1. Clinical Pathways: Special Focus on Sepsis!
Trevor Morris
Integrated Pathways Project Manager
Professor Morris Gordon
Professor of Evidence Synthesis and systematic review
Strategic Clinical Lead for Quality
Consultant Pediatrician
Homework
Focus for next session
Buddying up with each other
Kahootz platform
Communication Officer support

2. Why do we need clinical pathways?
Not just an evidence based guideline or protocol
Pathway conditions are those that we ensure:
Have right evidence based care agreed
Are delivered at the right times
Have the right outcomes achieved to give quality care!
Offering ‘best in NHS’ option
IT MAKES A DIFFERENCE

3. For many patients – the first doctor assessing them is often a “junior” doctor
Pathway is a “tool” to insure appropriate care is delivered by those with less experience
They are live prospectively audited and all ‘failures’ ed on daily basis!!!!!!
This empowers you to make sometimes difficult diagnostic decisions, using trust approved evidence based approach
These are not just suggested, but agreed in external contracts by the trust.
Our local partners, commissions, the national regulators and our patients can and do hold us to account

4. Blackpool Teaching Hospitals - 9 High Mortality Pathways
Pneumonia
Sepsis
Stroke
COPD
Heart Failure
Cardiac Chest Pain
Acute Kidney Injury
Fractured Neck of Femur
Acute Abdominal Pain

5. January 2018 32.70% Tasks MORTALITY Aug 16 – 141
*159 patient case notes reviewed
Tasks
Opportunities to Care Target: 90%
Overall Compliance Target: 40%
Oxygen given to maintain sats
99.37% (↓0.63%)
32.70%
Blood Cultures < 4 hrs
66.67% (↓1.96%)
Lactate Measured < 4 hrs
86.16% (↑5.11%)
IV Antibiotics administered < 4 hrs
55.35% (↑3.72%)
Fluid Challenge < 4 hrs
92.45% (↑9.44%)
Catheterised urine value monitored
91.82% (↓0.99%)
MORTALITY
Aug 16 – 141
Based on an analysis of Trust mortality data and national risk reduction in order to indicate the potential impact of success, it has been identified that 67* deaths could be prevented a year (6 deaths a month) if sepsis 6 was adhered to trust wide. The focus for was to improve time to antibiotic administration.

6. Initiatives implemented in 2018 to improve Inpatient Sepsis Care
Sepsis trolleys introduced into A&E and SAU
which include antibiotics and fluid packs
Blood Culture Packs introduced including:
Updated Sepsis Care Bundle
Pictorial Guide on Blood Culture
Patient Information leaflet for sepsis care
PGD (Patient Group Direction) for the key antibiotics
used according to infection source.
Sepsis education slot for junior doctor Induction
inc. Improving Sepsis Care Grand Round (03/10/18)
Modified and rolled out in the Acute and
community bed base setting the NEWS2 charts
including warning triangle prompts for sepsis and a
prompt Box for staff to 'think sepsis'

9. IT WORKS - SEPSIS
How we measure – we shifted the goal posts 12 months ago to be as strict as possible (evidence informed)
Clocks starts when you enter the building (not when we triage)
Delivery of all 6 elements – no compensation for missing items
Delivery within 4 hours
60+ lives could be saved per year!!!!
Delivery of full sepsis 6 is 74%.
Delivery of antibiotics 87% within
1 hour (100% within 4 hours)
SHMI dropping
COMPLIANCE
MORTALITY
PEERS (AQuA)
Jan 18 – 33%
Aug 16 – 141
Best in the North West
for 1 hour antibiotics
(BTH – 86%, NW Mean – 66%)
June 19 – 74%
Feb 19 – 92

10. System-Wide Approach to Pathways - Sepsis
PRESENTATION
ASSESSMENT
CONVEYANCE
ACUTE
POST INTERVENTION
RESIDENTIAL
Baseline
Obs
NEWS
>4
Handover
& Transfer
IPN
Support
COMMUNITY
Baseline
Obs
NEWS
>4
Handover
& Transfer
Follow Up
PRIMARY
Baseline
Obs
NEWS
>4
Handover
& Transfer
AMBULANCE
Baseline
Obs
NEWS
>4
Pre-Alert
HOSPITAL O2
Blood
Cultures
Lactate
Fluid
Baseline
Obs
NEWS
>4
Abx
Urine
Sepsis Six Compliance - 74% (June 19)

11. System-Wide Approach to Pathways
A single, standardised language and pathway for sickness.
Calculation of risk to start outside of a hospital setting with the introduction of pre-hospital Obs (Suspicion of Sepsis – SOS)
Temperature, Blood Pressure, Heart Rate, Respiratory Rate, AVPU
Implementation of National Early Warning Score 2 (NEWS2) Tool:
Baseline NEWS (inc. care homes), GP NEWS, Communication NEWS, Transportation NEWS, Arrival NEWS , Track/Trigger NEWS
Residential Care: Link into Infection Prevention Team at LCC (Sepsis Strategy for Lancashire Care Homes )  
Acute Care improvements to include: Introduction of Sepsis Nurse role (Part of integrated Acute Care Response team)
Introduction of pan pathway metrics – Including time patient becomes unwell, primary care input, ambulance input inc. pre-alert, A&E input inc. Antibiotic prescription & administration, Oxygen given to maintain sats, Blood Cultures, Lactate Measured, Fluid Challenge, Urine value, Discharge.

13. The specialist pathway audit team are watching you ALWAYS So write it down CLEARLY IT SAVES LIVES!!!!!!!

15. Summary
Pathways exist for many conditions, but these 9 are critical to patients, the trust, the commissioners, regulators, everyone!
They are monitored, all the time.
The evidence is we can improve by following – not just compliance, but outcomes
If use of pathways is challenged, tell us!
@drmorrisgordon
@RealTrevMorris
M Gordon, 2015 CC