1. The Good, the Bad and the How can we do better? (RRAILs audit)
Dr Harsha Reddy
Consultant (Anaesthetics & ICM)
Wrexham Maelor Hospital, BCUHB

2. Scoring Systems APACHE (2 & 3) Mortality Prediction Model
Simplified Acute Physiology Score
Pre 1984
APACHE = Acute Physiology and Chronic Health Evaluation

5. RRAILS Audit All adult medical (11) and surgical (9) wards
24 hours prior to 08:00 17th Sept
Part 1 : RRAILS metrics
Part 2 : Direct observation
Safety Briefing
SIRS / Sepsis
Use of sepsis bundle
Tuesday 17th September
Section 1: RRAILS Metrics.
This section requires you to identify whether there is data on the Metrics system for the RRAILS bundle within the audit timeframe (previous 24 hours - 8am previous day to 8am day of audit).
Section 2: Direct Observation.
This section looks at each individual patient that fits the inclusion criteria specified above.
Complete one form per ward.
Complete one line per patient.
The elements to be collected are:
Patient Present.
Please cross in the box to confirm that the patient is there to be audited. If the patient is absent and are not going to be included please leave the box blank
NEWS Completed (in line with criteria).
Was the NEWS completed along with each set of observations (in line with the required criteria)?
NEWS Score
Please record the highest NEWS score from the last 24 hours. Record in numerical format (i.e. 06, etc).
2 or more SIRS criteria present (If NEWS > 3)
SIRS Criteria consist of:
Temperature >38.3°C (101°F) or <36.0°C (96.8°F)
Tachycardia >90 bpm
Tachypnoea >20 breaths/minute
PCO2 <4.3 kPa (32 mmHg)
Hyperglycaemia (blood glucose >6.66 mmol/L [120 mg/dL]) in absence of diabetes mellitus
Acutely altered mental status
WBC count >12×10^9/L (12,000/microlitre) or <4×10^9/L (4000/microlitre), or normal WBC count with >10% immature forms.
Suspicion of new infection within 48 hrs (If 2 or more SIRS criteria present)
First Escalation (in line with NEWS score).
Within the audit timeframe (8am to 8am), was there documented evidence that the first NEWS-identified need for escalation did result in an actual escalation. A ‘Yes’ would mean that the first escalation requirement (in line with NEWS criteria) was followed. A ‘no’ (box left blank) would mean that the first escalation requirement was not followed. There is a ‘N/A’ option for cases where no escalation requirements were identified.
First Response (within time frame).
Within the audit timeframe (8am to 8am), was there documented evidence that the first NEWS-identified need for a response did result in an actual response. A ‘Yes’ would mean that the first response requirement (in line with NEWS criteria) was followed. A ‘no’ (box left blank) would mean that the first response requirement was not followed. There is a ‘N/A’ option for cases where no response requirements were identified.
Was there a confirmed diagnosis of Sepsis?
Was there documented evidence that sepsis had been diagnosed for this patient.
Was Sepsis 6 delivered within one hour?
Were the following six factors delivered within one hour of confirmed diagnosis of Sepsis:
Give oxygen
Take blood cultures
Give intravenous antibiotics
Start intravenous fluid resuscitation
Check lactate level
Monitor hourly urine output.

7. Acute Intervention Team

8. 323 patients on our site
Roughly 30% each site. Took out the patients who were not by the bedside as they skewed the data.
Wrexham had highest completion sat 90%
Safety briefing – YG worst at 50% - YGC and WMH were comparable though documentation better at WMH with 90% vs 60%
Overall only 30% escalated but if you delve into the notes most times appropriate…
Sepsis bundle – highest number of cases 12 in WMH but bundle not filled out – duplication. YGC best 1 case of sepsis that day who did get the bundle. YG had 6 cases with 3% getting bundle.

11. RRAILS completion

12. Taken from the 1000 lives document but adapted and on our TPR chart now.

13. Sepsis 6
Cases
Sepsis 6 (%)
East 5
Central 1
100
West 6
66.6

14. The GOOD… Clear documentation Correct patient details
Easily accessible
Overall NEWS score always completed
Excellent staff engagement

15. The BAD… Sepsis page never completed Difficult to read chronicity
Not universally applicable
Sepsis page never completed
Added up incorrectly

16. How can WE do better… Sepsis Care Pathway
Specific NEWS for specific patients…
Missed opportunity to raise awareness…
Not much forewarning so not best prepared for the event.

17. Themed activities
Multimedia awareness campaign
Drop in sessions to reinforce key points
Promote public confidence
Annual event to reinforce importance of messages
Change behaviour – education, accentuate the positive aspects whilst learning from the negatives.

18. Thank you to… Ms. Jo Garzoni Ms Kate Jones (ANP)
Mr Stuart Sailsbury (Resus Officer)
Dr. Mike Smith
Dr. Ibrahim Mohammed
Dr. Zac Hulme
Dr. Aman Harghandewal