1. SEPSIS KILLS program (general overview) add LHD and/or hospital name

2. Aims Provide an overview of the SEPSIS KILLS program and its impact in this LHD/facility Outline the elements of the inpatient SEPSIS KILLS program Identify the steps for the LHD inpatient program rollout 2

3. Defining sepsis… Systemic response to an infection leading to shock, organ failure and death Systemic Inflammatory Response Syndrome Infection Sepsis Severe Sepsis Septic Shock Increasing Mortality

4. Sepsis – what’s the problem? High mortality 20-25% in adults (ARISE 2007), 10 % in children (Han, 2003) Mortality increases with delays to treatment (Kumar, 2006) Approximately 15000 cases of severe sepsis/septic shock in Australia each year (Finfer et al, 2004) Increasing incidence – anticipated 60% increase by 2036 High costs – acuity, LOS, patient experience - NSW sepsis 2% acute bed days and mortality 17.82% vs 1.54% for general hospital population (2009/10) - Sepsis ALOS 11.1 days (vs 2.9 days) in NSW - Average cost weight/sep 3.39 vs 1.07 for all acute patients - Estimated costs at current rate to 2019 $ 3.7 billion (if in top 5 codes) (CEC Cost Effectiveness Analysis 2011)

5. Difficult diagnosis Not all patients have classic systemic inflammatory response syndrome (SIRS) Sepsis is a clinical diagnosis requiring experience and a high index of suspicion for interpretation of history, signs and symptoms Signs are often subtle Some groups at special risk eg infants, age >65, neutropaenia, haemodialysis, diabetes mellitus, alcoholism, lung disease, patients with invasive devices (Laupland et al Crit Care Med 2004)

6. The problem in NSW CEC Clinical Focus Report - 2009 167 sepsis related incidents over 18 month period from IIMS Failure to recognise sepsis Failure to take appropriate and timely action Poor patient outcomes Failure to see sepsis as a medical emergency

7. The SEPSIS KILLS program RECOGNISE: Risk factors, signs and symptoms of sepsis and inform senior clinician RESUSCITATE: With rapid antibiotics and IV fluids within one hour REFER: To specialist care and initiate retrieval if needed

8. Results - emergency departments

9. LHD results Add LHD and/or facility chart here 9

10. Next steps – the inpatient wards Leverage off success in the emergency departments Inpatient SEPSIS KILLS launch May 2014 Integration with deteriorating patient strategy and other quality and safety programs

11. What happens on the wards in NSW? Patients with sepsis are not getting the timely and appropriate care they need 30% of adult deteriorating patients requiring a Rapid Response are septic (CEC 2011, Jones, 2006) They are often sicker than they appear with a high potential mortality ED patients with severe sepsis are transferred to the wards and then deteriorating with poor outcomes There is an under appreciation of the significance of raised serum lactate (> 4mmol/L)

12. NSW sepsis mortality by severity CEC/HIE linked data n=3851 (2012)

13. Gao F, Melody, Daniels D et al. The impact of compliance with 6-hour and 24-hour sepsis bundles on hospital mortality in patients with severe sepsis: a prospective observational study Critical Care 2005 9:R764-R770 101 (wards 90, A&E 11) consecutive patients who met criteria for severe sepsis or septic shock Within 6 Hours 74% presumptive diagnosis including blood culture 74% had antibiotics 52% had serum lactate 84% had immediate fluids if hypotensive 70% had a vasopressor when MAP<65 and/or blood to Hb target 7- 9 g/L All elements in 52% Compliant vs non-compliant groups were compatible Mortality – 49% vs 23% RR 2.12 (95% CI 1.2 – 3.76), P=0.01 – NNT to save 1 life  4

14. Marwick, Guthrie, Pringle et al. A multifaceted intervention to improve sepsis management in general hospital wards with evaluation using segmented regression of interrupted time series BMJ Qual Saf 2013 epub 860 bed teaching hospital in Scotland, 22 medical, surgical, orthopaedic wards Looked at patients with sepsis >24 hours after admission Screened 999/1341 patients with blood cultures over 6 month period (Sept 2008 - Feb 2009) Mean time between sepsis onset and antibiotic administration was 11.0 hours (median 6.0 hours) Longest delay was from first medical review to antibiotic prescription (mean 7.2 hours, median 2.5 hours) 14

15. Jaderling et al ICU Admittance by a Rapid Response Team Versus Conventional Admittance, Characteristics, and Outcome (Crit Care Med 2013) Reviewed admissions from wards to ICU in 900 bed trauma referral centre in Stockholm between 2007 – 2009 355/694 (51.2%) as result of Rapid Response call Commonest diagnosis severe sepsis (18.3%) ‘...severe sepsis at the wards was mainly detected by the rapid response team and was the most common admitting diagnosis among the rapid response team patients’ 15

16. In NSW…. Wards highly complex environments with variable levels of monitoring Clinical management responsibility not always clear JMOs/Registrars often reluctant to prescribe new antibiotics especially overnight Therapeutic Guidelines: Antibiotic provide limited guidance for inpatients with sepsis Need clear local guidelines for escalation of sepsis to AMO and ID physician 16

17. What happens here? Add de-identified LHD case/RCA here 17

18. Linking BTF and sepsis…. from Recognition to Root Cause Recognition Is my patient between the flags? Response If not, what should I do? Root Cause Why is my patient deteriorating? Response How should I treat them? Charles Pain 2014

19. The ‘slippery slope’ 19 Patient Condition Time Clinical Review Rapid Response Prevention Death Advanced Life Support Source: Dr Charles Pain

20. 20 SAGO and SPOC charts ISBAR Escalation tools Adult & paediatric pathways 48 hour management plan Antibiotic guidelines Sepsis Toolkit PowerPoint presentations Case studies DETECT Video clips Time to IV antibiotics and IV fluids

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23. Sepsis 48 hour management plan Management plan includes - level of observation - review schedule - escalation plan

24. Implementation

26. Pilot work and early adopters Liverpool hospital pilot to whole of hospital rollout Westmead Hospital whole of hospital rollout early 2014 Orange Health Service integration with In Safe Hands program Griffith Base Hospital identified need for early review after transfer from ED and flag as high potential for deterioration in 48 hours post initial recognition/treatment Paediatric pathway trial in 7 facilities

27. Lessons learnt Leadership from the top is vital - executive and clinicians Preparation is important…take the time to get it right Linkage with deteriorating patient strategy and other Q&S programs Data will drive improvement – plan evaluation from the outset

28. Inpatient Sepsis Toolkit Implementation plan Facility and ward checklists Clinical tools Education resources Evaluation resources Available on CEC sepsis website

29. LHD/facility implementation LHD Exec sponsor and sepsis lead Committee Facility Exec sponsor Implementation team Ward Nursing lead Medical lead CLINICAL EXCELLENCE COMMISSION

30. Evaluation

31. Consider…. What will work in your LHD/facility? Who are the key players? How will you get started? What will success look like?

32. World Sepsis Day 13 SEPTEMBER 2014

33. Early recognition…. Early antibiotics…. Early IV fluids…. Usual treatment delivered sooner. Don’t turn your back on the bomb!

34. Contact details Mary Fullick, Sepsis Program Lead Mary.Fullick@cec.health.nsw.gov.au Tel: 9269 5542 Dr Tony Burrell, Director Patient Safety Tony.Burrell@cec.health.nsw.gov.au Tel: 9269 5550 34

35. References Australasian Resuscitation in Sepsis Evaluation (ARISE) Investigators and the Australian and New Zealand Intensive Care Society (ANZICS) Adult Patient Database (APD) Management Committee. The outcome of patients with sepsis and septic shock presenting to emergency departments in Australia and New Zealand. Critical Care and Resuscitation 2007; 9:8-18. Clinical Excellence Commission. Clinical Focus Report from review of root cause analysis and/or incident information management system (IIMS) data recognition and management of sepsis. Clinical Excellence Commission 2009; Sydney. Clinical Excellence Commission & Agency for Clinical Innovation. Cost effectiveness analysis stage one: do nothing and the case for change. ACI/CEC Policy and Technical Support Unit 2011; Sydney Dellinger RP, Mitchell M, Levy MD, et al. Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock: 2012. Critical Care Medicine 2013; 41: 2; 580-637. Fang G, Meloy T, Daniels D, et al. The impact of compliance with 6 hour and 24 hour bundles on hospital mortality in patients with severe sepsis: a prospective observational study. Critical Care 2005, 9:764-770. Finfer S, Bellomo R, Lipman J. Adult-population incidence of severe sepsis in Australian and New Zealand intensive care units. Intensive Care Medicine 2004; 30:589–596. D, Duke G, Green J et al. Medical Emergency Team syndromes and an approach to their management. [cited 2014, March 31] Available from: http://ccforum.com/content/10/1/R30 Han Y, Carcillo J, Dragotta M, Bills D, Watson S, Westerman M, Orr R. Early Reversal of Pediatric-Neonatal Septic Shock by Community Physicians Is Associated With Improved Outcome. Pediatrics 2003; 112(4) 793-799 Jaderling et al ICU Admittance by a Rapid Response Team Versus Conventional Admittance, Characteristics, and Outcome. Crit Care Med 2013 Kumar A, Roberts D, Wood KE, et al. Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock. Critical Care Medicine 2006; 34:1589-1596. Marwick, Guthrie, Pringle et al. A multifaceted intervention to improve sepsis management in general hospital wards with evaluation using segmented regression of interrupted time series BMJ Quality Safety 2013 epub