Improving the management of sepsis in general hospital wards
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Transcript of Improving the management of sepsis in general hospital wards
University of Dundee School of Medicine
Improving the management of sepsis in general hospital wards
Dr Charis MarwickCSO Clinical Academic Fellow & SpR Infectious Diseases
Prof. Peter DaveyProfessor and Consultant in Infectious Diseases
In comparison with severe sepsis on arrival at hospital, less is known about...
• Hospital inpatients who develop sepsis • The potential to improve care for these patients
in general hospital wards• Management in earlier stages of sepsis
– Logical to intervene before deterioration• Patients without proven bloodstream infection
– Previous studies focus on positive blood cultures– Only includes 7-17% of septic patients1
– Mortality and morbidity similar whether +/– ve1,2
1.Jones and Lowe 1996, 2.Kumar et al 2006
Defining the problem• Prospective case-note reviews hospital inpatients
– Develop case identification method: blood cultures taken
– Quantify deficiencies in patient management– Baseline Sept 2008 – Feb 2009 – Post-intervention Oct 2009 – Mar 2010
• Mortality among septic inpatients
Baseline clinical data
Demographic characteristics (n=339)
Mean age : 67 years (range 18-95)
Male gender: 193 (57%)
Ward type:General medicineGeneral surgeryOrthopaedicOther
140 (41%)120 (35%)
31 (9%)48 (14%)
Suspected site of infection:Respiratory tractSkin or soft tissueUrinary tractIntra-abdominalLine infectionOther More than one site
145 (43%)46 (14%)79 (23%)79 (23%)35 (10%)30 (9%)
68 (20%)
Intervention target
• 1144 patients screened, 339 (30%, 95%CI 27-32%) valid cases
Sepsis patients per ward
0
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Medicine:26 patients per month;
11 Wards
Surgery:21 patients per month;
6 Wards
Orthopaedics:5 patients per month;
4 Wards
Seps
is p
atien
ts p
er w
ard
per m
onth
Mean 2.3
Mean 3.6
Mean 0.7
Baseline study outcomes
Timing antibiotic therapy after sepsis onset (n=279)
Within four hours 107 (38%, 95%CI 33-44%)Mean 10.9 hours (95%CI 9.3-12.4)Median 6.0 hours (IQR 2.4-13.0)Within eight hours 169 (61%, 95%CI 55-66%)
Timely medical review (n=291) 139 (48%, 95%CI 42-54%Blood cultures before antibiotics (n=268) 212 (79%, 95%CI 74-84%)Severity assessment (n=339) 80 (24%, 95%CI 19-28%)Main component of delay = time between medical review and antibiotic prescription (mean 7.2 hours, median 2.5 hours)
Where do delays occur???
?? 1.0
0.0
3.2
7.1
0.9
Mean time in hours
Median time in hours
Main delay is from review to prescription
2.4
Improvement strategy• Implement intervention in Medical, Surgical and
Orthopaedic wards– 86% patients, feasible
• Sepsis “tools” = clinical care pathways– Recognition, risk stratifying and management
• Education and raising awareness – Presented to >300 clinical staff in Ninewells
• Monthly performance feedback to clinicians– Displayed as posters on intervention wards – Emailed to clinical staff
Outcome measure Pre-intervention cohort
Post-intervention cohort
Difference and significance test result
Antibiotics within four hours
91/241 (38%)(95%CI 32-44%)
139/297 (47%)(95%CI 41-52%)
9%X2=4.44, df=1, p=0.04
Antibiotics within eight hours
145/241 (60%)(95%CI 54-66%)
198/297 (67%)(95%CI 61-72%)
7%X2=2.43, df=1, p=0.12
Mean time to antibiotics
11.0hrs(95%CI 9.3-12.7hrs)
9.5hrs(95%CI 8.1-11.0hrs)
1.5hrst=1.30, df=536, p=0.19
Median time to antibiotics
6.0hrs(IQR 2.5-13.3hrs)
4.5hrs(IQR 2.0-12.0hrs)
1.5hrsU=32460, p=0.06
Timely medical review 118/251 (47%)(95%CI 41-53%)
126/250 (50%)(95%CI 44-57%)
3%X2=0.58, df=1, p=0.49
Blood cultures taken before antibiotics
183/230 (80%)(95%CI 74-85%)
246/290 (85%)(95%CI 81-89%)
5%X2=2.46, df=1, p=0.12
Blood lactate level measured (severity)
31/291 (11%)(95%CI 7-14%)
87/346 (25%)(95%CI 21-30%)
14%X2=21.99, df=1, p<0.01
Summary• Sepsis is common (>40 cases per month) in
Medical and Surgical Specialties • BUT, each Ward only has 1-6 patients per
month• Main delay in Time to First Antibiotic Dose
occurs AFTER medical review• Guidelines, education, audit &feedback at
Specialty level had little impact
Conclusions• Collection and reflection on measures for
improvement should be at Ward level– Weekly identification of case(s)
• EWS charts• Antibiotic prescriptions• Blood cultures• HDU transfers
– Weekly run chart of individual patient Time to First Antibiotic Dose
– Monthly report on Sepsis Six
Run Chart, Medical Ward, Sepsis & EWS 4+
0
5
10
15
20
25
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
Tim
e to
Firs
t Anti
bioti
c Dos
e (h
ours
)
Cases in date order
RESULTS: MORTALITY
Sepsis at Ninewells Hospital• 12 months data
Total Per Month
Blood cultures taken 2603 217
Patients screened for sepsis 2157 180
Patients with sepsis 1342 (62% BCs) 111
Hospital onset sepsis 641 (48% sepsis) 53
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Any blood culture versus comparators
BC with Sepsis versus comparators
BC without sepsis versus comparators
Odd
s Rati
o 30
Day
Mor
talit
y
Odds ratio for mortality in comparison with patients hospitalised on the same wards with the same length of stay (+ 1 day), adjusted for age, gender and co-morbidity
13% definite +ve
2% definite +ve
Mortality, multivariable analysis• 30 day: 124/640 (19%, 95%CI 16-22%)• 90 day: 180/640 (28%, 95%CI 25-32%)• Age (not comorbidity, gender or SIMD) associated• Severity scores risk-stratify, CURB65 performed best• Admission type, days to onset, and ward associated
Proposal• Mortality (30 day) in any patient who has
had a blood culture taken is likely to be a more specific outcome measure for sepsis than total hospital mortality
• Further work with SPSP hospitals & ISD– Prevalence of sepsis in BC patients– Identification of BC patients by Ward– Record linkage to standardise mortality