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.