2021 World Sepsis Day - National Sepsis Programme Webinar Dr Martina Healy Clinical Lead - Health Service Executive HSE ...
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2021 World Sepsis Day
National Sepsis Programme
Webinar
Dr Martina Healy
Clinical Lead
Clinical Design & Innovation
Office of the Chief Clinical Officer; Health Service Executive
Introduction to 2021 Webinar
Programme
12.30 – 12.40 Introduction and National Sepsis Report 2019 Summary
Dr Martina Healy, National Sepsis Clinical Lead
12.40 – 12.45 NCEC Intro to Adult Sepsis Guideline
NCEC Chair,Prof Gerry Fitzpatrick
12.45 - 12.55 Adult Sepsis Management National Clinical Guideline Update
Celine Conroy, IEHG Sepsis ADON
12.55– 13.05 Adult Sepsis Management HSeLanD e-learning Update & Introduction to
Updated Adult Sepsis Form
Mary Bedding, RCSI Hospitals Sepsis ADON
13.05 - 13.25 Launch of National Paediatric Sepsis Management Guidelines
Dr Martina Healy, National Sepsis Clinical Lead
13.25 -13.30 Introduction of incoming National Sepsis Clinical Lead
Dr Michael O’Dwyer, St Vincent’s University Hospital
This is the fifth National Sepsis Outcome Report describing the burden of sepsis on the Irish healthcare system, in terms of the number of cases and the associated mortality.
National Sepsis Report 2019
Key comparators with 2018 (adult non-maternity
cohort)
• Mortality: There was an 11.8% decrease in documented
cases of Sepsis and Septic Shock with a 2.9% decrease in
associated in-hospital mortality rate.
• There was a 5% increase on average length of stay.
• Sepsis: There were 11,819 cases documented in 2019, a
12.7% decrease when compared with 2018 (n=13,547),
• There was an in-hospital mortality of 18.1%,
representing a 2.6% decrease in mortality over 2018
(n=18.6%).
• This benchmarks well internationally: UK 20.3%1,
USA 25%2, Australia 19.7%3 and Globally 27%4.
National Sepsis Report 2019 • Septic Shock: There were 1,089 cases documented in 2019, a 0.27% decrease when compared with 2018 (n=1092), with an in-hospital mortality of 37%, representing an 11% decrease in mortality when compared with 2018 (n=41.6%). • This also benchmarks well internationally: Australia 23.9%3 and Globally 42%4.
National Sepsis Report 2019 Paediatric and Maternity data
Summary Summary 2011 – 2019 • Documented cases ↑ 114% • Sepsis associated mortality ↓ 22.68% Key Finding Sepsis patients have a 5.2 fold higher mortality over patients coded with infection and a 2 fold higher LOS
Recommendations for the future
Recommendations for future
Introduction to 2021 Webinar
Programme
12.30 – 12.40 Introduction and National Sepsis Report 2019 Summary
Dr Martina Healy, National Sepsis Clinical Lead
12.40 – 12.45 NCEC Intro to Adult Sepsis Guideline
NCEC Chair,Prof Gerry Fitzpatrick
12.45 - 12.55 Adult Sepsis Management National Clinical Guideline Update
Celine Conroy, IEHG Sepsis ADON
12.55– 13.05 Adult Sepsis Management HSeLanD e-learning Update & Introduction to
Updated Adult Sepsis Form
Mary Bedding, RCSI Hospitals Sepsis ADON
13.05 - 13.25 Launch of National Paediatric Sepsis Management Guidelines
Dr Martina Healy, National Sepsis Clinical Lead
13.25 -13.30 Introduction of incoming National Sepsis Clinical Lead
Dr Michael O’Dwyer, St Vincent’s University HospitalSepsis Management - National Clinical
Guideline No. 27
Celine Conroy, NSP & Group ADON, Sepsis, IEHG
12Sepsis management NCG No 26 (previously No. 6)
Purpose
• to implement the Surviving Sepsis Campaign Guideline (SSCG)
(2016) (updated 2018) in the management of the adult
patient in the acute hospital sector in Ireland in a format that
applies to the structures and functions of the Irish Acute
Health Care Sector.
• The wording of the recommendations have not been changed
from the SSCG publication with the exception of units of
measurement applicable to the Irish context
The NSP is very grateful to the SSC for their kind permission to
adopt the SSCG as the Irish National Clinical Guideline on
Sepsis Management
13Clinical Judgement
• National Clinical Guidelines are designed to guide
clinical judgement but not replace it.
• In individual cases a healthcare professional may,
after careful consideration, decide not to follow
guideline recommendations if it is deemed to be in
the best interests of the patient and is in line with
best practice.
• Clinical decisions and therapeutic options should be
discussed with a senior clinician on a case-by-case
basis as necessary and documented in the clinical
notes.
14NCG No 26 applies to:
• All adult patients including pregnant women and
women in the postnatal period up to 42 days, in the
acute hospital sector.
• All maternity specific information is highlighted
using purple text.
• This NCG does not apply to paediatric patients
up to the age of 16 years (HSE, 2016).
15Target Users
• All healthcare professionals involved in the care of
adult and maternity patients with sepsis and
suspicion of sepsis, working in the acute hospital
sector in the Republic of Ireland.
• DoH - to support the implementation and audit of
this National Clinical Guideline.
• HSE - to provide appropriate structured support and
adequate resources for the governance,
operationalisation, and audit of sepsis management.
16Target Users
• Hospital Group Leadership Teams, Hospital
Management and Clinical Directors - to:
• support sepsis QI
• facilitate implementation and audit
• facilitate and monitor required change arising from
outlier intervention.
• Pre-Hospital Emergency Care Council - to inform
their clinical practice guidelines across ambulance
services.
• The public - as an information resource.
17National Implementation Points
• Recognising that much of the research that informed
the SSCG occurred in the critical care setting, the
NCG provides Implementation Points after the SSCG
recommendations to aid the implementation of
these recommendations within the Irish healthcare
system.
• Implementation Points and are primarily aimed
at the pre- and post-critical care setting.
18Guideline Development Group
• The GDG was chaired by Dr Vida Hamilton, National
Clinical Lead for Sepsis (2014 – 2018).
• Membership nominations were sought from a
variety of clinical and non-clinical backgrounds so as
to be representative of all key stakeholders within
the acute sector, including:
• those involved in clinical practice, education,
administration, research methodology and 2
persons representing patients and the public.
19Sepsis – Definition (Sepsis 3)
• Sepsis is life-threatening organ dysfunction caused
by a dysregulated host response to infection (Singer
et al., 2016).
• Maternal sepsis: is a life-threatening condition
defined as organ dysfunction resulting from
infection during pregnancy, childbirth, post-abortion
or postpartum period (WHO, 2017).
20Sepsis 2 vs Sepsis 3
• The rationale behind the shift away from the SIRS-
based definition of sepsis (Sepsis 2) is primarily
three-fold:
1. The over-sensitivity of the previous definition that
included a cohort of patients who did not have a
life threatening illness and whose clinical course
would not be impacted by escalated care (Churpek
et al., 2015), (Comstedt et al., 2009).
21Sepsis 2 vs Sepsis 3
2. Its failure to recognise patients with a life-
threatening acute organ dysfunction due to
infection that would benefit from escalated care
but who did not present with a SIRS response
(Comstedt et al., 2009), (Kaukonen et al., 2015).
3. The lack of specificity of the SIRS response that
can be triggered by many non-infective insults
(Thoeni, 2012).
• Whilst the presence of a systemic inflammatory
response (SIRS) is helpful in diagnosing infection, it is
no longer a requirement for the diagnosis of sepsis,
(Singer et al., 2016).
22Septic Shock
• Septic shock is a subset of sepsis with circulatory and
cellular/metabolic dysfunction associated with a higher risk of
mortality (Singer et al., 2016).
• The sepsis definition taskforce has defined this as the
requirement for vasopressors/ inotropes to achieve a mean
arterial pressure of ≥ 65mmHg AND a lactate > 2mmols/l
despite adequate fluid resuscitation (Singer et al., 2016).
• The rationale behind this definition is to identify the cohort of
patients with a mortality risk of > 40% for the purposes of
international comparison.
• Note: Patients with a vasopressor requirement and normal lactate
post resuscitation have a mortality risk of > 30% (Singer et al.,
2016).
23Septic Shock
• For the purposes of facilitating clinical care in Ireland and
recognising that lactate measurement is not always available,
this NCG uses the persistent requirement for
vasopressors/inotropes post adequate fluid resuscitation as
its definition of septic shock, because patients who require
vasopressors or inotropes to maintain adequate perfusion
pressure post fluid resuscitation require critical care whether
their lactate is raised or not.
• This is a pragmatic approach and acknowledges that the
sepsis definition taskforce allowed for this interpretation:
• ‘In settings in which lactate measurement is not available, the use of
a working diagnosis of septic shock using hypotension and other
criteria consistent with tissue hypoperfusion (e.g. delayed capillary
refill) may be necessary’ (Singer et al., 2016).
24Sepsis 6
Sepsis 6 is the name given to a bundle of medical
therapies designed to reduce mortality in patients
with sepsis (Take 3 and Give 3).
• Sepsis 6 was developed by The UK Sepsis Trust
(Daniels et al., 2011) as a practical tool to help
healthcare professionals deliver the SSCG 1 hour
bundle.
• Sepsis 6 + 1 is the same as Sepsis 6 but + 1 refers to
Fetal wellbeing. Resuscitating the mother will
resuscitate the baby, however, it is important to
assess fetal wellbeing and formulate a plan for
delivery if required.
25SSCG 2018 Update
• SSCG 2018 Update: The 3-h and 6-h bundles have been
combined into a single “hour-1 bundle” with the explicit
intention of beginning resuscitation and management
immediately:
• For patients who present with clinically apparent
sepsis/septic shock on presentation, it is recommended that
the Sepsis 6 bundle be administered within 1 hour of
presentation (Levy et al., 2018).
• If infection is included in the differential diagnosis, and the
patient is in one of the at-risk groups then for these patients,
1 hour is allowed for screening and medical review and once
completed this is considered TIME ZERO. All elements of the
Sepsis 6 bundle are then to be initiated within 1 hour of TIME
ZERO.
26Operationalising the NCG
• The NSP provides Clinical decision
support tools (CDSTs) and Sepsis
eLearning education to promote
standardised clinical practice and
support implementation of the
NCG.
• The CDSTs have been updated in
line with the updated NCG and
include:
• Adult Sepsis Form In-patient and www.hse.ie/sepsis
Emergency Department use
• Sepsis Predisposition & Recognition www.hseland.ie
– Maternity patients
• Fluid resuscitation algorithm for
adults with sepsis
2728
HSeLand Introduction to Sepsis Management
for Adults including Maternity
Mary Bedding, NSP & Sepsis Group ADON, RCSI
Hospitals
29Why the update?
• 2016 – new Sepsis-3 sepsis definitions (Singer at al. 2016)
• Maternal sepsis
• Updated sepsis resources – CDSTs including Adult Sepsis
Form, algorithms
30Audience & Aim
• Audience - all staff involved in the recognition management
and escalation of treatment for sepsis in adults in the acute
hospital setting – includes nurses/midwives, doctors and
HSCP
• Aim - is to help the user to effectively recognise and manage
sepsis in the adult population in an acute care setting in
accordance with National Clinical Guideline No 26: Sepsis
Management for Adults (including maternity)
31Scope
Includes:
• Non-pregnant & pregnant adult patients over the age of 16
yrs
• Pregnant adults include from conception up to 42 days post
birth (including miscarriage or abortion)
32Learning Outcomes
At the end of the programme should be able to:
• Recognise patients that require sepsis screening – high risk
groups, deterioration due to infection & those with signs of
sepsis
• Know when & how to use the Sepsis Form to aid recognition
and treatment
• Identify when to escalate for a medical review
• Manage patients with 1 hr sepsis bundle (Sepsis 6 (+1))
• Review and respond to patient’s response to treatment
• Define sepsis & septic shock and document same
• Know when escalation to critical care is required
33Maternity Content
• Maternity specific
information highlighted
using purple text.
• Content is optional
• REMEMBER pregnant or
post birth women can be
in any acute care setting
outside of maternity
34Design
• Animation – similar to INEWS & IMEWS (own colour palette
and characters)
• Interactive – knowledge checks & scenarios
• Topics – content covered in the topic, information and
summary
• Reflects recommendations of other NCG – INEWS, IMEWS,
Clinical Handover
35Topics
36Topic 5 Scenarios
37Scenarios
38Scenarios
39Summary & Learning
• Summarises whole programme
• Directs participants to where to find sepsis resources
• ‘Extend my Learning’
40How to complete
• Will take approx. 1 hr to complete
• Can be completed in multiple sittings
• Must visit at least 80% slides to complete
• Must complete the high risk patient scenario (maternity is
optional)
• Certificate found in ‘My Certificates’ section on HSeLanD
• Awarded 1.5 NMBI CEUs or 2 RCSI CPD
• Programme is valid for 3 years
41Updated Sepsis Forms – Clinical Decision Tools
Mary Bedding, NSP & Sepsis Group ADON, RCSI
Hospitals
42Adult Sepsis Form
43Adult Sepsis Form – Page 1
44Adult Sepsis Form – Page 1
45Adult Sepsis Form – Page 1
46Adult Sepsis Form – Page 1
47Adult Sepsis Form – Page 2
48Maternity Sepsis Form
49Paediatric Sepsis Form
50Thanks & Feedback
• Thanks to Clinical Design & Innovation for providing the
funding for the e-learning update.
• Thanks to all of the members of the Sepsis Team and Ciara
Hughes (previous PM) for all their input for both the e-
learning update and the Sepsis Form update.
• Please contact any of the Mary Bedding
mary.bedding@hse.ie or any other members of the National
Sepsis Team - details of Team on the HSE Sepsis pages
https://www.hse.ie/eng/about/who/cspd/ncps/sepsis/contac
t/
51Paediatric Sepsis
Guidelines
An introduction and
guide to implementation
Dr Martina Healy
National Sepsis Programme
Clinical Lead
Clinical Design & Innovation
Office of the Chief Clinical Officer; Health Service Executive
52International Paediatric Guidelines
• February 2020 - The Surviving Sepsis Campaign international
guidelines for the management of septic shock and sepsis-
associated organ dysfunction in children was published
February 2020, Volume 46, Supplement 1, pp 10–67
Intensive Care Medicine
• The Irish National Sepsis Programme convened a
multidisciplinary paediatric sepsis working group.
• This Group recommended adopting the Surviving Sepsis
Campaign international guidelines for the management of
septic shock and sepsis-associated organ dysfunction in
children (SSCGC).
53SSCGC
Surviving sepsis campaign international guidelines for the management of septic shock
and sepsis-associated organ dysfunction in children
February 2020, Volume 46, Supplement 1, pp 10–67
Intensive Care Medicine
Scott L. Weiss, MD, MSCE, FCCM (Co-Vice Chair)1; Mark J. Peters, MD, PhD (Co-Vice Chair)2; Waleed Alhazzani, MD, MSc,
FRCPC (Methodology Chair)3; Michael S. D. Agus, MD, FCCM, FAAP4; Heidi R. Flori, MD, FAAP5; David P. Inwald, MB, BChir,
FRCPCH, FFICM, PhD6; Simon Nadel, MBBS, MRCP, FRCP6; Luregn J. Schlapbach, FCICM, FMH-ICU, FMH-Paeds, FMH-
Neonatology7; Robert C. Tasker, MB BS, MA, AM, MD, FRCPHC, FRCP4; Andrew C. Argent, MB BCh, MMed, MD
(Paediatrics)8; Joe Brierley, MD, MA9; Joseph Carcillo, MD10; Enitan D. Carrol, MB ChB, MD, FRCPCH, DTMH11; Christopher L.
Carroll, MD, MS, FCCM, FAAP12; Ira M. Cheifetz, MD, FCCM13; Karen Choong, MB, BCh, FRCP(C) (methodologist)3; Jeffry J.
Cies, PharmD, MPH, BCPS-AQ ID, BCPPS, FCCP, FCCM, FPPAG14; Andrea T. Cruz, MD, MPH, FAAP15; Daniele De Luca MD,
PhD16,43; Akash Deep, MB BS, MD, FRCPCH17; Saul N. Faust, MA, MB BS, FRCPCH, PhD, FHEA18; Claudio Flauzino De Oliveira,
MD, PhD19; Mark W. Hall, MD, FCCM, FAAP20; Paul Ishimine, MD, FAAP21; Etienne Javouhey, MD, PhD22; Koen F. M. Joosten,
PhD23 ; Poonam Joshi, PhD24; Oliver Karam, MD, PhD25; Martin C. J. Kneyber, MD, PhD, FCCM26; Joris Lemson, MD, PhD27;
Graeme MacLaren, MD, MSc, FCCM28; Nilesh M. Mehta, MD4; Morten Hylander Møller, MD, PhD29; Christopher J. L. Newth,
MD, ChB, FRCPC, FRACP30; Trung C. Nguyen, MD, FAAP15; Akira Nishisaki, MD, MSCE, FAAP1; Mark E. Nunnally, MD, FCCM
(methodologist)31; Margaret M. Parker, MD, MCCM, FAAP32; Raina M. Paul, MD, FAAP33; Adrienne G. Randolph, MD, MS,
FCCM, FAAP4; Suchitra Ranjit, MD, FCCM34; Lewis H. Romer, MD35; Halden F. Scott, MD, MSCS, FAAP, FACEP36; Lyvonne N.
Tume, BS, MSN, PhD, RN37; Judy T. Verger, RN, PhD, CPNP-AC, FCCM, FAAN1, 44; Eric A. Williams, MD, MS, MMM, FAAP15;
Joshua Wolf, MBBS, PhD, FRACP38; Hector R. Wong, MD39; Jerry J. Zimmerman, MD, PhD, FCCM40; Niranjan Kissoon, MB BS,
MCCM, FRCP(C), FAAP, FACPE (Co-Chair)41; Pierre Tissieres, MD, DSc (Co-Chair)16,42
54SSCGC
The International panel was assisted by various
methodological experts and split into six groups
• recognition and management of infection
• hemodynamics and resuscitation
• ventilation
• endocrine and metabolic therapies
• adjunctive therapies
55SSCGC – the big ticket items
Definition of Septic Shock
“For the purposes of these guidelines, we define septic
shock in children as severe infection leading to
cardiovascular dysfunction (including hypotension, need
for treatment with a vasoactive medication, or impaired
perfusion) and “sepsis-associated organ dysfunction” in
children as severe infection leading to cardiovascular
and/or non-cardiovascular organ dysfunction.”
56SSCGC – the big ticket items
• Septic shock was defined as the subset with
cardiovascular dysfunction, which included hypotension,
treatment with a vasoactive medication, or impaired
perfusion.
• greater than or equal to two age-based systemic
inflammatory response syndrome (SIRS) criteria
• confirmed or suspected invasive infection, and
cardiovascular dysfunction
• acute respiratory distress syndrome (ARDS), or greater
than or equal to two non-cardiovascular organ system
dysfunctions
57SSCGC – the big ticket items
Fluids in Paediatric sepsis
• Bolus if intensive care available, if not then don’t
unless documented hypotension
• In units with access to intensive care, 40-60ml/kg bolus
fluid (10-20ml/kg per bolus) over the first hour is
recommended. With no intensive care, and in the
absence of hypotension, then avoiding bolus and just
commencing maintenance is recommended. It is not
clear how long access to intensive care has to be to
switch from fluid liberal to restrictive.
58SSCGC – the big ticket items
• The panel suggests crystalloids, rather than albumin, and
balanced/buffered crystalloids rather than 0.9% saline.
They recommend against using starches or gelatin.
Take blood cultures but don’t delay treatment to
obtain them
59SSCGC – the big ticket items
• One hour time to treatment for those in shock but up to
three hours without it. This is the potential game-changer
from this body of work. While the evidence shows a temporal
relationship between the administration of antibiotics and
outcome in severe sepsis some pooled data demonstrated
that it was unlikely the hour alone made the difference.
• This will be a welcome relief for those working in areas
where there are associated penalties for not reaching the
hour window and hopefully will remove some of the gaming
associated with this target.
60SSCGC – the big ticket items
• For purposes of this weak recommendation,
hypotension can be defined as
61SSCGC – the big ticket items
• Broad spectrums antibiotics, but narrow when
pathogens available
• If no pathogen is identified, we recommend
narrowing or stopping empiric antimicrobial
therapy according to clinical presentation, site of
infection, host risk factors, and adequacy of
clinical improvement in discussion with
infectious disease and/or microbiological expert
advice.
62SSCGC – the big ticket items
• Intensive care vasoactive and ventilation management is
given but acknowledged as weak recommendations
• There is a list of suggestions regarding vasoactive infusion
and ventilatory strategies that are very specific to intensive
care management. While a number of recommendations
are given (epinephrine rather than dopamine for septic
shock for example) these are generally based on the panels
summation of weak evidence.
• There are further suggestions on corticosteroid
management, nutrition, and blood products which will be
of interest to those in intensive care and anaesthetic
settings.
•
63Initial Resuscitation Algorithm for
Children
64Fluid and vasoactive-inotrope
management algorithm for Children
65National Implementation Plan (NIP)
• The National Sepsis Programme convened a multidisciplinary
paediatric sepsis working group which recommended
adopting the Surviving Sepsis Campaign international
guidelines for the management of septic shock and sepsis-
associated organ dysfunction in children (SSCGC).
• Key stakeholders include those involved in clinical practice,
education, administration, research methodology and
persons representing patients and the public.
• With permission from Surviving Sepsis Campaign group, the
National Sepsis Programme developed a National
Implementation Plan (NIP) to support implementation of the
SSCGC recommendations within the acute paediatric
healthcare setting in Ireland.
66National Implementation Plan (NIP)
• The NIP contains the 77 SSCGC
statements on the early
management and resuscitation of
children with septic shock and
sepsis-associated organ
dysfunction, with implementation
points to assist clinicians in the
management of paediatric sepsis
in an Irish healthcare setting.
• Incorporated into the NIP is a
clinical decision support tool
(Sepsis Form) aimed at providing
guidance for clinicians to recognise
and treat sepsis in a timely
manner.
67Sepsis Form
Front page is the recognition and Back page is the treatment,
screening for Sepsis reassessment and referral
68National Implementation Plan (NIP)
• The NIP was widely disseminated for consultation
and feedback in Jan 2021 and externally reviewed by
Mark Peters, European Co-chair of the Paediatric
Surviving Sepsis Campaign.
• The NIP was clinically approved by the CCO Clinical
Forum in August 2021. It will accompany the
National Clinical Guideline for Sepsis (NCG No.26) to
ensure a unified national approach to sepsis
management across all age cohorts.
69Next Steps……..
Implementation of the SSCGC
recommendations
National Educational material:
• As an interim measure, a PowerPoint lecture and
accompanying video will be available for all sites
who care for children in the coming months.
• Funding for an E-learning module on HSELand has
been secured and it is envisaged that this will be
accessible from Q3 2022.
70Implementation of the SSCGC recommendations
To optimise sepsis recognition and
treatment, the Hospital Group NATIONAL SEPSIS TEAM
Sepsis Assistant Directors of SEPSIS ADON
Nursing (ADONs) and the National
Sepsis Team liaise with each site to
help support the local hospital
sepsis committees’ aims, by LOCAL SEPSIS COMMITTEE
performing audit and feedback on (Adult committee should have
representation from Paediatrics)
the sepsis care.
All paediatric hospitals and acute
hospitals with paediatric units are
advised to have a Sepsis
Committee whose role is to guide
IDENTIFY LOCAL IMPLEMENTATION
the implementation of the SSCGC LEADS TO COORDINATE
recommendations in their hospital. IMPLEMENTATION OF SEPSIS GUIDELINE
(NIP)
71Public awareness campaign
• Posters
• Leaflets
• Video/social media
https://vimeo.com/462650865
/610bbcef55
72Current programme activity and achievements • Awaiting confirmation from NCEC to publish updated guidelines for adults • Drafting implementation plan of Paediatric Sepsis Management Guidelines. First edition • Education and promotion of Paediatric Sepsis awareness and recognition • Updating e-learning module to reflect the content and of the updated adult guideline. • Sepsis Summit planned for September 2021 • Sepsis Awareness campaign planned for GP / Community • Launch of Paediatric Sepsis Tool pilot in May2021 • Drafting 2019 Sepsis Annual Report • Awaiting appointment of new programme manager 73
Thank you
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