Dr. Mark Simmonds Consultant in Acute and Critical Care Medicine Nottingham University Hospitals NHS Trust

Dr. Mark Simmonds Consultant in Acute and Critical Care Medicine Nottingham University Hospitals NHS Trust

Some History Sepsis at NUH Now The Future

Nottingham University Hospitals NHS Trust 1900 beds 1.2 Million population covered 16,000 staff Major Trauma Centre Burns Unit Neurosurgical Centre

Within 6 hours: Blood Cultures Broad spectrum antibiotics (within 3 hours) Measure lactate Adequate fluid resuscitation Use of Vasopressors if needed CVP line placed if needed CVP maintained at 8-12mmHg ScVO2/SVO2 measured Inotropes used if needed Use of Blood if needed

Within 24 hours: Blood sugar maintained <8.3 with Insulin if needed Administration of Steroids if needed Patient s eligibility for Activated Protein C determined Plateau pressures maintained <30cmH20 if ventilated

Critical Care Outreach Acute Medicine/ED doctors ICU Physicians Frontline Nurses Audit Team Microbiologists Junior Doctors Pharmacists Sepsis Action Group Senior Management

Adherence to the 6-hour and 24-hour bundle guidelines Comprehensive evaluation of patient journey Who was involved in care and when? Where was care being given? What role did Critical Care play? What role did Microbiology play? How did these patients present? What organisms were to blame? Where should resources be targeted to improve care?

Patient identifier: Positive Blood Cultures Initially carried out in 2005 Repeated to same protocol in 2010 at QMC, NCH and KMH

75% of patients had severe sepsis on admission Of these 85% of patients were admitted to medicine But, of those deteriorating on the ward, 50% were under surgical teams 45% are admitted to critical care, and stay there a long time

Median time to antibiotics- 2.5 hours (IQR 1-4.75 hours) 90 80 70 Antibiotic Administration 60 Percent 50 40 30 20 10 0 0 1 2 3 4 5 6 Hour

Sepsis Timeline at NUH Seen by first doctor Discussed with Senior Doctor Seen by Senior Doctor Arrive Critical Care Onset of Severe Sepsis Seen by Critical Care Specialist 12:00 13:00 14:00 15:00 16:00 17:00 18:00 19:00 20:00 21:00 Blood Culture taken Radiology Antibiotics given CVP line placed

Wide dissemination of audit results Report to QMC Medical Director Review of Ward Stock Antibiotics Lactate modules added to ABG machines Website designed Sepsis Action Group reformed in 2010

That s all very interesting but really it s not my problem!

Six hour bundle item Blood cultures Antibiotics as per guidelines in <1hr Lactate measured Adequate fluid resuscitation if needed CVP maintained at 8-12mmHg if needed ScVO 2 /SVO 2 measured Use of vasopressors if needed Use of inotropes if needed Use of blood if needed

Six hour bundle item Blood cultures Antibiotics as per guidelines in <1hr Lactate measured Adequate fluid resuscitation if needed Critical Care interventions CVP maintained at 8-12mmHg if needed ScVO 2 /SVO 2 measured Use of vasopressors if needed Use of inotropes if needed Use of blood if needed

Twenty-four hour bundle CORTICUS Blood sugar <8.3 with insulin if needed Administration of steroids if needed Patient eligibility for ApC determined Protective Lung Ventilation DVT Prophylaxis Gastric Protection Decontamination GI tract NICE SUGAR PROWESS- SHOCK

Recognise EWS and screening Blood Cultures Lactate Respond Early Antibiotics Fluid Resuscitation Rescue Early referral to Critical Care if fails to respond

2011/12 Round Again We Go

Sepsis CQUIN target 2012-14 2.5 million Using our existing audit technique (after much negotiation!!!!)

Compliance with: Guideline Antibiotics in <1hr Blood cultures taken Lactate Measured Fluid Resuscitation Baseline: 15% compliance Target: 30% by April 2013 50% by April 2014

Recognise Blood Cultures Lactate Respond Early Antibiotics Fluid Resuscitation Rescue Early referral to Critical Care if fails to respond

More streamlined audit process All critical care admissions with primary diagnosis of infection Higher pick-up rate and easier to perform Retain in depth analysis of patient pathway The audit process had to become PART of the improvement strategy

Intervention Target Time from Time Zero (hrs) Achieved EWS recorded and escalated - EWS=5 appropriately at time zero Escalated Seen by any doctor 0.5 25 mins Comment Seen by a senior clinician 2 65 mins (Reg/Cons) Blood Cultures taken 1 30 mins Broad Spectrum Antibiotics 1 75 mins Delay to given in line with guidelines administration?why Lactate measured 6 Lactate 1.5 Adequate initial fluid resuscitation in event of hypotension or lactate >4 Escalation to critical care requested in event of failure to improve with initial therapy 6 Appropriate fluid resus 6 Delay to MHDU 8 hours No beds

Since November 2011: Over 900 potential cases identified Over 700 patients reviewed Over 350 cases of severe sepsis audited and reported back to the treating clinician Since November 2012: -Over 95% of cases admitted to critical care with infection are being audited Reporting on approx 30-35/month

Nov-13 Oct-13 Sep-13 Aug-13 Jul-13 Jun-13 May-13 Apr-13 Mar-13 Feb-13 Jan-13 Dec-12 Nov-12 Oct-12 Sep-12 Aug-12 Jul-12 Jun-12 May-12 Apr-12 Mar-12 Feb-12 Jan-12 Dec-11 Nov-11 2010 2006 100 90 80 70 60 50 40 30 20 Percent

100 90 80 70 Percent 60 50 40 30 20 10

Seen by Senior Doctor Arrive Critical Care Seen by first doctor Onset of Severe Sepsis Seen by Critical Care Specialist 12:00 13:00 14:00 15:00 16:00 17:00 18:00 19:00 20:00 21:00 Blood Culture taken Antibiotics given

Seen by first doctor Onset of Severe Sepsis Seen by Senior Doctor Arrive Critical Care Seen by Critical Care Specialist 12:00 13:00 14:00 15:00 16:00 17:00 18:00 19:00 20:00 21:00 Blood Culture taken Antibiotics given

Seen by Senior Doctor Arrive Critical Care Seen by first doctor Onset of Severe Sepsis Seen by Critical Care Specialist 12:00 13:00 14:00 15:00 16:00 17:00 18:00 19:00 20:00 21:00 Blood Culture taken Antibiotics given

Presented both positive and negative feedback in an objective, constructive manner Acted as an educational tool in its own right Allowed for a conversation between improvement team and care givers Made sepsis personal

Crude Critical Care Mortality 2009/10 42% 2012/13 28% SMR for Septicaemia 2009 119 2012 86

Resus Sepsis AKI ETCRG CCOT AMCRG R&R EWS Steering CRC

Thank you for your time. Email: mark.simmonds@nuh.nhs.uk Twitter: @mjrsimmonds