Oxford AHSN Regional pathway

Transcription

1 Sepsis progress & challenges: What are we doing regionally? Andrew Brent Infectious Diseases & Medicine Consultant Sepsis Lead, OUH & Oxford Academic Health Sciences Network

2 From: The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) JAMA. 2016;315(8): doi: /jama

3 49,331 patients at 149 New York hospitals Risk adjusted OR for in-hospital mortality 1.04 ( ) per hour Seymour et al. NEJM 2017

4 Oxford AHSN Sepsis Group Aims Share quality improvement initiatives Share resources (e.g. for training) Share data (process & outcome; combine to max learning) Joint quality improvement projects (± research) Collaboratively review & apply guidelines

5 Oxford AHSN Regional pathway Will you be implementing NICE? National Sepsis Stakeholder Audit Adults Yes 24% Partially 51% No 25% 82 respondents >50 acute Trusts

6 Oxford AHSN approach Regional approach to implementation Integrate into existing pathways Community Acute admissions Deteriorating patients (Track & Trigger / Early Warning Scores) Keep simple; build on progress already made Red Flag Sepsis Sepsis Six Neutropaenic Sepsis Murray, Brent. Clinical Medicine 2018 (in press)

7 Person with possible infection Person with possible infection THINK SEPSIS be Think couldif this be sepsis? if they present with or symptoms infection, if they do not have a high Think could this sepsis? they present with signs or symptoms thatsigns indicate infection, that evenindicate if they do not haveeven a high temperature. temperature. with Be aware with sepsis may have non-specific, non-localising presentations (forunwell. example, feeling very unwell. Be aware that people sepsisthat maypeople have non-specific, non-localising presentations (for example, feeling very Pay particularexpressed attention by to concerns expressed by the person and family/carer. Pay particular attention to concerns the person and family/carer. Takeassessment particular care in thewho assessment of people have sepsis are unable,is or their parent/carer Take particular care in the of people might have sepsis who might are unable, or theirwho parent/carer unable, to give a goodis unable, to give a good history (for example, children, Englishpeople as a second language, peopleproblems) with communication problems) history (for example, young children, people young with English as apeople secondwith language, with communication ASSESSMENT People more vulnerable to sepsis People more vulnerable to sepsis the very young (under year) older(under people (over and 75 years) very frail 1the veryand young 1 year) older or people (overpeople 75 years) or very frail people Assess people with suspected infection to identify: recent trauma or surgery or invasive the last 6 weeks) Assess people with suspected infection to identify: recent traumaprocedure or surgery(within or invasive procedure (within the last 6 weeks) likely source of infection Impaired immunitydueimpaired to illnessimmunity or drugs (for steroids, chemotherapy or likely source of infection dueexample, to illness people or drugsreceiving (for example, people receiving steroids, chemotherapy or risk factors (see righthand immunosuppressants) immunosuppressants) risk box) factors (see righthand box) Indicators of clinical of Indicators concern such as / intravenous drug misusers, any breach skin integrity (for example, cuts, (for example, any cuts, of clinical of concern such as Indwelling lines / catheters Indwelling lines / catheters / intravenous drugofmisusers, any breach of skin any integrity abnormalities of behaviour, circulation abnormalities ofor behaviour, circulation or burns, blisters or skin infections). burns, blisters or skin infections). respiration. respiration. ASSESSMENT If at risk of neutropenic refer to secondary If atsepsis risk of -neutropenic sepsis -care refer to secondary care Healthcare professionals performing a remote performing a remote Healthcare professionals assessment of a personassessment with suspected infection of a person with suspected infection Additional risk factors for womenrisk whofactors are pregnant or who have pregnant, a termination Additional for women who are been pregnant or whogiven havebirth, beenhad pregnant, given birth, had a termination should seek to identify should factors seek that increase risk of that increase risk to identify factors of or miscarriage within the 6 weekswithin -gestational or other co-morbidities; invasive or past miscarriage the pastdiabetes, 6 weeks diabetes -gestational diabetes, diabetes orneeded other co-morbidities; needed invasive sepsis or indicators of clinical concern. sepsis or indicators of clinical concern. procedure such as caesarean section, delivery, removal of retained products ofof conception, prolonged procedure suchforceps as caesarean section, forceps delivery, removal retained products of conception, prolonged rupture of membranes,rupture close contract with someone with group streptococcal have continued vaginalhave continued vagin of membranes, close contract witha someone withinfection, group A streptococcal infection, bleeding or an offensivebleeding vaginal or discharge). an offensive vaginal discharge). Consider RISK FACTORS & Indicators of CLINICAL CONCERN Sepsis not suspected Sepsis not suspected Structured Assessment: no clinical cause for concern no clinical cause for concern no risk factors. no risk factors. SUSPECT SEPSIS SUSPECT SEPSIS If sepsis is suspected, use a structured set of use observations to assess people in a face-to-face setting. If sepsis is suspected, a structured set of observations to assess people in a face-to-face setting. Consider using early warning scores hospital settings. Consider usinginearly warning scores in hospital settings. Parental or carer concern is important shouldis be acknowledged. Parental or carerand concern important and should be acknowledged. Use clinical judgmentuseto clinical treat the judgment to treat the person, using NICE guidance person, relevant using NICE guidance relevant to their diagnosis whentoavailable. their diagnosis when available. Observations & Early Warning Scores Stratify risk of severe illness and death from illness sepsis and usingdeath algorithm appropriate to age andappropriate setting Stratify risk of severe from sepsis using algorithm to age and setting

8 NICE High Risk Red Flag Sepsis

9 NICE Care Bundle IV Antibiotics Pre-alert secondary care if high risk / red flag sepsis Mechanism for delivery pre-hospital if >1h transfer BenPen pre-hospital for suspected meningococcal disease IV Fluids - guided by need / lactate Consider Oxygen - target SaO % (88-92% if risk of T2RF) Blood cultures Lactate Monitoring (urine output) Sepsis Six Source Identification & Control Escalation criteria

10 Oxford AHSN Regional pathway Oxford AHSN Regional pathway

11 Sepsis Six and Red Flag Sepsis are copyright to and intellectual property of the UK Sepsis Trust, registered charity no sepsistrust.org Oxford AHSN Version 1 Your logo Patient details (affix label):... Generic Sepsis Screening & Action Tool To be applied to all non-pregnant adults and young people over 16 years with symptoms of infection, or who are clearly unwell with any abnormal observations Staff member completing form: Date: (DD/MM/YY): Name (print): Designation: Signature:... Early Warning Score Important: Is an end of life pathway in place? Yes Is escalation clinically inappropriate? Yes Initials Discontinue pathway 1. Does patient look sick? OR NEWS 3 [Inpatients 5 or single parameter 3]? Y 2. Could this be due to an infection? Yes, but source unclear at present Pneumonia Urinary Tract Infection Abdominal pain or distension Cellulitis/ septic arthritis/ infected wound Device-related infection Meningitis Other (specify:..) Y 3. ANY red flag criteria? Objective evidence of new altered mental state Heart rate > 130 per minute Systolic B.P 90 mmhg (or drop >40 from normal) Respiratory rate 25 per minute New O 2 requirement to keep SaO 2 92% (88% in COPD) Non-blanching rash / mottled / ashen / cyanotic Not passed urine in last ~18 h (or U.O. <0.5 ml/kg/hr) Lactate 2 mmol/l (if available) Severe immunosuppression, e.g. suspected neutropaenia Y Tick Tick Tick Y N N N Low risk of sepsis if normal behaviour and no high or moderate risk criteria present. Use standard protocols, consider discharge (approved by senior decision maker) with safety netting 4. Any amber flags (other sepsis concern)? Other risk factor(s) for severe infection 1 Acute deterioration in functional/mental state Systolic BP mmhg or new arrhythmia Hypothermia Patient, relative or health professional remains worried 1 E.g. recent surgery; immunosuppression; oral steroids; rapidly spreading cellulitis or possible necrotizing fasciitis (Is pain out of proportion to clinical signs of cellulitis?). [N.B. severe immunosuppression incl. neutropaenia = red flag ] Treat Urgently for Sepsis NOW (see overleaf) This is time critical, immediate action is required. N Y Send bloods (including blood cultures, FBC, U&Es, CRP, LFTs, clotting, VBG) Organize early clinical assessment USE SBAR! Review results within 1 hour Time clinician attended Clinician to make antimicrobial prescribing decision within 3h. Treat all bacterial infections promptly. If senior clinician happy, may discharge with appropriate safety netting [ED/AMU] Time complete AKI or Lactate 2? (& infection concern persists) YES NO Time complete Tick Initials Initials Simplified Amber criteria

12 Oxford AHSN Version 2 Early Warning Score Your logo Generic Sepsis Screening & Action Tool Patient details (affix label): Staff member completing form:... Date: (DD/MM/YY):... Name (print): Designation: Signature: N 1. Does patient look sick? OR# Y 2. Could this be due to an infection? 4. Assess further for possible sepsis No amber criteria: assess all patients N Y 3. ANY red flag criteria?!! N Y Y Treat Urgently for Sepsis NOW (see overleaf) Sepsis Six and Red Flag Sepsis are copyright to and intellectual property of the UK Sepsis Trust, registered charity no sepsistrust.org

13 Paediatric screening tool Regional Collaboration Paediatric Critical Care Network (PCCN) Children s Network Oxford & Wessex AHSNs Validated against NICE guideline Audit of 227 notes (PCCN) Equally sensitive, more specific Adopted by Oxford AHSN Sepsis group Implemented across Thames Valley including Oxford, Buckinghamshire, Milton Keynes, Frimley Health [Swindon agreed in principle]

14 Oxford AHSN Regional(OUH) pathway Technological innovation

15 Person with possible infection Person with possible infection THINK SEPSIS be Think couldif this be sepsis? if they present with or symptoms infection, if they do not have a high Think could this sepsis? they present with signs or symptoms thatsigns indicate infection, that evenindicate if they do not haveeven a high temperature. temperature. with Be aware with sepsis may have non-specific, non-localising presentations (forunwell. example, feeling very unwell. Be aware that people sepsisthat maypeople have non-specific, non-localising presentations (for example, feeling very Pay particularexpressed attention by to concerns expressed by the person and family/carer. Pay particular attention to concerns the person and family/carer. Takeassessment particular care in thewho assessment of people have sepsis are unable,is or their parent/carer Take particular care in the of people might have sepsis who might are unable, or theirwho parent/carer unable, to give a goodis unable, to give a good history (for example, children, Englishpeople as a second language, peopleproblems) with communication problems) history (for example, young children, people young with English as apeople secondwith language, with communication ASSESSMENT People more vulnerable to sepsis People more vulnerable to sepsis the very young (under year) older(under people (over and 75 years) very frail 1the veryand young 1 year) older or people (overpeople 75 years) or very frail people Assess people with suspected infection to identify: recent trauma or surgery or invasive the last 6 weeks) Assess people with suspected infection to identify: recent traumaprocedure or surgery(within or invasive procedure (within the last 6 weeks) likely source of infection Impaired immunitydueimpaired to illnessimmunity or drugs (for steroids, chemotherapy or likely source of infection dueexample, to illness people or drugsreceiving (for example, people receiving steroids, chemotherapy or risk factors (see righthand immunosuppressants) immunosuppressants) risk box) factors (see righthand box) Indicators of clinical of Indicators concern such as / intravenous drug misusers, any breach skin integrity (for example, cuts, (for example, any cuts, of clinical of concern such as Indwelling lines / catheters Indwelling lines / catheters / intravenous drugofmisusers, any breach of skin any integrity abnormalities of behaviour, circulation abnormalities ofor behaviour, circulation or burns, blisters or skin infections). burns, blisters or skin infections). respiration. respiration. ASSESSMENT If at risk of neutropenic refer to secondary If atsepsis risk of -neutropenic sepsis -care refer to secondary care Healthcare professionals performing a remote performing a remote Healthcare professionals assessment of a personassessment with suspected infection of a person with suspected infection Additional risk factors for womenrisk whofactors are pregnant or who have pregnant, a termination Additional for women who are been pregnant or whogiven havebirth, beenhad pregnant, given birth, had a termination should seek to identify should factors seek that increase risk of that increase risk to identify factors of or miscarriage within the 6 weekswithin -gestational or other co-morbidities; invasive or past miscarriage the pastdiabetes, 6 weeks diabetes -gestational diabetes, diabetes orneeded other co-morbidities; needed invasive sepsis or indicators of clinical concern. sepsis or indicators of clinical concern. procedure such as caesarean section, delivery, removal of retained products ofof conception, prolonged procedure suchforceps as caesarean section, forceps delivery, removal retained products of conception, prolonged rupture of membranes,rupture close contract with someone with group streptococcal have continued vaginalhave continued vagin of membranes, close contract witha someone withinfection, group A streptococcal infection, bleeding or an offensivebleeding vaginal or discharge). an offensive vaginal discharge). Consider RISK FACTORS & Indicators of CLINICAL CONCERN Sepsis not suspected Sepsis not suspected Structured Assessment: no clinical cause for concern no clinical cause for concern no risk factors. no risk factors. SUSPECT SEPSIS SUSPECT SEPSIS If sepsis is suspected, use a structured set of use observations to assess people in a face-to-face setting. If sepsis is suspected, a structured set of observations to assess people in a face-to-face setting. Consider using early warning scores hospital settings. Consider usinginearly warning scores in hospital settings. Parental or carer concern is important shouldis be acknowledged. Parental or carerand concern important and should be acknowledged. Use clinical judgmentuseto clinical treat the judgment to treat the person, using NICE guidance person, relevant using NICE guidance relevant to their diagnosis whentoavailable. their diagnosis when available. Observations & Early Warning Scores Stratify risk of severe illness and death from illness sepsis and usingdeath algorithm appropriate to age andappropriate setting Stratify risk of severe from sepsis using algorithm to age and setting

16 National Early Warning Score (NEWS)

17 Supplemental Oxygen Temperature Level of Consciousness (defined on the AVPU system) AHSN Regional pathway National EarlyOxford Warning Score (NEWS) The NEWS scores are directly linked to mortality, the higher the score above what would normally be expected for the patient, the worse the prognosis. When a single admission NEWS score is taken in patients with symptoms of infection (the commonest reason for admission) the mortality equates to: NEWS Score Mortality 0 0.5% <5 5.5% 5 22% 7 27% 9 38% Baseline observations Patients with chronic hypoxic states (e.g. COPD) are likely to always score for hypoxia even when well; knowing their baseline oxygen level and the presence of a deterioration in this and in their function is the best guide to determine admission A single admission NEWS score in patients with symptoms of infection predicts mortality

18 Vital Signs in General Practice Vital signs inconsistently recorded Safety netting advice not routinely documented Currently exploring NEWS implementation in primary care Audit of 123 patients admitted to hospital and vital signs recorded at last GP visit

19 NEWS and Sepsis Churpek et al. AJRCCM 2016

20

21 What s new in NEWS2?

22 Your logo Oxford AHSN Version 2 Oxford Generic Sepsis Screening & Action Tool Patient details (affix label): Staff member completing form:... Early Warning Score Date: (DD/MM/YY):... Name (print): Designation: Signature: AHSN Regional pathway N 1. Does patient look sick? OR# Y 2. Could this be due to an infection? 4. Assess further for possible sepsis No amber criteria: assess all patients N Y 3. ANY red flag criteria?!! N Y Y Treat Urgently for Sepsis NOW (see overleaf) Sepsis Six and Red Flag Sepsis are copyright to and intellectual property of the UK Sepsis Trust, registered charity no sepsistrust.org

23 Ambulance Service Hospitals NEWS2

24 Measurement & Publication Surveillance challenges HES sepsis codes insensitive QI initiatives ascertainment bias Need improved case definition HES Bacterial infection ( SOS ) codes More sensitive, less ascertainment bias Temporal and geographic trends Inada-Kim et al. BMJ Open 2017 Presented at Sepsis Unplugged 2016 NHSE collaboration to extend nationally

25 Education Oxford AHSN Regional pathway

26 Oxford AHSN Regional pathway Sepsis Working Together event Oxford, 19 Sep 2016pathway Oxford AHSN Regional 110 delegates Acute Trusts (6) Community Trusts (2) Clinical Commissioning Groups (2) South Central Ambulance Service Private Hospitals (3) Care home providers NHS England Oxford AHSN Oxford University

27 Patient information

28 Some Challenges Common language Sepsis = bad infection Deterioration (NEWS)

29 Some Challenges Common language Sepsis = bad infection Deterioration (NEWS) Competing clinical priorities

30 Some Challenges Common language Sepsis = bad infection Deterioration (NEWS) Competing clinical priorities Antibiotic resistance Targeting antibiotics appropriately Antimicrobial Stewardship

31 It s all about patients What can we learn? What can we improve? What might we do together?