Sexing up the Sepsis SixImproving use of the Sepsis Six care bundleShiva Sreenivasan 1 , Chris Custard 1, Rob Stacey 2, Charlie Candish 3, Maria–Belén Espina 1, Elizabeth Dawes 4, Andrew Seaton 51. Unscheduled Care Division (Acute Medicine), 2. Unscheduled Care Division (Emergency Medicine), 3. Department of Clinical Oncology, 4. Clinical Audit Department, 5. Department of Patient Safety

shivasreenivasan@nhs.net

Gloucestershire Hospitals NHS Foundation Trust, Gloucestershire

Use of the Sepsis Six Care Bundle (S6CB) improves mortality in patients with

severe sepsis 1. In September 2010, we identified through incident investigation,

clinical audit, and a short-term mortality alert that there was a problem with

management of severe sepsis at our Trust. Our audit revealed that only 5% of

eligible patients received the full S6CB within the recommended time. We set

out to improve use of the S6CB in patients with severe sepsis.

A Trust-wide Sepsis Six programme was

implemented in February 2012, and comprised

proformas (Figure 1), safety cafés 2 (Figure 2), a

mandatory eLearning package (Figure 5), desktop

screensavers, grand rounds, posters, global emails,

and opportunistic teaching. Improvement was

measured via continuous monthly notes audit and

the statistical process control method.

Our Plan-Do-Study-Act (PDSA) testing ramp (Figure 4) guaranteed form

redesign and pathway review. We set an initial

Unscheduled Care (Emergency Medicine and

Acute Medicine) completion rate target of 75%,

and an initial Ward inpatient completion rate

target of 50%.

 S6CB use in Unscheduled Care improved from 16% in April 2012 to 88% in

August 2013

 S6CB use in Ward Inpatients improved from 5% in September 2011 to 70%

in November 2012 (Figure 3).

We demonstrate improved S6CB use in both Unscheduled Care as well as

Ward inpatients as a result of a Trust-wide quality improvement programme.

Sepsis management has since become a local 2013 CQuIN goal with a financial

value of £802 500.

References1. Daniels R, Nutbeam T, MacNamara G, et al. The sepsis six and severe sepsis resuscitation bundle: a prospective

observational cohort study. Emerg Med J. 2011; 28:507–512.2. Anderson L. Use the World Café concept to create an interactive learning environment. Educ Prim Care 2011; 22:337–338.

AcknowledgementsThe authors would like to thank Dr. Alan Lees, consultant microbiologist, for his help and support with the Sepsis Six implementation project.

Introduction

Method

Results

Conclusions

Time Severe Sepsis Identified:

(complete tasks below within 1 hour)

Time taken:

Sepsis. Investigate, treat and monitor closely. Restart assessment if patient later deteriorates

Sepsis Six Pathway

EWS greater than 3 OR clinical suspicion of infection?

Are any 2 of the following present?

Temperature less than 36ºC or more than 38.3ºC

Respiratory Rate more than 20/minute

Acutely altered mental state

HR more than 90

Consider: Respiratory tract Urinary tract Intra-abdominal Joint infection

CNS Endocarditis Line infection

Measure Lactate - Result:

Name of person completing form:

Date: DD / MM / YYYY Signature:

Systolic BP less than 90, or MAP less than 65, or Lactate greater than 2, or other evidence of organ dysfunction(Creat greater than 177, Bili greater than 34, Plt less than 100, INR greater than 1.5, Urine output less than 0.5mL/kg/hour, SpO2 less than 90%)

Time doneReason not done. Continue overleaf

1 100% oxygenGive 15L/minute via facemask with reservoir bag unless oxygen restriction necessary (e.g. in chronic CO2 retention aim for an SaO2 of 88-92%).

2 IV fluid bolusGive a 500mL - 1000mL bolus of Hartmann’s. Larger bolus may be required e.g. if systolic BP less than 90 or lactate greater than 4, consider 1500–2000ml

3 Blood culturesTake as per Trust guideline. Culture other sites as clinically indicated e.g. sputum, wound swabs, etc.

4 IV antibioticsUse trust antibiotic guidelines. Prescribe first dose on the front of the drug chart. Document target time (‘to be given by’-time) in drug chart and inform nursing staff. Delay in administration increases mortality.

5Lactate + bloods

Lactate on arterial or venous sample. Also request FBC, U&E, LFT, clotting (INR and APTT) and glucose if not yet done.

Consider blood transfusion if Hb less than 7 (or above this with comorbidities)

6Monitor urine output

Consider catheter. Monitor output hourly. Dip urine and send MSU/CSU.

Fluid balance chart YES / NO

Catheter YES / NO

Repeat Lactate. Ensure urgent review by senior Doctor

Contact relevant specialty team to ensure source control e.g. surgeons and consider contacting Acute Care Response Team - Bleep 1700 (CGH), 2700 (GRH)

If Yes

If No

If Yes

GHNHSFT/Y1055/07_12TO BE FILED IN PATIENT CASE NOTES

Name:

Date of Birth: DD / MM / YYYY

MRN Number:

NHS Number:

(OR AFFIX HOSPITAL LABEL HERE)

Start/complete this form if EWS equal to/greater than 3 OR clinical suspicion of infection

Severe Sepsis (mortality rate ~35%) Inform Consultant / Senior Doctor

Figure 1 S6CB proforma

Safety cafés

Figure 2PD

S A

PD S

A

P DSA

PDS

A

Improvement measured through monthly audit

PDS

A

Cycle 1ADesign and complete testing of local pathway form

Cycle 1BDevelop eLearning for sepsis to support launch of form

Cycle 2AFinalise pathway form and commence ED tests

Cycle 2BSpread form to wider Trust through Safety cafés

Cycle 3AReview pathway and redesign form from testing

Figure 4

PDSA testing ramp

Figure 5

Severe sepsis eLearning package

Figure 3

Aug-13    Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13

100

0

10

20

30

40

50

60

70

80

90

Date

Perc

enta

ge o

f pat

ient

s

Unscheduled Care CQuIN target

Inpatient ward CQuIN target

S6CBimplemented

50%

75%

Unscheduled Care

Inpatient wards

Improving use of S6CB in Inpatient Wards and Unscheduled Care

UTOPIA

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Summary