Clinical Design & Innovation

Office of the Chief Clinical Officer; Health Service Executive

2021 World Sepsis Day National Sepsis Programme

Webinar

Dr Martina Healy

Clinical Lead

Introduction to 2021 Webinar

Programme

12.30 – 12.40 Introduction and National Sepsis Report 2019 Summary

Dr Martina Healy, National Sepsis Clinical Lead

12.40 – 12.45 NCEC Intro to Adult Sepsis Guideline

NCEC Chair,Prof Gerry Fitzpatrick

12.45 - 12.55 Adult Sepsis Management National Clinical Guideline Update

Celine Conroy, IEHG Sepsis ADON

12.55– 13.05 Adult Sepsis Management HSeLanD e-learning Update & Introduction to

Updated Adult Sepsis Form

Mary Bedding, RCSI Hospitals Sepsis ADON

13.05 - 13.25 Launch of National Paediatric Sepsis Management Guidelines

Dr Martina Healy, National Sepsis Clinical Lead

13.25 -13.30 Introduction of incoming National Sepsis Clinical Lead

Dr Michael O’Dwyer, St Vincent’s University Hospital

This is the fifth National Sepsis Outcome Report describing

the burden of sepsis on the Irish healthcare system, in terms of the number of cases and the associated mortality.

National Sepsis Report 2019

Key comparators with 2018 (adult non-maternity cohort)

• Mortality: There was an 11.8% decrease in documented cases of Sepsis and Septic Shock with a 2.9% decrease in associated in-hospital mortality rate.

• There was a 5% increase on average length of stay. • Sepsis: There were 11,819 cases documented in 2019, a

12.7% decrease when compared with 2018 (n=13,547), • There was an in-hospital mortality of 18.1%,

representing a 2.6% decrease in mortality over 2018 (n=18.6%).

• This benchmarks well internationally: UK 20.3%1, USA 25%2, Australia 19.7%3 and Globally 27%4.

National Sepsis Report 2019

• Septic Shock: There were 1,089 cases documented in 2019, a 0.27% decrease when compared with 2018 (n=1092), with an in-hospital mortality of 37%, representing an 11% decrease in mortality when compared with 2018 (n=41.6%).

• This also benchmarks well internationally: Australia 23.9%3 and Globally 42%4.

National Sepsis Report 2019 Paediatric and Maternity data

Summary

Summary 2011 – 2019

• Documented cases ↑ 114%

• Sepsis associated mortality ↓ 22.68%

Key Finding

Sepsis patients have a 5.2 fold higher mortality over patients coded with infection and a 2 fold higher LOS

Recommendations for the future

Recommendations for future

Introduction to 2021 Webinar

Programme

12.30 – 12.40 Introduction and National Sepsis Report 2019 Summary

Dr Martina Healy, National Sepsis Clinical Lead

12.40 – 12.45 NCEC Intro to Adult Sepsis Guideline

NCEC Chair,Prof Gerry Fitzpatrick

12.45 - 12.55 Adult Sepsis Management National Clinical Guideline Update

Celine Conroy, IEHG Sepsis ADON

12.55– 13.05 Adult Sepsis Management HSeLanD e-learning Update & Introduction to

Updated Adult Sepsis Form

Mary Bedding, RCSI Hospitals Sepsis ADON

13.05 - 13.25 Launch of National Paediatric Sepsis Management Guidelines

Dr Martina Healy, National Sepsis Clinical Lead

13.25 -13.30 Introduction of incoming National Sepsis Clinical Lead

Dr Michael O’Dwyer, St Vincent’s University Hospital

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Sepsis Management - National Clinical Guideline No. 27

Celine Conroy, NSP & Group ADON, Sepsis, IEHG

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Sepsis management NCG No 26 (previously No. 6)

Purpose

• to implement the Surviving Sepsis Campaign Guideline (SSCG) (2016) (updated 2018) in the management of the adult patient in the acute hospital sector in Ireland in a format that applies to the structures and functions of the Irish Acute Health Care Sector.

• The wording of the recommendations have not been changed from the SSCG publication with the exception of units of measurement applicable to the Irish context

The NSP is very grateful to the SSC for their kind permission to adopt the SSCG as the Irish National Clinical Guideline on Sepsis Management

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Clinical Judgement

• National Clinical Guidelines are designed to guide clinical judgement but not replace it.

• In individual cases a healthcare professional may, after careful consideration, decide not to follow guideline recommendations if it is deemed to be in the best interests of the patient and is in line with best practice.

• Clinical decisions and therapeutic options should be discussed with a senior clinician on a case-by-case basis as necessary and documented in the clinical notes.

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NCG No 26 applies to:

• All adult patients including pregnant women and women in the postnatal period up to 42 days, in the acute hospital sector.

• All maternity specific information is highlighted using purple text.

• This NCG does not apply to paediatric patients up to the age of 16 years (HSE, 2016).

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Target Users

• All healthcare professionals involved in the care of adult and maternity patients with sepsis and suspicion of sepsis, working in the acute hospital sector in the Republic of Ireland.

• DoH - to support the implementation and audit of this National Clinical Guideline.

• HSE - to provide appropriate structured support and adequate resources for the governance, operationalisation, and audit of sepsis management.

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Target Users

• Hospital Group Leadership Teams, Hospital Management and Clinical Directors - to: • support sepsis QI

• facilitate implementation and audit

• facilitate and monitor required change arising from outlier intervention.

• Pre-Hospital Emergency Care Council - to inform their clinical practice guidelines across ambulance services.

• The public - as an information resource.

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National Implementation Points

• Recognising that much of the research that informed the SSCG occurred in the critical care setting, the NCG provides Implementation Points after the SSCG recommendations to aid the implementation of these recommendations within the Irish healthcare system.

• Implementation Points and are primarily aimed at the pre- and post-critical care setting.

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Guideline Development Group

• The GDG was chaired by Dr Vida Hamilton, National

Clinical Lead for Sepsis (2014 – 2018).

• Membership nominations were sought from a variety of clinical and non-clinical backgrounds so as to be representative of all key stakeholders within the acute sector, including:

• those involved in clinical practice, education, administration, research methodology and 2 persons representing patients and the public.

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Sepsis – Definition (Sepsis 3)

• Sepsis is life-threatening organ dysfunction caused by a dysregulated host response to infection (Singer et al., 2016).

• Maternal sepsis: is a life-threatening condition defined as organ dysfunction resulting from infection during pregnancy, childbirth, post-abortion or postpartum period (WHO, 2017).

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Sepsis 2 vs Sepsis 3

• The rationale behind the shift away from the SIRS-based definition of sepsis (Sepsis 2) is primarily three-fold:

1. The over-sensitivity of the previous definition that included a cohort of patients who did not have a life threatening illness and whose clinical course would not be impacted by escalated care (Churpek et al., 2015), (Comstedt et al., 2009).

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Sepsis 2 vs Sepsis 3

2. Its failure to recognise patients with a life-

threatening acute organ dysfunction due to infection that would benefit from escalated care but who did not present with a SIRS response (Comstedt et al., 2009), (Kaukonen et al., 2015).

3. The lack of specificity of the SIRS response that can be triggered by many non-infective insults (Thoeni, 2012).

• Whilst the presence of a systemic inflammatory response (SIRS) is helpful in diagnosing infection, it is no longer a requirement for the diagnosis of sepsis, (Singer et al., 2016).

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Septic Shock

• Septic shock is a subset of sepsis with circulatory and cellular/metabolic dysfunction associated with a higher risk of mortality (Singer et al., 2016).

• The sepsis definition taskforce has defined this as the requirement for vasopressors/ inotropes to achieve a mean arterial pressure of ≥ 65mmHg AND a lactate > 2mmols/l despite adequate fluid resuscitation (Singer et al., 2016).

• The rationale behind this definition is to identify the cohort of patients with a mortality risk of > 40% for the purposes of international comparison.

• Note: Patients with a vasopressor requirement and normal lactate post resuscitation have a mortality risk of > 30% (Singer et al., 2016).

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Septic Shock

• For the purposes of facilitating clinical care in Ireland and recognising that lactate measurement is not always available, this NCG uses the persistent requirement for vasopressors/inotropes post adequate fluid resuscitation as its definition of septic shock, because patients who require vasopressors or inotropes to maintain adequate perfusion pressure post fluid resuscitation require critical care whether their lactate is raised or not.

• This is a pragmatic approach and acknowledges that the sepsis definition taskforce allowed for this interpretation: • ‘In settings in which lactate measurement is not available, the use of

a working diagnosis of septic shock using hypotension and other criteria consistent with tissue hypoperfusion (e.g. delayed capillary refill) may be necessary’ (Singer et al., 2016).

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Sepsis 6

Sepsis 6 is the name given to a bundle of medical therapies designed to reduce mortality in patients with sepsis (Take 3 and Give 3).

• Sepsis 6 was developed by The UK Sepsis Trust (Daniels et al., 2011) as a practical tool to help healthcare professionals deliver the SSCG 1 hour bundle.

• Sepsis 6 + 1 is the same as Sepsis 6 but + 1 refers to Fetal wellbeing. Resuscitating the mother will resuscitate the baby, however, it is important to assess fetal wellbeing and formulate a plan for delivery if required.

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SSCG 2018 Update

• SSCG 2018 Update: The 3-h and 6-h bundles have been combined into a single “hour-1 bundle” with the explicit intention of beginning resuscitation and management immediately:

• For patients who present with clinically apparent sepsis/septic shock on presentation, it is recommended that the Sepsis 6 bundle be administered within 1 hour of presentation (Levy et al., 2018).

• If infection is included in the differential diagnosis, and the patient is in one of the at-risk groups then for these patients, 1 hour is allowed for screening and medical review and once completed this is considered TIME ZERO. All elements of the Sepsis 6 bundle are then to be initiated within 1 hour of TIME ZERO.

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Operationalising the NCG

• The NSP provides Clinical decision support tools (CDSTs) and Sepsis eLearning education to promote standardised clinical practice and support implementation of the NCG.

• The CDSTs have been updated in line with the updated NCG and include: • Adult Sepsis Form In-patient and

Emergency Department use

• Sepsis Predisposition & Recognition – Maternity patients

• Fluid resuscitation algorithm for adults with sepsis

www.hse.ie/sepsis

www.hseland.ie

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HSeLand Introduction to Sepsis Management for Adults including Maternity

Mary Bedding, NSP & Sepsis Group ADON, RCSI Hospitals

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Why the update?

• 2016 – new Sepsis-3 sepsis definitions (Singer at al. 2016)

• Maternal sepsis

• Updated sepsis resources – CDSTs including Adult Sepsis Form, algorithms

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Audience & Aim

• Audience - all staff involved in the recognition management and escalation of treatment for sepsis in adults in the acute hospital setting – includes nurses/midwives, doctors and HSCP

• Aim - is to help the user to effectively recognise and manage sepsis in the adult population in an acute care setting in accordance with National Clinical Guideline No 26: Sepsis Management for Adults (including maternity)

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Scope

Includes:

• Non-pregnant & pregnant adult patients over the age of 16 yrs

• Pregnant adults include from conception up to 42 days post birth (including miscarriage or abortion)

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Learning Outcomes

At the end of the programme should be able to:

• Recognise patients that require sepsis screening – high risk groups, deterioration due to infection & those with signs of sepsis

• Know when & how to use the Sepsis Form to aid recognition and treatment

• Identify when to escalate for a medical review

• Manage patients with 1 hr sepsis bundle (Sepsis 6 (+1))

• Review and respond to patient’s response to treatment

• Define sepsis & septic shock and document same

• Know when escalation to critical care is required

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Maternity Content

• Maternity specific information highlighted using purple text.

• Content is optional

• REMEMBER pregnant or post birth women can be in any acute care setting outside of maternity

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Design

• Animation – similar to INEWS & IMEWS (own colour palette and characters)

• Interactive – knowledge checks & scenarios

• Topics – content covered in the topic, information and summary

• Reflects recommendations of other NCG – INEWS, IMEWS, Clinical Handover

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Topics

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Topic 5 Scenarios

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Scenarios

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Scenarios

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Summary & Learning

• Summarises whole programme

• Directs participants to where to find sepsis resources

• ‘Extend my Learning’

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How to complete

• Will take approx. 1 hr to complete

• Can be completed in multiple sittings

• Must visit at least 80% slides to complete

• Must complete the high risk patient scenario (maternity is optional)

• Certificate found in ‘My Certificates’ section on HSeLanD

• Awarded 1.5 NMBI CEUs or 2 RCSI CPD

• Programme is valid for 3 years

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Updated Sepsis Forms – Clinical Decision Tools

Mary Bedding, NSP & Sepsis Group ADON, RCSI Hospitals

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Adult Sepsis Form

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Adult Sepsis Form – Page 1

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Adult Sepsis Form – Page 1

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Adult Sepsis Form – Page 1

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Adult Sepsis Form – Page 1

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Adult Sepsis Form – Page 2

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Maternity Sepsis Form

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Paediatric Sepsis Form

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Thanks & Feedback

• Thanks to Clinical Design & Innovation for providing the funding for the e-learning update.

• Thanks to all of the members of the Sepsis Team and Ciara Hughes (previous PM) for all their input for both the e-learning update and the Sepsis Form update.

• Please contact any of the Mary Bedding mary.bedding@hse.ie or any other members of the National Sepsis Team - details of Team on the HSE Sepsis pages https://www.hse.ie/eng/about/who/cspd/ncps/sepsis/contact/

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Clinical Design & Innovation

Office of the Chief Clinical Officer; Health Service Executive

Paediatric Sepsis Guidelines

An introduction and guide to implementation

Dr Martina Healy

National Sepsis Programme

Clinical Lead

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International Paediatric Guidelines

• February 2020 - The Surviving Sepsis Campaign international guidelines for the management of septic shock and sepsis-associated organ dysfunction in children was published

February 2020, Volume 46, Supplement 1, pp 10–67 Intensive Care Medicine

• The Irish National Sepsis Programme convened a multidisciplinary paediatric sepsis working group.

• This Group recommended adopting the Surviving Sepsis Campaign international guidelines for the management of septic shock and sepsis-associated organ dysfunction in children (SSCGC).

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SSCGC

Surviving sepsis campaign international guidelines for the management of septic shock and sepsis-associated organ dysfunction in children

February 2020, Volume 46, Supplement 1, pp 10–67 Intensive Care Medicine

Scott L. Weiss, MD, MSCE, FCCM (Co-Vice Chair)1; Mark J. Peters, MD, PhD (Co-Vice Chair)2; Waleed Alhazzani, MD, MSc, FRCPC (Methodology Chair)3; Michael S. D. Agus, MD, FCCM, FAAP4; Heidi R. Flori, MD, FAAP5; David P. Inwald, MB, BChir, FRCPCH, FFICM, PhD6; Simon Nadel, MBBS, MRCP, FRCP6; Luregn J. Schlapbach, FCICM, FMH-ICU, FMH-Paeds, FMH-Neonatology7; Robert C. Tasker, MB BS, MA, AM, MD, FRCPHC, FRCP4; Andrew C. Argent, MB BCh, MMed, MD (Paediatrics)8; Joe Brierley, MD, MA9; Joseph Carcillo, MD10; Enitan D. Carrol, MB ChB, MD, FRCPCH, DTMH11; Christopher L. Carroll, MD, MS, FCCM, FAAP12; Ira M. Cheifetz, MD, FCCM13; Karen Choong, MB, BCh, FRCP(C) (methodologist)3; Jeffry J. Cies, PharmD, MPH, BCPS-AQ ID, BCPPS, FCCP, FCCM, FPPAG14; Andrea T. Cruz, MD, MPH, FAAP15; Daniele De Luca MD, PhD16,43; Akash Deep, MB BS, MD, FRCPCH17; Saul N. Faust, MA, MB BS, FRCPCH, PhD, FHEA18; Claudio Flauzino De Oliveira, MD, PhD19; Mark W. Hall, MD, FCCM, FAAP20; Paul Ishimine, MD, FAAP21; Etienne Javouhey, MD, PhD22; Koen F. M. Joosten, PhD23 ; Poonam Joshi, PhD24; Oliver Karam, MD, PhD25; Martin C. J. Kneyber, MD, PhD, FCCM26; Joris Lemson, MD, PhD27; Graeme MacLaren, MD, MSc, FCCM28; Nilesh M. Mehta, MD4; Morten Hylander Møller, MD, PhD29; Christopher J. L. Newth, MD, ChB, FRCPC, FRACP30; Trung C. Nguyen, MD, FAAP15; Akira Nishisaki, MD, MSCE, FAAP1; Mark E. Nunnally, MD, FCCM (methodologist)31; Margaret M. Parker, MD, MCCM, FAAP32; Raina M. Paul, MD, FAAP33; Adrienne G. Randolph, MD, MS, FCCM, FAAP4; Suchitra Ranjit, MD, FCCM34; Lewis H. Romer, MD35; Halden F. Scott, MD, MSCS, FAAP, FACEP36; Lyvonne N. Tume, BS, MSN, PhD, RN37; Judy T. Verger, RN, PhD, CPNP-AC, FCCM, FAAN1, 44; Eric A. Williams, MD, MS, MMM, FAAP15; Joshua Wolf, MBBS, PhD, FRACP38; Hector R. Wong, MD39; Jerry J. Zimmerman, MD, PhD, FCCM40; Niranjan Kissoon, MB BS, MCCM, FRCP(C), FAAP, FACPE (Co-Chair)41; Pierre Tissieres, MD, DSc (Co-Chair)16,42

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SSCGC

The International panel was assisted by various methodological experts and split into six groups

• recognition and management of infection

• hemodynamics and resuscitation

• ventilation

• endocrine and metabolic therapies

• adjunctive therapies

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SSCGC – the big ticket items

Definition of Septic Shock

“For the purposes of these guidelines, we define septic shock in children as severe infection leading to cardiovascular dysfunction (including hypotension, need for treatment with a vasoactive medication, or impaired perfusion) and “sepsis-associated organ dysfunction” in children as severe infection leading to cardiovascular and/or non-cardiovascular organ dysfunction.”

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SSCGC – the big ticket items

• Septic shock was defined as the subset with cardiovascular dysfunction, which included hypotension, treatment with a vasoactive medication, or impaired perfusion.

• greater than or equal to two age-based systemic inflammatory response syndrome (SIRS) criteria

• confirmed or suspected invasive infection, and cardiovascular dysfunction

• acute respiratory distress syndrome (ARDS), or greater than or equal to two non-cardiovascular organ system dysfunctions

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SSCGC – the big ticket items

Fluids in Paediatric sepsis

• Bolus if intensive care available, if not then don’t unless documented hypotension

• In units with access to intensive care, 40-60ml/kg bolus fluid (10-20ml/kg per bolus) over the first hour is recommended. With no intensive care, and in the absence of hypotension, then avoiding bolus and just commencing maintenance is recommended. It is not clear how long access to intensive care has to be to switch from fluid liberal to restrictive.

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SSCGC – the big ticket items

• The panel suggests crystalloids, rather than albumin, and balanced/buffered crystalloids rather than 0.9% saline. They recommend against using starches or gelatin.

Take blood cultures but don’t delay treatment to obtain them

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SSCGC – the big ticket items

• One hour time to treatment for those in shock but up to three hours without it. This is the potential game-changer from this body of work. While the evidence shows a temporal relationship between the administration of antibiotics and outcome in severe sepsis some pooled data demonstrated that it was unlikely the hour alone made the difference.

• This will be a welcome relief for those working in areas where there are associated penalties for not reaching the hour window and hopefully will remove some of the gaming associated with this target.

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SSCGC – the big ticket items

• For purposes of this weak recommendation, hypotension can be defined as

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SSCGC – the big ticket items

• Broad spectrums antibiotics, but narrow when pathogens available

• If no pathogen is identified, we recommend narrowing or stopping empiric antimicrobial therapy according to clinical presentation, site of infection, host risk factors, and adequacy of clinical improvement in discussion with infectious disease and/or microbiological expert advice.

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SSCGC – the big ticket items

• Intensive care vasoactive and ventilation management is given but acknowledged as weak recommendations

• There is a list of suggestions regarding vasoactive infusion and ventilatory strategies that are very specific to intensive care management. While a number of recommendations are given (epinephrine rather than dopamine for septic shock for example) these are generally based on the panels summation of weak evidence.

• There are further suggestions on corticosteroid management, nutrition, and blood products which will be of interest to those in intensive care and anaesthetic settings.

•

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Initial Resuscitation Algorithm for Children

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Fluid and vasoactive-inotrope management algorithm for Children

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National Implementation Plan (NIP)

• The National Sepsis Programme convened a multidisciplinary paediatric sepsis working group which recommended adopting the Surviving Sepsis Campaign international guidelines for the management of septic shock and sepsis-associated organ dysfunction in children (SSCGC).

• Key stakeholders include those involved in clinical practice, education, administration, research methodology and persons representing patients and the public.

• With permission from Surviving Sepsis Campaign group, the National Sepsis Programme developed a National Implementation Plan (NIP) to support implementation of the SSCGC recommendations within the acute paediatric healthcare setting in Ireland.

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National Implementation Plan (NIP)

• The NIP contains the 77 SSCGC

statements on the early management and resuscitation of children with septic shock and sepsis-associated organ dysfunction, with implementation points to assist clinicians in the management of paediatric sepsis in an Irish healthcare setting.

• Incorporated into the NIP is a clinical decision support tool (Sepsis Form) aimed at providing guidance for clinicians to recognise and treat sepsis in a timely manner.

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Sepsis Form

Front page is the recognition and screening for Sepsis

Back page is the treatment, reassessment and referral

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National Implementation Plan (NIP)

• The NIP was widely disseminated for consultation and feedback in Jan 2021 and externally reviewed by Mark Peters, European Co-chair of the Paediatric Surviving Sepsis Campaign.

• The NIP was clinically approved by the CCO Clinical Forum in August 2021. It will accompany the National Clinical Guideline for Sepsis (NCG No.26) to ensure a unified national approach to sepsis management across all age cohorts.

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Next Steps……..

Implementation of the SSCGC recommendations National Educational material:

• As an interim measure, a PowerPoint lecture and accompanying video will be available for all sites who care for children in the coming months.

• Funding for an E-learning module on HSELand has been secured and it is envisaged that this will be accessible from Q3 2022.

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Implementation of the SSCGC recommendations

To optimise sepsis recognition and treatment, the Hospital Group Sepsis Assistant Directors of Nursing (ADONs) and the National Sepsis Team liaise with each site to help support the local hospital sepsis committees’ aims, by performing audit and feedback on the sepsis care.

All paediatric hospitals and acute hospitals with paediatric units are advised to have a Sepsis Committee whose role is to guide the implementation of the SSCGC recommendations in their hospital.

NATIONAL SEPSIS TEAM

SEPSIS ADON

IDENTIFY LOCAL IMPLEMENTATION LEADS TO COORDINATE

IMPLEMENTATION OF SEPSIS GUIDELINE (NIP)

LOCAL SEPSIS COMMITTEE

(Adult committee should have representation from Paediatrics)

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Public awareness campaign

• Posters

• Leaflets

• Video/social media

https://vimeo.com/462650865/610bbcef55

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Current programme activity and achievements

• Awaiting confirmation from NCEC to publish updated guidelines for adults

• Drafting implementation plan of Paediatric Sepsis Management Guidelines. First edition

• Education and promotion of Paediatric Sepsis awareness and recognition

• Updating e-learning module to reflect the content and of the updated adult guideline.

• Sepsis Summit planned for September 2021

• Sepsis Awareness campaign planned for GP / Community

• Launch of Paediatric Sepsis Tool pilot in May2021

• Drafting 2019 Sepsis Annual Report

• Awaiting appointment of new programme manager

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Thank you