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2011 Quality Systems Assessment Self Assessment
Supplementary Report - Sepsis
Table of Contents
INTRODUCTION ........................................................................................................................................................ 4
HOW THE QSA WORKS ...................................................................................... ERROR! BOOKMARK NOT DEFINED.
NOTES ABOUT THE DATA: ................................................................................................................................... 35
MANAGEMENT OF SEPSIS ................................................................................ ERROR! BOOKMARK NOT DEFINED.
WHY IS THIS IMPORTANT? .................................................................................................. ERROR! BOOKMARK NOT DEFINED.
SUMMARY OF RESULTS ....................................................................................................... ERROR! BOOKMARK NOT DEFINED.
WHAT NEXT? ...................................................................................................................... ERROR! BOOKMARK NOT DEFINED.
STATEWIDE RECOMMENDATIONS ..................................................................................................................................... 6
May 2012
2
© Clinical Excellence Commission 2012
This work is copyright. Apart from any use as permitted under the Copyright Act 1968, no part may be reproduced
without prior written permission from the Clinical Excellence Commission. Requests and enquiries concerning
reproduction and rights should be directed to the Director, Corporate Services, Clinical Excellence Commission, GPO
Box 1614, Sydney NSW 2001.
This publication is part of the Clinical Excellence Commission’s Quality Systems Assessment Series. A complete list of
the CEC’s publications is available from the Director, Corporate Services, Clinical Excellence Commission, GPO Box 1614,
Sydney NSW 2001, or via the Institute’s web site (http://www.cec.health.nsw.gov.au).
Authors
Bernadette King, Roger Kerr, Jun Bai
Clinical Excellence Commission
Board Chair: Associate Professor Brian McCaughan AM
Chief Executive Officer: Professor Clifford F Hughes AO
Any enquiries about or comments on this publication should be directed to:
Dr Charles Pain Director Health Systems Improvement Clinical Excellence Commission Locked Bag A4062 Sydney South NSW 1235
Phone: (02) 9269 5500
Email: [email protected]
3
Table or Contents
EXECUTIVE SUMMARY ............................................................................................................................. 4
INTRODUCTION ....................................................................................................................................... 5
UNDERSTANDING THE DATA ................................................................................................................................... 5
STATE-WIDE RECOMMENDATIONS ........................................................................................................................... 6
RESULTS .................................................................................................................................................. 7
APPENDIX 1: NOTES ABOUT THE DATA ................................................................................................... 35
4
Executive Summary Sepsis is a potentially deadly medical condition that is associated with high mortality. The key to improving sepsis
outcomes is implementation of pre-hospital and hospital-wide systems that assist early recognition of at-risk or septic
patients and lead to rapid administration of effective therapy.
This supplementary report provides more detailed information from the self assessment results undertaken from
September 2011 to November 2011 relating to the management of sepsis in both adult and paediatric patients
responded by those who work in the local health district and NSW Ambulance Service. The 2011 self-assessment was
completed by over 1,500 respondents across, and at various levels, of the health system. At the unit level the overall
response rate was 99%. All medical and surgical specialties; maternity; intensive care and high dependency units;
mental health; emergency medicine and allied health services were represented at the department/clinical unit level.
The results provided here, unless stated otherwise, reflect data provided at the department/ clinical unit level for the
local health districts and networks and the station / paramedic level for the Ambulance Service. Results are presented
in graph form to allow comparison of performance between each LHD/organisation.
Some of the main findings include:
At the clinical unit level there were 52% of respondents that manage adult patients only, 12% manage children or
young people only and 36% manage adults and children/young people.
At the clinical unit level 80% of respondents manage or treat patients at risk of sepsis often, sometimes or rarely
At the station / paramedic level 94% of respondents manage patients at risk of sepsis often, sometimes or rarely.
Of those departments/clinical units responding that patients with suspected or confirmed sepsis were assessed or
managed on a weekly or more frequent basis also responded that the patient management needed improvement.
34% of departments/clinical units responding that patients with suspected or confirmed sepsis were assessed or
managed on a weekly or more often did not have guidelines and or protocols.
At the clinical unit level in response to the question ‘we have a standardised approach to the management of
patients with confirmed or suspected sepsis’ 29% responded always
At the clinical unit level 42% of respondents monitor some aspects of sepsis incident care and management and
38% routinely review sepsis cases at their local M&M meetings.
5
Introduction A critical element of the QSA is the reporting of findings of the assessment activities to relevant stakeholders. The initial
rationale for the development of the QSA was to provide NSW Health with assurance about the quality of health
services and assist the CEC in identifying areas for improvement and promotion of better practice in patient safety
management. Analysis of the findings of the QSA and reporting these findings to all levels of the health system is key to
achieving the objectives of the QSA.
This supplementary is the third reporting obligation the CEC has completed since the 2011 self assessment.
Two weeks following assessment closure the raw data (labelled and coded) was returned to each LHD / Network /
Organisation and facilities
Four weeks following assessment a ‘results’ report for each facility-level respondent (~198) was generated and
sent out to facilitate follow-up and action at facility level. These reports contained aggregated / comparative data
based on the LHD / Network
Thematic supplementary reports – Paediatrics, Sepsis, Delirium and Mental Health
It is expected that the above resources will be used by the LHD / Networks to identify areas with greatest risk and
vulnerability that apply to them and develop improvement plans to address them. Where appropriate they should also
be used by individual departments to review their data and respond to issues raised. For example, 34% of
departments/clinical units responding that patients with suspected or confirmed sepsis were assessed or managed on a
weekly or more often did not have guidelines and or protocols. This issue has an impact across the whole district so it is
likely the district will need to work at each level (i.e. facility and department / clinical unit) to address this issue.
While it is expected that action is taken in response to the results the CEC acknowledge that the timeline of the QSA
assessment was for September / November 2011 and it is probable that in some cases policy / programs have already
been implemented / completed by the time this report is published.
Understanding the data
In this report, charts and tables are used to provide information on department/clinical unit responses to the questions
from the 2011 QSA self assessment compared to the aggregated NSW results.
Except where noted the charts illustrate the responses for departments/clinical units from LHDs.
The report uses pie charts, summary graphs for multiple questions and tables summarising the statistical analysis
of the results.
Charts are also used to compare the responses for departments/clinical units from each peer hospital group and
the overall NSW proportion. The Peer Hospital Groups are collapsed to the main letter designation with the
exception of:
F2 Nursing Home & F3 Multi-Purpose Services facilities are mapped to F2-3
F1 – Psychiatric facilities that are mapped to F1 – MH
6
F4 Sub Acute, F6 Rehabilitation, F7 Mothercraft & F8 Ungrouped Non-Acute facilities are mapped to
“F4-8”
State-wide recommendations
In May 2012 the Statewide report will be released. This report will provide an overview of results and makes
recommendation on a system wide perspective. These recommendations come from the aggregated analysis of all data
from the self assessments.
All LHDs and facility executive support the implementation of the Sepsis Kills initiative as it is implemented
including:
o introducing guidelines
o data collection and regular reporting to facility and LHD quality / safety committees
o integrate the program into the quality and safety systems
All LHDs and facilities further develop the links between the Between the Flags and Sepsis Kills initiatives to
promote clinical uptake and sustainability
Clinical units that manage patients who have had an episode of severe sepsis or septic shock review the patients
management as part of the regular Mortality and Morbidity meeting
7
Results
At the clinical unit level 80% of respondents manage or treat patients at risk of sepsis; at the station / paramedic
level 94% of respondents manage patients at risk of sepsis (often, sometimes or rarely).
At the clinical unit level 80% of respondents manage or treat patients at risk of sepsis often, sometimes or rarely
Figure 1: % of Departments/clinical units reporting frequency of management of patients at risk of sepsis
Table 1: Count and % of Departments/clinical units reporting frequency of management of patients at risk of sepsis by LHD.
Description LHD Often (weekly or
more often)
Sometimes (at least
monthly but less often
than weekly)
Rarely (once every three
to twelve months) Never
Metropolitan
LHDs CCLHD 23 47.9% 8 16.7% 10 20.8% 7 14.6%
ISLHD 26 41.3% 14 22.2% 12 19.0% 11 17.5%
NBMLHD 21 60.0% 6 17.1% 4 11.4% 4 11.4%
NSLHD 36 36.7% 18 18.4% 18 18.4% 26 26.5%
SCHN 26 29.9% 20 23.0% 16 18.4% 25 28.7%
SESLHD 38 30.4% 33 26.4% 29 23.2% 25 20.0%
SVHN 11 52.4% 4 19.0% 4 19.0% 2 9.5%
SWSLHD 47 41.6% 23 20.4% 17 15.0% 26 23.0%
SYDLHD 50 50.0% 14 14.0% 17 17.0% 19 19.0%
WSLHD 23 37.1% 18 29.0% 10 16.1% 11 17.7%
Metro 301 40.0% 158 21.0% 137 18.2% 156 20.7%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
CC
LHD
ISLH
D
NB
MLH
D
NSL
HD
SCH
N
SESL
HD
SVH
N
SWSL
HD
SYD
LHD
WSL
HD
FWLH
D
HN
ELH
D
MLH
D
MN
CLH
D
NN
SWLH
D
SNSW
LHD
WN
SWLH
D
ASN
SW
Metropolitan LHDs Rural & Regional LHDs Other
Often (weekly or more often) Sometimes (at least monthly but less often than weekly)
Rarely (once every three to twelve months) Never
Please indicate the frequency that you assess or manage adults, children or young people with suspected or confirmed sepsis
__ Often (weekly or more often)
__ Sometimes (at least monthly but less often than weekly) -
__ Rarely (once every three to twelve months)
__ Never (answer no more questions in relation to sepsis)
8
Description LHD Often (weekly or
more often)
Sometimes (at least
monthly but less often
than weekly)
Rarely (once every three
to twelve months) Never
Total
Rural & Regional
LHDs FWLHD 2 16.7% 1 8.3% 7 58.3% 2 16.7%
HNELHD 50 38.8% 35 27.1% 29 22.5% 15 11.6%
MLHD 11 16.4% 10 14.9% 31 46.3% 15 22.4%
MNCLHD 15 40.5% 6 16.2% 10 27.0% 6 16.2%
NNSWLHD 17 30.4% 12 21.4% 17 30.4% 10 17.9%
SNSWLHD 17 31.5% 10 18.5% 16 29.6% 11 20.4%
WNSWLHD 20 21.1% 23 24.2% 27 28.4% 25 26.3%
R&R Total 132 29.3% 97 21.6% 137 30.4% 84 18.7%
NSW LHDs
433 36.0% 255 21.2% 274 22.8% 240 20.0%
ASNSW 17 10.2% 43 25.9% 95 57.2% 11 6.6%
45% of departments/clinical units from hospitals in Peer Group A and B reported that patients with suspected or
confirmed sepsis were assessed or managed on a weekly or more frequent basis.
Figure 2: % of Departments/clinical units reporting frequency of management of patients at risk of sepsis by Peer group
Table 2: Count and % of Departments/clinical units reporting frequency of management of patients at risk of sepsis by Peer group
Peer Group Often (weekly or more often) Sometimes (at least monthly
but less often than weekly)
Rarely (once every three to
twelve months) Never
A 231 44.8% 104 20.2% 88 17.1% 93 18.0%
B 121 44.6% 61 22.5% 53 19.6% 36 13.3%
C 64 29.6% 43 19.9% 59 27.3% 50 23.1%
D 6 9.4% 23 35.9% 28 43.8% 7 10.9%
F2-3 4 8.3% 10 20.8% 27 56.3% 7 14.6%
F1-MH 0 N/A 2 3.8% 14 26.9% 36 69.2%
F4-7 7 20.0% 12 34.3% 5 14.3% 11 31.4%
0%
20%
40%
60%
80%
100%
A B C D F2-3 F1-MH F4-7
Often (weekly or more often) Sometimes (at least monthly but less often than weekly)
Rarely (once every three to twelve months) Never
9
Intensive Care (79%), Emergency (68%) and Oncology (66%) departments/clinical units reported assessing or
managing adults, children or young people with suspected or confirmed sepsis at least weekly or more often.
70% of departments/clinical units responding that patients with suspected or confirmed sepsis were assessed or
managed on a weekly or more frequent basis also responded that the patient management needed improvement.
34% of departments/clinical units responding that patients with suspected or confirmed sepsis were assessed or
managed on a weekly or more often did not have guidelines and or protocols. Facility level self assessment results
illustrate a differential perception to department/clinical unit self assessment level results on the frequency of
assessing or managing adults, children or young people with suspected or confirmed sepsis.
Figure 3: % of Departments/clinical units reporting frequency of management of patients at risk of sepsis
Table 3: Count and % of Departments/clinical units reporting frequency of management of patients at risk of sepsis
Service type Often (weekly or more
often) Sometimes (at least monthly but less often than weekly)
Rarely (once every three to twelve months)
Never
Medical 84 35.7% 59 25.1% 62 26.4% 30 12.8%
Surgical 69 35.0% 51 25.9% 45 22.8% 32 16.2%
MH 0 N/A 2 2.2% 25 27.8% 63 70.0%
Obs & Gyn 12 14.3% 14 16.7% 40 47.6% 18 21.4%
ED 56 67.5% 19 22.9% 8 9.6% 0 N/A
Other 23 28.4% 10 12.3% 17 21.0% 31 38.3%
Aged Care 27 35.1% 13 16.9% 16 20.8% 21 27.3%
Paediatric 23 35.4% 15 23.1% 15 23.1% 12 18.5%
ICU 44 78.6% 11 19.6% 0 N/A 1 1.8%
Oncology 27 65.9% 7 17.1% 5 12.2% 2 4.9%
Imaging 9 25.0% 4 11.1% 6 16.7% 17 47.2%
Nephrology 14 40.0% 8 22.9% 11 31.4% 2 5.7%
Rehabilitation 7 21.2% 13 39.4% 8 24.2% 5 15.2%
Orthopaedic 13 50.0% 6 23.1% 7 26.9% 0 N/A
Cardiac/ Cardiology
13 50.0% 10 38.5% 2 7.7% 1 3.8%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Med
ical
Surg
ical
MH
Ob
s &
Gyn
ED
Oth
er
Age
d C
are
Pae
dia
tric
ICU
On
colo
gy
Imag
ing
Nep
hro
logy
Reh
abili
tati
on
Ort
ho
pae
dic
Car
dia
c/C
ard
iolo
gy
Pal
liati
ve C
are
Mic
rob
iolo
gy
Often (weekly or more often) Sometimes (at least monthly but less often than weekly)
Rarely (once every three to twelve months) Never
10
Service type Often (weekly or more
often) Sometimes (at least monthly but less often than weekly)
Rarely (once every three to twelve months)
Never
Palliative Care 5 25.0% 6 30.0% 5 25.0% 4 20.0%
Microbiology 7 41.2% 7 41.2% 2 11.8% 1 5.9%
Table 4: Count and % of Departments/clinical units reporting frequency of management of patients at risk of sepsis by how
managed
Managed Often (weekly or more often) Sometimes (at least monthly but
less often than weekly) Rarely (once every three to
twelve months)
Managed optimally - needs no improvement
29.6% 33.3% 39.4%
Managed variably - needs some improvement
70.2% 66.3% 58.4%
Managed poorly - needs considerable improvement
0.2% 0.4% 2.2%
Table 5: Count and % of Departments/clinical units reporting frequency of management of patients at risk of sepsis by having
guidelines / protocols in place
Guidelines & Protocols exist Often (weekly or
more often) Sometimes (at least monthly but less often
than weekly) Rarely (once every three to
twelve months)
Yes, for adults only 43.2% 31.4% 23.7%
Yes, for children and/or young people only
9.5% 10.2% 6.2%
Yes, for both (adults and children/young people)
13.9% 18.4% 19.7%
No 33.5% 40.0% 50.4%
Table 6: Comparison of facility and department response by LHD to question frequency of management of patients at risk of
sepsis
LHD Self assessment Level
Often (weekly or more often)
Sometimes (at least monthly but less often
than weekly)
Rarely (once every three to twelve months)
Never
CCLHD Service/ Unit 48% 17% 21% 15%
Facility 67% 33% 0% 0%
ISLHD Service/ Unit 41% 22% 19% 17%
Facility 60% 20% 0% 20%
NBMLHD Service/ Unit 60% 17% 11% 11%
Facility 75% 0% 25% 0%
NSLHD Service/ Unit 37% 18% 18% 27%
Facility 67% 17% 17% 0%
SCHN Service/ Unit 30% 23% 18% 29%
Facility 100% 0% 0% 0%
SESLHD Service/ Unit 30% 26% 23% 20%
Facility 43% 14% 43% 0%
SVHN Service/ Unit 52% 19% 19% 10%
Facility 50% 0% 50% 0%
SWSLHD Service/ Unit 42% 20% 15% 23%
Facility 50% 13% 13% 25%
SYDLHD Service/ Unit 50% 14% 17% 19%
Facility 33% 17% 33% 17%
WSLHD Service/ Unit 37% 29% 16% 18%
11
LHD Self assessment Level
Often (weekly or more often)
Sometimes (at least monthly but less often
than weekly)
Rarely (once every three to twelve months)
Never
Facility 75% 0% 25% 0%
FWLHD Service/ Unit 17% 8% 58% 17%
Facility 0% 100% 0% 0%
HNELHD Service/ Unit 39% 27% 22% 12%
Facility 38% 19% 41% 3%
MLHD Service/ Unit 16% 15% 46% 22%
Facility 40% 20% 20% 20%
MNCLHD Service/ Unit 41% 16% 27% 16%
Facility 67% 33% 0% 0%
NNSWLHD Service/ Unit 30% 21% 30% 18%
Facility 40% 60% 0% 0%
SNSWLHD Service/ Unit 31% 19% 30% 20%
Facility 30% 40% 20% 10%
WNSWLHD Service/ Unit 21% 24% 28% 26%
Facility 56% 0% 22% 22%
Table 7 shows that respondents in metropolitan facilities assessed that they have sufficient skills and knowledge in
managing sepsis compared to rural and regional respondents (p<0.001). Metropolitan facilities were more likely to
be aware of sepsis campaign (p<0.001); and more often managed sepsis patients than the rural and regional ones
(p<0.001). However, there was no significant difference of having standard approach for sepsis management
between metropolitan and rural areas (p=0.35).
Table 7 Comparison of Metropolitan and Rural & Regional responses
Metropolitan Rural & Regional P-Value
Sepsis skills and knowledge are sufficient % 79.0 69.1 <0.001
Awareness of sepsis campaign by all/most % 94.0 87.2 <0.001
Having standard approach for sepsis % 74.3 62.8 0.35
Managing sepsis often/sometimes % 61.0 50.9 <0.001
Table 8 shows comparison between the facility peer groups. It has demonstrated a clear trend that the higher
tertiary level of the facility the more likely to have sufficient skills and knowledge of managing sepsis (p<0.001), the
more likely to be aware of the sepsis campaign (p<0.001), the more likely to have standard approach for managing
sepsis (p=0.03), and the more often to manage sepsis patients (p<0.001).
Table 8 Comparison between facility peer groups re skills and knowledge and standard approach to sepsis management
Facility Peer Group (Tertiary Level) P-Value for
trend A B C D & F
Sepsis skills and knowledge are sufficient % 82.0 76.6 66.3 62.2 <0.001
Awareness of sepsis campaign by all/most % 94.6 94.0 88.0 80.6 <0.001
Having standard approach for sepsis % 75.9 74.5 69.3 67.4 0.03
Managing sepsis often/sometimes % 64.9 67.2 49.5 38.4 <0.001
12
Management of Sepsis
Across NSW 67% of departments/clinical units responding to the self assessment indicated that management of
sepsis in their departments/clinical units needed improvement. This response was reasonably consistent across all
LHDs.
Figure 4: % of Departments/clinical units reporting how well is sepsis managed by LHD
Table 9 Count and % of Departments/clinical units reporting how well is sepsis managed by LHD
Description LHD Managed optimally - needs no
improvement
Managed variably - needs some
improvement
Managed poorly - needs
considerable improvement
Metropolitan
LHDs CCLHD 11 26.8% 30 73.2% 0 N/A
ISLHD 17 32.7% 33 63.5% 2 3.8%
NBMLHD 11 35.5% 20 64.5% 0 N/A
NSLHD 20 27.8% 51 70.8% 1 1.4%
SCHN 33 53.2% 29 46.8% 0 N/A
SESLHD 40 40.0% 60 60.0% 0 N/A
SVHN 4 21.1% 15 78.9% 0 N/A
SWSLHD 33 37.9% 51 58.6% 3 3.4%
SYDLHD 33 40.7% 48 59.3% 0 N/A
WSLHD 23 45.1% 28 54.9% 0 N/A
Metro Total 225 37.8% 365 61.2% 6 1.0%
Rural &
Regional LHDs FWLHD 2 20.0% 8 80.0% 0 N/A
HNELHD 33 28.9% 81 71.1% 0 N/A
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
CC
LHD
ISLH
D
NB
MLH
D
NSL
HD
SCH
N
SESL
HD
SVH
N
SWSL
HD
SYD
LHD
WSL
HD
Met
ro T
ota
l
FWLH
D
HN
ELH
D
MLH
D
MN
CLH
D
NN
SWLH
D
SNSW
LHD
WN
SWLH
D
R&
R T
ota
l
ASN
SW
Metropolitan Rural & Regional Other
LHD - Managed optimally Management Needs Improvement
NSW - Managed optimally
13
Description LHD Managed optimally - needs no
improvement
Managed variably - needs some
improvement
Managed poorly - needs
considerable improvement
MLHD 11 21.2% 40 76.9% 1 1.9%
MNCLHD 7 22.6% 24 77.4% 0 N/A
NNSWLHD 16 34.8% 30 65.2% 0 N/A
SNSWLHD 10 23.3% 32 74.4% 1 2.3%
WNSWLHD 17 24.3% 53 75.7% 0 N/A
R&R Total 96 26.2% 268 73.2% 2 0.5%
NSW NSW 321 33.4% 633 65.8% 8 0.8%
ASNSW 10 6.5% 107 69.0% 38 24.5%
60% of departments/clinical units in hospitals in Peer Group A responded that management of sepsis in their
departments/clinical units needed improvement while the corresponding figure for Peer Group D was 81%.
Figure 5: % of Departments/clinical units reporting how sepsis is managed by peer group
Table 10: Count and % of Departments/clinical units reporting how sepsis is managed by peer group
Peer Group Managed optimally - needs no
improvement
Managed variably - needs some
improvement
Managed poorly - needs considerable
improvement
A 171 40.4% 252 59.6% 0 N/A
B 80 34.0% 153 65.1% 2 0.9%
C 40 24.1% 122 73.5% 4 2.4%
D 11 19.3% 46 80.7% 0 N/A
F2-3 7 17.1% 34 82.9% 0 N/A
F1-MH 3 18.8% 11 68.8% 2 12.5%
F4-7 9 37.5% 15 62.5% 0 N/A
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
A B C D F2-3 F1-MH F4-7
Peer group - Managed optimally Management Needs Improvement
NSW - Managed optimally
14
Figure 6: % of Departments/clinical units reporting how sepsis is managed by service type
Table 11: Count and % of Departments/clinical units reporting how sepsis is managed by service type
Service type Managed optimally - needs no
improvement
Managed variably - needs some
improvement
Managed poorly - needs considerable
improvement
Medical 48 23.4% 157 76.6% 0 N/A
Surgical 63 38.2% 101 61.2% 1 0.6%
ED 7 8.4% 76 91.6% 0 N/A
Obs &
Gynaecology 33 50.0% 32 48.5% 1 1.5%
Aged Care 9 16.1% 47 83.9% 0 N/A
ICU 25 45.5% 30 54.5% 0 N/A
Paediatric 21 39.6% 31 58.5% 1 1.9%
Other 24 48.0% 25 50.0% 1 2.0%
Oncology 19 48.7% 20 51.3% 0 N/A
Nephrology 14 42.4% 18 54.5% 1 3.0%
Rehabilitation 13 46.4% 15 53.6% 0 N/A
MH 6 22.2% 18 66.7% 3 11.1%
Orthopaedic 7 26.9% 19 73.1% 0 N/A
Cardiac/Cardiol
ogy 6 24.0% 19 76.0% 0 N/A
Imaging 10 52.6% 9 47.4% 0 N/A
Palliative Care 7 43.8% 9 56.3% 0 N/A
Microbiology 9 56.3% 7 43.8% 0 N/A
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100% M
edic
al
Surg
ical
ED
Ob
s &
Gyn
Age
d C
are
ICU
Pae
dia
tric
Oth
er
On
colo
gy
Nep
hro
logy
Reh
abili
tati
on
MH
Ort
ho
pae
dic
Car
dia
c/C
ard
iolo
gy
Imag
ing
Pal
liati
ve C
are
Mic
rob
iolo
gy
Managed optimally - needs no improvement Management Needs Improvement
NSW - Managed optimally
15
Table 12: Count and % of Departments/clinical units reporting how well sepsis is managed compared to facility by LHD.
LHD Self assessment
Level
Managed optimally - needs no
improvement
Managed variably - needs some
improvement
Managed poorly - needs
considerable improvement
CCLHD Service/ Unit 27% 73% 0%
Facility 0% 100% 0%
ISLHD Service/ Unit 33% 63% 4%
Facility 25% 75% 0%
NBMLHD Service/ Unit 35% 65% 0%
Facility 0% 100% 0%
NSLHD Service/ Unit 28% 71% 1%
Facility 33% 67% 0%
SCHN Service/ Unit 53% 47% 0%
Facility 100% 0% 0%
SESLHD Service/ Unit 40% 60% 0%
Facility 0% 100% 0%
SVHN Service/ Unit 21% 79% 0%
Facility 50% 50% 0%
SWSLHD Service/ Unit 38% 59% 3%
Facility 0% 100% 0%
SYDLHD Service/ Unit 41% 59% 0%
Facility 20% 80% 0%
WSLHD Service/ Unit 45% 55% 0%
Facility 25% 75% 0%
FWLHD Service/ Unit 20% 80% 0%
Facility 0% 100% 0%
HNELHD Service/ Unit 29% 71% 0%
Facility 6% 90% 3%
MLHD Service/ Unit 21% 77% 2%
Facility 25% 75% 0%
MNCLHD Service/ Unit 23% 77% 0%
Facility 0% 100% 0%
NNSWLHD Service/ Unit 35% 65% 0%
Facility 20% 80% 0%
SNSWLHD Service/ Unit 23% 74% 2%
Facility 22% 78% 0%
WNSWLHD Service/ Unit 24% 76% 0%
Facility 0% 100% 0%
16
Always (100%)
Often (67%-99%)
Sometimes (34% – 66%)
Rarely (1% - 33%)
Never (0%)
Our staff are aware of sepsis __ __ __ __ __
Results for this question demonstrated a high level of awareness for staff of sepsis across all LHDs participating in
the self assessment. At the state level the facility level self assessment results were consistent with the
department/clinical unit level.
Figure 7: % of Departments/clinical units reporting that their staff were aware of sepsis
Table 13: Count and % of Departments/clinical units reporting that that their staff were aware of sepsis by LHD.
Description LHD Always (100%) Often (67%-99%) Sometimes (34%–66%) Rarely (1%-33%)
Metropolitan LHDs CCLHD 11 26.8% 28 68.3% 2 4.9% 0 N/A
ISLHD 19 36.5% 31 59.6% 1 1.9% 1 1.9%
NBMLHD 9 29.0% 18 58.1% 3 9.7% 1 3.2%
NSLHD 23 31.9% 45 62.5% 4 5.6% 0 N/A
SCHN 35 56.5% 25 40.3% 2 3.2% 0 N/A
SESLHD 47 47.0% 45 45.0% 7 7.0% 1 1.0%
SVHN 6 31.6% 9 47.4% 3 15.8% 1 5.3%
SWSLHD 26 29.9% 57 65.5% 2 2.3% 2 2.3%
SYDLHD 43 53.1% 36 44.4% 2 2.5% 0 N/A
WSLHD 22 43.1% 25 49.0% 3 5.9% 1 2.0%
Metro Total 241 40.4% 319 53.5% 29 4.9% 7 1.2%
Rural & Regional LHDs FWLHD 1 10.0% 8 80.0% 1 10.0% 0 N/A
HNELHD 35 30.7% 64 56.1% 13 11.4% 2 1.8%
MLHD 14 26.9% 29 55.8% 9 17.3% 0 N/A
MNCLHD 8 25.8% 20 64.5% 3 9.7% 0 N/A
NNSWLHD 8 17.4% 34 73.9% 4 8.7% 0 N/A
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
CC
LHD
ISLH
D
NB
MLH
D
NSL
HD
SCH
N
SESL
HD
SVH
N
SWSL
HD
SYD
LHD
WSL
HD
Met
ro T
ota
l
FWLH
D
HN
ELH
D
MLH
D
MN
CLH
D
NN
SWLH
D
SNSW
LHD
WN
SWLH
D
R&
R T
ota
l
Metropolitan LHDs Rural & Regional LHDs
LHD - Always or Often NSW - Always or Often
17
Description LHD Always (100%) Often (67%-99%) Sometimes (34%–66%) Rarely (1%-33%)
SNSWLHD 10 23.3% 30 69.8% 3 7.0% 0 N/A
WNSWLHD 17 24.3% 41 58.6% 10 14.3% 2 2.9%
R&R Total 93 25.4% 226 61.7% 43 11.7% 4 1.1%
NSW NSW 334 34.7% 545 56.7% 72 7.5% 11 1.1%
Table 14: Count and % of Departments/clinical units and Ambulance station / paramedics reporting that that their staff are aware
of sepsis
Strongly agree Agree Neutral Disagree Strongly disagree
ASNSW 36 23.2% 84 54.2% 23 14.8% 10 6.5% 2 1.3%
LHD Department 334 34.7% 545 56.7% 72 7.5% 11 1.1% 0 N/A
18
N/A Always
(100%)
Often (67%-99%)
Sometimes (34% – 66%)
Rarely (1% - 33%)
Never (0%)
We have a standardised approach to the
management of patients with confirmed or
suspected, sepsis
__ __ __ __ __ __
While the overall NSW average was 73% of respondents having a standardised approach to sepsis management
there was some variability in responses from Metropolitan LHDs with results between 42% and 85%.
Figure 8: % of Departments/clinical units reporting that there was a standardised approach to the management of patients with
confirmed or suspected sepsis by LHD
Table 15 Count and % of Departments/clinical units reporting that there was a standardised approach to the management of
patients with confirmed or suspected sepsis by LHD
Description LHD Always (100%) Often (67%-99%) Sometimes (34%–
66%) Rarely (1%-33%) Never (0%)
Metropolitan
LHDs CCLHD 13 31.7% 11 26.8% 14 34.1% 1 2.4% 2 4.9%
ISLHD 10 19.2% 34 65.4% 5 9.6% 3 5.8% 0 N/A
NBMLHD 6 19.4% 14 45.2% 6 19.4% 3 9.7% 2 6.5%
NSLHD 18 25.0% 29 40.3% 13 18.1% 8 11.1% 4 5.6%
SCHN 24 38.7% 29 46.8% 6 9.7% 2 3.2% 1 1.6%
SESLHD 37 37.0% 42 42.0% 13 13.0% 7 7.0% 1 1.0%
SVHN 4 21.1% 4 21.1% 6 31.6% 5 26.3% 0 N/A
SWSLHD 27 31.0% 35 40.2% 22 25.3% 2 2.3% 1 1.1%
SYDLHD 36 44.4% 33 40.7% 10 12.3% 2 2.5% 0 N/A
WSLHD 17 33.3% 20 39.2% 10 19.6% 4 7.8% 0 N/A
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
CC
LHD
ISLH
D
NB
MLH
D
NSL
HD
SCH
N
SESL
HD
SVH
N
SWSL
HD
SYD
LHD
WSL
HD
Met
ro T
ota
l
FWLH
D
HN
ELH
D
MLH
D
MN
CLH
D
NN
SWLH
D
SNSW
LHD
WN
SWLH
D
R&
R T
ota
l Metropolitan LHDs Rural & Regional LHDs
LHD - Always or Often NSW - Always or Often
19
Description LHD Always (100%) Often (67%-99%) Sometimes (34%–
66%) Rarely (1%-33%) Never (0%)
Metro Total 192 32.2% 251 42.1% 105 17.6% 37 6.2% 11 1.8%
Rural &
Regional LHDs FWLHD 1 10.0% 5 50.0% 3 30.0% 1 10.0% 0 N/A
HNELHD 30 26.3% 54 47.4% 22 19.3% 6 5.3% 2 1.8%
MLHD 12 23.1% 27 51.9% 5 9.6% 5 9.6% 3 5.8%
MNCLHD 9 29.0% 13 41.9% 9 29.0% 0 N/A 0 N/A
NNSWLHD 10 21.7% 27 58.7% 5 10.9% 3 6.5% 1 2.2%
SNSWLHD 9 20.9% 22 51.2% 10 23.3% 0 N/A 2 4.7%
WNSWLHD 15 21.4% 28 40.0% 16 22.9% 6 8.6% 5 7.1%
R&R Total 86 23.5% 176 48.1% 70 19.1% 21 5.7% 13 3.6%
NSW NSW 278 28.9% 427 44.4% 175 18.2% 58 6.0% 24 2.5%
Surgical (63%), Emergency (68%) and Intensive Care (68%) departments/clinical units reported lower than the NSW
average. At the state level the facility level self assessment results were consistent with the department/clinical
unit level.
Table 16: Count and % of Departments/clinical units, facilities and Ambulance station / paramedics reporting that there was a
standardised approach to the management of patients with confirmed or suspected sepsis
Strongly agree Agree Neutral Disagree Strongly disagree
ASNSW 9 5.8% 53 34.2% 46 29.7% 40 25.8% 7 4.5%
LHD Department 278 28.9% 427 44.4% 175 18.2% 58 6.0% 24 2.5%
LHD Facility 24 23.3% 45 43.7% 23 22.3% 11 10.7% 0 N/A
20
N/A Always
(100%)
Often (67%-99%)
Sometimes (34% – 66%)
Rarely (1% - 33%)
Never (0%)
The skills and knowledge of staff are sufficient to
manage the identification and optimal
management of sepsis
__ __ __ __ __ __
Across NSW 75% of departments/clinical units “Strongly Agreed” or “Agreed” with the statement “The skills
and knowledge of staff are sufficient to manage the identification and optimal management of sepsis”.
Figure 9: % of Departments/clinical units reporting that skills and knowledge of staff are sufficient to manage the identification
and optimal management of sepsis
Table 17: Count and % of Departments/clinical units reporting that skills and knowledge of staff are sufficient to manage the
identification and optimal management of sepsis by LHD.
Description LHD Always (100%) Often (67%-99%) Sometimes (34%–
66%) Rarely (1%-33%) Never (0%)
Metropolitan
LHDs CCLHD 11 26.8% 20 48.8% 8 19.5% 2 4.9% 0 N/A
ISLHD 6 11.5% 35 67.3% 10 19.2% 1 1.9% 0 N/A
NBMLHD 3 9.7% 16 51.6% 7 22.6% 4 12.9% 1 3.2%
NSLHD 15 20.8% 38 52.8% 16 22.2% 1 1.4% 2 2.8%
SCHN 21 33.9% 35 56.5% 4 6.5% 1 1.6% 1 1.6%
SESLHD 26 26.0% 52 52.0% 19 19.0% 3 3.0% 0 N/A
SVHN 2 10.5% 5 26.3% 10 52.6% 2 10.5% 0 N/A
SWSLHD 16 18.4% 55 63.2% 14 16.1% 1 1.1% 1 1.1%
SYDLHD 36 44.4% 40 49.4% 5 6.2% 0 N/A 0 N/A
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
CC
LHD
ISLH
D
NB
MLH
D
NSL
HD
SCH
N
SESL
HD
SVH
N
SWSL
HD
SYD
LHD
WSL
HD
Met
ro T
ota
l
FWLH
D
HN
ELH
D
MLH
D
MN
CLH
D
NN
SWLH
D
SNSW
LHD
WN
SWLH
D
R&
R T
ota
l Metropolitan LHDs Rural & Regional LHDs
LHD - Always or Often NSW - Always or Often
21
Description LHD Always (100%) Often (67%-99%) Sometimes (34%–
66%) Rarely (1%-33%) Never (0%)
WSLHD 14 27.5% 25 49.0% 7 13.7% 5 9.8% 0 N/A
Metro Total 150 25.2% 321 53.9% 100 16.8% 20 3.4% 5 0.8%
Rural &
Regional LHDs FWLHD 1 10.0% 7 70.0% 1 10.0% 1 10.0% 0 N/A
HNELHD 25 21.9% 56 49.1% 29 25.4% 4 3.5% 0 N/A
MLHD 4 7.7% 30 57.7% 16 30.8% 2 3.8% 0 N/A
MNCLHD 4 12.9% 14 45.2% 12 38.7% 1 3.2% 0 N/A
NNSWLHD 5 10.9% 32 69.6% 7 15.2% 2 4.3% 0 N/A
SNSWLHD 10 23.3% 23 53.5% 10 23.3% 0 N/A 0 N/A
WNSWLHD 11 15.7% 31 44.3% 23 32.9% 4 5.7% 1 1.4%
R&R Total 60 16.4% 193 52.7% 98 26.8% 14 3.8% 1 0.3%
NSW NSW 210 21.8% 514 53.4% 198 20.6% 34 3.5% 6 0.6%
Table 18: Count and % of Departments/clinical units, facilities and Ambulance station / paramedics reporting that there was a
standardised approach to the management of patients with confirmed or suspected sepsis
Strongly agree Agree Neutral Disagree Strongly disagree
ASNSW 10 6.5% 46 29.7% 52 33.5% 42 27.1% 5 3.2%
LHD
Department 210 21.8% 514 53.4% 198 20.6% 34 3.5% 6 0.6%
LHD Facility 13 12.6% 41 39.8% 37 35.9% 12 11.7% 0 N/A
22
Figure 10: % of Departments/clinical units reporting that Paramedics alert triage staff if sepsis is suspected by LHD
Table 19: Count and % of Departments/clinical units reporting that Paramedics alert triage staff if sepsis is suspected by LHD.
Description LHD Always (100%) Often (67%-99%) Sometimes (34%-
66%) Rarely (1%-33%) Never (0%)
Metropolitan LHD
CCLHD 0 N/A 1 25.0% 0 N/A 3 75.0% 0 N/A
ISLHD 2 20.0% 3 30.0% 1 10.0% 2 20.0% 2 20.0%
NBMLHD 0 N/A 1 16.7% 2 33.3% 2 33.3% 1 16.7%
NSLHD 0 N/A 5 31.3% 7 43.8% 4 25.0% 0 N/A
SCHN 2 28.6% 2 28.6% 1 14.3% 2 28.6% 0 N/A
SESLHD 1 9.1% 2 18.2% 2 18.2% 6 54.5% 0 N/A
SVHN 0 N/A 0 N/A 0 N/A 0 N/A 1 100.0%
SWSLHD 1 4.8% 9 42.9% 5 23.8% 4 19.0% 2 9.5%
SYDLHD 3 20.0% 7 46.7% 3 20.0% 0 N/A 2 13.3%
WSLHD 2 11.1% 6 33.3% 8 44.4% 1 5.6% 1 5.6%
Rural & Regional LHD
FWLHD 1 50.0% 0 N/A 1 50.0% 0 N/A 0 N/A
HNELHD 1 2.6% 12 31.6% 13 34.2% 8 21.1% 4 10.5%
MLHD 1 3.3% 9 30.0% 9 30.0% 7 23.3% 4 13.3%
MNCLHD 1 12.5% 3 37.5% 2 25.0% 1 12.5% 1 12.5%
NNSWLHD 1 5.6% 4 22.2% 8 44.4% 2 11.1% 3 16.7%
SNSWLHD 2 11.8% 3 17.6% 8 47.1% 2 11.8% 2 11.8%
WNSWLHD 0 N/A 10 29.4% 9 26.5% 13 38.2% 2 5.9%
ASNSW ASNSW 15 9.7% 58 37.4% 63 40.6% 18 11.6% 1 0.6%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
CC
LHD
ISLH
D
NB
MLH
D
NSL
HD
SCH
N
SESL
HD
SVH
N
SWSL
HD
SYD
LHD
WSL
HD
FWLH
D
HN
ELH
D
MLH
D
MN
CLH
D
NN
SWLH
D
SNSW
LHD
WN
SWLH
D
Metropolitan Rural & Regional
LHD - Always or Often ASNSW - Always or Often
Paramedics alert triage staff if sepsis is suspected
__ Always (100%)
__ Often (67%-99%)
__ Sometimes (34% – 66%)
__ Rarely (1% - 33%)
__ Never (0%)
__ Not applicable
23
Challenges in management of Sepsis
Figure 11: Count of most challenging issues when managing patients with suspected or confirmed sepsis identified by
department / clinical unit
49%
33%
31%
27%
25%
19%
14%
10%
16%
0% 10% 20% 30% 40% 50% 60%
Deficits in skill and knowledge e.g. lack of familiarity with assessment/screening tools
Time/workload constraints
Issues relating to referrals/consultation
Multiple physicians admit to the unit, such that care processes and teams are fragmented
Absent or unclear procedures/protocols
Lack of supervision of junior clinicians
Other
Access to relevant information, assistance or other resources
Nothing
NSW - % of Departments/Clinical Units responding
From the following list please indicate the most challenging issues when managing patients with suspected or
confirmed sepsis (tick a maximum of three and provide additional details as necessary)
__ None
__ Deficits in skill and knowledge e.g. lack of familiarity with assessment / screening tools
__ Absent or unclear procedures / protocols
__ Issues relating to referrals / consultation
__ Access to relevant information, assistance or other resources
__ Multiple physicians admit to the unit, such that care processes are fragmented
__ Lack of supervision of junior clinicians
__ Time / workload constraints
__ Other
24
Table 20: Count of most challenging issues when managing patients with suspected or confirmed sepsis identified by department / clinical unit by LHD.
Description LHD
Deficits in skill
and knowledge
Time/workload
constraints
Issues relating to
referrals/consultat
ion
Multiple physicians
admit to the unit, such
that care processes and
teams are fragmented
Absent or
unclear
procedures/
protocols
Lack of
supervision of
junior clinicians Other
Access to
relevant
information,
assistance or
other resources Nothing
Metropolitan CCLHD 23 56% 17 41% 9 22% 17 41% 12 29% 13 32% 3 7% 2 5% 8 20%
ISLHD 25 48% 12 23% 17 33% 19 37% 10 19% 10 19% 9 17% 3 6% 7 13%
NBMLHD 17 55% 13 42% 10 32% 5 16% 14 45% 12 39% 4 13% 6 19% 5 16%
NSLHD 29 40% 23 32% 23 32% 14 19% 13 18% 16 22% 13 18% 7 10% 8 11%
SCHN 11 18% 16 26% 10 16% 14 23% 2 3% 5 8% 12 19% 1 2% 16 26%
SESLHD 36 36% 33 33% 26 26% 26 26% 12 12% 18 18% 11 11% 9 9% 25 25%
SVHN 11 58% 8 42% 5 26% 6 32% 10 53% 6 32% 6 32% 4 21% 1 5%
SWSLHD 31 36% 30 34% 31 36% 27 31% 14 16% 22 25% 10 11% 6 7% 18 21%
SYDLHD 9 11% 31 38% 19 23% 12 15% 7 9% 10 12% 15 19% 6 7% 23 28%
WSLHD 20 39% 17 33% 18 35% 11 22% 16 31% 10 20% 6 12% 6 12% 14 27%
Rural &
Regional FWLHD
5 50% 3 30% 3 30% 5 50% 1 10% 2 20% 1 10% 0% 0%
HNELHD 73 64% 49 43% 47 41% 48 42% 26 23% 35 31% 13 11% 16 14% 17 15%
MLHD 31 60% 14 27% 20 38% 11 21% 10 19% 4 8% 7 13% 5 10% 5 10%
MNCLHD 15 48% 13 42% 12 39% 15 48% 7 23% 5 16% 5 16% 2 6% 3 10%
NNSWLHD 25 54% 21 46% 20 43% 14 30% 8 17% 9 20% 10 22% 5 11% 3 7%
SNSWLHD 27 63% 20 47% 14 33% 16 37% 12 28% 9 21% 5 12% 5 12% 8 19%
WNSWLHD 49 70% 23 33% 32 46% 25 36% 26 37% 17 24% 11 16% 11 16% 4 6%
Other ASNSW 105 68% 30 19% 26 17% 14 9% 83 54% 11 7% 10 6% 18 12% 10 6%
NSW 542 49% 373 33% 342 31% 299 27% 283 25% 214 19%
15
1 14% 112 10% 175 16%
25 2011 Quality Systems Assessment - Sepsis
Guidelines / protocols
For NSW 60% of departments/clinical units responding to the self assessment reported that guidelines and / or
local protocols were in place that were specifically developed for the management of patients identified with, or
suspected of, sepsis.
At the LHD level 96% reported having guidelines and at the facility level 79% reported have guidelines / protocols
in place specifically developed for the management of patients identified with, or suspected of, sepsis
Figure 12: % of Departments/clinical units reporting that they have guidelines and / or local protocols in place specifically
developed for the management of patients identified with, or suspected of, sepsis
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
CC
LHD
ISLH
D
NB
MLH
D
NSL
HD
SCH
N
SESL
HD
SVH
N
SWSL
HD
SYD
LHD
WSL
HD
Met
ro T
ota
l
FWLH
D
HN
ELH
D
MLH
D
MN
CLH
D
NN
SWLH
D
SNSW
LHD
WN
SWLH
D
R&
R T
ota
l
Metropolitan LHDs Rural & Regional LHDs
LHD - Yes NSW Yes
Do you have guidelines and / or local protocols in place specifically developed for the management of
patients identified with, or suspected of, sepsis?
__ Yes, for adults only
__ Yes, for children and / or young people only
__ Yes, for both (adults and children / young people)
__ No
26 2011 Quality Systems Assessment - Sepsis
Table 21: Count and % of Departments/clinical units reporting that they have guidelines and / or local protocols in place
specifically developed for the management of patients identified with, or suspected of, sepsis by LHD.
Description LHD Yes, for adults only Yes, for children and/or
young people only
Yes, for both (adults and
children/young people) No
Metropolitan
LHDs CCLHD 13 31.7% 4 9.8% 0 N/A 24 58.5%
ISLHD 20 38.5% 2 3.8% 10 19.2% 20 38.5%
NBMLHD 6 19.4% 3 9.7% 4 12.9% 18 58.1%
NSLHD 27 37.5% 6 8.3% 9 12.5% 30 41.7%
SCHN 0 N/A 35 56.5% 3 4.8% 24 38.7%
SESLHD 33 33.0% 4 4.0% 13 13.0% 50 50.0%
SVHN 8 42.1% 0 N/A 0 N/A 11 57.9%
SWSLHD 32 36.8% 2 2.3% 13 14.9% 40 46.0%
SYDLHD 46 56.8% 3 3.7% 9 11.1% 23 28.4%
WSLHD 22 43.1% 3 5.9% 2 3.9% 24 47.1%
Metro Total 207 34.7% 62 10.4% 63 10.6% 264 44.3%
Rural &
Regional LHDs FWLHD 5 50.0% 1 10.0% 2 20.0% 2 20.0%
HNELHD 43 37.7% 9 7.9% 34 29.8% 28 24.6%
MLHD 17 32.7% 3 5.8% 15 28.8% 17 32.7%
MNCLHD 16 51.6% 0 N/A 7 22.6% 8 25.8%
NNSWLHD 17 37.0% 3 6.5% 10 21.7% 16 34.8%
SNSWLHD 13 30.2% 2 4.7% 11 25.6% 17 39.5%
WNSWLHD 14 20.0% 4 5.7% 19 27.1% 33 47.1%
R&R Total 125 34.2% 22 6.0% 98 26.8% 121 33.1%
NSW NSW 332 34.5% 84 8.7% 161 16.7% 385 40.0%
The rate for six of the seven Rural & Regional LHDs was higher than the NSW average. 81% of Departments/clinical
units from Rural & Regional LHDs that indicated that there were guidelines and / or local protocols in place for
“children and/or young people only” also reported that “All (100%)” or “Most (67%-99%)” staff were trained in
their use.
Table 22 % of Departments/clinical units reporting that they have guidelines and / or local protocols in place specifically
developed for the management of patients identified with, or suspected of, sepsis by Metropolitan and Rural & Regional LHD.
Description Guidelines & Protocols exist All or Most Some, Few, None or Don't know
Metropolitan LHDs Yes, for adults only 68.4% 31.6%
Yes, for both (adults and children/young
people) 73.0% 27.0%
Yes, for children and/or young people only 71.7% 28.3%
Rural & Regional LHDs Yes, for adults only 52.0% 48.0%
Yes, for both (adults and children/young
people) 53.1% 46.9%
Yes, for children and/or young people only 81.0% 19.0%
27 2011 Quality Systems Assessment - Sepsis
Across NSW 64% of departments/clinical units responding to the self assessment indicated that “All (100%)” or
“Most (67%-99%)” relevant clinical staff who have been orientated to and / or trained in the use of, the guidelines /
protocols.
Figure 13: % of Departments/clinical units reporting that relevant clinical staff who have been orientated to and / or trained in the
use of, the guidelines / protocols.
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
CC
LHD
ISLH
D
NB
MLH
D
NSL
HD
SCH
N
SESL
HD
SVH
N
SWSL
HD
SYD
LHD
WSL
HD
Met
ro T
ota
l
FWLH
D
HN
ELH
D
MLH
D
MN
CLH
D
NN
SWLH
D
SNSW
LHD
WN
SWLH
D
R&
R T
ota
l
Metropolitan LHDs Rural & Regional LHDs
LHD - All or Most NSW - All or Most
Please estimate the percentage of relevant clinical staff who have been orientated to and / or trained in the
use of, the guidelines / protocols
__ All (100%)
__ Most(67%-99%)
__ Some (34% – 66%)
__ Few (1% - 33%)
__ None (0%)
__ Don’t know
28 2011 Quality Systems Assessment - Sepsis
Table 23: Count and % of Departments/clinical units reporting that relevant clinical staff who have been orientated to and / or
trained in the use of, the guidelines / protocols by LHD.
Description LHD All (100%) Most (67%-99%) Some (34%–
66%) Few (1%-33%) None (0%) Don't know
Metropolitan
LHDs CCLHD 4 23.5% 5 29.4% 3 17.6% 2 11.8% 1 5.9% 2 11.8%
ISLHD 5 15.6% 15 46.9% 6 18.8% 3 9.4% 1 3.1% 2 6.3%
NBMLHD 2 15.4% 9 69.2% 0 N/A 0 N/A 0 N/A 2 15.4%
NSLHD 6 14.6% 25 61.0% 7 17.1% 1 2.4% 0 N/A 2 4.9%
SCHN 8 21.6% 15 40.5% 6 16.2% 1 2.7% 0 N/A 7 18.9%
SESLHD 10 20.0% 30 60.0% 5 10.0% 2 4.0% 1 2.0% 2 4.0%
SVHN 1 12.5% 1 12.5% 3 37.5% 0 N/A 0 N/A 3 37.5%
SWSLHD 6 13.0% 24 52.2% 3 6.5% 5 10.9% 1 2.2% 7 15.2%
SYDLHD 19 32.8% 29 50.0% 3 5.2% 1 1.7% 2 3.4% 4 6.9%
WSLHD 7 25.9% 9 33.3% 5 18.5% 1 3.7% 0 N/A 5 18.5%
Metro Total 68 20.7% 162 49.2% 41 12.5% 16 4.9% 6 1.8% 36 10.9%
Rural &
Regional LHDs FWLHD 2 25.0% 3 37.5% 1 12.5% 1 12.5% 1 12.5% 0 N/A
HNELHD 10 12.0% 40 48.2% 22 26.5% 4 4.8% 2 2.4% 5 6.0%
MLHD 1 2.9% 12 34.3% 12 34.3% 6 17.1% 1 2.9% 3 8.6%
MNCLHD 3 13.0% 8 34.8% 6 26.1% 3 13.0% 1 4.3% 2 8.7%
NNSWLHD 4 13.3% 15 50.0% 6 20.0% 3 10.0% 0 N/A 2 6.7%
SNSWLHD 3 11.5% 11 42.3% 7 26.9% 4 15.4% 1 3.8% 0 N/A
WNSWLHD 3 8.1% 18 48.6% 11 29.7% 3 8.1% 0 N/A 2 5.4%
R&R Total 26 10.7% 107 44.2% 65 26.9% 24 9.9% 6 2.5% 14 5.8%
NSW NSW 94 16.5% 269 47.1% 106 18.6% 40 7.0% 12 2.1% 50 8.8%
29 2011 Quality Systems Assessment - Sepsis
Figure 14: Count of sepsis management issues explicitly covered in guidelines / protocols identified by department / clinical unit
0% 5% 10% 15% 20% 25% 30% 35% 40%
Clear guidelines for response and escalation when sepsis is identified/suspected
A standardised sepsis screening protocol which includes criteria/parameters for recognition/identification
Treatment pathway/resuscitation protocol/algorithm with early goal directed therapy (EGDT) measures included
Standardised septic shock order set for IV fluids/antibiotic etc
Referral/discharge/transfer protocol/s
Other
NSW - % of Departments/Clinical Units responding
Please indicate which of the following sepsis management issues are explicitly covered in your guidelines /
protocols: (tick all that apply)
__ Clear guidelines for response and escalation when sepsis is identified / suspected
__ A standardised sepsis screening protocol (adult and paediatric) which includes criteria / parameters for
recognition / identification
__ Treatment / Resuscitation protocol / algorithm with early goal directed therapy (EGDT) measures including
Monitoring, airway management, fluid resuscitation blood cultures, BGL monitoring and antibiotic
administration.
__ A standardised septic shock order set for IV fluids/antibiotic etc
__ Referral /discharge / transfer protocol/s
__ Other
30 2011 Quality Systems Assessment - Sepsis
Monitoring and Reporting
Rural & Regional LHDs (33%) reported a lower % of departments/clinical units monitoring aspects of sepsis
incidence, care and management than Metropolitan LHDs (49%). Emergency (28%), Aged Care (31%), Medical
(31%) and Surgical (38%) departments/clinical units reported lower overall rates than the NSW average (43%).
Figure 15: % of Departments/clinical units reporting that they monitor any aspects of sepsis incidence, care and management
Table 24: Count and % of Departments/clinical units reporting that they monitor any aspects of sepsis incidence, care and
management by LHD.
Description LHD Yes Yes - LHD No No
Metropolitan LHDs CCLHD 12 29.3% 29 70.7%
ISLHD 19 36.5% 33 63.5%
NBMLHD 18 58.1% 13 41.9%
NSLHD 36 50.0% 36 50.0%
SCHN 25 40.3% 37 59.7%
SESLHD 45 46.4% 52 53.6%
SVHN 12 63.2% 7 36.8%
SWSLHD 49 57.6% 36 42.4%
SYDLHD 48 63.2% 28 36.8%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
CC
LHD
ISLH
D
NB
MLH
D
NSL
HD
SCH
N
SESL
HD
SVH
N
SWSL
HD
SYD
LHD
WSL
HD
Met
ro T
ota
l
FWLH
D
HN
ELH
D
MLH
D
MN
CLH
D
NN
SWLH
D
SNSW
LHD
WN
SWLH
D
R&
R T
ota
l
Metropolitan LHDs Rural & Regional LHDs
Yes - LHD Yes - NSW
Do you monitor any aspects of sepsis incidence, care and management?
__ Yes
__ No
31 2011 Quality Systems Assessment - Sepsis
Description LHD Yes Yes - LHD No No
WSLHD 24 48.0% 26 52.0%
Metro Total 288 49.2% 297 50.8%
Rural & Regional
LHDs FWLHD 4 40.0% 6 60.0%
HNELHD 41 36.6% 71 63.4%
MLHD 17 32.7% 35 67.3%
MNCLHD 7 23.3% 23 76.7%
NNSWLHD 11 24.4% 34 75.6%
SNSWLHD 20 46.5% 23 53.5%
WNSWLHD 18 25.7% 52 74.3%
R&R Total 118 32.6% 244 67.4%
NSW NSW 406 42.9% 541 57.1%
Figure 16: % of Departments/clinical units reporting that monitor any aspects of sepsis incidence, care and management
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Med
ical
Surg
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Oth
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MH
Ob
s &
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ED
Age
d C
are
Pae
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ICU
On
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Imag
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Re
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Ort
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Yes Yes - NSW
32 2011 Quality Systems Assessment - Sepsis
Figure 17: Count of sepsis performance measures utilised identified by department / clinical unit
Analysis of ‘other’ responses showed that most departments are reviewing their own specific infection
data / rates suchs as hip repleacement prosthesis; intravascular line / CLAB incidence and wound
infection or have only just commenced using the data collection set from sepsis project.
0
0% 5% 10% 15% 20% 25% 30% 35% 40%
Other
Rapid Response/Medical Emergency Team (MET) …
Time to antibiotics (delay)
Admissions to Intensive Care (ICU) due to sepsis
Serum lactate measure taken
Delay in blood cultures
Time to commencement of 2nd litre of IV fluid
Time to completion of 1st litre of IV fluids
None
NSW - % of Departments/Clinical Units responding "Yes" that aspects of sepsis incidence, care and management are monitored
Please indicate what performance measures you utilise (tick all that apply)
__ None
__ Delay in blood cultures
__ Time to antibiotics (delay)
__ Admissions to ICU due to sepsis
__ Time to completion of 1st
litre of IV fluids
__ Time to commencement of 2nd litre of IV fluid
__ Serum lactate measure taken
__ Rapid Response / Medical Emergency Team (MET) calls related to sepsis
__ other
33 2011 Quality Systems Assessment - Sepsis
For NSW, 57% of departments/clinical units responding to the self assessment reviewed all sepsis cases at local
morbidity and mortality meetings.
Departments/clinical units from hospital peer groups B & C reported rates lower than the NSW average.
Figure 18: % of Departments/clinical units reporting that all sepsis cases are reviewed at local morbidity and mortality meetings,
including those patients transferred to ICU and / or transferred to another facility
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
CC
LHD
ISLH
D
NB
MLH
D
NSL
HD
SCH
N
SESL
HD
SVH
N
SWSL
HD
SYD
LHD
WSL
HD
Met
ro T
ota
l
FWLH
D
HN
ELH
D
MLH
D
MN
CLH
D
NN
SWLH
D
SNSW
LHD
WN
SWLH
D
R&
R T
ota
l
Metropolitan LHDs Rural & Regional LHDs
Yes - LHD Yes - NSW
All sepsis cases are reviewed at local morbidity and mortality meetings, including those patients transferred to ICU and / or transferred to another facility
__ Yes, routinely
__ Yes, occasionally but not routine
__ No
__ Not applicable
34 2011 Quality Systems Assessment - Sepsis
Table 25: Count and % of Departments/clinical units reporting that all sepsis cases are reviewed at local morbidity and mortality
meetings, including those patients transferred to ICU and / or transferred to another facility by LHD.
Description LHD Yes, routinely Yes, occasionally but not
routine No Not applicable
Metropolitan LHDs
CCLHD 4 9.8% 10 24.4% 13 31.7% 14 34.1%
ISLHD 15 28.8% 18 34.6% 5 9.6% 14 26.9%
NBMLHD 9 29.0% 8 25.8% 8 25.8% 6 19.4%
NSLHD 25 34.7% 32 44.4% 6 8.3% 9 12.5%
SCHN 14 22.6% 19 30.6% 10 16.1% 19 30.6%
SESLHD 33 34.0% 24 24.7% 13 13.4% 27 27.8%
SVHN 5 26.3% 6 31.6% 6 31.6% 2 10.5%
SWSLHD 32 37.6% 29 34.1% 14 16.5% 10 11.8%
SYDLHD 42 55.3% 17 22.4% 7 9.2% 10 13.2%
WSLHD 13 26.0% 12 24.0% 16 32.0% 9 18.0%
Metro Total 192 32.8% 175 29.9% 98 16.8% 120 20.5%
Rural & Regional LHDs
FWLHD 1 10.0% 4 40.0% 2 20.0% 3 30.0%
HNELHD 18 16.1% 40 35.7% 26 23.2% 28 25.0%
MLHD 5 9.6% 13 25.0% 14 26.9% 20 38.5%
MNCLHD 4 13.3% 5 16.7% 10 33.3% 11 36.7%
NNSWLHD 10 22.2% 18 40.0% 6 13.3% 11 24.4%
SNSWLHD 11 25.6% 12 27.9% 8 18.6% 12 27.9%
WNSWLHD 8 11.4% 19 27.1% 22 31.4% 21 30.0%
R&R Total 57 15.7% 111 30.7% 88 24.3% 106 29.3%
NSW NSW 249 26.3% 286 30.2% 186 19.6% 226 23.9%
Figure 19 % department / clinical units reporting that all sepsis cases are reviewed at local morbidity and mortality meetings,
including those patients transferred to ICU and / or transferred to another facility by service type
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Med
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Surg
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ED
Ob
s &
Gyn
ICU
Age
d C
are
Pae
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tric
Oth
er
On
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Ne
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gy
Re
hab
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n
MH
Ort
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Car
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c/C
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Imag
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Service Type - Yes Yes - NSW
35 2011 Quality Systems Assessment - Sepsis
Appendix 1: Notes about the data
In this report, charts and tables are used to provide information on department/clinical unit responses to the questions from the
2011 QSA self assessment compared to the aggregated NSW results.
Except where noted the charts illustrate the responses for departments/clinical units from LHDs.
The report uses pie charts, summary graphs for multiple questions and tables summarising the statistical analysis of the results.
In the chart below, responses for the block of six questions on the paediatric Between the Flags program for all NSW are summarised.
.
Figure X: % of “Strongly agree” or “Agree” responses to questions on the Paediatric Between the Flags Program for
departments/clinical units reporting that children/young people were assessed and treated (Q.7x; NSW).
The section of the report that reviews each question in detail makes use of 3 types of chart to summarise the
department/clinical unit responses. The chart below is used to compare the responses for departments/clinical units from
each LHD, Metropolitan and Rural based LHDs and the overall NSW proportion. A list of Metropolitan and Rural & Remote
LHDs is available at http://www.health.nsw.gov.au/services/index.asp
Figure X: % of Departments/clinical units responding “Strongly agree” or “Agree” by LHD.
0% 10% 20% 30% 40% 50% 60% 70% 80% 90%
100%
Q7a. Executive support
important part of success
Q7b. Clinical lead critical to
uptake & acceptance
Q7c. Blue zone assists early
detection
Q7d. Yellow zone assists
early detection
Q7e. Red zone assists rapid
response
Q7f. Overall BTF Benefits patient
safety
0%
20%
40%
60%
80%
100%
CC
LHD
ISLH
D
NB
MLH
D
NSL
HD
SCH
N
SESL
HD
SWSL
HD
SYD
LHD
WSL
HD
Met
ro T
ota
l
FWLH
D
HN
ELH
D
MLH
D
MN
CLH
D
NN
SWLH
D
SNSW
LHD
WN
SWLH
D
R&
R T
ota
l
Metropolitan Rural & Regional
LHD - Strongly agree or Agree NSW - Strongly agree or Agree
1
This chart summarises the responses to the group of statements from Question 7
in the 2011QSA, LHD Department/Clinical Unit self assessment. The results are
aggregated at the NSW level.
2
Aggregate result for Rural &
Regional based LHDs.
Aggregate result for Metropolitan
based LHDs.
36 2011 Quality Systems Assessment - Sepsis
The chart below is used to compare the responses for departments/clinical units from each peer hospital
group and the overall NSW proportion. The Peer Hospital Groups are collapsed to the main letter designation
with the exception of:
F2 Nursing Home & F3 Multi-Purpose Services facilities are mapped to F - Other
F1 – Psychiatric facilities that are mapped to F1 – MH
F4 Sub Acute, F6 Rehabilitation, F7 Mothercraft & F8 Ungrouped Non-Acute facilities are mapped to
“Other”
A list of NSW Peer Hospital Groups 2011/12 is available at http://www.health.nsw.gov.au/hospitals/peer_groups.asp
Figure X: % of Departments/clinical units responding “Strongly agree” or “Agree” by Peer Hospital Group.
The chart below is used to compare the responses for departments/clinical units from each aggregated service
type and the overall NSW proportion. The aggregated service types are derived from the response to Question
88 from the Department/Clinical Unit Self assessment. The primary respondent for the self assessment was
asked to indicate the main type of service their department/clinical unit provides. A table showing the
mapping of these responses is provided in Appendix A of this document.
Figure X: % of Departments/clinical units responding “Strongly agree” or “Agree” by Service type.
0%
20%
40%
60%
80%
100%
A B C D F - Other F1 - MH Other
Peer group - Strongly agree or Agree NSW - Strongly agree or Agree
0% 10% 20% 30% 40% 50% 60% 70% 80% 90%
100%
Med
ical
ED
Surg
ical
Pae
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tric
Ob
s &
Gyn
Oth
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MH
Ort
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On
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Pal
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Reh
abili
tati
on
Service type - Strongly agree or Agree NSW - Strongly agree or Agree
3
4
This line shows the
aggregate result for
all NSW (77%)
37 2011 Quality Systems Assessment - Sepsis
Tables used in the report.
This table summarises the statistical analysis made for a group of questions.
The P-Value indicates if there is a statistically significant association between the variables (in this case) of LHD
location and response to the question. Using an -level of 0.05 for this test, the conclusion is the variables are
associated.
Table X: Summary of metropolitan and rural/regional Department/clinical unit self assessment responses regarding
the level of agreement with the SPOC/BTF statements.
Metropolitan Rural & Regional P-Value
BTF SPOC implemented % 70.3 91.3 <0.001
Agree on BTF clinical leader benefits % 64.7 66.2 0.78
Agree on BTF blue zone benefits % 53.9 73.7 <0.001
Agree on BTF yellow zone benefits % 72.9 81.3 0.06
Agree on BTF red zone benefits % 68.6 79.7 0.02
Agree on BTF benefits % 71.7 81.8 0.02
BTF NSW CPGs utilised always/often % 42.9 77.3 <0.001
This table summarises the responses for LHDs or clinical units to a single question. The responses for the
question are arranged across the top of the table with the values arranged in columns.
Table X: Count and % of Departments/clinical units reporting that children/young people were assessed and treated
and the SPOC implantation status by LHD.
Description LHD Yes
No Not applicable - our department
does not manage or treat children
Metropolitan CCLHD 5 41.7% 3 25.0% 4 33.3%
ISLHD 7 41.2% 6 35.3% 4 23.5%
NBMLHD 11 73.3% 3 20.0% 1 6.7%
NSLHD 18 47.4% 8 21.1% 12 31.6%
SCHN 66 75.9% 9 10.3% 12 13.8%
SESLHD 14 33.3% 15 35.7% 13 31.0%
SVHN 0 N/A 1 100.0% 0 N/A
SWSLHD 18 42.9% 8 19.0% 16 38.1%
SYDLHD 10 43.5% 4 17.4% 9 39.1%
WSLHD 11 64.7% 2 11.8% 4 23.5%
Metro Total 160 54.4% 59 20.1% 75 25.5%
Rural & Regional FWLHD 8 100.0% 0 N/A 0 N/A
HNELHD 61 82.4% 5 6.8% 8 10.8%
MLHD 40 97.6% 1 2.4% 0 N/A
MNCLHD 10 71.4% 0 N/A 4 28.6%
NNSWLHD 28 84.8% 5 15.2% 0 N/A
SNSWLHD 23 59.0% 4 10.3% 12 30.8%
WNSWLHD 52 77.6% 6 9.0% 9 13.4%
R&R Total 222 80.4% 21 7.6% 33 12.0%
NSW 382 67.0% 80 14.0% 108 18.9%
Similar tables have been provided for peer hospital groups and aggregated service types where applicable.
5
6
7
7
38 2011 Quality Systems Assessment - Sepsis
39
Offices
Level 13, 227 Elizabeth Street
SYDNEY NSW 2000
Correspondence
Bernadette King
QSA Program leader
Locked Bag A4062,
Sydney South NSW 1235
Tel 61 2 9269 5500
Fax 61 2 9269 5599
www.cec.health.nsw.gov.au