NEWSLETTER

AUTUMN 2014

Inpatient Sepsis Pathway Launch May 2014

Sepsis is a medical emergency and delays in treatment can have tragic outcomes. For every hour an adult or child in septic shock doesnt receive antibiotics, the mortality increases dramatically. Sepsis has a huge toll on our hospitals causing prolonged stays, intensive care needs and contributes to a major proportion of in-hospital deaths. It kills more adults than prostate cancer, breast cancer and HIV combined! The SEPSIS KILLS program was commenced in emergency departments Statewide in 2011. The program is based on three key elements:
Photo: Dr Tony Burrell (left) and LHD Sepsis Leads at the Inpatient Sepsis Pathway workshop

Sepsis is one of the most dangerous and difficult to treat conditions in healthcare today.
The Inpatient SEPSIS KILLS program links directly with the Between the Flags system. Preliminary data suggests that 30% of adult deteriorating patients requiring a Rapid Response call are septic. Many of these patients have signs and symptoms of sepsis long before the Rapid Response call and their clinical outcome may well have been different with earlier intervention. The program is structured around five inter-related areas: Governance, Between the Flags CERS, Sepsis Clinical Tools (pathway), Education and Evaluation. The program will be launched Statewide in May 2014. Local health districts have commenced work to develop a sustainable process to improve sepsis recognition and management in all wards throughout NSW. Make a difference to YOUR patients and find out how the Inpatient SEPSIS KILLS program is being rolled out to your hospital wards. For more information on the program, education and promotion resources, please visit
http://www.cec.health.nsw.gov.au/programs/sepsis#phase2.

RECOGNISE: sepsis risk factors, signs and symptoms RESUSCITATE: with intravenous fluids and antibiotics REFER: to specialty teams to manage ongoing care
Adults and children who are at the greatest risk of developing sepsis are those with: Any kind of infection Invasive procedures, intravenous lines or surgery Pre-existing (chronic) medical conditions Underactive immune system Elderly and very young patients

Using Data to Drive Improvement in the ED

Collecting data can be a time consuming burden. Data can however be a powerful tool to drive change. By linking the data to clinical practice, improvements can be made. The graph below shows how Hornsby Hospital has done this very successfully with dramatically decreased time to administration of antibiotics sustained for the last 12 months.

There is a high incidence of sepsis in the elderly which is often associated with delirium and falls. The graph below shows that 63% of the patients entered in the CEC database are over 65 years of age.
Age of NSW Sepsis Patients (years)
14% 12% % of Patients 10% 8% 6% 4% 2% 0% 0-5

40-45

10-15

20-25

30-35

50-55

60-65

70-75

80-85

Preminiary data to 29 January 2014

Delays to treatment can occur if the patient with suspected sepsis is inappropriately triaged. The graph below shows that almost 60% of patients with suspected sepsis have been given a Triage category 1 or 2. There are currently more than 100 EDs entering data in the CEC Sepsis Database. By January 2014, over 13,000 cases had been entered in the database - approximately 350-500 cases entered each month. The graph below shows the decrease in the aggregated NSW median time of triage/recognition of sepsis to the time of administration of antibiotics.
Triage Category of NSW Sepsis Patients
60.0% 50.0% % 0f Patients 40.0% 30.0% 20.0% 10.0% 0.0% 1 2 3 4 3.5% 6.6% 0.3% 5 34.9% 53.7%

This is a significant improvement from 2011 when the SEPSIS KILLS program commenced, when less than 40% of patients were triaged Category 1 or 2. The SEPSIS KILLS project team are available to assist with data queries and can provide suggestions on how you could use your data to further drive improvement and highlight success.

Age range is 0-106 yrs with 63% being over 65 yrs

90-95

St Vincents Emergency: The Sepsis Journey so Far

By Julie McCabe, Clinical Nurse Specialist (Grade 2), Emergency Department, St Vincents Hospital

The Emergency Department (ED) is a constant of unpredictable activity. We strive for excellence in the care we provide but how good is it? The SEPSIS KILLS program has afforded us the opportunity to measure outcomes in real time and challenge us to make improvements in care and outcomes for patients with sepsis. Pre-implementation data showed long delays in administration of antibiotics and intravenous fluids with no standard process for recognising septic patients or monitoring of performance. The St Vincents ED Sepsis team comprised key members from the Emergency, Intensive Care and Pharmacy Departments with Executive Sponsorship and support from the Patient Safety and Quality Unit. Interventions included: Development of a local sepsis identification tool, antibiotic guidelines and blood culture process Mandating Triage Category 2 for sepsis Sepsis packages at Triage Sepsis identifiers for medical imaging and pathology to expedite results Posters and education for medical and nursing staff with real cases presented Care bundle monitoring model Weekly data analysis to guide improvement Incident management and analysis Liaison with ICU, ARISE team and the wards.

Several care processes have been improved since 2012 including 56% of septic patients being given an ATS Category 2 and 79% have had lactate measures. Median time from triage to administration of first IV antibiotic has been reduced from 190 minutes to 42 minutes. Sepsis is included on the St Vincents Hospital Quality Improvement map and 6-monthly feedback is provided to the Patient Safety and Quality Committee. There is an ED Quality board to display achievements and we provide regular feedback to all staff via a monthly newsletter and reports to meetings in the ED. Next steps include the development of: St Vincents Sepsis Pathway and Policy Blood Culture Policy Coding of the medical record Admitting teams identified for sepsis patients Roll-out e-learning/coding Phase 2 Sepsis in the General Wards and link to the Between the Flags program. The early work in Emergency has produced a successful model that can be replicated in wards across the Hospital to improve patient outcomes and increase staff satisfaction
Acknowledgements: Ms Julie McCabe (Emergency); Dr Andrew Finckh (Emergency) and Dr Brett Gardiner (Director of Clinical Governance, Executive Sponsor

Paediatric Sepsis Update

Sepsis is a difficult diagnosis and there are some specific challenges in the recognition of sepsis in children. The physiological responses to sepsis (fever, tachycardia and tachypnoea) may be similar in children with viral illness and high fever causing tachycardia and tachypnoea. It is important to avoid treatment of a large number of children with antibiotics and fluids unnecessarily. On the other hand, the natural progression of sepsis in children means that early recognition and management is crucial. Due to these challenges the emphasis is on having a senior clinician involved for these patients when they activate the pathway with risk factors and abnormal observations. Documentation of this practice is a critical component to the escalation process. Congratulations to the 145 emergency departments who have implemented the paediatric pathway and resources. The pathway is now available on the CEC sepsis web page as a worksheet which combines the sepsis pathway and data collection sheet. At the CEC, we are constantly inspired by the ingenuity of sites in adapting and implementing these resources locally. There are now 58 sites (350 records) entering paediatric data into the CEC sepsis database. Keep up the good work. Ongoing education has been the major factor to the success of the program. The Paediatric Emergency Sepsis Learning Sessions will continue during April and June. These sessions are not only a great opportunity to see paediatric sepsis case studies, but also to hear about the experiences of emergency departments across NSW where the pathway was utilised successfully and achieved positive outcomes. Thank you to all the clinical leads and champions across the state responsible for the success of this important program.

Top Tips for Paed Sepsis

Children can compensate with sepsis for some time maintaining their blood pressure with increasing heart rate. Persistent tachycardia is often consistent with sepsis. Senior clinician involvement is crucial for all patients activating the pathway. Not all infants and children with sepsis will present with a fever. Rapid antibiotic and aggressive fluid resuscitation improves survival (every hour a child remains in shock their mortality rate doubles). Early recognition and management is crucial - when untreated this is followed by a rapid deterioration in BP and cardiac function - a state which is often difficult to reverse.

Sepsis Noticeboard
Upcoming Sepsis Learning Sessions
25 March & 15 May 2014: Inpatient Sepsis Program: WHAT, WHY, WHEN? 16 April 2014: Paediatric Sepsis Toolkit 23 April 2014: Bugs, Drugs and Sepsis 17 June 2014: Paediatric Sepsis Toolkit

Inpatient SEPSIS KILLS Program Launch

2 May 2014: See your LHD Sepsis Lead for further information

If you would like more information on the activities above, please email the CEC sepsis team sepsis@cec.health.nsw.gov.au For further information on the SEPSIS KILLS program, scan the QR code with your Smart Phone or Android or visit:

www.cec.health.nsw.gov.au/programs/sepsis