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Improving the management of sepsis in general hospital wards

Improving the management of sepsis in general hospital wards. Dr Charis Marwick CSO Clinical Academic Fellow & SpR Infectious Diseases Prof. Peter Davey Professor and Consultant in Infectious Diseases. In comparison with severe sepsis on arrival at hospital, less is known about.

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Improving the management of sepsis in general hospital wards

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  1. Improving the management of sepsis in general hospital wards Dr Charis Marwick CSO Clinical Academic Fellow & SpR Infectious Diseases Prof. Peter Davey Professor and Consultant in Infectious Diseases

  2. 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

  3. 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

  4. Baseline clinical data • 1144 patients screened, 339 (30%, 95%CI 27-32%) valid cases Intervention target

  5. Sepsis patients per ward

  6. Baseline study outcomes Main component of delay = time between medical review and antibiotic prescription (mean 7.2 hours, median 2.5 hours)

  7. Where do delays occur? ?? 3.2 ?? 1.0 7.1 2.4 Mean time in hours Median time in hours Main delay is from review to prescription 0.9 0.0

  8. 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

  9. 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

  10. 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

  11. Run Chart, Medical Ward, Sepsis & EWS 4+

  12. Results: mortality

  13. Sepsis at Ninewells Hospital • 12 months data 13% definite +ve 2% definite +ve

  14. 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

  15. 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

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