1. National Sepsis Audit National Registrar Research Collaborative Audit Project 2013 Nationally led by SPARCS (Severn and Peninsula Audit and Research Collaborative for Surgeons) Regionally led by NWRC (North West Research Collaborative)

2. Background Previous national audit Multicentre observational study of performance variation in provision and outcome of emergency appendicectomy 3326 patients from 95 centres British Journal of Surgery 2013; 100: 1240–1252 Led by West Midlands Research Collaborative International audit of sepsis in general surgical admission Including general, vascular and breast surgery

3. Aims Examine the proportion of emergency surgical patients presenting with severe sepsis Establish compliance with the Sepsis Six and Surviving Sepsis Resuscitation Bundles. Establish compliance with Source Control guidelines for patients with severe sepsis

4. SIRS, Sepsis and Severe Sepsis A. Systemic Inflammatory Response Syndrome (SIRS): Presence of two or more of the following: 1. Temperature >38.3°C or <36°C 2. Heart rate >90 beats/min 3. Respiratory rate >20 breaths/min 4. WBC >12,000 cell/mm3 or <4,000 cell/mm3 5. Acutely altered mental status 6. Hyperglycaemia (plasma glucose of >7.7mM/l) in the absence of diabetes B. Sepsis Sepsis is deemed present when SIRS is accompanied by a clinical suspicion of infection.

5. SIRS, Sepsis and Severe Sepsis C. Severe sepsis Sepsis-induced tissue hypoperfusion or organ dysfunction: 1. Sepsis-induced hypotension (systolic Bp of < 90 or MAP < 65mmHg) 2. Lactate >2 mmol/L 3. Urine output 176.8mmol/l 4. Acute lung injury with PaO2/FIO2 < 300 in the absence of pneumonia 5. Acute lung injury with PaO2/FIO2 < 200 in the presence of pneumonia source 6. Bilirubin >34.2mmol/L 7. Platelet count < 100,000 μL 8. Coagulopathy (international normalized ratio > 1.5 or a PTT>60 secs)) D. Septic Shock Sepsis-induced hypotension, persisting despite adequate fluid resuscitation.

6. Audit Standards Sepsis Six guidelines: ALL of the following interventions should be performed within one hour of severe sepsis: a) Delivery of high flow oxygen b) Obtainment of blood cultures prior to antibiotic administration c) Administration of empirical broad-spectrum antibiotics d) Fluid resuscitation e) Measurement of serum lactate and full blood count f) Commence accurate urine output measurement (may require catheterisation)

7. Audit Standards Surviving Sepsis guidelines: ALL of the following interventions should be performed within six hours of severe sepsis: a) In the event of hypotension or lactate ≥4mmol/L: i. Deliver an immediate minimum of 30ml/kg crystalloid ii. Give vasopressors for hypotension not responding to initial fluid resuscitation to maintain mean arterial pressure ≥65mmHg b) In the event of persistent hypotension despite volume resuscitation and/or initial lactate >4mmol/l: i. Achieve central venous pressure of ≥8mmHg ii. Achieve central venous oxygen saturation ≥70% c) Source of infection to be identified and controlled

8. Patient Identification Presence of sepsis will be elicited for the first 24 hours of each patient’s hospital admission only Age >16 years Urology, neurosurgery, plastics, obstetrics and gynaecology, ENT, cardiothoracics, ophthalmology and maxillofacial surgery will be excluded Inpatients and referrals from other medical specialties will also be excluded Eligible Patients admitted between: 09:00 on Monday 21st October – 09:00 on Monday 28th October

9. Data Extraction Commence 30 days after admission For all patients: demographic data will be recorded data concerning the presence or absence of sepsis markers during the first 24 hour of admission. Where sepsis was not present, no further data collection will be required. If sepsis was present further data extraction will be performed: adherence to surviving sepsis guidance, investigation of source and timing of source control, total of 30 days post admission.

10. Next Steps PI (Primary Investigator) at each trust: Consultant who agrees to support the audit Register the project with the audit department Team of trainees (Insert name[s] here) responsible for data collection Accurate daily list of all general surgical admissions during the study period (Insert name[s] here) will collate 30-day follow-up data