Sepsis in primary care. what is good care?

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1 Sepsis in primary what is good care? Emmanuel Nsutebu Consultant Infectious Disease Physician & Clinical lead for sepsis Tropical and Infectious Disease Unit Royal Liverpool Hospital

2 Do you see patients with suspected sepsis?? Pneumonia is the most frequent cause of sepsis especially in winter Have you had your flu jab?

3 Delphine s tragic story

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5 Why is it important for GPs? Delay in diagnosis and referral can be catastrophic GP practice is a risky area Risk Sink You don t see many cases You often see patients early in the course of their illness when there is a higher degree of uncertainty You don t have access to urgent investigations e.g. lactate

6 NCEPOD report Just Say Sepsis! 54 GP case notes reviewed 75% admitted via ED and 8% via AMU No EWS used in any case note Erratic recording of observations BP, HR, less RR, mental status, temperature, blood glucose Evidence of safety netting in 10% of cases GP referral letter could be found in 50% of cases

7 Diagnosis of suspected sepsis written in <50 % of cases 10% had a pre-alert to hospital Room for improvement in 40% of cases

8 Recommendations Use observations and EWS for patients you are admitting or at risk Use safety netting Use standard referral method from primary to secondary care Mention sepsis on referral document Training for all clinical staff Appoint a clinical lead champion??

9 What will we cover? Definition and scale of the problem New sepsis definitions What you can do to save lives What can we do to improve sepsis management in primary care?

10 Definition and diagnosis?

11 Definitions

12 Definitions

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15 New sepsis definition Use infection PLUS SOFA score of > or = 2

16 New septic shock definition Definition needs to be result in higher mortality than new sepsis definition MAP < 65 mmhg not improving with fluid resuscitation +vasopressors AND lactate >2

17 quick SOFA score (qsofa) Reduced GCS (< or =13) Raised RR (> or =22) SBP < or = of these appear to have similar predictive value to SOFA score and superior to SIRS especially outside ICU (Prehospital and ED)

18 qsofa Use qsofa Quick SOFA as simple bedside criteria to identify patients Use this to Screen Investigate for organ dysfunction Initiate treatment Refer to critical care or monitor closely

19 New definition Life threatening organ dysfunction due to a dysregulated response to infection Septic shock is defined as a subset of sepsis with particularly profound circulatory, cellular and metabolic abnormalities associated with a greater risk of mortality than sepsis alone Severe sepsis should no longer be used

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21 Case1 45 year old man Background fit and well Recent sore throat and swelling in parotid area with a diagnosis of mumps Shivering, neck pain, difficulties eating, malaise, painful and swollen right knee and arm over 7 days

22 Presentation On arrival on AMU temp 34, RR 22, HR 69, BP 85 systolic, Right parotid swelling, tender and swollen right calf and knee.

23 Results and management CRP 344 ALT 333 HB 10.6 WCC 3.6 (N 3.2) Platelets 119 Diagnosis Mumps or vasculitis Plan IV fluid, blood cultures and transfer to 3Y on ward -RR 32/HR111/T 38.2/BP 83

24 On ward Diagnosis of septic shock made 17 hours after admission by ID cons Started on meropenem, clindamycin, fluids Admitted to ITU 12 day stay with ventillation and inotropes, parapharyngeal abscess drained Further 3 week stay with rehab? Diagnosis

25 Learning points Patients with sepsis can look well especially if young and fit Sepsis can give you a subnormal body temperature Sepsis should be considered in any acute presentation of someone non specifically unwell Lactate is a useful marker of severity in secondary care!

26 Scale of the problem?

27 Breast cancer

28 Acute MI & Trauma 5% Mortality 3% Mortality 35% for Severe Sepsis and Septic shock currently!

29 Disease burden in UK Every year in the UK there are cases of Sepsis, resulting in a staggering 37,000 deaths more than bowel, breast and prostate cancer combined Northwest perspective cases involving sepsis codes died In hospital mortality rate of 28%

30 Cognitive impairment Iwashyna et al: Long-term cognitive impairment & functional disability among survivors of severe sepsis. JAMA, 2010.

31 Key points Important cause of mortality Morbidity is now an area of focus RCGP intends to make it a priority area or spot light area

32 How can you save lives?

33 Moore LJ, Jones SL, Kreiner LA, et al: Validation of a screening tool for the early identification of sepsis. J Trauma 2009; 66:

34 Early Detection of Sepsis Measure observations and use EWS Use for at risk patients OR patients being admitted? identifies sick patients and gives you a tool to justify need and route of admission??further validation needed Inform the hospital about your suspicion Just say Sepsis! it speeds up their care in secondary care! If evidence of severe sepsis/red flag- admit to ED not AMU

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36 Utility of SIRS criteria for suspected infection Temperature >38.3 or <36.00C New confusion/drowsines Pulse >90/min WBC >12 or <4.0 x 109/L RR >20/min Blood glucose >7.7 mmol/l (not if diabetic)

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38 If any red flags? Arrange blue light ambulance to hospital Document observations, past history, recent antibiotics and drug allergies Ensure the diagnosis of sepsis is recorded in your handover letter

39 If no red flags Document observations Document safety netting Document antibiotics precribed Consider a planned next day review assessment and an invitation for open selfreferral should the patient deteriorate or be concerned

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41 Case 2 40 year old lady Usually fit and well 3 days of fever, rigors followed by profuse vomiting, headache and loose stools on admission BP 80, RR 24, HR 130, Temp 39, SaO2 94% Right flank tenderness WCC24, INR 2.4, lactate 3.5

42 Progress seen by 3 doctors Treated as gastro-enteritis Diagnosis = Sepsis with pyelonephritis!

43 The Sepsis Six 1. Give high-flow oxygen via non-rebreathe bag 2. Take blood cultures and consider source control 3. Give IV antibiotics according to local protocol 4. Start IV fluid resuscitation Hartmann s or equivalent 5. Check lactate 6. Monitor hourly urine output consider catheterisation within one hour..plus Critical Care support to complete EGDT

44 Improving outcomes in sepsis - evidence Early recognition Timely antibiotics Timely and adequate fluid resuscitation Senior review and monitoring of circulation Bundled care

45 Case 3 A 20 year old gentleman was admitted via ED on the 01/03/2015 a week s history of a cough, feeling unwell, fever, arthralgia and myalgia. He was screened for sepsis HR 127, RR 22 and the sepsis bundle started by nursing staff. Admitted to AMU with a diagnosis of LRTI/viral illness following ED consultant review. WCC was raised with neutrophilia. Recalled because of positive blood cultures =???

46 What do these people have in common?

47 Key points Easy to miss SCREEN for sepsis when ever infection suspected or dealing with ill patient!!! Check for red flag signs Just say sepsis and refer to ED if you find red flags Use safety netting in cases of sepsis

48 AMU patient story Hi Emmanuel I just wanted to make you aware of some extremely good practice that I witnessed yesterday. A patient with suspected sepsis was highlighted on the GP phone line. The patient was brought in by ambulance and looked unwell. On arrival to AMU Vicky Price asked the SHO to review this lady immediately. Michelle who was coordinating in assessment organised for this lady to go straight to a bed and she was then triaged efficiently by Paul Scott. The sepsis six bundle was delivered by the team within 30 minutes of arrival. It just shows that when everyone works together great care is delivered. Victoria Riley

49 Thank you Acknowledgement: Ron Daniels, UK Sepsis Trust