SEPSIS Recognition, Treatment and Referral Dr. Vida Hamilton National Clinical Lead Sepsis www.hse.ie/sepsis

The Burden International estimates Sepsis: 300 per 100,000 per annum AMI: 208 per 100,000 per annum Mortality: 20 - 55% Mortality from sepsis today is the same as that for AMI in the 1960s More than breast cancer, bowel cancer and HIV/AIDS combined Sepsis incidence is rising internationally Most expensive since condition being managed in the US healthcare system 25,000 euros per patient

Bowel cancer Breast cancer Annual UK sepsis deaths

The Burden in Ireland HIPE data: 60% all in-hospital deaths has a sepsis or infection diagnosis Number of sepsis cases = 8,770 Number of bed days = 220,288 2013 2012 2011 In-hospital mortality 28.8% 31.3% 32.4% Sepsis not routinely documented in case notes rather site of infection. Percentage of deaths with sepsis code 16.3%, with sepsis or infection 60.3%

Reality of Sepsis 2013 Without With ALOS Sepsis 5.59 26 ALOS Infection 10 ALOS Maternity 2.61 5.47 ALOS Paediatrics 3.08 22.19

Age standardised hospital discharge rate for medical septic shock, 2005 - 2012

Age standardised hospital discharge rate for surgical septic shock, 2005 - 2012

Sepsis 2013 National Average Sepsis cases as % of all cases 1.44 Sepsis as % of all bed days 6.8 Sepsis + Infection as % of all cases 20.22 Sepsis + Infection as % of all bed days 42.3

Costs Sepsis consumes 30% of the UK critical care budget £20,000 per patient £2.5 billion annually Chronic health burden for survivors

Cognitive impairment Iwashyna et al: Long-term cognitive impairment & functional disability among survivors of severe sepsis. JAMA, 2010.

Issues 90% of cases with poor outcome in the Australian sepsis database, inadequate recognition was found to be the most common feature

An Irish Report The categorisation of the severity of a patients illness The early detection of that deterioration The use of a standardised and structured communication tool such as ISBAR Early medical review that is prompted by evidence based trigger points A definite escalation plan that is monitored and audited on a regular basis

National Sepsis Guidelines Aim for mortality 20 – 30% Care pathway for every patient diagnosed with sepsis in Ireland Recognition, Resuscitation, Referral Education, audit

Diagnostic criteria for sepsis SIRS Infectious & non infectious causes Clinical response arising from a non specific insult Sepsis SIRS plus Presumed or confirmed infection Severe Sepsis Sepsis plus Sepsis-induced organ dysfunction or tissue hypoperfusion Septic Shock Sepsis-induced hypo-perfusion or hypotension persisting despite 30 mls/kg fluid rescusitation

SIRS Criteria T > 38.3, < 36 HR > 90 RR > 16 WCC > 12, < 4 BSL > 7.7 mmol/l in non-diabetic Altered mental status

SIRS criteria continued Other inflammatory parameters eg CRP, PCT Organ dysfunction parameters Hypoxia, Oliguria, Creatinine, Coag, Platelet, Bilirubin, Ileus Tissue perfusion parameters Mottling, capillary refill, lactate Haemodynamic variables BP <90, MAP < 70, SBP  > 40mmHg from baseline

Common sources of sepsis Respiratory 38% Urinary tract 21% Intra-abdominal 16.5% CRBSI 2.3% Device 1.3% CNS 0.8% Others 11.3%

Sepsis screening Early recognition 2% of all ED referrals are due to sepsis NSW audit of NEWS: sepsis is the cause of 30% of triggered reviews UK: NEWS > 5; 52% sepsis

ED vs In-patient ED Ward Hospital acquired Community acquired Less co-morbidities Generalised training Mortality 20% Hospital acquired Co-morbidities Second – Hit Specialist training Mortality ??? Higher

Sepsis 6 in the Ist hour Give 3 Take 3 1.OXYGEN: Titrate O2 to saturations of 94 -98% or 88-92% in chronic lung disease. 1. CULTURES: Take blood cultures before giving antimicrobials (if no significant delay i.e. >45 minutes) and consider source control.  2. FLUIDS: Start IV fluid resuscitation if evidence of hypovolaemia. 500ml bolus of isotonic crystalloid over 15mins & give up to 30ml/kg, reassessing for signs of hypovolaemia, euvolaemia, or fluid overload. 2.BLOODS: Check lactate & full blood count.  3. ANTIMICROBIALS: Give IV antimicrobials according to local antimicrobial guidelines. 3. URINE OUTPUT: Assess urine output and consider urinary catheterisation for accurate measurement in patients with severe sepsis/septic shock.

Management of sepsis in adult in-patient Identify yourself, Situation, Background, assessment, recommendation

Prompt treatment Sepsis is a time-dependent medical emergency Mortality increases by 7.6% for each hour delay to appropriate antibiotics (Kumar CCM 2006)

Early antibiotics are good Author N Setting Median time (mins) Odds ratio for death Gaieski CCM 2010; 38;1045-53 261 ED, USA (shock) 119 0.30 (1st hour vs all times) Daniels Emerg Med J 2010; doi:10.1136 567 Whole hospital, UK 121 0.62 Kumar CCM 2006; 34(6): 1589-1596 2154 ED, Canada 360 0.59 (1st 3 hours vs delayed) Appelboam CCM 2010; 14(Suppl 1):50 375 240 0.74 (1st 3 hours vs delayed) Levy CCM 2010; 38(2): 1-8 15022 Multi-centre 0.86

Start Smart 9-fold increase in mortality with inappropriate antibiotics Independent risk factors COPD Immunocompromised Chronic dialysis

Then Focus Daily patient review Five options Investigations Culture results Five options Continue current antimicrobial Change antimicrobial Change iv to oral Stop OPAT

Risk stratification Trzeciak, S et al. Int Care Med 2007; 33(6):870-7. n-=1177

Compliance with sepsis 6 Reduces the relative risk of death by 46.6% 1 additional life saved for every 5 care episodes Mortality reduced from 44% to 20% Daniels et al, Emergency medicine journal 2011

Compliance with Sepsis 6

ProCESS Feb 2014, ARISE Sept 2014 ED Hypotension or lactate > 4 ProCESS EGDT vs Simplified quantitative resus vs Usual Care Pre-randomisation 30mls/kg (2l/kg) Study fluid 3.3, 2.8, 2.3 litres Mortalities 21%, 18.2%, 18.9% ARISE EGDT vs Usual Care Pre-randomisation 34mls/kg (2.5l) Study fluid 2.7 – 2.9 litres Mortality 18.6%, 18.8%

Impress Sept 2014 Mortality US 24% Europe 28% Bundle compliant 20% Non-bundle compliant 30% p=0.026

Is that it? Sepsis 6 is the minimum intervention Sepsis is a continuum Source control Seasonal and other outbreaks, recent travel, patient at risk of MDR organisms

Niccolo Machiavelli, The Prince, 1513 “….as the physicians say it happens in hectic fever, that in the beginning of the malady it is easy to cure but difficult to detect, but in the course of time, not having been either detected or treated in the beginning, it becomes easy to detect but difficult to cure.” Niccolo Machiavelli, The Prince, 1513

Barriers to implementation Lack of awareness, Lack of agreement Lack of self-efficacy Perception – Reality gap, Education, Audit Lack of outcome expectancy Audit Inertia of previous practice Lactate, Audit, Discussion forums, Bottom-up/ Top-down Perception – reality gap

External barriers Guideline related Patient related Lack of maternity guidelines Poor specificity of SIRS criteria Patient related Late presentation, co-morbidities Environment related Lack of resources

Overcoming barriers Education Audit Resourcing HIPE, KPI, ward-based audit Resourcing

Thank you www.hse.ie/sepsis