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The Clinical Excellence Commission The eChartbook


SEPSIS KILLS CEC eChartbook
Sepsis Recognition, Resuscitation and Referral
For more information about this CEC program, click here
 


Why is this important?


Sepsis is a medical emergency and its management is time-critical. Sepsis arises when the body’s response to infection injures its own tissues and organs [1]. It can develop in any patient and in any clinical setting. Severe sepsis is sepsis plus organ dysfunction, including hypotension and/or hypoperfusion of the organs. Septic shock occurs when there is severe sepsis and hypotension that is unresponsive to intravenous fluid resuscitation. It can lead to multi-organ failure and death. There is an increase in mortality as the patient moves along the sepsis continuum.


Appropriate recognition and timely management of patients with severe infection and sepsis is a significant problem in NSW hospitals and health care organisations around the world. Severe sepsis and septic shock are associated with high morbidity and mortality of around 25 per cent [1] and have significant impact on the patient and the health care system. The mortality rate for patients with septic shock has been shown to increase by 7.6 per cent for every hour of delay in starting antibiotic therapy [2].


Sepsis has been identified by the NSW Clinical Risk Review Committee as a recurrent problem. The findings from the Clinical Excellence Commission (CEC) Clinical Focus Report on the Recognition and Management of Sepsis [3] demonstrated significant deficits in its identification and management, in a range of clinical settings. Preliminary NSW sepsis data suggests that 30 per cent of adult inpatients who need a Rapid Response are septic.


The CEC's SEPSIS KILLS Economic Analysis [4] estimated that "if the status quo was to be maintained over the following ten years, sepsis-related conditions in the NSW health system would constitute a cost of $3.7 billion, 1.3 million bed days, 701,000 cost-weighted separations and an unknown number of potentially avoidable deaths."


The SEPSIS KILLS program was developed by the CEC, in collaboration with clinicians, to improve recognition and treatment of sepsis and septic shock and to reduce their impact on mortality and financial costs in NSW. It was introduced into NSW public hospitals in a phased approach, starting with emergency departments in 2011, paediatrics in 2013 and extending to inpatient wards in 2014.


Links between the CEC’s programs - Between the Flags, Falls Prevention, In Safe Hands, Partnering with Patients, Antimicrobial Stewardship, Healthcare Associated Infections, and the Agency for Clinical innovation’s Delirium program [5] have been strongly established, ensuring an integrated and comprehensive approach in the management of patients with sepsis.



References

[1] The Australasian Resuscitation in Sepsis Evaluation (ARISE) Investigators and the Australian and New Zealand Intensive Care Society (ANZICS) Adult Patient Database (APD) Management Committee. The outcome of patients with sepsis and septic shock presenting to emergency departments in Australia and New Zealand. Critical Care and Resuscitation. 2007 Mar;9(1): 8-18.
[2] Kumar A, Roberts D, Wood KE, Light B, Parrillo JE, Sharma S, Suppes R, Feinstein D, Zanotti S, Taiberg L, Gurka D, Kumar A, Cheang M. Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock. Critical Care Medicine. 2006 Jun; 34(6): 1589-96.
[3] Clinical Excellence Commission. Clinical Focus Report from review of root cause analysis (RCA) and/or Incident Information Management System (IIMS) data:Recognition and management of sepsis, December 2009. Sydney: Clinical Excellence Commission.
[4] King B, Kerr R, Bai J. 2011 Quality Systems Assessment Self-assessment Supplementary Report - Sepsis, May 2012. Sydney: Clinical Excellence Commission.
[5] Agency for Clinical Innovation and Clinical Excellence Commission. Cost effective analysis, stage one: do nothing and the case for change. 2011. Sydney: Clinical Excellence Commission.
[6] Burrell AR, McLaws M-L, Fullick M, Sullivan RB, Sindhusake D. ‘SEPSIS KILLS: early intervention saves lives. Med J Aust. 2016 Feb 1;204(2):73.


Findings


The Clinical Excellence Commission’s Sepsis Data Collection provides a tool to collect and analyse data, to facilitate improvement in the recognition and management of sepsis in the NSW health system. It is a web-based application, via the NSW Health intranet system. Data entry allows facilities and local health districts/networks to evaluate the impact and effectiveness of the change in the clinical management of sepsis patients.


Data has been entered by facilities since the introduction of the CEC SEPSIS KILLS program in May 2011. The database collects a minimum dataset, including: date of birth; triage time and date; triage category; observations (including systolic blood pressure); lactate, administration time and date of first intravenous antibiotic; the presumptive source of sepsis; and, the disposition of patients following emergency department treatment.


A total of 33,274 records, with triage dates from 1 August 2009 to 31 Dec 2016, were entered into the database. This data was submitted by 128 facilities across 17 local health districts/specialty networks (LHDs/SNs). The sepsis records comprises data from; Principle referral hospitals (33.6 per cent), Paediatric specialty (0.3 per cent), Referral (1.7 per cent), Major hospitals (32.4 per cent), District hospitals (27.5 per cent), Community (3.1 per cent), Psychiatry, Multi-purpose, Rehabilitation and Sub- acute (1.4 per cent combined).


Of the total records, 31,924 relate to adult patients aged 16 years and over and were included in the analysis. Of this, 30,444 records belong to patients presented at emergency departments and 1,480 to patients admitted to wards.


Patients with sepsis ranged from 16 to 112 years old, with 61.9 per cent being aged 65 years or older. Emergency Department (ED) patients were triaged to all categories, with 3.1 per cent Category 1 (n=943, immediately life-threatening), 61.4 per cent Category 2 (n=18,706, imminently life-threatening) and 30.2 per cent Category 3 (n=9,187, potentially life-threatening).


The time to administration of the first intravenous antibiotic, is measured from triage or sepsis recognition.  As the data are highly skewed due to outliers, the median time to antibiotic was used instead of the mean as the measure of central tendency. In summary, the state’s median time has steadily decreased from an average of 104.0 minutes in 2009-11 (pre-pathway) to 58.0 minutes in 2016 (data not shown here). In 2016, around 4 in 5 patients (81.2 per cent) were administered with IV antibiotic within 2 hours, an increase from 56.6 per cent in 2009-11 (Chart SK04).


Administration of intravenous fluid resuscitation following sepsis recognition has continued to be difficult to measure. As a process measure the time to the second litre of intravenous fluids is no longer collected and is therefore not reported here.


Analysis of the data is focussed on defining the outcome for patients with sepsis, depending upon their triage category, systolic blood pressure, lactate measurement, time to antibiotics and presumptive source of sepsis.


Implications


Since the start of the SEPSIS KILLS program, the data demonstrates a significant and sustained improvement in its management and recognition. There are improvements in the time to intravenous antibiotic administration per facility, over a period of time. A key preliminary finding is that triage category is a significant determinant of the time to intravenous antibiotic administration (see Charts SK02 and SK03).


NSW LHDs/SNs and facilities are encouraged to analyse their sepsis data and chart their results, to demonstrate progress and identify opportunities for further improvement.


While efforts continue to make improvement in emergency departments, the focus is now on inpatient wards. The inpatient pathway and other tools were launched in May 2014. An important aspect is the sepsis 48-hour management plan, to ensure that the patient is closely monitored, test results and antibiotics are reviewed in appropriate timeframes and the management plan is adjusted as necessary.


Since the start of the program, there has been a significant improvement in sepsis recognition and management. A number of issues have been raised for patients in wards, which include management of the deteriorating patient and antimicrobial stewardship.


What we don't know


LHDs/SNs did not receive additional resources for data collection. Facilities have, however, entered more than 33,000 records in seven years. Due to limited data management resources, a guideline for periodic audit was developed and disseminated to LHDs in early 2014.   It remains unknown what impact periodic audit may have on the statistical significance of the data. Matching of data has occurred with the statewide dataset (HIE) to December 2013 and analysis was discussed in a recent MJA article https://www.mja.com.au/journal/2016/204/2/sepsis-kills-early-intervention-saves-lives [6]


Investigation into delays in administration of antibiotics has not been undertaken by the CEC. Facilities and LHDs/SNs are encouraged to review this data locally.


Chart SK01 - Median time to first antibiotic by year and LHD/SN
 

Median time to first antibiotic (patients* aged 16 years and over)
by LHD/SN, NSW, 2013 - 2016



eChartbook
Source: SEPSIS Kills Team, Clinical Excellence Commission. This static chart presents the same data as the default view of dynamic chart. *Public hospitals only. See 'Definitions' for 95%CI calculation.
Chart SK02 - Median time to first antibiotic by time and triage category
 

Median time between to first antibiotic (Emergency Department patients*aged 16 years & over
by triage category, NSW, Aug 2009 - Dec 2016



eChartbook
Source: SEPSIS Kills Team, Clinical Excellence Commission. *Public hospitals only. See 'Definitions' for 95% CI calculation.
Chart SK03 - Mean time to first antibiotic by time and triage category
 

Mean time to first antibiotic (Emergency Department patients* aged 16 years and over)
by triage category, NSW, Aug 2009 - Dec 2016



eChartbook
Source: SEPSIS Kills Team, Clinical Excellence Commission. *Public hospitals only.
Chart SK04 - Antibiotic administered within specified time (%) by year and LHD/SN
 

Antibiotic administered within specified time (patients* aged 16 years and over)
by LHD/SN, NSW, 2013 - 2016


eChartbook
Source: SEPSIS Kills Team, Clinical Excellence Commission. *Public hospitals only.
Chart SK05 - Antibiotic administered within specified time (%) by year and Hospital peer group
 

Antibiotic administered within specified time (Emergency Department patients* aged 16 years & over)
by Peer group, 2013 - 2016


eChartbook
Source: SEPSIS Kills Team, Clinical Excellence Commission. *Public hospitals only.

Chart SK06 - Antibiotic administered within specified time (%) by year and Hospital peer group

 

Antibiotic administered within specified time (Ward patients* 16 years and over)
by Peer group, NSW, 2013 - 2016


eChartbook
Source: SEPSIS Kills Team, Clinical Excellence Commission. *Public hospitals only.
Chart SK01d - Median time to first antibiotic by year and LHD/SN
 

Median time to first antibiotic (patients* aged 16 years and over) by LHD/SN, NSW, data to Dec 2016


Source: SEPSIS Kills Team, Clinical Excellence Commission.*Public hospitals only.


End Matter


Contributors
Drafted by: CEC Sepsis team, Patient Safety Directorate
Data analysis by: CEC eChartbook team
Reviewed by: CEC Sepsis team, Patient Safety Directorate
Edited by: CEC eChartbook team


Suggested citation
Clinical Excellence Commission (access year). eChartbook Portal: Safety and Quality of Healthcare in New South Wales. Sydney: Clinical Excellence Commission. Available at: http://www.cec.health.nsw.gov.au/echartbook/cec-indicators-intro-chartbook/sepsis Accessed (insert date of access).


© Clinical Excellence Commission 2017
This work is copyright. Apart from any use as permitted under the Copyright Act 1968, no part may be reproduced without prior written permission from the Clinical Excellence Commission (CEC). Requests and enquiries concerning reproduction and rights should be directed to the Director, Information Management, Locked Bag 8, Haymarket NSW 1240.


Evidence-base for this initiative
Dellinger RP, Levy MM, Carlet JM, et al. Surviving Sepsis campaign: International guidelines for management of severe sepsis and septic shock: 2008. Critical Care Medicine. 2008 Jan;36(1):296-327.


Reported elsewhere
None


Definitions


Chart: SK01

Admin Status: Current, Dec 2016

Indicator Name: Median time to first antibiotic by year and LHD/SN

Description: Median time (minute) to first antibiotic (patients aged 16 years and over who were admitted to NSW public hospitals) by LHD/SN and NSW, 2013 - 2016

Dimension: Patients safety

Clinical Area: Initiatives in safety and quality

Data Inclusions: All patients aged 16 years and over who were admitted to NSW public hospitals between Aug 2009 and Dec 2015, entered into the CEC sepsis database

Data Exclusions: Paediatric patients and ward inpatients

Numerator: Median time to first antibiotic by year and LHD/SN

Denominator: Total number of sepsis patients by year and LHD/SN

Standardisation: None (crude median and mean by triage category calculated)

Data Source: CEC sepsis database

Comments: The 95% confidence intervals for medians in this chart were calculated using the approach described in "Campbell MJ, Gardner MJ. Calculating confidence intervals for some non-parametric analyses. Stat Med 1988;296:1454-6."
Chart: SK02

Admin Status: Current, Dec 2016

Indicator Name: Median time to first antibiotic by year and triage category

Description: Median time (minute) to first antibiotic (patients aged 16 years and over who were admitted to Emergency Department in NSW public hospitals) by triage category, NSW, Aug 2009 - Dec 2016

Dimension: Patients safety

Clinical Area: Initiatives in safety and quality

Data Inclusions: Emergency patients aged 16 years and over who were admitted to NSW public hospitals between Aug 2009 and Dec 2016, entered into the CEC sepsis database

Data Exclusions: Paediatric patients and ward inpatients

Numerator: Median time to first antibiotic by triage category and time

Denominator: Total number of sepsis patients by triage category and month

Standardisation: None (median and mean by triage category calculated)

Data Source: CEC sepsis database

Comments: The 95% confidence intervals for medians in this chart were calculated using the approach described in "Campbell MJ, Gardner MJ, Calculating confidence intervals for some non-parametric analyses. Stat Med 1988;296:1454-6."
Chart: SK03

Admin Status: Current, Dec 2016

Indicator Name: Mean time to first antibiotic by year and triage category

Description: Mean time (minute) to first antibiotic (patients aged 16 years and over who were admitted to Emergency Department in NSW public hospitals) by triage category, NSW, Aug 2009 to Dec 2016

Dimension: Patients safety

Clinical Area: Initiatives in safety and quality

Data Inclusions: Emergency patients aged 16 years and over who were admitted to NSW public hospitals between Aug 2009 and Dec 2016, entered into the CEC sepsis database

Data Exclusions: Paediatric patients and ward inpatients

Numerator: Mean time to first antibiotic by triage category and time

Denominator: Total number of sepsis patients by triage category and time

Standardisation: None (median and mean by triage category calculated)

Data Source: CEC sepsis database

Comments: In recent years, mean time to first antibiotic may vary from the previously published data on the eChartbook as LHDs/SNs continue to update their data. CEC eChartbook data are current and accurate at the time of publication.
Chart: SK04

Admin Status: Current, Dec 2016

Indicator Name: Antibiotic administered within specified time (%) by year and LHD/SN

Description: Antibiotic administered within specified time of diagnosis (patients aged 16 years and over who were admitted to NSW public hospitals) by LHD/SN and NSW, 2013 - 2016

Dimension: Patients safety

Clinical Area: Initiatives in safety and quality

Data Inclusions: All patients aged 16 years and over who were admitted to NSW public hospitals between 2013 and 2016, entered into the CEC sepsis database

Data Exclusions: Paediatric patients and ward inpatients

Numerator: Number of sepsis patients who receive antibiotic within specified time of diagnosis by LHD/SN

Denominator: Total number of sepsis patients by LHD/SN

Standardisation: None

Data Source: CEC sepsis database

Comments: None
Chart: SK05

Admin Status: Current, Dec 2016

Indicator Name: Antibiotic administered within specified time (%) by year and Hospital peer group

Description: Antibiotic administered within specified time of diagnosis (patients aged 16 years and over who were admitted to Emergency Department of NSW public hospitals) by Hospital peer group, 2013 - 2016

Dimension: Patients safety

Clinical Area: Initiatives in safety and quality

Data Inclusions: All patients aged 16 years and over who were admitted to Emergency Department of NSW public hospitals between 2013 and 2016, entered into the CEC sepsis database

Data Exclusions: Paediatric patients and ward inpatients

Numerator: Number of sepsis patients who receive antibiotic within specified time of diagnosis by Hospital peer group

Denominator: Total number of sepsis patients by LHD/SN

Standardisation: None

Data Source: CEC sepsis database

Comments: Chart 5 provides peer group as well as description of peer group. Reference is below.

A1 = principal referral hospital.
A3 = tertiary referral hospital. B1 – major hospital with between 17 000-35 000 acute weighted separations (AWS) and specialist services.
B2 = major hospital with 10 000-35 000 AWS and no specialist services.
C1 – district group (4000-10 000 AWS)
C2 district group (2000-4000 AWS) D1a community with surgery (200-2000)
D1b – community without surgery
F3 – multipurpose including aged care
F4 – subacute care

Source: NSW Ministry of Health, Clinical Excellence Commission. Public hospitals only.
Note: The peer groups used in the analysis are based on the NSW Peer Hospital Groups 2011/12 definitions.
Chart: SK06

Admin Status: Current, Dec 2016

Indicator Name: Antibiotic administered within specified time (%) by year and Hospital peer group

Description: Antibiotic administered within specified time of diagnosis (patients aged 16 years and over who were admitted to Wards of NSW public hospitals) by Hospital peer group, 2013 - 2016

Dimension: Patients safety

Clinical Area: Initiatives in safety and quality

Data Inclusions: All patients aged 16 years and over who were admitted to Wards of NSW public hospitals between 2013 and 2016, entered into the CEC sepsis database

Data Exclusions: Paediatric patients and ward inpatients

Numerator: Number of sepsis patients who receive antibiotic within specified time of diagnosis by Hospital peer group

Denominator: Total number of sepsis patients by LHD/SN

Standardisation: None

Data Source: CEC sepsis database

Comments: Chart 6 provides peer group as well as description of peer group. Reference is below.

A1 = principal referral hospital.
A3 = tertiary referral hospital. B1 – major hospital with between 17 000-35 000 acute weighted separations (AWS) and specialist services.
B2 = major hospital with 10 000-35 000 AWS and no specialist services.
C1 – district group (4000-10 000 AWS)
C2 district group (2000-4000 AWS)
D1a community with surgery (200-2000)
D1b – community without surgery
F3 – multipurpose including aged care
F4 – subacute care

Source: NSW Ministry of Health, Clinical Excellence Commission. Public hospitals only.
Note: The peer groups used in the analysis are based on the NSW Peer Hospital Groups 2011/12 definitions.