1. Dr Alex Goodwin Consultant Anaesthetist, NCEPOD Clinical Co-ordinator and author of the NCEPOD sepsis report NCEPOD report for sepsis study www.kssahsn.net/safety

2. @NCEPOD #sepsis

3. National Confidential Enquiry into Patient Outcome and Death (NCEPOD) 27 Years

4. History Mechanism of studies Achievements

5. History 1982 - Mortality associated with anaesthesia (Lunn and Mushin) 1987 - Report of a Confidential Enquiry into Perioperative Deaths (Associations of Anaesthetists and Surgeons) 1989

6. Original Aims Independent Identify remedial factors Consider Quality Peer Review

7. Coverage England Scotland Wales Northern Ireland Offshore Islands Independent sector

8. NCEPOD Supporting bodies Faculty of Public Health Medicine of RCP Association of Anaesthetists Association of Surgeons Royal College of Anaesthetists Royal College of Radiologists Royal College of Ophthalmologists Royal College of Surgeons Lay Representatives Faculty of Dental Surgery of RCS Royal College of Pathologists Royal College of Obstetricians & Gynaecologists Royal College of Physicians Royal College of General Practitioners Royal College of Nursing Royal College of Child Health and Paediatrics

9. Methodology Confidential clinical questionnaires Organisational questionnaires Local reporter Anonymous peer review Qualitative analysis Recommendations

10. Choosing study topics Topic selection protocol –Seek ideas from all stakeholders –Shortlist –Present to Steering Group for decision –Pilot

11. Confidentiality BS 7799 PIAG DPA NRES Anonymisation

12. ‘Learning lessons’ Learning from the insight of the experience of others “Pattern recognition” Research evidence may not be available Encourage reflective comments

13. Key Role of Advisor Groups Cases reviewed and graded –Good practice –Room for Improvement –Less than satisfactory –Cause for concern

14. 1997 2003 20% increase in consultant presence 50 -75% decrease in unsupervised trainees out of hours Doubling of emergency theatre time WOW 1 WOW 2

15. Reports Forty reports published –Traditionally around deaths within 30 days of a surgical procedures

17. @NCEPOD #sepsis Report available in.pdf at ncepod.org.uk

18. Study aim To identify and explore avoidable and remediable factors in the process of care for patients with sepsis.

19. Study objectives To examine organisational structures, processes, protocols and care pathways for sepsis recognition and management To identify remediable factors in the management of the care of adult patients with sepsis, focusing on the following areas of care:

20. Study objectives Timely identification, escalation and treatment of sepsis: use of systems, early warning scores, care bundles Multidisciplinary team approach Communication: -Primary/secondary care -Healthcare professionals; Documentation of sepsis- -Patients, families and carers

21. Study population Adult patients diagnosed with sepsis and admitted to critical care (HDU/ICU) or reviewed by CCOT or equivalent during the study period: 6 th -20 th May 2014

22. Exclusions Pregnant women up to 6 weeks post partum Patients undergoing chemotherapy, organ transplant Patients already on end of life care pathway when sepsis diagnosed Patients who developed sepsis after 48 hours on ICU

23. Method Prospective case identification –Study contact –Identify cases: 6 th -20 th May 2014 –Spreadsheet Case selection –5 randomly selected at each hospital Questionnaire/ case note request sent to each named clinician Case ascertainment

24. Method Cases reviewed by MD panel of Reviewers –Assessment form Identified cases where patient attended the GP –Sent request for GP notes Organisational questionnaire –Acute / non-acute hospitals Data collection

25. Returns

26. Pre-hospital Care Pages 37 - 50

27. Demographics Males = 56%

28. Demographics

29. Organisational data However, for only 8/133 patients seen prior to hospital admission was a pre-alert sent to the ED

30. Organisational data

32. Pre hospital care

34. 129 hospital notes had details of GP consultation Named GP contacted requesting their notes from the last 3 contacts before admission 60 sets of notes returned 54 suitable for review 3 GP case note reviewers recruited and trained Pre hospital care

35. Last visit before hospitalisation: – 16/54 in surgery – 27/54 home visit – 10/54 other: telephone/ nursing home Pre hospital care

37. EWS was not used in any of the cases reviewed

38. Pre hospital care GP casenotes review

39. Pre hospital care Hospital casenotes review

40. 37 patients had no vital signs recorded at triage or senior review 152 patients complete set between 2 assessments Emergency care

41. Pre hospital care

43. GP casenotes review

44. Pre hospital care Hospital casenotes review

45. Overall quality of care

46. Key Findings Page 55

47. Recommendations All hospitals should have a formal protocol for the early identification and immediate management of patients with sepsis. The protocol should be easily available to all clinical staff, who should receive training in its use. Compliance with the protocol should be regularly audited. This protocol should be updated in line with changes to national and international guidelines and local antimicrobial policies.

48. Recommendations An early warning score, such as the National Early Warning Score (NEWS) should be used in both primary care and secondary care for patients where sepsis is suspected. This will aid the recognition of the severity of sepsis and can be used to prioritise urgency of care.

49. Recommendations On arrival in the emergency department a full set of vital signs, as stated in the Royal College of Emergency Medicine standards for sepsis and septic shock should be undertaken.

50. Recommendations In line with previous NCEPOD and other national reports’ recommendations on recognising and caring for the acutely deteriorating patients, hospitals should ensure that their staffing and resources enable: All acutely ill patients to be reviewed by a consultant within the recommended national timeframes (14 hrs post adm.) Formal arrangements for handover Access to critical care facilities if escalation is required; and Hospitals with critical care facilities to provide a Critical Care Outreach service (or equivalent) 24/7.

51. Recommendations All patients diagnosed with sepsis should benefit from management on a care bundle as part of their care pathway. The implementation of this bundle should be audited and reported on regularly. Trusts/Health Boards should aim to reach 100% compliance and this should be encouraged by local and national commissioning arrangements.

52. Thank you www.ncepod.org.uk