SEPSIS KILLS program
(general overview)
add LHD and/or hospital name
Aims
• Provide an overview of the SEPSIS KILLS program and
its impact in this LHD/facility
• Outline the elements of the inpatient SEPSIS KILLS
program
• Identify the steps for the LHD inpatient program
rollout
2
Defining sepsis…
Systemic response to an infection leading to shock, organ failure and death
Infection
Systemic
Inflammatory
Response
Syndrome
Severe
Sepsis
Sepsis
Increasing Mortality
•
Septic
Shock
Sepsis – what’s the problem?
• High mortality 20-25% in adults (ARISE 2007), 10 % in children
(Han, 2003)
• Mortality increases with delays to treatment (Kumar, 2006)
• Approximately 15000 cases of severe sepsis/septic shock in
Australia each year (Finfer et al, 2004)
• Increasing incidence – anticipated 60% increase by 2036
• High costs – acuity, LOS, patient experience
- NSW sepsis 2% acute bed days and mortality 17.82% vs 1.54% for general hospital population (2009/10)
- Sepsis ALOS 11.1 days (vs 2.9 days) in NSW
- Average cost weight/sep 3.39 vs 1.07 for all acute patients
- Estimated costs at current rate to 2019 $3.7 billion (if in top 5 codes)
(CEC Cost Effectiveness Analysis 2011)
Difficult diagnosis
• Not all patients have classic systemic inflammatory
response syndrome (SIRS)
• Sepsis is a clinical diagnosis requiring experience and a
high index of suspicion for interpretation of history, signs
and symptoms
• Signs are often subtle
• Some groups at special risk eg infants, age >65,
neutropaenia, haemodialysis, diabetes mellitus,
alcoholism, lung disease, patients with invasive devices
(Laupland et al Crit Care Med 2004)
The problem in NSW
CEC Clinical Focus Report - 2009
• 167 sepsis related incidents over
18 month period from IIMS
• Failure to recognise sepsis
• Failure to take appropriate and
timely action
• Poor patient outcomes
• Failure to see sepsis as a medical
emergency
The SEPSIS KILLS program
RECOGNISE:
Risk factors, signs and symptoms of sepsis and
inform senior clinician
RESUSCITATE:
With rapid antibiotics and IV fluids within one hour
REFER:
To specialist care and initiate retrieval if needed
Results - emergency departments
NSW
Time to 1st Antibiotic
(mins)
50%
45%
44%
40%
35%
27%
30%
25%
20%
13%
15%
7%
10%
5%
3% 2% 4%
Preliminary data
>360
300-360
240-300
181-240
121-180
61-120
0-60
% of Patients
0%
LHD results
• Add LHD and/or facility chart here
9
Next steps – the inpatient wards
• Leverage off success in the emergency departments
• Inpatient SEPSIS KILLS launch May 2014
• Integration with deteriorating patient strategy and other
quality and safety programs
What happens on the wards in NSW?
• Patients with sepsis are not getting the timely and appropriate
care they need
• 30% of adult deteriorating patients requiring a Rapid Response
are septic (CEC 2011, Jones, 2006)
• They are often sicker than they appear with a high potential
mortality
• ED patients with severe sepsis are transferred to the wards and
then deteriorating with poor outcomes
• There is an under appreciation of the significance of raised
serum lactate (> 4mmol/L)
NSW sepsis mortality by severity
CEC/HIE linked data n=3851 (2012)
30%
26%
27.30%
25%
Occult hypoperfusion or
cryptic shock
20%
15%
13.40%
9.30%
10%
5%
4.00%
0%
BP>90 lac<2
BP<90 lac<2
BP>90 lac>2
BP<90 lac>2
lac >4
Gao F, Melody, Daniels D et al.
The impact of compliance with 6-hour and
24-hour sepsis bundles on hospital mortality in patients with severe sepsis:
a prospective observational study Critical Care 2005 9:R764-R770
101 (wards 90, A&E 11) consecutive patients who met criteria for severe
sepsis or septic shock
Within 6 Hours
• 74% presumptive diagnosis including blood culture
• 74% had antibiotics
• 52% had serum lactate
• 84% had immediate fluids if hypotensive
• 70% had a vasopressor when MAP<65 and/or blood to Hb target 79 g/L
• All elements in 52%
• Compliant vs non-compliant groups were compatible
Mortality
– 49% vs 23% RR 2.12 (95% CI 1.2 – 3.76), P=0.01
– NNT to save 1 life  4
Marwick, Guthrie, Pringle et al. A multifaceted intervention to improve sepsis
management in general hospital wards with evaluation using segmented regression of
interrupted time series BMJ Qual Saf 2013 epub
• 860 bed teaching hospital in Scotland, 22 medical, surgical,
orthopaedic wards
• Looked at patients with sepsis >24 hours after admission
• Screened 999/1341 patients with blood cultures over 6 month
period (Sept 2008 - Feb 2009)
• Mean time between sepsis onset and antibiotic
administration was 11.0 hours (median 6.0 hours)
• Longest delay was from first medical review to antibiotic
prescription (mean 7.2 hours, median 2.5 hours)
14
Jaderling et al ICU Admittance by a Rapid Response Team Versus Conventional
Admittance, Characteristics, and Outcome (Crit Care Med 2013)
• Reviewed admissions from wards to ICU in 900 bed trauma
referral centre in Stockholm between 2007 – 2009
• 355/694 (51.2%) as result of Rapid Response call
• Commonest diagnosis severe sepsis (18.3%)
• ‘...severe sepsis at the wards was mainly detected by the rapid
response team and was the most common admitting
diagnosis among the rapid response team patients’
15
In NSW….
• Wards highly complex environments with variable levels of
monitoring
• Clinical management responsibility not always clear
• JMOs/Registrars often reluctant to prescribe new
antibiotics especially overnight
• Therapeutic Guidelines: Antibiotic provide limited guidance
for inpatients with sepsis
• Need clear local guidelines for escalation of sepsis to AMO
and ID physician
16
What happens here?
• Add de-identified LHD case/RCA here
17
Linking BTF and sepsis….from Recognition to Root Cause
Recognition
Response
Root Cause
Response
• Is my patient between the flags?
• If not, what should I do?
• Why is my patient deteriorating?
• How should I treat them?
Charles Pain 2014
The ‘slippery slope’
Clinical
Review
Rapid
Response
Patient Condition
Prevention
Advanced
Life
Support
Time
Death
Source: Dr Charles Pain
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• Adult &
paediatric
pathways
• 48 hour
management
plan
• Antibiotic
guidelines
• Sepsis Toolkit
• PowerPoint
presentations
• Case studies
• DETECT
• Video clips
• SAGO and
SPOC charts
• ISBAR
• Escalation
tools
• Time to IV
antibiotics
and IV fluids
20
-
22
Sepsis 48 hour management plan
Management plan includes
- level of observation
- review schedule
- escalation plan
Implementation
Pilot work and early adopters
• Liverpool hospital
pilot to whole of hospital rollout
• Westmead Hospital
whole of hospital rollout early 2014
• Orange Health Service
integration with In Safe Hands program
• Griffith Base Hospital
identified need for early review after transfer from ED and flag as high
potential for deterioration in 48 hours post initial recognition/treatment
• Paediatric pathway trial in 7 facilities
Lessons learnt
• Leadership from the top is vital - executive and clinicians
• Preparation is important…take the time to get it right
• Linkage with deteriorating patient strategy and other Q&S
programs
• Data will drive improvement – plan evaluation from the
outset
Inpatient Sepsis Toolkit
•
•
•
•
•
Implementation plan
Facility and ward checklists
Clinical tools
Education resources
Evaluation resources
Available on CEC sepsis website
LHD/facility implementation
LHD
Facility
Ward
Exec sponsor
and sepsis lead
Exec sponsor
Nursing lead
Committee
Implementation
team
Medical lead
CLINICAL EXCELLENCE COMMISSION
Evaluation
Consider….
• What will work in your LHD/facility?
• Who are the key players?
• How will you get started?
• What will success look like?
World Sepsis Day
13 SEPTEMBER 2014
Early recognition….
Early antibiotics….
Early IV fluids….
Usual treatment delivered sooner.
Don’t turn your back on the bomb!
Contact details
Mary Fullick, Sepsis Program Lead
Mary.Fullick@cec.health.nsw.gov.au
Tel: 9269 5542
Dr Tony Burrell, Director Patient Safety
Tony.Burrell@cec.health.nsw.gov.au
Tel: 9269 5550
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References
Australasian Resuscitation in Sepsis Evaluation (ARISE) Investigators and the Australian and New Zealand Intensive Care Society (ANZICS) Adult Patient
Database (APD) Management Committee. The outcome of patients with sepsis and septic shock presenting to emergency departments in Australia and
New Zealand. Critical Care and Resuscitation 2007; 9:8-18.
Clinical Excellence Commission. Clinical Focus Report from review of root cause analysis and/or incident information management system (IIMS) data
recognition and management of sepsis. Clinical Excellence Commission 2009; Sydney.
Clinical Excellence Commission & Agency for Clinical Innovation. Cost effectiveness analysis stage one: do nothing and the case for change. ACI/CEC Policy
and Technical Support Unit 2011; Sydney
Dellinger RP, Mitchell M, Levy MD , et al. Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock: 2012.
Critical Care Medicine 2013; 41: 2; 580-637.
Fang G, Meloy T, Daniels D, et al. The impact of compliance with 6 hour and 24 hour bundles on hospital mortality in patients with severe sepsis: a
prospective observational study. Critical Care 2005, 9:764-770.
Finfer S, Bellomo R, Lipman J. Adult-population incidence of severe sepsis in Australian and New Zealand intensive care units. Intensive Care Medicine 2004;
30:589–596.
D, Duke G, Green J et al. Medical Emergency Team syndromes and an approach to their management. [cited 2014, March 31] Available from:
http://ccforum.com/content/10/1/R30
Han Y, Carcillo J, Dragotta M, Bills D, Watson S, Westerman M, Orr R. Early Reversal of Pediatric-Neonatal Septic Shock by Community Physicians Is
Associated With Improved Outcome. Pediatrics 2003; 112(4) 793-799
Jaderling et al ICU Admittance by a Rapid Response Team Versus Conventional Admittance, Characteristics, and Outcome. Crit Care Med 2013
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. Critical Care Medicine 2006; 34:1589-1596.
Marwick, Guthrie, Pringle et al. A multifaceted intervention to improve sepsis management in general hospital wards with evaluation using segmented
regression of interrupted time series BMJ Quality Safety 2013 epub