Amith Shetty
SMEDSA study
Westmead
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Sepsis noted as leading cause for SAC 1
incidents and RCAs in NSW
A process for early recognition, review and
resuscitation of septic patients
Timely early interventions – antibiotics and
intravenous fluids
CEC Sepsis kills program
http://www.cec.health.nsw.gov.au/programs/sepsis
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RECOGNISE - risk factors, signs and
symptoms of sepsis
RESUSCITATE with rapid intravenous fluids
and antibiotics within the first hour of
recognition of sepsis
REFER to senior clinicians and specialty
teams, including retrieval as required
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Initiate sepsis pathway based on suspected
infection + 2 SIRS criteria
Up-triaging to ATS category 2
Sepsis bomb
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Oxygen
Blood cultures
Lactate
Intravenous fluids – 20ml/kg crystalloid bolus
Antibiotics <60 minutes
◦ Based on clinician predicted source
◦ Antibiotic stewardship program and guidelines
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Monitoring
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Early senior review and assessment
Early referral to intensive care services
Inpatient sepsis management pathway
being launched soon
24-48 hr sepsis management tool in
pipeline
• Improvement in time to antibiotics to 60 minutes in last three
years
• >18000 patients registered on CEC sepsis archive
• Crude patient level data available on archive – time to
antibiotics , lactate level, SIRS data
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Retrospective evaluation of prospectively
identified patients presenting to ED with
sepsis
Multicentre approval
◦ Westmead
◦ Concord
◦ RPA
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Single centre data collection and analysis
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850 bed tertiary hospital
45 treatment space Emergency department
>65000 annual census ED presentations
35-40% ED to ward admission rates
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Sepsis kills pathway
ATS category 2 for suspected infection + 2
SIRS criteria
Clinicians encouraged to report
Sepsis pathway antibiotic guidelines
Antibiotic stewardship guidance
Patient safety officer and audits
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~1200 patients recorded at Westmead in past
24 months
Interim analysis at 590 patients
Median age of patients = 59.5 (IQR 36-75)
Females = 306 median age 54.5 (IQR 32-76)
Males = 284 median age 63 (IQR 46-75)
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Antibiotics ceased or not given in 48 hours –
non bacterial etiology, DNR
Exclusions (no antibiotics 9 + antibiotics
ceased <48 hours 76) 85
Median age of female (44 exclusions) = 33
(IQR27.5-43.5)
Median age for males (41 exclusions) = 49
(IQR 26-68)
Mann-Whitney U test comparing Age in
inclusions versus exclusions Median
difference = -17 (CI: -24 to -11) (p<0.001)
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Total number of inclusions = 505
Median age of patients = 63 (IQR 42-78)
Females = 262 median age 59.5 (IQR 35-78)
Males = 243 median age 64 (IQR 50-77)
507/ 590 patients triaged to ATS category 2
 85.9% adherence to guideline
 Median time to clinician 36 mins (IQR 16-73)
ATS<2 versus >2
 Time to clinician– 35 versus 84 minutes
(p<0.001)
 Time to antibiotics – 66.5 versus 129 minutes
(p<0.001)
 Time to 2nd L fluids – 99.5 versus 228
minutes
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492/590 (83.4% 95%CI 80.2-86.2) underwent
lactate testing
Exclusions vs inclusions – median 1.4 v 1.8
(p<0.01)
Sepsis versus severe sepsis/ septic shock –
median 1.5 v 2.2 (p<0.01)
Dead versus alive – 2.8 v 1.7 (p<0.001)
But significant overlap of tails
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484/505 patients had blood cultures
collected
95.8% adherence (95% CI 93.7-97.3)
94 /484 (19.4%) positive BC, 13/94 (13.8%
contamination rates) → 81/ 484 (16.7% 95%CI
13.7-20.3) significant results
26.5% BC + for severe sepsis group versus
13.4% BC + in plain sepsis group
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329/505 Urine cultures – 62/329 positive
results
193/ 505 other cultures – 100/193 positive
results
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297/ 505 (58.8%) received appropriate
antibiotics according to guidelines
192 / 505 (38.0%) received at least one
antibiotic as per guidelines
16 / 505 (3.2%) received antibiotics not
according to guidelines
Severe sepsis definition = sepsis-induced tissue
hypoperfusion or organ dysfunction (any of the following
thought to be due to the infection)
 Sepsis-induced hypotension
 Lactate above upper limits laboratory normal (>2)
 Urine output < 0.5 mL/kg/hr for more than 2 hrs despite
adequate fluid resuscitation
 Acute lung injury with Pao2/Fio2 < 250 in the absence of
pneumonia as infection source
 Acute lung injury with Pao2/Fio2 < 200 in the presence of
pneumonia as infection source
 Creatinine > 2.0 mg/dL (176.8 μmol/L)
 Bilirubin > 2 mg/dL (34.2 μmol/L)
 Platelet count < 100,000 μL
 Coagulopathy (international normalized ratio > 1.5)
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Age – 58 (IQR 38-75) versus 67 (49-80)
Lactate value → 1.5 (1.1-2.2) v 2.2 (1.4-3.8)
Total MEDS score → 5 (3-9) v 8 (6-12)
Charlson score → 3 (0-7) v 5 (2-9)
Hospital LOS → 4 (2-8.5) v 7 (3-13)
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Time to antibiotics →69 minutes (IQR 42126.5) in patients with plain sepsis versus 67
minutes (IQRR 49-80) in patients with severe
sepsis or septic shock
Time to second litre fluids → 196 minutes
(107.5-403.5) v 249 minutes (136-489)
no sepsis
severe sepsis/ septic shock
Plain sepsis
SIRS 0
17
6
14
37
SIRS 1
14
28
55
97
SIRS 2
28
46
116
190
SIRS 3
18
57
78
153
SIRS 4
6
42
34
82
SIRS 5
2
16
8
26
SIRS 6
0
5
0
5
total
85
200
305
590
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Sensitivity 0.80 95%CI 0.76- 0.83
Specificity 0.36 95%CI 0.27- 0.48
Positive predictive value = 0.88
Negative predictive value = 0.25
Patients with severe sepsis more likely to
have >3 SIRS criteria (p<0.001)
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AMBULANCE vs PRIVATE transport 274 vs 231
(Mann-Whitney)
Median age 74 versus 48 (MD 23 p<0.01)
>SIRS 3 vs 2 (MD 1 p<0.01)
Higher lactate 2.2 vs 1.5 (MD 0.6 p<0.01)
Severe sepsis rates 132/274 (48.2% 95% CI 42.354.1) versus 68/231 (29.4% 95% CI 23.9-35.6)
(p<0.01)
◦ MEDS score 9 vs 3 (MD 5 p<0.01)
◦ Mortality (51/231 22.1% 95%CI 17.2-27.9%) versus
(6/231 2.6% 95% CI 1.2-5.5%)
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478/ 505 (94.7%) concurrence of clinician
prediction of presumed source of diagnosis
when compared to final discharge diagnosis
Source
Number
Chest/ respiratory
219
Urine
84
Skin/ soft tissue/ Orthopedic
44
Abdominal / biliary
41
PUO/ unknown
51
Neuro/ CNS
6
Bloodstream
10
Oral/ Dental
22
Mixed / others
28
Total
505
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Mortality rates – in-hospital, 30-day or 90day
Hospital LOS
Discharge location
Occurrence of severe sepsis or septic shock
Time to
antibiotic
Total
patients
≤ 1 hour
224
127
97
X
>1 to ≤ 2
hours
134
95
39
x
> 2 to ≤ 3
hours
57
33
24
x
> 3 hours
86
47
39
x
501
302
199
x
Total
Plain sepsis
Severe
sepsis and
septic shock
Mortality
Time to
second litre
fluids
Total
patients
Plain sepsis
Severe
sepsis and
septic shock
In-hospital
mortality
≤ 1 hour
35
13
22
X
>1 to ≤ 2
hours
65
35
30
X
>2 to ≤ 3
hours
76
46
30
X
>3 hours
279
177
102
X
Total
455
271
184
x
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More clinical trials needed on sepsis patients
not just focus on severe sepsis and septic
shock – ED from ICU shopfront
Overall benefit of bundles care – risk versus
benefit
? RCT on antibiotics after source
identification versus clinician prediction
based – stratified risk tool development
Risk factors for progression to severe sepsis
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Bundled care can lead to significant
improvements in delivery of care to sepsis
patients
Ambulance cohort significantly more unwell –
focus for future studies
Senior clinicians are able to reliably predict
source of infection