1. STAG Sepsis Audit Pilot Study 2008 Phase 1: Resuscitation Room Casemix Phase 2: Physiological Derangement Phase 3: Physiological Derangement (GP referrals)

2. Audit Questions How should we design the audit? How do we identify our patient group? Where can we find the information we need? Where are the patients managed? What is the typical patient journey?

3. Definitions Systemic Inflammatory Response Syndrome (SIRS) is diagnosed when two or more of the following are present: Temperature greater than 38°C or less than 36°C Heart rate greater than 90 beats per minute (bpm) Respiratory rate greater than 20 breaths per minute or PaCO2 less than 32 mmHg/4.26 kPa White blood cell count greater than 12,000/µL or 12.0*10 9 /L, less than 4000/µL or 4.0*10 9 /L, or 10% immature (band) forms*. Sepsis is diagnosed where SIRS is present and the patient is suffering from an infection. *Neutrophil granulocytes lacking nuclear lobes (a high proportion of such cells often indicates a systemic response to infection).

4. Phase 1: Resuscitation Room Casemix Target group: Patients seen in resuscitation room during ED stay 19 Emergency Departments across Scotland 28 days between 3 rd March 2008 to 30 th March 2008 A total of 77,059 ED presentations 3,609 (4.7%) managed in Resus (average 143 patients/day) How many of our patients were managed in the Resuscitation Room?

5. The patient journey (Resuscitation Room)* 49% of Resuscitation Room patients had evidence of sepsis/SIRS 32% of sepsis/SIRS patients were given IV antibiotics in the ED 16% of sepsis/SIRS patients went directly to ICU/HDU 56% of sepsis/SIRS patients went directly to a ward Median inpatient days for sepsis/SIRS Resus patients was 4 days Median inpatient days for non-sepsis/SIRS Resus patients was 4 days 18% of the sepsis/SIRS Resus patients died 9% of the non-sepsis/SIRS Resus patients died * Only seven EDs had sufficient physiological information available (n=1511). All of the above information relates solely to those seven EDs.

6. Phase 2: Physiological Derangement Target group: ED patients with sepsis/SIRS 19 Emergency Departments 14 days between 11.06.08 and 24.07.08 40,012 ED presentations 1,591 (4.04%) with suspected sepsis/SIRS (average 115 patients/day) How many ED patients had sepsis/SIRS?

7. Phase 3: Physiological Derangement (GP referral) Target group: Patients with sepsis/SIRS referred to ED/admissions unit by GPs Emergency Departments and Admission Units in 11 hospitals 7 days between 31.08.08 and 26.09.08 10,797 presentations 165 (1.53%) with suspected sepsis/SIRS (average 24 patients/day) Note: Phases 2 and 3 data are combined hereafter (n=1,756) How many patients referred to EDs/Admissions Units by GPs had sepsis/SIRS?

8. The patient journey* 64% of suspected sepsis/SIRS patients arrived by ambulance 21% suspected sepsis/SIRS were referred to hospital by their GP 4% of sepsis/SIRS patients were sent to ICU or HDU from ED/Admissions Unit 82% of sepsis/SIRS patients went to a ward from ED/Admissions Unit Median stay for sepsis/SIRS patients admitted via ED was 5 days Median stay for sepsis/SIRS patients admitted via the Admissions Unit was 7 days Outcome up to 28 days was recorded: 9% of sepsis/SIRS patients admitted via ED died 17% of sepsis/SIRS patients admitted via Admissions Units died *Analysis utilises combined phase 2 and 3 data (n=1,756)

9. Who is included in the patient group?* Evidence of sepsis/SIRS was observed among 94% (1655) of patients. The remaining 101 were included because sepsis/infection was suspected and there was no sufficient basis for exclusion. 32% of patients with sepsis/SIRS were given IV antibiotics in the ED or admissions unit. *Analysis utilises combined phase 2 and 3 data (n=1,756)

10. What information can we get?* *Analysis utilises combined phase 2 and 3 data (n=1,756) **Physiological information was gathered from SAS notes, ED notes, Observation charts, computerised laboratory results and casenotes. Temperature, HR, systolic and diastolic BP28/28 Respiratory rate and O 2 saturation27/28 WBC 20/28 GCS/AVPU scores19/28 SEWS etc. chart scores 8/28 BM measurements 1/28 Lactate measurements 0/28 EDs/admission units** (n=28) with valid physiological data for  80% patients:

11. STAG Sepsis Audit We will identify every eligible patient from 01.03.09 to 31.05.09 admitted via the ED or Admissions Units We will check ICU and HDU for patients who were admitted to a ward and then deteriorated We will check all in-hospital deaths We will then collect all the data we need from patients’ casenotes How you can help: Can you indicate if you think a patient has sepsis/SIRS? Can you record the first set of observations on the ED computer system (where applicable) in order to assist with case identification and follow-up? Can your record their other observations (as per your STAG Sepsis card)? Can you document the administration of antibiotics? Thanks!