Network Session B Reliability & Screening Corinne Thomas, Tracy Broom, Matt Inada-Kim PSC

Improvement AIM All patients presenting to all hospital emergency front doors Screen <60 minutes Antibiotics <60 minutes

Dialects & Tribes Hospital Ambulance Community

Sepsis Improvement Strategies Simplify & Spread Standardize Synergize

Simplifying definitions Sepsis is a deleterious autoimmune host response to infection leading to organ dysfunction and shock ≈ Infection + Compromise

Simplifying Terminology InfectionSepsis Septic shock SEVERITY

2500 Death Certificate Audit HHFT with thanks to the Governance team HHFT SEPSIS = 42% of Total Deaths Part 1a of 2500 death certificates over 20 months NNT Sepsis2 Acute MI~ 50 Acute Stroke∞ (8-16) Dr Foster data suggested <100 deaths in their “septicaemia” group Cancer + Acute MI + Heart Failure + Stroke = 28% of Total Deaths What is your local sepsis burden- building the WILL

Overview of pathway With Minimal added work

friend Pharmacy GP A&E Home Admissions unit ICU Downstream Ward GP, DN, Receptionist Admissions Nurse coordinator, SHO, SpR, Cons Microbiology, Pharmacist, Physio, Ward Clerk/admin, Managers Receptionist, Triage nurse, SHO Ambulance 111 Ambulance 111 Porters Outreach, SHO, Cons F1,SHO,SpR,Cons, Pharmacist, Physio, Ward Clerk/admin, Managers The pathway must work in all areas and for all staff

How do you tell if someone is sick? ExperienceIntuitionKnowledgePhysiologyTestsExamination How well do you communicate this? LanguageObservationsSBARWritten/verbal/computerised Across silos Across geography CommunityAmbulance Hospital What is the evidence?

NEWS implementation pilots North / mid HANTS North Lactate pilot EMIS NEWS app NHS Scotland NEWS sepsis app Pilot of 60 across mid Hampshire Spread from GP VTS Integration of NEWS based observation Ongoing…

Ambulances EPR-> NEWS Call prioritisation Assessments and reviews Communication with GPs/community and hospitals App development & integration with 111 Large pilot

Systemic problems within Sepsis Person Awareness is low Unpredictable Heterogeneous Non-specific presentations (No ECG, hemiparesis) The Human Factor E.g. Teams, Distractions, old medical model Hierarchies, Communication System Unclear definitions/coding Lack of outcome data Non-standardised Multiple screening tools Lack of Ownership Dialects & Tribes Uncoordinated Pathways

Dialects & Tribes

A41 Admissions/Mortality in England

Wessex Patient Safety Collaborative Pan Wessex Screening discussion Dr Matt Inada-Kim, Corinne Thomas Tracy Broom

15:00 Introduction – what’s happening across region, nationally 15:15 Screening Introduction-Evidence around screening (MIK) Group discussion AIM- Agree screening tool, definitions 16:15 Interventions Introduction-Evidence around interventions (MIK) Group discussion Agree standards 16:30 CQUIN Questions & Support 16:45- 17:00 Wrap up- Summary & A.O.B. Pan Wessex Sepsis Group Timetable

Terminology InfectionSepsis Septic shock Minor physiological disturbance Low mortality (<3%) Moderate physiological disturbance Moderate mortality (<22%) Severe physiological disturbance High mortality (>35%) SEVERITY

NEWS vs SIRS NEWS Score Mortality +/- ICU admission % ≥ % SensitivitySpecificity NEWS 392%77% SIRS88%Low Corfield et al Keep et al Kaukonen et al NEWS or SIRS for sepsis diagnosis NEWS as a prognostic indicator “SIRS fails to define a transition point in risk of death” RIP SIRS

Odds ratios with NEWS NEWSOdds Ratio ICU Mortality (30 days) Combine d (ICU/mort ality) Predictive value of NEWS Common language Care/Nursing homes Ambulances ? Community medicine Psychiatry Triage tool????

SepticsEDAMU <60 minutes20 >60 minutes117 % <6015%0% Pre intervention (SIRS)Post intervention (NEWS) EDAMU %40% Timely Administration of antibiotics in Septic patients on AMU Sarah Edwards & Sarah Zarif RHCH 2015

“Does any coder here speak doctor?” Getting the language right and ensuring its visible Confusion…“Septic diagnoses” vs “sepsis or severe sepsis” With Clinical reclassification 47 diagnoses in “Sepsis diagnoses” vs 19 in “Septicaemia” At HHFT and nationally, there were 7 times more sepsis deaths than were being recorded. 100,000->660,000 admissions and 37,000->55,000 English deaths / year £1 billion vs £13 billion in hospital costs