Clinical Pathways: Special Focus on Sepsis! Trevor Morris Integrated Pathways Project Manager Professor Morris Gordon Professor of Evidence Synthesis and systematic review Strategic Clinical Lead for Quality Consultant Pediatrician Homework Focus for next session Buddying up with each other Kahootz platform Communication Officer support

Why do we need clinical pathways? Not just an evidence based guideline or protocol Pathway conditions are those that we ensure: Have right evidence based care agreed Are delivered at the right times Have the right outcomes achieved to give quality care! Offering ‘best in NHS’ option IT MAKES A DIFFERENCE

For many patients – the first doctor assessing them is often a “junior” doctor Pathway is a “tool” to insure appropriate care is delivered by those with less experience They are live prospectively audited and all ‘failures’ emailed on daily basis!!!!!! This empowers you to make sometimes difficult diagnostic decisions, using trust approved evidence based approach These are not just suggested, but agreed in external contracts by the trust. Our local partners, commissions, the national regulators and our patients can and do hold us to account

Blackpool Teaching Hospitals - 9 High Mortality Pathways Pneumonia Sepsis Stroke COPD Heart Failure Cardiac Chest Pain Acute Kidney Injury Fractured Neck of Femur Acute Abdominal Pain

January 2018 32.70% Tasks MORTALITY Aug 16 – 141 *159 patient case notes reviewed Tasks Opportunities to Care Target: 90% Overall Compliance Target: 40% Oxygen given to maintain sats 99.37% (↓0.63%) 32.70% Blood Cultures < 4 hrs 66.67% (↓1.96%) Lactate Measured < 4 hrs 86.16% (↑5.11%) IV Antibiotics administered < 4 hrs 55.35% (↑3.72%) Fluid Challenge < 4 hrs 92.45% (↑9.44%) Catheterised urine value monitored 91.82% (↓0.99%) MORTALITY Aug 16 – 141 Based on an analysis of Trust mortality data and national risk reduction in order to indicate the potential impact of success, it has been identified that 67* deaths could be prevented a year (6 deaths a month) if sepsis 6 was adhered to trust wide. The focus for 2018-19 was to improve time to antibiotic administration.

Initiatives implemented in 2018 to improve Inpatient Sepsis Care Sepsis trolleys introduced into A&E and SAU which include antibiotics and fluid packs Blood Culture Packs introduced including: Updated Sepsis Care Bundle Pictorial Guide on Blood Culture Patient Information leaflet for sepsis care PGD (Patient Group Direction) for the key antibiotics used according to infection source. Sepsis education slot for junior doctor Induction inc. Improving Sepsis Care Grand Round (03/10/18) Modified and rolled out in the Acute and community bed base setting the NEWS2 charts including warning triangle prompts for sepsis and a prompt Box for staff to 'think sepsis'

IT WORKS - SEPSIS How we measure – we shifted the goal posts 12 months ago to be as strict as possible (evidence informed) Clocks starts when you enter the building (not when we triage) Delivery of all 6 elements – no compensation for missing items Delivery within 4 hours 60+ lives could be saved per year!!!! Delivery of full sepsis 6 is 74%. Delivery of antibiotics 87% within 1 hour (100% within 4 hours) SHMI dropping COMPLIANCE MORTALITY PEERS (AQuA) Jan 18 – 33% Aug 16 – 141 Best in the North West for 1 hour antibiotics (BTH – 86%, NW Mean – 66%) June 19 – 74% Feb 19 – 92

System-Wide Approach to Pathways - Sepsis PRESENTATION ASSESSMENT CONVEYANCE ACUTE POST INTERVENTION RESIDENTIAL Baseline Obs NEWS >4 Handover & Transfer IPN Support COMMUNITY Baseline Obs NEWS >4 Handover & Transfer Follow Up PRIMARY Baseline Obs NEWS >4 Handover & Transfer AMBULANCE Baseline Obs NEWS >4 Pre-Alert HOSPITAL O2 Blood Cultures Lactate Fluid Baseline Obs NEWS >4 Abx Urine Sepsis Six Compliance - 74% (June 19)

System-Wide Approach to Pathways A single, standardised language and pathway for sickness. Calculation of risk to start outside of a hospital setting with the introduction of pre-hospital Obs (Suspicion of Sepsis – SOS) Temperature, Blood Pressure, Heart Rate, Respiratory Rate, AVPU Implementation of National Early Warning Score 2 (NEWS2) Tool: Baseline NEWS (inc. care homes), GP NEWS, Communication NEWS, Transportation NEWS, Arrival NEWS , Track/Trigger NEWS Residential Care: Link into Infection Prevention Team at LCC (Sepsis Strategy for Lancashire Care Homes 2017-20)   Acute Care improvements to include: Introduction of Sepsis Nurse role (Part of integrated Acute Care Response team) Introduction of pan pathway metrics – Including time patient becomes unwell, primary care input, ambulance input inc. pre-alert, A&E input inc. Antibiotic prescription & administration, Oxygen given to maintain sats, Blood Cultures, Lactate Measured, Fluid Challenge, Urine value, Discharge.

The specialist pathway audit team are watching you ALWAYS So write it down CLEARLY IT SAVES LIVES!!!!!!!

Summary Pathways exist for many conditions, but these 9 are critical to patients, the trust, the commissioners, regulators, everyone! They are monitored, all the time. The evidence is we can improve by following – not just compliance, but outcomes If use of pathways is challenged, tell us! Morris.gordon@nhs.net @drmorrisgordon Trevor.morris2@nhs.net @RealTrevMorris M Gordon, 2015 CC