I acknowledge their advocacy and look forward to working with them in working our way through this complex messaging we have to get, not just to the public but to the healthcare professionals in balancing those issues of antimicrobial resistance and awareness of sepsis.

An Cathaoirleach

I thank Dr. Healy, Dr. O'Dwyer and Dr. Martin. It has been very beneficial to the committee to have them in. We will suspend for five minutes to let the witnesses leave the room.

Sitting suspended at 2.48 p.m. and resumed at 2.51 p.m.