First Phase: Definition of Criteria and Standards

The SEPSIS PROJECT IN THE EMERGENGY FLOOR

Time is life in sepsis. Are scores and numbers all we worry about?

First phase: definition of criteria and standards.

The problem

Sepsis is known to carry a high mortality, however, if identified early, can be very treatable. Mortality is reduced by prompt delivery of the ‘sepsis six’ bundle, which includes oxygen administration, fluid resuscitation, blood cultures, serial lactate measurements, hourly urine output monitoring and intravenous antibiotic administration within 1 hour of the patient’s arrival. In those with severe sepsis and septic shock, mortality is known to increase by 7.6% for every 1 hour delay in antibiotic administration.

In 2013-2014 the Royal College of Emergency Medicine performed a national audit of the management of severe sepsis and septic shock. The audit report highlighted that although across trusts, a median of 94% of patients with severe sepsis and septic shock received antibiotics in the ED, only a median of 32% of patients received antibiotics within 1 hour. Despite our Trust appeared to be within the few EDs managing to meet the target of delivering antibiotics within 1 hour (63%, RCEM target 50%), we felt we needed to improve according to new data that antibiotics should be delivered within 1 hour to patient with severe sepsis.

The Audit also highlighted the need to improve the early detection of sepsis in the ED and the need to document vital signs for all patients with sepsis. Other room for improvement was related to the measurement of lactates ( 48% of patients had lactate measured within 1 hour), urinary output measurement (48% of patients had this measured before leaving our ED),Oxygen delivery (81% before leaving ED but only 33% of patients received O2 within 1 hour).

RCEM STANDARDS:

1) Temperature, pulse rate, respiratory rate, blood pressure, mental status (AVPU or GCS) and capillary

blood glucose on arrival.

2) Senior EM assessment of patient within 60mins of arrival.

3) High flow O2 via non-rebreathemask was initiated (unless there is a documented reason to the contrary) before leaving the ED.

4) Serum lactatemeasured before leaving the ED.

5) Blood cultures obtained before leaving the ED.

6) Fluids - first intravenous crystalloid fluid bolus (up to 20mls/kg given: 75% within 1 hour of arrival; 100% before leaving the ED.

7) Antibiotics administered:50% within 1 hour of arrival; 100% before leaving the ED.

8) Urine output measurements instituted before leaving the ED.

The RCEM Audit (2013/14) showed that in our ED (data collection):

The treatment of severe sepsis and septic shock in the ED with antibiotics shows a favourable upward trend across the board. Antibiotics given in the ED is at a median of 94% and within the first hour of attendance has increased from 27% to 32% and from 13% to 62% in our ED.

• Vital signs: recorded <15 min 38%. Fully 71% fully/partially 95%.
• BM yes < 15 min 38%; at any time 76%.
• Oxygen initiated in ED: Before leaving 81%; < 1 hour 33%.
• Arterial Lactate: at any time 90%; < 1 hour 48%.
• Blood cultures: < 1 hour 24%; < 2hours 24%; at any time 38%.
• IV fluids bolus < 2hours 76%; < 1 hour 67%; before leaving 86%.
• Antibiotic before leaving ED 100%. < 1 hour 62%.
• urinary output before leaving 48%.

Assessment of performance against standards

Our performance was assessed against the RCEM standards and CQUIN targets, hence an action plan based on a better recording of Vital signs, using of lactate and lactate clearance as a prognostic factor in severe sepsis and Antibiotic administration within 60 minutes from arrival above 90% in patients with severe sepsis was agreed by the team

Identification of changes/actionplan:

We noticed that the use of the trust pathway, which has been giving positive results for sepsis in patients admitted to the wards, failed to identify all patients in the EF setting with severe sepsis and led to an overtreatment of patients with uncomplicated sepsis, due to the particular characteristics of patients presenting to the ED, compared to inpatients. This prompted the team to create an EF specific sepsis screening tool which included the use of clinical acumen and clear risk stratification criteria for identifying patients with severe sepsis.

Strategy for change

In May 2015, a sepsis screening tool was created which included the use of clinical acumen alongside the EWS and SIRS scores, an assessment of the likely source infection, and a risk stratification using the red flag features immediately available in the EF. Doctors were encouraged to quickly seek senior advice if criteria for sepsis were met but the diagnosis remained unclear.

The screening tool was introduced in June 2015, on the front page of EF clerking booklets. Nurses and doctors were required to complete the screening tool for all patients seen in the EF at first assessment and immediately escalate in cases presenting with features of severe sepsis. The completion of the screening tool was included in the Rapid Assessment and Treatment (RAT) project, in order to improve the early detection of acutely unwell patients. Exclusion criteria included patients admitted due to major trauma, those not for active treatment (end of life treatment), minors patients not requiring observations and patients already diagnosed with sepsis.

Formal sepsis teaching sessions were carried out to educate and raise awareness amongst doctors, nurses and other healthcare professionals. The multi-professional team championed the project daily on the shop floor with dedicated teaching and engagement of the nurse and consultant in charge each shift. A dedicated resource was created on the Trust website with monthly data and literature reviews (“SPACE”) and a leaflet was disseminated in the department to assist the medical staff in the use of the tool. Signposting to the sepsis protocol was made available on the drug cupboard to remind staff of the need for prompt treatment in severe sepsis, according to the Trust Microguide antibiotic guidelines. Small flashcards with red flags for severe sepsis identification and “syringe pens” were distributed to the medical staff.

Lessons learnt

The reasons for delays in administering antibiotics were multifactorial, however common themes were identified. Problems included delays in identification of septic patients contributed to by the long wait times in the ED, shortages of nurses to administer the antibiotics and lack of availability of antibiotics in the drug cupboard.

To improve the early identification of patients we found it extremely useful to engage the nurse in charge and to include the sepsis screen in the initial RAT assessment. The creation of a specific logo and the dissemination of the leaflets and posters with the logo helped in reminding people about the project.

We highlighted the need to have more nurses with IV training available in the department and this was promptly addressed by the nursing leads. Presentation of the data as part of an M&M review during the governance meetings also helped in raising the awareness of the project.

Re evaluation

I have been conducting a monthly review and audit of CasCards from September 2015. The Audit showed a positive trend in the use of screening tool (approximately 85% of eligible patients screened for sepsis) and in the administration of Antibiotic within 60 minutes from arrival in patient identified as severe sepsis.

We still need to improve the number of patients with severe sepsis receiving the Antibiotic within 60 minutes from arrival.

A sepsis drop in event took place the 13th January and the nurses and Doctors attending made some valuable suggestions. We are introducing a specific “box” for spsis in the Rapid Assessment proforma currently in use in the Emergency floor.

Review of cases is carried out at governance meetings and face to face.

The CQUIN quarter 4 terminates in March 2016 but the RCEM is re auditing sepsis in 2016, so the project will be continuing.

Dr. Monica Minardi

1. clear guidance, policies and clinical pathways

1. all patients with physiological derangements, elevated mews or clinical suspicion of infection to be screened for severe sepsis/septic shock and have lactate within 30 minutes from arrival

1. clinical pathways to include initiation of all investigations necessary to confirm or exclude organ dysfunction and to include criteria for escalation

1. the sepsis six to be used as a delivery method for early sepsis care and Antibiotics to be delivered within 1 hour from arrival as per CQUIN

1. 24 hours availability of microbiology advice

1. Documented decision made about the presence/absence of sepsis and the level of severity at time of admission to hospital from ED

1. Mandatory annual sepsis training for all clinical members of ED staff.

1. A minimum of 80% of permanent staff to have received appropriate sepsis training at any one time point, audited at least biannualy

1. A nominated Medical and Nursing Lead within the ED

1. Interdisciplinary meetings

1. Regular case reviews to be undertaken with critical care staff

1. Sepsis should be on the organization’s Risk Register, with an identified Board leve person with responsibility for sepsis. The mortality rate from sepsis and pneumonia should be on the monthly quality dashboard.

1. Mandatory prospective data collection and continuous audit

NCEPOD report

The Sepsis Six is a well-known set of 3 investigations and

3 initial therapies, none of which are remotely surprising:

start the patient on high flow oxygen and take blood for

culture before treatment starts: put up intravenous fluids

and give intravenous antimicrobials and later change them

if the cultures suggest they are wrong; measure the lactate,

do a full blood count, and monitor the urine output. None

of these first line interventions are beyond the competence

of juniors or the resources of the departments in which

they work. Of course the management of the later onset of

multi organ failure is extraordinarily difficult and will usually

require sub-specialist involvement, as will the management

of culture-negative organisms, but a good outcome for

many appears to depend primarily on recognising the

problem and doing the simple things right and promptly

Given that this is a progressive disease it is not surprising

that the clinicians found it easier to recognise that their

patients were ill when their condition had evolved and the

severity had become more obvious. But that is precisely why

the protocols and pathways are designed to elicit the subtle

gradations that may reveal a downward trend in time to

make the difference between life and death. They are there

to help the inexperienced who understandably find it harder

to recognise the sick patient, but the evidence seems to be

that they are not being used consistently.

It is hard to

escape the conclusion that an appropriate sense of urgency

is lacking in far too many cases.

Early recognition and management of sepsis leads to

reduction in morbidity and mortality23,24 and administration of

an effective antimicrobial within the first hour of hypotension

has been associated with a survival rate of 79.9%.25,26

Handovers

Good communication, safe and efficient handovers are

important factors in improving quality of care. Over 40%

of hospitals reported that they did not have a policy on

handovers

Sepsis response kit

The use of a sepsis response kit, bag or trolley can help deliver

the sepsis early care bundle in the shortest time possible. A

total of 112 hospitals reported that a sepsis response kit, bag

or trolley was being used (Table 2.33). The kits were located

in the ED in 89% of hospitals.

At triage there were 66 patients for whom none of the

listed vital signs were recorded and 150 patients at the

stage of ED senior review, and 37 cases where none of the

listed vital signs were recorded at either assessment. At

triage, 103 sets of case notes had all the listed vital signs

recorded. For 152 cases there were a complete set of vital

siConfusion and delirium can be important indicators of

developing or worsening sepsis and are easier to measure

at the bedside compared to some vital signs that require

an instrument. The common scores in use are ‘AVPU’ or the

Glasgow Coma Scale. Despite their ease, they were recorded

It is known that identifying the source of sepsis and

controlling it is vital in managing sepsis.2 Reviewers noted

that there were 173 cases at triage and 64 at the ED review,

in whom the likely source of infection was not documented

(Table 3.33). In half of the cases not documented at triage

(59/120) and one third of those not documented at the ED

review (17/51) the Reviewers felt that it should have been in only 69.4% of patients gns recorded between the two assessments