Surviving Sepsis in Ashford and St Peter’s NHS Trust An overview of changes to practice in the Emergency Department to achieve CQUIN targets: A very long audit. Dr Trisha Gupta (F2 emergency dept), Dr Irum Akbar, Dr Asim Nayeem (ED Consultant) Q2 OCT NOV DEC Q3 JAN Q4 Patients with severe sepsis 12 22 26 47 40 25 21 Patients administered the Sepsis Six Bundle within 1 hour 18 19 35 32 Percentage 67% 82% 81% 74% 80% 88% 90% B A C K G R O U N D 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 . Approximately 35,000 deaths attributed to sepsis annually in the UK, affecting all age groups, of which, it is estimated, 15,000 are preventable. In this current climate, it is prudent to note it costs the NHS 2 billion pounds a year. 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. For 2014/2015, a Local CQUIN targeted at ‘”Sepsis Pathway: Compliance with severe sepsis bundle” was agreed with North West Surrey CCG, with an aim of initiating the “sepsis six bundle ” within an hour from identification of sepsis in 90% of documented cases by the fourth quarter. Table 1. Internal audits per month and external audits per quarter assessing the administration of the Sepsis Six Bundle within the CQUIN target of 1hour, achieved in the last quarter – March 2015. T H E S T A N D A R D 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. At least 2 of…. and 1 or more of…. WHITE CELL COUNT <4 OR >11 LACTATE >2.0 TEMPERATURE <36.0 OR >38.0 REPSPIRATORY RATE >20 BLOOD PRESSURE – SYSTOLIC <90 OR MAP<64 HEART RATE >90 S E P S I S I N 2 0 1 2 - 2 0 1 3 AUDIT 2012 “Time to Antibiotics” audit found an average time to definitive treatment with antibiotics of 232 MINUTES from identification of sepsis. CHANGE Sepsis Group: Consisting of lead nurses, consultants and junior doctors for regular auditing of information and championing peer education in the department. ‘Fast Track’ System: Patient meeting SIRS criteria were prioritised in the queue with nursing staff taking initiative to ask for prescription of fluids and antibiotics, and pre-ordering investigations before assessment to aid with efficient management. ‘Sepsis Six’ Stickers: Colourful adhesives that could be inserted into patient notes to indicate that they met the criteria to be considered for sepsis. A useful visual tool to quickly assess risk. RE-AUDIT Average time to definitive treatment with antibiotics fell to 113 MINUTES Graph 1. Trend-view representation of the percentage of identified sepsis cases that received care as outlined in the CQUIN and Sepsis Six Bundle within one hour of identification. As a reference point. August 2013 data has been included. AUDIT 2013 May to August 2013: 57 patients that presented with sepsis as an emergency admission through ED. Measured against ALL Sepsis Six guidelines – including antibiotics. Only 37% had all of the Sepsis Six bundle initiated in first hour. a b c Images. Exhibiting pages of the ED pro forma for Sepsis. (a) Page 1 is targeted towards triage nurses and prompts for treatment (b) aimed towards doctors to assess degree of escalation (c) Audit tool to aid in time to treatment of Sepsis Six Bundle. C Q U I N 2 0 1 4 / 1 5 : L O C A L G O A L S Our aims and objectives for the 2014/2015 year were: “Sepsis Pathway”: to assess compliance with severe sepsis bundle by monitoring time taken to each of the sepsis six being initiated. The implementation of the Sepsis Six bundle in ED in an easy, accessible way Target was a 90% compliance by end of Quarter 4 as per CQUIN guidance, to be measured via audit with members of North West CCG. R E S U L T S With a multidisciplinary approach and a particular focus on education, by external review of quarter 3 and 4, St Peter’s ED was achieving 80% and 90% respectively. The audit sheets which are included as part of the pro-forma provided a good summary of information. It is interesting to note that prior to 2014/15, similar efforts, although successful did not yield dramatic results. ED led Sepsis Group Doctors/Nurses from ED were recruited to be part of sepsis management drive, to manage the project, and conduct monthly audits and reviews. A Service Improvement Project Manager was assigned to provide project support along with a Critical Care nurse . Regular monthly meetings/audits held to review our progress both as a team and as a department. New Sepsis Pro forma For Triage Consider SIRS criteria Fluid balance chart for better monitoring in ED. For Doctors Checklist of sepsis six Antibiotic guidelines for treating the source of infection Triggers for when to escalate to ITU/ outreach For Audit Audit form to measure performance against target time of < 1 hr from arrival to ED. Ongoing Education Consultant led teaching at ED  induction for junior doctors Teaching at board rounds Teaching at nursing handovers via sepsis champion nurses Awareness pocket cards Specific focus on the escalation by triage nurses of potential septic patient Consultant led 1-2-1 teaching on identified missed cases for doctors and nurses Changes to achieve targets D I S C U S S I O N S & F U R T H E R S C O P E Whilst it is incredibly encouraging as a department that CQUIN targets set by North West Surrey CCG are achievable, it also highlights the effort required to improve standards to this level. Subsequent audits have shown that, since the CQUIN was achieved, the time delay to complete the bundle within one hour has increase, albeit marginally. Consistent and active effort is required to maintain the 90% target which questions sustainability and the importance of a change in sepsis-aware culture. Under-reporting of sepsis must be taken into account when analyzing data; a general pattern noted was that triage nurses were excellent at completing the front sheet of the pro forma, however the audit checklist was often left out. It is likely that cases that were identified and treated as sepsis were missed. Idealistically, all patient CAS cards should be assessed for meeting the sepsis criteria. Hence since January 2016, the ED patient CAS card was redesigned to include a sepsis screening box as part of initial triage. Over 90% of patients triaged as ‘Majors’ are now screened as of March 2016. Realistically, education is perhaps the best tool including the hands-on experience of treating the unwell septic patient, nevertheless, the challenges of an ever-changing cohort of doctors and nurses in the ED must not be overlooked. One way in which our trust has attempted to overcome this is by extending teaching beyond the remit of those employed in the ED and rolling out Sepsis teaching to all grades of doctors and nursing staff within the hospital as part of regional teaching. In addition to this, junior doctors in the department are given the task of auditing the monthly identification of sepsis which is useful both as an department audit and a learning tool for medical education. R E F E R E N C E S 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.