Sepsis The Silent Killer in the NHS Kate Beaumont, Trustee, UK Sepsis Trust Nurse Director The Learning Clinic Director QGi Ltd Former Head of Patient Safety and lead for deterioration, National Patient Safety Agency With Rhian Oliver, patient representative
Failure to rescue In 2006 we reviewed the NRLS and identified three themes: No observations made for a prolonged period and therefore changes in a patient s vital signs not detected. No recognition of the importance of the deterioration and/or no action taken other than recording of observations. Delay in the patient receiving medical attention, even when deterioration has been detected and recognised.
Suspect Sepsis
Say Sepsis Sepsis remains the primary cause of death from infection despite advances in modern medicine, including vaccines, antibiotics and acute care. 37,000 people die annually across the UK from sepsis. The yearly mortality from sepsis is greater than breast and bowel cancer combined.
Save someone s life today Surviving sepsis campaign introduced in 2002 Several studies have shown that early recognition and treatment (the CEM standards) reduces mortality from sepsis. Each hour of delay in antimicrobial administration over the ensuing 6 hrs was associated with an average decrease in survival of 7.6%. Time to initiation of effective antimicrobial therapy was the single strongest predictor of outcome.
5% Mortality 3% Mortality Acute MI & Trauma
Implications of sepsis Sepsis makes up 40% critical care workload Patients with severe sepsis have a mortality rate of 40% (7x higher than ACS) Patients in septic shock have a mortality approaching 50%
Suspect Sepsis 1. SIRS: 2 of: > 38.3 C or < 36. 0 C HR > 90 RR > 20 WCC <4 or >12 x 109/L Acutely altered mental status Glucose > 8.3 (unless diabetic) Sepsis = SIRS + infection
Why is implementation so difficult? Time sensitive process - not seen as emergency -?sepsis box Difficult to diagnosis sepsis early affects everyone Human Factors get in the way empower nurses -?bedside lactate testing, bedside technology, Too many elements in some bundles promote sepsis six Why don t doctors who prescribe Abx give first dose??
Improving patient safety = Improve the culture Improve the system
The Sepsis Six 1. Deliver O 2 (>94% SpO 2 ) 2. Take blood cultures and consider source control 3. Give IV antibiotics according to local protocol 4. Start IV fluid resuscitation (min 500ml) and reassess 5. Check serum lactate & FBC 6. Commence accurate urine output measurement and consider urinary catheterisation All within one hour Ron Daniels 2010
Lucien Leape on patient safety culture Mistakes are caused by bad systems, not bad people Systems set people up to fail, or fall into a trap We must recognise that humans are error prone and try to error-proof our systems Remove hazards wherever possible People need to believe that errors are never all their fault Safety is about the future not the past
Doing the right thing It is very rare for staff in healthcare to go to work with the intention of causing harm or failing to do the right thing. Therefore we have to ask, why there are many incidents where some of the latent conditions are caused by staff not doing the right thing, even when they know what the right thing is? Many processes and policies in healthcare are complex or seem to create difficulties for busy staff thus creating the temptation to take shortcuts or workarounds. Patient Safety First s How to Guide for Implementing Human Factors in Healthcare
Perception (from NPSA training material)
We re all human In summary, some of the common human factors that can increase risk include: mental workload distractions the physical environment physical demands device/product design teamwork process design
A human factors approach means; thinking realistically about how people work and prospectively assessing risk, for the mundane as well as the seemingly high risk maintaining a system s overview, so that someone, somewhere, has an understanding of how all of the pieces of the jigsaw come together.
In healthcare, where we often find ourselves working with: equipment that doesn t match our mental models of the way things work information systems that don t allow us to access the data we need quickly and when we need it environments that are cramped or don t have the equipment we need protocols that conflict with the practical ways of getting a job done colleagues who are used to different ways of working time pressures that force us to cut corners teams that don t know each other and where there is conflict.
Say Sepsis Applying human factors principles means - making the right thing the easiest thing,..setting staff up to get it right A safer, more reliable and efficient NHS will remain a pipe-dream until we create a culture where human error is seen as normal, inevitable and as a source of important learning. http://www.chfg.org
We cannot change the human condition, but we can change the conditions under which humans work. Jim Reason (2000) If we accept human fallibility, we need to rely on welldesigned systems to support us in the workplace. And remove error traps wherever possible.
Save someone s life today For each year, for every 500 beds.. 62 lives saved 883 fewer bed days 520 fewer CC bed days Direct costs for survivors reduced by 0.78M (Ron Daniels, Chair UKST)