NHS Borders Sepsis Webex 25th April 2013

NHS Borders Melrose

Core Team Members

Evelyn Fleck Director of Nursing and Midwifery, Executive Lead

Dr Edward James Consultant Microbiologist, Consultant Lead

Ronnie Dornan Clinical Nurse Specialist, Critical Care Outreach

Dr Jonathan Aldridge Consultant Anaesthetics & Intensive Care

Geoff Anderson Charge Nurse, Ward 7 Lisa White Sister, Ward 7

Dr Anne Duguid Antimicrobial Pharmacist

Adam Wood Senior Nurse Specialist, Infection Control

Julieann Brennan Clinical Audit Facilitator

Christine Irving Clinical Practice Facilitator for IV Meds

Ellen Poole Staff Nurse, Ward 12

Allison Roebuck Patient Safety Administrator

Julia Scott Clinical Governance & Quality Facilitator: Patient Safety

Gill Lunn Senior Midwife/ Maternity Champion

Lorraine Dickson Hospital at Night Team

FY1 docs From Wards 4, 7, 12 and A&E

To improve recognition and

timely management of

patients identified with sepsis

on ward 7, by achieving 95%

compliance with evidence

based therapy (SEPSIS 6) by

September 2013

Reliable Recognition &

Assessment

Reliable Care Delivery

Improve Patient and

Family Centred Care

Promote a Culture of

safety & Improvement

Refine Education &

Awareness

Primary Drivers

Development and modification of current tool

(SIRS) to include (SEPSIS 6) – Sepsis bundle

Timely rescue of patients identified through

reliable escalation to higher level of care

Ensure appropriate medical intervention and

timely rescue of deteriorating patient by

competent teams

Establish Ward agreement for implementation

Development of team project support

Establish working relationship with Clinical

Governance and Audit for project support in

developing a measurement framework to guide

improvement

Develop Communication – posters/information

Involve Patients and family in treatment

processes and planning and ensure

appropriate feedback and understanding is

provided.

Develop an effective and appropriate support

through executive sponsorship, clinical lead,

multidisciplinary team working, approval/money

support

Increase confidence in the monitoring tool –

identify early symptoms through the

Implementation of the screening tool to

include the SEPSIS 6 checklist

Increase the number of patients who receive

antibiotics within 1 hour of recognition -

Achieve 80% initially.

Increase understanding of condition all

professional, patients and public – “SEPSIS

as a medical emergency” e.g. Local and

National awareness campaign

Secondary Drivers Specific Change Ideas

Link “at risk” patients with ward safety brief

Support education on burden of illness and

current performance

Provide training to staff on clinical knowledge

and improvement skills Ensure reliable process of communication

through SBAR for consultants, doctors,

nursing staff and outreach teams.

AIM

BGH SEPSIS Driver Diagram

Tests of change

Initial

Test

Version 6

Version 10

NAME OF DOCTOR:

SIGNED:

PATIENT DETAILS RECORDED ON SEPSIS 6 MASTER LIST YES

_____:_____Monitor urine output6

_____:_____Lactate (consider ABG)5

_____:_____Fluid Bolus started 4

_____:_____

IV ANTIBIOTICS

STARTED3

_____:_____Blood cultures taken2

_____:_____Start on high flow oxygen 1

COMMENTS / REASON IF NOT DONE START TIMESEPSIS 6

SEPSIS 6 – 1st HOUR OF TREATMENT

SUSPICION OF INFECTION

YES Commence Sepsis 6 NO Prescribe Appropriate Plan

of Care

LIKELY SOURCE OF INFECTION:

SIRS SCORE :_______

INFORMED: DOCTOR OUTREACH HAN

Date :

Time:

Signed:

SYSTEMIC INFLAMMATORY RESPONSE SYNDROME (When SIRS ≥ 2)

SIRS ALERT (≥2) v (10) 19/02/2013

NAME OF DOCTOR:

SIGNED:

PATIENT DETAILS RECORDED ON SEPSIS 6 MASTER LIST YES

_____:_____Monitor urine output6

_____:_____Lactate (consider ABG)5

_____:_____Fluid Bolus started 4

_____:_____

IV ANTIBIOTICS

STARTED3

_____:_____Blood cultures taken2

_____:_____Start on high flow oxygen 1

COMMENTS / REASON IF NOT DONE START TIMESEPSIS 6

SEPSIS 6 – 1st HOUR OF TREATMENT

SUSPICION OF INFECTION

YES Commence Sepsis 6 NO Prescribe Appropriate Plan

of Care

LIKELY SOURCE OF INFECTION:

SIRS SCORE :_______

INFORMED: DOCTOR OUTREACH HAN

Date :

Time:

Signed:

SYSTEMIC INFLAMMATORY RESPONSE SYNDROME (When SIRS ≥ 2)

SIRS ALERT (≥2) v (10) 19/02/2013

Data Collection Form BORDERS GENERAL HOSPITAL SEPSIS 6 DATA COLLECTION FORM INCLUSION CRITERIA: Patients who score 2 or more Systemic Inflammatory Response Syndrome (SIRS) criteria and there is a suspicion of sepsis. ADMISSION DATE:__________________ADMISSION TIME:______________________DISCHARGE DATE:_____________________ DATE OF SEPSIS DIAGNOSIS:________________SIRS:___________TIME ZERO: _________________ Time Zero = time of meeting inclusion criteria

PROCESS MEASURES Document Time of

Measure / Comments (A)* Achieved <1 hour of time Zero

Oxygen Administered to saturation of .95% (or target saturation of 88-92% if at risk of hypercapnic respiratory failure)

Yes No N/A

Time: Not Recorded

Yes Total Time Taken: No

Blood Cultures Taken

Yes No N/A

Time: Not Recorded

Yes Total Time Taken: No

Antibiotics Administered

Yes IV Oral No N/A

Time: Not Recorded

Yes Total Time Taken: No

IV Fluid Bolus Commenced

Yes No N/A

Time: Not Recorded

Yes Total Time Taken: No

Serum Lactate Measured

Yes No N/A

Time: Not Recorded

Yes Total Time Taken: No

Urine Output Measurement **PLEASE RECORD METHOD/S USED Catheter Urinal/Bedpan Bladder Scan

Yes No N/A

Time: Not Recorded

Yes Total Time Taken: No

Was Sepsis Six Performed < hour of Zero Time? To achieve this all above boxes in (A)* must be YES

Yes No

Other Comments on Process Measures: (i.e. note achieving <1 hour)

OUTCOME MEASURES

Alive at 30 days

Yes No

DATE OF DEATH

Length of Stay (Total number of days in BGH) days

ANTIBIOTICS COMPLIANT WITH LOCAL POLICY Yes No

ICU admission Stay (Total number of days in ICU)

days

ICU ADMISSION DATE: ICU DISCHARGE DATE:

PT LABEL

Percentage of patients with blood culture performed within 1 hour of time zero

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Oct-12 Nov-12 Dec-12 Jan-13 Feb-13

Admissions Unit Accident & Emergency Ward 7 -pilot ward

Percentage of patients receiv ing oxygen therapy to achieve appropriate saturation levels within 1 hour of time zero

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Oct-12 Nov-12 Dec-12 Jan-13 Feb-13

Admissions Unit Accident & Emergency Ward 7 -pilot ward

Results:

Blood Cultures

O2

Percentage of patients who receive all required IV antibiotics within 1 hour of time zero

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Oct-12 Nov-12 Dec-12 Jan-13 Feb-13

Admissions Unit Accident & Emergency Ward 7 -pilot ward

Percentage of patients receiv ing IV fluid challenge and reassessment within 1 hour of time zero

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Oct-12 Nov-12 Dec-12 Jan-13 Feb-13

Admissions Unit Accident & Emergency Ward 7 -pilot ward

Results:

IV antibiotics

Fluids

Percentage of patients with Serum Lactate and FBC measured with 1 hour of time zero

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Oct-12 Nov-12 Dec-12 Jan-13 Feb-13

Admissions Unit Accident & Emergency Ward 7 -pilot ward

Percentage of patients who commenced accurate urine output measurement and had consideration of Urinary Catheter within 1

hour of time zero

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Oct-12 Nov-12 Dec-12 Jan-13 Feb-13

Admissions Unit Accident & Emergency Ward 7 -pilot ward

Results:

Urine output

Lactate

Compliance with Sepsis 6

Percentage of patients with Sepsis Six performed within 1 hour of time zero

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Oct-12 Nov-12 Dec-12 Jan-13 Feb-13

Admissions Unit Accident & Emergency Ward 7 -pilot ward

Percentage of patients with Sepsis Six performed within 1 hour of time zero

2012: 2 + hrs 2013: < 30 mins

Time to Antibiotic Administration - January 2013 (n=23)

0

20

40

60

80

100

120

140

160

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23

Patient

Min

ute

s

Antibiotics administered (XX%) median

Diagnosis Delay

Balancing measure:

Are all Patients with a SIRS of 2 and above captured?

Spot checks on all the wards are done monthly on one day .

The spot check includes checking all patients SIRS chart on all the wards for a reading of ≥ 2 using the headings.

• 44 notes were inspected on 18th April 2012.

• 3 patients had a SIRS of 2.

• 2 received Sepsis Six.

• 1 did not enter into the programme.

Date Sirs2? Action Dr/Han sticker Sepsis 6 Diagnoses Ward

Our Successes

– Patients are increasingly receiving evidence based treatment for sepsis

– Patients are receiving timely management

– We have a committed driven team

– We have increased awareness of the sepsis six interventions

– We have achieved a better understanding of the interconnection between the process and outcomes of the interventions

– We have achieved meaningful real time data collection

– Have successfully used the model for improvement and PDSA methodology

– Well received at ‘Grand Round’

Our Challenges

– AUDIT

– Time resources and capacity

– The early recognition of sepsis

– New FY1 every 4 months (+ Rotating Shifts (wards/HAN/Day/ night))

– Nursing teams relying on “bank staff” frequently

– Hospital wide education

– The compliance with the use of the sticker for all patients with a SIRS of 2

– Highlighting sepsis as a medical emergency

– Concern with diagnostic accuracy obscures the early recognition of Sepsis

– Maintaining momentum

– Keep the focus of the model for improvement

– Achieving standardisation and sustainability as the project develops

Forward Planning:

• Create a structured monthly feedback on all wards.

• Create a Sepsis Pathway.

• Increase awareness in the middle grade doctors.

• Incorporate the Maternity Units/ McQIC workstream.

• Review progress and continue to have local core group meetings every 2 weeks.

• Improve the data collection sheet (PDSA).

• Learn from mortality reviews.