Sepsis remains a leading cause of preventable morbidity and mortality. UK clinicians often draw on both NICE NG51 and guidance from the Royal College of Emergency Medicine (RCEM). Although these documents are aligned on early antibiotics and fluids, they differ in how they frame recognition, risk stratification, and operational urgency. This article compares the two, with a focus on frontline application.
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Audience: ED clinicians, acute physicians, paramedics, ICU outreach, and primary care teams who want fast clarity on triage, escalation, and treatment timing.
Recognition and risk stratification
NICE
- Risk-stratified approach using clinical criteria and red/amber/green flags.
- Discourages sole reliance on qSOFA; encourages broader clinical assessment (vitals, lactate if available, mental status, perfusion).
- Supports structured observation and repeat assessment to detect deterioration.
RCEM
- Emergency-focused: emphasises early identification, rapid escalation, and senior review.
- Accepts pragmatic clinical judgement when formal scores are not immediately available.
- Prioritises time-critical recognition triggers (e.g., severe hypotension, lactate elevation if available, acute altered mental status) to initiate the sepsis bundle.
Key difference: NICE is structured and risk-based; RCEM is operationally urgent and clinically pragmatic, avoiding delays for scoring.
Treatment: antibiotics, fluids, and timing
Both guidelines agree on early, appropriate antibiotics and timely fluid resuscitation.
- Antibiotics: Administer promptly once sepsis is suspected and cultures obtained where feasible. RCEM highlights “time-to-antibiotics” operational targets.
- Fluids: Early balanced crystalloids; reassess response. RCEM emphasises rapid initial bolus in shocked patients with frequent reassessment.
- Source control: Identify and address source early (drainage, removal of infected devices, surgical consults as needed).
Key difference: Both endorse early antibiotics/fluids; RCEM messaging is more time-critical, aiming to shorten door-to-needle intervals.
Escalation and senior input
NICE encourages escalation based on risk strata, including ICU/HDU review for high-risk patients, and structured handover of red flags.
RCEM stresses rapid senior involvement, clear ownership, and transfer to higher acuity areas when deterioration is suspected, often without waiting for full scoring completion.
Monitoring, lactate, and reassessment
NICE supports lactate measurement when available, serial observations, and repeat assessment of organ dysfunction. It embeds reassessment into its risk tiers.
RCEM aligns but focuses on operational execution: early lactate (if possible), frequent obs, and rapid response to trends. It acknowledges settings where lactate isn’t immediately available and encourages acting on clinical signs.
Special populations
- Children: Both have paediatric adjustments. RCEM emphasises weight-based dosing and rapid escalation for paediatric red flags.
- Older adults/frail: Both stress atypical presentations and the need for low thresholds for escalation.
- Pregnancy: Both advise obstetric input and awareness of physiological changes masking sepsis signs.
Practical flow you can apply
- Recognise early: Do not rely on qSOFA alone; use clinical judgement + vitals. Act on red flags immediately.
- Escalate fast: Senior review and appropriate location of care; consider ICU outreach if high risk.
- Start bundle: Cultures (if no delay), early broad-spectrum antibiotics, fluids, and source control planning.
- Reassess: Monitor response, repeat obs, consider lactate if available; adjust therapy based on trajectory.
- Hand over clearly: Communicate risk, treatments given, response, and outstanding actions.
FAQs: quick answers
Should I use qSOFA to diagnose sepsis? No. Use clinical assessment and broader criteria; qSOFA alone is insufficient. NICE discourages sole reliance; RCEM agrees.
How fast should antibiotics be given? As soon as sepsis is suspected and cultures drawn if feasible. RCEM emphasises operational targets to minimise delays.
When to call critical care? High-risk flags (hypotension, hypoxia, lactate elevation if available, altered mental state), non-response to initial fluids, or rapid deterioration.
What if lactate isn’t available? Act on clinical signs; do not delay for lactate. RCEM explicitly supports pragmatic action.
Do both guidelines agree on fluids? Yes—early balanced crystalloids, reassess frequently, and avoid fluid overload, especially in heart failure/renal impairment.
Source links (official)
Why this matters
Sepsis outcomes depend on rapid recognition and timely intervention. NICE provides structured risk strata and broader clinical criteria, reducing reliance on narrow scores. RCEM focuses on operational speed and escalation to senior decision-makers. Using both helps teams standardise recognition while ensuring time-critical care isn’t delayed.