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The Digital Alerting for Sepsis (DiAlS) study

The DiAlS study will investigate the impact of digital sepsis alerts on patient outcomes and staff activity in NHS hospital Trusts across England and Wales. As UK hospitals move from paper based to electronic health records, the integration of digital alerts to identify patients at risk of deterioration has also become common.

Logo of the DiAlS study

The implementation of digital alerts in hospitals is a complex health intervention. Therefore, we are using both a mixed methods approach to ensure understanding of the relationship between inherent aspects of the alerts, such as the underlying algorithm and the method of clinician notification. Using appropriate qualitative and quantitative methods, based on the analysis of natural experiments, we will evaluate the implementation of alerts across six NHS trusts, which have adopted distinctive digital alerts.

Outcomes will include in-hospital mortality within 30 days, transfer to ICU, length of stay and administration of intravenous (IV) antibiotics. We will also consider unintended consequences related to unnecessary and inappropriate use of antibiotics.

Findings from the DiAlS study will inform clinicians and hospital managers on the most effective alerts, the optimal implementation process and possible unintended consequences.

Why is this research important?

Identifying clinical deterioration in order to prevent death is a major focus for health systems across the world. Sepsis is a specific cause of clinical deterioration and death with an estimated 123,000 cases and 46,000deaths in the UK each year. Similarly, high levels of sepsis have been reported internationally and sepsis is recognised by the World Health Organisation as a global health priority.

Many countries have nationwide sepsis action plans and all UK hospitals have set targets to rapidly diagnose and treat patients with sepsis. Timely appropriately targeted intravenous (IV) antibiotics have been shown to be effective in improving outcomes for patients, with a 4% increase in odds of mortality for every hour’s delay in administration of IV antibiotics.

Early warning screening systems are used to identify clinical deterioration and prevent avoidable mortality. Many of these systems use Early Warning Scores (EWS), based on patients’ vital signs, including: heart rate; blood pressure; temperature and oxygen saturation. Predetermined levels in each vital sign are associated with scores, these are then added up. The total score determines the risk group a patient is allocated. These scores can be embedded in electronic health systems and the scores can automatically trigger an alert.

The Global Digital Health Unit working with Imperial College Healthcare Trust have shown that the introduction of a digital sepsis alert reduced the risk of death by 14% (Honeyford, 2020). This research was funded by the Imperial Biomedical Research CentreThe views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care.

Currently there is little evidence available to support Trusts in selecting the most effective algorithms, alert thresholds and which patients benefit. The DiAlS study will inform clinicians and hospital managers on the most effective alerts, the optimal implementation process and possible unintended consequences.

Our key objectives

Our key question is - How effective is the introduction of digital alerts in terms of improving outcomes of patients with sepsis?

In order to answer this we have four key objectives:

  1. Map the digital alerts currently in use in multiple UK hospitals to identify patients at risk of having sepsis.
    The team will use a range of methods to understand which underlying algorithms are used in different Trusts to identify patients at risk of sepsis. We will also explore workflow and how the alerts were introduced.
  2. Evaluate the impact of digital alerts on outcomes for patients at risk of sepsis.
    The introduction of alerts in hospitals can be seen as a series of natural experiments. We will use a variety of statistical approaches to assess the impact of the digital alerts on patient outcomes and use approaches including multi-level interrupted time series. The primary outcome will be in-hospital mortality. Secondary outcomes will include administration of IV-antibiotics, length of stay and transfer to intensive care. We will examine unintended outcomes associated with the alerts.
  3. Explore the implementation of digital alerts across contexts and the impact of these on digital alert performance.
    A range of qualitative approaches, including interviews and focus groups, will allow us to examine the implementation process and its impact on digital alert performance.
  4. Make recommendations on the effectiveness of different digital alerts and the most effective method of implementation.
    Qualitative and quantitative findings will be brought together in a mediation analysis.

Who is carrying out the study?

This study is being carried out by an experienced research team led by Dr Ceire Costelloe (Principal Investigator), Director of the Global Digital Health Unit in the School of Public Health at Imperial College London. The lead researcher for the DiAlS study is Dr Kate Honeyford. The work is being supported by the NIHR Health Informatics Collaborative and the UK Sepsis Trust.

A key strength of the DiAlS study is the collaboration between researchers in the Global Digital Health Unit and clinicians and researchers across six NHS hospital Trusts and three universities.

We are working with a range of stakeholders including health professionals and patients to share and exchange knowledge at all stages of the study.

This work is funded by the NIHR. The views expressed here are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care.

The project has ethical approval from the Health Regulatory Authority (Project ID - 288328).

Publications and dissemination


Evaluating a digital sepsis alert in a London multisite hospital network: a natural experiment using electronic health record data, Journal of the American Medical Informatics Association, Volume 27, Issue 2, February 2020, Pages 274–283,


Naked Scientists interview: Sepsis alert saves lives in hospital

Study protocols

Quantifying the impact of a digital sepsis alert on key patient outcomes (PDF)

Comparison of different alerting algorithms across 5 NHS hospital Trusts (PDF)

Public and patient involvement

We are keen to involve people in our research who have experience of sepsis, either directly or through someone close to them. Our project management group includes a patient representative and we also have two patient representatives on the DiAlS independent steering group.

If you would like to get involved in our research please contact Dr Kate Honeyford.

UK Sepsis Trust

We work with the UK Sepsis Trust, a registered charity, to capture a wide range of patient experiences and to ensure research findings from DiAlS are widely disseminated to the public.

Dr Ron Daniels BEM is the Chief Executive of UK Sepsis Trust. He is a Consultant in Critical Care at University Hospitals Birmingham NHS Foundation Trust, Birmingham, England and a Fellow of the Royal College of Physicians of Edinburgh, Royal College of Anaesthetists and Faculty of Intensive Care Medicine.

In addition to public duties, he provides clinical advice to NHS England, Public Health England, and the Department of Health in capacity of the UK Sepsis Trust. He has lobbied the United Kingdom Government, together with devolved governments in Scotland and Wales, over several years resulting in the development of a national commissioning incentive for sepsis in England, a NICE Clinical Guideline and Quality Standard, and a public awareness campaign on sepsis in children.

Ron and his team developed both the ‘Sepsis Six’ care bundle, now in use in 36 countries, and the clinical concept of ‘Red Flag Sepsis’. Both are endorsed and recommended by the UK Royal Colleges and by NHS England, and in 2019 were formally endorsed by NICE.

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The DiAlS study