The Good, the Bad and the How can we do better? (RRAILs audit) Dr Harsha Reddy Consultant (Anaesthetics & ICM) Wrexham Maelor Hospital, BCUHB

Scoring Systems APACHE (2 & 3) Mortality Prediction Model Simplified Acute Physiology Score Pre 1984 APACHE = Acute Physiology and Chronic Health Evaluation

RRAILS Audit All adult medical (11) and surgical (9) wards 24 hours prior to 08:00 17th Sept Part 1 : RRAILS metrics Part 2 : Direct observation Safety Briefing SIRS / Sepsis Use of sepsis bundle Tuesday 17th September Section 1: RRAILS Metrics. This section requires you to identify whether there is data on the Metrics system for the RRAILS bundle within the audit timeframe (previous 24 hours - 8am previous day to 8am day of audit). Section 2: Direct Observation. This section looks at each individual patient that fits the inclusion criteria specified above. Complete one form per ward. Complete one line per patient. The elements to be collected are: Patient Present. Please cross in the box to confirm that the patient is there to be audited. If the patient is absent and are not going to be included please leave the box blank NEWS Completed (in line with criteria). Was the NEWS completed along with each set of observations (in line with the required criteria)? NEWS Score Please record the highest NEWS score from the last 24 hours. Record in numerical format (i.e. 06, etc). 2 or more SIRS criteria present (If NEWS > 3) SIRS Criteria consist of: Temperature >38.3°C (101°F) or <36.0°C (96.8°F) Tachycardia >90 bpm Tachypnoea >20 breaths/minute PCO2 <4.3 kPa (32 mmHg) Hyperglycaemia (blood glucose >6.66 mmol/L [120 mg/dL]) in absence of diabetes mellitus Acutely altered mental status WBC count >12×10^9/L (12,000/microlitre) or <4×10^9/L (4000/microlitre), or normal WBC count with >10% immature forms. Suspicion of new infection within 48 hrs (If 2 or more SIRS criteria present) First Escalation (in line with NEWS score). Within the audit timeframe (8am to 8am), was there documented evidence that the first NEWS-identified need for escalation did result in an actual escalation. A ‘Yes’ would mean that the first escalation requirement (in line with NEWS criteria) was followed. A ‘no’ (box left blank) would mean that the first escalation requirement was not followed. There is a ‘N/A’ option for cases where no escalation requirements were identified. First Response (within time frame). Within the audit timeframe (8am to 8am), was there documented evidence that the first NEWS-identified need for a response did result in an actual response. A ‘Yes’ would mean that the first response requirement (in line with NEWS criteria) was followed. A ‘no’ (box left blank) would mean that the first response requirement was not followed. There is a ‘N/A’ option for cases where no response requirements were identified. Was there a confirmed diagnosis of Sepsis? Was there documented evidence that sepsis had been diagnosed for this patient. Was Sepsis 6 delivered within one hour? Were the following six factors delivered within one hour of confirmed diagnosis of Sepsis: Give oxygen Take blood cultures Give intravenous antibiotics Start intravenous fluid resuscitation Check lactate level Monitor hourly urine output.

Acute Intervention Team

323 patients on our site Roughly 30% each site. Took out the patients who were not by the bedside as they skewed the data. Wrexham had highest completion sat 90% Safety briefing – YG worst at 50% - YGC and WMH were comparable though documentation better at WMH with 90% vs 60% Overall only 30% escalated but if you delve into the notes most times appropriate… Sepsis bundle – highest number of cases 12 in WMH but bundle not filled out – duplication. YGC best 1 case of sepsis that day who did get the bundle. YG had 6 cases with 3% getting bundle.

RRAILS completion

Taken from the 1000 lives document but adapted and on our TPR chart now.

Sepsis 6 Cases Sepsis 6 (%) East 5 Central 1 100 West 6 66.6

The GOOD… Clear documentation Correct patient details Easily accessible Overall NEWS score always completed Excellent staff engagement

The BAD… Sepsis page never completed Difficult to read chronicity Not universally applicable Sepsis page never completed Added up incorrectly

How can WE do better… Sepsis Care Pathway Specific NEWS for specific patients… Missed opportunity to raise awareness… Not much forewarning so not best prepared for the event.

Themed activities Multimedia awareness campaign Drop in sessions to reinforce key points Promote public confidence Annual event to reinforce importance of messages Change behaviour – education, accentuate the positive aspects whilst learning from the negatives.

Thank you to… Ms. Jo Garzoni Ms Kate Jones (ANP) Mr Stuart Sailsbury (Resus Officer) Dr. Mike Smith Dr. Ibrahim Mohammed Dr. Zac Hulme Dr. Aman Harghandewal