An audit to determine timing of first dose antimicrobial administration and choice following diagnosis of sepsis

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1 ICE Score 1 An audit to determine timing of first dose antimicrobial administration and choice following diagnosis of sepsis Rakhee Patel, Reju Joy, Alison Williams & Armando Gonzalez May 2010

2 Surviving Sepsis Campaign (SSC) Launched December 2008 The SSC aimed to reduce mortality from sepsis via a multi-point strategy Administration of abx within the first hour of diagnosis crucial

3 Definitions SIRS (Systemic Inflammatory Response Syndrome) = 2 of: Heart rate > 90 WCC < 4 or > 11 Temp < 36 or > 38 Resp rate > 20 Severe sepsis = with organ hypoperfusion / dysfunction Sepsis = SIRS due to infection Septic shock = with hypotension unresponsive to fluids and/or requiring vasopressor support

4 Background Severe sepsis is a major cause of morbidity & mortality in ICUs worldwide UK 64,000 deaths annually from severe sepsis Mortality rate from severe sepsis estimated between 28-50% Approx 10% do not receive prompt abx therapy = 10-15% higher mortality rate

5 Aim & Objectives Aim: To determine if we are following SSC guidelines appropriately Objectives: To determine if first dose administration of antimicrobial therapy is within the recommended time frame of 1 hour from time of diagnosis/antibiotic prescription as per SSC guidelines To determine if the Trust is compliant with guidelines relating to choice of empirical antimicrobials To characterise the clinical and laboratory variables of septic patients as per the SSC guidelines

6 Standards & Methodology 100% of patients achieve the target of 1 hour for 1st dose administration from time of diagnosis & appropriateness of empirical antimicrobial therapy Retrospective audit Data collection between September 2009 & December patients identified All adult patients included A&E excluded

7 Results Patient Outcome 12 out of 49 patients deceased (24%), remainder discharged Is administration of antimicrobial therapy within the recommended time frame of 1 hour? Time Scale 1 hour 1-4 hours 4-12 hours > 12 hours Not Documented Number of patients total %

8 Where do delays occur? Patient Sepsis * Times taken from documentation in notes regarding diagnosis of sepsis & antibiotic initiation & time of administration documented on drug chart???? Observations Checked Antibiotic Given???? Mean time* = 4.82 hours (Min of 5 minutes & Max of 24 hrs) Medical Review Antibiotic Prescribed

9 Number of patients endorsed by microbiology Are we following Trust guidelines relating to empirical choice of antimicrobials? Number of patients with no microbiology involvement Total % 31% 100% Number of patients as per Abx guidelines Number of patients not as per Abx guidelines Total % 14% 100%

10 Manifestation of clinical & laboratory variables in septic patients? Results for clinical variables based on 46 patients Clinical Variables Yes Fever 39% Hypothermia 2% Tachycardia 59% Tachypnea 35% Hypotension 22% Results for laboratory variables based on 49 patients Laboratory Variables Yes Leukocytosis 51% Leukopenia 22% Plasma CRP 88% Creatinine 47% INR > % (37% not recorded) Thrombocytopenia 12% Hyberbilirubinemia 67% (10% not reordered) Hyperlactatemia 0% (100% not recorded) Hyperglycaemia 22% (53% not recorded)

11 Clinical Variables Number of Clinical Criterion Met vs Number of Patients Number of Patients Number of Variables

12 Laboratory Variables Number of Laboratory Criterion Met vs Number of Patients Number of Patients Number of Variables

13 Conclusions Mean time to administration of appropriate abx therapy for patients with sepsis was much longer than internationally recommended 1 hour A high index of suspicion is required to diagnose severe sepsis In this audit population, septic syndrome with 4 clinical criteria was not apparent

14 Limitations Retrospective audit Small number of patients Unable to obtain 3 patients notes Poor documentation in notes & charts

15 Recommendations Band 7 nurses to be given ownership of regular audits validation audits conducted by pharmacy Reasons for the delay need to be identified to improve current practice & achieve the target of 1 hour for 1 st dose administration Improve notes/chart documentation & communication between clinical ward teams Doctors to prescribe stat doses including time of administration required for 1 st dose A Surviving Sepsis awareness campaign initiated & a multidisciplinary working group for management of acutely ill patients formed

16 Any Questions?