Accurate prescribing of antibiotics for sepsis in the Emergency Department at St Peter’s Hospital Dr Trisha Gupta (F2) & Dr Sherry Fang (F2) ED Sepsis Lead: Dr Asim Nayeem (ED Consultant ) Supported by: Dr Clive Grundy (Consultant Microbiologist) & Mr Hani Habayeb (Antimicrobial & Critical Care Pharmacist) INTRODUCTION RESULTS Sepsis is a common and potentially life-threatening condition: the body’s immune system goes into overdrive in response to an infection, that can lead to widespread inflammation, swelling and blood clotting. It is a recognised cause of shock and is associated with significant mortality and morbidity in the NHS. Approximately 35,000 deaths attributed to sepsis annually in the UK, affecting all age groups. The foremost issue is the recognition of sepsis and then its timely management, especially on presentation in the acute setting such as the emergency department. While a range of actions are recommended for rapid implementation when a patient presents with sepsis (referred to as the ‘Sepsis Six’), rapid administration of antibiotics is the single most crucial action that can prevent deaths from sepsis. The “Surviving Sepsis Campaign” helpfully provides guidance on antibiotic administration. The points summarised below are those that are most applicable in the emergency department setting: Administer intravenous antimicrobials within the first hour of recognition Initial empiric antibiotics include one or more drugs that have activity against all likely pathogens in adequate concentrations. Empiric therapy should attempt to provide cover against the most likely pathogens based upon each patient’s presenting illness and local patterns of infection. Antibiotics should not be used in patients in non-infectious severe inflammatory states Fluids given within the hour 100% Lactate performed 97% Blood cultures taken 83% Antibiotics given within the hour 75% Oxygen prescribed 53% Urinary catheterisation 25% SEPSIS SIX The results above demonstrate the speed at which the “sepsis six” were performed following identification of a severely septic patient i.e. a patient with >2 SIRS criteria and a lactate >2 OR MAP <64 OR BP <90 systolic. N=16. Only 2 of the patients did not fulfil the SIRS criteria on triage observations. LACTATE Every patient who satisfies the SIRS criteria is required to have a lactate level performed. Lactate is a sign of anaerobic respiration that has a directly proportional relationship with mortality in trauma and sepsis both in the acute as well as the delayed hospital inpatient setting. Therefore a lactate of 2 and above suggests severe sepsis. OBJECTIVES ANTIBIOTIC PRESCRIBING ACCORDING TO CLINICAL IMPRESSION 47% followed Trust Guidelines for antibiotics 17% of clinical impressions not documented and antibiotics given Chest sepsis 67% prescribed appropriately Urosepsis 67% prescribed appropriately Intra-abdominal sepsis 20% prescribed appropriately The graph on the left demonstrates the incidence of specific trust-approved antibiotic use. At the time of audit, the antimicrobial guideline on the treatment of intra-abdominal sepsis was not available easily. To evaluate how many patients were being accurately diagnosed as having sepsis To evaluate timeliness of treatment To evaluate prescription of appropriate antibiotics for a particular source of sepsis CURRENT STANDARDS DOCUMENTED CLINICAL IMPRESSIONS 17% of CAS cards did not have a documented impression by which to explain their rationale for commencing particular antibiotics. A diagnosis of sepsis is made with two or more SIRS criteria and the clinical suspicion of an infective source. If lactate/MAP/systolic BP is affected, it falls under the criteria of “severe” sepsis. It suggests end-organ hypoperfusion and subsequent dysfunction. Septic “shock” is characterised by a hypotensive BP that is not responsive to aggressive fluid therapy. INTERVENTIONS CONCLUSIONS AND FURTHER RE-AUDIT SCOPE At least 2 of…. And possibly more than 1 of… Temperature <36 or >38 Lactate >2 Heart Rate >90 Respiratory rate>20 BP <90 systolic OR MAP of <64 White cell count <4 or >11 Ongoing discussions with pharmacy and microbiology with regards to changing guidelines and increasing awareness of sepsis on a more trust wide basis 2 new large A2 posters in A&E and all wards with antimicrobial summaries (PINK!) Increasing awareness of appropriate prescribing during board rounds and fortnightly ED assemblies Updates on current sepsis antibiotic pro forma for initial empirical therapy as below: Re-auditing is currently underway with the updated guidance on empirical antibiotic therapies now in place in the ED. The department has an excellent track record with its provision of definitive treatment for sepsis, previously achieving NHS England’s CQUIN target of >90%. The authors of this poster do not underestimate the confounding affects of the ever-changing prescribers, or not accurately completing the pro formas that aid in auditing the Trust’s performance. We hope this, in part, helps in rectifying the small sample size collected in this audit and therefore increase the reliability of the data upon closing the loop. METHODS Intra-abdominal Sepsis regime Generic doses for adults All CAS cards with completed sepsis pro formas were collected between August 1st and 31st 2015. Excel data sheets were collated with physiological data, documented clinical impressions and time to treatment. Results were collated in graphic format and discussions were held at several forums including an F2 teaching session as well as the December 2015 Microbiology Meeting. REFERENCES Safe in renal impairment Penicillin-allergy alternatives NHS England: Commissioning for Quality and Innovation (CQUIN) Guidance for 2015/16.https://www.england.nhs.uk/wp-content/uploads/2015/03/9-cquin-guid-2015-16.pdf Dellinger et al, Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock 2012. Critical Care Medicine Journal 22013; 41 (2): 580-637 Bone, R; Balk, R; Cerra, F; Dellinger, R; et al. (1992). "Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. The ACCP/SCCM Consensus Conference Committee. American College of Chest Physicians/Society of Critical Care Medicine" (PDF). Chest 101 (6): 1644–55. Blomkalns AL, et al. Lactate - A Marker for Sepsis and Trauma. Emergency Medicine Cardiac Research and Education Group. September 2006; Vol. 2 Neutropenic Sepsis regime 38 cards collected 16 matched sepsis criteria