Size of Sepsis in Wales on the General Wards: Results of a Feasibility Pilot

Size of sepsis in Wales on the general wards: results of a feasibility pilot

Tamas Szakmany MD, PhD1,2,, Gemma Ellis MSc1,3, Robert M. Lundin1, Ilaria Pignatelli1, Ben Sharif1, Shrivan Joshi1, Danielle Donoghue1, Christopher Hancock4, Paul Morgan MBBCh3, Judith E. Hall MD1 on behalf of the Size of sepsis in Wales Collaborators5

1 Faculty of Medicine, Cardiff University, Cardiff, UK

2 ACT Directorate, Cwm Taf UHB, Llantrisant, UK

3 Critical Care Directorate, Cardiff&Vale UHB, Cardiff, UK

4 Public Health Wales, Cardiff, UK

5 See list of Collaborators in the Acknowledgement

Corresponding author: Dr Tamas Szakmany, Institute of Infection and Immunity, Cardiff University, Heath Park Campus, UHW Tower Block B3, Cardiff, CF14 4XN, UK

e-mail:

The authors disclose no conflict of interest.

Funding source: Dr Tamas Szakmany and Mrs Gemma Ellis were recipients of the National Institute of Social and Health Care Research Allied Health and Social Care Clinical Research Fellowship

Editor - In Wales, epidemiologic information on sepsis is limited.Whilst about 30% of all ICUpatients in the UK have severe sepsis, thereare no data published on the incidence of sepsis on the general wards in Wales or indeed in the rest of the UK.1It has been suggested that delivering six simple interventions, the ‘Sepsis 6’ bundle, within 1 hour of recognition of sepsis may improve outcome on the general ward setting.2 3

We conducted a point prevalence study in four acute hospitals (Cardiff and Vale University Health Board: University Hospital Wales and University Hospital Llandough; Cwm Taff University Health Board: Royal Glamorgan Hospital and Prince Charles Hospital)including a tertiary academic centre and three medium sized district general hospitals serving a population of 735000 people, to evaluate the incidence of sepsis in patients admitted to general wards using the Surviving Sepsis Campaign (SSC) definitions and to establish if the ‘Sepsis 6’ bundle is being delivered reliably to these patients within 1 hour of recognition of the condition.

On the 18/06/2014 from 0800 to 0759 the following day, consecutive adult patients presenting to the emergency department (ED) and hospital wards with sepsis related admission and patients presenting to the ED and hospital wards with acute ongoing sepsis were enrolled. Those with National Early Warning Score(NEWS) ≥3 were further screened for signs of SIRS, sepsis and severe sepsis using the dedicated Sepsis Screening Tool adopted by the 1000 Lives Campaign.4

Cwm Taf institutional review board approved the protocols and waived the need for written consent.Medical students in both Health Boards collected data.

Differences between the study cohorts were assessed using the two-sided Fisher’s exact test and one-way ANOVA.

There were 2716 in-patients in the four hospitals during the study period. 312 patients had NEWS ≥3. 84 patients fulfilled 2 or more SIRS criteria. Out of these 51 (1.89%) had signs of infection, classified as sepsis, and 21 (0.8%) had infection and organ dysfunction fulfilling severe sepsis criteria according to the SSC definitions.5

Demographic data, comorbid conditions, admission source, place of inclusion and 90-day outcome are presented in Table 1.

Table 1.

NEWS ≥3
N=228 / SIRS
N=33 / Sepsis
N=51 / p-value
Age (years) / 70 (59-80) / 75 (64-86) / 71 (59-83) / NS
Sex (M/F) / 108/120 / 9/24 / 32/19 / 0.01
NEWS / 3(3-4) / 4(3-6) / 4 (3-6) / NS
Smoking / 9.2% / 6.1% / 21.6% / NS
Alcohol abuse / 8.8% / 9.1% / 9.8% / NS
Drug abuse / 0.4% / 0.0% / 0.0% / NS
Chronic steroid use / 18.0% / 18.2% / 31.4% / NS
Statins / 33.3% / 33.3% / 33.3% / NS
Diuretics / 27.2% / 30.3% / 29.4% / NS
Insulin / 5.3% / 12.1% / 3.9% / NS
Immunosuppressant drugs / 3.1% / 3.0% / 7.8% / NS
Number of chronic conditions / 1 (0-1) / 1 (0-2) / 1 (0-1) / NS
Admission from home / 74.1% / 66.7% / 80.4% / NS
Patients on ward at study inclusion / 86.2% / 78.8% / 82.4% / NS
Delivery of ‘Sepsis 6’ elements
O2 administered / 0.4% / 3.0% / 35.3%
Fluid bolus delivered / 0.4% / 0.0% / 39.2%
Antibiotics administered / 0.4% / 0.0% / 39.2%
Blood cultures taken / 0.4% / 0.0% / 31.4%
Lactate measured / 0.4% / 0.0% / 25.5%
Fluid balance commenced / 0.0% / 0.0% / 23.5%
All six completed within 1 hour / N/A / N/A / 5.9%
90-day mortality / 18.4% / 30.3% / 35.3% / 0.026

Differences between the groups were evaluated with Fisher’s exact test and ANOVA.

NEWS: National Early Warning Score; SIRS: Systemic Inflammatory Response Syndrome; NS: not significant.

Out of the 51 patients with sepsis,critical care clinicians saw only seven, and two patients were admitted to the ICU. Three patientsreceived the full ‘Sepsis 6’ bundle within 1 hour.Apart from the male/female ratio, all other demographic data was comparable across the groups. Patients with sepsis had significantly higher mortality compared to the other groups.

In our feasibility pilot we have shown that sepsis is present in almost 2% of all hospitalized patients on the general ward. Our data further highlights the need for increased awareness of the condition on the general wards,as simple bundles were not administered, critical care involvement was rare and in our cohort patients with sepsis had more than 35% mortality.

Although our feasibility pilot was limited to four hospitals, our methods proved scalable and reliable for developing a multicenter trial across Wales.Utilizing medical students as data collectors was very successful and reliable in applying the sepsis-screening tool on the wards.

Acknowledgement

The authors would like to thank the Size of Sepsis in Wales collaborators listed below for their assistance during this study. University Hospital Wales: Danielle Donoghue, Toni Saad, NerysMair Jones, Kit Wing Lam, Jane Richardson, Robert Spencer, SitiWardahAbdul Jabar, ShivaliFulchand, Robert DJ Whitham, Jack Gibb, Ruth Shephard, Lisa Grundy, VasileiosGkiousias, Meghan Doherty, Niall Doherty, Catrin Evans, Imogen John, Mohammed Chowdhury, Blanche Lumb, AletheaMeiyan Tang, AmritDhadda, Elizabeth McAleer;Royal Glamorgan Hospital: Ben Sharif, AzelBotes, Matthew Spurr, Catherine Tuke, Louise Channon, Benjamin Morgan, Thomas Lemon, Sarah Davies, Charlotte Mann, Georgina Evans, Francesca Hill, Michael Atkinson, Rebecca Smith, BrenigLlwydGwilym, Naomi Dennehey, Rebecca Parsonson, Stephanie Wai Yee Ng, Kimberly Richardson, Josh Courtney McMullan, Harriet Whewell, Hannah Turley, Kathryn Gillian Szymczak; Prince Charles Hospital: Shivani Joshi, Sally Williams, Grace Carr, Freya Ridley-Davies, Katherine Luke, Alice Cassels-Barker, James Lloyd, James Hassall, Alastair Penty, Roshani Mann, Ashveen Gill, Annabel Lochrane; University Hospital Llandough: Ilaria Pignatelli, Robert Michael Lundin, Andrea Ling, Matthew Williams, Manon Jenkins, Atilla Randle, Myra Naeem, KueniIgbagiri, Rebecca Whatmough, Sarah Jayne Lewis, Nick Hargreaves, Sarah Rollason, Tom Hickin, Ceridwen Jones, SohiniChatterjee, Dong Ying, JurgenaLukani, Jennifer Gough, Christina Rasanayagam, Rachel Iles Dillon, Rhodri Martin, Louise Rogers, Emma Brownlow

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