improving the management of sepsis in general hospital wards
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Improving the management of sepsis in general hospital wards. Dr Charis Marwick CSO Clinical Academic Fellow & SpR Infectious Diseases Prof. Peter Davey Professor and Consultant in Infectious Diseases. In comparison with severe sepsis on arrival at hospital, less is known about. - PowerPoint PPT PresentationTRANSCRIPT
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University of Dundee School of Medicine
Improving the management of sepsis in general hospital wards
Dr Charis MarwickCSO Clinical Academic Fellow & SpR Infectious Diseases
Prof. Peter DaveyProfessor and Consultant in Infectious Diseases
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In comparison with severe sepsis on arrival at hospital, less is known about...
• Hospital inpatients who develop sepsis • The potential to improve care for these patients
in general hospital wards• Management in earlier stages of sepsis
– Logical to intervene before deterioration• Patients without proven bloodstream infection
– Previous studies focus on positive blood cultures– Only includes 7-17% of septic patients1
– Mortality and morbidity similar whether +/– ve1,2
1.Jones and Lowe 1996, 2.Kumar et al 2006
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Defining the problem• Prospective case-note reviews hospital inpatients
– Develop case identification method: blood cultures taken
– Quantify deficiencies in patient management– Baseline Sept 2008 – Feb 2009 – Post-intervention Oct 2009 – Mar 2010
• Mortality among septic inpatients
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Baseline clinical data
Demographic characteristics (n=339)
Mean age : 67 years (range 18-95)
Male gender: 193 (57%)
Ward type:General medicineGeneral surgeryOrthopaedicOther
140 (41%)120 (35%)
31 (9%)48 (14%)
Suspected site of infection:Respiratory tractSkin or soft tissueUrinary tractIntra-abdominalLine infectionOther More than one site
145 (43%)46 (14%)79 (23%)79 (23%)35 (10%)30 (9%)
68 (20%)
Intervention target
• 1144 patients screened, 339 (30%, 95%CI 27-32%) valid cases
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Sepsis patients per ward
0
1
2
3
4
5
6
7
Medicine:26 patients per month;
11 Wards
Surgery:21 patients per month;
6 Wards
Orthopaedics:5 patients per month;
4 Wards
Seps
is p
atien
ts p
er w
ard
per m
onth
Mean 2.3
Mean 3.6
Mean 0.7
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Baseline study outcomes
Timing antibiotic therapy after sepsis onset (n=279)
Within four hours 107 (38%, 95%CI 33-44%)Mean 10.9 hours (95%CI 9.3-12.4)Median 6.0 hours (IQR 2.4-13.0)Within eight hours 169 (61%, 95%CI 55-66%)
Timely medical review (n=291) 139 (48%, 95%CI 42-54%Blood cultures before antibiotics (n=268) 212 (79%, 95%CI 74-84%)Severity assessment (n=339) 80 (24%, 95%CI 19-28%)Main component of delay = time between medical review and antibiotic prescription (mean 7.2 hours, median 2.5 hours)
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Where do delays occur???
?? 1.0
0.0
3.2
7.1
0.9
Mean time in hours
Median time in hours
Main delay is from review to prescription
2.4
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Improvement strategy• Implement intervention in Medical, Surgical and
Orthopaedic wards– 86% patients, feasible
• Sepsis “tools” = clinical care pathways– Recognition, risk stratifying and management
• Education and raising awareness – Presented to >300 clinical staff in Ninewells
• Monthly performance feedback to clinicians– Displayed as posters on intervention wards – Emailed to clinical staff
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Outcome measure Pre-intervention cohort
Post-intervention cohort
Difference and significance test result
Antibiotics within four hours
91/241 (38%)(95%CI 32-44%)
139/297 (47%)(95%CI 41-52%)
9%X2=4.44, df=1, p=0.04
Antibiotics within eight hours
145/241 (60%)(95%CI 54-66%)
198/297 (67%)(95%CI 61-72%)
7%X2=2.43, df=1, p=0.12
Mean time to antibiotics
11.0hrs(95%CI 9.3-12.7hrs)
9.5hrs(95%CI 8.1-11.0hrs)
1.5hrst=1.30, df=536, p=0.19
Median time to antibiotics
6.0hrs(IQR 2.5-13.3hrs)
4.5hrs(IQR 2.0-12.0hrs)
1.5hrsU=32460, p=0.06
Timely medical review 118/251 (47%)(95%CI 41-53%)
126/250 (50%)(95%CI 44-57%)
3%X2=0.58, df=1, p=0.49
Blood cultures taken before antibiotics
183/230 (80%)(95%CI 74-85%)
246/290 (85%)(95%CI 81-89%)
5%X2=2.46, df=1, p=0.12
Blood lactate level measured (severity)
31/291 (11%)(95%CI 7-14%)
87/346 (25%)(95%CI 21-30%)
14%X2=21.99, df=1, p<0.01
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Summary• Sepsis is common (>40 cases per month) in
Medical and Surgical Specialties • BUT, each Ward only has 1-6 patients per
month• Main delay in Time to First Antibiotic Dose
occurs AFTER medical review• Guidelines, education, audit &feedback at
Specialty level had little impact
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Conclusions• Collection and reflection on measures for
improvement should be at Ward level– Weekly identification of case(s)
• EWS charts• Antibiotic prescriptions• Blood cultures• HDU transfers
– Weekly run chart of individual patient Time to First Antibiotic Dose
– Monthly report on Sepsis Six
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Run Chart, Medical Ward, Sepsis & EWS 4+
0
5
10
15
20
25
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
Tim
e to
Firs
t Anti
bioti
c Dos
e (h
ours
)
Cases in date order
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RESULTS: MORTALITY
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Sepsis at Ninewells Hospital• 12 months data
Total Per Month
Blood cultures taken 2603 217
Patients screened for sepsis 2157 180
Patients with sepsis 1342 (62% BCs) 111
Hospital onset sepsis 641 (48% sepsis) 53
0
1
2
3
4
5
6
Any blood culture versus comparators
BC with Sepsis versus comparators
BC without sepsis versus comparators
Odd
s Rati
o 30
Day
Mor
talit
y
Odds ratio for mortality in comparison with patients hospitalised on the same wards with the same length of stay (+ 1 day), adjusted for age, gender and co-morbidity
13% definite +ve
2% definite +ve
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Mortality, multivariable analysis• 30 day: 124/640 (19%, 95%CI 16-22%)• 90 day: 180/640 (28%, 95%CI 25-32%)• Age (not comorbidity, gender or SIMD) associated• Severity scores risk-stratify, CURB65 performed best• Admission type, days to onset, and ward associated
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Proposal• Mortality (30 day) in any patient who has
had a blood culture taken is likely to be a more specific outcome measure for sepsis than total hospital mortality
• Further work with SPSP hospitals & ISD– Prevalence of sepsis in BC patients– Identification of BC patients by Ward– Record linkage to standardise mortality