1. Sepsis Collaborative: The National Perspective Professor Kevin Rooney, 12th December 2012

2. Background ICU Consultant Royal Alexandra Hospital, Paisley National Clinical Lead for Sepsis Healthcare Improvement Scotland Conflicts of Interest In the last 5 years I have acted as consultant, or received honoraria / research grants from: Abbott, Baxter, Eli Lilly

3. Royal Alexandra Hospital Clyde –124K ED attendances –25K Medical attendances –50% discharges in first 48hrs –ALOS 6.8 Days RAH –40 med admissions/day –17 GP referrals –Same day discharge 43%

4. Scotland HSMR – 11.4% reduction

5. What is Sepsis?

6. Acute MI & Trauma 5% Mortality 3% Mortality

7. Courtesy of Dr I Roberts

9. Why is it important?

10. The Lingering Consequences of Sepsis A Hidden Public Health Disaster D Angus JAMA 2010 Cohort study of 27,000 older Americans with detailed information on physical & neurocognitive performance Identified episodes of Sepsis in hospital from Medicare data Showed incidence of moderate to severe cognitive impairment increasing 3x – from 6.1% to 16.7% ie possibly 20,000 new cases per year in US Iwashyna et al JAMA 2010

11. Variation In Sepsis Care

12. 15,022 Patients 165 Hospitals Median of 14 Months Mortality Decreased from 37 to 30.8 Percent 6.2% Absolute 16% Relative

13. STAG Sepsis Management in Scotland Signs of sepsis < 2 days 2% of emergency admissions (~5000) 71% had a EWS 34% had severe sepsis 21% blood cultures 32% IV Antibiotics 70% IV fluids Scottish Defect Rate was 18-74% Gray et al Emerg Med J (2012) doi:10.1136/emermed-2012-201361

14. Why is implementation so difficult? Too many elements in the bundle Some are controversial Time Sensitive Process Difficult To Diagnosis Sepsis Early Human Factors Get In The Way Invasive procedures needed ICU stuff??

15. Complacency, Education & Trying Harder isn’t enough

16. New ways of thinking

17. Front line engagement Segmentation Real Time Data Collection Early Feed Back of Metrics Early Case Review and Feedback Use Level 2 Reliability Tools

18. The Collaborative Model LS Alignment with national work Supports Expert clinical faculty Listserve Site Visit Phone conf Assessments Monthly Reports via web LS A P D S A D P S 1.5 day Kickoff D S P A LS Key Changes Improvement Measures Organisational Self Assessment Continued Supports

19. Spreading Ink blot Strategy Based on military tactics –Small area of “Good Practice” across site –As expand will join up MAU ED Surgical –Hospital At night –Medical Wards –DOME Acute Medical Unit Acute Surgical RAH ED

20. Evidence for the Change Package

21. Reliable Sepsis screening (EWS + SIRS) Ensure reliable communication across clinical teams of at risk patients Ensure timely rescue of deteriorating patient by competent teams To improve the recognition and timely management of Sepsis in acute hospitals Outcome: Reduction in mortality in pilot population from Sepsis 5% by December 2012 10% by December 2014 AIM Reliable Recognition & Assessment Reliable Care Delivery Education & Awareness Culture of safety and Quality Improvement PRIMARY DRIVERS Ensure reliable delivery of Sepsis Six within 1 hour Source Control Ensure reliable escalation of septic patients to higher level of care Improve Antimicrobial stewardship - 3 day review Education on burden of illness & current performance Provide training to staff on clinical knowledge and improvement skills Executive Sponsorship Clinical Leadership Multidisciplinary team working Develop measurement frameworks to guide improvement Involve patients & families in treatment process and care planning SECONDARY DRIVERS Patient & Family Centred Care JOINT COLLABORATIVE - SEPSIS DRIVER DIAGRAM

22. “He who must not be named” or “Homer”

23. Reliable Recognition, Assessment & Rescue

24. Type of physiological abnormality at time of ED patient inclusion in audit (first signs of sepsis) n=626 – median age 73 years Gray et al Emerg Med J (2012) doi:10.1136/emermed- 2012-201361

25. Difficult diagnosis Not all patients have classic SIRS Some groups at special risk eg neutropaenia, haemodialysis, diabetes mellitus, alcoholism, lung disease, patients with invasive devices –Laupland et al Crit Care Med 2004 Elderly patients (age > 65 years ) Decreased inflammatory response Often not febrile More likely to be delirious Falls may be only evidence of sepsis-induced delirium More likely to develop septic shock and multiple organ dysfunction syndrome (MODS)

26. Sepsis Screening MEWS: >95% reliable in pilot wards Systemic Inflammatory Response Syndrome (SIRS) criteria

27. SIRS Criteria

28. The Sepsis Six 1.Deliver O 2 (>94% SpO 2 ) 2.Take blood cultures and consider source control 3.Give IV antibioticsaccording to local protocol 4.Start IV fluid resuscitation (min 500ml) and reassess 5.Check lactate & FBC 6.Commence accurate urine output measurement and consider urinary catheterisation All within one hour © Ron Daniels 2010

29. © 2006 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins. Published by Lippincott Williams & Wilkins, Inc. 5 Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock *. Kumar, Anand; Roberts, Daniel; Wood, Kenneth; Light, Bruce; Parrillo, Joseph; Sharma, Satendra; Suppes, Robert; Feinstein, Daniel; Zanotti, Sergio; Taiberg, Leo; Gurka, David; Kumar, Aseem; Cheang, Mary Critical Care Medicine. 34(6):1589-1596, June 2006. DOI: 10.1097/01.CCM.0000217961.75225.E9 Figure 1. Cumulative effective antimicrobial initiation following onset of septic shock-associated hypotension and associated survival. The x-axis represents time (hrs) following first documentation of septic shock-associated hypotension. Black bars represent the fraction of patients surviving to hospital discharge for effective therapy initiated within the given time interval. The gray bars represent the cumulative fraction of patients having received effective antimicrobials at any given time point. Why within an hour?

30. Why all septic patients? Sepsis Disease Continuum: 15% → 30% → 50%

31. When to Escalate Care?

32. Progress to date

34. Top Tips from WebEx Brightly coloured paper for screening tool draws attention Simplify the screening tool Screening tool in blood culture bags to connect essential elements of the process Case note review builds knowledge of system successes and failures Target doctors through induction

36. Lessons from Beware –Prescribing / Charting eg ward chart not ED stat dose –Communication – doctor/nurse – no urgency –Investigation & specimen collection – waiting for results before Abs!! –“Don’t give Abs until I see him” –Avoid infusions, go for IV bolus

37. Twitter

38. More Top Tips Align data collection with junior doctors projects Monthly snapshot audit of triggering patients – ‘who did we miss?’ Open door policy for staff to give real time feedback – what can we do better next time? Named doctor as ‘rapid responder’ ‘Sepsis order set’ for bloods Sepsis pathways on front of EWS chart Use patient stories – good and bad – to drive awareness

39. Considering the side effects of change Process Measures Outcome Measures Balancing Measures –Increased antibiotic use –Clostridium Difficile –MRSA –Staff morale

40. Community of Practice website and Extranet

41. Measurement - Acute

43. Patient not given antibiotics within the hour because of difficulties obtaining access delay in administration of Abs in 1 patient prescribed 1500, given 1610, another patient 1 hr15 mins to abs. Neutropenic sepsis patient 3 hours to Abs, patient with SEWS 7 1 hr 55 to Abs. 1 patient SEWS 8, 2 hrs to ABs. Burning Platform

44. RAH MAU

45. All or nothing

47. Measurement - Specialty

48. Crosshouse Hospital

49. Heart & Minds ‘If you want to build a ship do not gather men together and assign tasks. Instead teach them the longing for the wide endless sea.’ (Saint Exupery, Little Prince)

50. Thank you “I hated every minute of training, but I said, don’t quit, suffer now and live the rest of your life as a champion.” Muhammed Ali

51. Further information kevin.rooney@uws.ac.uk kevin.rooney@uws.ac.uk http://www.knowledge.scot.nhs.uk/sepsisvte/sepsis.aspx