Sepsis...a major Medical Emergency Dr Ron Daniels Fellow: NHS Improvement Faculty Chair: United Kingdom SSC, Sepsis Trust & Pre-hospital Working Group December 2010

Archives of Surgery 2010

What is sepsis?

Merinoff definition 30 th September 2010 Sepsis is a life-threatening condition that arises when the body's response to an infection injures its own tissues and organs. Sepsis leads to shock, multiple organ failure and death especially if not recognized early and treated promptly. Sepsis remains the primary cause of death from infection despite advances in modern medicine, including vaccines, antibiotics and acute care. Millions of people die of sepsis every year worldwide

Lung 1 Colon 2 Breast 3 Sepsis 4 cancers Annual UK mortality (2003), thousands 1,2,3 4 Intensive Care National Audit Research Centre (2006) A U.K. Perspective © Ron Daniels 2010

Practice guidelines

Revision due 2012

The Sepsis Six 1.Give high-flow oxygen via non-rebreathe bag 2.Take blood culturesand consider source control 3.Give IV antibioticsaccording to local protocol 4.Start IV fluid resuscitation Hartmann’s or equivalent 5.Check lactate 6.Monitor hourly urine output consider catheterisation within one hour..plus Critical Care support to complete EGDT © Ron Daniels 2010

Funk and Kumar Critical Care Clinics 2011 (in press) Running average survival in septic shock based on antibiotic delay (n=4195)

Funk and Kumar Critical Care Clinics 2011 (in press) Running average survival in septic shock based on antibiotic delay (n=4195) For each hour’s delay in administering antibiotics in septic shock, mortality increases by 7.6%

Evidence emerging

Sepsis Nurse Practitioners

Compliance at Good Hope Hospital (%) © Ron Daniels 2008

Compliance and mortality at Good Hope Hospital (%) © Ron Daniels 2008

Mortality by Sepsis Six Cohort sizeMortality %RRR Total ‘Sepsis Six’ : Oxygen therapy Blood culture Antibiotic administration Fluid challenges Lactate and haemoglobin measurement Urine output monitoring…. within one hour Resuscitation Bundle: SSC, within 6 hours following recognition © Ron Daniels 2010

Mortality by Sepsis Six Cohort size (%) Mortality %RRR % (NNT) Total 567 (100)34.7- Sepsis Six  220 (38.8)20.0 Sepsis Six  347 (61.2) (4.16) © Ron Daniels 2010

Mortality by antibiotics Cohort sizeMortality %RRR % (NNT) Total 567 (100%)34.7- Delayed Antibiotics 217 (38.4%)45.4 Antibiotics within 1 h 350 (61.6%) (5.77) © Ron Daniels 2010

Mortality by fluid challenges Cohort sizeMortality %RRR % (NNT) Total 567 (100%)34.7- No fluids in 1h 183 (32.3%)44.8 Fluids in 1h 384 (67.7%) (6.73) © Ron Daniels 2010

Perspective Severe SepsisAcute coronary syndrome No. cases per 100,000 per annum NNT ‘basic’ care Sepsis Six (our data) 6 First hour antibiotics 5 Clopidogrel 48 β-blockade 42 Aspirin 26 NNT invasive care EGDT (Rivers) 6 Resusc Bundle (SSC) 18 Thrombolysis 15 PCI over thrombolysis 33

For patients receiving the Sepsis Six 2.0 fewer Critical Care bed days 3.4 fewer hospital bed days Compared with other survivors Equates to c. £3,000 cost ‘saving’

SSC Results: Critical Care Medicine 2010; 38(2): 1-8 © Ron Daniels 2010

SSC Results: Critical Care Medicine 2010; 38(2): 1-8 © Ron Daniels 2010 Bundle targetOR (95% CI) for mortality p Antibiotics0.86 ( ) Blood cultures0.76 ( )0.0001

National context

National Outcomes Framework

National Quality Board

A sepsis quality standard Sepsis

Stroke 67,000 deaths per year FAST Campaign National Stroke Association Target: Specialist assessment in 60 min 40% mortality reduction Myocardial infarction/ ACS 89,000 deaths per year National Infarct Angioplasty Project Target: Call-to-needle 60 min Door-to-needle 20 min Sepsis 42,000 deaths per year

Process improvements

Local context

Know your reliability

Know your processes

Sepsis as a CQUIN measure

Achieving 80% reliability For each year, for every 500 beds.. 62 lives saved 883 fewer bed days 520 fewer CC bed days Direct costs for survivors reduced by £0.78M

Sepsis is a medical emergency- and our second biggest killer Awareness and recognition are the key Reliable, early antibiotics and fluids will save more lives than Critical Care will..... even if CC were infinitely resourced Summary

Declaration of interests Within the last 24 months, I have received travel expenses and honoraria to deliver two U.K lectures from Astra Zeneca, manufacturers of the antibiotic Meropenem. I have also received consultancy fees from CareFusion, manufacturers of the antiseptic preparation ChloraPrep Thank you