SEPSIS: IMPROVING CARE, IMPROVING OUTCOME
Professor Kevin Rooney
World Sepsis Day
13th September 2012
Scotland HSMR – 10.6% Reduction
0.5
1.0
1.5
Oct-Dec2006
Jan-Mar2007
Apr-Jun
2007
Jul-Sep2007
Oct-Dec2007
Jan-Mar2008
Apr-Jun
2008
Jul-Sep2008
Oct-Dec2008
Jan-Mar2009
Apr-Jun
2009
Jul-Sep2009
Oct-Dec2009
Jan-Mar2010
Apr-Jun
2010
Jul-Sep2010
Oct-Dec2010
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Apr-Jun
2011
Jul-Sep2011
Oct-Dec2011
Jan-Mar
2012p
Sta
ndar
dise
d M
orta
lity
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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
0
20
30
40
10
© 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.
2
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.
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%
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
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 Blood Cultures
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 of Blood Cultures
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 Lactate
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 of Lactate
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
Percentage Compliance Catheter
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
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
00:00
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%
50%60%
70%
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)
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