Objective: To implement a statewide program for the early recognition and treatment of sepsis in New South Wales, Australia.
Setting: Ninety-seven emergency departments in NSW hospitals.
Intervention: A quality improvement program (SEPSIS KILLS) that promoted intervention within 60 minutes of recognition, including taking of blood cultures, measuring serum lactate levels, administration of intravenous antibiotics, and fluid resuscitation.
Main outcome measures: Time to antibiotics and fluid resuscitation; mortality rates and length of stay.
Results: Data for 13 567 patients were entered into the database. The proportion of patients receiving intravenous antibiotics within 60 minutes of triage increased from 29.3% in 2009–2011 to 52.2% in 2013. The percentage for whom a second litre of fluid was started within 60 minutes rose from 10.6% to 27.5% (each P < 0.001). The proportion of patients classed as Australasian Triage Scale (ATS) 1 increased from 2.3% in 2009–2011 to 4.2% in 2013, and the proportion classed as ATS 2 rose from 40.7% in 2009–2011 to 60.7% in 2013 (P < 0.001). There was a linear decrease in mortality from 19.3% in 2009–2011 to 14.1% in 2013; there was also a significant decline in time in intensive care and total length of stay (each P < 0.0001). The mortality rate for patients with severe sepsis (serum lactate ≥ 4 mmol/L or systolic blood pressure [SBP] < 90 mmHg) was 19.7%. The mortality rates for patients with severe sepsis admitted to intensive care and for those admitted to a ward did not change significantly over time. The proportion of patients with uncomplicated sepsis (SBP ≥ 90 mmHg, serum lactate < 4 mmol/L) transferred to a ward increased, and the mortality rate after transfer increased from 3.2% in 2009–2011 to 6.2% in 2013 (P < 0.05). The survival benefit was greatest for patients with evidence of haemodynamic instability (SBP < 90 mmHg) but normal lactate levels (P = 0.03).
Conclusions: The SEPSIS KILLS program has improved the process of care for patients with sepsis in NSW hospitals. The program has focused attention on sepsis management in the wards.
- 1. Mayr FB, Yende S, Angus DC. Epidemiology of severe sepsis. Virulence 2014; 5: 4-11.
- 2. Wang HE, Shapiro NI, Griffin R, et al. Chronic medical conditions and risk of sepsis. PLoS One 2012; 7: e48307.
- 3. Dellinger RP, Levy MM, Rhodes A, et al. Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2012. Crit Care Med 2013; 41: 580-637.
- 4. Kaukonen K-M, Bailey M, Pilcher D, et al. Systemic inflammatory response syndrome criteria in defining severe sepsis. N Engl J Med 2015; 372: 1629-1638.
- 5. Gray A, Ward K, Lees F, et al. The epidemiology of adults with severe sepsis and septic shock in Scottish emergency departments. Emerg Med J 2013; 30: 397-401.
- 6. Clinical Excellence Commission. Recognition and management of sepsis (clinical focus report). Sydney: CEC, 2012. http://www.cec.health.nsw.gov.au/__data/assets/pdf_file/0004/259375/patient-safety-report-sepsis-2012.pdf (accessed Nov 2015).
- 7. Clinical Excellence Commission. 2011 Quality Systems Assessment self assessment. Supplementary report – sepsis. Sydney: CEC, 2012. http://www.cec.health.nsw.gov.au/__data/assets/pdf_file/0009/259308/2011-qsa-thematic-report-sepsis_qsa_final.pdf (accessed Nov 2015).
- 8. Hughes C, Pain C, Braithwaite J, Hillman K. “Between the flags”: implementing a rapid response system at scale. BMJ Qual Saf 2014; 23: 714-717.
- 9. Australasian College for Emergency Medicine. Policy on the Australasian Triage Scale. (Policy P06.). July 2013. https://www.acem.org.au/getattachment/693998d7-94be-4ca7-a0e7-3d74cc9b733f/Policy-on-the-Australasian-Triage-Scale.aspx (accessed Nov 2015),
- 10. Sundararajan V, Macisaac CM, Presneill JJ, et al. Epidemiology of sepsis in Victoria, Australia. Crit Care Med 2005; 33: 71-80.
- 11. Kumar A, Roberts D, Wood KE, et al. Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock. Crit Care Med 2006; 34: 1589-1596.
- 12. Puskarich MA, Trzeciak S, Shapiro NI, et al. Association between timing of antibiotic administration and mortality from septic shock in patients treated with a quantitative resuscitation protocol. Crit Care Med 2011; 39: 2066-2071.
- 13. Ferrer R, Martin-Loeches I, Phillips G, et al. Empiric antibiotic treatment reduces mortality in severe sepsis and septic shock from the first hour: results from a guideline-based performance improvement program. Crit Care Med 2014; 42: 1749-1755.
- 14. Kaukonen KM, Bailey M, Suzuki S, et al. Mortality related to severe sepsis and septic shock among critically ill patients in Australia and New Zealand, 2000–2012. JAMA 2014; 311: 1308-1316.
- 15. Peake SL, Delaney A, Bailey M, et al. Goal-directed resuscitation for patients with early septic shock. N Engl J Med 2014; 371: 1496-1506.
- 16. Mikkelsen ME, Miltiades AN, Gaieski DF, et al. Serum lactate is associated with mortality in severe sepsis independent of organ failure and shock. Crit Care Med 2009; 37: 1670-1677.
- 17. Whittaker SA, Fuchs BD, Gaieski DF, et al. Epidemiology and outcomes in patients with severe sepsis admitted to the hospital wards. J Crit Care 2015; 30: 78-84.
- 18. Esteban A, Frutos-Vivar F, Ferguson ND, et al. Sepsis incidence and outcome: contrasting the intensive care unit with the hospital ward. Crit Care Med 2007; 35: 1284-1289.
- 19. Gao F, Melody T, Daniels DF, et al. The impact of compliance with 6-hour and 24-hour sepsis bundles on hospital mortality in patients with severe sepsis: a prospective observational study. Crit Care 2005; 9: R764-R770.
- 20. Marwick CA, Guthrie B, Pringle JE, et al. A multifaceted intervention to improve sepsis management in general hospital wards with evaluation using segmented regression of interrupted time series. BMJ Qual Saf 2014; 23: e2.
- 21. Jaderling G, Bell M, Martling CR, et al. ICU admittance by a rapid response team versus conventional admittance, characteristics, and outcome. Crit Care Med 2013; 41: 725-731.
- 22. Liu V, Escobar GJ, Greene JD, et al. Hospital deaths in patients with sepsis from 2 independent cohorts. JAMA 2014; 312: 90-92.
- 23. Runciman WB, Hunt TD, Hannaford NA, et al. CareTrack: assessing the appropriateness of health care delivery in Australia. Med J Aust 2012; 197: 100-105. <MJA full text>
- 24. Kumar A, Ellis P, Arabi Y, et al. Initiation of inappropriate antimicrobial therapy results in a fivefold reduction of survival in human septic shock. Chest 2009; 136: 1237-1248.
- 25. Cross G, Bilgrami I, Eastwood G, et al. The epidemiology of sepsis during rapid response team reviews in a teaching hospital. Anaesth Intensive Care 2015; 43: 193-198.
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