Sepsis- a nation’s response

Matt Inada-Kim, Acute Physician, Hampshire Hospitals, National Clinical Advisor NHSE & NHSI

Clinical Lead Deterioration & Sepsis, Wessex PSC

Kate Cheema, Associate Director Transformation Analytics and Health Economics

NHS South, Central and West Commissioning Support Unit

Deterioration

Trauma

Vascular

Infection

Frailty

SEPSIS

Learning & ListeningUnderstanding Context

Measurably Winning (after 3000 years)

Why we must be Relentless

Understanding BadnessEvolving from Blaming Individuals to Systems Improvement

The opportunities NEWS2 and a ‘sepsis test’ will bring

SEPSIS

Balance & Evidence

Measurement

Process & Outcome

Collaboration & Alignment

Mandate &

Learning

Innovation & Research

menu

1. Context

2. Opportunity

3. Balance

4. Measurement

5. Resources

6. Future

Admissions are sicker with more comorbiditiesInfection is the most common cause of deterioration leading to acute admission

Infection with badness

A life-threatening organ dysfunction caused by a dysregulated host

response to infection

Tensions

BLAME LEARNING

36,000 cases/ 9,000 deaths in ICU in England per year

Est. 250,000 cases / 44,000 deaths in England per year

treatment stewardship

ClinicialJudgement

Protocol

V

Sepsis is Infection with Badness

Sepsis has no test

when it is determined affects accuracy and the ‘N’

Hospital Discharge (most reliable)Death certificate

ICU adm

AmbulanceEmergency DepartmentGP (unreliable)NCEPOD Just Say Sepsis! 2015

Even when spotted & treated, it’s poorly documented (No mention of Sepsis on death certificates in 60%)

We don’t TREAT sepsis, we treat SUSPICION, informed by JUDGEMENT

Patients are admitted with Opacity & Greyness

The diagnosis is best established at the end & not the beginning of admission

e.g. results, conviction/response to treatment

‘Badness’ is defined by where they are managed

Undifferentiated

Sick Patient

Suspicion

of……

Suspected

……..

Clinical decision making in vivo

Reality check

Time critical treatment medical model The undifferentiated sick patient pathway

Deterioration

Trauma

Vascular

SEPSIS

Multiplicity of ‘sepsis’ definitions

With thanks to S.Tees

Which chart for monitoring physiology?

Variation & Separation

Timeline of key publications700BC Hippocrates defines ‘Sepsi’

2006 Kumar, Rivers (EGDT)

2013 Ombudsman, Time to Act

2014 SIRS Toolkit

2015 CQUIN, NCEPOD-Just Say Sepsis, RFS

NHSE, Improving Outcomes for Patients with Sepsis

2016 Consensus 3, qSOFA (Quick SOFA), NICE Clinical Guideline 20

2017 NHSE Sepsis guidance

2018 NEWS2 MANDATE, CQUIN revision, Patient Safety Alert

2019 Combined Sepsis/Deterioration Pathway

Suspected Sepsis = NEWS 5 + clinical judgement

An aggregate NEWS of 5 or more identifies adult hospital patients who are severely ill with likely organ dysfunction and who require urgent assessment. Where accompanied by suspicion of sepsis this should prompt the senior clinical decision-maker, using clinical judgement, to start appropriate treatment, as indicated, within an hour of the risk being recognised.

opportunities for sepsis improvement

Awareness

Whose Leading?

communication

Poor Handover

Teamwork

TrainingAbsent induction

No stable definition

Human error

Disregard for clinical judgement

Non standardised/aligned pathways

What is sepsis?

National issue Local issue

Infection AMR

CQUIN Annex April 2018

menu

1. Context

2. Opportunity

3. Balance

4. Measurement

5. Resources

6. Future

The common pathway

Life

Infection

Any Cause

DETERIORATION Organ Failure Death

Sepsis doesn’t kill, deterioration does

Before every death, there is a worsening in physiology- A Deterioration

Time

The slippery slope of deterioration

‘badness’

Communication in Deterioration is

the #1 Avoidable cause of death

NEWS2 would improve nearly all the common root

causes

Thematic analysis of Safety Incidents Donaldson et al 2010

Mismanaged Deterioration 35%Failure to Prevent 26%Deficient Checking/oversight 11%

Systems Learning from Failure

@mattinadakim

The next great advance in healthcare will not be a cure, but a change in the way we work as a system

Vital signs recorded GP % completion

Temperature 26.4

Blood pressure 24.8

Heart Rate 31.0

Respiratory Rate 6.2

AVPU 6.2

Physiology predicts deathMrs Jones is…SICK, UNWELL, PEAKY, CRITICAL, DETERIORATING, DEBILITATED, IMPAIRED, ILL, DECLINING, OFF LEGSIN A BAD WAY, SICK AS A DOG, RUN DOWN, MORIBUND

pathway communication reliability

Hypothesis- A standardised, reliable system will save lives and money

A single language of sickness across healthcare

pathway communication reliability

Situation:

Background:

Assessment:

What’s the Problem/Urgency?

Mrs X is sick with a NEWS of 7

Recommendation: Clinical Judgement

Collective intelligence across the NHS to guide Priority, Planning, Preparation, Placement

NEWS2 & Sepsis Changes

NEWS of 5 > Single parameter 3

Hypercapnic hypoxia subchart New Confusion/Delirium

Single component 3 scores have significantly lower risk (OR 0.26) than an aggregate value of 5 (OR 1.0).

The Deadline for those seeking to achieve the sepsis CQUIN is Dec. 18, the mandate for all acute trusts is by March 2019

Use Scale 2 when there is confirmed previous/current hypercapnic respiratory failureUse Scale 1 in all other cases

C is New Confusion or confusion that is worse than the patient’s baseline.It also represents altered mental state with a Glasgow coma scale <15

NHS England & RCP Sepsis definition

Suspected Sepsis = NEWS 5 + Clinical Judgement

• the same system for “describing” the level of sickness in any healthcare system must be usable, utilised and communicated across all settings

• NEWS is at the heart of the national operational pathway for deterioration & sepsis

• Paving the way for a potential combined all cause deterioration pathway

DeteriorationTrauma

Vascular

SEPSIS

Could this be sepsis in every deterioration?But not all deterioration is due to sepsis

Spot Deterioration, Consider Sepsis

Inada-Kim & Nsutebu BMJ March 30th 2018

Reduce

Avoidable

Deaths

RECOGNITION

STANDARDISE TO NEWS2

Establish/Support NEWS2 Champions

Reliable Monitoring

ACTIVATIONReliable Escalation

Reliable Communication

ESCALATION Reliable Appropriateness

MEASUREMENT Processes & Outcomes

LEARNING

Ensure competence of healthcare professionals taking observations and responding

Regular reflection of deterioration episodes

Deterioration Driver Diagram

Time

Patient Safety Alert April 26th

Aligned National Bodies can do great things

menu

1. Context

2. Opportunity

3. Balance

4. Measurement

5. Resources

6. Future

Balanced Sepsis improvement

Understand that sepsis delays are rarely the fault of an individual but commonly due to system failures and that 70% of Sepsis arises in the community

Optimise systems in your area & across the pathway

Learning vs Blame

Communication is the #1 cause of harm in healthcare, standardise the language and the pathway

Consider Sepsis in all deteriorations, but remember that all deteriorations are not due to sepsis

Don’t be blinkered

A system with reflex antibiotics administration for anyone with a temperature needs to be guarded against.

Support Antibiotic stewardship, early senior review and Clinical Judgement

Practice Engaged, Supportive & Just leadership.

Celebrate successes, Learn from failure

Sepsis Leadership in Acute Care

Antimicrobial Stewardship

AimsInappropriate Antibiotic prescribing Gram Negative Bloodstream InfectionStart Smart then Focus

General Public Clinicians

Micro / IPC Pharmacists

CollaborationAPPROPRIATE use

EARLY cessation

NARROW spectrum

O’Neill reports estimate 10 million deaths worldwide each year due to AMR in 2050

The importance of Systems in Blood cultures & Getting Antibiotic choices right

They Should not be left on the side of the counter…

Admission Processing 60 min < 72 hours 10 days

This can only be improved with a

systems approach

Blood cultures save lives

Aseptic technique2 bottles not 120 ml of blood not 2ml

Specimen reception

Urgent Blood Culture incubation

Microbiology

Flag Positive- ID of organism and sensitivities

Septic patient journey

Best guess Antibiotics Focused Antibiotics

The quicker a blood culture reaches the lab (incubation), the sooner a bacteria can be identified

so the correct antibiotic can be prescribedFor a septic patient, minutes count

There is huge national variation in how soon & reliably this happensHow does your trust compare?

menu

1. Context

2. Opportunity

3. Balance

4. Measurement

5. Resources

6. Future

CQUIN process improvement

Admission or Ward

DeteriorationNEWS 5

SCREEN(Clinical Judgement)

TREATMENTANTIBIOTIC

REVIEW

Time zero 60 minutes 72 hours

CQUIN Annex April 2018

00:00:00

02:24:00

04:48:00

07:12:00

09:36:00

12:00:00

14:24:00

1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 53 55 57

Admission to prescription time Prescription to Administration time

Admission to Administration time

60%

72%

79%

82%83%

85% 86%87%

90%91% 92%

66%

73% 74% 73%

81%83%

85%86%

40%

50%

60%

70%

80%

90%

100%

2015/16 Q12015/16 Q2 2015/16 Q3 2015/16 Q4 2016/17 Q1 2016/17 Q2 2016/17 Q3 2016/17 Q42017/18 Q1 2017/18 Q2 2017/18 Q3 2017/18 Q4

% o

f p

atie

nts

scr

een

ed

fo

r se

psi

s

Emergency Screening % Inpatient Screening %

SEPSIS SCREENING

Proportion of appropriate patients, screened for sepsis

51%

59%

64%

55%

62% 63%64%

76%

78% 77% 78%

59%

66%

70%

73%

76%

81% 80% 80%

40%

45%

50%

55%

60%

65%

70%

75%

80%

85%

2015/16 Q1 2015/16 Q2 2015/16 Q3 2015/16 Q4 2016/17 Q1 2016/17 Q2 2016/17 Q3 2016/17 Q4 2017/18 Q1 2017/18 Q2 2017/18 Q3 2017/18 Q4

% o

f p

atie

nts

scr

een

ed

fo

r se

psi

s

Emergency Antibiotics % Inpatient Antibiotics %

Proportion of appropriate patients given ANTIBIOTICS < 60 min of admission or inpatient deterioration

SEPSIS TREATMENT

Definition change

Identifying ‘sepsis’ from ICD10 codes is not the answer

Increased Awareness/Coding & Definitions has led to swings in ‘N'

Causing Media reporting Chaos

the size of the infection bubble is the only relative

constant

JL Vincent

We need a proxy measureIt must be reproducible and less

subject to variation and time

It must be easy to get, from administrative data

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

35.00%

40.00%

0

20000

40000

60000

80000

100000

120000

140000

160000

180000

200000

0910 1011 1112 1213 1314 1415 1516 1617 1718

English A41 'sepsis code' admissions, deaths and mortality 2009-18

A41 admissions A41 Deaths A41 mortality

https://twitter.com/mattinadakim/status/1025365554742403072

@mattinadakim

Measuring sepsis…lessons from mental health

FlawedNo gold standard test

legion presentations

Unreliable documentation

UncertainCoding change April 2017

Variable & dynamic sepsis definition Interpretation and operationalisation

Internationally & Chronologically corrupt

ProximateIn the face of this, a proxy is the only thing we can credibly measure

(vast There were allegedly 250,000 cases last year)

Birth of suspicion of sepsis (SOS)

All patients who die or are discharged are given an ICD 10 discharge code

Look at all ICD 10 codes- Find all codes that relate to bacterial infection

Clinically validate - Send them to clinicians from each affected specialty

Apply SOS to Oxford’s population

Apply this to all regions and acute trusts in England

Apply this over the last 7 years

With thanks to P.Meredith, P.Schmidt, G.Smith, D.Prytherch, E.Nsutebu, P.Martin

ValidationLiverpool- 93.3% of 1040 Sepsis patients identified by CQUIN had SOSPortsmouth- 86.6% of 500 patients with positive E.coli and S.aureusbacteraemia had SOS5 site study underway

Community Hospital

Infection Suspicion of Sepsis(SOS)

Severity of condition or ‘Badness’

Sepsis is Infection with Badness - “measuring Badness”

SuspectedSepsis

SEPSIS

Wicked ProblemSepsis has no gold standard test or standard definition

Leading to variable reported numbers, mortality

Solution- a Credible ProxyThe only reproducible measure are

emergency admissions with infection

Those patients admitted as emergencies to hospitals with bacterial infection that can cause sepsis.

Sepsis can only be suspected at initial assessment. SOS with evidence of

physiological compromise (NEWS 5) and/or clinical concern.

only confirmed once investigation results and response to treatment

processed and other diagnoses have been excluded.

Nationally, SOS is the most common reason for admission & Death, and is growing

Proportion of Total Deaths 2017-18

Non SOS Deaths

Proportion of Total Admissions 2017-18

1.9 million SOS admissions in England/year (38% of total)SOS occupies 75% of NHS Beds

There are 120,000 SOS Deaths in England/yearadmission reason in 2/3rd of deaths

0

200,000

400,000

600,000

800,000

1,000,000

1,200,000

1,400,000

1,600,000

1,800,000

2,000,000

2011-12 2012-13 2013-14 2014-15 2015-16 2016-17 2017-18

English SOS Admissions 2011-2018

0 - 4 5 - 49 50 - 59 60 - 69 70 - 79 80+

2011-12 2012-13 2013-14 2014-15 2015-16 2016-17 2017-18

0 - 4 0.107% 0.095% 0.088% 0.091% 0.080% 0.071% 0.063%

0.000%

0.020%

0.040%

0.060%

0.080%

0.100%

0.120%

SOS

mo

rtal

ity

Age 0 - 4 SOS mortality England

2011-12 2012-13 2013-14 2014-15 2015-16 2016-17 2017-18

5 - 49 0.651% 0.600% 0.579% 0.578% 0.600% 0.570% 0.567%

0.520%

0.540%

0.560%

0.580%

0.600%

0.620%

0.640%

0.660%

SOS

mo

rtal

ity

Age 5 - 49 SOS mortality England

2011-12 2012-13 2013-14 2014-15 2015-16 2016-17 2017-18

50 - 59 3.353% 3.254% 3.114% 3.096% 3.046% 2.799% 2.920%

2.500%

2.600%

2.700%

2.800%

2.900%

3.000%

3.100%

3.200%

3.300%

3.400%

SOS

mo

rtal

ity

Age 50 - 59 SOS mortality England

2011-12 2012-13 2013-14 2014-15 2015-16 2016-17 2017-18

60 - 69 6.347% 6.316% 6.074% 5.918% 5.701% 5.613% 5.511%

5.000%

5.200%

5.400%

5.600%

5.800%

6.000%

6.200%

6.400%

6.600%

SOS

mo

rtal

ity

Age 60 - 69 SOS mortality England

2011-12 2012-13 2013-14 2014-15 2015-16 2016-17 2017-18

70 - 79 10.411% 10.260% 9.479% 9.306% 8.898% 8.678% 8.573%

0.000%

2.000%

4.000%

6.000%

8.000%

10.000%

12.000%

SOS

mo

rtal

ity

Age 70 - 79 SOS mortality England

2011-12 2012-13 2013-14 2014-15 2015-16 2016-17 2017-18

80+ 17.515% 17.137% 15.866% 15.940% 15.181% 14.838% 14.754%

13.000%

13.500%

14.000%

14.500%

15.000%

15.500%

16.000%

16.500%

17.000%

17.500%

18.000%

SOs

mo

rtal

ity

Age 80+ SOS mortality England

so how are we doing across different ages?

What if we could do this for every organisation, region, country, postcode?

And measures this over time?

But has the CQUIN made a difference to SOS outcomes?

NEWS implementation across an entire Region (WEAHSN)

STANDARDISE all Acutes to NEWSSWAmbulance NEWS EPR TOOLThe ED Safety CHECKLIST

calculation of NEWSRegional Sepsis MasterclassesImplement COMMUNITY NEWS

u

v

w

x y

w

u

v

x

y

SOS dashboard• Product of partnership• Number of admissions• Survival• Bed days• Length of stay (LoS) by

• Trust• PSC/AHSN/STP Region• Disease categories

• Available from end of July• ‘Soft’ Launch/Trial sites• National Launch in SeptemberAccessible from https://imperialcollegehealthpartne

rs.com/http://psmu.improvement.nhs.uk/

menu

1. Context

2. Opportunity

3. Balance

4. Measurement

5. Resources

6. Future

• Document shows a fictional patient’s journey through

a Suboptimal VS Optimal sepsis pathway

• The two stories are compared, showing variation in

terms of patient outcomes, quality of care and costs

to the system

• Developed in partnership with NHS England’s cross-

system sepsis programme board

• Co-authored with expert clinicians, analysts and the

RightCare team

NHS RightCare sepsis scenario

39Published in June 2018

Robert is a 72 year old man who has recently undergone gallbladder surgery

Post-op complications lead to sepsis, but in the suboptimal scenario it is not immediately suspected or recognised

Improved awareness, consistent cross-system language and the use of NEWS2 in the optimal story lead to less time in hospital and better outcomes

Role of Biomarkers

In both scenarios Rob ‘recovers’ but the differences for him, his family and the health economy are clear

Our patient: Robert

40

The document also includes:

• Information about NEWS2

• A summary of CQUIN data

• Julie’s story

• Links to supporting

• clinical guidelines,

• policy documents and resources

• Financial analysis of both patient journeys

Additional information

41

How the scenario will be used

• NHS RightCare has a team of Delivery Partners

• Each is aligned to named CCGs, STPs and regional teams

• Delivery Partners support and facilitate local improvement programmes

• The scenario is also being shared through sepsis networks and PSCs

• Feedback about its use will inform the development of future work

• The sepsis scenario can be found

on the RightCare website

• Summary slide packs are available

to help present the story at meetings

• Other scenarios and RightCare resources are also

on the website

• For more information you can:

• Visit www.england.nhs.uk/rightcare

• Email rightcare@nhs.net

• Tweet @nhsrightcare

Further support and information

43

HEE/ e-Learning for Healthcare (eLfH)

Sepsis programme siteHospitals, Primary Care, Paediatrics

THINK SEPSIS eLearning for Healthcare (eLfH)

http://www.e-lfh.org.uk/programmes/sepsis

Antimicrobial resistance A training resources guide

@NHS_HealthEdEng #sepsis #AMR

A learning resource in sepsis, incorporating AMR & IPC for Execs, NEDs and managementLed by Sir Stephen Moss – HEE Non-Executive Director, Dr Matt Inada Kim, Clinical Sepsis Lead, NHS England

Sepsis Leadership in Acute Care

@NHS_HealthEdEng #sepsis

Understand that sepsis delays are rarely the fault of an individual but commonly due to system failures and that 70% of Sepsis arises in the communityOptimise systems in your area & across the pathway

Systems Learning vs Individual Blame

Communication is the #1 cause of harm in healthcare, standardise to NEWS2

Consider Sepsis in all deteriorations, but remember that all deteriorations are not due to sepsis

A system with reflex antibiotics administration for anyone with a temperature needs to be guarded against. Support Antibiotic stewardship, early senior review and Clinical Judgement

Practice Engaged, Supportive & Just leadership. Celebrate successes, Admit and apologise for failures- Learn & Improve from them

menu

1. Context

2. Opportunity

3. Balance

4. Measurement

5. Resources

6. Future

DETerioration Sepsis Escalation Planning

Deterioration

Trauma

VascularInfection FrailtySepsis

Infection symptoms *

Fever, ConfusionRTI= Cough, Shortness of breath

UTI= Frequency, dysuria, loin painCellulitis= Red tender skin

Ulcer= New redness or dischargeAbdominal pain, diarrhoea, vomiting

Deterioration symptoms *

Limb pain, swelling, bleedingfaint/dizzy

Weakness, sensory lossconstipation

chest pain, palpitations

Pan pathway acute deterioration

1 week before

2 days before Time zero

*Hard (Medical) signs

Emergency Admission

Severe symptomsFall

ConfusionInability to Cope

?

Potential Admission Avoidance points

High RiskInfection symptoms *

Fever, ConfusionRTI= Cough, Shortness of breath

UTI= Frequency, dysuria, loin painCellulitis= Red tender skin

Ulcer= New redness or dischargeAbdominal pain, diarrhoea, vomiting

FUNCTION

BEHAVIOUR

CONCERN

Soft Signs

DETERIORATION

Deterioration symptoms *

Limb pain, swelling, bleedingfaint/dizzy

Weakness, sensory lossconstipation

chest pain, palpitations

‘Soft Signs’ of acute deterioration

1 week before

2 days before Time zero

Medium Risk

Low Risk

*Hard (Medical) signs

Emergency Admission

Urgent Assessment

1. DNAR2. Do not admit3. Do not treat (IV/PO)4. Do not artificially

feed/hydrate/ventilate

Severe symptomsFall

ConfusionInability to Cope

evolved pathways from learning

Rapid progressionPain/Ill out of proportion

Sense of Impending DoomRepeated attendances

Can’t Walk / StandCan’t PeeConfusion

Off Baseline

CLINICALJUDGEMENTThekeyirreplaceablewebringasclinicians

augmentedwithevidencearoundphysiologymakesitevenmorepredictive

PHYSIOLOGYMattInada-Kim,AcutePhysician&SepsisLead,HampshireHospitals

ClinicalLeadDeterioration&Sepsis,WessexPSCNationalClinicalAdvisorSepsisNHSEngland

NationalClinicalAdvisorDeteriorationNHSImprovement

Consider Sepsis High Risk Factors

Age ≥ 75 <1 PeripartumImmunosuppressed / ChemoIVDU, Surgery/trauma <6/52,

Indwelling line/catheter /broken skinPrev. sepsis, current antibiotics

Function ↓ Behaviour ↕Concern ↑

Soft signs Worrying features Red Flags

NEWS

5Clinical

Judgement

Worrying features

Red Flags

Suspected Sepsis

Recognise Soft Signs

Take observations

Calculate NEWS

Escalate using Escalation

Tool

Communicate using SBARD

Recognise Soft Signs

Take Observations

Get the right help early

Get your message across

Calculate NEWS2

LOCAL NEWS implementation across the pathway

Hospital

Please indicate the baseline NEWS on all summaries. This is particularly useful for GPs when deciding if their patients have deteriorated and for us if the patient returns. The documentation of chronic hypoxia, its baseline level and risk of CO2 narcosis is similarly useful.

Community -to prioritise, plan, prepare and place appropriatelyWhen making emergency referrals, we require the NEWS in order to risk assess, place and guide urgency.

If we have one language, standardised protocols develop

Nursing home NEWS GP NEWS referral in use

“The tool gives me the confidence to speak to

others about my concerns”

ReferralNEWS

Ambulance Disposition Area Mortality/ICU(est.)

0-2 AMU Clinic Chairs 0.5-2%

3-4 AMU Trolley 8%

5-6 60min ED

AMU

Majors

High Care

23%

7 + Blue LightPre Alert

ED Resus 30%

NEWS to triage Hospital location

**Consider Sepsis High Risk Factors

Age ≥ 75 <1 PeripartumImmunosuppressed / ChemoIVDU, Surgery/trauma <6/52,

Indwelling line/catheter /broken skinPrev. sepsis, current antibiotics

NEWS 0-2 NEWS 3-4 NEWS ≥ 5 or +3 from baseline

Wessex All Cause Deterioration (including Sepsis) Guidance

For Adult ( 16) non-pregnant patients in Hospital settings (Acute and Community)

SENIOR REVIEWPts should be reviewed urgently if non-responsive to treatment within 1 hr

Follow organisational

NEWS or Condition specific protocol

YES

NO

Urgent Clinical Assessment

Apply Clinical Judgement

• Commence appropriate Treatment

• Follow organisational NEWS protocol

• Closely monitor patient

Is Sepsis Suspected?

Apply Clinical Judgement

No Yes**

Very Urgent Clinical Assessment

NEWS ≥ 7

Hourly obs2-4 hourly obs6-12 hourly obs 30 minute obs

WorryABCDE

Do Physiological observations

Any concerning clinical features?

• New Confusion

• Worry (Dr/Nurse/Pt/Carer)• Significant Pain• Single NEWS parameter of 3 • Mottled / ashen skin / cyanosis / new rash

• Inadequate urine output*• Lactate 2+• Cap Refill ≥ 3 sec

NHS England, NICE & NEWS2 compliantFor use in all healthcare settings

SEPSISSerious Bacterial InfectionSOSInfection

Gp A streptococcal soft tissue infection and has a spectrum of severity

Skin infection Mild Cellulitis Severe Cellulitis Necrotising Fasciitis

NEWS 0-1 1-4 5-6 ≥ 7

Blood Culture/CRP/WBC +/- +/- +/- +/-

Mortality 0.5% 8% 12% 25%

The continuum of Badness in Group A Strep - NEWS, Biomarkers & mortality

PCT - + ++ +++

ProADM - - + +++

A ‘Sepsis Test’ encompassing Clinical Judgement + Risk Factors + NEWS + Biomarkers

Apps, E Obs & Machine Learning

Great progress so far…

Wicked problems have pragmatic solutions

Spot the sick patient, consider sepsis

Collaboration & compromise is critical

-what can you do in your area, region?-what are your takeaways?

Always measure & Understand the data

Evolving from Blame to Learning

(… we are winning)

In summary

SEPSIS

Balance & Evidence

Measurement

Process & Outcome

Collaboration & Alignment

Mandate & Learning Innovation

& ResearchDeterioration

Trauma

Vascular

SOS

Frailty

Sepsis