Supported by JPUH Transformation Team Sepsis at JPUH THE STORY SO FAR

Supported by JPUH Transformation Team Every year in the UK there are 150,000 cases of Sepsis, resulting in a staggering 44,000 deaths – more than bowel, breast and prostate cancer combined.

116 deaths due to Sepsis from July 2015 to July 2016. Sepsis at JPUH 116 deaths due to Sepsis from July 2015 to July 2016. 44 with a primary diagnosis (41 sepsis and 3 septic shock), 72 more with some diagnosis of sepsis.

Supported by JPUH Transformation Team Sepsis at JPUH July 16 Baseline data. Mortality increases by 8% for every hour of delay in Antibiotic Administration

Supported by JPUH Transformation Team

Supported by JPUH Transformation Team

Supported by JPUH Transformation Team

New Outpatients & Children's Sepsis Easy Guides coming very soon.

New PGD

Spreading the message around Bespoke teaching on all wards Corporate induction ALERT HCA induction Overseas nurse induction Mini ALERT Critical care study days CLAW Grand Round 10th Nov 16 All A&E Staff Trained in Nov 16 Sepsis Teaching F1 & F2 completed. Sepsis week in February and April. Ward Study days when required. National publications: NHS Improvement & Academy of Fab Stuff.

Sepsis at JPUH Dec.16 68% July 16 58% July 16 Supported by JPUH Transformation Team Sepsis at JPUH Dec.16 68% July 16 58% July 16 Mortality increases by 8% for every hour of delay in Antibiotic Administration

JPUH 22nd of 95 nationally JPUH 34th of 87 nationally CQUIN indicator 2a(ii) (Percentage of adult ED patient requiring review that were reviewed) CQUIN indicator 2a(ii) (Percentage of adult IPS requiring review that were reviewed)

CQUIN Performance (Adult ED review), December 2016 CQUIN Performance (Adult IP review), December 2016

Mean LoS for patients with sepsis, Sep-Dec 2016 Text Mean length of stay, by month of discharge, given primary diagnosis group of “Septicaemia (except in labour)”, for patients at JPUH; comparison to acute providers nationally and in the East of England. Source: Dr Foster Healthcare Intelligence Portal. Since the introduction of the CQUIN, the Trust’s mean LoS have been consistently near to or below that of regional and national peers. Over Q3 the length of stay has been substantially reduced to a position well below the current regional and national average LoS.

Crude mortality rate of sepsis cases, July-Dec 2016 (by quarter) Given a primary diagnosis group of “Septicaemia (except in labour)”, the proportion of patients with an outcome of death, by quarter of discharge, for patients at JPUH; comparison to acute providers nationally and in the East of England. JPUH figures for periods: Q2 10 deaths on 69 spells, Q3 11 deaths on 91 spells. Source: Dr Foster Healthcare Intelligence Portal. The work on the early identification and treatment of sepsis has also had an impact on the crude mortality rate. While nationally and the trend for Q3 was a rise, the Trust has managed to reduce its crude mortality rate. The Trust outperformed both the national and regional figures on almost all areas of the Sepsis CQUIN in Q3, and passed all areas of the screening part of the audit. By identifying the patients early the risk of the patient dying is substantially reduced.

PROUD OF THE PAGET THE RELATIVE RISK OF MORTALITY AND READMISSION FOR SEPSIS PATIENTS WAS ALSO WELL BELOW THE EXPECTED AT THE END OF DECEMBER. IF YOU ARE GOING TO DEVELOP SEPSIS, ONE OF THE BEST PLACES TO BE IS AT THE JAMES PAGET UNIVERSITY HOSPITAL .

PROUD OF THE PAGET

90% Target to give antibiotic inside 60 minutes for IP & A&E 90% Target to give antibiotic inside 60 minutes for IP & A&E . Ward times reduced from 90 minutes to 60 minutes. For next two years.

DOCUMENTATION, DOCUMENTATION! Improve documentation

New Sepsis Proforma simplyfied.

Management Sepsis 6: 1.- Oxygen 2.- IV fluids 3.- Blood cultures / Sputum cultures 4.- Antibiotics – prescribe according to hospital guidelines 5.- Lactate + blood tests 6.- Monitor Urine output ANTIBIOTICS – THH GUIDELINES HOSPITAL-ACQUIRED PNEUMONIA (HAP) Pneumonia developing in a patient 72 hours after admission. In non-ventilated patients  Patients with no risk factors* who have not received antibiotics previously Co-amoxiclav 1.2g IV tds 5-7 days If no response within 24-48 hours, consult the Microbiologist.  Patients with risk factors*, and/or who have received antibiotics previously: Discuss with team consultant / consultant microbiologist. Ventilator-associated pneumonia (VAP) Co-amoxiclav 1.2g IV tds *Risk factors: Thoraco-abdominal surgery, prolonged ICU stay, immunosuppressive therapy. ASPIRATION PNEUMONIA Benzyl penicillin 1.2g IV qds +/- Clarithromycin 500mg PO/IV bd Penicillin allergy: Clarithromycin 500mg IV bd FROM NICE 1.3 Hospital-acquired pneumonia Antibiotic therapy 1.3.1 Offer antibiotic therapy as soon as possible after diagnosis, and certainly within 4 hours, to patients with hospital-acquired pneumonia. 1.3.2 Choose antibiotic therapy in accordance with local hospital policy (which should take into account knowledge of local microbial pathogens) and clinical circumstances for patients with hospital-acquired pneumonia. 1.3.3 Consider a 5- to 10-day course of antibiotic therapy for patients with hospital-acquired pneumonia. 2.4 Hospital-acquired pneumonia Can rapid microbiological diagnosis of hospital-acquired pneumonia reduce the use of extended spectrum antibiotic therapy, without adversely affecting outcomes? Why this is important Data are limited on the microbiology of hospital-acquired pneumonia to guide antibiotic therapy. Hospital-acquired infections can be caused by highly resistant pathogens that need treatment with extended-spectrum antibiotics (for example, extended-spectrum penicillins, third-generation cephalosporins, aminoglycosides, carbapenems, linezolid, vancomycin, or teicoplanin), as recommended by British Society of Antimicrobial Chemotherapy guidance. Because routine microbial tests lack sensitivity and take 24–48 hours to identify a causative pathogen, patient characteristics are used to guide antibiotic choice. However, this may lead to unnecessary use of extended-spectrum antibiotics in patients infected with non-resistant organisms, and inappropriate use of first-line antibiotics (such as beta-lactam stable penicillins, macrolides or doxycycline) in patients infected with resistant organisms. Rapid diagnostic tests to identify causative bacterial pathogens and determine whether they are resistant to antibiotics may have a role in guiding antibiotic choice for postoperative Pneumonia NICE clinical guideline 191 ©

Blood cultures In all septic patients who are started on antibiotics irrespective of temperature. Part of sepsis 6 bundle Ideally, obtained prior to administration of antimicrobial therapy whilst adhering to strict ANTT procedures. Adults – 2 bottles per set – Aerobic and Anaerobic Very important to identify causative agent. Also enables antibiotic susceptibility testing

When IV antibiotics are administered to a septic patient within one hour, the mortality is reduced by half.

Supported by JPUH Transformation Team Thank you