Sepsis noted as leading cause for SAC 1 incidents and RCAs in NSW
A process for early recognition, review and resuscitation of septic patients
Timely early interventions – antibiotics and intravenous fluids
The Challenge
RECOGNISE - risk factors, signs and symptoms of sepsis
RESUSCITATE with rapid intravenous fluids and antibiotics within the first hour of recognition of sepsis
REFER to senior clinicians and specialty teams, including retrieval as required
Program focus
Initiate sepsis pathway based on suspected infection + 2 SIRS criteria
Up-triaging to ATS category 2 Sepsis bomb
RECOGNISE
Oxygen Blood cultures Lactate Intravenous fluids – 20ml/kg crystalloid
bolus Antibiotics <60 minutes
◦ Based on clinician predicted source◦ Antibiotic stewardship program and guidelines
Monitoring
RESUSCITATE – SEPSIS SIX
Early senior review and assessment Early referral to intensive care services Inpatient sepsis management pathway
being launched soon 24-48 hr sepsis management tool in
pipeline
REFER
CEC sepsis kills achievements
• Improvement in time to antibiotics to 60 minutes in last three years
• >18000 patients registered on CEC sepsis archive• Crude patient level data available on archive – time to
antibiotics , lactate level, SIRS data
Retrospective evaluation of prospectively identified patients presenting to ED with sepsis
Multicentre approval◦ Westmead ◦ Concord ◦ RPA
Single centre data collection and analysis
The SMEDSA initiative
850 bed tertiary hospital 45 treatment space Emergency department >65000 annual census ED presentations 35-40% ED to ward admission rates
Westmead hospital
Sepsis kills pathway ATS category 2 for suspected infection + 2
SIRS criteria Clinicians encouraged to report Sepsis pathway antibiotic guidelines Antibiotic stewardship guidance Patient safety officer and audits
Interventions
~1200 patients recorded at Westmead in past 24 months
Interim analysis at 590 patients Median age of patients = 59.5 (IQR 36-75) Females = 306 median age 54.5 (IQR 32-
76) Males = 284 median age 63 (IQR 46-75)
Demographics
Antibiotics ceased or not given in 48 hours – non bacterial etiology, DNR
Exclusions (no antibiotics 9 + antibiotics ceased <48 hours 76) 85
Median age of female (44 exclusions) = 33 (IQR27.5-43.5)
Median age for males (41 exclusions) = 49 (IQR 26-68)
Mann-Whitney U test comparing Age in inclusions versus exclusions Median difference = -17 (CI: -24 to -11) (p<0.001)
Exclusions
Total number of inclusions = 505 Median age of patients = 63 (IQR 42-78) Females = 262 median age 59.5 (IQR 35-
78) Males = 243 median age 64 (IQR 50-77)
Inclusions
507/ 590 patients triaged to ATS category 2 85.9% adherence to guideline Median time to clinician 36 mins (IQR 16-73)ATS<2 versus >2 Time to clinician– 35 versus 84 minutes
(p<0.001) Time to antibiotics – 66.5 versus 129
minutes (p<0.001) Time to 2nd L fluids – 99.5 versus 228
minutes
Triage guideline
492/590 (83.4% 95%CI 80.2-86.2) underwent lactate testing
Exclusions vs inclusions – median 1.4 v 1.8 (p<0.01)
Sepsis versus severe sepsis/ septic shock – median 1.5 v 2.2 (p<0.01)
Dead versus alive – 2.8 v 1.7 (p<0.001) But significant overlap of tails
Lactate testing
484/505 patients had blood cultures collected
95.8% adherence (95% CI 93.7-97.3) 94 /484 (19.4%) positive BC, 13/94 (13.8%
contamination rates) → 81/ 484 (16.7% 95%CI 13.7-20.3) significant results
26.5% BC + for severe sepsis group versus 13.4% BC + in plain sepsis group
Blood culture testing
329/505 Urine cultures – 62/329 positive results
193/ 505 other cultures – 100/193 positive results
Other cultures
297/ 505 (58.8%) received appropriate antibiotics according to guidelines
192 / 505 (38.0%) received at least one antibiotic as per guidelines
16 / 505 (3.2%) received antibiotics not according to guidelines
Antibiotic guidance and stewardship
Severe sepsis definition = sepsis-induced tissue hypoperfusion or organ dysfunction (any of the following thought to be due to the infection) Sepsis-induced hypotension Lactate above upper limits laboratory normal (>2) Urine output < 0.5 mL/kg/hr for more than 2 hrs despite
adequate fluid resuscitation Acute lung injury with Pao2/Fio2 < 250 in the absence of
pneumonia as infection source Acute lung injury with Pao2/Fio2 < 200 in the presence of
pneumonia as infection source Creatinine > 2.0 mg/dL (176.8 μmol/L) Bilirubin > 2 mg/dL (34.2 μmol/L) Platelet count < 100,000 μL Coagulopathy (international normalized ratio > 1.5)
Severe sepsis criteria (SSC 2012)
Age – 58 (IQR 38-75) versus 67 (49-80) Lactate value → 1.5 (1.1-2.2) v 2.2 (1.4-3.8) Total MEDS score → 5 (3-9) v 8 (6-12) Charlson score → 3 (0-7) v 5 (2-9) Hospital LOS → 4 (2-8.5) v 7 (3-13)
Plain sepsis versus Severe Sepsis
Time to antibiotics →69 minutes (IQR 42-126.5) in patients with plain sepsis versus 67 minutes (IQRR 49-80) in patients with severe sepsis or septic shock
Time to second litre fluids → 196 minutes (107.5-403.5) v 249 minutes (136-489)
Time to antibiotics / IV fluids
no sepsis
severe sepsis/ septic shock
Plain sepsis
SIRS 0 17 6 14 37
SIRS 1 14 28 55 97
SIRS 2 28 46 116 190
SIRS 3 18 57 78 153
SIRS 4 6 42 34 82
SIRS 5 2 16 8 26
SIRS 6 0 5 0 5
total 85 200 305 590
SIRS characterisation
Sensitivity 0.80 95%CI 0.76- 0.83 Specificity 0.36 95%CI 0.27- 0.48 Positive predictive value = 0.88 Negative predictive value = 0.25 Patients with severe sepsis more likely to
have >3 SIRS criteria (p<0.001)
SIRS >2 criteria
AMBULANCE vs PRIVATE transport 274 vs 231 (Mann-Whitney)◦ Median age 74 versus 48 (MD 23 p<0.01)◦ >SIRS 3 vs 2 (MD 1 p<0.01)◦ Higher lactate 2.2 vs 1.5 (MD 0.6 p<0.01)◦ Severe sepsis rates 132/274 (48.2% 95% CI 42.3-
54.1) versus 68/231 (29.4% 95% CI 23.9-35.6) (p<0.01)
◦ MEDS score 9 vs 3 (MD 5 p<0.01)◦ Mortality (51/231 22.1% 95%CI 17.2-27.9%)
versus (6/231 2.6% 95% CI 1.2-5.5%)
Mode of arrival statistics
478/ 505 (94.7%) concurrence of clinician prediction of presumed source of diagnosis when compared to final discharge diagnosis
Clinician predicted source vs final diagnosis
Final diagnosesSource Number
Chest/ respiratory 219
Urine 84
Skin/ soft tissue/ Orthopedic 44
Abdominal / biliary 41
PUO/ unknown 51
Neuro/ CNS 6
Bloodstream 10
Oral/ Dental 22
Mixed / others 28
Total 505
Mortality rates – in-hospital, 30-day or 90-day
Hospital LOS Discharge location Occurrence of severe sepsis or septic shock
Outcome measures
Time to antibiotic
Total patients
Plain sepsis
Severe sepsis and septic shock
Mortality
≤ 1 hour 224 127 97 X
>1 to ≤ 2 hours
134 95 39 x
> 2 to ≤ 3 hours
57 33 24 x
> 3 hours 86 47 39 x
Total 501 302 199 x
Time to antibiotic analysis
Time to second litre fluids
Total patients
Plain sepsis
Severe sepsis and septic shock
In-hospital mortality
≤ 1 hour 35 13 22 X
>1 to ≤ 2 hours
65 35 30 X
>2 to ≤ 3 hours
76 46 30 X
>3 hours 279 177 102 X
Total 455 271 184 x
Time to intravenous fluid analysis
More clinical trials needed on sepsis patients not just focus on severe sepsis and septic shock – ED from ICU shopfront
Overall benefit of bundles care – risk versus benefit
? RCT on antibiotics after source identification versus clinician prediction based – stratified risk tool development
Risk factors for progression to severe sepsis
Future focus