Sepsis time is life

e-Newsletter - Issue 3

Sepsis Time is Life www.rlbuht.nhs.uk

Sepsis Public Engagement Event - September 2016

Dr Emmanuel Nsutebu Consultant Infectious Diseases Physician and Clinical Lead for Sepsis AQuA Leadership for Improvement Fellow AQ Sepsis Clinical Lead National Sepsis Advisor – NHSE

Welcome to our third annual e-newsletter This is an opportunity to review what we have achieved in the last year and highlight what we need to achieve in the coming year. Whilst writing this newsletter, I was taken aback by the amount of work we have done and would like to start by extending thanks to all of you! Last year we achieved most of our objectives and most importantly, continued to improve outcomes for patients with sepsis. This is why we do what we do so well done! This newsletter will highlight developments in the following areas: 1.

Making patients better 7.

2.

Working with patients and relatives 8.

3.

Education and training of staff 4.

Developing our team 9.

5.

Improving our service 10.

6.

Improving data and performance

Improving prehospital care for sepsis Collaboration with regional, national and international partners Application for awards Our Challenges for the coming year

1. Making patients better Our project was set up to transform the care of patients with sepsis and improve outcomes. I am happy to confirm that the data we have, suggests we have continued to do exactly this. We have identified the following improvements since the project began in 2014, when compared against this year’s figures.2.

Improvement area

2014/15 (Project inception)

2015/16

2016/17

Impact (against start point)

Activity – (patients coded as sepsis)

1282

1453

1610

21% increase

In-hospital mortality

26.7%

21.1%

23.1%

2.6% reduction

Length of stay (median number of days)

11

10

8.5

2.5 day reduction

16%

14%

No reduction

% readmitted within 30 days 14%

2. Working with patients and relatives We decided that we would co-design and deliver this project with patients and relatives. We ran a public engagement event in September 2016 and it was a great success. The key learning points from the public engagement workshop were:

• We need to focus more on after-care for sepsis and provide information about what to expect after patients have had sepsis. We have updated our patient information leaflet accordingly and included this in our training material.

• Patients were impressed with the care we provide and our systems to improve sepsis care. One of the patients said “Seeing the use of a sepsis team and trolley provided reassurance/confidence that there was a system and the staff knew what they were doing”.

• The need to listen to relatives when assessing patients with suspected sepsis as they often cannot provide an accurate history.

Unfortunately, Julie Carman who was our patient representative on our steering group can no longer attend the meetings for personal reasons. We would like to thank her for the support she gave us to ensure that our work is patient centred. We have identified other patients who should be able to attend our steering group meetings and will continue to develop this project with patients and relatives.

3. Education and training of staff Education and training has continued at a steady pace for clinical and non-clinical staff.

The Sepsis Nurse team run an interactive sepsis study day every month. Staff get the chance to participate in simulation scenarios and practical workshops such as blood culture and Arterial Blood Gas training. The study day is very popular and early booking is recommended. To book on to the sepsis study day please log onto Staff ESR. The Sepsis Nurse team have also delivered wardbased simulation training. This consists of 1520 minutes ward based training sessions to suit the demands and shift patterns of the staff. The feedback from these training sessions has been positive, and the training will continue in 2017.

Should any ward/clinical areas wish to have further training please contact the sepsis nurse team on sepsisnurseteam@rlbuht.nhs.uk ext 3865.

Training in 2017 will focus on ensuring that staff know and use the new international consensus definition of sepsis. Although we now have a new international consensus definition for sepsis - “Life threatening organ dysfunction caused by a dysregulated immune response to infection”, this definition is not being consistently used by clinical staff. Sepsis is now defined as patients with “bad infection” or “seriously ill patients with infection”.

In the coming year, we will focus on educating staff to use criteria such as early warning scores, lactate levels and any indication of organ dysfunction in order to identify patients with sepsis. Our sepsis pathway has also been updated to reflect this.

Model used for simulation training

4. Developing our team We now have one of the largest sepsis nurse teams in the country – 4 nurses working 7 days a week between 8 am and 8 pm and supporting the Emergency department. The feedback so far from patients and staff has been extremely positive. We plan to evaluate the sepsis nurse team’s role in March 2017. We will also assess whether the team needs to be expanded to provide 24 hour cover. There is some evidence that care for patients with sepsis during the night may not be as good during the day.

Dr Mona Fong has joined the Emergency Department/Acute Medicine Unit (ED/AMU) Sepsis Group as ED clinical lead for sepsis. Dr Ray Raj was the previous lead and we would like to thank him for the contribution he has made to improving sepsis care in the ED. Paul Scott is also the new sepsis nurse lead for the AMU. We have also identified sepsis champions in a number of clinical areas such as Broadgreen hospital, surgical and haematology wards.

Sepsis Nurse Team

5. Improving our service We have continued to reduce human factors that prevent good sepsis care in our hospital. For example, we have piloted sepsis trolleys and shown that they can potentially reduce time to antibiotics and improve patient outcomes. As a result we have purchased 4 sepsis trolleys which will be used in the Emergency Department, AMU and ESAU. We are currently working with our IT department to develop electronic sepsis alerts and screening on the back of electronic early warning scores. We expect that this will be in place by April 2017 and should also facilitate data collection and evaluation of our work.

Our sepsis nurses ran a “perfect week” in December 2016 when they piloted seeing patients before they were triaged and whilst they were in the ED corridors.

The data we have so far suggests that it improved care for patients with sepsis however we do not have the resources to sustain this way of working. We have fed back the lessons learnt to the ED so that they can explore ways of improving identification and management of deteriorating patients before they are triaged and therefore speed up care.

ED staff using Sepsis trolley

6. Collaboration with regional, national and international partners We are now recognised as one of the best hospitals for sepsis care and sepsis improvement nationally. Our work has been recognised by NHS England and we presented our work at a National “Think Sepsis” event organised in December 2017.

Our work has also meant that we are represented at the Global Sepsis Alliance Quality Improvement Committee.

We have shared our experience of sepsis improvement with other hospitals in the NW of England. We have continued to work with other teams in AQ/AQuA and the Academic Health Science Network to improve sepsis care.

We took part in a breakthrough collaborative event organised by AQ/AQuA to teach sepsis teams’ quality improvement.

The event involved 15 sepsis teams in the NW with over 100 staff being taught quality improvement skills over 3 workshops and with coaching in between the workshops.

NHS England ‘Think Sepsis’ Event - December 2016

7. Improving data and performance We have continued to be part of the AQ (Advancing Quality) regional Sepsis Collaborative and data suggests that we now achieve perfect care (appropriateness care score) in 62% of patients with sepsis. We are the second best in the region. In December 2016, we decided to move to using a sample of patients for this project in order to reduce the work load related to data collection.

We have not achieved our Commissioning for Quality and Innovation (CQUIN) target for administration of intravenous antibiotics in patients with sepsis. We currently administer intravenous antibiotics in 50% of patients with sepsis within 1 hour. The main reason for this is waiting times in the Emergency Department.

However antibiotics are administered in >80% of patients with sepsis once they are seen by clinical staff.

We will continue to work with our colleagues in ED to improve triage so that patients with sepsis can receive antibiotics in a timely manner.

We have identified that we need to focus more on improving recognition and management of patients who develop sepsis on our wards. This is a priority area for 2017.

8. Improving pre-hospital care for sepsis We have done a lot to improve prehospital care for sepsis in the last year. We cannot transform care for patients with sepsis at the Royal without working with our colleagues in primary and community care.

North West Ambulance Service (NWAS) launched a screening tool and pathway for sepsis in December 2016.

We are now seeing more sepsis pre-alerts from the ambulance services. There will be a formal evaluation of this initiative to assess the impact on sepsis care and other balancing measures such as ED attendances.

We have provided numerous teaching sessions for GPs and community nurses across the North West by working with AQuA and the Family Doctors Association. We also produced a 10 top tips leaflet for primary care which has been distributed widely in the North West.

We have worked with Urgent Care 24 in Liverpool who have run a quality improvement project to improve recording of observations for patients with suspected sepsis. This has already led to improvements in assessment of patients with sepsis and pre-alerting of patients before they are sent to hospital.

A recent example is an elderly gentleman with sepsis who was sent by UC24 with a NEWS score of 11 and received antibiotics within 30 minutes of arrival. He was able to return home and back to his usual self within 4 days of admission to hospital. This is a good example of what can be achieved when care is joined up between us and the community.

We will continue to build on this work and hope to improve leadership for sepsis improvement in the community so that we can improve coordination of sepsis improvement across Liverpool.

AQUA/AQ Sepsis Breakthrough Collaborative - September 2016

9. Application for awards We were shortlisted for the 2016 Make A difference, Chairman’s Award. Despite not winning, it was an achievement to get to this stage for the second year running so well done to all the team.

I was nominated by AQuA/AQ and shortlisted for the NW Leadership Academy Awards under the category of “Emerging Leader”. Again, although I did not win, it was an achievement to be a finalist and it is thanks to all the hard work that you have done in the Trust.

NW Leadership Academy Awards - December 2016

10. Our challenges for the coming year Our vision for the next year is summarised in our updated sepsis strategy for the coming year (Figure 1) which has been developed by members of the sepsis steering group. These are going to be our main challenges and focus for next year: • Improving care for patients who develop sepsis on our wards • Improving antibiotic stewardship and reducing use of broad spectrum antibiotics • Ensuring that all staff are aware of and use the new international consensus definition for sepsis • Continue to improve prehospital care for sepsis • Improve after care for patients with sepsis • Expand our sepsis nurse team to a 24 hour a day service.

• Introduce electronic sepsis alerts and improve our systems for collection and use of data • Use our data and resources to do more research in sepsis We are going to introduce electronic sepsis (e-sepsis) alerts in April 2017 to prompt staff to consider sepsis and implement the sepsis pathway.

Our mission is to continuously transform sepsis care in the Royal Liverpool and Broadgreen University Hospitals NHS Trust and I have no doubt that we will achieve this.

Sepsis Public Engagement Event - September 2016

Evaluate and expand sepsis nurse team to 24 hour cover across the Trust

Vision

Strategy

Creative

Rollout systems and education to ensure new definition of sepsis used by clinical staff.

Develop and deliver research projects based upon work delivered

Consistently review and reduce human factors to improve the identification and treatment of patients with sepsis.

Robust triage process in ED and AMU that incorporates sepsis treatment and care

Collaborative

Best performing Trust nationally within the next five years, based upon the national CQUIN

Continued real time robust data collection and dissemination to front line clinicians.

Also use data for research and QI

Improve management of patients who develop sepsis on inpatient wards

Introduce e-Sepsis and sepsis alerts linked to e-NEWS

Improve antibiotic stewardship and reduce the use of broad spectrum antibiotics

Objectives

Open and engaged

Values

To be the best performing Trust in the region within 12 months, based upon AQ and national CQUIN

Collaboration with the local health economy including CCG and Liverpool Community Health

Consistent use of sepsis pathway and consistent care

Where we all make a difference

Improve sepsis data for patients who develop sepsis on wards

Reduce mortality by 20% for patients with sepsis and sepsis shock

Professional

Provide a gold standard of care for every patient, every time.

Patient centred

Mission

To continuously transform sepsis care across the Royal Liverpool and Broadgreen University Hospitals NHS Trust

Sepsis Strategy 2017 - 18