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University of DundeeSchool of Medicine Improving the management of sepsis in general hospital wards Dr Charis Marwick CSO Clinical Academic Fellow & SpR.

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Presentation on theme: "University of DundeeSchool of Medicine Improving the management of sepsis in general hospital wards Dr Charis Marwick CSO Clinical Academic Fellow & SpR."— Presentation transcript:

1 University of DundeeSchool of Medicine Improving the management of sepsis in general hospital wards Dr Charis Marwick CSO Clinical Academic Fellow & SpR Infectious Diseases Prof. Peter Davey Professor and Consultant in Infectious Diseases

2 In comparison with severe sepsis on arrival at hospital, less is known about... Hospital inpatients who develop sepsis The potential to improve care for these patients in general hospital wards Management in earlier stages of sepsis – Logical to intervene before deterioration Patients without proven bloodstream infection – Previous studies focus on positive blood cultures – Only includes 7-17% of septic patients 1 – Mortality and morbidity similar whether +/– ve 1,2 1.Jones and Lowe 1996, 2.Kumar et al 2006

3 Defining the problem Prospective case-note reviews hospital inpatients – Develop case identification method: blood cultures taken – Quantify deficiencies in patient management – Baseline Sept 2008 – Feb 2009 – Post-intervention Oct 2009 – Mar 2010 Mortality among septic inpatients

4 Baseline clinical data Demographic characteristics (n=339) Mean age :67 years (range 18-95) Male gender:193 (57%) Ward type: General medicine General surgery Orthopaedic Other 140 (41%) 120 (35%) 31 (9%) 48 (14%) Suspected site of infection: Respiratory tract Skin or soft tissue Urinary tract Intra-abdominal Line infection Other More than one site 145 (43%) 46 (14%) 79 (23%) 35 (10%) 30 (9%) 68 (20%) Intervention target 1144 patients screened, 339 (30%, 95%CI 27-32%) valid cases

5 Sepsis patients per ward

6 Baseline study outcomes Timing antibiotic therapy after sepsis onset (n=279) Within four hours107 (38%, 95%CI 33-44%) Mean10.9 hours (95%CI 9.3-12.4) Median6.0 hours (IQR 2.4-13.0) Within eight hours169 (61%, 95%CI 55-66%) Timely medical review (n=291)139 (48%, 95%CI 42-54% Blood cultures before antibiotics (n=268)212 (79%, 95%CI 74-84%) Severity assessment (n=339)80 (24%, 95%CI 19-28%) Main component of delay = time between medical review and antibiotic prescription (mean 7.2 hours, median 2.5 hours)

7 Where do delays occur? Patient sepsis Observations checked Medical review Antibiotic prescribed Antibiotic given ?? 1.0 0.0 3.2 7.1 0.9 Mean time in hours Median time in hours Main delay is from review to prescription 2.4

8 Improvement strategy Implement intervention in Medical, Surgical and Orthopaedic wards – 86% patients, feasible Sepsis “tools” = clinical care pathways – Recognition, risk stratifying and management Education and raising awareness – Presented to >300 clinical staff in Ninewells Monthly performance feedback to clinicians – Displayed as posters on intervention wards – Emailed to clinical staff

9 Outcome measure Pre-intervention cohort Post-intervention cohort Difference and significance test result Antibiotics within four hours 91/241 (38%) (95%CI 32-44%) 139/297 (47%) (95%CI 41-52%) 9% X 2 =4.44, df=1, p=0.04 Antibiotics within eight hours 145/241 (60%) (95%CI 54-66%) 198/297 (67%) (95%CI 61-72%) 7% X 2 =2.43, df=1, p=0.12 Mean time to antibiotics 11.0hrs (95%CI 9.3-12.7hrs) 9.5hrs (95%CI 8.1-11.0hrs) 1.5hrs t=1.30, df=536, p=0.19 Median time to antibiotics 6.0hrs (IQR 2.5-13.3hrs) 4.5hrs (IQR 2.0-12.0hrs) 1.5hrs U=32460, p=0.06 Timely medical review 118/251 (47%) (95%CI 41-53%) 126/250 (50%) (95%CI 44-57%) 3% X 2 =0.58, df=1, p=0.49 Blood cultures taken before antibiotics 183/230 (80%) (95%CI 74-85%) 246/290 (85%) (95%CI 81-89%) 5% X 2 =2.46, df=1, p=0.12 Blood lactate level measured (severity) 31/291 (11%) (95%CI 7-14%) 87/346 (25%) (95%CI 21-30%) 14% X 2 =21.99, df=1, p<0.01

10 Summary Sepsis is common (>40 cases per month) in Medical and Surgical Specialties BUT, each Ward only has 1-6 patients per month Main delay in Time to First Antibiotic Dose occurs AFTER medical review Guidelines, education, audit &feedback at Specialty level had little impact

11 Conclusions Collection and reflection on measures for improvement should be at Ward level – Weekly identification of case(s) EWS charts Antibiotic prescriptions Blood cultures HDU transfers – Weekly run chart of individual patient Time to First Antibiotic Dose – Monthly report on Sepsis Six

12 Run Chart, Medical Ward, Sepsis & EWS 4+

13 RESULTS: MORTALITY

14 Sepsis at Ninewells Hospital 12 months data TotalPer Month Blood cultures taken2603217 Patients screened for sepsis2157180 Patients with sepsis1342 (62% BCs)111 Hospital onset sepsis641 (48% sepsis)53 13% definite +ve 2% definite +ve

15 Mortality, multivariable analysis 30 day: 124/640 (19%, 95%CI 16-22%) 90 day: 180/640 (28%, 95%CI 25-32%) Age (not comorbidity, gender or SIMD) associated Severity scores risk-stratify, CURB65 performed best Admission type, days to onset, and ward associated

16 Proposal Mortality (30 day) in any patient who has had a blood culture taken is likely to be a more specific outcome measure for sepsis than total hospital mortality Further work with SPSP hospitals & ISD – Prevalence of sepsis in BC patients – Identification of BC patients by Ward – Record linkage to standardise mortality


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