NHS BordersSepsis Webex 25th April 2013

NHS Borders Melrose

Core Team MembersEvelyn Fleck Director of Nursing and Midwifery, Executive LeadDr Edward James Consultant Microbiologist, Consultant LeadRonnie Dornan Clinical Nurse Specialist, Critical Care Outreach Dr Jonathan Aldridge Consultant Anaesthetics & Intensive CareGeoff Anderson Charge Nurse, Ward 7Lisa White Sister, Ward 7Dr Anne Duguid Antimicrobial PharmacistAdam WoodSenior Nurse Specialist, Infection Control Julieann Brennan Clinical Audit FacilitatorChristine Irving Clinical Practice Facilitator for IV MedsEllen Poole Staff Nurse, Ward 12Allison Roebuck Patient Safety AdministratorJulia Scott Clinical Governance & Quality Facilitator: Patient SafetyGill Lunn Senior Midwife/ Maternity ChampionLorraine Dickson Hospital at Night TeamFY1 docs From Wards 4, 7, 12 and A&E

To improve recognition and timely management of patients identified with sepsis on ward 7, by achieving 95% compliance with evidence based therapy (SEPSIS 6) by September 2013

Reliable Recognition & Assessment

Reliable Care Delivery

Improve Patient and Family Centred Care

Promote a Culture of safety & Improvement

Refine Education & Awareness

Primary Drivers

Development and modification of current tool (SIRS) to include (SEPSIS 6) – Sepsis bundle

Timely rescue of patients identified through reliable escalation to higher level of care

Ensure appropriate medical intervention and timely rescue of deteriorating patient by competent teams

Establish Ward agreement for implementation

Development of team project support

Establish working relationship with Clinical Governance and Audit for project support in developing a measurement framework to guide improvement

Develop Communication – posters/information

Involve Patients and family in treatment processes and planning and ensure appropriate feedback and understanding is provided.

Develop an effective and appropriate support through executive sponsorship, clinical lead, multidisciplinary team working, approval/money support

Increase confidence in the monitoring tool – identify early symptoms through the Implementation of the screening tool to include the SEPSIS 6 checklist

Increase the number of patients who receive antibiotics within 1 hour of recognition - Achieve 80% initially.

Increase understanding of condition all professional, patients and public – “SEPSIS as a medical emergency” e.g. Local and National awareness campaign

Secondary Drivers Specific Change Ideas

Link “at risk” patients with ward safety brief

Support education on burden of illness and current performance

Provide training to staff on clinical knowledge and improvement skills

Ensure reliable process of communication through SBAR for consultants, doctors, nursing staff and outreach teams.

AIM

BGH SEPSIS Driver Diagram

Tests of change

Initial Test

Version 6

Version 10

NAME OF DOCTOR:SIGNED:

PATIENT DETAILS RECORDED ON SEPSIS 6 MASTER LIST YES

_____:_____Monitor urine output6

_____:_____Lactate (consider ABG)5

_____:_____Fluid Bolus started 4

_____:_____IV ANTIBIOTICS STARTED3

_____:_____Blood cultures taken2

_____:_____Start on high flow oxygen 1

COMMENTS / REASON IF NOT DONE START TIMESEPSIS 6

SEPSIS 6 – 1st HOUR OF TREATMENT

SUSPICION OF INFECTIONYES Commence Sepsis 6 NO Prescribe Appropriate Plan of CareLIKELY SOURCE OF INFECTION:

SIRS SCORE :_______ INFORMED: DOCTOR OUTREACH HAN

Date : Time: Signed:

SYSTEMIC INFLAMMATORY RESPONSE SYNDROME (When SIRS ≥ 2)

SIRS ALERT (≥2) v (10) 19/02/2013

NAME OF DOCTOR:SIGNED:

PATIENT DETAILS RECORDED ON SEPSIS 6 MASTER LIST YES

_____:_____Monitor urine output6

_____:_____Lactate (consider ABG)5

_____:_____Fluid Bolus started 4

_____:_____IV ANTIBIOTICS STARTED3

_____:_____Blood cultures taken2

_____:_____Start on high flow oxygen 1

COMMENTS / REASON IF NOT DONE START TIMESEPSIS 6

SEPSIS 6 – 1st HOUR OF TREATMENT

SUSPICION OF INFECTIONYES Commence Sepsis 6 NO Prescribe Appropriate Plan of CareLIKELY SOURCE OF INFECTION:

SIRS SCORE :_______ INFORMED: DOCTOR OUTREACH HAN

Date : Time: Signed:

SYSTEMIC INFLAMMATORY RESPONSE SYNDROME (When SIRS ≥ 2)

SIRS ALERT (≥2) v (10) 19/02/2013

Data Collection FormBORDERS GENERAL HOSPITAL SEPSIS 6 DATA COLLECTION FORM INCLUSION CRITERIA: Patients who score 2 or more Systemic Inflammatory Response Syndrome (SIRS) criteria and there is a suspicion of sepsis. ADMISSION DATE:__________________ADMISSION TIME:______________________DISCHARGE DATE:_____________________ DATE OF SEPSIS DIAGNOSIS:________________SIRS:___________TIME ZERO: _________________ Time Zero = time of meeting inclusion criteria

PROCESS MEASURES Document Time of Measure / Comments

(A)* Achieved <1 hour of time Zero

Oxygen Administered to saturation of .95% (or target saturation of 88-92% if at risk of hypercapnic respiratory failure)

Yes No N/A

Time: Not Recorded

Yes Total Time Taken: No

Blood Cultures Taken

Yes No N/A

Time: Not Recorded

Yes Total Time Taken: No

Antibiotics Administered

Yes IV Oral No N/A

Time: Not Recorded

Yes Total Time Taken: No

IV Fluid Bolus Commenced

Yes No N/A

Time: Not Recorded

Yes Total Time Taken: No

Serum Lactate Measured

Yes No N/A

Time: Not Recorded

Yes Total Time Taken: No

Urine Output Measurement **PLEASE RECORD METHOD/S USED Catheter Urinal/Bedpan Bladder Scan

Yes No N/A

Time: Not Recorded

Yes Total Time Taken: No

Was Sepsis Six Performed < hour of Zero Time? To achieve this all above boxes in (A)* must be YES Yes No

Other Comments on Process Measures: (i.e. note achieving <1 hour)

OUTCOME MEASURES

Alive at 30 days

Yes No

DATE OF DEATH

Length of Stay (Total number of days in BGH) days

ANTIBIOTICS COMPLIANT WITH LOCAL POLICY Yes No

ICU admission Stay (Total number of days in ICU)

days

ICU ADMISSION DATE: ICU DISCHARGE DATE:

PT LABEL

Percentage of patients with blood culture performed within 1 hour of time zero

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Oct-12 Nov-12 Dec-12 J an-13 Feb-13

Admissions Unit Acc ident & Emergency Ward 7 -pilot ward

Percentage of patients receiving oxygen therapy to achieve appropriate saturation levels within 1 hour of time zero

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Oct-12 Nov-12 Dec-12 J an-13 Feb-13

Admissions Unit Acc ident & Emergency Ward 7 -pilot ward

Results:

Blood Cultures

O2

Percentage of patients who receive all required IV antibiotics within 1 hour of time zero

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Oct-12 Nov-12 Dec-12 J an-13 Feb-13

Admissions Unit Accident & Emergency Ward 7 -pilot ward

Percentage of patients receiving IV fluid challenge and reassessment within 1 hour of time zero

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Oct-12 Nov-12 Dec-12 J an-13 Feb-13

Admissions Unit Accident & Emergency Ward 7 -pilot ward

Results:

IV antibiotics

Fluids

Percentage of patients with Serum Lactate and FBC measured with 1 hour of time zero

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Oct-12 Nov-12 Dec-12 J an-13 Feb-13

Admissions Unit Accident & Emergency Ward 7 -pilot ward

Percentage of patients who commenced accurate urine output measurement and had consideration of Urinary Catheter within 1 hour of time zero

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Oct-12 Nov-12 Dec-12 J an-13 Feb-13

Admissions Unit Acc ident & Emergency Ward 7 -pilot ward

Results:

Urine output

Lactate

Compliance with Sepsis 6

Percentage of patients with Sepsis Six performed within 1 hour of time zero

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Oct-12 Nov-12 Dec-12 J an-13 Feb-13

Admissions Unit Accident & Emergency Ward 7 -pilot ward

Percentage of patients with Sepsis Six performed within 1 hour of time zero

2012: 2 + hrs 2013: < 30 mins

Time to Antibiotic Administration - January 2013 (n=23)

0

20

40

60

80

100

120

140

160

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23

Patient

Min

utes

Antibiotics administered (XX%) median

Diagnosis Delay

Figure 2 - Time taken to commence antibiotics (n=38)

00:00

02:24

04:48

07:12

09:36

12:00

14:24

16:48

Case (Date of Zero Time)

Time (h

h:mm)

ABXTIME MEDIAN GOAL

Balancing measure: Are all Patients with a SIRS of 2 and above captured?

Spot checks on all the wards are done monthly on one day .The spot check includes checking all patients SIRS chart on all the wards

for a reading of ≥ 2 using the headings.

• 44 notes were inspected on 18th April 2012. • 3 patients had a SIRS of 2.• 2 received Sepsis Six.• 1 did not enter into the programme.

Date Sirs2? Action Dr/Han sticker Sepsis 6 Diagnoses Ward

Our Successes– Patients are increasingly receiving evidence based

treatment for sepsis– Patients are receiving timely management– We have a committed driven team– We have increased awareness of the sepsis six

interventions– We have achieved a better understanding of the

interconnection between the process and outcomes of the interventions

– We have achieved meaningful real time data collection– Have successfully used the model for improvement

and PDSA methodology– Well received at ‘Grand Round’

Our Challenges– AUDIT – Time resources and capacity– The early recognition of sepsis – New FY1 every 4 months (+ Rotating Shifts (wards/HAN/Day/ night))– Nursing teams relying on “bank staff” frequently– Hospital wide education– The compliance with the use of the sticker for all patients with a SIRS

of 2 – Highlighting sepsis as a medical emergency – Concern with diagnostic accuracy obscures the early recognition of

Sepsis– Maintaining momentum– Keep the focus of the model for improvement– Achieving standardisation and sustainability as the project develops

Forward Planning:• Create a structured monthly feedback on all wards.• Create a Sepsis Pathway.• Increase awareness in the middle grade doctors.• Incorporate the Maternity Units/ McQIC workstream.• Review progress and continue to have local core group meetings every 2

weeks.• Improve the data collection sheet (PDSA).• Learn from mortality reviews.