Sepsis Collaborative: The
National Perspective
Professor Kevin Rooney, 12th December 2012
Background
ICU Consultant
Royal Alexandra Hospital,
Paisley
National Clinical Lead for Sepsis
Healthcare Improvement Scotland
Conflicts of Interest
In the last 5 years I have acted
as consultant, or received
honoraria / research grants
from:
Abbott, Baxter, Eli Lilly
Royal Alexandra Hospital
• Clyde
– 124K ED attendances
– 25K Medical
attendances
– 50% discharges in first
48hrs
– ALOS 6.8 Days
• RAH
– 40 med admissions/day
– 17 GP referrals
– Same day discharge
43%
Scotland HSMR – 11.4%
reduction
What is Sepsis?
Acute MI & Trauma
5% Mortality
3% Mortality
Courtesy of Dr I
Roberts
Why is it important?
The Lingering Consequences of Sepsis
A Hidden Public Health Disaster
D Angus JAMA 2010
• Cohort study of 27,000 older Americans with detailed
information on physical & neurocognitive performance
• Identified episodes of Sepsis in hospital from Medicare
data
• Showed incidence of moderate to severe cognitive
impairment increasing 3x – from 6.1% to 16.7% ie
possibly 20,000 new cases per year in US
Iwashyna et al JAMA 2010
Variation In Sepsis Care
15,022 Patients
165 Hospitals
Median of 14
Months
Mortality Decreased from
37 to 30.8 Percent
6.2% Absolute
16% Relative
STAG Sepsis Management in
Scotland
• Signs of sepsis < 2
days
• 2% of emergency
admissions
(~5000)
Scottish
• 71% had a EWS
Defect
Rate
• 34% had severe sepsis
18-74%
• was
21% blood
cultures
• 32% IV Antibiotics
• 70% IV fluids
Gray et al Emerg Med J (2012)
doi:10.1136/emermed-2012-201361
Why is implementation so
difficult?
•
•
•
•
•
•
•
Too many elements in the bundle
Some are controversial
Time Sensitive Process
Difficult To Diagnosis Sepsis Early
Human Factors Get In The Way
Invasive procedures needed
ICU stuff??
Complacency, Education &
Trying Harder isn’t enough
New ways of thinking
New ways of thinking
• Front line engagement
• Segmentation
• Real Time Data Collection
• Early Feed Back of Metrics
• Early Case Review and Feedback
• Use Level 2 Reliability Tools
The Collaborative Model
Organisational
Self Assessment
P
A
P
D
1.5 day
Kickoff
A
D
A
D
S
S
S
Alignment
with national
work
P
LS
LS
LS
Supports
Key Changes
Expert clinical faculty
Improvement
Listserve Site Visit
Measures
Phone conf
Assessments
Monthly Reports via web
Continued
Supports
Spreading Ink blot Strategy
• Based on military
tactics
– Small area of “Good
Practice” across site
– As expand will join up
Acute Medical Unit
RAH
• MAU ED Surgical
ED
– Hospital At night
– Medical Wards
– DOME
Acute Surgical
Evidence for the Change
Package
JOINT COLLABORATIVE - SEPSIS DRIVER DIAGRAM
AIM
To improve the
recognition and
timely
management of
Sepsis in acute
hospitals
Outcome:
Reduction in
mortality in pilot
population from
Sepsis
5% by December 2012
10% by December
2014
PRIMARY DRIVERS
Reliable
Recognition &
Assessment
Reliable Care
Delivery
Education
&
Awareness
Culture of safety
and Quality
Improvement
Patient & Family
Centred Care
SECONDARY DRIVERS
Reliable Sepsis screening (EWS + SIRS)
Ensure reliable communication across clinical
teams of at risk patients
Ensure timely rescue of deteriorating patient by
competent teams
Ensure reliable delivery of Sepsis Six within 1 hour
Source Control
Ensure reliable escalation of septic patients to
higher level of care
Improve Antimicrobial stewardship - 3 day review
Education on burden of illness & current
performance
Provide training to staff on clinical knowledge and
improvement skills
Executive Sponsorship
Clinical Leadership
Multidisciplinary team working
Develop measurement frameworks to guide
improvement
Involve patients & families in treatment
process
and care planning
“He who must not be
named” or “Homer”
Reliable Recognition,
Assessment & Rescue
Type of physiological abnormality at time of
ED patient inclusion in audit (first signs of
sepsis) n=626 – median age 73 years
Gray et al Emerg Med J (2012) doi:10.1136/emermed2012-201361
Difficult diagnosis
• Not all patients have classic SIRS
• Some groups at special risk eg neutropaenia,
haemodialysis, diabetes mellitus, alcoholism, lung
disease, patients with invasive devices
– Laupland et al Crit Care Med 2004
• Elderly patients (age > 65 years)
•
•
•
•
•
Decreased inflammatory response
Often not febrile
More likely to be delirious
Falls may be only evidence of sepsis-induced delirium
More likely to develop septic shock and multiple organ dysfunction syndrome
(MODS)
Sepsis Screening
• MEWS: >95% reliable in pilot wards
• Systemic Inflammatory Response Syndrome
(SIRS) criteria
SIRS Criteria
The Sepsis Six
1.
Deliver O2 (>94% SpO2)
2.
Take blood cultures and consider source control
3.
Give IV antibiotics according to local protocol
4.
Start IV fluid resuscitation (min 500ml) and reassess
5.
Check lactate & FBC
6.
Commence accurate urine output measurement and consider
urinary catheterisation
All within one hour
© Ron Daniels 2010
Why within an hour?
Duration of hypotension before initiation of effective
antimicrobial therapy is the critical determinant of
survival in human septic shock *.
Kumar, Anand; Roberts, Daniel; Wood, Kenneth; Light,
Bruce; Parrillo, Joseph; Sharma, Satendra; Suppes,
Robert; Feinstein, Daniel; Zanotti, Sergio; Taiberg, Leo;
Gurka, David; Kumar, Aseem; Cheang, Mary
Critical Care Medicine. 34(6):1589-1596, June 2006.
DOI: 10.1097/01.CCM.0000217961.75225.E9
Figure 1. Cumulative effective antimicrobial initiation
following onset of septic shock-associated hypotension
and associated survival. The x-axis represents time (hrs)
following first documentation of septic shock-associated
hypotension. Black bars represent the fraction of
patients surviving to hospital discharge for effective
therapy initiated within the given time interval. The gray
bars represent the cumulative fraction of patients having
received effective antimicrobials at any given time point.
© 2006 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins. Published by Lippincott Williams
& Wilkins, Inc.
5
Why all septic patients?
• Sepsis Disease Continuum:
• 15% → 30% → 50%
When to Escalate Care?
Progress to date
Top Tips from
WebEx
• Brightly coloured paper for screening tool draws
attention
• Simplify the screening tool
• Screening tool in blood culture bags to connect essential
elements of the process
• Case note review builds knowledge of system successes
and failures
• Target doctors through induction
Lessons from
• Beware
– Prescribing / Charting eg ward chart not ED
stat dose
– Communication – doctor/nurse – no urgency
– Investigation & specimen collection – waiting
for results before Abs!!
– “Don’t give Abs until I see him”
– Avoid infusions, go for IV bolus
Twitter
More Top Tips
• Align data collection with junior doctors projects
• Monthly snapshot audit of triggering patients – ‘who did
we miss?’
• Open door policy for staff to give real time feedback –
what can we do better next time?
• Named doctor as ‘rapid responder’
• ‘Sepsis order set’ for bloods
• Sepsis pathways on front of EWS chart
• Use patient stories – good and bad – to drive awareness
Considering the side effects
of change
• Process Measures
• Outcome Measures
• Balancing Measures
– Increased antibiotic use
– Clostridium Difficile
– MRSA
– Staff morale
Community of Practice
website and Extranet
Measurement - Acute
Burning Platform
Patient not given antibiotics within the hour because of
difficulties obtaining access delay in administration of
Abs in 1 patient prescribed 1500, given 1610, another
patient 1 hr15 mins to abs. Neutropenic sepsis patient 3
hours to Abs, patient with SEWS 7 1 hr 55 to Abs.
1 patient SEWS 8, 2 hrs to ABs
.
RAH MAU
Total Percentage Compliance
120%
100%
80%
60%
40%
20%
0%
02/04/2012 02/05/2012 02/06/2012 02/07/2012 02/08/2012 02/09/2012 02/10/2012 02/11/2012
All or nothing
All or nothing Compliance
120%
100%
80%
60%
40%
20%
0%
02/04/2012
02/05/2012
02/06/2012
02/07/2012
02/08/2012
02/09/2012
02/10/2012
02/11/2012
% compliance with Antibiotics within 1 hour
Scottish Acute Teams ( n = 9)
100
90
80
70
60
average_team
50
median
40
30
20
10
0
Feb-12
Mar-12
Apr-12
May-12
Jun-12
Jul-12
Aug-12
Sep-12
Measurement - Specialty
patient23
patient22
Time to first antibiotic wards 4B, 2A,2B,2C,5E,5D,,4E
patient21
patient20
patient19
patient18
patient17
patient16
patient15
Dual
implementation
commenced
patient14
patient13
Patient 12
Patient 11
Patient 10
Patient 9
Patient 8
Patient 7
Patient 6
Patient 5
Patient 4
04:48
Patient 3
Patient 2
Patient 1
Crosshouse Hospital
Measure
Median
06:00
pts not handed over to
ERT
03:36
02:24
01:12
00:00
Heart & Minds
• ‘If you want to build a
ship do not gather
men together and
assign tasks. Instead
teach them the
longing for the wide
endless sea.’
(Saint Exupery, Little Prince)
Thank you
“I hated every
minute of training,
but I said, don’t
quit, suffer now
and live the rest of
your life as a
champion.”
Muhammed Ali
Further information
kevin.rooney@uws.ac.uk
http://www.knowledge.scot.nhs.uk/sepsisvte/sepsis.aspx