Presentation is loading. Please wait.

Presentation is loading. Please wait.

Amith Shetty SMEDSA study Westmead.  Sepsis noted as leading cause for SAC 1 incidents and RCAs in NSW  A process for early recognition, review and.

Similar presentations


Presentation on theme: "Amith Shetty SMEDSA study Westmead.  Sepsis noted as leading cause for SAC 1 incidents and RCAs in NSW  A process for early recognition, review and."— Presentation transcript:

1 Amith Shetty SMEDSA study Westmead

2  Sepsis noted as leading cause for SAC 1 incidents and RCAs in NSW  A process for early recognition, review and resuscitation of septic patients  Timely early interventions – antibiotics and intravenous fluids

3

4  RECOGNISE - risk factors, signs and symptoms of sepsis  RESUSCITATE with rapid intravenous fluids and antibiotics within the first hour of recognition of sepsis  REFER to senior clinicians and specialty teams, including retrieval as required

5

6  Initiate sepsis pathway based on suspected infection + 2 SIRS criteria  Up-triaging to ATS category 2  Sepsis bomb

7  Oxygen  Blood cultures  Lactate  Intravenous fluids – 20ml/kg crystalloid bolus  Antibiotics <60 minutes ◦ Based on clinician predicted source ◦ Antibiotic stewardship program and guidelines  Monitoring

8  Early senior review and assessment  Early referral to intensive care services  Inpatient sepsis management pathway being launched soon  hr sepsis management tool in pipeline

9 Improvement in time to antibiotics to 60 minutes in last three years >18000 patients registered on CEC sepsis archive Crude patient level data available on archive – time to antibiotics, lactate level, SIRS data

10

11  Retrospective evaluation of prospectively identified patients presenting to ED with sepsis  Multicentre approval ◦ Westmead ◦ Concord ◦ RPA  Single centre data collection and analysis

12  850 bed tertiary hospital  45 treatment space Emergency department  >65000 annual census ED presentations  35-40% ED to ward admission rates

13  Sepsis kills pathway  ATS category 2 for suspected infection + 2 SIRS criteria  Clinicians encouraged to report  Sepsis pathway antibiotic guidelines  Antibiotic stewardship guidance  Patient safety officer and audits

14  ~1200 patients recorded at Westmead in past 24 months  Interim analysis at 590 patients  Median age of patients = 59.5 (IQR 36-75)  Females = 306 median age 54.5 (IQR 32-76)  Males = 284 median age 63 (IQR 46-75)

15  Antibiotics ceased or not given in 48 hours – non bacterial etiology, DNR  Exclusions (no antibiotics 9 + antibiotics ceased <48 hours 76) 85  Median age of female (44 exclusions) = 33 (IQR )  Median age for males (41 exclusions) = 49 (IQR 26-68)  Mann-Whitney U test comparing Age in inclusions versus exclusions Median difference = -17 (CI: -24 to -11) (p<0.001)

16  Total number of inclusions = 505  Median age of patients = 63 (IQR 42-78)  Females = 262 median age 59.5 (IQR 35-78)  Males = 243 median age 64 (IQR 50-77)

17  507/ 590 patients triaged to ATS category 2  85.9% adherence to guideline  Median time to clinician 36 mins (IQR 16-73) ATS 2  Time to clinician– 35 versus 84 minutes (p<0.001)  Time to antibiotics – 66.5 versus 129 minutes (p<0.001)  Time to 2 nd L fluids – 99.5 versus 228 minutes

18  492/590 (83.4% 95%CI ) underwent lactate testing  Exclusions vs inclusions – median 1.4 v 1.8 (p<0.01)  Sepsis versus severe sepsis/ septic shock – median 1.5 v 2.2 (p<0.01)  Dead versus alive – 2.8 v 1.7 (p<0.001)  But significant overlap of tails

19  484/505 patients had blood cultures collected  95.8% adherence (95% CI )  94 /484 (19.4%) positive BC, 13/94 (13.8% contamination rates) → 81/ 484 (16.7% 95%CI ) significant results  26.5% BC + for severe sepsis group versus 13.4% BC + in plain sepsis group

20  329/505 Urine cultures – 62/329 positive results  193/ 505 other cultures – 100/193 positive results

21  297/ 505 (58.8%) received appropriate antibiotics according to guidelines  192 / 505 (38.0%) received at least one antibiotic as per guidelines  16 / 505 (3.2%) received antibiotics not according to guidelines

22 Severe sepsis definition = sepsis-induced tissue hypoperfusion or organ dysfunction (any of the following thought to be due to the infection)  Sepsis-induced hypotension  Lactate above upper limits laboratory normal (>2)  Urine output < 0.5 mL/kg/hr for more than 2 hrs despite adequate fluid resuscitation  Acute lung injury with Pao2/Fio2 < 250 in the absence of pneumonia as infection source  Acute lung injury with Pao2/Fio2 < 200 in the presence of pneumonia as infection source  Creatinine > 2.0 mg/dL (176.8 μmol/L)  Bilirubin > 2 mg/dL (34.2 μmol/L)  Platelet count < 100,000 μL  Coagulopathy (international normalized ratio > 1.5)

23  Age – 58 (IQR 38-75) versus 67 (49-80)  Lactate value → 1.5 ( ) v 2.2 ( )  Total MEDS score → 5 (3-9) v 8 (6-12)  Charlson score → 3 (0-7) v 5 (2-9)  Hospital LOS → 4 (2-8.5) v 7 (3-13)

24  Time to antibiotics →69 minutes (IQR ) in patients with plain sepsis versus 67 minutes (IQRR 49-80) in patients with severe sepsis or septic shock  Time to second litre fluids → 196 minutes ( ) v 249 minutes ( )

25 no sepsissevere sepsis/ septic shockPlain sepsis SIRS SIRS SIRS SIRS SIRS SIRS SIRS total

26  Sensitivity %CI  Specificity %CI  Positive predictive value = 0.88  Negative predictive value = 0.25  Patients with severe sepsis more likely to have >3 SIRS criteria (p<0.001)

27  AMBULANCE vs PRIVATE transport 274 vs 231 (Mann-Whitney) ◦ Median age 74 versus 48 (MD 23 p<0.01) ◦ >SIRS 3 vs 2 (MD 1 p<0.01) ◦ Higher lactate 2.2 vs 1.5 (MD 0.6 p<0.01) ◦ Severe sepsis rates 132/274 (48.2% 95% CI ) versus 68/231 (29.4% 95% CI ) (p<0.01) ◦ MEDS score 9 vs 3 (MD 5 p<0.01) ◦ Mortality (51/ % 95%CI %) versus (6/ % 95% CI %)

28  478/ 505 (94.7%) concurrence of clinician prediction of presumed source of diagnosis when compared to final discharge diagnosis

29 SourceNumber Chest/ respiratory219 Urine84 Skin/ soft tissue/ Orthopedic44 Abdominal / biliary41 PUO/ unknown51 Neuro/ CNS6 Bloodstream10 Oral/ Dental22 Mixed / others28 Total505

30  Mortality rates – in-hospital, 30-day or 90- day  Hospital LOS  Discharge location  Occurrence of severe sepsis or septic shock

31 Time to antibiotic Total patients Plain sepsisSevere sepsis and septic shock Mortality ≤ 1 hour X >1 to ≤ 2 hours x > 2 to ≤ 3 hours x > 3 hours x Total x

32 Time to second litre fluids Total patients Plain sepsisSevere sepsis and septic shock In-hospital mortality ≤ 1 hour351322X >1 to ≤ 2 hours X >2 to ≤ 3 hours X >3 hours X Total x

33  More clinical trials needed on sepsis patients not just focus on severe sepsis and septic shock – ED from ICU shopfront  Overall benefit of bundles care – risk versus benefit  ? RCT on antibiotics after source identification versus clinician prediction based – stratified risk tool development  Risk factors for progression to severe sepsis

34  Bundled care can lead to significant improvements in delivery of care to sepsis patients  Ambulance cohort significantly more unwell – focus for future studies  Senior clinicians are able to reliably predict source of infection


Download ppt "Amith Shetty SMEDSA study Westmead.  Sepsis noted as leading cause for SAC 1 incidents and RCAs in NSW  A process for early recognition, review and."

Similar presentations


Ads by Google