sepsis collaborative: the national perspective professor kevin rooney, 12th december 2012
TRANSCRIPT
Sepsis Collaborative: The National Perspective
Professor Kevin Rooney, 12th December 2012
Background
ICU ConsultantRoyal Alexandra Hospital, PaisleyNational Clinical Lead for SepsisHealthcare 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 SepsisA 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 from37 to 30.8 Percent
6.2% Absolute16% Relative
STAG Sepsis Management in Scotland
• Signs of sepsis < 2 days
• 2% of emergency admissions (~5000)
• 71% had a EWS• 34% had severe sepsis• 21% blood cultures• 32% IV Antibiotics• 70% IV fluids
Scottish Defect Rate was 18-74%
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
LSAlignment with national
workSupports
Expert clinical faculty
Listserve Site Visit
Phone conf Assessments
Monthly Reports via web
LS
A
P
D
S
A D
P
S
1.5 day Kickoff
D
S
P
A
LS
Key Changes
Improvement
Measures
OrganisationalSelf Assessment
Continued Supports
Spreading Ink blot Strategy
• Based on military tactics– Small area of “Good
Practice” across site– As expand will join up
• MAU ED Surgical
– Hospital At night– Medical Wards– DOME
Acute Medical Unit
Acute Surgical
RAH
ED
Evidence for the Change Package
Reliable Sepsis screening (EWS + SIRS)Ensure reliable communication across clinical teams of at risk patientsEnsure timely rescue of deteriorating patient by competent teams
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
AIM
Reliable Recognition &Assessment
Reliable Care Delivery
Education &
Awareness
Culture of safety and Quality
Improvement
PRIMARY DRIVERS
Ensure reliable delivery of Sepsis Six within 1 hourSource Control Ensure reliable escalation of septic patients to higher level of careImprove Antimicrobial stewardship - 3 day review
Education on burden of illness & current performanceProvide training to staff on clinical knowledge and improvement skillsExecutive SponsorshipClinical LeadershipMultidisciplinary team working Develop measurement frameworks to guide improvement
Involve patients & families in treatment processand care planning
SECONDARY DRIVERS
Patient & Family Centred Care
JOINT COLLABORATIVE - SEPSIS DRIVER DIAGRAM
“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/emermed-2012-201361
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
© 2006 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins. Published by Lippincott Williams & Wilkins, Inc.
5
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.
Why within an hour?
Why all septic patients?
• Sepsis Disease Continuum:
• 15% → 30% → 50%
When to Escalate Care?
Progress to date
Top Tips fromWebEx
• 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
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
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 .
Burning Platform
RAH MAU
Total Percentage Compliance
0%
20%
40%
60%
80%
100%
120%
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
0%
20%
40%
60%
80%
100%
120%
02/04/2012 02/05/2012 02/06/2012 02/07/2012 02/08/2012 02/09/2012 02/10/2012 02/11/2012
Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-120
10
20
30
40
50
60
70
80
90
100
% compliance with Antibiotics within 1 hourScottish Acute Teams ( n = 9)
average_team
median
Measurement - Specialty
Crosshouse HospitalP
atie
nt 1
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t 12
pa
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pa
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pa
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t23
00:00
01:12
02:24
03:36
04:48
06:00
Time to first antibiotic wards 4B, 2A,2B,2C,5E,5D,,4E MedianMeasure
pts not handed over to ERT
Dual implementa-tion commenced
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
