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Sepsis – The Silent Killer in the NHS Kate Beaumont, Trustee, UK Sepsis Trust Nurse Director The Learning Clinic Director QGi Ltd Former Head of Patient Safety and lead for deterioration, National Patient Safety Agency With Rhian Oliver, patient representative
In 2006 we reviewed the NRLS and identified
three themes:
No observations made for a prolonged
period and therefore changes in a patient’s
vital signs not detected.
No recognition of the importance of the
deterioration and/or no action taken other than
recording of observations.
Delay in the patient receiving medical
attention, even when deterioration has been
detected and recognised.
Failure to rescue
Suspect Sepsis
Say Sepsis
• Sepsis remains the primary cause of death from
infection despite advances in modern medicine,
including vaccines, antibiotics and acute care.
• 37,000 people die annually across the UK from
sepsis.
• The yearly mortality from sepsis is greater than
breast and bowel cancer combined.
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• Surviving sepsis campaign introduced in 2002
• Several studies have shown that early recognition
and treatment (the CEM standards) reduces mortality
from sepsis.
• Each hour of delay in antimicrobial administration
over the ensuing 6 hrs was associated with an
average decrease in survival of 7.6%.
• Time to initiation of effective antimicrobial therapy
was the single strongest predictor of outcome.
Acute MI & Trauma
5% Mortality 3% Mortality
Implications of sepsis
• Sepsis makes up 40% critical care workload
• Patients with severe sepsis have a mortality rate of
40% (7x higher than ACS)
• Patients in septic shock have a mortality approaching
50%
1. SIRS:
– ≥ 2 of:
– > 38.3°C or < 36. 0°C
– HR > 90
– RR > 20
– WCC <4 or >12 x 109/L
– Acutely altered mental status
– Glucose > 8.3 (unless diabetic)
Sepsis = SIRS + infection
Suspect Sepsis
Why is implementation so
difficult?
• Time sensitive process - not seen as emergency -
?sepsis box
• Difficult to diagnosis sepsis early – affects everyone
• Human Factors get in the way – empower nurses -
?bedside lactate testing, bedside technology,
• Too many elements in some bundles – promote
sepsis six
• Why don’t doctors who prescribe Abx give first
dose??
Improving patient safety =
• Improve the culture
• Improve the system
The Sepsis Six
1. Deliver O2 (>94% SpO2)
2. Take blood cultures and consider source control
3. Give IV antibiotics according 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
• Mistakes are caused by bad systems, not bad people
• Systems set people up to fail, or fall into ‘a trap’
• We must recognise that humans are error prone and try to
error-proof our systems
• Remove hazards wherever possible
• People need to believe that errors are never ‘all their fault’
• Safety is about the future not the past…
Lucien Leape on patient safety
culture
It is very rare for staff in healthcare to go to work with the intention of causing harm or failing to do the right thing.
Therefore we have to ask, why there are many incidents where some of the latent conditions are caused by staff not doing the right thing, even when they know what the right thing is?
Many processes and policies in healthcare are complex or seem to create difficulties for busy staff thus creating the temptation to take shortcuts or ‘workarounds’.
Patient Safety First’s ‘How to Guide’ for Implementing Human Factors in Healthcare
Doing the right thing
Perception (from NPSA training material)
We’re all human
In summary, some of the common human factors
that can increase risk include:
• mental workload
• distractions
• the physical environment
• physical demands
• device/product design
• teamwork
• process design
A human factors approach means;
• thinking realistically about how people work and prospectively assessing risk, for the mundane as well as the seemingly ‘high risk’
• maintaining a system’s overview, so that someone, somewhere, has an understanding of how all of the pieces of the jigsaw come together.
In healthcare, where we often find ourselves working with:
• equipment that doesn’t match our mental models of the way
things work
• information systems that don’t allow us to access the data we
need quickly and when we need it
• environments that are cramped or don’t have the equipment we
need
• protocols that conflict with the practical ways of getting a job
done
• colleagues who are used to different ways of working
• time pressures that force us to cut corners
• teams that don’t know each other and where there is conflict.
Applying human factors principles means -
making the right thing the easiest thing, ……………………..setting staff up to get it right
‘A safer, more reliable and efficient
NHS will remain a pipe-dream until we create a culture where human error is seen as normal, inevitable and as a source of important learning.’ http://www.chfg.org
Say Sepsis
‘We cannot change the human condition, but we can change the conditions under which humans work.’
Jim Reason (2000)
If we accept human fallibility, we need to rely on well-designed systems to support us in the workplace.
And remove error traps wherever possible.
For each year, for every 500 beds…..
62 lives saved
883 fewer bed days
520 fewer CC bed days
Direct costs for survivors reduced by £0.78M (Ron Daniels, Chair UKST)
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