Small ED Quality &Safety Teleconference July 2017

Gabrielle Mane ECI Advanced Trainee Emergency Care Institute

Case 1 - triage • 70 year old male • BIBA with vomiting, diarrhoea & abdominal pain for 2 days • PMHx – T2DM, HT

• Triage – observations on arrival at 1600

• BP 80/55, HR 75, temp 37.7, RR 27, O2 sats 93% RA • BSL 8.4

• Triaged as category 3 and placed in an isolation room

Case 1 - ED assessment • Further hx

• Multiple episodes of vomiting & diarrhoea over last 2 days • Generalised abdominal pain • Felt weak and short of breath – wife called ambulance when she

found him too weak to get out of bed in the afternoon • Work colleagues had recently had similar symptoms

• On examination • Chest clear • Abdomen soft non tender, BS+ • Clinically dehydrated

ED treatment • Metoclopramide 10mg IV • Buscopan 10mg IV • N/saline 3L IV Progress • POCT - low K, elevated urea & Cr • Pt was feeling much better after rehydration • Discharged home in the evening around 2000

Comments…. Are you satisfied with this management plan Anything further that should have been done…

Later that evening • Woke up feeling short of breath and distressed around

midnight - brought back to ED by his family • Triage - observations on arrival around 0100

• BP 90/55, HR 80, temp 37.8, RR 27, O2 sats 93% RA

• Triage category 2

ED assessment #2 • Looked pale, short of breath & dehydrated • Abdomen was firm & distended, no focal tenderness • Given morphine & IV fluids

• POCT completed – lactate 5.72 • IDC inserted – anuric • Call to base hospital around 0200 • Advised transfer ASAP to base hospital • Obs prior to T/F - BP 80/45, HR 90, RR 36, sats 94% 15L NRB

At the base hospital • Arrived around 0300 • Diagnosis of septic shock made soon after arrival • Commenced on sepsis pathway, unknown source

• IV flucloxacillin, gentamicin & ampicillin around 0400

• Remained hypotensive, commenced on inotropes • Reviewed by ICU around 0600 • Continued to deteriorate – needed intubation around 0800 • Despite all measures, further deterioration - passed away at 1200 • Urine & blood cultures subsequently grew Pseudomonas • Likely cause of death was Pseudomonal sepsis

Points for discussion

• Recognition / diagnosis of sepsis • Management of sepsis

What is sepsis? Definition from “Sepsis 3” Guidelines 2016

• Sepsis is life threatening organ dysfunction caused by a dysregulated

host response to infection

• Septic shock is a subset of sepsis where underlying circulatory and cellular/metabolic abnormalities are profound

enough to substantially increase mortality, i.e. persistent hypotension needing vasopressors to keep MAP > 65mmHg

AND serum lactate > 2mmol/L despite adequate fluid resuscitation

• (NB: “Severe sepsis” is no longer a separate group)

Recognising sepsis • Sepsis is life threatening organ dysfunction caused by a

dysregulated host response to infection

How to identify organ dysfunction? • Sepsis-3 uses an increase in SOFA score of ≥ 2 points Calculating the SOFA score (SOFA = Sequential [sepsis related] Organ Failure Assessment)

SOFA Parameters include • GCS • PaO2 / FiO2

• Platelet count • Bilirubin • Creatinine • Urine output • MAP & inotrope requirements

Is this really practical for ED?

Recognising sepsis in the ED • Sepsis is life threatening organ dysfunction caused by a

dysregulated host response to infection

How to identify organ dysfunction in the ED? • Sepsis-3 also defines a q-SOFA score for use in ED

qSOFA (“quick-SOFA”) score 1 pt for each of the following present:

• Hypotension SBP ≤ 100

• Altered mental state GCS < 15

• Tachypnoea RR ≥ 22

In ED, qSOFA score of ≥ 2 is considered significant

qSOFA score has been shown to identify patients who are likely to have prolonged ICU stay or die in hospital

Sepsis & “SIRS criteria” Previous definitions of sepsis, severe sepsis & septic shock

used SIRS criteria (Surviving Sepsis campaign 2012 definitions) • Sepsis is the presence of an infection with evidence of SIRS

i.e. presence of ≥ 2 of the following SIRS criteria • Temp > 38.3°C or < 36°C (in adults) • HR > 90 • RR > 20 or PaCO2 < 32mmHg • WCC > 12 or < 4 (or > 10% immature band forms) • BSL > 7.7 mmol/L (in absence of diabetes) • Altered mental state

Severe sepsis & septic shock • Severe sepsis is sepsis with organ dysfunction i.e. at least one of

the following variables present • Arterial hypotension

• SBP < 90, MAP < 70 or systolic BP reduced > 40mmHg from baseline • Arterial hypoxaemia with new pulmonary infiltrates (PaO2 : FiO2 ratio < 300) • New or increased oxygen requirements to maintain sats > 90% • Acute oliguria (UO < 0.5mL/kg/hr for > 2 hr) OR serum Cr > 177 μmol/L • Coagulation abnormalities (INR > 1.5, APTT > 60) • Thrombocytopaenia (plt < 100) • Lactate > 2.0 mmol/L (after fluid resuscitation)

• Septic shock is a subset of severe sepsis, and is defined as • Arterial hypotension persisting for >1 hr despite adequate fluid resus • Serum lactate > 4.0 mmol/L (after fluid resuscitation)

NSW Health Sepsis Pathway

Case 1 – Triage observations on 1st presentation RR 27 O2 sats 93% RA BP 80/55 HR 75 temp 37.7 BSL 8.4 Should a sepsis pathway have been commenced?

Once sepsis is recognised, important to start treatment - includes early antibiotics & fluid resuscitation

Sepsis management • Early antibiotics shown to improve mortality

• Sepsis pathway targets • Severe sepsis / septic shock – antibiotics within 1 hr of recognition • Sepsis – antibiotics within 2 hrs

Case 2 • 80 yo female • Presented with fever & right leg swelling for 1 day • PMHx – COPD, previous CVA, CLL

• Triage - on arrival at 1800

• Temp 38.1, BP 160/70, HR 120, RR 25, O2 sats 100%RA • Noted to be confused (compared with baseline) • Triage as category 2 and commenced on sepsis pathway

ED assessment & management • Seen by on call GP VMO within 10 minutes

• Pt febrile with right lower leg hot, red & swollen – likely cellulitis • Given flucloxacillin 2g IV and paracetamol 1g within 1 hour

• Investigations • Bloods sent including blood cultures; lactate 2.0 • CXR clear

• Progress in rural ED

• Increasing confusion with persistent fevers • D/W Base Hospital and decision made for transfer (via road)

Base Hospital – assessment & management

• Arrived at Base Hospital around 2300 • Provisional diagnosis of sepsis - triage category 2 • Afebrile on arrival, remained confused

• S/B medical registrar & surgical registrar in ED

• Diagnosed with cellulitis • Sepsis pathway not continued - i.e. regularity of obs / lactate

• Progress at Base Hospital • Fevers settled and pt symptomatically improved overnight • Transferred back to peripheral hospital the following day (day 2)

Peripheral facility

• Day 2 at peripheral facility • Flucloxacillin 2g IV qid was continued • Spiked temp 38.3 again that night

• Day 3 of admission

• Persistently febrile again in the evening – S/B on call GP VMO • Decision made to transfer pt back to Base Hospital the next day due to

ongoing fevers; given stat dose of IV metronidazole

• Day 4 of admission • Fever and worsening leg pain in the morning • Decision made to transfer back to Base Hospital around 0830 • Delayed transfer due to difficult in obtaining IV access

Day 4 – at the Base Hospital • On arrival at Base Hospital around 1230

• BP 100/45, HR 160, O2 sats 90% 6L oxygen • Oliguric - UO 40mL in last 3 hrs • Diagnosis – septic shock, acute renal failure • Earlier blood cultures now positive – gram negative rod • ABG – lactate 2.2; Cr 195; nil else significant • On arrival at Base Hospital around 1230

• Mx: IV flucloxacillin, vancomyin & ceftriaxone on arrival • T/F to ICU – continued to deteriorate; intubated around 2000 • Blood culture organism identified as Serratia marrescens • Changed to tazocin and gentamicin • Remained in septic shock overnight; leg amputation advised by

surgeons; decision made for palliation by family

Lessons to learn • Importance of maintaining sepsis pathway once started

• Regular observations

• Need to review diagnosis if pt is not improving

• Early antibiotics is important in sepsis