#sepsis 1 Method Hannah Shotton 2 Study Advisory Group Study - - PowerPoint PPT Presentation

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#sepsis 1 Method Hannah Shotton 2 Study Advisory Group Study - - PowerPoint PPT Presentation

Oct 19, 2023 477 likes •1.71k views

@NCEPOD #sepsis 1 Method Hannah Shotton 2 Study Advisory Group Study proposal Study Advisory Group Study design: key themes, method, questionnaire Acute medicine Emergency medicine General practice Surgery

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@NCEPOD #sepsis

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Method Hannah Shotton

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Study Advisory Group

  • Study proposal
  • Study Advisory Group

– Study design: key themes, method, questionnaire

  • Acute medicine
  • Emergency medicine
  • General practice
  • Surgery
  • Intensive care medicine
  • Microbiology
  • Pathology
  • Nursing, critical care outreach
  • Patient representative

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Study aim

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

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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

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Study objectives

  • Timely identification, escalation and treatment
  • f sepsis: use of systems, EWS, care bundles
  • Multidisciplinary team approach
  • Communication:
  • Primary/secondary care
  • Healthcare professionals; documentation of sepsis
  • Patients, families and carers
  • End of life care

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Study population

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

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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
  • n ICU

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Method

  • Prospective case identification

– Study contact – Identify cases – Spreadsheet

  • Clinician details
  • Case selection

– 5 randomly selected at each hospital

  • Questionnaire/ case note request sent to each

named clinician

Case ascertainment

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Method

  • Cases reviewed by panel of Reviewers

– Assessment form

  • Identified cases where patient attended the GP

– Sent request for GP notes – GP Reviewers

  • Organisational questionnaire

– Acute / non-acute hospitals

Data collection

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Returns Returns

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Demographics Demographics

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Demographics Co-morbidities

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Demographics Mode of admission

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Demographics Previous admission to hospital

192/702 (27.4%) previous admission for sepsis

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Organisational data Vivek Srivastava

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Organisational data Organisational data

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Organisational data Organisational data

81% protocols are based on national/ international guidance 93% hospitals without a sepsis protocol had a protocol for deteriorating patients

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Organisational data

95% protocols – timeframe for actions within 1 hour of diagnosis

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Organisational data

Protocol available on hospital intranet in 97.4% hospitals

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Organisational data

Table 3.21 - Pre-alert sent for 8/133 patients attending the ED

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Organisational data

165/216 acute hospitals had a policy for who can administer antimicrobials

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Organisational data

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Organisational data

Time to transfer to critical care if not on-site

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Organisational data

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Organisational data

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Hospitals with policy - 94% had time set aside for face-to-face handover

Organisational data

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Organisational data

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Organisational data

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Organisational data

199/223 (89%) hospitals with critical care have a CCOT

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44.2% of hospitals had CCOT

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Organisational data

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Organisational data

Sepsis nurse in 11%

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Organisational data

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Organisational data

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Organisational data

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Pre hospital care Vivek Srivastava

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Pre hospital care

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  • 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

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  • Last visit before hospitalisation:

– 16/54 in surgery – 27/54 home visit – 10/54 other: telephone/nursing home

Pre hospital care

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Pre hospital care

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Pre hospital care

EWS was not used in any of the cases reviewed

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Pre hospital care

GP case note review

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Pre hospital care

Hospital case note review

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

Emergency care

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Organisational data

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Inpatient care

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Inpatient care

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Pre hospital care

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Pre hospital care

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Pre hospital care

GP case note review

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Pre hospital care

Hospital case note review

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Emergency care Vivek Srivastava

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Emergency care

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Emergency care

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Emergency care

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Inpatient care Alex Goodwin

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Inpatient care

Correct location according to Reviewers in 93%

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Inpatient care

Admission to ward delayed in 49/361 (13.9%)

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17.9% consultant review delayed according to Reviewers

Inpatient care

20.4% > 14 hours

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Changes made following consultant review in 281/457 (61.5%)

Inpatient care

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Hospital-acquired infection Alex Goodwin

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Inpatient care - source of infection

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Inpatient care

Answers may be multiple, n=115

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Inpatient care

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Inpatient care

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Diagnosis Alex Goodwin

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Inpatient care

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Inpatient care

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Inpatient care

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Inpatient care

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128/479 (26%) used screening tool/ EWS

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Inpatient care

28% 36% 35% 55% 30% 31%

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Inpatient care

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Inpatient care

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Blood cultures taken in 366/477 (77%) fluid cultures in 48, tissue cultures in 43

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Blood gases taken in 375/509 (74%)

Inpatient care

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Inpatient care

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Inpatient care

Where not timely, patient deteriorated in 51 Outcome affected in 20

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Inpatient care

Room for improvement in fluid management in 203/447 cases

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Inpatient care

Pathogen identified in 198/481 (41%)

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Inpatient care

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Outcome affected in 43 cases

Inpatient care

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Inpatient care

  • Reviewers: patient started on sepsis care bundle

following diagnosis: 135/434 (31%)

  • Clinician questionnaire: 207/318 (39%)

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Inpatient care

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With care bundle Without care bundle Delay in escalation 9% 26% Delay in administration of administration of antimicrobials 18.5% 38% Fluids delayed/ not received 13% 23% Oxygen delayed / not received 5% 15% Investigation of source of infection 10% 28% Blood cultures not taken 60% 79.5% Less than good documentation

  • f sepsis

19% 33% Blood gases not taken 19% 33%

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  • 224/226 (99%) acute hospitals had an

antimicrobial policy

  • 139/204 (68%) daily microbiology ward rounds
  • n ICU
  • 20/194 (10%) daily microbiology ward rounds
  • n general medical wards
  • 13/196 (7%) daily microbiology ward rounds on

general surgical wards

Inpatient Care (organisational data)

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Inpatient care

Appropriate antimicrobial in 472/571(91%) Correct dose in 405/414 (98%)

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Inpatient care

Regular review of antimicrobial therapy in 317/404 (78.5%)

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Inpatient care

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85.2% 74.3% 79.7%

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Inpatient care

  • Opinion of treating clinician

– Investigations to identify source omitted/delayed:

80/649 (12.3%)

  • Reviewer opinion

– Investigations to identify source delayed:

101/505 (20%)

– Investigations to identify source omitted:

113/495 (23%)

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Inpatient care

  • Source of sepsis identified in 434/493 (88%)
  • Identified in appropriate timeframe in 340/421 (80%)

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Emergency care

Comparison in identification of source

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Inpatient care

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Inpatient care

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Inpatient care

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Inpatient care

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Inpatient Care (Organisational data)

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Inpatient care

  • Room for improvement in initial management

in 292/551 (53%)

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Inpatient care

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Inpatient care

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Inpatient care

278 referred to critical care

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Inpatient care

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Inpatient care

Answers may be multiple; n=71 107

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Inpatient care

Delayed discharge: 28/56 less than 1 week 11/56 1-2 weeks 17/56 more than 2 weeks

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Inpatient care

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Inpatient care

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Inpatient care

GP was informed of admission in 222/294 (75.5%)

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Inpatient care

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Inpatient care

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Inpatient care

Sepsis not recorded on the death certificate in 61/103 patients; should have been in 48/61

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Overall quality of care

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Summary

  • Care less than good in 64% cases
  • Identification

– Vital signs recording – Use of EWS – Communication between primary and secondary care

  • Treatment

– Delay, Delay, Delay – Benefit of pathways, bundles and documentation – Antibiotic stewardship

  • Follow up

– Recognition of complications and appropriate treatment – Information

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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.

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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.

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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.

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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:

  • a. All acutely ill patients to be reviewed by a consultant

within the recommended national timeframes (14 hrs post adm.)

  • b. Formal arrangements for handover
  • c. Access to critical care facilities if escalation is required; and
  • d. Hospitals with critical care facilities to provide a Critical Care

Outreach service (or equivalent) 24/7.

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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.

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Thank you www.ncepod.org.uk

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