National Sepsis Audit• National Registrar Research Collaborative Audit Project 2013• Nationally led by SPARCS (Severn and Peninsula Audit and

Research Collaborative for Surgeons)• Regionally led by NWRC (North West Research Collaborative)

Background• Previous national audit• Multicentre observational study of performance variation in

provision and outcome of emergency appendicectomy• 3326 patients from 95 centres• British Journal of Surgery 2013; 100: 1240–1252

• Led by West Midlands Research Collaborative

• International audit of sepsis in general surgical admission• Including general, vascular and breast surgery

Aims• Examine the proportion of emergency surgical patients

presenting with severe sepsis• Establish compliance with the Sepsis Six and Surviving Sepsis

Resuscitation Bundles.• Establish compliance with Source Control guidelines for

patients with severe sepsis

SIRS, Sepsis and Severe Sepsis• A. Systemic Inflammatory Response Syndrome (SIRS):• Presence of two or more of the following:

• 1. Temperature >38.3°C or <36°C• 2. Heart rate >90 beats/min• 3. Respiratory rate >20 breaths/min• 4. WBC >12,000 cell/mm3 or <4,000 cell/mm3• 5. Acutely altered mental status• 6. Hyperglycaemia (plasma glucose of >7.7mM/l) in the absence of

diabetes

• B. Sepsis• Sepsis is deemed present when SIRS is accompanied by a clinical

suspicion of infection.

SIRS, Sepsis and Severe Sepsis• C. Severe sepsis• Sepsis-induced tissue hypoperfusion or organ dysfunction:

• 1. Sepsis-induced hypotension (systolic Bp of < 90 or MAP < 65mmHg)• 2. Lactate >2 mmol/L• 3. Urine output < 0.5mL/kg/hr for more than 2 hrs despite adequate

fluid resuscitation or creatinine > 176.8mmol/l• 4. Acute lung injury with PaO2/FIO2 < 300 in the absence of pneumonia• 5. Acute lung injury with PaO2/FIO2 < 200 in the presence of pneumonia

source• 6. Bilirubin >34.2mmol/L• 7. Platelet count < 100,000 μL• 8. Coagulopathy (international normalized ratio > 1.5 or a PTT>60 secs))

• D. Septic Shock• Sepsis-induced hypotension, persisting despite adequate fluid

resuscitation.

Audit Standards

• Sepsis Six guidelines: ALL of the following interventions should be performed within one hour of severe sepsis: • a) Delivery of high flow oxygen • b) Obtainment of blood cultures prior to antibiotic administration • c) Administration of empirical broad-spectrum antibiotics • d) Fluid resuscitation • e) Measurement of serum lactate and full blood count • f) Commence accurate urine output measurement (may require

catheterisation)

Audit Standards• Surviving Sepsis guidelines: ALL of the following interventions

should be performed within six hours of severe sepsis: • a) In the event of hypotension or lactate ≥4mmol/L:

• i. Deliver an immediate minimum of 30ml/kg crystalloid • ii. Give vasopressors for hypotension not responding to initial fluid

resuscitation to maintain mean arterial pressure ≥65mmHg

• b) In the event of persistent hypotension despite volume resuscitation and/or initial lactate >4mmol/l: • i. Achieve central venous pressure of ≥8mmHg • ii. Achieve central venous oxygen saturation ≥70%

• c) Source of infection to be identified and controlled

Patient Identification• Presence of sepsis will be elicited for the first 24 hours of each

patient’s hospital admission only• Age >16 years• Urology, neurosurgery, plastics, obstetrics and gynaecology,

ENT, cardiothoracics, ophthalmology and maxillofacial surgery will be excluded

• Inpatients and referrals from other medical specialties will also be excluded

• Eligible Patients admitted between: 09:00 on Monday 21st October – 09:00 on Monday 28th October

Data Extraction• Commence 30 days after admission• For all patients:• demographic data will be recorded • data concerning the presence or absence of sepsis markers

during the first 24 hour of admission. • Where sepsis was not present, no further data collection will

be required. • If sepsis was present further data extraction will be

performed:• adherence to surviving sepsis guidance, • investigation of source and timing of source control, • total of 30 days post admission.

Next Steps• PI (Primary Investigator) at each trust: Consultant who agrees

to support the audit• Register the project with the audit department• Team of trainees (Insert name[s] here) responsible for data

collection• Accurate daily list of all general surgical admissions during the

study period• (Insert name[s] here) will collate 30-day follow-up data