Original Article
A nationwide survey to explore sepsis awareness among the Dutch general public and former patients
Inhoud:

    Auteur(s):

    N.J.B. Waalders1, E. Zubeldia2, V. Smits2, K.A.H. Kaasjager3,4, A.R.H. van Zanten3,5,6, P. Pickkers1,3, H.R. Bouma3,7,8

    1Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, the Netherlands

    2Hanze Hogeschool University of Applied Sciences, Groningen, the Netherlands

    3Dutch Sepsisnet Society, Wageningen, the Netherlands

    4Department of Internal Medicine, University Medical Center Utrecht, Utrecht, the Netherlands

    5Department of Intensive Care Medicine, Gelderse Vallei Hospital, Ede, the Netherlands

    6Division of Human Nutrition & Health, Wageningen University & Research, Wageningen, the Netherlands

    Departments of 7Internal Medicine and 8Clinical Pharmacy & Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands

     

    Correspondentie:

    H. Bouma - h.r.bouma@umcg.nl
    Original Article

    A nationwide survey to explore sepsis awareness among the Dutch general public and former patients

    Abstract

    Background: Sepsis is a life-threatening syndrome for which early recognition and treatment are essential to improve clinical outcomes yet it is not known how aware the general public in the Netherlands are about sepsis.

    Methods: In March 2020, an online survey via social media with 11 multiple choice questions about sepsis was carried out among the general public in the Netherlands to assess sepsis awareness. A separate survey explored knowledge gaps experienced by former patients and how to disseminate knowledge to the general public.

    Results: Of the 916 persons who completed the survey, 22% had a medical background. Only 17% of the responders without a medical background were familiar with sepsis, compared with 66% with a medical background. Only 19% of former patients were aware of sepsis before they became ill. Fever (52% and 87%), flu-like feeling (38% and 61%) and rapid heart rate (30% and 69%) were most often mentioned to be associated with sepsis by responders without and with a medical background, respectively. Former patients associated rapid breathing (75%) and confusion (74%) with sepsis. Mortality was estimated at 5-15% by those with no medical background, 15-25% by those with a medical background and 30-40% by former patients. Former patients identified (early) recognition and symptoms, what sepsis entails, and what to expect after sepsis as relevant knowledge gaps and suggested addressing these in a national campaign.
    Conclusions Sepsis awareness in the Netherlands is poor. Since awareness is essential for early recognition and timely initiation of treatment, raising awareness may improve prognosis.

    Introduction

    Sepsis is defined as a life-threatening organ dysfunction caused by a dysregulated immune response to infection, leading to (multi)organ failure or even death.[1] In May 2017, the World Health Organisation (WHO) acknowledged sepsis as a global medical emergency and urged governments to reduce the burden of sepsis by improving prevention, diagnosis and treatment.[2] Recently, using data from 2017 and hence excluding sepsis caused by COVID-19, a study estimated the annual incidence of sepsis at 48.9 million cases globally, with one out of five deaths being sepsis-related.[3]

    Although the worldwide incidence of sepsis is decreasing, general practitioners, emergency physicians and other physicians will be more often confronted with sepsis in the elderly due to a society with rising numbers of (frail) elderly people. After the age of 40, the incidence of sepsis roughly doubles every ten years.[4] Sepsis is a common reason for admission to the intensive care unit (ICU) in the Netherlands, with one out of three patients in the ICU being diagnosed with sepsis.[5] In critically ill patients, the mortality rate is approximately 30%, which is in line with current international literature.[4-9]

    Despite the global burden of sepsis, knowledge of sepsis among the general public seems limited and incorrect. The terms ‘blood poisoning’ or ‘septicaemia’ are often used to describe sepsis towards laymen. These terms are inadequate since they suggest the need for positive blood cultures, which is not common in sepsis and not required for the diagnosis.[10,11] Several analyses based on national surveys showed that awareness of sepsis is low. As such, only 7% of the surveyed people in Brazil were aware of sepsis in 2014.[2] One study in Singapore revealed a low level of public awareness of sepsis (5%), while stroke was commonly known (90%).[12] This problem is also present in more ‘Western’ countries. The number of responders reporting to be aware of sepsis and know what it entails is approximately 4% in France, while reported sepsis awareness in Sweden, Italy, Spain and the United Kingdom ranged from 8-21%.[13,14] National campaigns can successfully increase public awareness of sepsis, as revealed in Germany where awareness increased to 62% after a national campaign in 2013.[15] Remarkably, lack of sepsis awareness is common among people with a medical background. Only one-third of the surveyed resident doctors and nurses in Japan knew what sepsis entails.[16] Thus, despite the high global burden of sepsis, the awareness of sepsis among the general public and healthcare professionals seems low. Educational and clinical exposure to sepsis seems to affect sepsis awareness, as recent education or work in a hospital with high exposure to sepsis in the ICU was associated with increased sepsis awareness among Dutch emergency nurses and a teaching intervention significantly increased the knowledge of internal medicine residents.[17,18]

    To date, public awareness of sepsis in the Netherlands and whether this is affected by having a medical background or being a former sepsis patient is unknown. Since awareness of sepsis is critical for early recognition, we performed a nationwide survey to obtain insight into sepsis awareness, symptoms associated with sepsis and estimated mortality among persons with and without a medical background and former patients. Additionally, we asked former patients about their specific knowledge gaps when they suffered sepsis.

    Materials and methods

    Survey and population

    This cross-sectional study was conducted in the Netherlands in March 2020 using an anonymised survey. The survey was set up in REDCap (Research Electronic Data Capture), which is a secure web application to build and manage online surveys and databases.[19,20] Dutch residents, aged 15 years or above, were eligible to fill in the survey that was disseminated through Facebook and LinkedIn. The Dutch survey consisted of eleven multiple-choice questions to assess awareness of sepsis and other diseases (including synonyms of diseases to assess if they are unaware of a specific word or any of the terms for the disease), sepsis knowledge (e.g., symptoms and mortality) and preferred social media channels to gather information about sepsis. Supplemental file 1 shows the translated survey.

    A separate Dutch survey was sent to former sepsis patients through the social network (Facebook group and email) of the patient association ‘Sepsis en daarna’ (‘Sepsis and thereafter’). The survey consisted of 16 multiple-choice questions to assess their knowledge about sepsis (e.g., symptoms and mortality rate), explore specific knowledge gaps, and disseminate relevant information about sepsis to the general public. Supplemental file 2 shows the translated survey.

    Ethical considerations

    The study was carried out in the Netherlands in accordance with the applicable rules concerning the review of research ethics committees and informed consent.

    Statistical analysis

    Categorical variables are expressed as percentages with the number in parentheses and analysed using Fisher’s exact or Chi-square tests. A p-value <0.05 was defined as significant. Graphs were created using GraphPad Prism 8 for Mac (GraphPad Software). Based on current literature of awareness in other Western European countries, the expected prevalence of sepsis awareness in the Netherlands is 10%. This would lead to a sample size of 139 respondents, calculated with a confidence interval of 95% and a precision of 5%.[21]

    Results

    In total, 922 people from different age groups completed the survey. Six of them had to be excluded because of an incomplete survey, yielding 916 completed surveys for further analysis. Of these, 22% (n=202) had a medical background (see supplemental file 3), as reported by the responders in reply to the question ‘Do you have a medical background?’ A separate survey was completed by 138 responders. Of these, 82% (n=113) were former sepsis patients and 18% (n=25) of the surveys were completed by former patient representatives.

    To compare the awareness of sepsis with other conditions, we asked the responders whether they were familiar with acquired immunodeficiency syndrome (AIDS), blood poisoning, flu, influenza, sepsis, amyotrophic lateral sclerosis (ALS) and pneumonia. Only 17% (n=119) of the group without a medical background had heard about sepsis before, while 60% (n=430) had heard of blood poisoning (figure 1A). In the group with a medical background, higher percentages were found as 66% (n=134) were aware of sepsis and 79% (n=159) of blood poisoning (both questions were compared with responders without a medical background, respectively p<0.001; figure 1A). In total, 17% (n=123) of the responders were aware of the association between sepsis and blood poisoning compared with 72% (n=146) of the respondents with a medical background (figure 1B). In contrast, responders with and without a medical background were more aware of flu, AIDS and ALS. In addition, of the 119 responders who had heard of sepsis, 90% (n=107) had heard of blood poisoning before, whereas of the 430 responders who had heard of blood poisoning, only 25% (n=107) had heard of sepsis. Of the 134 responders with a medical background who had heard of sepsis before, 96% (n=129) had heard of blood poisoning, whereas of the 159 responders who had heard of blood poisoning, only 81% (n=129) had heard of sepsis as well. Former patients were asked whether they were familiar with the term sepsis before they became ill. In line with the responders without a medical background, only 19% (n=22) knew about sepsis.

    Figure 1. Awareness and knowledge of sepsis among the Dutch population. Percentage of respondents who are familiar with sepsis as compared with other diseases (A); percentage of respondents who knew that sepsis and blood poisoning refer to the same clinical picture (B); percentage of respondents who knew what sepsis entails (C). P-values were calculated using Fisher’s exact test (*p=0.03, ****p<0.001). AIDS = acquired immunodeficiency syndrome; ALS = amyotrophic lateral sclerosis.

    Next, knowledge was tested by asking the participants about the definition of sepsis in a multiple-choice question. The question was answered correctly by 38% (n=268) of the responders without a medical background, as compared with 85% (n=172) of the responders with a medical background (figure 1C). In total, 85% (n=96) of the former patients were aware that sepsis and blood poisoning refer to the same illness, and all former patients knew the definition of sepsis (both questions were compared with responders with and without a medical background, both p<0.001; figure 1B-C).

    To further assess knowledge about sepsis, we asked responders to tick items from a list of symptoms that they thought were associated with sepsis. Fever, flu-like feeling and a rapid heart rate were most often mentioned in both groups (table 1). Former patients most often associated fever, rapid and laboured breathing, confusion and flu-like feeling with sepsis. Thus, while responders with and without a medical background and former patients all associate fever and flu-like feeling with sepsis, former patients also mention confusion and rapid and laboured breathing with sepsis.

    Table 1. Symptoms associated with sepsis by the general public and former patients

    Next, we asked participants to estimate the mortality associated with sepsis in a multiple-choice question. Given an actual in-hospital mortality rate of approximately 20%, this seems to be overestimated by former patients, while responders without a medical background clearly underestimated sepsis mortality (figure 2).[22] Overall, the answers were significantly different between the three groups, p<0.001. The answers for estimated mortality were significantly different between responders without a medical background versus those with a medical background (p=0.003). Similarly, the difference in answers between responders without a medical background versus former patients and responders with a medical background versus former patients were significant (both p<0.001).

    Figure 2. Estimated mortality rate of patients with sepsis in the Netherlands, displayed for three different groups. Data are shown as % of estimate per mortality category (i.e., 5-15%, 15-25%, 30-40%, 55-60%).

    Finally, former patients were asked to identify knowledge gaps and also via which channels they would have liked to have been informed about sepsis. Therefore, former patients were asked with an open question to mention information about sepsis that they had missed and should be provided to the Dutch population. The answers to this question were clustered into categories (figure 3). The most common categories were providing information about what to expect after sepsis, (early) recognition and symptoms of sepsis and what sepsis entails. They were also asked about how the information should be provided, with the most common answers to be by flyers (33%, n=37; especially in waiting rooms of for example a general practitioner, emergency department or hospitals, or at the pharmacy), educational videos (25%, n=28) and by television commercials/programs (18%, n=20).

    Figure 3. Overview of sepsis-related topics that should be addressed by the government and healthcare professionals. The number displays the frequency of the answer given by former patients.

    Discussion

    Our data illustrate that the knowledge and awareness of sepsis among the general public in the Netherlands without a medical background is poor, as only one out of six responders had heard about sepsis before. Symptoms of sepsis were not well recognised. The mortality rate was underestimated by the general public and overestimated by former patients. In contrast, the awareness of blood poisoning was higher, but only a minority were aware that sepsis and blood poisoning often refer to the same clinical picture. In addition, of the group with a medical background, 72% were familiar with sepsis. Former patients also reported low awareness of sepsis before they became ill, in line with the level of awareness among the general public. According to former patients, the focus of informing should be on providing more information to the general public about (early) recognition, symptoms, what sepsis entails and what to expect after sepsis. Former patients advised raising sepsis awareness using flyers, educational videos, television commercials and programs. Of interest, while flyers usually present a large amount of information about a disease and its treatment, former patients reveal that they would prefer to have received information about (early) recognition signals and symptoms, what sepsis entails and what to expect after sepsis.

    In line with other countries in Europe, the awareness of sepsis is low in the Netherlands.[13-15] It is essential to raise sepsis awareness to facilitate early recognition, which is critical to timely initiate adequate treatment and lower sepsis-related morbidity and mortality. A delay in administrating antibiotics in patients with septic shock increases the odds of dying.[23-25] Besides raising sepsis awareness in the general Dutch population (without a medical background), the awareness of sepsis should also be improved among people with a medical background. A recent study in the Netherlands illustrates that emergency department (ED) nurses working at a hospital with an ICU with a low exposure to sepsis patients know less about sepsis compared with ED nurses working at a hospital with a large ICU and high prevalence of sepsis patients. Recent education about sepsis significantly increased the knowledge in the group working in a smaller ICU with less exposure.[17] Also, it was shown that education to internal medicine residents significantly increased the knowledge level and that this was a sustained effect.[18] In addition, improving knowledge of sepsis in one target group, such as healthcare professionals, could be expected to raise awareness in other groups as well, as they would likely talk about the disease more frequently to colleagues, patients and their families.

    Time-dependent acute diseases, such as myocardial infarction, stroke and sepsis, are recognised to require early recognition and intervention to avert further organ injury and preclude death. National campaigns for myocardial infarction and stroke have been commonly used to increase awareness about the disease and its symptoms to reduce prehospital delays, whereas a national campaign for sepsis is considered unconventional and its effects on timely initiation of treatment and outcome (e.g. length of stay in the ICU/hospital, mortality) are unknown.[26] Nevertheless, several countries have already shown the beneficial effects on awareness of a national campaign focusing on sepsis. A recent survey of the Centers for Disease Control and Prevention (CDC) in the United States showed that, after seeing the campaign, 71% sought more information about sepsis and 50% asked for more information from a medical professional.[27] In England, the UK Sepsis Trust campaign increased public awareness of sepsis by 28%, while in Scotland it increased to 77% after the Sepsis Research Feat campaign.[28,29] Both report a decrease in sepsis mortality after the start of these campaigns. The campaign of the Royal College of Surgeons in Ireland resulted in almost 3 out of 4 people knowing what sepsis is, an increase of 31%.[30] In the Netherlands, a national campaign focusing on sepsis and the specific knowledge gaps as addressed by former patients has not yet been performed. Although two campaigns on sepsis report a decrease in mortality after initiation, it is debatable whether this decrease is solely due to the national campaign. One can argue that also improvement in healthcare facilities and treatment options are important factors. A national campaign has potential benefits as is shown for acute myocardial infarction and stroke; however, it could also have negative side effects. Since sepsis is a complex syndrome, warning symptoms as mentioned by other national campaigns (high heart rate/ weak pulse, fever/uncontrollable shivering/feeling very cold, confusion/disorientation, shortness of breath, and pain/discomfort) are often seen in other diseases as well. This could lead to more, perhaps unnecessary, visits to the general practitioner or emergency department, therefore leading to higher healthcare costs. However, a well set up campaign educating people about the importance of certain symptoms and when to reach out to a doctor could find a good balance between improving early recognition and preventing unnecessary visits to healthcare providers.

    This study has several limitations. First, limited demographic information is available, especially in responders with a medical background, as no detailed information about their specific occupation (e.g., student, nurse, medical doctor) and field of work was obtained. Therefore, no direct conclusions can be deducted from the level of awareness in specific groups of responders with a medical background. However, as recent studies have shown, education for healthcare professionals is needed and beneficial.[17,18] Second, because of the limited demographic information, it is difficult to determine whether the findings can be generalised to the Dutch population as a whole, especially since the highest risk group for sepsis (65+ years) had a low response rate (8%). This might be due to the use of social media to spread the survey, which is probably used less in the highest age group. However, spreading the survey via multiple social media channels was the easiest way to potentially reach people all over the Netherlands. To verify whether we reached all age groups, we were allowed to obtain this information on responders, which showed a response in every age group.

    The level of awareness and knowledge of sepsis among the general public and those with a medical background in the Netherlands is poor. Former patients identify multiple knowledge gaps, specifically (early) recognition and its symptoms, what sepsis entails, and longer-term consequences of sepsis. It was suggested to perform a national campaign to increase awareness among the general public using flyers, educational videos and information on television (e.g., commercials and programs) to improve these knowledge gaps. Disseminating sepsis knowledge among the general public, with and without a medical background, to raise sepsis awareness may contribute to early recognition, which is essential for timely initiation of treatment that may avert sepsis-related organ failure and mortality.

    Conflict of interest

    All authors declare no conflicts of interest. No funding or financial support was received.

    Acknowledgements

    The authors thank the patient association ‘Sepsis en daarna’ (‘Sepsis and thereafter’) for helping to disseminate the survey amongst former patients through their social network.

    Vragen

    Bijlagen

    Referenties

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    15. Eitze S, Fleischmann-Struzek C, Betsch C, Reinhart K; vaccination60+ study group. Determinants of sepsis knowledge: a representative survey of the elderly population in Germany. Crit Care. 2018;22:273.
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    17. van den Hengel LC, Visseren T, Meima-Cramer PE, Rood PP, Schuit SC. Knowledge about systemic inflammatory response syndrome and sepsis: a survey among Dutch emergency department nurses. Int J Emerg Med. 2016;9:19.
    18. Tromp M, Bleeker-Rovers CP, van Achterberg T, Kullberg BJ, Hulscher M, Pickkers P. Internal medicine residents’ knowledge about sepsis: effects of a teaching intervention. Neth J Med. 2009;67:312-5. Erratum in: Neth J Med. 2009;67:393. van Achterberg, T [corrected to van Achterberg, T].
    19. Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap) –A metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform. 2009;42:377-81.
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    21. Pourhoseingholi MA, Vahedi M, Rahimzadeh M. Sample size calculation in medical studies. Gastroenterol Hepatol Bed Bench. 2013;6:14-7.
    22. Fleischmann C, Scherag A, Adhikari NK, et al. Assessment of Global Incidence and Mortality of Hospital-treated Sepsis. Current Estimates and Limitations. Am J Respir Crit Care Med. 2016;193:259-72.
    23. Kumar A, Roberts D, Wood KE, et al. Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock. Crit Care Med. 2006;34:1589-96.
    24. Liu VX, Fielding-Singh V, Greene JD, et al. The timing of early antibiotics and hospital mortality in sepsis. Am J Respir Crit Care Med. 2017;196:856-63.
    25. Seymour CW, Gesten F, Prescott HC, et al. Time to Treatment and Mortality during Mandated Emergency Care for Sepsis. N Engl J Med. 2017;376:2235-44.
    26. Naegeli B, Radovanovic D, Rickli H, et al. Impact of a nationwide public campaign on delays and outcome in Swiss patients with acute coronary syndrome. Eur J Cardiovasc Prev Rehabil. 2011;18:297-304.
    27. Centers for Disease Control and Prevention. Get ahead of sepsis partner presentation. [Internet]. Available from: cdc.gov/sepsis/pdfs/Get-Ahead-of-Sepsis-Partner-Presentation-508.pdf. [Accessed June 30th 2021].
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    29. Scottish Government. Increase in awareness of sepsis. [Internet]. Available from: gov.scot/news/increase-in-awareness-of-sepsis/. [Accessed June 30th 2021].
    30. RCSI, university of medicine and health sciences. Awareness of sepsis increases following rcsi public awareness campaign. [Internet]. Available from: rcsi.com/dublin/news-and-events/news/news-article/2019/09/awareness-of-sepsis-increases-following-2018-rcsi-public-awareness-campaign. [Accessed June 30th 2021].

     

    Referenties Nederlands artikel

    1. Singer M, Deutschman CS, Seymour CW, Shankar-Hari M, Annane D, Bauer M, et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016;315:801–10.
    2. Reinhart K, Daniels R, Kissoon N, Machado FR, Schachter RD, Finfer S. Recognizing Sepsis as a Global Health Priority – A WHO resolution. N Engl J Med. 2017;377:414-7.
    3. van Gestel A, Bakker J, Veraart CP, van Hout BA. Prevalence and incidence of severe sepsis in Dutch intensive care units. Crit Care. 2004 Aug;8(4):R153-62.
    4. Angus DC, Linde-Zwirble WT, Lidicker J, Clermont G, Carcillo J, Pinsky MR. Epidemiology of severe sepsis in the United States: analysis of incidence, outcome, and associated costs of care. Crit Care Med. 2001;29(7):1303-1310.
    5. Stichting NICE. Sepsis op de IC: demografie en (lange-)termijnuitkomsten [Dutch]. NICE magazine. 2015:36-9.
    6. Vincent JL, Sakr Y, Sprung CL, Ranieri VM, Reinhart K, Gerlach H, et al. Sepsis in European intensive care units: results of the SOAP study.Crit Care Med. 2006;34(2):344-353.
    7. Cecconi M, Evans L, Levy M, Rhodes A. Sepsis and septic shock.Lancet. 2018;392(10141):75-87.
    8. Sakr Y, Jaschinski U, Wittebole X, Szakmany T, Lipman J, Ñamendys-Silva SA, et al. Sepsis in Intensive Care Unit Patients: Worldwide Data From the Intensive Care over Nations Audit. Open Forum Infect Dis. 2018;5(12):ofy313.
    9. Mellhammar L, Christensson B, Linder A. Public Awareness of Sepsis Is Low in Sweden. Open Forum Infect Dis. 2015;2(4):ofv161.
    10. Rubulotta FM, Ramsay G, Parker MM, Dellinger RP, Levy MM, Poeze M; Surviving Sepsis Campaign Steering Committee; European Society of Intensive Care Medicine; Society of Critical Care Medicine. An international survey: Public awareness and perception of sepsis. Crit Care Med. 2009;37(1):167-70.
    11. Eitze S, Fleischmann-Struzek C, Betsch C, Reinhart K; vaccination60+ study group. Determinants of sepsis knowledge: a representative survey of the elderly population in Germany. Crit Care. 2018;22(1):273.
    12. Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap) –A metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform. 2009;42:377-81.
    13. Harris PA, Taylor R, Minor BL, Elliott V, Fernandez M, O’Neal L, et al.The REDCap consortium: Building an international community of software partners. J Biomed Inform. 2019.
    14. Pourhoseingholi MA, Vahedi M, Rahimzadeh M. Sample size calculation in medical studies. Gastroenterol Hepatol Bed Bench. 2013 Winter;6(1):14-7.
    15. Fleischmann C, Scherag A, Adhikari NK, Hartog CS, Tsaganos T, Schlattmann P, et al. Assessment of Global Incidence and Mortality of Hospital-treated Sepsis. Current Estimates and Limitations. Am J Respir Crit Care Med. 2016 Feb 1;193(3):259-72.
    16. Kumar A, Roberts D, Wood KE, Light B, Parillo JE, Sharma S, et al. Duration of hypotension before intitiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock. Crit Care Med. 2006;34:1589-96.
    17. Liu VX, Fielding-Singh V, Greene JD, Baker JM, Iwashyna TJ, Bhattacharya, et al. The timing of early antibiotics and hospital mortality in sepsis. Am J Respir Crit Care Med. 2017;196:856-63.
    18. Seymour CW, Gesten F, Prescott HC, Friedrich ME, Iwashyna TJ, Phillips GS, et al. Time to Treatment and Mortality during Mandated Emergency Care for Sepsis. N Engl J Med. 2017 June 8th;376(23):2235-2244.
    19. Naegeli B, Radovanovic D, Rickli H, Erne P, Seifert B, Duvoisin N, et al. Impact of a nationwide public campaign on delays and outcome in Swiss patients with acute coronary syndrome. Eur J Cardiovasc Prev Rehabil. 2011 Apr;18(2):297-304.
    20. Centers for Disease Control and Prevention. Get ahead of sepsis partner presentation. [Internet]. Beschikbaar op: cdc.gov/sepsis/pdfs/Get-Ahead-of-Sepsis-Partner-Presentation-508.pdf. [Geraadpleegd op 30 juni 2021].
    21. The UK Sepsis Trust. About the charity. [Internet]. Beschikbaar op: https://sepsistrust.org/about/about-the-charity/. [Geraadpleegd op 30 juni 2021].
    22. Scottish Government. Increase in awareness of sepsis. [Internet]. Beschikbaar op: gov.scot/news/increase-in-awareness-of-sepsis/. [Geraadpleegd op 30 juni 2021].
    23. RCSI, university of medicine and health sciences. Awareness of sepsis increases following rcsi public awareness campaign. [Internet]. Beschikbaar op: rcsi.com/dublin/news-and-events/news/news-article/2019/09/awareness-of-sepsis-increases-following-2018-rcsi-public-awareness-campaign. [Geraadpleegd op 30 juni 2021].
    24. van den Hengel LC, Visseren T, Meima-Cramer PE, Rood PP, Schuit SC. Knowledge about systemic inflammatory response syndrome and sepsis: a survey among Dutch emergency department nurses. Int J Emerg Med. 2016 Dec;9(1):19.
    25. Tromp M, Bleeker-Rovers CP, van Achterberg T, Kullberg BJ, Hulscher M, Pickkers P. Internal medicine residents’ knowledge about sepsis: effects of a teaching intervention. Neth J Med. 2009 Oct;67(9):312-5. Erratum in: Neth J Med. 2009 Dec;67(11):393. van Achterberg, T [corrected to van Achterberg, T].