SEPSIS: IMPROVING CARE, IMPROVING OUTCOME

Professor Kevin Rooney

World Sepsis Day

13th September 2012

Scotland HSMR – 10.6% Reduction

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Oct-Dec2006

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Standardised Mortality Ratio (SMR) Regression line

Good but room for improvement

Sepsis

What is Sepsis?

Acute MI & Trauma

5% Mortality 3% Mortality

Severe Sepsis And HAI Mortality

• SEVERE SEPSIS

• 2004: 14000 DEATHS

• 300 per million dying of severe sepsis in any one year

• ODDS: 1 in 3333

• SEPSIS in UK: 37000 DEATHS • ODDS 1 in 125

• MRSA & CDI

• 2006: 8132 DEATHS

• 91 per million dying of MRSA or CDI in any one year.

• ODDS: 1 in 11,000.– For those aged under 45

years : 1 in 250,000.– For those aged 85 years or

older, 1 in 300.

www.statistics.gov.uk); ; UK Sepsis Group Harrison D et al Critical Care 2006; 10:R42

Lung1 Colon2 Breast3 Sepsis4

cancers

Annual

UK mortality

(2003),

thousands

1,2,3 www.statistics.gov.uk,

4 Intensive Care National Audit Research Centre (2006)

A U.K. Perspective

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20

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© Ron Daniels 2010

Copyright 2010 by the American Medical Association. All Rights Reserved. Applicable FARS/DFARS Restrictions Apply to Government Use. American Medical Association, 515 N. State St, Chicago, IL 60610. Published by American Medical Association.

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Sepsis in General Surgery: The 2005-2007 National Surgical Quality Improvement Program Perspective.Moore, Laura; Moore, Frederick; Todd, S; Jones, Stephen; Turner, Krista; Bass, Barbara

Archives of Surgery. 145(7):695-700, July 2010.

Surgical Sepsis

Not just anyone

Tip of the Iceberg

Courtesy of Dr I Roberts

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%

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

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

Reliable Recognition, Assessment & Rescue

Sepsis Screening

• MEWS: >95% reliable in pilot wards• Systemic Inflammatory Response Syndrome

(SIRS) criteria

The Sepsis Six

1. Deliver high-flow O2 (>98% 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 serum 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.

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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%

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

Median Time To Oxygen Target

00:00

00:07

00:14

00:21

00:28

00:36

00:43

00:50

00:57

01:04

02/04/12 02/05/12 02/06/12 02/07/12 02/08/12 02/09/12

Percentage Oxygen Complance

0%

20%

40%

60%

80%

100%

120%

02/04/12 02/05/12 02/06/12 02/07/12 02/08/12 02/09/12

Median Time to IV Fluids

00:00

00:28

00:57

01:26

01:55

02:24

02:52

02/04/12 02/05/12 02/06/12 02/07/12 02/08/12 02/09/12

Percentage Compliance IV Fluids

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120%

02/04/12 02/05/12 02/06/12 02/07/12 02/08/12 02/09/12

Median Time to Blood Cultures

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00:28

00:57

01:26

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Percentage Compliance of Blood Cultures

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120%

02/04/12 02/05/12 02/06/12 02/07/12 02/08/12 02/09/12

Median Time to Lactate

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00:28

00:57

01:26

01:55

02:24

02:52

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Percentage Compliance of Lactate

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120%

02/04/12 02/05/12 02/06/12 02/07/12 02/08/12 02/09/12

Percentage Compliance Catheter

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100%

02/04/12 02/05/12 02/06/12 02/07/12 02/08/12 02/09/12

Median Time to Catheter

00:00

00:28

00:57

01:26

01:55

02:24

02:52

02/04/12 02/05/12 02/06/12 02/07/12 02/08/12 02/09/12

Median Time to ABX

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00:28

00:57

01:26

01:55

02:24

02:52

03:21

02/04/12 02/05/12 02/06/12 02/07/12 02/08/12 02/09/12

Percentage Compliance ABX

0%10%

20%

30%40%

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80%90%

100%

02/04/12 02/05/12 02/06/12 02/07/12 02/08/12 02/09/12

The Future

Acute Medical Unit

Acute Surgical

RAH

EDMedical/ Surgical Wards

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)