Andy Collen Consultant Paramedic Screening 999 callers seen by ambulance staff for sepsis Daniel Dodd Clinical Lead for Sepsis South East Coast Ambulance Service

Screening 999 callers seen by ambulance clinicians for sepsis Andy Collen – Consultant Paramedic/ Head of Clinical Development Daniel Dodd – Paramedic Practitioner #SecambCodeYellow

Warning! The following Images may cause spontaneous aaaawwing, naawwing, clucking and melting. If these symptoms persist, seek medical attention

Nittono H, Fukushima M, Yano A, Moriya H (2012) The Power of Kawaii: Viewing Cute Images Promotes a Careful Behavior and Narrows Attentional Focus. PLoS ONE 7(9): e doi: /journal.pone Why the pictures??

"Except on few occasions, the patient appears to die from the body's response to infection rather than from it.” William Osler - (1904) The Evolution of Modern Medicine.

The Problem Deaths per year in the UK 2500 admissions in KSS, Almost 1 in 5 die Trust Audit – No Fluids in 60%, No Oxygen in 26%, No Pre-alert in 65%. Education: (214 surveyed) – 45% No previous training. – 40% Believe that cannot diagnose sepsis in pre hospital setting. – 39% believe that paracetamol is the first line of treatment. – 50% have poor understanding of diastolic BP and there is to much focus on systolic BP. Cookbook Medicine culture 14 Acute Trusts, difficult to disseminate information to all emergency departments - Difficult to engage.

Challenges in pre-hospital setting Variety in grades of staff attending patients No core education in identifying sepsis No systematised assessment process No care pathway Limited opportunity to apply Sepsis 6, raising the threshold of suspicion Over-emphasis on symptomatic relief of the pyrexial patient

Sepsis 6 in pre-hospital care Sepsis Six to be completed in the first hour following recognition of sepsis Give Three: –High Flow Oxygen –Antibiotics –Fluids Take Three –Blood Cultures –Lactate –Urine

SECAmb Code Yellow Approach Early identification of sepsis Care bundle Rapid transfer to ED for definitive care IV Antibiotics considered by not introduced at this stage

What treatment is emphasised in Code Yellow High flow oxygen IV fluids Monitoring Hospital pre-alert

What treatment is de-emphasised Anti-pyretics –Oral paracetamol indicated for symptomatic pyrexia >39°c –IV paracetamol de-emphasised to ensure that IV fluid therapy is prioritised –Education package covers utility of fever –ED decision to treat pyrexia in parallel with Sepsis 6 Long on-scene duration –focussed history and assessment only. Once sepsis identified – rapid transport to ED

Fever and Antipyretic in Critically ill patients Evaluation (FACE, 2012) Non-septic patients with fever >39.5°C is independently associated with mortality In sepsis the administration of paracetamol or NSAIS is independently associated with 28-Day mortality Septic patients whose temperature was between 37.5°C and 38.4°C was associated with a decreased mortality rate at 28 Days compared with those whose temperature was 36.5°C and 37.3°C.

Early Antibiotics – priority #1 TIME IS TISSUE! Mortality increases 7.6% hourly without antibiotic administration in the presence of hypotension

Code Yellow Sepsis Pathway

Step 1: Does the patient have an infection?

Step 2: Is the Infection Systemic?

Step 3: Is Perfusion Affected?

Step 4: Diagnosis – If all steps +ve, the patient now has One Hour to receive antibiotics!

SECAmb Sepsis Care Bundle

Results from pilot at Epsom General There were 27 patients audited in the trial The age range was between 30 and 90 years old There were 14 Females and 13 Males The Mean Time to Antibiotics was 1:03 from pre-hospital diagnosis

Code Yellow vs Standard ED StandardCOEM AuditSECAmb Code Yellow Pathway Antibiotics administered ≤ 1 Hour 32%94.3% Antibiotics administered ≤ 2 Hours 64%100% Average Time ED Arrival to Antibiotics Not Recorded00:35 Average Time from PH Diagnosis to Antibiotics Not Recorded1:12

Adoption of Code Yellow All hospitals in the region are being passed Code Yellow ASHICE alerts Some hospitals have aligned Code Yellow to internal clinical processes Most hospitals receive Code Yellow alerts on the strength of screening tool Many hospitals report a high rate of alert to immediate IV AB therapy Primary and Community Care can now call 999 and use the term “Red Flag Sepsis” to get an immediate response We continue to work alongside partners within the Patient Safety Collaborative to promote the importance of sepsis screening and management

The Future? Pre-hospital IV Antibiotics where diagnosis to ED needle time >60mins (NICE Consultation) Point of Care Testing to enhance diagnostic accuracy (WCC, lactate, CRP) Research into use of End Tidal CO2 More focus on the management of sepsis for patients at end of life

Thank you for listening. Any questions?