Dr. Mark Simmonds Consultant in Acute and Critical Care ......Sepsis Timeline at NUH Onset of Severe...

Dr. Mark Simmonds

Consultant in Acute and Critical Care Medicine

Nottingham University Hospitals NHS Trust

� Some History

Sepsis at NUH Now� Sepsis at NUH Now

� The Future

Nottingham University Hospitals NHS Trust

1900 beds

1.2 Million population

coveredcovered

16,000 staff

Major Trauma Centre

Burns Unit

Neurosurgical Centre

� Within 6 hours:

Blood Cultures

Broad spectrum antibiotics (within 3 hours)

Measure lactateMeasure lactate

Adequate fluid resuscitation

Use of Vasopressors if needed

CVP line placed if needed

CVP maintained at 8-12mmHg

ScVO2/SVO2 measured

Inotropes used if needed

Use of Blood if needed

� Within 24 hours:

Blood sugar maintained <8.3 with Insulin if needed

Administration of Steroids if needed

Patient’s eligibility for Activated Protein C determined

Plateau pressures maintained <30cmH20 if ventilated

Frontline Nurses

Critical Care

Outreach

Acute Medicine/ED

doctors ICU

Physicians

Audit Team

Sepsis Action Group

Pharmacists

Microbiologists

Nurses

JuniorDoctors

Senior Management

� Adherence to the ‘6-hour’ and ‘24-hour’ bundle guidelines

� Comprehensive evaluation of patient journey▪ Who was involved in care and when?▪ Who was involved in care and when?

▪ Where was care being given?

▪ What role did Critical Care play?

▪ What role did Microbiology play?

▪ How did these patients present?

▪ What organisms were to blame?

� Where should resources be targeted to improve care?

� Patient identifier: Positive Blood Cultures

Initially carried out in 2005� Initially carried out in 2005

� Repeated to same protocol in 2010 at QMC,

NCH and KMH

� 75% of patients had severe sepsis on admission

� Of these 85% of patients were admitted to ‘medicine’

� But, of those deteriorating on the ward, 50% were under surgical teams

� 45% are admitted to critical care, and stay there a long time

Median time to antibiotics-

2.5 hours (IQR 1-4.75 hours)

90

0

10

20

30

40

50

60

70

80

0 1 2 3 4 5 6

Pe

rce

nt

Hour

Antibiotic Administration

Seen by first doctorDiscussed with Senior Doctor

Seen by Senior Doctor Arrive Critical Care

Sepsis Timeline at NUH

Onset of Severe Sepsis

Seen by first doctor

Blood Culture taken

Antibiotics given

Radiology

Seen by Critical Care Specialist

CVP line placed

12:00 13:00 14:00 15:00 16:00 17:00 18:00 19:00 20:00 21:00

� Wide dissemination of audit results

� Report to QMC Medical Director

� Review of ‘Ward Stock’ Antibiotics� Review of ‘Ward Stock’ Antibiotics

� Lactate modules added to ABG machines

� Website designed

� Sepsis Action Group reformed in 2010

That’s all very interesting…

…but really…

…it’s not my problem!

Six hour bundle item

Blood cultures

Antibiotics as per guidelines in <1hr

Lactate measured

Adequate fluid resuscitation if needed

CVP maintained at 8-12mmHg if

needed

ScVO2/SVO2 measured

Use of vasopressors if needed

Use of inotropes if needed

Use of blood if needed

Six hour bundle item

Blood cultures

Antibiotics as per guidelines in <1hr

Lactate measured

Adequate fluid resuscitation if needed

CVP maintained at 8-12mmHg if

needed

ScVO2/SVO2 measured

Use of vasopressors if needed

Use of inotropes if needed

Use of blood if needed

Critical Care

interventions

Twenty-four hour bundle

Blood sugar <8.3 with insulin if needed

Administration of steroids if needed

NICE SUGAR

CORTICUS Administration of steroids if needed

Patient eligibility for ApC determined

Protective Lung Ventilation

DVT Prophylaxis

Gastric Protection

Decontamination GI tract

PROWESS-

SHOCK

CORTICUS

• EWS and screening

• Blood Cultures

• LactateRecognise

• Early Antibiotics

• Fluid ResuscitationRespond

• Early referral to Critical Care if fails to respondRescue

Round 2011/12

We

Go

Again

� Sepsis CQUIN target 2012-14

£2.5 million� £2.5 million

� Using our existing audit technique ▪ (after much negotiation!!!!)

� Compliance with:� Guideline Antibiotics in <1hr

� Blood cultures taken

� Lactate Measured� Lactate Measured

� Fluid Resuscitation

� Baseline: 15% compliance� Target: 30% by April 2013

50% by April 2014

• Blood Cultures

• LactateRecognise

• Early Antibiotics

• Fluid Resuscitation

Respond

• Early referral to Critical Care if fails to respond

Rescue

� More streamlined audit process▪ All critical care admissions with primary diagnosis of infection

▪ Higher ‘pick-up rate’ and easier to perform

� Retain in depth analysis of patient pathway

� The audit process had to become PART of the

improvement strategy

Intervention Target Time from Time Zero (hrs)

Achieved Comment

EWS recorded and escalated

appropriately at time zero

- EWS=5

Escalated

Seen by any doctor 0.5 25 mins

Seen by a senior clinician

(Reg/Cons)

2 65 mins

Blood Cultures taken 1 30 mins

Broad Spectrum Antibiotics 1 75 mins Delay to Broad Spectrum Antibiotics

given in line with guidelines

1 75 mins Delay to

administration ?why

Lactate measured 6 Lactate 1.5

Adequate initial fluid

resuscitation in event of

hypotension or lactate >4

6 Appropriate

fluid resus

Escalation to critical care

requested in event of failure to

improve with initial therapy

6 Delay to

MHDU 8 hours

No beds

� Since November 2011:Over 900 potential cases identifiedOver 700 patients reviewedOver 350 cases of severe sepsis audited and Over 350 cases of severe sepsis audited and reported back to the treating clinician

� Since November 2012:-Over 95% of cases admitted to critical care with “infection” are being audited

� Reporting on approx 30-35/month

80

90

100

20

30

40

50

60

70

20

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20

10

No

v-1

1

De

c-1

1

Ja

n-1

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b-1

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r-12

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r-12

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n-1

2

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Au

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p-1

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Oct-1

2

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v-1

2

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2

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b-1

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r-13

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3

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v-1

3

Pe

rce

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70

80

90

100

10

20

30

40

50

60

70

Perc

en

t

Seen by first doctor

Seen by Senior Doctor Arrive Critical Care

Onset of Severe Sepsis

Blood Culture taken

Antibiotics given

Seen by Critical Care Specialist

12:00 13:00 14:00 15:00 16:00 17:00 18:00 19:00 20:00 21:00

Seen by first doctor

Seen by Senior Doctor Arrive Critical Care

Onset of Severe Sepsis

Blood Culture taken

Antibiotics given

Seen by Critical Care Specialist

12:00 13:00 14:00 15:00 16:00 17:00 18:00 19:00 20:00 21:00

Seen by first doctor

Seen by Senior Doctor Arrive Critical Care

Onset of Severe Sepsis

Blood Culture taken

Antibiotics given

Seen by Critical Care Specialist

12:00 13:00 14:00 15:00 16:00 17:00 18:00 19:00 20:00 21:00

� Presented both positive and negative feedback

in an objective, constructive manner

Acted as an educational tool in its own right� Acted as an educational tool in its own right

� Allowed for a conversation between

improvement team and care givers

� Made sepsis ‘personal’

� Crude Critical Care Mortality

� 2009/10 42%

� 2012/13 28%

� SMR for Septicaemia

� 2009 119

� 2012 86

ETCRG

Resus

Sepsis

AKI

CCOT

R&RAMCRGEWS

Steering

CRC

Thank you for your time.

Email: mark.simmonds@nuh.nhs.uk

Twitter: @mjrsimmonds