dr. mark simmonds consultant in acute and critical care ......sepsis timeline at nuh onset of severe...
TRANSCRIPT
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
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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
06
20
10
No
v-1
1
De
c-1
1
Ja
n-1
2
Fe
b-1
2
Ma
r-12
Ap
r-12
Ma
y-1
2
Ju
n-1
2
Ju
l-12
Au
g-1
2
Se
p-1
2
Oct-1
2
No
v-1
2
De
c-1
2
Ja
n-1
3
Fe
b-1
3
Ma
r-13
Ap
r-13
Ma
y-1
3
Ju
n-1
3
Ju
l-13
Au
g-1
3
Se
p-1
3
Oct-1
3
No
v-1
3
Pe
rce
nt
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
