Four consecutive yearly point-prevalence studies in Wales indicate lack of improvement in sepsis care on the wards

Abstract

The ‘Sepsis Six’ bundle was promoted as a deliverable tool outside of the critical care settings, but there is very little data available on the progress and change of sepsis care outside the critical care environment in the UK. Our aim was to compare the yearly prevalence, outcome and the Sepsis Six bundle compliance in patients at risk of mortality from sepsis in non-intensive care environments. Patients with a National Early Warning Score (NEWS) of 3 or above and suspected or proven infection were enrolled into four yearly 24-h point prevalence studies, carried out in fourteen hospitals across Wales from 2016 to 2019. We followed up patients to 30 days between 2016–2019 and to 90 days between 2017 and 2019. Out of the 26,947 patients screened 1651 fulfilled inclusion criteria and were recruited. The full ‘Sepsis Six’ care bundle was completed on 223 (14.0%) occasions, with no significant difference between the years. On 190 (11.5%) occasions none of the bundle elements were completed. There was no significant correlation between bundle element compliance, NEWS or year of study. One hundred and seventy (10.7%) patients were seen by critical care outreach; the ‘Sepsis Six’ bundle was completed significantly more often in this group (54/170, 32.0%) than for patients who were not reviewed by critical care outreach (168/1385, 11.6%; p < 0.0001). Overall survival to 30 days was 81.7% (1349/1651), with a mean survival time of 26.5 days (95% CI 26.1–26.9) with no difference between each year of study. 90-day survival for years 2017–2019 was 74.7% (949/1271), with no difference between the years. In multivariate regression we identified older age, heart failure, recent chemotherapy, higher frailty score and do not attempt cardiopulmonary resuscitation orders as significantly associated with increased 30-day mortality. Our data suggests that despite efforts to increase sepsis awareness within the NHS, there is poor compliance with the sepsis care bundles and no change in the high mortality over the study period. Further research is needed to determine which time-sensitive ward-based interventions can reduce mortality in patients with sepsis and how can these results be embedded to routine clinical practice.Trial registration Defining Sepsis on the Wards ISRCTN 86502304 https://doi.org/10.1186/ISRCTN86502304 prospectively registered 09/05/2016.

The Use of Different Sepsis Risk Stratification Tools on the Wards and in Emergency Departments Uncovers Different Mortality Risks: Results of the Three Welsh National Multicenter Point-Prevalence Studies

“…Our current results support this notion as we have observed significantly better care process and completion of “Sepsis Six” among the patients who have been seen by critical care outreach; however, the compliance with this bundle was very low both in the ED and on the wards ( 36 ). We have previously reported that antimicrobial treatment, arguably one of the most important elements of “Sepsis Six,” was similarly disorganized in this patient group ( 37 ).…”

“…The association between higher compliance with resuscitation bundles and patients scores using SOFA and SIRS poses an interesting question regarding a potential confounding effect on mortality; for example, components of these tools could be identifying patients in these settings who visibly look more unwell in comparison with other tools. In turn, this could lead to earlier recognition and more aggressive management including the completion of “Sepsis Six”; however, overall, the bundle completion rates within our study are very low, making any conclusions difficult to draw ( 37 ). Examining the user perception and acceptance of different scoring tools should be a priority in any future study as they might influence healthcare provider behavior and treatment processes.…”