1. SEPSIS: IMPROVING CARE, IMPROVING OUTCOME Professor Kevin Rooney World Sepsis Day 13 th September 2012

2. Scotland HSMR – 10.6% Reduction

3. Good but room for improvement Sepsis

4. What is Sepsis?

6. Acute MI & Trauma 5% Mortality 3% Mortality

7. Severe Sepsis And HAI Mortality SEVERE SEPSIS 2004: 14000 DEATHS 300 per million dying of severe sepsis in any one year ODDS: 1 in 3333 SEPSIS in UK: 37000 DEATHS ODDS 1 in 125 MRSA & CDI 2006: 8132 DEATHS 91 per million dying of MRSA or CDI in any one year. ODDS: 1 in 11,000. –For those aged under 45 years : 1 in 250,000. –For those aged 85 years or older, 1 in 300. www.statistics.gov.ukwww.statistics.gov.uk); ; UK Sepsis Group Harrison D et al Critical Care 2006; 10:R42

8. Lung 1 Colon 2 Breast 3 Sepsis 4 cancers Annual UK mortality (2003), thousands 1,2,3 www.statistics.gov.uk, 4 Intensive Care National Audit Research Centre (2006) A U.K. Perspective 0 20 30 40 10 © Ron Daniels 2010

9. Copyright 2010 by the American Medical Association. All Rights Reserved. Applicable FARS/DFARS Restrictions Apply to Government Use. American Medical Association, 515 N. State St, Chicago, IL 60610. Published by American Medical Association. 2 Sepsis in General Surgery: The 2005-2007 National Surgical Quality Improvement Program Perspective. Moore, Laura; Moore, Frederick; Todd, S; Jones, Stephen; Turner, Krista; Bass, Barbara Archives of Surgery. 145(7):695-700, July 2010. Surgical Sepsis

10. Not just anyone

11. Tip of the Iceberg

12. Courtesy of Dr I Roberts

14. Variation In Sepsis Care

15. 15,022 Patients 165 Hospitals Median of 14 Months Mortality Decreased from 37 to 30.8 Percent 6.2% Absolute 16% Relative

16. STAG Sepsis Management in Scotland Signs of sepsis < 2 days 2% of emergency admissions (~5000) 71% had a EWS 34% had severe sepsis 21% blood cultures 32% IV Antibiotics 70% IV fluids Scottish Defect Rate was 18-74%

17. Why is implementation so difficult? Too many elements in the bundle Some are controversial Time Sensitive Process Difficult To Diagnosis Sepsis Early Human Factors Get In The Way Invasive procedures needed ICU stuff??

18. Complacency, Education & Trying Harder isn’t enough

19. New ways of thinking

20. Front line engagement Segmentation Real Time Data Collection Early Feed Back of Metrics Early Case Review and Feedback Use Level 2 Reliability Tools

21. Evidence for the Change Package

22. Reliable Sepsis screening (EWS + SIRS) Ensure reliable communication across clinical teams of at risk patients Ensure timely rescue of deteriorating patient by competent teams To improve the recognition and timely management of Sepsis in acute hospitals Outcome: Reduction in mortality in pilot population from Sepsis 5% by December 2012 10% by December 2014 AIM Reliable Recognition & Assessment Reliable Care Delivery Education & Awareness Culture of safety and Quality Improvement PRIMARY DRIVERS Ensure reliable delivery of Sepsis Six within 1 hour Source Control Ensure reliable escalation of septic patients to higher level of care Improve Antimicrobial stewardship - 3 day review Education on burden of illness & current performance Provide training to staff on clinical knowledge and improvement skills Executive Sponsorship Clinical Leadership Multidisciplinary team working Develop measurement frameworks to guide improvement Involve patients & families in treatment process and care planning SECONDARY DRIVERS Patient & Family Centred Care JOINT COLLABORATIVE - SEPSIS DRIVER DIAGRAM

23. Reliable Recognition, Assessment & Rescue

24. Sepsis Screening MEWS: >95% reliable in pilot wards Systemic Inflammatory Response Syndrome (SIRS) criteria

25. The Sepsis Six 1.Deliver high-flow O 2 (>98% SpO 2 ) 2.Take blood cultures and consider source control 3.Give IV antibioticsaccording to local protocol 4.Start IV fluid resuscitation (min 500ml) and reassess 5.Check serum lactate & FBC 6.Commence accurate urine output measurement and consider urinary catheterisation All within one hour © Ron Daniels 2010

26. © 2006 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins. Published by Lippincott Williams & Wilkins, Inc. 5 Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock *. Kumar, Anand; Roberts, Daniel; Wood, Kenneth; Light, Bruce; Parrillo, Joseph; Sharma, Satendra; Suppes, Robert; Feinstein, Daniel; Zanotti, Sergio; Taiberg, Leo; Gurka, David; Kumar, Aseem; Cheang, Mary Critical Care Medicine. 34(6):1589-1596, June 2006. DOI: 10.1097/01.CCM.0000217961.75225.E9 Figure 1. Cumulative effective antimicrobial initiation following onset of septic shock-associated hypotension and associated survival. The x-axis represents time (hrs) following first documentation of septic shock-associated hypotension. Black bars represent the fraction of patients surviving to hospital discharge for effective therapy initiated within the given time interval. The gray bars represent the cumulative fraction of patients having received effective antimicrobials at any given time point. Why within an hour?

27. Why all septic patients? Sepsis Disease Continuum: 15% → 30% → 50%

28. Spreading Ink blot Strategy Based on military tactics –Small area of “Good Practice” across site –As expand will join up MAU ED Surgical –Hospital At night –Medical Wards –DOME Acute Medical Unit Acute Surgical RAH ED

32. The Future Acute Medical Unit Acute Surgical RAH ED Medical/ Surgical Wards

34. Heart & Minds ‘If you want to build a ship do not gather men together and assign tasks. Instead teach them the longing for the wide endless sea.’ (Saint Exupery, Little Prince)