1. Sepsis Improvement Project “Sepsis Kills” Wirral University Teaching Hospital NHS FT

2. Team Details NamesRolesContact Details Mark HughesSepsis Lead, ICM ConsultantMhughes5@nhs.net Louise TaylorAQ/Compliance Manager, Q&S Jane LangleyClinical Audit Lead, Q&S Leeanne LockleyAQ Case Manager, Acute Care Tori YoungLead Antimicrobial Pharmacist John CunniffeInfection Control Lead, Med Micro Consultant Andrea WoottenConsultant in Emergency Medicine Helen MorrisED Senior Sister (Helen KieltyClinical Coding Manager) (Conor McgrathICM Consultant)

3. What was your original project Aim and has this changed? Original AIM: To improve the awareness, recognition and timely management of Sepsis. Increase use of WUTH Sepsis pathway. Details of changes: The original aim focused more on pathway use as a means to achieve improved recognition and care. We have actually driven all components above. Explanation of changes: Difficult to collect all measures (particularly accurate Pathway use) due to manpower shortages. We have had to focus on key measures (required by AQ) therefore. In process of converting paper Sepsis pathway to electronic version.

4. DRIVER DIAGRAM

5. Driver diagram Please insert your driver diagram 5

6. Measures and Data Measures: Dara challenges AQ measures Patients with community sepsis (70%) Performance within 3 hours of hospital arrival May not be recognised within first 3 hours! Includes: 1.EWS <60 mins of hospital arrival 2.Evidence of sepsis (and documentation of suspected source) within 2 hours of arrival 3.BC taken < 3h of hospital arrival 4.Abs given <3h of arrival 5.Lactate measured <3h 6.Senior review <4h of arrival Our measures All patients with suspected or confirmed sepsis Performance within 1 hour from recognition of sepsis Includes: 1.Sepsis recorded in case notes: 2.Severity of sepsis recorded? 3.Use of pathway: Used at all? Used correctly? 4.Blood cultures within 1 hour of recognition of possible sepsis? 5.Antibiotics within 1 hour of recognition 6.Serum lactate measured within 1 hour

7. Data: Improved recognition & Coding

8. Performance Data

9. Performance Data:

10. Key Achievements & Lessons Learnt What have we learned –Targeted teaching and promotions achieves better buy in –Temperatures checks are very useful tools –Not easy driving improvement changes As soon as we relax, performance dips!! What has worked well and why –The team: highly motivated and functional group –“Sepsis September” (& equivalent) campaigns Month long education & awareness drives Providing support and materials, but encouraging clinical leads in the targeted area to decide best way to deliver No prescribed formulae for these! What would you do differently –Look to get full time team members in much earlier Still not achieved this, but on executive agenda (Full time Sepsis nurses)

11. Key Achievements & Lessons Learnt What impact have you made –Raised Sepsis profile within Trust –Improved recognition & clinical coding –Improved antibiotic delivery times in community Sepsis (AQ population) –Making a difference (but slowly!) What are you most proud of –Team effort & performance: Functional, committed group Very effective operationally –Early days yet, but implementing an electronic (IT) Sepsis ALERT

12. What should AQuA do differently More time for team work Excellent facilitator support – continue to encourage