From confusion to consensus: The Oxford AHSN Sepsis Pathway Andrew Brent Sepsis Clinical Lead, Oxford AHSN & Oxford University Hospitals NHS Foundation Trust
2013 2014 2015 2016 2017 From: The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) JAMA. 2016;315(8):801-810. doi:10.1001/jama.2016.0287
Oxford AHSN Sepsis Group Aims Share experience of QI initiatives Share resources (e.g. for training) Share data (process & outcome; combine to max learning) Joint QI projects (± research) Collaboratively review & apply guidelines
Oxford AHSN Regional pathway Oxford AHSN Regional pathway Will you be implementing NICE? National Sepsis Stakeholder Audit Adults es 24% Partially 51% No 25% 82 respondents >50 acute Trusts
Oxford AHSN approach Regional approach to implementation Integrate into existing pathways Community Acute admissions Deteriorating patients (Track & Trigger / Early Warning Scores) Build on progress already made Red Flag Sepsis Sepsis Six Neutropaenic Sepsis
THINK SEPSIS Person with possible Person infection with possible infection Think could this be Think sepsis? could if this they present be sepsis? with signs if they or symptoms present with that signs indicate or symptoms infection, that even indicate if they do infection, not have even a high if they do not have a high temperature. temperature. Be aware that people with Be aware sepsis that may people have non-specific, with sepsis may non-localising have non-specific, presentations non-localising (for example, presentations feeling very (for unwell. example, feeling very unwell. Pay particular attention Pay to concerns particular expressed attention by to concerns the person expressed and family/carer. by the person and family/carer. Take particular care in the Take assessment particular care of people in the who assessment might have of people sepsis who might are unable, have sepsis or their who parent/carer unable, is or unable, their parent/carer to give a good is unable, to give a good history (for example, young history children, (for example, people young with English children, as a people second with language, English people as a second with communication language, people problems) with communication problems) ASSESSMENT ASSESSMENT People more vulnerable People to sepsis more vulnerable to sepsis the very young (under 1 the year) very and young older (under people 1 year) (over and 75 years) older or people very frail (over people 75 years) or very frail people Assess people with suspected Assess people infection with to identify: suspected infection to identify: recent trauma or surgery recent or invasive trauma procedure or surgery (within or invasive the last procedure 6 weeks) (within the last 6 weeks) likely source of infection likely source of infection Impaired immunity due Impaired to illness immunity or drugs (for due example, to illness people or drugs receiving (for example, steroids, people chemotherapy receiving steroids, or chemotherapy or risk factors (see righthand risk box) factors (see righthand box) immunosuppressants) immunosuppressants) Indicators of clinical of Indicators concern such of clinical as of concern such as Indwelling lines / catheters Indwelling / intravenous lines / catheters drug misusers, / intravenous any breach drug of misusers, skin integrity any breach (for example, of skin any integrity cuts, (for example, any cuts, abnormalities of behaviour, abnormalities circulation of or behaviour, circulation or burns, blisters or skin infections). burns, blisters or skin infections). respiration. respiration. If at risk of neutropenic If at sepsis risk of - neutropenic refer to secondary sepsis - care refer to secondary care Healthcare professionals Healthcare performing professionals a remote performing a remote assessment of a person assessment with suspected of a person infection with suspected infection Additional risk factors for Additional women risk who factors are pregnant for women or who who have are been pregnant pregnant, or who given have birth, been had pregnant, a termination given birth, had a termination should seek to identify should factors seek that increase to identify risk factors of that increase risk or miscarriage of within the or past miscarriage 6 weeks within -gestational the past diabetes, 6 weeks diabetes -gestational or other diabetes, co-morbidities; diabetes or needed other co-morbidities; invasive needed invasive sepsis or indicators of clinical sepsis or concern. indicators of clinical concern. procedure such as caesarean procedure section, such forceps as caesarean delivery, section, removal forceps of retained delivery, products removal of of conception, retained products prolonged of conception, prolonged rupture of membranes, rupture close contract of membranes, with someone close contract with group with A someone streptococcal with infection, group A streptococcal have continued infection, vaginal have continued vagin bleeding or an offensive bleeding vaginal or discharge). an offensive vaginal discharge). Consider RISK FACTORS & Indicators of CLINICAL CONCERN Structured Assessment: Sepsis not suspected Sepsis not suspected no clinical cause for concern no clinical cause for concern no risk factors. no risk factors. Use clinical judgment Use to clinical treat the judgment to treat the person, using NICE guidance person, relevant using NICE guidance relevant to their diagnosis Observations when to available. their diagnosis when & available. Early Warning Scores SUSPECT SEPSIS SUSPECT SEPSIS If sepsis is suspected, use If sepsis a structured is suspected, set of use observations a structured to assess set of observations people in a face-to-face assess people setting. a face-to-face setting. Consider using early warning Consider scores using in early hospital warning settings. scores in hospital settings. Parental or carer concern Parental is important carer and concern should is be important acknowledged. and should be acknowledged. Stratify risk of severe illness Stratify and risk death of severe from illness sepsis and using death algorithm from sepsis appropriate using algorithm to age and appropriate setting to age and setting
Communication: Lactate > 2 mmol/l 5 Check haemoglobin and serial lactates. Heart rate > 130 per minute Inform senior clinician 6 Hourly (e.g. registrar urine output or above). measurement. Respiratory rate > 25 per minute Additional: Record the time each of these actions is Oxygen saturations < 91% Bloods should include: completed. FBC, U/E s, All actions LFT s, should and be completed as clotting profile. soon as possible but always within 60 minutes. Responds only to voice or pain/ unresponsive Observations Purpuric rash should be taken every 30 minutes Lactate should be repeated Communication: within 2 hours. NICE High Risk Red Flag Sepsis Perform a CXR and Inform Urinalysis senior clinician (e.g. registrar or above). Consider source control Additional: ( e.g. surgical intervention) Bloods should include: FBC, U/E s, LFT s, and clotting profile. 34 mmol/l, INR > 1.5, Lactate > 2 mmol/l, Platelets <100x10 9 /L, Creatinine Observations >177 mmol/l should be taken every 30 minutes Lactate should be repeated within 2 hours. Perform a CXR and Urinalysis Consider source control ( e.g. surgical intervention) * = Bilirubin > 34 mmol/l, INR > 1.5, Lactate > 2 mmol/l, Platelets <100x10 9 /L, Creatinine >177 mmol/l
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 2 94-98% (88-92% if risk of T2RF) Blood cultures Lactate Monitoring (urine output) Sepsis Six Source Identification & Control Escalation criteria
Oxford AHSN Regional pathway Oxford AHSN Regional pathway Oxford AHSN Regional pathway
% % Oxford AHSN Version our logo (use%sbar)% Sepsis Six Pathway minor wording changes Source#control# # simplified escalation criteria or%if%pa1ent%cri1cally%ill%at%any%1me% % Sepsis Six and Red Flag Sepsis are copyright to and intellectual property of the UK Sepsis Trust, registered charity no. 1158843. sepsistrust.org
Sepsis Six and Red Flag Sepsis are copyright to and intellectual property of the UK Sepsis Trust, registered charity no. 1158843. sepsistrust.org Oxford AHSN Version 1 our 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/): Name (print): Designation: Signature:... Early Warning Score Important: Is an end of life pathway in place? es Is escalation clinically inappropriate? es Initials Discontinue pathway 1. Does patient look sick? OR NEWS 3 [Inpatients 5 or single parameter 3]? 2. Could this be due to an infection? es, but source unclear at present Pneumonia Urinary Tract Infection Abdominal pain or distension Cellulitis/ septic arthritis/ infected wound Device-related infection Meningitis Other (specify:..) 3. AN 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 Tick Tick Tick 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 91-100 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 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) ES NO Time complete Tick Initials Initials Simplified Amber criteria
Oxford AHSN Version 2 our logo Generic Sepsis Screening & Action Tool Patient details (affix label): Staff member completing form:... Date: (DD/MM/):... Name (print): Designation: Signature: N 1. Does patient look sick? OR# 2. Could this be due to an infection? 4. Assess further for possible sepsis No amber criteria: assess all patients N 3. AN red flag criteria?!! N 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. 1158843. sepsistrust.org
Oxford AHSN Regional pathway Paediatric screening tool Oxford AHSN Regional pathway 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]
Going forwards? Churpek et al. AJRCCM 2016
Oxford AHSN approach Regional approach to implementation Integrate into existing pathways Community Acute admissions Deteriorating patients (Track & Trigger / Early Warning Scores) Build on progress already made Red Flag Sepsis Sepsis Six Neutropaenic Sepsis