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Sepsis Masterclass 3
Tuesday 3 February 2016
Welcome & Introductions
Lesley Jordan, Consultant Anaesthetist
Royal United Hospital Bath
#sepsissavvy
About the WEAHSN
The West of England AHSN is delivering positive healthcare outcomes
locally and nationally by driving the...
Session 1 – The UK Picture
Chair: Dr Amanda Pegden
Great Western Hospital Swindon
#sepsissavvy
Sam’s Story
Susanna Morrish
Mother
#sepsissavvy
@SepsisUK
The changing face of sepsis.
Dr Ron Daniels B.E.M.
CEO, UK Sepsis Trust
CEO, Global Sepsis Alliance
Breast cancer
Iwashyna et al: Long-term cognitive impairment & functional disability among survivors of severe sepsis.
JAMA, 2010.
16.8
...
Basics limit severity
NCEPOD 2015
@SepsisUK
Prehospital care
@SepsisUK
At least
53% of
patients
had sepsis
prior to
arrival in
hospital
ED & hospital care
@SepsisUK
Recognition 2014-16
@SepsisUK
Burns
Burns
Infection Sepsis
Severe
Sepsis
Septic
shock
Systemic Inflammatory Organ dysfunction Hypoperfusion
Response (SI...
Burns
Burns
Infection Sepsis
Severe
Sepsis
Septic
shock
Systemic Inflammatory Organ dysfunction Hypoperfusion
Response (SI...
Funk and Kumar
Critical Care Clinics 2011 (in press)
‘For each hour’s delay in
administering antibiotics,
mortality increa...
Burns
Burns
Infection Sepsis
Severe
Sepsis
Septic
shock
Systemic Inflammatory
Response (SIRS)
<1% 10% 35%
Burns
Burns
Infection Sepsis
Severe
Sepsis
Septic
shock
Burns
Burns
Infection Sepsis
Severe
Sepsis
Septic
shock
Systemic Inflammatory Organ dysfunction Hypoperfusion
Response (SI...
CVS SBP <90, MAP <70, or SBP decrease >40
SvO2 70% or ScvO2 <65%
Cardiac index <3.5 Lmin-1
Decreased capillary refill or m...
Prehospital SepsisScreeningandActionTool
1. Areany2of thefollowingpresent?
Temperature > 38.30Cor < 360C
Respiratoryrate >...
3. Is any red flag present?
Systolic B.P < 90 mmHg or MAP < 65 mmHg
Lactate > 2 mmol/l
Heart rate > 130 per minute
Respira...
3. Is any red flag present?
Systolic B.P <90 mmHg/ MAP <65 mmHg
Lactate >2 mmol/l
Heart rate >130 per minute
Respiratory r...
3. Is any red flag present?
Systolic B.P <90 mmHg/ MAP <65 mmHg
Lactate >2 mmol/l
Heart rate >130 per minute
Respiratory r...
3. Is any red flag present?
Systolic B.P <90 mmHg/ MAP <65 mmHg
Lactate >2 mmol/l
Heart rate >130 per minute
Respiratory r...
3. Is any red flag present?
Systolic B.P <90 mmHg/ >40mmHg < n.
Lactate >2 mmol/l
Heart rate >130 per minute
Respiratory r...
3. Is any red flag present?
Systolic B.P <90 mmHg/ >40mmHg < n.
Lactate >2 mmol/l
Heart rate >130 per minute
Respiratory r...
3. Is any red flag present?
Systolic B.P <90 mmHg/ >40mmHg < n.
Lactate >2 mmol/l
Heart rate >130 per minute
Respiratory r...
3. Is any red flag present?
Systolic B.P <90 mmHg/ >40mmHg < n.
Lactate >2 mmol/l
Heart rate >130 per minute
Respiratory r...
3. Is any red flag present?
Systolic B.P <90 mmHg/ >40mmHg < n.
Lactate >2 mmol/l
Heart rate >130 per minute
Respiratory r...
3. Is any red flag present?
Systolic B.P <90 mmHg/ >40mmHg < n.
Lactate >2 mmol/l
Heart rate >130 per minute
Respiratory r...
3. Is any red flag present?
Systolic B.P <90 mmHg/ >40mmHg < n.
Lactate >2 mmol/l
Heart rate >130 per minute
Respiratory r...
3. Is any red flag present?
Systolic B.P <90 mmHg/ >40mmHg < n.
Lactate >2 mmol/l
Heart rate >130 per minute
Respiratory r...
3. Is any red flag present?
Systolic B.P <90 mmHg/ >40mmHg < n.
Lactate >2 mmol/l
Heart rate >130 per minute
Respiratory r...
3. Is any red flag present?
Systolic B.P <90 mmHg/ >40mmHg < n.
Lactate >2 mmol/l
Heart rate >130 per minute
Respiratory r...
Managing sepsis
@SepsisUK
To be completed within 3 hours:
1) Measure lactate level
2) Obtain blood cultures prior to administration of antibiotics
3...
Mikkelsen, ME et al. Crit Care Med 2009; 37 (5): 1670-7 n= 830
Risk stratification
Cohort OR for 28 day death p
Non-shock ...
The Sepsis Six
1. Give oxygen as needed to target SpO2 > 94%
2. Take blood cultures consider source control
3. Give IV ant...
Fixing the system.
@SepsisUK
Secretary of State goes further 2016
Systems approach
Rivers 2001
RCT
Sebat 2005
Before-After
Nguyen 2007
Complete or Not
Thiel 2009
Before-After
Levy 2011
Bef...
Breast cancer
Mortality
Breast cancer
ron@sepsistrust.org
@SepsisUK
www.sepsistrust.org
www.world-sepsis-day.org
@NCEPOD
#sepsis
www.ncepod.org.uk
75
Mark Juniper
Great Western Hospitals Swindon
Just Say Sepsis!
• Study description
– Aim, objectives
– Population selected, exclusions
– Data returns, demographics
• Vi...
Study aim and objectives
To identify and explore avoidable and remediable
factors in the process of care for patients with...
Study population
Adult patients diagnosed with sepsis and
admitted to critical care (HDU/ICU) or reviewed
by CCOT or equiv...
Exclusions
• Pregnant women up to 6 weeks post partum
• Patients undergoing chemotherapy, organ
transplant
• Patients alre...
Method
• Prospective case identification
• 5 cases selected per hospital
• Case notes requested, clinician questionnaire
•...
ReturnsReturns
81
DemographicsDemographics
82
• First NCEPOD study to look at whole pathway
• Primary care
• Ambulance service
• Emergency Department
• In-patient care
...
Pre hospital care
EWS was not used in any of the cases reviewed
84
Pre hospital care
GP case note review
85
Pre hospital care
Hospital case note review
86
37 patients had no vital signs recorded at triage or senior review
152/369 (41%) patients complete set between 2 assessmen...
Organisational data
88
Inpatient care
89
Inpatient care
90
Recommendation
An early warning score, such as the National Early
Warning Score (NEWS) should be used in both primary
care...
Recommendations
On arrival in the emergency department a full set of vital
signs, as stated in the Royal College of Emerge...
Delayed review: Emergency care
93
Areas for improvement: Emergency care
94
Areas for improvement: Emergency care
95
17.9% consultant review delayed according to Reviewers
Consultant review: Inpatient care
20.4% > 14 hours
96
Changes made following consultant review in 281/457 (61.5%)
Inpatient care
97
Recommendations
In line with previous NCEPOD and other national reports’
recommendations on recognising and caring for the...
Screening tools to improve diagnosis: Inpatient
care
99
Use of screening tools: Inpatient care
100
128/479 (26%) used screening tool/ EWS
Screening tools reduce delay
28%
36% 35%
55%
30% 31%
101
Care bundles: Inpatient care
102
Blood cultures taken in 366/477 (77%)
fluid cultures in 48, tissue cultures in 43
Blood gases taken in 375/509 (74%)
Inpatient care
103
Inpatient care
104
Inpatient care
Where not timely, patient deteriorated in 51
Outcome affected in 20
105
Inpatient care
Room for improvement in fluid management in 203/447 cases 106
Inpatient care
107
Outcome affected in 43 cases
Inpatient care
108
Inpatient care
• Reviewers: patient started on sepsis care bundle
following diagnosis: 135/434 (31%)
• Clinician questionn...
Inpatient care
110
With care bundle Without care bundle
Delay in escalation 9% 26%
Delay in administration of
administrati...
Recommendations
All patients diagnosed with sepsis should benefit from
management on a care bundle as part of their care
p...
Correlation does not prove
causation but ...
@chris23han
Christopher.hancock2@wales.nhs.uk
NEWS embedded in 18/18 acute ho...
Recommendations
All hospitals should have a formal protocol for the early
identification and immediate management of patie...
Overall quality of care
114
Thank you
www.ncepod.org.uk
115
116
Challenges in recognition
and management of
paediatric sepsis
Akash Deep
Director - PICU
King’s College Hospital
London
SEPSIS EDUCATION MOTIVE
• Raise awareness : all healthcare
professions are capable and should be able
to recognise sepsis ...
Overview
• How big is this problem? - Impact of sepsis
on patient, families, healthcare economy
• Importance of Early diag...
Problem 1
More sepsis around
Retrospective observational cohort dataset from seven U.S.
states from 1995, 2000, and 2005.
Incidence Paediatric Sepsis
Author Sepsis Incidence Year
Watson et al (U.S) 42,364 /annum 1995 ( published 2005)
Hartman M...
Lozano R et al Global and Regional Mortality… Lancet 2012
Global Child Deaths
Global and regional mortality from 235 cause...
Global Years Life Lost By Cause 2010
Lozano R et al Global and Regional Mortality… Lancet 2012
Problem 2
Sepsis is under-reported!!
127
Global Burden of Disease Report
In the WHO’s Global Burden of Disease
Report (GBDR), sepsis appears only as
“neonatal seps...
Overcome deficits in estimating sepsis
cases – only what can be counted counts!
• Coding
• Databases
129
King’s PICANet data by Diagnosis
1-1.2012 – 31-12.2013
Condition n Sepsis Septic shock
Pneumonia 42 3 7
Bronchiolitis 105 ...
Coding data
• Coded 50 set of notes from HDU/PICU,
General Paediatrics, paediatric surgery
and paediatric liver
• Of the 2...
Remedies
To correct this oversight, we need to
achieve the following:
Spread the understanding that most acute
infectious...
Problem 3
Deaths happen early
Septic Shock
referrals
n, (%)
2005 168
2004 131
2003 162 15 (83)
12 (75)
17 (81)
Deaths
pre ICU
18 (11)
16 (12)
21 (13)
De...
Problem 4
Care is often poor
1) Decreased awareness of
medical/paramedical team about sepsis
2) failure to be looked after by a
paediatrician,
3) failu...
Sepsis in children – A challenge
Signs and symptoms may be non-specific
and subtle but deterioration is usually rapid.
P...
yes no I don’t know1000 inhabitants in each
country were interviewed.
Have you heard the term ‘sepsis’ before?
Surviving S...
Experience of sepsis from those who
deal with it at first contact in the
hospital – Awareness and practice
Dr Trisha Radia...
• Variable
• Consistent feature – always some degree
of anxiety and concern
• Positive outcome of anxiety and concern:
– D...
Trainee concerns at different levels
Foundation Year Doctor:
– Knowing what’s normal and what’s not!
Number correctly answ...
Trainee concerns at different levels
Foundation Year Doctor:
– Is it sepsis?
– What questions should I ask?
– Is that hear...
Trainee concerns at different levels
Senior House Officer
– ‘CANNULATE’
– What if I can’t cannulate?
– Have I calculated t...
Trainee concerns at different levels
Paediatric Registrar:
– Central access?
– Fluid/fluid/fluid?
– Anaesthetist : intubat...
Problem / solution 4..
Early Care has a dramatic effect
Crit Care Med 2006: 34(6):1589-96
2,731 adults with septic shock
147
148
5 Component sepsis Bundle
(1)Recognition of septic shock
(2) vascular access
(3) administration of intravenous (IV) fluid
...
American College of Critical Care Medicine-Pediatric Advanced
Life Support Hemodynamic Support Algorithm
Brierley J. Crit ...
• I992/93 – Case fatality from MD – 23%
• New PICU specialising in MD opened
• Implementation of : Health care delivery
sy...
152
Decrease in case fatality
rate from 23 to 2%
&
PRISM adjusted reduction
in OR of mortality of 0.5
PIM2 predicted mortality 15% (6-35)
Findings
Patients in shock at PICU admission – 107 ( 83 who had shock
on referral and did not reverse shock + 24 who were ...
Findings
• 9/107 (8%) followed 2002 ACCM guidelines in
children with shock at PICU admission
• If steroids disregarded – s...
Conclusions
Problem- 5- Not enough realisation that
sepsis is a time critical emergency akin to
MI!!!!!!
Solution to a problem lies in...
158
Background
Root-cause analyses and morbidity and
mortality conferences identified system problems
with sepsis recognition ...
Barriers
• Variation in experience of staff in performing initial
evaluations
• Lack of adequate nursing staff for resourc...
QI Project
Quality-improvement (QI) intervention : recognise shock
and implement early treatment strategy
Computerised tr...
Results
• After protocol initiation- 191 encounters in 167
patients with suspected sepsis.
• Time from triage to first bol...
• Time to first
bolus
• Time to third
bolus
• Time to
antibiotics
• Reduced
mechanical
ventilation
– 3.2% to 2.0%
• Reduce...
Conclusion
The protocol resulted in earlier recognition
of suspected sepsis and substantial
reductions in both time to rec...
165
• 79% shock recognised in 5 minutes of which 59% had vascular access
secured
• Of those with recognised shock + vascul...
Barriers in Early adequate fluid
resuscitation
• Lack of knowledge regarding PALS
recommendations
• Early Recognition/Secu...
QI Project
Plan – do – Study – Act
Focused on IV fluid delivery as a key driver
impacting bundle adherence
169
Level -1 interventions
• Weekly e-mails to individual providers
involved in the care of a specific patient
detailing adher...
Level -2 Reliability interventions
• PALS algorithm with local modifications was
pasted at prominent sites in Resus room,
...
Firing the bolt concept
• Lightening bolt symbol on ED tracking board
with ordering the set – alert the nurses that
patien...
Level -3 interventions – SHOCK CLOCK
• Shock clock was placed in all resuscitation
areas – LARGE AND CENTRALLY PLACED
• Sm...
Effectiveness of interventions - Monthly
• Outcome measures
 Primary – Adherence to the total algorithm bundle
 Secondar...
Median time to administration of IV fluid decreased from 83 minutes in the
baseline group, to 33 minutes in the QI group.
...
Conclusions
• QI interventions planned carefully can go a
long way in improving outcomes
• Importance of knowing what is g...
Common themes at King’s
Review of PICU admissions for paediatric
sepsis – 2014-15
Delayed presentation (parental educatio...
EDUCATION, EDUCATION, EDUCATION
• Awareness
– FY vital sign
– SHO fluid calculations/Abx
– SPR guidelines on referral poli...
Provide operation solutions for
early diagnosis and treatment
Treat sepsis in a time critical
way
181
Y
Is any one Red Flag present?
•Hypotension
•Heart rate
•- Blood gas lactate > 4 mmol/l
•- Capillary refill > 5 seconds
•-...
Paediatric sepsis 6
• Tool designed by UK sepsis Trust to assist clinicians in the
early recognition and timely management...
Future steps
• Implementation of standardised toolkit/guideline with
measurable outcomes – LOS/PICU admission/mortality
• ...
Joint HTA Application
• Imperial – London
• King’s College Hospital
• Birmingham Children’s Hospital
• Leicester- Royal In...
188
Research objectives – Feasibility, impact,
compliance and cost effectiveness
Evaluate the feasibility of implementing ...
SEPSIS IS A MEDICAL EMERGENCY
• Sepsis is very common, but least recognized
disease
• Incidence is increasing dramatically...
190
WORLD SEPSIS DAY -2014
191
Session 2 – Maternity
Chair: Ann Remmers
West of England AHSN and
SW Maternity and Children’s Strategic
Clinical Network
#...
Severe maternal sepsis – key messages for
care from the national confidential enquiries
into maternal morbidity and mortal...
Programmes of work
www.npeu.ox.ac.uk/mbrrace-uk/reports
www.npeu.ox.ac.uk/ukoss/completed-surveillance
Maternal Morbidity and Mortality
Annual Report Topics
• Year 1 (2014): Sepsis, haemorrhage, AFE,
anaesthetic, neurological...
New work – maternal morbidity
• New morbidity topic selected annually
• Confidential enquiry of a sample of
approximately ...
Maternal Mortality 2003-13
35% reduction in overall maternal death rate, p=0.005
Maternal Mortality 2003-13
53% reduction in direct maternal death rate, p=0.005
No significant decrease in indirect matern...
Causes of maternal death 2011-13
Dark bars show indirect causes, pale bars direct causes
Sepsis – all causes 2009-12
Influenza 2009-12
Sepsis mortality 2009-13
Late Maternal Deaths 2009-13
Sepsis morbidity - UKOSS
• 365 women diagnosed with severe sepsis
associated with pregnancy over one year
(47 per 100,000 ...
Sources of severe sepsis
Genital tract
31%
Urinary tract
20%
Wound
9%
Respiratory
5%
Other
9%
Unknown
26%
Acosta, Kurinczu...
Sources of maternal sepsis –
critical care data
Pregnant or recently pregnant women admitted to
critical care UK 2008-2010...
Key message 1
• Genital tract infection forms only a small
proportion of maternal morbidity and
mortality from infectious ...
Vignette: sepsis
Two hours after delivery a woman became unwell on the
postnatal ward feeling faint. Her oxygen saturation...
Vignette; sepsis
Seven days after giving birth a woman became unwell at home
with a fever. She was advised to attend the m...
Confidential Enquiry Themes Postnatal
Delay in Diagnosis & Incomplete Assessment
Recommendations
• In the postnatal period...
Confidential Enquiry Theme:
Delay in Diagnosis
• The key actions for diagnosis and management
of sepsis are:
• Timely reco...
Antibiotics
• Time to administration is a predictor of
mortality.
• From time of diagnosis each hour’s delay
in administra...
Antibiotic administration among
women who died 2009-12
Symptom onset Diagnosis Antibiotics Death
43 40 37
3
<1 hour
3
1 – ...
Causative organisms
Escherichia coli
21%
Group A
streptococcus
9%
Group B
streptococcus
8%
Other
streptococcus
6%Staphyloc...
Causative organism by source
of infection
0
20
40
60
80
100
120
Numberofcases
Source of infection
No Lab confirmed infecti...
Causative organism by mode of
delivery
0
20
40
60
80
100
120
Spontaneous
vaginal
Operative
vaginal
Pre-labour
caesarean
Ca...
Key messages 2
• Antibiotics should cover the appropriate
spectrum, dependent on suspected source
and mode of delivery
• I...
“A woman presented in labour and was noted to have genital
tract sepsis. She was delivered by caesarean section. The
opera...
“A woman was admitted in second trimester with
vomiting and preterm pre-labour rupture of the
membranes. She was septic - ...
Rapid progression to severe
sepsis
• <24 hours between the first signs of SIRS and sepsis:
– 83% of cases and 85% of septi...
Key messages 3
• Use of a sepsis bundle
– International Surviving Sepsis Campaign
– “Sepsis six” (within the first hour):
...
Causative organism according
to septic shock diagnosis
0
5
10
15
20
25
30
35
40
45
50
E.coli Group A
strep
Group B
strep
O...
Rapid progression to severe
sepsis for Group A strep cases
• 50% <2 hours between the first signs of SIRS and sepsis
diagn...
Key messages 4
• Clinical suspicion of group A strep is a red
flag for urgent action
– Association with spontaneous vagina...
Severity
n (%)
Total=365
Level 2 or ITU admission 286 (78)
Level 2 admission 171 (47)
ITU admission* 114 (31)
Septic shock...
Timing of infection
• 37% cases antenatal
• 63% cases postnatal
• Median diagnosis to delivery interval
(antenatal sepsis)...
Key messages 5
• Some women may need intensive care on
delivery suite
• Some women may need obstetric care in
the critical...
Significant medical risk factors
Cases
n (%)
Controls
n (%) aOR* 95% CI
n=365 n=757
Parity
0 197 (54) 330 (44) 1.6 (1.2-2....
Significant delivery risk factors
Postpartum
cases
n (%)
Controls
n (%) aOR* 95% CI
n=302 n=757
Mode of delivery
Spontaneo...
Significant factors associated
with mortality - ICNARC
Survivors
n (%)
Deaths
n (%) aOR* 95% CI
n=610 n=29
Maternal age
<2...
Absolute risk (95% CI) of all sepsis and severe
sepsis/septic shock as a function of the number of
a priori risk factors.
...
Key points 6
• It cannot be assumed that antibiotics will
prevent progression to severe sepsis and
safety net checks shoul...
Influenza: Delays in diagnosis and treatment
• Presentation: Route of presentation into health care
services: 33% to Prima...
“A pregnant woman who smoked refused
vaccination offered by her GP for seasonal
influenza or H1N1. She presented in the
th...
Influenza Vaccination
• Vaccination is the main Public Health
response to influenza
• Influenza vaccination in pregnancy
–...
Influenza Vaccination
• None of the women who died in this review had been
documented to have received seasonal flu vaccin...
Use of neuraminidase inhibitors
• A Cochrane Review (2014) on the efficacy of
neuraminidase inhibitors for influenza found...
Key recommendations
- Influenza
1. Department of Health/RCOG Guideline on the
investigation and management of pregnant wom...
Influenza 2011-13
• Statistically significant decrease in deaths due to
influenza (RR 0.33, 95% CI 0.14-0.78, when compari...
Saving Lives,
Improving Mothers’ Care
0
2
4
6
8
10
12
14
16
2004 2005 2006 2007 2008 2009 2010 2011
Rateper100000materniti...
Maternal immune system changes
Cell mediated immunity (Th1 response)
Humoral immunity (Th2 response)
 Increase in endogen...
 ‘Tip of the iceberg’
 Scottish major morbidity audit for major morbidity (ITU
admission) & major haemorrhage 2003-2005
...
Session 3 – Sepsis Cafés
Chair: Dr Seema Srivastava
North Bristol Trust
#sepsissavvy
Café Groups & Rooms
Café Group First Café Second Café
Maternity
Murrayfield Room (downstairs)
1 3 & 5
Paediatrics
Twickenh...
Session 4 – The Future
Chair: Dr Lesley Jordan
Royal United Hospital Bath
#sepsissavvy
Procalcitonin (PCT) Real life
application Sepsis, SIRS and
localised infections
Dr Kordo Saeed
#sepsissavvy
Background
• Procalcitonin is a 116 aa peptide - Precursor of the
hormone Calcitonin
• Synthesis in healthy persons in the...
Role in the Absence of Infection?
PCT
Role in infection?
Becker KL, et al. J Endotoxin Res. 2003;9(6):367-74.
Localised infection
Systemic infection
Serum test
Serum test
Heart
Muscle
Skin
Fat
Testes
Thyroid, lungs, WBC, Spleen
Bria...
• 3487 reports, of which 30
included (3244 patients).
• Mean sensitivity of 0·77 (95% CI
0·72–0·81) and specificity of
0·7...
91.3
8.7
0
10
20
30
40
50
60
70
80
90
100
Yes No
%
Do we give Antibiotics “Just in case” ?
What was the reason you wrote the last
prescription of antibiotic therapy?
Straw poll of F1, F2 doctors
“Clinical Infectio...
Why did you stop the antibiotic therapy?
Views from ICU
“We said 8 days”
“Micro round said stop”
“Patient is stable”
“Pati...
Harrison PF, Lederberg J, eds. Antimicrobial resistance: issues and options.
Washington, DC: National Academy Press, 1998
...
Antibiotic therapy
Who cares?
Bacterial
resistance £££
Toxicity -
interactions
Integration of PCT into antibiotic
decision-making process to aid diagnosis?
• Provide antibiotic therapy to those who
nee...
The following PCT levels (in microg/L) were used as a cut - off
• MAU patients ≥ 0.25
• ICU Medical patients ≥ 0.5
• ICU P...
Results:
ICU
MAU
* Out of the 87 tests, four
tests did not affect patients’
management in ICU:
# During the evaluation per...
19.3
12.8 15.7
8
16.2
25 21
171
77
143
125
43
100
209
0
15
30
45
60
75
90
105
120
135
150
165
180
195
210
225
06-Jul 13-Ju...
19.3
12.8 15.7
8
16.2
25 21
171
77
143
125
43
100
209
0
15
30
45
60
75
90
105
120
135
150
165
180
195
210
225
06-Jul 13-Ju...
AW Pancreatitis [cut off 4 ug/L]
Discharged
home
Procalcitonin and (SAFE) reduction in antibiotic use (1)
~ 17% reduction in antibiotic use = ~ £14,450/ 6m
+ Savings from ...
PCT HHFT summary
Puedomyxoma (1)
PCT predicts infections in puedomyxoma patients
24hr prior to clinical suspicion (Gray li...
So far 17 cases with implants
Median synovial PCT in the PJI group was 3.15 µg/L vs. 0.05µg/L in the aseptic loosening.
St...
• Gp A streptococcal soft tissue infection
• A range of severity
PCT = 0.75 microg/L
PCT = 1.8 microg/L & +ve BC
PCT = 26....
0.1
1
10
100
1000
PCT(ng/mL)
0 2 4 6 8 10 12 14 16
Days
0.1
1
10
100
1000
PCT(ng/mL)
0 2 4 6 8 10 12 14 16
Days
Survived D...
PCT and mortality
• A 72-hour PCT decrease >80% had a negative
predictive value of around 90%; conversely, no
decrease or ...
Pro-adrenomedullin
• Pro-ADM, a prohormone of adrenomedullin
and hormokine.
• Member of the calcitonin peptide superfamily...
Pro-ADM and PCT values on day 0 and 3 of
Sepsis and outcomes @28 days
6.4755
4.567
33.73
8.336
1.724 1.586 2.006 2.006
0
5...
What do we want rapid diagnostics to do?
• Identify bacterial infection
• Support starting or withholding Abx
• Exclude ba...
Non-specific PCT inducers – potential false positive results
include:
 Surgical Trauma, poly trauma:
 Pregnancy
 Neonat...
Patient with AIDS and sepsis
Patient with AIDS and sepsis
0
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Sepsis Masterclass 3
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Sepsis Masterclass 3

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How we as healthcare professionals can fight the fight against sepsis.

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Sepsis Masterclass 3

  1. 1. Sepsis Masterclass 3 Tuesday 3 February 2016
  2. 2. Welcome & Introductions Lesley Jordan, Consultant Anaesthetist Royal United Hospital Bath #sepsissavvy
  3. 3. About the WEAHSN The West of England AHSN is delivering positive healthcare outcomes locally and nationally by driving the development and adoption of new innovations and making a meaningful contribution to the economy. We are one of 15 AHSNs across England, established by NHS England in 2013 to spread innovation at pace and scale. As the only bodies that connect NHS and academic organisations, the third sector and industry, we are catalysts that create the right conditions to facilitate change across whole health and social care economies, with a clear focus on improving outcomes for patients.
  4. 4. Session 1 – The UK Picture Chair: Dr Amanda Pegden Great Western Hospital Swindon #sepsissavvy
  5. 5. Sam’s Story Susanna Morrish Mother #sepsissavvy
  6. 6. @SepsisUK The changing face of sepsis. Dr Ron Daniels B.E.M. CEO, UK Sepsis Trust CEO, Global Sepsis Alliance
  7. 7. Breast cancer
  8. 8. Iwashyna et al: Long-term cognitive impairment & functional disability among survivors of severe sepsis. JAMA, 2010. 16.8 3.8 6.2 7.1 0 5 10 15 20 Moderate-severe Mild Before sepsis After sepsis Cognitive impairment
  9. 9. Basics limit severity
  10. 10. NCEPOD 2015 @SepsisUK
  11. 11. Prehospital care @SepsisUK
  12. 12. At least 53% of patients had sepsis prior to arrival in hospital
  13. 13. ED & hospital care @SepsisUK
  14. 14. Recognition 2014-16 @SepsisUK
  15. 15. Burns Burns Infection Sepsis Severe Sepsis Septic shock Systemic Inflammatory Organ dysfunction Hypoperfusion Response (SIRS)
  16. 16. Burns Burns Infection Sepsis Severe Sepsis Septic shock Systemic Inflammatory Organ dysfunction Hypoperfusion Response (SIRS) <1% 10% 30% 50%
  17. 17. Funk and Kumar Critical Care Clinics 2011 (in press) ‘For each hour’s delay in administering antibiotics, mortality increases by 7.6%’ Septic shock
  18. 18. Burns Burns Infection Sepsis Severe Sepsis Septic shock Systemic Inflammatory Response (SIRS) <1% 10% 35%
  19. 19. Burns Burns Infection Sepsis Severe Sepsis Septic shock
  20. 20. Burns Burns Infection Sepsis Severe Sepsis Septic shock Systemic Inflammatory Organ dysfunction Hypoperfusion Response (SIRS)
  21. 21. CVS SBP <90, MAP <70, or SBP decrease >40 SvO2 70% or ScvO2 <65% Cardiac index <3.5 Lmin-1 Decreased capillary refill or mottling Lactate >2 mmolL-1 RS PaO2/FIO2 <300 or SpO2 <90% Renal Urine output <0.5 mLkg-1hr-1 for 2 hrs Creatinine >177 micromolL-1 Hepatic Bilirubin >4 mgdL-1 or >70mmolL-1 Coagulation INR >1.5 or aPTT >60s Platelets <100,000 x 106L-1 GI Ileus
  22. 22. Prehospital SepsisScreeningandActionTool 1. Areany2of thefollowingpresent? Temperature > 38.30Cor < 360C Respiratoryrate > 20per minute Heart rate > 90per minute Acuteconfusion/ reducedconsciouslevel Glucose > 7.7mmol/l (unlessDM) 3. Isanyredflagpresent? SystolicB.P< 90mmHg Lactate> 2mmol/l Heart rate> 130per minute Respiratoryrate> 25per minute Oxygensaturations< 91% Respondsonlytovoiceor pain/ unresponsive Purpuricrash Sepsisnot present Treat tostandardprotocols RedFlagSepsis Thisisatimecritical condition, immediateactionisrequired. Resuscitation: 250ml bolusescrystalloidtomaximum2000ml (careinCHD) Oxygen15L/minNRB (careinCOPD) Intravenousantibiotics(ifavailable) Recordlactate(ifavailable) Communication: Pre-alert receivinghospital ofRedFlagSepsis Divert totheEmergencyDepartment (or other agreeddestination) Handover presenceofRedFlagSepsis Y Y Y Sepsispresent Transport todesignated destination. Communicatepresenceof sepsisat handover N N N Sepsisisatimecritical condition. Screening, earlyinterventionandimmediatetreatment saveslives. Thistool shouldbeappliedtoall adult patientswhoarenot pregnant whohaveasuspected infectionor their clinical observationsareoutsideofnormal limits 2. Couldthisbeasevereinfection? For example: Pneumonia UrinaryTract Infection Abdominal painor distension Meningitis Cellulitis/ septicarthritis/ infectedwound
  23. 23. 3. Is any red flag present? Systolic B.P < 90 mmHg or MAP < 65 mmHg Lactate > 2 mmol/l Heart rate > 130 per minute Respiratory rate > 25 per minute Oxygen saturations < 91% Responds only to voice or pain/ unresponsive Purpuric rash Red Flag Sepsis This is a time critical condition, immediate action is required. Assume severe sepsis present. Sepsis Six 1 High-flow oxygen. 2 Blood cultures and consider source control. 3 Intravenous antibiotics. 4 Intravenous fluid resuscitation. 5 Check haemoglobin and serial lactates. 6 Hourly urine output measurement. Record the time each of these actions is completed. All actions should be completed as soon as possible but always within 60 minutes. Communication: Inform senior clinician (e.g. registrar or above). Additional: Bloods should include: FBC, U/E’s, LFT’s, clotting profile. Observations should be taken every 30 mins Lactate should be repeated within 2 hours. Perform a CXR and Urinalysis Consider source control ( e.g. surgical intervention) Y
  24. 24. 3. Is any red flag present? Systolic B.P <90 mmHg/ MAP <65 mmHg Lactate >2 mmol/l Heart rate >130 per minute Respiratory rate >25 per minute Oxygen saturations <91% Responds only to voice/pain/unresponsive Purpuric rash
  25. 25. 3. Is any red flag present? Systolic B.P <90 mmHg/ MAP <65 mmHg Lactate >2 mmol/l Heart rate >130 per minute Respiratory rate >25 per minute Oxygen saturations <91% Responds only to voice/pain/unresponsive Purpuric rash
  26. 26. 3. Is any red flag present? Systolic B.P <90 mmHg/ MAP <65 mmHg Lactate >2 mmol/l Heart rate >130 per minute Respiratory rate >25 per minute Oxygen saturations <91% Responds only to voice/pain/unresponsive Purpuric rash
  27. 27. 3. Is any red flag present? Systolic B.P <90 mmHg/ >40mmHg < n. Lactate >2 mmol/l Heart rate >130 per minute Respiratory rate >25 per minute Oxygen saturations <91% Responds only to voice/pain/unresponsive Purpuric rash
  28. 28. 3. Is any red flag present? Systolic B.P <90 mmHg/ >40mmHg < n. Lactate >2 mmol/l Heart rate >130 per minute Respiratory rate >25 per minute Oxygen saturations <91% Responds only to voice/pain/unresponsive Purpuric rash
  29. 29. 3. Is any red flag present? Systolic B.P <90 mmHg/ >40mmHg < n. Lactate >2 mmol/l Heart rate >130 per minute Respiratory rate >25 per minute Oxygen saturations <91% Responds only to voice/pain/unresponsive Purpuric rash
  30. 30. 3. Is any red flag present? Systolic B.P <90 mmHg/ >40mmHg < n. Lactate >2 mmol/l Heart rate >130 per minute Respiratory rate >25 per minute Oxygen saturations <91% Responds only to voice/pain/unresponsive Purpuric rash
  31. 31. 3. Is any red flag present? Systolic B.P <90 mmHg/ >40mmHg < n. Lactate >2 mmol/l Heart rate >130 per minute Respiratory rate >25 per minute Oxygen saturations <91% Responds only to voice/pain/unresponsive Purpuric rash
  32. 32. 3. Is any red flag present? Systolic B.P <90 mmHg/ >40mmHg < n. Lactate >2 mmol/l Heart rate >130 per minute Respiratory rate >25 per minute Needs oxygen to keep SpO2 >92% Responds only to voice/pain/unresponsive Purpuric rash
  33. 33. 3. Is any red flag present? Systolic B.P <90 mmHg/ >40mmHg < n. Lactate >2 mmol/l Heart rate >130 per minute Respiratory rate >25 per minute Needs oxygen to keep SpO2 >92% Responds only to voice/pain/unresponsive Purpuric rash
  34. 34. 3. Is any red flag present? Systolic B.P <90 mmHg/ >40mmHg < n. Lactate >2 mmol/l Heart rate >130 per minute Respiratory rate >25 per minute Needs oxygen to keep SpO2 >92% Responds only to voice/pain/unresponsive Purpuric rash
  35. 35. 3. Is any red flag present? Systolic B.P <90 mmHg/ >40mmHg < n. Lactate >2 mmol/l Heart rate >130 per minute Respiratory rate >25 per minute Needs oxygen to keep SpO2 >92% Responds only to voice/pain/unresponsive Purpuric rash/ mottled/ ashen/ cyanotic
  36. 36. 3. Is any red flag present? Systolic B.P <90 mmHg/ >40mmHg < n. Lactate >2 mmol/l Heart rate >130 per minute Respiratory rate >25 per minute Needs oxygen to keep SpO2 >92% Responds only to voice/pain/unresponsive Purpuric rash/ mottled/ ashen/ cyanotic Not passed urine for 18 hours
  37. 37. Managing sepsis @SepsisUK
  38. 38. To be completed within 3 hours: 1) Measure lactate level 2) Obtain blood cultures prior to administration of antibiotics 3) Administer broad spectrum antibiotics 4) Administer 30 mL/kg crystalloid for hypotension or lactate 4mmol/L To be completed within 6 hours: 5) Apply vasopressors for hypotension that does not respond to initial fluid resuscitation to maintain a mean arterial pressure [MAP] 65 mm Hg) 6) In the event of persistent arterial hypotension despite volume resuscitation (septic shock) or initial lactate 4 mmol/L (36 mg/dL): - Measure central venous pressure (CVP)* - Measure central venous oxygen saturation (ScvO2)* 7) Remeasure lactate if initial lactate was elevated* SSC Bundle 2012
  39. 39. Mikkelsen, ME et al. Crit Care Med 2009; 37 (5): 1670-7 n= 830 Risk stratification Cohort OR for 28 day death p Non-shock intermediate 2.05 0.024 Non-shock high 4.87 <0.001 Shock intermediate 3.27 0.022 Shock high 4.87 <0.001
  40. 40. The Sepsis Six 1. Give oxygen as needed to target SpO2 > 94% 2. Take blood cultures consider source control 3. Give IV antibiotics according to local protocol 4. Start IV fluid resuscitation Hartmann’s or equivalent 5. Check lactate repeat within 2h 6. Monitor urine output consider catheterisation within one hour ..plus Critical Care support to complete EGDT
  41. 41. Fixing the system. @SepsisUK
  42. 42. Secretary of State goes further 2016
  43. 43. Systems approach Rivers 2001 RCT Sebat 2005 Before-After Nguyen 2007 Complete or Not Thiel 2009 Before-After Levy 2011 Before-After Goals CVP >8 MAP > 65 ScVO2 >70% HCT >30 MAP > 70 SaO2 > 92 UOP > 30ml/h SvO2 > 60 CI > 2.5 ABX in 4 h CVP > 8, MAP > 65, ScVO2 > 70%, HCT > 30 Check Lactate Steroids Appropriate ABX in 4 h, CVP > 8, MAP > 65, ScVO2 > 70% Early ABX, Blood Cultures, Appropriate ABX, CVP > 8, MAP > 65, SvO2 > 70% Specific Interventions Fluids, Blood, Pressors ABX, Fluids Pressors ABX, Fluids, Blood, Pressors ABX, Fluids, Pressors, Steroids, Xigris, Other Supportive Care ABX, Fluids, Pressors, Steroids, Xigris, Other Supportive Care System Interventions ED-based Sepsis Team Screening, Education, Shock Team, Protocols Education, In- services, Protocols Education, In- services, Order Set, Protocols Screening, Education, Order Sets Absolute Change in Mortality -16% -12% -19% -16% -7%
  44. 44. Breast cancer
  45. 45. Mortality
  46. 46. Breast cancer
  47. 47. ron@sepsistrust.org @SepsisUK www.sepsistrust.org www.world-sepsis-day.org
  48. 48. @NCEPOD #sepsis www.ncepod.org.uk 75 Mark Juniper Great Western Hospitals Swindon
  49. 49. Just Say Sepsis! • Study description – Aim, objectives – Population selected, exclusions – Data returns, demographics • Vital signs and use of early warning scores • Delays • Sepsis screening tools / care bundle • Focus on key recommendations 76
  50. 50. Study aim and objectives To identify and explore avoidable and remediable factors in the process of care for patients with sepsis. – To examine organisational structures, processes, protocols and care pathways for sepsis recognition and management – To identify remediable factors in the management of the care of adult patients with sepsis – Timely identification, escalation and treatment of sepsis: use of systems, EWS, care bundles 77
  51. 51. Study population Adult patients diagnosed with sepsis and admitted to critical care (HDU/ICU) or reviewed by CCOT or equivalent during the study period: 6th-20th May 2014 78
  52. 52. Exclusions • Pregnant women up to 6 weeks post partum • Patients undergoing chemotherapy, organ transplant • Patients already on end of life care pathway when sepsis diagnosed • Patients who developed sepsis after 48 hours on ICU 79
  53. 53. Method • Prospective case identification • 5 cases selected per hospital • Case notes requested, clinician questionnaire • Cases reviewed by panel of Reviewers • Identified cases where patient attended the GP – Sent request for GP notes – GP Reviewers • Organisational questionnaire – Acute / non-acute hospitals Cases / Data collection 80
  54. 54. ReturnsReturns 81
  55. 55. DemographicsDemographics 82
  56. 56. • First NCEPOD study to look at whole pathway • Primary care • Ambulance service • Emergency Department • In-patient care Vital Signs and Early Warning Scores 83
  57. 57. Pre hospital care EWS was not used in any of the cases reviewed 84
  58. 58. Pre hospital care GP case note review 85
  59. 59. Pre hospital care Hospital case note review 86
  60. 60. 37 patients had no vital signs recorded at triage or senior review 152/369 (41%) patients complete set between 2 assessments Emergency care 87
  61. 61. Organisational data 88
  62. 62. Inpatient care 89
  63. 63. Inpatient care 90
  64. 64. Recommendation An early warning score, such as the National Early Warning Score (NEWS) should be used in both primary care and secondary care for patients where sepsis is suspected. This will aid the recognition of the severity of sepsis and can be used to prioritise urgency of care. 91
  65. 65. Recommendations On arrival in the emergency department a full set of vital signs, as stated in the Royal College of Emergency Medicine standards for sepsis and septic shock should be undertaken. 92
  66. 66. Delayed review: Emergency care 93
  67. 67. Areas for improvement: Emergency care 94
  68. 68. Areas for improvement: Emergency care 95
  69. 69. 17.9% consultant review delayed according to Reviewers Consultant review: Inpatient care 20.4% > 14 hours 96
  70. 70. Changes made following consultant review in 281/457 (61.5%) Inpatient care 97
  71. 71. Recommendations In line with previous NCEPOD and other national reports’ recommendations on recognising and caring for the acutely deteriorating patients, hospitals should ensure that their staffing and resources enable: a. All acutely ill patients to be reviewed by a consultant within the recommended national timeframes (14 hrs post adm.) b. Formal arrangements for handover c. Access to critical care facilities if escalation is required; and d. Hospitals with critical care facilities to provide a Critical Care Outreach service (or equivalent) 24/7. 98
  72. 72. Screening tools to improve diagnosis: Inpatient care 99
  73. 73. Use of screening tools: Inpatient care 100 128/479 (26%) used screening tool/ EWS
  74. 74. Screening tools reduce delay 28% 36% 35% 55% 30% 31% 101
  75. 75. Care bundles: Inpatient care 102 Blood cultures taken in 366/477 (77%) fluid cultures in 48, tissue cultures in 43
  76. 76. Blood gases taken in 375/509 (74%) Inpatient care 103
  77. 77. Inpatient care 104
  78. 78. Inpatient care Where not timely, patient deteriorated in 51 Outcome affected in 20 105
  79. 79. Inpatient care Room for improvement in fluid management in 203/447 cases 106
  80. 80. Inpatient care 107
  81. 81. Outcome affected in 43 cases Inpatient care 108
  82. 82. Inpatient care • Reviewers: patient started on sepsis care bundle following diagnosis: 135/434 (31%) • Clinician questionnaire: 207/318 (39%) 109
  83. 83. Inpatient care 110 With care bundle Without care bundle Delay in escalation 9% 26% Delay in administration of administration of antimicrobials 18.5% 38% Fluids delayed/ not received 13% 23% Oxygen delayed / not received 5% 15% Investigation of source of infection 10% 28% Blood cultures not taken 60% 79.5% Less than good documentation of sepsis 19% 33% Blood gases not taken 19% 33%
  84. 84. Recommendations All patients diagnosed with sepsis should benefit from management on a care bundle as part of their care pathway. The implementation of this bundle should be audited and reported on regularly. Trusts/Health Boards should aim to reach 100% compliance and this should be encouraged by local and national commissioning arrangements. 111
  85. 85. Correlation does not prove causation but ... @chris23han Christopher.hancock2@wales.nhs.uk NEWS embedded in 18/18 acute hospitals Standard Sepsis Screening Tool CC Outreach Teams
  86. 86. Recommendations All hospitals should have a formal protocol for the early identification and immediate management of patients with sepsis. The protocol should be easily available to all clinical staff, who should receive training in its use. Compliance with the protocol should be regularly audited. This protocol should be updated in line with changes to national and international guidelines and local antimicrobial policies. 113
  87. 87. Overall quality of care 114
  88. 88. Thank you www.ncepod.org.uk 115
  89. 89. 116 Challenges in recognition and management of paediatric sepsis Akash Deep Director - PICU King’s College Hospital London
  90. 90. SEPSIS EDUCATION MOTIVE • Raise awareness : all healthcare professions are capable and should be able to recognise sepsis early • Improve reliability of and access to care institute basic treatment in whatever setting the patient is • Measure and improve outcomes
  91. 91. Overview • How big is this problem? - Impact of sepsis on patient, families, healthcare economy • Importance of Early diagnosis and treatment • Challenges in paediatrics • Treatment bundles and barriers to achievement of standard treatment protocols • Paediatric sepsis toolkit
  92. 92. Problem 1 More sepsis around
  93. 93. Retrospective observational cohort dataset from seven U.S. states from 1995, 2000, and 2005.
  94. 94. Incidence Paediatric Sepsis Author Sepsis Incidence Year Watson et al (U.S) 42,364 /annum 1995 ( published 2005) Hartman ME et al (U.S) 75255/annum 2005 Sara S (U.S) 95,055/ annum 2009 PICANet (U.K) 1000 PICU/annum 2013 124
  95. 95. Lozano R et al Global and Regional Mortality… Lancet 2012 Global Child Deaths Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010.
  96. 96. Global Years Life Lost By Cause 2010 Lozano R et al Global and Regional Mortality… Lancet 2012
  97. 97. Problem 2 Sepsis is under-reported!! 127
  98. 98. Global Burden of Disease Report In the WHO’s Global Burden of Disease Report (GBDR), sepsis appears only as “neonatal sepsis” and ranks in 16th place, while about 60% of deaths of children under 5 are due to severe infections. That should be – but is not, classified as sepsis. 128
  99. 99. Overcome deficits in estimating sepsis cases – only what can be counted counts! • Coding • Databases 129
  100. 100. King’s PICANet data by Diagnosis 1-1.2012 – 31-12.2013 Condition n Sepsis Septic shock Pneumonia 42 3 7 Bronchiolitis 105 5 Empyaema 13 0 1 Cellulitis 3 0 - Meningitis/enceph alitis 15 3 2 130
  101. 101. Coding data • Coded 50 set of notes from HDU/PICU, General Paediatrics, paediatric surgery and paediatric liver • Of the 24 children with some kind of infection leading to sepsis and therefore to admission – ONLY 1 has sepsis coded 131
  102. 102. Remedies To correct this oversight, we need to achieve the following: Spread the understanding that most acute infectious diseases only become deadly when they develop into sepsis with organ failure Have sepsis accurately coded as primary and secondary diagnosis in hospitals under the International Classification of Diseases Systems of the WHO (ICD9 or ICD10). 132
  103. 103. Problem 3 Deaths happen early
  104. 104. Septic Shock referrals n, (%) 2005 168 2004 131 2003 162 15 (83) 12 (75) 17 (81) Deaths pre ICU 18 (11) 16 (12) 21 (13) Deaths n (%) Sepsis Deaths – N. Thames ICU case fatality rate = 11/417 = 2.6% Interventions aimed at pre-ICU care crucial
  105. 105. Problem 4 Care is often poor
  106. 106. 1) Decreased awareness of medical/paramedical team about sepsis 2) failure to be looked after by a paediatrician, 3) failure of sufficient supervision of junior staff / escalation pathways not well defined Ninis N et al. The role of healthcare delivery in the outcome of meningococcal disease in children. BMJ. 2005;330:1475
  107. 107. Sepsis in children – A challenge Signs and symptoms may be non-specific and subtle but deterioration is usually rapid. Patients, caregivers and health care professionals do not suspect sepsis Low awareness of sepsis as a discrete clinical entity compounded by a lack of reliable systems to aid identification and speed delivery of care. The variation in normal physiological parameters with age is a further contributor to difficulties in identifying acute illness early
  108. 108. yes no I don’t know1000 inhabitants in each country were interviewed. Have you heard the term ‘sepsis’ before? Surviving Sepsis Campaign: Public Awareness Survey
  109. 109. Experience of sepsis from those who deal with it at first contact in the hospital – Awareness and practice Dr Trisha Radia - Paediatric SpR (PICU KCH) Dr Claire Matthews – Foundation Year 2 (GSTT) Supervisor – Akash Deep – King’s College Hospital
  110. 110. • Variable • Consistent feature – always some degree of anxiety and concern • Positive outcome of anxiety and concern: – Desire to learn – Sense of urgency – Sense of importance What are the experiences of sepsis from those who come into first contact with it?
  111. 111. Trainee concerns at different levels Foundation Year Doctor: – Knowing what’s normal and what’s not! Number correctly answered 5 true false questions on vital signs in children 0 1 or 2 3 or 4 5
  112. 112. Trainee concerns at different levels Foundation Year Doctor: – Is it sepsis? – What questions should I ask? – Is that heart rate normal? – Is that respiratory rate normal? – Am I right to feel concerned? – Am I right to escalate? – How can I help? – How do I take a blood pressure from a child? – What equipment do they need? – Sepsis 6… how does it translate in paediatrics? • What is an appropriate fluid challenge? • How do I monitor urine output? FY1 FY2 ST1 ST2 ST3 ST4 ST5 ST6
  113. 113. Trainee concerns at different levels Senior House Officer – ‘CANNULATE’ – What if I can’t cannulate? – Have I calculated the fluids correctly? – How do I tell the parents? GP SHO – Is this child unwell? – What if you get it wrong? – What key information/signs must you document? – How do you appropriately safety net? – What do you tell parents to do? FY1 FY2 ST1 ST2 ST3 ST4 ST5 ST6
  114. 114. Trainee concerns at different levels Paediatric Registrar: – Central access? – Fluid/fluid/fluid? – Anaesthetist : intubate/ chose correct anaesthetic agent? – Inotropes, which inotropes, how quickly to increase rate of inotropes, will the nursing staff know how to make them up? – When to stop giving fluid bolus’? – When to give blood/ blood products? – Retrieval team on their way? – Where the patient should be managed in the interim? – What to tell the parents? – Did I chose the correct antibiotics? FY1 FY2 ST1 ST2 ST3 ST4 ST5 ST6
  115. 115. Problem / solution 4.. Early Care has a dramatic effect
  116. 116. Crit Care Med 2006: 34(6):1589-96 2,731 adults with septic shock
  117. 117. 147
  118. 118. 148
  119. 119. 5 Component sepsis Bundle (1)Recognition of septic shock (2) vascular access (3) administration of intravenous (IV) fluid (4) antibiotics (5) vasoactive agents Diagnosed and treated in the first hour following presentation - > 80% survival rate. 30% Survival rate - after the sixth hour Golden hour Management reduces the risk of death from sepsis by 50% 149
  120. 120. American College of Critical Care Medicine-Pediatric Advanced Life Support Hemodynamic Support Algorithm Brierley J. Crit Care Med. 2009;37:666-688
  121. 121. • I992/93 – Case fatality from MD – 23% • New PICU specialising in MD opened • Implementation of : Health care delivery system with education programmes on ‘’Early recognition and resuscitation’’ implemented in : Referring Community Hospitals Specialised paediatric Retrieval teams Specialised PICU 151
  122. 122. 152 Decrease in case fatality rate from 23 to 2% & PRISM adjusted reduction in OR of mortality of 0.5
  123. 123. PIM2 predicted mortality 15% (6-35)
  124. 124. Findings Patients in shock at PICU admission – 107 ( 83 who had shock on referral and did not reverse shock + 24 who were not shocked at referral but subsequently developed shock) 21 (20%) were not given >60 ml/kg fluid despite persisting signs of shock 16 (15%) were given >60 ml/kg fluid but were not given dopamine / dobutamine despite fluid refractory shock 25 (23%) were dopamine/dobutamine refractory but were not given catecholamines 32 (30%) were catecholamine-refractory but were not given replacement hydrocortisone
  125. 125. Findings • 9/107 (8%) followed 2002 ACCM guidelines in children with shock at PICU admission • If steroids disregarded – still ONLY 39/107(36%) followed ACCM guidelines for early management • 24/107 – not shocked at referral but subsequently developed shock – NONE followed guidelines thereby signs of shock were155
  126. 126. Conclusions
  127. 127. Problem- 5- Not enough realisation that sepsis is a time critical emergency akin to MI!!!!!! Solution to a problem lies in collective realisation that problem exists!!!! 157
  128. 128. 158
  129. 129. Background Root-cause analyses and morbidity and mortality conferences identified system problems with sepsis recognition and management which was variable Hypothesis - process barriers resulted in delays in shock recognition and management in ED System changes would result in improved outcomes. 159
  130. 130. Barriers • Variation in experience of staff in performing initial evaluations • Lack of adequate nursing staff for resource- intensive patients • Difficulty obtaining frequent vital-sign measurements • Lack of standardization of empiric antibiotics and diagnostic tests • Lack of medication prioritization 160
  131. 131. QI Project Quality-improvement (QI) intervention : recognise shock and implement early treatment strategy Computerised triage system – alarmed on abnormal vital signs – child goes to Resusc Additional manpower recruited Antibiotics and lab tests – ordered and prioritised Frequent vital signs and interventions noted on graphical flow sheet to facilitate easy interpretation of response to therapy 161
  132. 132. Results • After protocol initiation- 191 encounters in 167 patients with suspected sepsis. • Time from triage to first bolus decreased from a median of 56 pre-intervention era to 22 minutes • Triage to first antibiotics decreased from a median of 130 to 38 minutes. 162
  133. 133. • Time to first bolus • Time to third bolus • Time to antibiotics • Reduced mechanical ventilation – 3.2% to 2.0% • Reduced vasoactive agents – 16% to 10.1% • Reduced mortality – 4% to 2.5% Cruz A T et al. Pediatrics. 2011;127:e758-e766 Statistical Process Control Charts of Time to First Bolus for Children Identified at Triage
  134. 134. Conclusion The protocol resulted in earlier recognition of suspected sepsis and substantial reductions in both time to receipt of time- sensitive interventions and a decrement in treatment variation. 164
  135. 135. 165 • 79% shock recognised in 5 minutes of which 59% had vascular access secured • Of those with recognised shock + vascular access – 29% received fluids • Adherence to fluid resuscitation component – 37% which decreased overall bundle adherence to 17% • Therefore –overall bundle adherence could improve with improvements in fluid resuscitation
  136. 136. Barriers in Early adequate fluid resuscitation • Lack of knowledge regarding PALS recommendations • Early Recognition/Securing Vascular access • Inability to administer iv fluids quickly –iv infusion pump was used in 49% cases • Infusion pump – max fluid can be 999 mls/hour ( 60 mls/kg/hour ONLY in children < 16 kg) 168
  137. 137. QI Project Plan – do – Study – Act Focused on IV fluid delivery as a key driver impacting bundle adherence 169
  138. 138. Level -1 interventions • Weekly e-mails to individual providers involved in the care of a specific patient detailing adherence to the 5 components of the sepsis bundle and providing recommendations regarding any observed barriers to timely care. • For each patient seen, a 10 question electronic survey was completed, allowing the caregiver to give feedback regarding barriers to care. 170
  139. 139. Level -2 Reliability interventions • PALS algorithm with local modifications was pasted at prominent sites in Resus room, charting areas, office areas & break rooms • Pockets cards distributed to all healthcare professionals – dosing of medications, details of care and septic shock definitions • Standardized order set incorporated into EMR- guidance on IV fluid bolus volume and infusion time, recommended laboratory tests, and antibiotic and vasoactive agent choices. 171
  140. 140. Firing the bolt concept • Lightening bolt symbol on ED tracking board with ordering the set – alert the nurses that patient requires additional resources and personnel • Address nursing concern over limited resources by alerting the charge nurse to redirect additional nursing resources to the bedside. • The bolt also alerted the pharmacist that all medications and fluids were needed emergently for that patient. 172
  141. 141. Level -3 interventions – SHOCK CLOCK • Shock clock was placed in all resuscitation areas – LARGE AND CENTRALLY PLACED • Small clock in non-resuscitation areas • Physicians or nurses to start the shock clock for any patient with concern for severe sepsis or septic shock. • This visual cue allowed providers to be aware of the 60-minute time goal to complete all the components of the algorithm. 173
  142. 142. Effectiveness of interventions - Monthly • Outcome measures  Primary – Adherence to the total algorithm bundle  Secondary – Change in mortality • Process measures  Adherence to the time goals for the 5 components of the algorithm. • Balancing measures  ED LOS (for all patients) to evaluate whether the redirection of personnel/resources affected ED throughput.  Patients for whom lightening bolt inappropriately fired 174
  143. 143. Median time to administration of IV fluid decreased from 83 minutes in the baseline group, to 33 minutes in the QI group. Median time to delivery of vasoactive agents decreased- 90 mins to 35 mins  NO INCREASE IN LOS IN ED OF OTHER PATIENTS  MINIMAL NUMBER OF INAPPROPRIATE BOLT FIRING
  144. 144. Conclusions • QI interventions planned carefully can go a long way in improving outcomes • Importance of knowing what is going wrong • Ask a question ‘ Why are we not achieving a goal when we all know what to do and how to do’’ • Address the process and the system • Reevaluate the changes with a plan-do-study- act cycles 177
  145. 145. Common themes at King’s Review of PICU admissions for paediatric sepsis – 2014-15 Delayed presentation (parental education) Delayed recognition Failure to escalate concerns to senior clinician Interestingly all had delayed venous access – IO not sited Time critical bundles not followed 178
  146. 146. EDUCATION, EDUCATION, EDUCATION • Awareness – FY vital sign – SHO fluid calculations/Abx – SPR guidelines on referral policies • Practice – FY recognising sepsis – SHO Managing sepsis, communicating with parents – SPR Managing severe sepsis, PICU transfer Paediatric Sepsis Six PICU outreach teaching Simulation Smart-phone App’s Drug calculation web-pages
  147. 147. Provide operation solutions for early diagnosis and treatment Treat sepsis in a time critical way
  148. 148. 181
  149. 149. Y Is any one Red Flag present? •Hypotension •Heart rate •- Blood gas lactate > 4 mmol/l •- Capillary refill > 5 seconds •-Pale/mottled/blue/non blanching(purpuric) rash •Oxygen needed to maintain saturations >92% in the absence of known cardiac cause •Respiratory rate – tachypnoea, hypopnea, apnea or grunting •- AVPU = V, P or U •- Parents report one of: excessively dry nappies, lack of response to social cues, significantly decreased activity, or weak, high-pitched or continuous cry RED FLAG SEPSIS
  150. 150. Paediatric sepsis 6 • Tool designed by UK sepsis Trust to assist clinicians in the early recognition and timely management of children at risk of sepsis • Developed according to the guidelines of the American College of Critical care Medicine/Pediatric Advanced Life Support (ACCM/APLS) guidelines • 3 sections :  Identification of any child with suspected sepsis  Patients with confirmed sepsis for escalaltion/senior clinician review  Recemmended diagnostic and therapeutic interventions 183
  151. 151. Future steps • Implementation of standardised toolkit/guideline with measurable outcomes – LOS/PICU admission/mortality • Integrated working between various stakeholders especially RCPCH and especially commissioners/NHS England • Commissioning for Quality and Innovation have assigned the timely recognition and management of children at risk of sepsis as one of their quality indicators for 2015/16. • Testing the feasibility, impact, compliance and cost- effectiveness of an easy to use diagnostic/management sepsis bundle • Active involvement of parents in managing febrile children and teaching them red flag signs 186
  152. 152. Joint HTA Application • Imperial – London • King’s College Hospital • Birmingham Children’s Hospital • Leicester- Royal Infirmary To improve the recognition and early clinical management of children with sepsis in paediatric emergency care and to evaluate the impact of the paediatric SEPSIS 6 tool on clinical decision making 187
  153. 153. 188 Research objectives – Feasibility, impact, compliance and cost effectiveness Evaluate the feasibility of implementing the paediatric SEPSIS6 tool as a clinical tool for early recognition and subsequent clinical management of children at risk of sepsis in paediatric emergency care settings Determine the effect of the paediatric SEPSIS6 tool on timeliness of diagnostic and therapeutic interventions for children at risk for sepsis fulfilling the paediatric SEPSIS6 criteria Assess if implementation of the paediatric SEPSIS6 tool can improve patient outcomes, measured in predicted mortality scores on admission to hospital Calculate diagnostic performance measures of the paediatric sepsis 6 tool for detecting sepsis in children, and the physician’s decision to escalate clinical care.
  154. 154. SEPSIS IS A MEDICAL EMERGENCY • Sepsis is very common, but least recognized disease • Incidence is increasing dramatically • Diagnosis of sepsis often is delayed • Sepsis carries a high risk of death and long-term complications - number of deaths from sepsis preventable • Awareness, education and training are the key to successfully combat sepsis • Recognise before de-compensation • DEVELOP A CULTURE WHERE SEPSIS IS CONSIDERED AN EMERGENCY REQUIRING 189
  155. 155. 190 WORLD SEPSIS DAY -2014
  156. 156. 191
  157. 157. Session 2 – Maternity Chair: Ann Remmers West of England AHSN and SW Maternity and Children’s Strategic Clinical Network #sepsissavvy
  158. 158. Severe maternal sepsis – key messages for care from the national confidential enquiries into maternal morbidity and mortality Marian Knight National Perinatal Epidemiology Unit
  159. 159. Programmes of work www.npeu.ox.ac.uk/mbrrace-uk/reports www.npeu.ox.ac.uk/ukoss/completed-surveillance
  160. 160. Maternal Morbidity and Mortality Annual Report Topics • Year 1 (2014): Sepsis, haemorrhage, AFE, anaesthetic, neurological, respiratory, endocrine and other indirect • Year 2 (2015): Psychiatric, thrombosis, malignancy, late and coincidental • Year 3 (2016): Pre-eclampsia and eclampsia, cardiac, early pregnancy, critical care
  161. 161. New work – maternal morbidity • New morbidity topic selected annually • Confidential enquiry of a sample of approximately 30-40 cases nationally • Cases can be identified through a variety of sources depending on the topic • 2014 morbidity enquiry – sepsis. Cases identified from a UKOSS national study of severe maternal sepsis
  162. 162. Maternal Mortality 2003-13 35% reduction in overall maternal death rate, p=0.005
  163. 163. Maternal Mortality 2003-13 53% reduction in direct maternal death rate, p=0.005 No significant decrease in indirect maternal deaths, p=0.28
  164. 164. Causes of maternal death 2011-13 Dark bars show indirect causes, pale bars direct causes
  165. 165. Sepsis – all causes 2009-12
  166. 166. Influenza 2009-12
  167. 167. Sepsis mortality 2009-13
  168. 168. Late Maternal Deaths 2009-13
  169. 169. Sepsis morbidity - UKOSS • 365 women diagnosed with severe sepsis associated with pregnancy over one year (47 per 100,000 maternities) • 71 women developed septic shock (9 per 100,000 maternities) • 5 women died • For every woman who dies, 14 have septic shock; a further 60 have severe sepsis Acosta, Kurinczuk, Lucas at al 2014 (PLoS Med)
  170. 170. Sources of severe sepsis Genital tract 31% Urinary tract 20% Wound 9% Respiratory 5% Other 9% Unknown 26% Acosta, Kurinczuk, Lucas at al 2014 (PLoS Med) • 37% (N=134) antenatal – UTI (34%) • 63% (N=231) postnatal – Genital-tract (37%) (P<0.0001)
  171. 171. Sources of maternal sepsis – critical care data Pregnant or recently pregnant women admitted to critical care UK 2008-2010 (ICNARC) Source of infection Number of women (n=646) Pneumonia/ respiratory infection 257 (39.8) Genital tract 157 (24.3) UTI/ Pyelonephritis 59 (9.1) Surgical trauma 24 (3.7) Septicaemia 20 (3.1) Appendicitis 19 (2.9) Other infection 62 (9.6) Unknown 48 (7.4)
  172. 172. Key message 1 • Genital tract infection forms only a small proportion of maternal morbidity and mortality from infectious disease • Consideration of the source is important when planning management • “Think sepsis” in a wider context of symptoms and signs
  173. 173. Vignette: sepsis Two hours after delivery a woman became unwell on the postnatal ward feeling faint. Her oxygen saturation was low. She was reviewed by junior staff and found to be shocked, without evidence of major bleeding. Her temperature was never measured. A diagnosis of haemorrhage was made and she was treated with fluids. She failed to improve and was taken to theatre where she had a cardiac arrest and could not be revived. At postmortem she was found to have overwhelming infection due to Group A Streptococcus.
  174. 174. Vignette; sepsis Seven days after giving birth a woman became unwell at home with a fever. She was advised to attend the maternity unit immediately. On admission she was noted to be breathless with a rapid pulse and high temperature. She was seen quickly by the on call doctor. A diagnosis of severe infection was made and fluid resuscitation started immediately. Intravenous antibiotics were started within one hour of the diagnosis and she was transferred to the high dependency unit. She made a full recovery. Early recognition, clear advice and prompt treatment led to a good outcome without any further complications.
  175. 175. Confidential Enquiry Themes Postnatal Delay in Diagnosis & Incomplete Assessment Recommendations • In the postnatal period health professionals must perform and record a full set of physiological vital signs, pulse, blood pressure, temperature and respiratory rate, in any woman with symptoms or signs of ill health. • NICE Postnatal Care Guideline CG37 & RCOG green-top guideline 64a • (National Institute for Healthcare Excellence 2006; RCOG 2012)
  176. 176. Confidential Enquiry Theme: Delay in Diagnosis • The key actions for diagnosis and management of sepsis are: • Timely recognition • Fast administration of intravenous antibiotics • Quick involvement of experts - senior review is essential • NHS England Patient Safety Alert NHS/PSA/R/2014/015 (NHS England 2014)
  177. 177. Antibiotics • Time to administration is a predictor of mortality. • From time of diagnosis each hour’s delay in administration of antibiotics increases the chance of death by 8%. (Kumar et al. Crit Care Med. 2006,34;1589-1596)
  178. 178. Antibiotic administration among women who died 2009-12 Symptom onset Diagnosis Antibiotics Death 43 40 37 3 <1 hour 3 1 – 2 hours 2 – 3 hours 3 – 24 hours < 24 hours (missing time) > 24 hours Death at home or on arrival Never commenced on antibiotics Progression of disease Time 14 7 4 4 3 5 Mohamed-Ahmed O et al, BJOG 2015 43 women died from bacterial sepsis 14 (33%) received antibiotics within one hour
  179. 179. Causative organisms Escherichia coli 21% Group A streptococcus 9% Group B streptococcus 8% Other streptococcus 6%Staphylococcus 6% Mixed organisms 5% Other 7% Unknown 2% No laboratory confirmed infection 36% Acosta, Kurinczuk, Lucas at al 2014 (PLoS Med)
  180. 180. Causative organism by source of infection 0 20 40 60 80 100 120 Numberofcases Source of infection No Lab confirmed infection Unknown Other Mixed Staph Other strep Group B strep Group A strep E.coli Acosta, Kurinczuk, Lucas at al 2014 (PLoS Med)
  181. 181. Causative organism by mode of delivery 0 20 40 60 80 100 120 Spontaneous vaginal Operative vaginal Pre-labour caesarean Caesarean after labour onset Numberofcases No Lab confirmed infection Unknown Other Mixed Staph Other strep Group B strep Group A strep E.coli Acosta, Kurinczuk, Lucas at al 2014 (PLoS Med)
  182. 182. Key messages 2 • Antibiotics should cover the appropriate spectrum, dependent on suspected source and mode of delivery • If there appears to be no response, rethink – Antibiotic spectrum – Collection – Other infection source
  183. 183. “A woman presented in labour and was noted to have genital tract sepsis. She was delivered by caesarean section. The operation was complicated by a lateral tear and atony with an estimated blood loss of 1500mls. She was given intravenous antibiotics for 48 hours after delivery but her sepsis did not improve. There were several changes of antibiotics. On day 5 postpartum a CT scan was performed and found what was thought to be an area of sepsis in the wound communicating with the uterine cavity. On day 6 she worsened and a laparotomy was performed. The uterus was necrotic and the abdomen contained a great deal of pus. She had a sub-total hysterectomy and wound debridement. Despite intensive care she developed acute respiratory distress syndrome, deteriorated and died”
  184. 184. “A woman was admitted in second trimester with vomiting and preterm pre-labour rupture of the membranes. She was septic - chorioamnionitis caused intrauterine death of the fetus. The sepsis resuscitation bundle was promptly applied and following blood cultures and discussion with a consultant microbiologist, antibiotics were commenced within one hour of diagnosis. Despite resuscitation she failed to improve. The team then proceeded to hysterotomy to remove the source of the sepsis. After two days of supportive care on the intensive care unit she made a full and complete recovery. Her treatment was prompt and effective with rapid source control when she failed to respond to conservative treatments. The time from admission to control of the sepsis was 18 hours.”
  185. 185. Rapid progression to severe sepsis • <24 hours between the first signs of SIRS and sepsis: – 83% of cases and 85% of septic shock cases • <48 hours between the first signs of SIRS and sepsis: – 89% of cases and 95% of septic shock cases Acosta, Kurinczuk, Lucas at al 2014 (PLoS Med)
  186. 186. Key messages 3 • Use of a sepsis bundle – International Surviving Sepsis Campaign – “Sepsis six” (within the first hour): • Administer high flow oxygen • Take blood cultures • Give broad spectrum antibiotics • Give intravenous fluid challenges • Measure serum lactate and haemoglobin • Measure accurate hourly urine output
  187. 187. Causative organism according to septic shock diagnosis 0 5 10 15 20 25 30 35 40 45 50 E.coli Group A strep Group B strep Other strep Staph Mixed Other Unknown No Lab confirmed infection Proportionofwomen(%) Septic shock No shock Acosta, Kurinczuk, Lucas at al 2014 (PLoS Med)
  188. 188. Rapid progression to severe sepsis for Group A strep cases • 50% <2 hours between the first signs of SIRS and sepsis diagnosis • 75% <9 hours between the first signs of SIRS and sepsis diagnosis Acosta, Kurinczuk, Lucas at al 2014 (PLoS Med)
  189. 189. Key messages 4 • Clinical suspicion of group A strep is a red flag for urgent action – Association with spontaneous vaginal delivery • Positive culture for group A strep should be reported by telephone
  190. 190. Severity n (%) Total=365 Level 2 or ITU admission 286 (78) Level 2 admission 171 (47) ITU admission* 114 (31) Septic shock 71 (20) Death 5 (1) * Irrespective of level 2 admission
  191. 191. Timing of infection • 37% cases antenatal • 63% cases postnatal • Median diagnosis to delivery interval (antenatal sepsis) = 0 days (IQR 0-36 days) • Median time between delivery and sepsis (postpartum cases) = 3 days (IQR 1-7 days) Acosta, Kurinczuk, Lucas at al 2014 (PLoS Med)
  192. 192. Key messages 5 • Some women may need intensive care on delivery suite • Some women may need obstetric care in the critical care unit • Facilities/processes need to be available for both
  193. 193. Significant medical risk factors Cases n (%) Controls n (%) aOR* 95% CI n=365 n=757 Parity 0 197 (54) 330 (44) 1.6 (1.2-2.2) ≥1 167 (46) 427 (56) 1 Pre-existing medical problems Yes 120 (33) 171 (23) 1.4 (1.0-1.9) No 245 (67) 583 (77) 1 Febrile illness or antibiotics in 2 wks before delivery Yes 153 (42) 42 (6) 12.1 (8.1-18.0) No 212 (58) 715 (94) 1 *Adjusted for all other factors examined
  194. 194. Significant delivery risk factors Postpartum cases n (%) Controls n (%) aOR* 95% CI n=302 n=757 Mode of delivery Spontaneous vaginal 57 (21) 443 (59) 1 Operative vaginal 39 (14) 100 (13) 3.4 (1.7-7.0) Pre-labour caesarean 67 (25) 119 (16) 3.5 (2.0-6.1) Caesarean after labour onset 108 (40) 92 (12) 6.7 (3.8-12.0) Complications of delivery Yes 103 (34) 279 (37) 1.7 (1.1-2.5) No 199 (66) 478 (63) 1 *Adjusted for all other factors examined
  195. 195. Significant factors associated with mortality - ICNARC Survivors n (%) Deaths n (%) aOR* 95% CI n=610 n=29 Maternal age <25 234 (38) 5 (17) 1 25-34 254 (42) 15 (52) 2.2 (0.7-7.0) ≥ 35 121 (20) 9 (31) 3.3 (0.9-11.0) BMI Unknown 317 (52) 13 (45) 1.2 (0.2-9.1) <25 126 (21) 3 (10) 1 25-29.9 90 (15) 7 (24) 5.2 (1.4-18.9) ≥ 30 76 (13) 6 (21) 6.3 (1.5-27.0) IMD Quintiles 4&5 354 (58) 17 (58) 2.6 (1.0-6.7) *Adjusted for all other factors examined
  196. 196. Absolute risk (95% CI) of all sepsis and severe sepsis/septic shock as a function of the number of a priori risk factors. Acosta CD, Knight M, Lee HC, Kurinczuk JJ, et al. (2013) The Continuum of Maternal Sepsis Severity: Incidence and Risk Factors in a Population-Based Cohort Study. PLoS ONE 8(7): e67175. doi:10.1371/journal.pone.0067175
  197. 197. Key points 6 • It cannot be assumed that antibiotics will prevent progression to severe sepsis and safety net checks should therefore be in place to make sure a pregnant woman has recovered • Older and obese women are at particular risk of mortality
  198. 198. Influenza: Delays in diagnosis and treatment • Presentation: Route of presentation into health care services: 33% to Primary care, 36% to Obstetric services, 28% to A+E/UCC • Diagnostic delay: Influenza was not even considered as a possible diagnosis in the vast majority (n=34, 94%) of women at initial presentation with respiratory illness even at the height of the H1N1 pandemic. This led to delays in appropriate referral, testing and treatment which likely affected outcome • Treatment delay: In 75% of women who died from influenza, antiviral treatment was not commenced until after a positive H1N1 result was received, even though this was thought the most likely underlying aetiology in a clinically deteriorating patient
  199. 199. “A pregnant woman who smoked refused vaccination offered by her GP for seasonal influenza or H1N1. She presented in the third trimester with flu-like symptoms including fever, cough and dyspnoea. Rapid deterioration led to her requiring ventilation in ITU, but she died within 24 hours of admission”
  200. 200. Influenza Vaccination • Vaccination is the main Public Health response to influenza • Influenza vaccination in pregnancy – Reduces maternal morbidity and mortality – improves fetal outcomes including reduced likelihood of perinatal death, prematurity and low birth weight, – prevents influenza in the infant up to 6 months of age through transfer of maternal antibodies and potentially improves long-term adult outcomes for the infant
  201. 201. Influenza Vaccination • None of the women who died in this review had been documented to have received seasonal flu vaccine or H1N1 vaccination in those who presented after 21st October 2009 (when the UK A/H1N1 vaccination programme commenced) • Of the deaths from H1N1, 38% occurred prior to vaccine availability in the UK and 62% after a vaccine was available • Of those who could have been vaccinated against H1N1, 3 women refused • It was not clear how many of the others had been actively offered vaccination through primary care or obstetric services
  202. 202. Use of neuraminidase inhibitors • A Cochrane Review (2014) on the efficacy of neuraminidase inhibitors for influenza found little evidence of benefit • However most patients in the treatments studies included in the review were not at high risk of severe complications and no pregnant women were included • Observational data in pregnancy show significant benefit from early use • DH/RCOG guidelines recommend that antiviral treatment should be commenced as early as possible in pregnant women with signs of flu, particularly within the first 48 hours of onset of symptoms • Recommended agent is Relenza (zanamivir) though Tamiflu if other airway problems or severe H1N1 Refs: Cochrane Database Syst Rev 2014; 4: CD008965, Siston, Rasmussen et al. 2010; Pierce, Kurinczuk et al. 2011; Muthuri, Venkatesan et al. 2014; Nguyen-Van-Tam, Openshaw et al. 2014
  203. 203. Key recommendations - Influenza 1. Department of Health/RCOG Guideline on the investigation and management of pregnant women with seasonal or pandemic flu should be followed (Department of Health and the Royal College of Obstetricians and Gynaecologists 2009) 2. The benefits of influenza vaccination to pregnant women should be strongly promoted and pregnant women at any stage of pregnancy should be offered vaccination against seasonal and pandemic influenza with inactivated vaccine. Immunisation against Infectious Disease – “The Green Book” (Public Health England 2014) 3. Early neuraminidase inhibitor treatment should be instigated for pregnant women with symptoms consistent with influenza, in line with national UK guidance. (Department of Health and the Royal College of Obstetricians and Gynaecologists 2009)
  204. 204. Influenza 2011-13 • Statistically significant decrease in deaths due to influenza (RR 0.33, 95% CI 0.14-0.78, when comparing 2011-13 with 2009-10) • May be due to a lower level of influenza activity in 2011- 13 compared to 2009 and 2010 when there was a major impact from pandemic 2009/AH1N1 influenza • Uptake of vaccination among all pregnant women has increased by varying degrees across the UK – England: increased from 27% in 2011-12 to 40% in 2013-14 – Northern Ireland: 58% for both time-periods – Scotland: increased from 41% in 2011-12 to 49% in 2013-14 – Wales: increased from 32% in 2011-12 to 71% in 2013-14
  205. 205. Saving Lives, Improving Mothers’ Care 0 2 4 6 8 10 12 14 16 2004 2005 2006 2007 2008 2009 2010 2011 Rateper100000maternities Mid-year of each three-year period Timely recognition of risk, the severity of the condition, accurate diagnosis, involvement of the correct senior staff from multiple disciplines, escalation and prompt treatment and action can make the difference between life and death
  206. 206. Maternal immune system changes Cell mediated immunity (Th1 response) Humoral immunity (Th2 response)  Increase in endogenous corticosteroids  Temporary immunosuppressive state  Increase in infections in pregnancy
  207. 207.  ‘Tip of the iceberg’  Scottish major morbidity audit for major morbidity (ITU admission) & major haemorrhage 2003-2005  ITU admission 845 1:188 women  Major PPH (>2.5 litres) 572 1:273 women  Extrapolated to UK figures 2003-2005 2,114 004 births 7744 cases of major PPH  14 deaths in 2003-2005
  208. 208. Session 3 – Sepsis Cafés Chair: Dr Seema Srivastava North Bristol Trust #sepsissavvy
  209. 209. Café Groups & Rooms Café Group First Café Second Café Maternity Murrayfield Room (downstairs) 1 3 & 5 Paediatrics Twickenham Room (downstairs) 2 & 5 4 Community Priory Suite (this room) 3 & 4 1 & 2 • Group numbers are listed on your badge • 20 mins per session. • 2nd café will commence at 14:25pm
  210. 210. Session 4 – The Future Chair: Dr Lesley Jordan Royal United Hospital Bath #sepsissavvy
  211. 211. Procalcitonin (PCT) Real life application Sepsis, SIRS and localised infections Dr Kordo Saeed #sepsissavvy
  212. 212. Background • Procalcitonin is a 116 aa peptide - Precursor of the hormone Calcitonin • Synthesis in healthy persons in the C-Cells of the thyroid • PCT is enzymatically converted
  213. 213. Role in the Absence of Infection? PCT Role in infection? Becker KL, et al. J Endotoxin Res. 2003;9(6):367-74.
  214. 214. Localised infection Systemic infection Serum test Serum test Heart Muscle Skin Fat Testes Thyroid, lungs, WBC, Spleen Brian, Spine, GIT, liver, lung, kidney, adrenal Procalcitonin
  215. 215. • 3487 reports, of which 30 included (3244 patients). • Mean sensitivity of 0·77 (95% CI 0·72–0·81) and specificity of 0·79 (95% CI 0·74–0·84). • The area under the ROC curve was 0·85 (95% CI 0·81–0·88). • The studies had substantial heterogeneity investigated— population, admission category, assay used, severity of disease Wacker et al. The Lancet Infectious Diseases, 13: 426 - 435, 2013.
  216. 216. 91.3 8.7 0 10 20 30 40 50 60 70 80 90 100 Yes No % Do we give Antibiotics “Just in case” ?
  217. 217. What was the reason you wrote the last prescription of antibiotic therapy? Straw poll of F1, F2 doctors “Clinical Infection” “Fever” “ Off legs” “ Mucky urine” “ ? aspiration” “ Increased respiratory requirements” “Rising CRP” “Wound infection” “The boss asked me to” “Positive culture” … Local audit, Parker and Dryden, RHCH 2009
  218. 218. Why did you stop the antibiotic therapy? Views from ICU “We said 8 days” “Micro round said stop” “Patient is stable” “Patient is transferring to the ward” “Patient developed a rash” “Renal function is deteriorating” “New consultant on” “Cultures came back negative” … Local audit, Parker and Dryden, RHCH 2009
  219. 219. Harrison PF, Lederberg J, eds. Antimicrobial resistance: issues and options. Washington, DC: National Academy Press, 1998 Where Antibiotics are used Types of use Questionable use Human use (50%) 20% hospital 80% community Agricultural use (50%) 20% Therapeutic 80% Prophylactic growth promotion 20-50% Unnecessary 40-80% Highly questionable Questionable use of antibiotics
  220. 220. Antibiotic therapy Who cares? Bacterial resistance £££ Toxicity - interactions
  221. 221. Integration of PCT into antibiotic decision-making process to aid diagnosis? • Provide antibiotic therapy to those who need it • Avoid antibiotic prescription to those without infection • Infection prevention »To reduce need for antibiotics • Micro/ Infection round initiated. • Rapid result • Without compromising care Saeed K, Dryden M et al. JHI. 2011;78: 289- 292
  222. 222. The following PCT levels (in microg/L) were used as a cut - off • MAU patients ≥ 0.25 • ICU Medical patients ≥ 0.5 • ICU Post operative patients ≥ 2.0 (within 48 hrs) • ICU Acute Severe pancreatitis ≥ 4.0 • Decisions on whether to start antibiotics or not or to discontinue were guided by the PCT concentration* • Patients were followed up clinically for 7 days or for length of stay in ICU to determine episode outcome. Methods: Christ-Crain M, et al. Lancet 2004; 363 : 600-607. Brunkhorst FM, et al. Intensive Care Med. 2000; 26:148– 152. Liaudat S, et al. Eur J Clin Microbiol Infect Dis 2001; 20 : 524-527. Giamarellos-Bourboulis EJ, et al. Intensive Care Med 2002; 28: 1351-1356. Rau BM, et al. Ann Surg 2007; 245: 745–754. Reith HB etal. Intensive Care Med. 2000 Mar;26 Suppl 2:S165-9. *Clinical judgment can override the PCT at all points
  223. 223. Results: ICU MAU * Out of the 87 tests, four tests did not affect patients’ management in ICU: # During the evaluation period, in ICU, 4 patients died from infection, all of these were on appropriate antibiotics with mean PCT 21µg/L. No patient suffered adverse effect or died as a result of withholding antibiotics on the basis of low PCT value within the follow up period.
  224. 224. 19.3 12.8 15.7 8 16.2 25 21 171 77 143 125 43 100 209 0 15 30 45 60 75 90 105 120 135 150 165 180 195 210 225 06-Jul 13-Jul 15-Jul 23-Jul 06-Aug 11-Aug 17-Aug Date CRP/WCCValue 0 0.4 0.8 1.2 1.6 2 2.4 2.8 3.2 PCTValue WCC CRP PCT AW Pancreatitis [cut off 4 ug/L]
  225. 225. 19.3 12.8 15.7 8 16.2 25 21 171 77 143 125 43 100 209 0 15 30 45 60 75 90 105 120 135 150 165 180 195 210 225 06-Jul 13-Jul 15-Jul 23-Jul 06-Aug 11-Aug 17-Aug Date CRP/WCCValue 0 0.4 0.8 1.2 1.6 2 2.4 2.8 3.2 PCTValue WCC CRP PCT AW Pancreatitis [cut off 4 ug/L]
  226. 226. AW Pancreatitis [cut off 4 ug/L] Discharged home
  227. 227. Procalcitonin and (SAFE) reduction in antibiotic use (1) ~ 17% reduction in antibiotic use = ~ £14,450/ 6m + Savings from hidden costs associated with antibiotic therapy (2) 13 –113% of the overall costs for treatment with antibiotics. i.e. additional savings of £1,880 –£16,328/ 6m More importantly!! • Patients were not exposed to Abx unnecessarily • bed days, secondary CDAD and IV line infection cases that is been potentially prevented by reduction of unnecessary antibiotic use. Different cut-off values in different clinical infections. (1) Saeed K, Dryden M, et al.JHI 2011; 78: 289- 292 (2) van Zanten AR, et al. Crit Care. 2003;7:R184–90.
  228. 228. PCT HHFT summary Puedomyxoma (1) PCT predicts infections in puedomyxoma patients 24hr prior to clinical suspicion (Gray line) and 48 hr prior to CRP and WCC (Data not shown) 0 1 2 3 4 5 6 7 8 Day 0 POD1 POD3 POD6 PCTvalueMicrog/L Infected Non infected Confusion and eldelry ? UTI to avoid just in case Abx! (2) 55 patients (1 ward  3 months) Confusion ? + potential (chest, or urine or etc infection) In low PCT group 4/ 46 patients RIP (> 14 days after the PCT decision non due to infection) In High PCT group 6/9 patients RIP all on antibiotics deemed appropriate SYNOVIAL PCT (3, 4) Synovial PCT higher in SA vs non SA (caution with crystal arthropathy and concomitant malignancy Synovial fluid PCT <0.5 µg/L  NPV of 0.90 More promising in excluding PJI (1) Saeed K, Dale A etal. EJSO in press, Oct 2015 (2) Eddie F, Joyce A etal. J Infect Non Infect Dis 2015 (3) Saeed K, Dryden M etal. Infection. 2013; 28: 201-206 (4) Saeed K, Ahmad N etal. Exp Rev Molec Diagn 2014;14:47-54.
  229. 229. So far 17 cases with implants Median synovial PCT in the PJI group was 3.15 µg/L vs. 0.05µg/L in the aseptic loosening. Staphylococcus aureus (n =5), Enterococcus spp.(n=1), Escherichia coli (n=1) and Coagulase-Negative Staphylococcus (n=1) Only two cases with PJIs had concomitant positive blood cultures, Highest synovial PCT levels were seen in Staphylococcus aureus infections regardless of presence of concomitant positive blood cultures. Saeed & Dryden EBJIS 2014 The Netherlands
  230. 230. • Gp A streptococcal soft tissue infection • A range of severity PCT = 0.75 microg/L PCT = 1.8 microg/L & +ve BC PCT = 26.2 microg/L: nec fasciitis Slide: courtesy of M Dryden
  231. 231. 0.1 1 10 100 1000 PCT(ng/mL) 0 2 4 6 8 10 12 14 16 Days 0.1 1 10 100 1000 PCT(ng/mL) 0 2 4 6 8 10 12 14 16 Days Survived Died The evolution of PCT levels with time predicts outcome Harbarth et al. Am J Respir Crit Care Med 2001 Prognostic tool?
  232. 232. PCT and mortality • A 72-hour PCT decrease >80% had a negative predictive value of around 90%; conversely, no decrease or an increase in PCT over 72 hours had a positive predictive value around 50% Philipp Schuetz. Critical Care 2013, 17:R115 doi:10.1186/cc12787
  233. 233. Pro-adrenomedullin • Pro-ADM, a prohormone of adrenomedullin and hormokine. • Member of the calcitonin peptide superfamily. • A strong vasodilator • Immunomodulatory and bactericidal properties.
  234. 234. Pro-ADM and PCT values on day 0 and 3 of Sepsis and outcomes @28 days 6.4755 4.567 33.73 8.336 1.724 1.586 2.006 2.006 0 5 10 15 20 25 30 35 40 Pro- ADM0 Pro- ADM3 PCT0 PCT3 Pro-ADM nmol/L and PCT microg/L RIP Survived Lee M et al, 2014 FIS
  235. 235. What do we want rapid diagnostics to do? • Identify bacterial infection • Support starting or withholding Abx • Exclude bacterial infection • Identify the pathogen • Detect antibiotic resistance and guide Abx Rx • Support stopping Abx • Predicting prognosis
  236. 236. Non-specific PCT inducers – potential false positive results include:  Surgical Trauma, poly trauma:  Pregnancy  Neonates less than 48 hrs of age  Auto immune diseases  Immune-stimulatory drugs (OKT3,TNFa,IL-2.)  Severe Burns >60% Weak or no increase in PCT  Early course of infection (re-measure 6-12 hours later!)  Previous effective antibiotic therapy  Atypical pneumonia (M.pneumoniae, C.pneumoniae) PCT Test limitations False negative PCT in true sepsis following multiple blood transfusion Immunosuppression?
  237. 237. Patient with AIDS and sepsis
  238. 238. Patient with AIDS and sepsis 0 2 4 6 8 10 12 14 16 Pre HAART Post HAART WCC PCT
  239. 239. • Another limitation of the current PCT test Turnaround time and lab mergers, closures etc
  240. 240. QUANTITATIVE Point of care PCT • Single drop of blood • Result in 20 minutes • So far our evaluation in HHFT is very promising
  241. 241. Decision making tool at the bedside, a theatre or a clinic?
  242. 242. Acknowledgement • Patients and relatives • Doctors, nurses and other supporting staff in HHFT • Laboratory staff in HHFT • R and D in HHFT Transparency Previous speaker honorarium from Thermofisher
  243. 243. www.england.nhs.uk Antimicrobial Stewardship – why it matters Elizabeth Beech Healthcare Acquired Infection and Antimicrobial Resistance Project Lead NHS England West of England Sepsis Master class @weahsn #sepsissavvy February 2016 elizabeth.beech@nhs.net @elizbeech
  244. 244. www.england.nhs.uk
  245. 245. www.england.nhs.uk Superbugs to kill 'more than cancer' by 2050
  246. 246. www.england.nhs.uk
  247. 247. www.england.nhs.uk In the UK If we fail to act, we are looking at an almost unthinkable scenario where antibiotics no longer work and we are cast back into the dark ages of medicine– David Cameron, UK Prime Minister Fears grow over increased antibiotic resistance BBC 16 October 2015 UK experts said the study confirmed their fears that antibiotic resistance would affect routine surgery. England's chief medical officer has called the issue a ticking time bomb
  248. 248. www.england.nhs.uk
  249. 249. www.england.nhs.uk G7 Health Ministers meeting Oct 2015 Antibiotic consumption links to AMR
  250. 250. AMR: individual risk Risk of resistance persists for at least 12 months in individuals after each intake of an antibiotic Increased risk of resistant organism Antibiotic in past 2 months Antibiotic in past 12 months UTI 5 studies: n = 14,348 2.5 times 1.33 times RTI 7 studies: n = 2,605 2.4 times 2.4 times A meta analysis of English Primary Care Costello et al. BMJ. (2010) 340:c2096. 308 AMR: Strategic Overview Dr Diane Ashiru-Oredope
  251. 251. 309 Health Matters PHE
  252. 252. www.england.nhs.uk
  253. 253. CMOAnnual Report 2011* 311 *published: March 2013 UK 5-year AMR Strategy 2013 -18 1. Improve the knowledge and understanding of AMR 2. Conserve and steward the effectiveness of existing treatments 3. Stimulate the development of new antibiotics, diagnostics and novel therapies Strategic aims‘One Health’
  254. 254. UK 5-yearAMR Strategy 2013-18: Seven key areas for action Presentation title - edit in Header and Footer PHE Human health DH – High Level Steering Group Defra Animal health DH • 1) Better access to and use of surveillance data • 2) Optimising prescribing practice • 3) Improving infection prevention and control • 4) Improving professional education, training and public engagement • 5) Improving the evidence base through research • 6) Developing new drugs, vaccines and other diagnostics and treatments • 7) Strengthening UK and international collaboration
  255. 255. Antimicrobial Prescribing Quality Measures Primary care Secondary care Measures to reduce total antibiotic prescribing Total antibiotic prescribing to be reduced to 2010 levels at CCG level as measured by number of antibiotic prescriptions (“items”) per 100 patients per year Total antibiotic consumption to be reduced by 1% per year 2015- 2019 as measured by DDD per 1000 admissions per year. Measures to encourage narrow spectrum antibiotic prescribing Proportion of antibiotics from cephalosporin, quinolone or co- amoxiclav classes to be reduced to less than the current median for English CCGs as measured by the number of prescriptions (“items”) from target classes in comparison with the total number of antibiotic prescriptions per year. Total carbapenem consumption to be reduced to 2010 consumption levels as measured by DDD per 1000 admissions per year. Table 3: ARHAI recommended antimicrobial prescribing quality measures October 2014
  256. 256. www.england.nhs.uk ESPAUR 2015 • Antibiotic prescribing has increased in England 2014 on 2013 but more slowly, by 2.4% • Hospital ↑ • Primary care items per STAR-PU ↓ • but DDD per1000 inhabitants per day ↑
  257. 257. www.england.nhs.uk PHE ESPAUR report 2015
  258. 258. www.england.nhs.uk Antibacterial items and proportion of broad spectrum items by CCG Oct14-Sep15
  259. 259. www.england.nhs.uk ESPAUR 2014 – Top choices with growth rates
  260. 260. www.england.nhs.uk PHE ESPAUR report 2015
  261. 261. www.england.nhs.uk Patient Harm – prevent and reduce • Patients with AMR have 2-3 times higher mortality and risk of complications • CDI rates are rising in 2015 • Co-amoxiclav use ↑ resistance ↑ association with CDI • E.coli bacteraemia rates are increasing • CAUTI remain a concern • Carbapenemase-producing Enterobacteriaceae CPE surveillance for all NHS organisations and global increasing resistance – avoid use • Sepsis – Needs antibiotics to work • Vaccination prevents infection
  262. 262. www.england.nhs.uk Maternal deaths from influenza
  263. 263. www.england.nhs.uk
  264. 264. www.england.nhs.uk AMR - New guidance and incentives in 2015 • 2008 Health & Social Care Act Code of Practice now includes AMS – criterion 3: ensure antibiotic use optimises outcomes &  risk of adverse events and AMR. Applies to dentists and GP practices also • NHS England patient safety alert August 2015 • Start Smart then Focus and TARGET stewardship toolkits • NICE guidelines NG15: Antimicrobial Stewardship • NICE guidelines consultation changing risk-related behaviours in the general population • NHS England 2015-16 Quality premium for CCGs • NHS England Sepsis CQUIN for acute care providers • e-LfH free AMR learning for health and social care staff
  265. 265. www.england.nhs.uk IV Antibiotic consumption in A&E - DEFINE
  266. 266. www.england.nhs.uk IV Antibiotic consumption in ALL - DEFINE
  267. 267. www.england.nhs.uk NHSE Antibiotic Quality Premium 2015-16 and what it means for CCGs The Quality Premium is intended to • Improve the quality of services commissioned, improving health outcomes and reducing inequalities in health outcomes • Reward CCGs for quality improvement, paid in the following financial year, and must be reinvested in quality or health outcome improvement
  268. 268. www.england.nhs.uk NHSE Antibiotic Quality Premium 2015-16 and what it means for CCGs The Antibiotic element has 3 parts, 2 relate to primary care prescribing (80% of payment) • Reduction in the number of antibiotic prescriptions by 1% as measured by population – antibacterial items per STAR-PU • Reduction in the proportion of broad spectrum antibiotics (cephalosporins, quinolones & co-amoxiclav) by 10% from 2013-14 baseline or to stay below England 2013-14 median value of 11.3% • Validation of acute provider antibacterial consumption data for PHE • CCGs have individual targets published on NHSE Quality Premium webpage
  269. 269. www.england.nhs.uk Antibiotic prescribing variability – all England CCGs last 12 months Oct14 - Sep15
  270. 270. www.england.nhs.uk Antibiotic prescribing variability – all England GP practices last 12 months Oct14 - Sep15
  271. 271. www.england.nhs.uk NHSE Antibiotic Quality Premium dashboard Both Comparators Antibiotics/STAR-PU Co-amoxiclav, cephalosporins & quinolones NHS England Antibiotic Quality Premium monitoring data set National Antibiotic Quality Premium Dashboard National view trend charts for both antibiotic comparators showing number of CCGs who have met / not met each of the comparator targets, National CCG median trend chart & chart showing direction of travel from previous time period. Trend charts showing number of CCGs who have met both / have not met either antibiotic comparator target. NHS England Sub-Region Antibiotic Quality Premium Dashboard Sub-Region view charts for both antibiotic comparators showing number of CCGs within each Sub-Region who have met / not met each of the comparator targets. NHS England Area Antibiotic Quality Premium Dashboard Area view charts for both antibiotic comparators showing number of CCGs within each Area who have met / not met each of the comparator targets. Information Trend chart & data showing number of CCGs who have met both antibiotic comparator targets Trend chart & data showing number of CCGs who have not met either antibiotic comparator target (12 month rolling CCG data) CCG Trend Chart CCG Trend Chart CCGs who have met target CCGs who have met target (12 month rolling CCG data) CCGs who have not met target CCGs who have not met target
  272. 272. www.england.nhs.uk National Antibiotic Quality Premium dashboard
  273. 273. www.england.nhs.uk National Antibiotic Quality Premium dashboard CCG performance versus target and all England
  274. 274. www.england.nhs.uk National Antibiotic Quality Premium dashboard CCG performance versus target and all England
  275. 275. www.england.nhs.uk PrescQIPP AMS Hub https://www.prescqipp.info Antimicrobial Stewardship Hub Launched The Antimicrobial Stewardship (AMS) Hub, hosted as part of a PrescQIPP collaboration with NHS England to support CCG Quality Premium activity. This work has been led by Elizabeth Beech, Healthcare Acquired Infection and Antimicrobial Resistance Project Lead, Patient Safety Domain, NHS England, who is responsible or the range of content available on this AMS Hub. The AMS hub offers a selection of resources and links to help you better understand and navigate this key area of work for commissioners and providers alike. Free access Lots of links to resources Primary care prescribing data – use it and contribute
  276. 276. www.england.nhs.uk TARGET resources – http://www.rcgp.org.uk/clinical-and- research/toolkits/target-antibiotics-toolkit.aspx
  277. 277. www.england.nhs.uk Antimicrobial Stewardship Activity • Guidelines – NICE, PHE, and local • Audit – 46K people in BaNES (pop 200K) had at least 1 antibiotic Rx last year • Incentive schemes for GP practices • Education – Healthcare professionals and the public • Pathway review – really important to develop this • Implementing No and delayed (Back up) antibiotic systems • Use of TARGET and Start Smart Then Focus resources • Local CQUINs of providers • Promoting vaccination – join up with AMR messages • Lots of collaboration - development of AMS networks • Champions – most effective intervention • Behaviour change – PHE interventions
  278. 278. www.england.nhs.uk Key take home AMR messages • The Drugs Don’t Work - Tough action needed to slow antibiotic resistance • Prevent Infection – vaccinate, hand wash, stay home! • Tackling AMR is everybody's (professional) responsibility • Collaboration is essential – across health economies and pathways • Behaviour change is key • Evidence suggests what works is a bundle of interventions • Effective Antimicrobial stewardship matters • Useful resources and tools are available – use & share them • Don’t forget Healthcare Associated Infections • Become an AntibioticGuardian.com and a champion
  279. 279. www.england.nhs.uk Implementation of national AMS toolkits in England Dr Diane Ashiru-Oredope You are invited to become an Antibiotic Guardian today (available via mobiles) 337AMR: Strategic Overview Dr Diane Ashiru-Oredope
  280. 280. Thank you #sepsissavvy

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