Initial Sepsis Assessment and Management at a New Zealand Tertiary Hospital – A Pre-Intervention Audit of Practice
Authors:
Wright HJ1
1Te Whatu Ora – Waitaha Canterbury
Introduction: Sepsis is defined as the life-threatening organ dysfunction caused by a dysregulated host response to infection. It is a major contributor to death and morbidity worldwide, but New Zealand lacks a structured plan for addressing it. In light of this, Te Whatu Ora – Waitaha Canterbury is currently revising the management pathway for sepsis in non-pregnant adult patients. This audit aimed to assess characteristics of this population, and the baseline rates of simple tests and interventions common in sepsis management, in order to guide education campaigns and pathway rollout and to provide a pre-intervention baseline.
Methods: Patients were selected by National Health Index identifier using an established ICD-10-AM based coding algorithm – the New Zealand Sepsis Indicator. All patients meeting this criteria, 15 years or older, that were not pregnant were selected. From that 20 patients per month for August to December 2021 were randomly selected and assessed whether they met the criteria of the ‘Red Flag Sepsis’ screening tool published by the New Zealand Sepsis Trust. Baseline rates of the six recommended actions (‘Sepsis Six’) were then measured, as well as demographic information and other hospital management.
Results: 153 patients were screened to select the 120 patients. Males outnumbered females 2:1 (80:40). The ages ranged from 20 to 96 years (median 79). Over half (63%) had only one or two red flags present. The most common were a lactate ≥2 mmol/l (68 patients) and respiratory rate > 25 (54 patients). 95 of 120 patients met Red Flag Criteria (T0) at the point of admission. The majority (85.8%) of patients met T0 in the emergency department, and 86.4% were under the care of the Emergency Medicine team at that time. Source of suspected infection was attributed to 6 categories with source unclear (48/120) and then urinary source (26/120) being the most common suspected. 2/3 of patients’ admission source of infection correlated with the discharge suspected source.
In regards to the Sepsis Six interventions, administration of oxygen if required to keep SpO2 >94% was done in all but five patients within the first hour. 85/120 patients had blood cultures taken within the first hour. 58% of patients had negative blood cultures during the admission, and of those that were positive, similar numbers of Gram Positive (23/48) and Gram Negative (25/48) patients were seen. In regards to timing of antibiotics, 64/120 had them within 1 hour of meeting T0. 68/120 had their prescribing aligning with local antibiotic prescribing guidelines. Of the 77 patients for which fluid would be recommended (due to hypotension or lactate ≥2 mmol/l), 57 did receive it, and 32 of those within the first hour after T0. The median volume of fluid administered within the first hour was 1000ml. 87 patients had their lactate checked with a median of 3 mmol/l. Only 5 patients had their urine output recorded as being measured within the first hour. 39 patients were referred to Intensive Care and 21 were admitted there. 22 patients were actively palliated during their stay.
Conclusion: This audit has demonstrated that the burden of acute Sepsis assessment and management occurs on admission, predominantly in the Emergency Department. Of the six interventions that are recommended within the first hour, there is wide variation in baseline performance with almost all patients needing oxygen getting it, around 2/3 of patients getting blood cultures and a lactate checked, around half of patients getting fluid if needed and antibiotics, and very few having urine output monitoring occurring. A lot of the burden of sepsis lies on the wards rather than in Intensive Care, often in elderly and frail patients. There is significant scope for improvement for the initial management of sepsis.
Disclosure of Interest Statement:
No disclosures
Wright HJ1
1Te Whatu Ora – Waitaha Canterbury
Introduction: Sepsis is defined as the life-threatening organ dysfunction caused by a dysregulated host response to infection. It is a major contributor to death and morbidity worldwide, but New Zealand lacks a structured plan for addressing it. In light of this, Te Whatu Ora – Waitaha Canterbury is currently revising the management pathway for sepsis in non-pregnant adult patients. This audit aimed to assess characteristics of this population, and the baseline rates of simple tests and interventions common in sepsis management, in order to guide education campaigns and pathway rollout and to provide a pre-intervention baseline.
Methods: Patients were selected by National Health Index identifier using an established ICD-10-AM based coding algorithm – the New Zealand Sepsis Indicator. All patients meeting this criteria, 15 years or older, that were not pregnant were selected. From that 20 patients per month for August to December 2021 were randomly selected and assessed whether they met the criteria of the ‘Red Flag Sepsis’ screening tool published by the New Zealand Sepsis Trust. Baseline rates of the six recommended actions (‘Sepsis Six’) were then measured, as well as demographic information and other hospital management.
Results: 153 patients were screened to select the 120 patients. Males outnumbered females 2:1 (80:40). The ages ranged from 20 to 96 years (median 79). Over half (63%) had only one or two red flags present. The most common were a lactate ≥2 mmol/l (68 patients) and respiratory rate > 25 (54 patients). 95 of 120 patients met Red Flag Criteria (T0) at the point of admission. The majority (85.8%) of patients met T0 in the emergency department, and 86.4% were under the care of the Emergency Medicine team at that time. Source of suspected infection was attributed to 6 categories with source unclear (48/120) and then urinary source (26/120) being the most common suspected. 2/3 of patients’ admission source of infection correlated with the discharge suspected source.
In regards to the Sepsis Six interventions, administration of oxygen if required to keep SpO2 >94% was done in all but five patients within the first hour. 85/120 patients had blood cultures taken within the first hour. 58% of patients had negative blood cultures during the admission, and of those that were positive, similar numbers of Gram Positive (23/48) and Gram Negative (25/48) patients were seen. In regards to timing of antibiotics, 64/120 had them within 1 hour of meeting T0. 68/120 had their prescribing aligning with local antibiotic prescribing guidelines. Of the 77 patients for which fluid would be recommended (due to hypotension or lactate ≥2 mmol/l), 57 did receive it, and 32 of those within the first hour after T0. The median volume of fluid administered within the first hour was 1000ml. 87 patients had their lactate checked with a median of 3 mmol/l. Only 5 patients had their urine output recorded as being measured within the first hour. 39 patients were referred to Intensive Care and 21 were admitted there. 22 patients were actively palliated during their stay.
Conclusion: This audit has demonstrated that the burden of acute Sepsis assessment and management occurs on admission, predominantly in the Emergency Department. Of the six interventions that are recommended within the first hour, there is wide variation in baseline performance with almost all patients needing oxygen getting it, around 2/3 of patients getting blood cultures and a lactate checked, around half of patients getting fluid if needed and antibiotics, and very few having urine output monitoring occurring. A lot of the burden of sepsis lies on the wards rather than in Intensive Care, often in elderly and frail patients. There is significant scope for improvement for the initial management of sepsis.
Disclosure of Interest Statement:
No disclosures