Understanding sepsis

New tools and guidelines

Amanda Pegden Acute Medicine Consultant

Clinical lead for Sepsis and ASK team lead GWH NHS Foundation Trust

Swindon

Overwhelming systemic inflammatory response. Driven by the immune system and inflammatory pathways in response to an infection.

“Sepsis is a life-threatening condition that arises when the body’s response to an infection injures its own tissues and organs.

Infections which can give rise to sepsis are common, and include lung infections (pneumonia), urine infections and wound/skin/joint infections.

Sepsis can lead to shock, multiple organ failure and death, especially if not recognized and treated early” UK sepsis trust

Size of the problem in UK

Wembley stadium capacity 90,000

Why is sepsis a problem?....

Incidence is rising by over 8% each

year

Affects around 30 million in the

world each year

Can affect any speciality, for any

age patient

Kills more than lung cancer….

…more than COPD…..

…more likely to die of sepsis than

heart attack or stroke.

More than 44,000 deaths in the UK

each year …more than

breast, bowel, and prostate cancer,

HIV and AIDS and RTCs combined…

Iwashyna et al: Long-term cognitive impairment & functional disability among survivors of severe sepsis.

JAMA, 2010.

16.8

3.8

6.2

7.1

0 5 10 15 20

Moderate-severe

Mild

Before sepsis After sepsis

Cognitive impairment

The Burden of Sepsis

In the UK sepsis is estimated to cost the NHS £2.5 billion

Daniels R. The incidence, mortality and economic burden of sepsis. (2009) In: NHS Evidence emergency and urgent care.

http://library.nhs.uk/Emergency/

Global, National and Local action • Sepsis recognition and timely treatment- a global issue • “Surviving Sepsis campaign” launched - guidelines 1st published in 2004 & updated in 2012 • Dr. Ron Daniels and UK Sepsis Trust

• UK national CQUINN 2015 • NCEPOD- “Just say sepsis” Nov. 2015 • New NICE guidelines July 2016

The battleground…

CQUIN

SEPSIS

@NCEPOD #sepsis www.ncepod.org.uk

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Study aim and objectives

To identify and explore avoidable and remediable factors in the

process of care for patients with sepsis.

– To examine organisational structures, processes, protocols and care pathways for sepsis recognition and management

– To identify remediable factors in the management of the care of adult patients with sepsis

– Timely identification, escalation and treatment of sepsis: use of systems, EWS, care bundles

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Study population

Adult patients diagnosed with sepsis and

admitted to critical care (HDU/ICU) or reviewed

by CCOT or equivalent during the study period:

6th-20th May 2014

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Exclusions

• Pregnant women up to 6 weeks post partum

• Patients undergoing chemotherapy, organ transplant

• Patients already on end of life care pathway when sepsis diagnosed

• Patients who developed sepsis after 48 hours on ICU

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Returns Returns

14

• First NCEPOD study to look at whole pathway • Primary care • Ambulance service • Emergency Department • In-patient care

Vital Signs and Early Warning Scores

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At least

53% of

patients

had sepsis

prior to

arrival in

hospital

Recommendation

An early warning score, such as the National Early Warning Score (NEWS) should be used in both primary care and secondary care for patients where sepsis is suspected. This will aid the recognition of the severity of sepsis and can be used to prioritise urgency of care.

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37 patients had no vital signs recorded at triage or senior review 152/369 (41%) patients complete set between 2 assessments

Emergency care

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Recommendations

On arrival in the emergency department a full set of vital signs, as stated in the Royal College of Emergency Medicine standards for sepsis and septic shock should be undertaken.

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Delayed review: Emergency care

21

Screening tools to improve diagnosis: Inpatient care

24

Use of screening tools: Inpatient care

26

128/479 (26%) used screening tool/ EWS

Inpatient care

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Delay with care bundle

Delay without care bundle

Delay in escalation 9% 26%

Delay in administration of administration of antimicrobials

18.5% 38%

Fluids delayed/ not received 13% 23%

Oxygen delayed / not received 5% 15%

Investigation of source of infection

10% 28%

Blood cultures not taken 60% 79.5%

Less than good documentation of sepsis

19% 33%

Blood gases not taken 19% 33%

Screening tools reduce delay

28%

36% 35%

55%

30% 31%

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Recommendations

All hospitals should have a formal protocol for the early identification and immediate management of patients with sepsis. The protocol should be easily available to all clinical staff, who should receive training in its use. Compliance with the protocol should be regularly audited. This protocol should be updated in line with changes to national and international guidelines and local antimicrobial policies.

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Recommendations

All patients diagnosed with sepsis should benefit from management on a care bundle as part of their care pathway. The implementation of this bundle should be audited and reported on regularly. Trusts/Health Boards should aim to reach 100% compliance and this should be encouraged by local and national commissioning arrangements.

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17.9% consultant review delayed according to Reviewers

Consultant review: Inpatient care

20.4% > 14 hours

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Changes made following consultant review in 281/457 (61.5%)

Inpatient care

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Recommendations

In line with previous NCEPOD and other national reports’ recommendations on recognising and caring for the acutely deteriorating patients, hospitals should ensure that their staffing and resources enable:

a. All acutely ill patients to be reviewed by a consultant within the recommended national timeframes (14 hrs post adm.)

b. Formal arrangements for handover

c. Access to critical care facilities if escalation is required; and

d. Hospitals with critical care facilities to provide a Critical Care Outreach service (or equivalent) 24/7.

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New definitions

• “Sepsis is defined as life-threatening organ dysfunction caused by a dysregulated host response to infection”

• “Patients with septic shock can be identified with a clinical construct of sepsis with persisting hypotension requiring vasopressors to maintain MAP ≥65 mm Hg and having a serum lactate level >2 mmol/L (18 mg/dL) despite adequate volume resuscitation”

Date of download: 7/17/2016 Copyright © 2016 American Medical

Association. All rights reserved.

From: The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3)

JAMA. 2016;315(8):801-810. doi:10.1001/jama.2016.0287

Sequential [Sepsis-Related] Organ Failure Assessment Scorea

qSOFA, SIRS, and early warning scores for detecting clinical deterioration in infected patients outside the ICU. Churpek MM et al. E-pub ahead of print in Am J Respir Crit Care Med.

“This study also shows that the NEWS score out-performs qSOFA…. Increased utilization of risk-stratification tools such as NEWS could facilitate early recognition of sepsis as well as other critical illnesses (cardiogenic shock, pulmonary embolism, hemorrhage, etc.).”

Burns

Burns

Infection Sepsis Severe Sepsis

Septic shock

Systemic Inflammatory Organ dysfunction Hypoperfusion

Response (SIRS)

<1% 10% 30% 50%

Burns

Burns

Infection Sepsis Septic shock

“badness”

Funk and Kumar

Critical Care Clinics 2011 (in press)

‘For each hour’s delay in

administering antibiotics,

mortality increases by

7.6%’

Septic shock

The Sepsis Six

1. Give oxygen as needed to target SpO2 > 94%

2. Take blood cultures consider source control

3. Give IV antibiotics according to local protocol

4. Start IV fluid resuscitation Hartmann’s or equivalent

5. Check lactate repeat within 2h

6. Monitor urine output consider catheterisation

within one hour

..plus Critical Care support to complete EGDT

In the Community

• Meet with your secondary care sepsis leads to link up local primary and secondary action – particularly a “sepsis community tool”

• Use NEWS and teach NEWS

• Communicate using SBAR when you need to

transfer

• Use the UK sepsis trust site for their toolkits http://sepsistrust.org/

Recognition