improving outcomes in patients with sepsis, pop up uni, 2pm, 2 september 2015

Improving outcomes in patients with sepsis

Celia Ingham Clark, Director, Reducing Premature Mortality, NHS England

Ron Daniels, CEO - UK Sepsis Trust and Chief Executive – Global Sepsis Alliance

Paula Evans, Volunteer Coordinator, The UK Sepsis Trust Ltd

Part 1 – Sepsis Overview

Celia Ingham Clark

Director for Reducing Premature Mortality

NHS England

What is sepsis?

• Sepsis is a common condition triggered by the body’s immune response

to an infection.

• If not treated quickly, sepsis can eventually lead to multiple organ failure

and death.

• It is estimated that in the UK, there 102,000 cases of sepsis arise

annually, with 36,800 deaths as a result, claiming more lives than lung

cancer (the second biggest killer after cardiovascular disease).

Why does it matter?

• Sepsis is now widely recognised as a key patient safety issue and a cause of

avoidable death and lasting ill health.

• Around 10,000 of the 36,800 deaths are thought to be preventable.

• Improving patient outcomes in this area would have the largest impact on

reducing premature mortality over a 5 year time period.

The role of NHS England

• In December 2014 the Secretary of State announced a range of measures

to tackle sepsis and NHS England is taking forward some of these actions:

• CQUIN - a national measure to incentivise both the screening of patients

for sepsis when they present in a clinical condition suggestive of sepsis

and the administration of intravenous antibiotics within one hour where

sepsis is suspected

• Primary Care Audit Tool - for general practice which will assess

compliance with the NICE Clinical Guideline on treating children with

febrile illness, which can lead to sepsis.

The role of NHS England cont.

Cross-system Programme Board

• NHS England has convened a cross-system sepsis programme board with

representation from statutory health and care organisations, Royal Colleges,

the UK Sepsis Trust, expert clinicians and ambulance services.

• The Board will produce a short report outlining a small number of

‘commitments to action’ to drive improvement in the identification and

treatment of sepsis, with the aim of improving patient outcomes and

reducing mortality and morbidity

Part 2 - Driving improvement in management

of sepsis

Dr Ron Daniels

CEO, UK Sepsis Trust

Chief Executive, Global Sepsis Alliance

@SepsisUK

Sepsis. Why we need Red

Flags.

Dr Ron Daniels FFICM FRCA

FRCPEd

CEO, UK Sepsis Trust

CEO, Global Sepsis Alliance

Breast cancer

Iceberg?

Iceberg?

Top 20 most expensive conditions treated in U.S. hospitals, all payers, 2011

Rank CCS principal diagnosis category

and name

Aggregate hospital costs, US$, in millions

National costs, %

Number of hospital discharges, in

thousands

1 Septicemia (except in labor) 20,298 5.2 1,094

2 Osteoarthritis 14,810 3.8 964

3 Complication of device, implant

or graft 12,881 3.3 699

4 Liveborn 12,390 3.2 3,818

5 Acute myocardial infarction 11,504 3.0 612

6 Spondylosis, intervertebral disc disorders, other back problems

11,218 2.9 667

7 Pneumonia (except that caused

by tuberculosis and sexually transmitted diseases)

10,570 2.7 1,114

8 Congestive heart failure,

nonhypertensive 10,535 2.7 970

9 Coronary atherosclerosis 10,400 2.7 605

10 Respiratory failure, insufficiency,

arrest (adult) 8,749 2.3 404

50

28

11

9

%

Pneumonia

UTI

Abdominal

SSTI

Iwashyna et al: Long-term cognitive impairment & functional disability among survivors of severe sepsis. JAMA, 2010.

16.8

3.8

6.2

7.1

0 5 10 15 20

Moderate-severe

Mild

Before sepsis After sepsis

Cognitive impairment

Basics limit severity

Recognition 2014.

@SepsisUK

Burns

Burns

Infection Sepsis Severe Sepsis

Septic shock

Systemic Inflammatory Organ dysfunction

Hypoperfusion

Response (SIRS)

<1% 10% 35%

50%

Funk and Kumar

Critical Care Clinics 2011 (in press)

‘For each hour’s delay in

administering antibiotics,

mortality increases by

7.6%’

Septic shock

CVS SBP <90, MAP <70, or SBP decrease >40

SvO2 70% or ScvO2 <65%

Cardiac index <3.5 Lmin-1

Decreased capillary refill or mottling

Lactate >2 mmolL-1

RS PaO2/FIO2 <300 or SpO2 <90%

Renal Urine output <0.5 mLkg-1hr-1 for 2 hrs

Creatinine >177 micromolL-1

Hepatic Bilirubin >4 mgdL-1 or >70mmolL-1

Coagulation INR >1.5 or aPTT >60s

Platelets <100,000 x 106L-1

GI Ileus

Ward Sepsis Screening and Action Tool

1. Are any 2 of the following present?

Temperature > 38.30C or < 360C

Respiratory rate > 20 per minute

Heart rate > 90 per minute

Acute confusion/ reduced conscious level

Glucose > 7.7 mmol/l (unless DM)

3. Is any red flag present?

Systolic B.P < 90 mmHg

Lactate > 2 mmol/l



Oxygen saturations < 91%

Responds only to voice or pain/ unresponsive

Purpuric rash

Sepsis unlikely to be present Treat to standard protocols

Red Flag Sepsis This is a time critical condition,

immediate action is required.

Sepsis Six 1 High-flow oxygen

2 Blood cultures, consider source control

3 Intravenous antibiotics

4 Intravenous fluid resuscitation

5 Check haemoglobin and serial lactates

6 Hourly urine output measurement

Record the time, each of these actions is

completed. All actions should be completed as

soon as possible but always within 60 minutes.

Communication: Inform senior clinician (Registrar or above).

Inform Outreach team or local equivalent.

Additional: Bloods (or review or recent samples)) should

include: FBC, U/E’s, LFT’s, and clotting profile.

Observations should be taken every 30

minutes

Lactate should be repeated within 2 hours.

For a chest source is considered order a a

CXR

Y

Y

Y

Sepsis likely

Inform responsible clinician.

Begin hourly observations Reassess for sepsis hourly

Review bloods for markers of

severe sepsis

Consider life threatening sepsis

mimics e.g. Asthma

N

N

N

Sepsis is a time critical condition. Screening, early intervention and immediate treatment saves

lives.

This tool should be applied to all adult patients who are not pregnant who have a suspected

infection or their clinical observations are outside of normal limits

2. Could this be a severe infection?

For example:

Pneumonia

Urinary Tract Infection

Abdominal pain or distension

Meningitis

Cellulitis/ septic arthritis/ infected wound


Systolic B.P < 90 mmHg or MAP < 65 mmHg

Lactate > 2 mmol/l




Responds only to voice or pain/ unresponsive

Purpuric rash

Red Flag Sepsis This is a time critical

condition, immediate action

is required. Assume severe

sepsis present.

Sepsis Six 1 High-flow oxygen. 2 Blood cultures and consider source control. 3 Intravenous antibiotics. 4 Intravenous fluid resuscitation. 5 Check haemoglobin and serial lactates.

6 Hourly urine output measurement. Record the time each of these actions is completed. All actions should be completed as soon as possible but always within 60 minutes.

Communication: Inform senior clinician (e.g. registrar or above).

Additional: Bloods should include: FBC, U/E’s, LFT’s, clotting profile. Observations should be taken every 30 mins Lactate should be repeated within 2 hours. Perform a CXR and Urinalysis Consider source control ( e.g. surgical intervention)

Y


Systolic B.P < 90 mmHg or MAP < 65

mmHg

Lactate > 2 mmol/l




Responds only to voice or pain/

unresponsive

Purpuric rash

Fixing the system.

@SepsisUK

“I’m worried my Dad might have

sepsis”

“Try not to worry. I’ve activated a sepsis alert. The Paramedic crew are on their way. They’ll check for

signs of sepsis and if necessary take

him straight to ED Resusc. The

hospital team will work together to get him treated quickly- we all

know what we’re doing.”

#3andAhalf bit.ly/SepsisNovel

http://bit.ly/SepsisNovel

http://bit.ly/SepsisNovel

Breast

cancer

[email protected]

@SepsisUK

www.sepsistrust.org

www.world-sepsis-day.org

Part 3 – My Experience

Paula Evans

Volunteer Coordinator

The UK Sepsis Trust Ltd

Questions Welcome. Thank you

• Celia Ingham Clark, Director, Reducing Premature Mortality, NHS England

• Ron Daniels, CEO - UK Sepsis Trust and Chief Executive – Global Sepsis Alliance

• Paula Evans, Volunteer Coordinator, The UK Sepsis Trust Ltd

improving outcomes in patients with sepsis, pop up uni, 2pm, 2 september 2015

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