sepsis...a major medical emergency dr ron daniels fellow: nhs improvement faculty chair: united...
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Sepsis...a major Medical Emergency
Dr Ron Daniels
Fellow: NHS Improvement Faculty
Chair: United Kingdom SSC, Sepsis Trust & Pre-hospital Working Group
December 2010
Archives of Surgery 2010
What is sepsis?
Merinoff definition 30th September 2010
• Sepsis is a life-threatening condition that arises when the body's response to an infection injures its own tissues and organs.
• Sepsis leads to shock, multiple organ failure and death especially if not recognized early and treated promptly.
• Sepsis remains the primary cause of death from infection despite advances in modern medicine, including vaccines, antibiotics and acute care.
• Millions of people die of sepsis every year worldwide
Lung1 Colon2 Breast3 Sepsis4
cancers
Annual
UK mortality
(2003),
thousands
1,2,3 www.statistics.gov.uk,
4 Intensive Care National Audit Research Centre (2006)
A U.K. Perspective
0
20
30
40
10
© Ron Daniels 2010
Practice guidelines
Revision due 2012
The Sepsis Six
1. Give high-flow oxygen via non-rebreathe bag
2. Take blood cultures and consider source control
3. Give IV antibiotics according to local protocol
4. Start IV fluid resuscitation Hartmann’s or equivalent
5. Check lactate
6. Monitor hourly urine output consider catheterisation
within one hour
..plus Critical Care support to complete EGDT© Ron Daniels 2010
Running Average Survival in Septic ShockBased on Antibiotic Delay (n=4195)
AbRx Delay (hrs)0 20 40 60 80 100
frac
tion
0.0
0.2
0.4
0.6
0.8
1.0
running average survivalcumulative fraction of total survivors
Funk and Kumar
Critical Care Clinics 2011 (in press)
Running average survival in septic shock based on antibiotic delay (n=4195)
Funk and Kumar
Critical Care Clinics 2011 (in press)
Running average survival in septic shock based on antibiotic delay (n=4195)
For each hour’s delay in administering antibiotics in
septic shock, mortality increases by 7.6%
Evidence emerging
Sepsis Nurse Practitioners
Compliance at Good Hope Hospital (%)
0
10
20
30
40
50
60
70
Apr-09 Jun-09 Aug-09 Oct-09
Sepsis 6
Resusc
Both
© Ron Daniels 2008
Compliance and mortality at Good Hope Hospital (%)
0
10
20
30
40
50
60
70
Apr-09 Jun-09 Aug-09 Oct-09
Sepsis 6
Resusc
Both
Mortality
© Ron Daniels 2008
Mortality by Sepsis Six
Cohort size Mortality % RRR
Total 567 34.7
‘Sepsis Six’ : Oxygen therapy
Blood culture
Antibiotic administration
Fluid challenges
Lactate and haemoglobin measurement
Urine output monitoring…. within one hour
Resuscitation Bundle: SSC, within 6 hours following recognition
© Ron Daniels 2010
Mortality by Sepsis Six
Cohort size (%)
Mortality % RRR %
(NNT)
Total 567 (100) 34.7 -
Sepsis Six 220 (38.8) 20.0
Sepsis Six 347 (61.2) 44.0 46.6
(4.16)
© Ron Daniels 2010
Mortality by antibiotics
Cohort size Mortality % RRR %
(NNT)
Total 567 (100%) 34.7 -
Delayed Antibiotics
217 (38.4%) 45.4
Antibiotics within 1 h
350 (61.6%) 28.1 38.1
(5.77)
© Ron Daniels 2010
Mortality by fluid challenges
Cohort size Mortality % RRR %
(NNT)
Total 567 (100%) 34.7 -
No fluids in 1h 183 (32.3%) 44.8
Fluids in 1h 384 (67.7%) 30.0 33.0
(6.73)
© Ron Daniels 2010
PerspectiveSevere Sepsis Acute coronary
syndrome
No. cases per 100,000 per annum 127 200
NNT ‘basic’ care Sepsis Six (our data) 6
First hour antibiotics 5
Clopidogrel 48
β-blockade 42
Aspirin 26
NNT invasive care EGDT (Rivers) 6
Resusc Bundle (SSC) 18
Thrombolysis 15
PCI over thrombolysis 33
For patients receiving the Sepsis Six
2.0 fewer Critical Care bed days
3.4 fewer hospital bed days
Compared with other survivors
Equates to c. £3,000 cost ‘saving’
SSC Results: Critical Care Medicine 2010; 38(2): 1-8
© Ron Daniels 2010
SSC Results: Critical Care Medicine 2010; 38(2): 1-8
© Ron Daniels 2010
Bundle target OR (95% CI)for mortality
p
Antibiotics 0.86 (0.79-0.93) 0.0001
Blood cultures 0.76 (0.70-0.83) 0.0001
National context
National Outcomes Framework
National Outcomes Framework
National Quality Board
A sepsis quality standard
Sepsis
Stroke67,000 deaths per year
FAST Campaign
National Stroke Association
Target: Specialist assessment in 60 min
40% mortality reduction
Myocardial infarction/ ACS89,000 deaths per year
National Infarct Angioplasty Project
Target: Call-to-needle 60 min
Door-to-needle 20 min
Sepsis42,000 deaths per year
...........
Process improvements
K͌
Local context
Know your reliability
Know your processes
Sepsis as a CQUIN measure
Achieving 80% reliability
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
Sepsis is a medical emergency- and our second biggest killer
Awareness and recognition are the key
Reliable, early antibiotics and fluids will save more lives than Critical Care will..... even if CC were infinitely resourced
Summary
Declaration of interests
Within the last 24 months, I have received travel expenses and honoraria to deliver two U.K lectures from Astra Zeneca, manufacturers of the antibiotic
Meropenem. I have also received consultancy fees from CareFusion, manufacturers of the antiseptic preparation ChloraPrep
Thank you