Network Session B

Reliability & Screening

Corinne Thomas, Tracy Broom, Matt Inada-KimPSC

Improvement AIM

All patients presenting to all hospital emergency front doors

Screen <60 minutes

Antibiotics <60 minutes

Dialects & Tribes

Hospital

Ambulance

Community

CQUIN

33% avoidable deaths

£40 million wasted

Sepsis Improvement Strategies

Simplify & SpreadStandardize

Synergize

Simplifying definitions

Sepsis is a deleterious autoimmune host response to infection leading to organ dysfunction and shock

≈Infection + Compromise

Simplifying Terminology

Infectio

n

Sepsis

Septic

shock

SEVERITY

Overview of pathway

With Minimal added work

friend

Pharmacy

GP

A&E

Home

Admissions unit

ICU

Downstream Ward

GP, DN, Receptionist

Admissions Nurse coordinator, SHO, SpR, ConsMicrobiology, Pharmacist, Physio, Ward

Clerk/admin, Managers

Receptionist, Triage nurse, SHO

Ambulance111

Porters

Outreach,SHO, Cons

F1,SHO,SpR,Cons, Pharmacist, Physio, Ward Clerk/admin,

Managers

The pathway must work in all areas and for all staff

How do you tell if someone is sick?

ExperienceIntuitionKnowledgePhysiologyTestsExamination

How well do you communicate this?

LanguageObservationsSBARWritten/verbal/computerised

Across silosAcross geography

CommunityAmbulance

Hospital

What is the evidence?

OOH community

NEWS implementation pilots North / mid HANTSNorth Lactate pilot

GPs

EMIS NEWS appNHS Scotland NEWS sepsis appPilot of 60 across mid HampshireSpread from GP VTS

Integration of NEWS based observationOngoing…

Care Homes- NH/RC/MH

Ambulances

EPR-> NEWSCall prioritisationAssessments and reviewsCommunication with GPs/community and hospitalsApp development & integration with 111Large pilot

Systemic problems within Sepsis

PersonAwareness is low

UnpredictableHeterogeneous

Non-specific presentations(No ECG, hemiparesis)

The Human FactorE.g. Teams, Distractions, old medical

modelHierarchies, Communication

SystemUnclear definitions/coding

Lack of outcome dataNon-standardised

Multiple screening toolsLack of OwnershipDialects & Tribes

Uncoordinated Pathways

Dialects & Tribes

A41 Admissions/Mortality in England

2010/11 2011/12 2012/13 2013/14 2014/150

5000

10000

15000

20000

25000

30000

35000

40000

45000

50000

0

5

10

15

20

25

30

35

A41 admissionsA41 deathsA41 Mortality Rate(%)

Wessex Patient Safety Collaborative

Pan Wessex Screening discussion

Dr Matt Inada-Kim, Corinne ThomasTracy Broom

15:00 Introduction – what’s happening across region, nationally

15:15 Screening Introduction-Evidence around screening (MIK)Group discussion AIM- Agree screening tool, definitions

16:15 InterventionsIntroduction-Evidence around interventions (MIK)

Group discussion Agree standards

16:30 CQUINQuestions & Support

16:45- 17:00 Wrap up- Summary & A.O.B.

Pan Wessex Sepsis Group Timetable

Terminology

Infectio

n

Sepsis

Septic

shockMinor physiological

disturbanceLow mortality (<3%)

Moderate physiological disturbanceModerate mortality (<22%)

Severe physiological disturbanceHigh mortality (>35%)

SEVERITY

NEWS vs SIRS

NEWS Score Mortality +/- ICU admission

0-4 7.9%

≥ 5 22.7%

Sensitivity Specificity

NEWS 3 92% 77%

SIRS 88% Low

Corfield et al

Keep et al

Kaukonen et al

NEWS or SIRS for sepsis diagnosis

NEWS as a prognostic indicator

“SIRS fails to define a transition point in risk of death”

RIP SIRS

Odds ratios with NEWSNEWS Odds

Ratio

ICU

0-4 0.96

5-6 1.22

7-8 2.01

9-20 5.76

Mortality (30 days)

0-4 1.04

5-6 1.72

7-8 2.26

9-20 5.64

Combined

(ICU/mortality)

0-4 1.01

5-6 1.72

7-8 2.17

9-20 5.78

Predictive value of NEWS

Common language

Care/Nursing homes

Ambulances

? Community medicine

Psychiatry

Triage tool????

Septics ED AMU

<60 minutes 2 0

>60 minutes 11 7

% <60 15% 0%

Pre intervention (SIRS) Post intervention (NEWS)

ED AMU

20 4

7 6

75% 40%

Timely Administration of antibiotics in Septic patients on AMUSarah Edwards & Sarah Zarif RHCH 2015

“Does any coder here speak doctor?”Getting the language right and ensuring its visible

Confusion…“Septic diagnoses” vs “sepsis or severe sepsis”

With Clinical reclassification47 diagnoses in “Sepsis diagnoses” vs 19 in “Septicaemia”

At HHFT and nationally, there were 7 times more sepsis deaths than were being recorded.

0

100000

200000

300000

400000

500000

600000

700000

2009/10 2010/11 2011/12 2012/13 2013/14

Septicaemia (except in labour)

Sepsis diagnoses

Septicaemia (except in labour) vs Septic Diagnoses Inpatient spells April 09 to March 14

100,000->660,000 admissions and 37,000->55,000 English deaths / year£1 billion vs £13 billion in hospital costs