National Sepsis Audit
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National Registrar Research Collaborative Audit Project 2013
Nationally led by SPARCS (Severn and Peninsula Audit and
Research Collaborative for Surgeons)
Regionally led by NWRC (North West Research Collaborative)
Background
• Previous national audit
• Multicentre observational study of performance variation in
provision and outcome of emergency appendicectomy
• 3326 patients from 95 centres
• British Journal of Surgery 2013; 100: 1240–1252
• Led by West Midlands Research Collaborative
• International audit of sepsis in general surgical admission
• Including general, vascular and breast surgery
Aims
• Examine the proportion of emergency surgical patients
presenting with severe sepsis
• Establish compliance with the Sepsis Six and Surviving Sepsis
Resuscitation Bundles.
• Establish compliance with Source Control guidelines for
patients with severe sepsis
SIRS, Sepsis and Severe Sepsis
• A. Systemic Inflammatory Response Syndrome (SIRS):
• Presence of two or more of the following:
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1. Temperature >38.3°C or <36°C
2. Heart rate >90 beats/min
3. Respiratory rate >20 breaths/min
4. WBC >12,000 cell/mm3 or <4,000 cell/mm3
5. Acutely altered mental status
6. Hyperglycaemia (plasma glucose of >7.7mM/l) in the absence of
diabetes
• B. Sepsis
• Sepsis is deemed present when SIRS is accompanied by a clinical
suspicion of infection.
SIRS, Sepsis and Severe Sepsis
• C. Severe sepsis
• Sepsis-induced tissue hypoperfusion or organ dysfunction:
• 1. Sepsis-induced hypotension (systolic Bp of < 90 or MAP < 65mmHg)
• 2. Lactate >2 mmol/L
• 3. Urine output < 0.5mL/kg/hr for more than 2 hrs despite adequate fluid
resuscitation or creatinine > 176.8mmol/l
• 4. Acute lung injury with PaO2/FIO2 < 300 in the absence of pneumonia
• 5. Acute lung injury with PaO2/FIO2 < 200 in the presence of pneumonia
source
• 6. Bilirubin >34.2mmol/L
• 7. Platelet count < 100,000 μL
• 8. Coagulopathy (international normalized ratio > 1.5 or a PTT>60 secs))
• D. Septic Shock
• Sepsis-induced hypotension, persisting despite adequate fluid
resuscitation.
Audit Standards
• Sepsis Six guidelines: ALL of the following interventions
should be performed within one hour of severe sepsis:
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a) Delivery of high flow oxygen
b) Obtainment of blood cultures prior to antibiotic administration
c) Administration of empirical broad-spectrum antibiotics
d) Fluid resuscitation
e) Measurement of serum lactate and full blood count
f) Commence accurate urine output measurement (may require
catheterisation)
Audit Standards
• Surviving Sepsis guidelines: ALL of the following interventions
should be performed within six hours of severe sepsis:
• a) In the event of hypotension or lactate ≥4mmol/L:
• i. Deliver an immediate minimum of 30ml/kg crystalloid
• ii. Give vasopressors for hypotension not responding to initial fluid
resuscitation to maintain mean arterial pressure ≥65mmHg
• b) In the event of persistent hypotension despite volume
resuscitation and/or initial lactate >4mmol/l:
• i. Achieve central venous pressure of ≥8mmHg
• ii. Achieve central venous oxygen saturation ≥70%
• c) Source of infection to be identified and controlled
Patient Identification
• Presence of sepsis will be elicited for the first 24 hours of each
patient’s hospital admission only
• Age >16 years
• Urology, neurosurgery, plastics, obstetrics and gynaecology,
ENT, cardiothoracics, ophthalmology and maxillofacial surgery
will be excluded
• Inpatients and referrals from other medical specialties will
also be excluded
• Eligible Patients admitted between: 09:00 on Monday 21st
October – 09:00 on Monday 28th October
Data Extraction
• Commence 30 days after admission
• For all patients:
• demographic data will be recorded
• data concerning the presence or absence of sepsis markers
during the first 24 hour of admission.
• Where sepsis was not present, no further data collection will
be required.
• If sepsis was present further data extraction will be
performed:
• adherence to surviving sepsis guidance,
• investigation of source and timing of source control,
• total of 30 days post admission.
Next Steps
• PI (Primary Investigator) at each trust: Consultant who agrees
to support the audit
• Register the project with the audit department
• Team of trainees (Insert name[s] here) responsible for data
collection
• Accurate daily list of all general surgical admissions during the
study period
• (Insert name[s] here) will collate 30-day follow-up data