A multifaceted intervention to improve sepsis management in general hospital wards with evaluation using segmented regression of interrupted time series

Marwick, Charis; Guthrie, Bruce; Pringle, Jan; Evans, Josie; Nathwani, Dilip; Donnan, Peter T.; Davey, Peter

doi:10.1136/bmjqs-2013-002176

Cited by 15 publications

(8 citation statements)

References 32 publications

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“…In this cohort study we retrospectively analysed data that had been collected prospectively. We identified patients who developed sepsis while inpatients in Ninewells Hospital in two cohorts, from September 2008 to February 2009 and October 2009 to March 2010, as part of a larger quality improvement project [ 18 ]. The study case definition was: an adult (≥18 years old) patient with sepsis occurring ≥24 h after admission to hospital, either as a first episode of sepsis or following a period of ≥24 h without meeting SIRS criteria.…”

Section: Methodsmentioning

confidence: 99%

Identifying which septic patients have increased mortality risk using severity scores: a cohort study

et al. 2014

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BackgroundEarly aggressive therapy can reduce the mortality associated with severe sepsis but this relies on prompt recognition, which is hindered by variation among published severity criteria. Our aim was to test the performance of different severity scores in predicting mortality among a cohort of hospital inpatients with sepsis.MethodsWe anonymously linked routine outcome data to a cohort of prospectively identified adult hospital inpatients with sepsis, and used logistic regression to identify associations between mortality and demographic variables, clinical factors including blood culture results, and six sets of severity criteria. We calculated performance characteristics, including area under receiver operating characteristic curves (AUROC), of each set of severity criteria in predicting mortality.ResultsOverall mortality was 19.4% (124/640) at 30 days after sepsis onset. In adjusted analysis, older age (odds ratio 5.79 (95% CI 2.87-11.70) for ≥80y versus <60y), having been admitted as an emergency (OR 3.91 (1.31-11.70) versus electively), and longer inpatient stay prior to sepsis onset (OR 2.90 (1.41-5.94) for >21d versus <4d), were associated with increased 30 day mortality. Being in a surgical or orthopaedic, versus medical, ward was associated with lower mortality (OR 0.47 (0.27-0.81) and 0.26 (0.11-0.63), respectively). Blood culture results (positive vs. negative) were not significantly association with mortality. All severity scores predicted mortality but performance varied. The CURB65 community-acquired pneumonia severity score had the best performance characteristics (sensitivity 81%, specificity 52%, positive predictive value 29%, negative predictive value 92%, for 30 day mortality), including having the largest AUROC curve (0.72, 95% CI 0.67-0.77).ConclusionsThe CURB65 pneumonia severity score outperformed five other severity scores in predicting risk of death among a cohort of hospital inpatients with sepsis. The utility of the CURB65 score for risk-stratifying patients with sepsis in clinical practice will depend on replicating these findings in a validation cohort including patients with sepsis on admission to hospital.

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Section: Methodsmentioning

confidence: 99%

Identifying which septic patients have increased mortality risk using severity scores: a cohort study

et al. 2014

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“…Although there are other audits of ‘sepsis bundle’ implementation in the literature, these are retrospective,7 8 focused on severe sepsis,9 or focused on acute receiving or accident and emergency departments 2 4 12. We believe that our study is unique.…”

Section: Discussionmentioning

confidence: 99%

“…Therefore, SIRS is widely used as part of screening tools for patients at risk of sepsis. SIRS is also often used for case identification in sepsis quality improvement work 7 8…”

Section: Introductionmentioning

confidence: 99%

“…There are published audit reports about implementing the sepsis six bundle. These are mostly in emergency departments, are often retrospective and may only include qualitative methods to identify reasons for deficiencies 2 7–9 12. In contrast, we wanted to undertake a systematic, prospective study of the factors that influence the management of patients at risk of sepsis on a single inpatient ward.…”

Section: Introductionmentioning

confidence: 99%

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Successful prospective quality improvement programme for the identification and management of patients at risk of sepsis in hospital

et al. 2019

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ObjectiveThis audit aimed to improve the speed and completeness of delivery of treatment to urology patients at risk of sepsis in the hospital.Patients and methodsPatients were prospectively included if they developed a new-onset systemic inflammatory response syndrome, were reviewed by a doctor who thought this was due to infection and prescribed antibiotics. We measured median time to antibiotic administration (TTABx) as the primary outcome. Factors associated with delays in management were identified, targeted quality improvement interventions implemented and then reaudited.ResultsThere were 74 patients in the baseline cohort and 69 following interventions. Median TTABx fell from 3.6 (1.9–6.9) hours to 1.7 (1.0–3.8) p<0.001 hours after interventions. In the baseline cohort, factors significantly associated with a delay in TTABx were: an Early Warning Score less than the medical review trigger level; a temperature less than 38°C; having had surgery versus not. Interventions included: reduced medical review trigger thresholds, education sessions, communication aids, a department-specific sepsis protocol. There were significant improvements in the speed and completeness of sepsis management. Improvements were most marked in postoperative patients. Improvement longevity was achieved through continued work by permanent ward nurse practitioners.ConclusionA period of baseline prospective study, followed by tailored quality improvement initiatives, can significantly improve the speed and quality of sepsis management for inpatients on an acute hospital ward.

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“…Shortening the time between recognition of the first symptoms of sepsis and thereby the suspicion of its occurrence and antibiotic administration is one of the main objectives aimed at improving a patient's chances of survival. 7,[10][11][12] In Poland, primary and outpatient care, emergency departments and ambulances do not carry antibiotics, which significantly delays the onset of causal treatment. However, it is the lack of risk awareness and the need to take immediate action that is the most significant determinant of medical errors.…”

Section: Discussionmentioning

confidence: 99%

Sepsis: Medical errors in Poland

Rorat

2015

Med Sci Law

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Health, safety and medical errors are currently the subject of worldwide discussion. The authors analysed medico-legal opinions trying to determine types of medical errors and their impact on the course of sepsis. The authors carried out a retrospective analysis of 66 medico-legal opinions issued by the Wroclaw Department of Forensic Medicine between 2004 and 2013 (at the request of the prosecutor or court) in cases examined for medical errors. Medical errors were confirmed in 55 of the 66 medico-legal opinions. The age of victims varied from 2 weeks to 68 years; 49 patients died. The analysis revealed medical errors committed by 113 health-care workers: 98 physicians, 8 nurses and 8 emergency medical dispatchers. In 33 cases, an error was made before hospitalisation. Hospital errors occurred in 35 victims. Diagnostic errors were discovered in 50 patients, including 46 cases of sepsis being incorrectly recognised and insufficient diagnoses in 37 cases. Therapeutic errors occurred in 37 victims, organisational errors in 9 and technical errors in 2. In addition to sepsis, 8 patients also had a severe concomitant disease and 8 had a chronic disease. In 45 cases, the authors observed glaring errors, which could incur criminal liability. There is an urgent need to introduce a system for reporting and analysing medical errors in Poland. The development and popularisation of standards for identifying and treating sepsis across basic medical professions is essential to improve patient safety and survival rates. Procedures should be introduced to prevent health-care workers from administering incorrect treatment in cases.

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A multifaceted intervention to improve sepsis management in general hospital wards with evaluation using segmented regression of interrupted time series

Cited by 15 publications

References 32 publications

Identifying which septic patients have increased mortality risk using severity scores: a cohort study

Identifying which septic patients have increased mortality risk using severity scores: a cohort study

Successful prospective quality improvement programme for the identification and management of patients at risk of sepsis in hospital

Sepsis: Medical errors in Poland

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