1. Qatar’s National Approach to Reducing Sepsis Morbidity and Mortality Prof. Kevin Rooney, Dr. Ahmed Labib Shehatta and Mr. Brent Foreman 24th March 2018

2. Declaration of Conflict of Interest
We have no financial conflict of interest in presenting this topic

4. Agenda 10:45-11:50am / 1:00pm-2:05pm
Develop a better understanding of Sepsis and its sequelae
Learn about Qatar’s National Breakthrough Series Patient Safety Collaborative
Learn about the new Sepsis pathways developed by Hamad Medical Corporation
Learn about the role of the nurse in implementation of the Sepsis pathways and Qatar’s National Breakthrough Series Patient Safety Collaborative
Questions and discussions

5. Why does it matter?

6. The Right Stuff
2,010 deaths between June 2010 and October 2012 in acute hospitals in England
The UK National Health Service database was searched for incidents resulting in a reported death of an adult over the period of the study. The study population comprised 2,010 incidents involving patients aged 16 y and over in acute hospital settings. Each incident report was reviewed by two of the authors, and, by scrutinising the structured information together with the free text, a main reason for the harm was identified and recorded as one of 18 incident types. These incident types were then aggregated into six areas of apparent systemic failure: mismanagement of deterioration (35%), failure of prevention (26%), deficient checking and oversight (11%), dysfunctional patient flow (10%), equipment-related errors (6%), and other (12%). The most common incident types were failure to act on or recognise deterioration (23%), inpatient falls (10%), healthcare-associated infections (10%), unexpected per-operative death (6%), and poor or inadequate handover (5%). Analysis of these 2,010 fatal incidents reveals patterns of issues that point to actionable areas for improvement.
Patient-Safety-Related Hospital Deaths in England: Thematic Analysis of Incidents Reported to a National Database, 2010–2012

7. Sepsis 3.0 Definitions
Life-threatening organ dysfunction caused by a dysregulated host response to infection.
Organ dysfunction can be identified as an acute change in total SOFA score ≥2 points.
qSOFA (Quick SOFA) Criteria
Resp Rate ≥22/min
Altered Mentation
Systolic blood pressure ≤100mmHg
Septic Shock
Persisting hypotension requiring vasopressors to maintain MAP ≥65mmHg
Serum lactate level >2 mmol/L despite adequate volume resuscitation

8. Sources of Sepsis

9. Sepsis: A global burden
Half of patients recover, one-third die during the following year, and one-sixth have severe persistent impairments.

10. Sepsis Increase

11. Sepsis Incidence & Awareness
Apparently according to this paper sepsis awareness is at 62% in the UK.

12. Post-sepsis Syndrome
Impairments include development of an average of 1 to 2 new functional limitations (eg, inability to bathe or dress independently), a 3-fold increase in prevalence of moderate to severe cognitive impairment (from 6.1% before hospitalization to 16.7% after hospitalization), and a high prevalence of mental health problems, including anxiety (32% of patients who survive), depression (29%), or posttraumatic stress disorder (44%).
About 40% of patients are rehospitalized within 90 days of discharge, often for conditions that are potentially treatable in the outpatient setting, such as infection (11.9%) and exacerbation of heart failure (5.5%). Compared with patients hospitalized for other diagnoses, those who survive sepsis (11.9%) are at increased risk of recurrent infection than matched patients (8.0%) matched patients (P < .001), acute renal failure (3.3% vs 1.2%, P < .001), and new cardiovascular events (adjusted hazard ratio [HR] range, ).

13. Timing is everything

14. Timing is everything

15. Sepsis: Early Therapy

16. Baseline Sepsis Data HMC Corporate Mortality Review Jan-to-Dec 2016
340 out of 1077 (31.6%) HMC deaths are sepsis-related
Death to case ration: number of deaths related to sepsis x 100
number of sepsis cases
Proportionate Mortality: number of deaths related to sepsis x 100
all deaths (all causes)
Courtesy of Dr Ahmed Labib

17. Gap between Evidence & Practice
Knowledge Barriers
Attitude Barriers
Behaviour Barriers

18. Breakthrough Series Collaborative Model

19. Qatar’s National Patient Safety Collaborative
Launched by Ministry of Public Health on 15th January 2018
National Patient Safety Collaborative of local partners
System wide issues
Focus on Sepsis, VTE and patient access and flow
This five-year quality improvement initiative will provide a foundation for exchanging ideas and best practice and to reinforce continuous learning efforts and improvement by enhancing the capability and capacity of the system to improve safety. The program will enable a strong support infrastructure to help providers embed quality improvement capability in their organisations. Immediate priorities include a focus on sepsis, VTE and patient flow to make measurable improvements in outcomes for patients and their families.

20. National Patient Safety Collaborative Sepsis Driver Diagram

21. Our guiding principle

22. HMC Sepsis Pathways Dr Ahmed Labib Shehatta, Senior Consultant ECMO, ICM and Anaesthesia

23. Objectives Understand current status of sepsis care across HMC
Understand HMC sepsis care strategy
Improve awareness on HMC Sepsis Program
Engage staff and generate sepsis champions

24. How Did it All Start?

25. Operational Definition
Sepsis is defined as ‘’life-threatening organ dysfunction caused by a dysregulated host response to infection. Sepsis and septic shock are medical emergencies that require immediate treatment and resuscitation’’
Septic Shock is a subset of sepsis in which ‘’profound circulatory, cellular, and metabolic abnormalities after adequate fluid resuscitation are associated with a greater risk of mortality than with sepsis alone’’. Patients with septic shock are those who’s lactate still greater than 2 and require a vasopressor to maintain MAP > 65 mmHg

26. 5 Directives for Sepsis Prevention
Prevent avoidable cases of sepsis.
Key to improving patient outcome from sepsis is early identification and prompt treatment. However, some cases of sepsis are likely to be preventable, particularly in at risk groups including older people, the immunosuppressed, pregnant women and children.
Increase awareness of sepsis amongst professionals and the public.
Over 70% of cases of sepsis arise in the community and yet a large proportion of the public do not recognize the symptoms, which can lead to a delay in treatment.
The range of health and care professionals who will come into contact with patients with suspected sepsis is huge. Though many are aware of and trained in responding to sepsis, some are not, and there is significant variation in the training provided to different professional groups.
Improve the identification and treatment of sepsis across the whole patient pathway.
Though there are pockets of good practice and protocols in distinct settings and localities, improvements are needed across the whole patient pathway, and at interfaces between different settings, to ensure that at risk patients and those presenting with early sepsis are recognized and treated promptly.

27. 5 Directives for Sepsis Prevention
Improve consistency of standards and reporting.
The data we currently have on sepsis are limited, due to a lack of consistency of definitions used to describe sepsis and due to differences in coding practice between professionals and organizations.
Better information is needed on the true prevalence and associated burden of sepsis to inform future quality improvement initiatives.
Underpin all actions with the principles of appropriate antibiotic use and antimicrobial stewardship.
Antimicrobial resistance (AMR) now poses a significant threat to the delivery of healthcare. It is imperative to ensure that principles of good antimicrobial stewardship and appropriate use of antibiotics are built into all activities, communication, training and actions

28. HMC Sepsis Program Program Documents Alert Order set
Baseline data collection
Pilot
Maternity, neonate and Pediatrics pathway
Education
Communication
Evaluation

29. Governance Structure

30. HMC Sepsis Program Aim:
Save lives across HMC by reducing sepsis related mortality by:
Standardizing care (corporate policy and clinical pathways)
Increasing awareness, knowledge and skills (90% of HMC clinical staff completing e-learning module by end 2018)
Early recognition and timely management (95% compliance with the Sepsis Six Care Bundle by end 2019)

31. A Standardized Pathway for All Patients

32. Where are We? Strategies Status Corporate Policy for Sepsis Complete
Standardize care pathways
Standardize diagnostics
Approved
Local facility implementation teams
Operational
Collaboration and IHI tools and methodology for change
Ongoing
Communication strategy
Standardize educational tools
Program measures (KPIs)
Standardize CIS solution

33. Awareness, Knowledge and Skills
Strategies
Status
HMC intranet site
Under development and review
Posters and promotional materials
Under development
Facility awareness symposiums
Completed in Al Khor and Al Wakra
Annual WSD Symposium
600 participants in participants in 2017
Grand Rounds
245 participants in Sept 2017
Orientation programs (Nurses & Physicians)
148 physicians in Nurse rollout planned Q2 2018
ALERT course
1,039 participants in 2017
E-learning module
Under development – rollout planned Q2 2018
Bedside training
40+ educators trained – rollout planned Q2 2018
Cerner training
Curriculum developed – rollout planned Q2 2018

34. Recognition of Suspected Sepsis
Strategies
Status
Vital signs entered at the bedside
Review underway of IT enhancements to assist with the timely and accurate entry of vitals
SIRS/Sepsis alerts in Cerner
Alerts developed/latest updates to be uploaded
Physician notification of patient deterioration
Sepsis icon in ED tracking list under development to alert physician
Clinical review/ Rapid Response procedure
Integration with QEWS documentation under development

35. S6 Bundle Strategies Status
Golden Hour order set in CIS (adult, maternity, pediatrics, neonates)
Approved/under development
Subsequent Hour order set in CIS (adult, maternity, pediatrics, neonates)
Diagnostics and antibiotics in every ward
Approved/for local implementation
Availability of Point of Care (POC) lactate testing
Complete
Priority markers for sepsis lab tests
Agreed

36. Evaluation Questions: Outcome Measures
Death-to-Case Ratio (number of sepsis-related deaths/diagnosed sepsis cases)
Proportionate mortality (number of sepsis-related deaths/total deaths)
*Above measures include in-hospital deaths. Sepsis-related deaths that occurred outside of HMC, but where the deceased had an HMC encounter 30 days prior to death, will be reported separately.
Potential alternative measure to explore: Deaths (in any setting) occurring 30 days after date of onset of confirmed sepsis.

37. Confirmed Sepsis Cases

38. Process Measures Evaluation Questions
Governance – are arrangements in place, roles and responsibilities clear, standard processes agreed?
Education and training – do staff have the appropriate knowledge and skills to carry out their roles and responsibilities according to the agreed pathway?
Pathway –
Are vitals being entered in a timely and accurate manner,
Are nursing staff notifying physicians when an alert fires,
Are physicians reviewing these patients,
Is the Sepsis Six Care Bundle being administered within 1 hour of time zero,
Are order sets being utilized,
How many patients are being transferred to a higher level of care?

39. What are the Process Measures?
Measures that can currently be electronically captured include:
Percent of SIRS/Sepsis alerts that were notified to the physician
Percent of suspected sepsis patients with Sepsis Six Care Bundle completed within one hour of time zero
First IV antibiotic dose administered <60 minutes
Serum lactate result released <60 minutes
Blood cultures taken <60 minutes
IV fluid administered <60 minutes
Oxygen saturation assessed
Oxygen administered <60 minutes
Urine output monitoring commenced <60 minutes
Percent of suspected sepsis cases transferred to a higher level of care

40. Process Measures: What is Time Zero?
Time zero is defined as per pathway:
time of SIRS/ Severe Sepsis alert, OR
time of RRT activation, OR
time sepsis order set initiated
Whichever event occurs first!

41. Process Measures Questions: Suspected Sepsis
Work is ongoing to identify best method of extracting suspected sepsis cases from the electronic system.
Agreed next steps:
Validate NCCCR ‘triangulation’ method with results of prevalence study
Explore potential for Cerner Power Form to capture suspected cases
You Can’t Control What You Can’t Measure!!!

42. Sepsis care: The Nurses Role and Responsibilities Mr
Sepsis care: The Nurses Role and Responsibilities Mr. Brent Foreman RN, MAM(N) Executive Director – Nursing Education and Research

43. Sepsis Care: Nursing and Midwifery Roles and Responsibilities Sessions Objectives
At the conclusion of this presentation, you will be able to:
Understand the global impact of sepsis
Identify the 6 root causes of failures in healthcare systems
Identify sepsis contributing factors
Understand the import role of Nurses and Midwives in improving patient care
Describe the nursing interventions required to prevent and treat sepsis
Describe the successes, challenges, opportunities and lessons learned in roll-out

44. Sepsis Care: Nursing and Midwifery Roles and Responsibilities The Global Impact of Sepsis
World Health Organization (WHO) estimates sepsis affects 30 million people annually
To put this into perspective this graphic holds 30 million dots.
However a dotted graphic doesn’t have the same impact as if we were discussing (click to next slide)
World Health Organization. (2018). Sepsis. [online] Available at: [Accessed 8 Mar. 2018].

45. Sepsis Care: Nursing and Midwifery Roles and Responsibilities The Global Impact of Sepsis
145
82,191
747 jumbo jets.
This equates to 82,191 people daily or approximately jumbo jets
World Health Organization. (2018). Sepsis. [online] Available at: [Accessed 18 Mar. 2018].

46. Sepsis Care: Nursing and Midwifery Roles and Responsibilities The Global Impact of Sepsis29
16,438
According to the WHO, this would be equal to 29 of these 747 falling from the sky daily, everyday, for the forseeable future, unless we do something about this.
World Health Organization. (2018). Sepsis. [online] Available at: [Accessed 8 Mar. 2018].

47. Sepsis Care: Nursing and Midwifery Roles and Responsibilities 6 Universal Root Causes of Failure in Health Systems
Culture – punitive, blaming system, which is tribal, and disengages crucial groups, particularly the clinicians
Clinical governance – ambiguities about who is responsible for what in healthcare, and lack of clear lines of accountability for safety and quality
Communication – poor exchange of essential information among healthcare providers and with patients and their families
Teamwork and coordination of care – poor multi-disciplinary collaboration, care planning and delivery in a fragmented system of care
Capacity and capability – mal-distribution of human resource and skills, both geographically, and over time (daily, weekly and seasonally)
Appropriateness of care – failure to deliver an appropriate level of service to patients when it is needed or failure to escalate care to a service that can meet patients’ needs.
Source: The Clinical Excellence Commission - advisory body on patient safety and quality in the New South Wales health system, Australia.

48. Sepsis Care: Nursing and Midwifery Roles and Responsibilities Sepsis Contributing Factors
Centers for Disease Control and Prevention (CDC)
7 in 10 patients with sepsis had recently used healthcare services or had chronic diseases requiring frequent medical care
Common Infections leading to Sepsis in Adults
Lung infection such as pneumonia (35%)
Kidney or urinary tract infection (25%)
Gut, stomach, or intestine infection (11%)
Skin infection (11%)
Cdc.gov. (2018). Data Reports | Sepsis | CDC. [online] Available at: [Accessed 1Mar. 2018].
Content updated August 2017

49. Sepsis Care: Nursing and Midwifery Roles and Responsibilities Contributing Factors – How do we measure up?
Based on the WHO 20% mortality from patients with sepsis (30 mill with sepsis and 6 mill deaths), HMC may have seen 138 deaths as a result of these infections.

50. Sepsis Care: Nursing and Midwifery Roles and Responsibilities How do we measure up – When we have greater control?
“All systems produce the outcomes that they are designed to produce. The health care system is no different. ” Don Berwick
Based on the WHO 20% mortality from patients with sepsis (30 mill with sepsis and 6 mill deaths), HMC may have seen 138 deaths as a result of these infections.

51. Sepsis Care: Nursing and Midwifery Roles and Responsibilities Nurses and Midwives on the Frontlines

52. Prevention & Assessment
Sepsis Care: Nursing and Midwifery Roles and Responsibilities Care Planning and Delivery
Prevention & Assessment
Clinical Review / QEWS
Patient Condition
Sepsis Pathway
Deteriorating patient
Time
Death
Adapted from Between the Flags, Education Strategy & Implementation Guide 2012

53. Sepsis Care: Nursing and Midwifery Roles and Responsibilities Successes, Challenges, Opportunities and Lessons Learned

54. Sepsis Care: Nursing and Midwifery Roles and Responsibilities Next Steps
Clinical pathway signoff
Full education rollout
iHeed
Workshops
Clinical
Full implementation across patient populations
Neonates, paediatric, adult
Evaluation
Further development
Dashboard
Information systems implementation
Support nurses & midwives to work to the full scope of their practice.
Agree measures to be included on the nursing and midwifery dashboard
Through established governance, ensure unit level responsibility and accountability for improvements
Support full interprofessional collaboration, recognizing the role each of us plays in patient safety and care
Support the implementation, integration and optimization of the sepsis bundle

55. Questions and discussion

56. Presenter Contact Information
Dr. Ahmed Labib Shehatta @
Mr. Brent Foreman
@brent_foreman
Prof. Kevin Rooney
@kevindrooney