Article Text

Download PDFPDF

Impact of the Surviving Sepsis Campaign on the recognition and management of severe sepsis in the emergency department: are we failing?
  1. Helen Lindsay Cronshaw1,
  2. Ron Daniels2,
  3. Anthony Bleetman3,
  4. Emma Joynes4,
  5. Mark Sheils5
  1. 1Emergency Department, Leicester Royal Infirmary, UK
  2. 2Intensive Care unit, Good Hope Hospital, Birmingham, UK
  3. 3Emergency Department, Good Hope Hospital, Birmingham, UK
  4. 4Good Hope Hospital, Heart of England NHS Foundation Trust, Birmingham, UK
  5. 5Heartlands Hospital, Heart of England NHS Foundation Trust, Birmingham, UK
  1. Correspondence to Dr Helen Lindsay Cronshaw, Emergency Department, Leicester Royal Infirmary, Infirmary Square, Leicester LE1 5WW, UK; hcronshaw{at}doctors.org.uk

Abstract

Background Severe sepsis/septic shock (SS/SS) has a high mortality. The past decade lays witness to a concerted international effort to tackle this problem through the Surviving Sepsis Campaign (SSC). However, bundle delivery remains problematic. In 2009, the College of Emergency Medicine (CEM) set out guidelines for the management of SS/SS. These set the standards for this audit.

Objectives To assess the recognition and management of patients presenting with SS/SS across three emergency departments (EDs) within the West Midlands.

Methods Data were collected retrospectively over a 3-month period. Patients in the ED with a diagnostic code of, or presenting complaint suggestive of, sepsis, had their scanned notes assessed for evidence of SS/SS. Compliance with the CEM guidelines, and evidence of referral to the intensive care staff was evaluated.

Results 255 patients with SS/SS were identified. Of these, 17% (44/255) were documented as septic by ED staff. The CEM standard of care was received in 41% of those with a documented diagnosis of severe sepsis in the ED, and 23% of patients with SS/SS overall. 89% of patients received the ‘treatment’ aspects of care: oxygen, IV antibiotics and IV fluids. Twelve patients with a raised lactate level and normal blood pressure (cryptic shock) failed to receive fluid resuscitation. 71% of patients with SS/SS had no documented discussion or consideration of referral to the intensive care unit.

Conclusions The SSC has had some impact; however, there is still a long way to go. It is assumed that the picture is similar in EDs across the UK and recommendations are made based on these local findings.

  • Sepsis
  • shock
  • emergency medicine
  • intensive care
  • lactate
  • infectious diseases
  • intensive care
  • management
  • emergency department management
  • wounds
  • infection

Statistics from Altmetric.com

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.

Introduction

Severe sepsis (acute organ dysfunction secondary to infection) and septic shock (sepsis with hypotension refractory to fluid challenge) are life-threatening conditions with an associated mortality of 28–50%.1–3 Left untreated, mortality in septic shock rises by 8% an hour.4 The documented annual incidence of sepsis world wide is 18 million.5 In 1992, it was estimated that every day 1400 people world wide die from severe sepsis.6 This figure is probably arrived at owing to low rates of recognition and diagnosis, with a tendency to record the causative pathology (eg, pneumonia) rather than the systemic condition. One credible study attempting to identify the incidence of all cases in the United States estimated that 3.0 cases occur per 1000 population per year.1 This would give an estimate of 20 million cases per year. With a mortality of around 35%, this would mean around 20 000 deaths per day world wide. In the UK we might expect to see 64 000 deaths annually from severe sepsis if this estimated incidence were true. Recent estimates give an incidence of sepsis requiring an intensive care unit admission of 0.25–0.38 per 1000 population, giving rise to around 2 million cases admitted to intensive care units alone.7 8

In the past decade there has been a concerted international effort to tackle severe sepsis.9 In 2002, a collaboration of international professional bodies launched the Surviving Sepsis Campaign (SSC). Updated in 2004 and 2008, the SSC published recommendations arising from research and clinical trials.10 11 Following these recommendations, collaboration with the Institute for Healthcare Improvement led to the development and distribution of the severe sepsis resuscitation and management care bundles. The resuscitation bundle (‘bundle’) is to be completed within the first 6 h after presentation with severe sepsis, and is of relevance to emergency physicians. It comprises a number of fundamental aspects of patient management, complemented by early goal-directed treatment for non-responding patients.9 The third phase of the SSC led to a drive to undertake global ‘plan-do-study-act’ cycles aiming at improving delivery of the bundles, and required the collection of data on delivery and outcomes from across the globe. Experience has shown that adherence to the bundle improves outcome in patients with severe sepsis.12–14 Reliable delivery of the bundle remains a challenge in many healthcare organisations.

In 2009, the College of Emergency Medicine (CEM) set out standards for the management of severe sepsis/septic shock (SS/SS).15 This encompasses eight recommendations to be completed in the emergency department (ED) within 4 h. These include measuring urine output and serum lactate level, taking blood cultures and a full set of observations. Administering oxygen, intravenous antibiotics and fluids, and obtaining a review by a senior ED physician or intensive care outreach/doctor.

The ‘sepsis six’ pioneered in our trust, is a mnemonic alliteration, which aims to improve delivery of initial sepsis management.16 It comprises six of the above CEM standards to be completed within 1 h of ED presentation. These include: oxygen administration, serum lactate measurement, IV fluids, blood cultures, IV antibiotics and urine output measurement.

Our trust proforma provides a flow chart to help identify patients with SS/SS in accordance with SSC advice. It then outlines the ‘sepsis six’ along with a request for regular observations and for senior ED/intensive care advice in line with CEM guidance. The only difference is that our trust proforma demands that the ‘sepsis six’ is completed within 1 h, whereas CEM gives 1, 2 and 4 h targets depending on the standard of care. The remainder of the proforma ensures completion of the resuscitation bundle within 6 h in line with SSC advice.

This study looks at recognition and management of SS/SS across a large hospital trust in accordance with CEM guidance. The aim of this retrospective chart review is to establish whether a large sepsis launch can provide good compliance with CEM standards. Since SSC and therefore CEM guidance is evidence based we have not correlated compliance with mortality/morbidity as this is beyond the scope of this paper. This paper comes just before the proposed CEM sepsis audits in all EDs nationally and will hopefully highlight the challenges of delivering care at the front door.

Methods

Retrospective data were collected across three ED sites over a 3-month period (1 January to 31 March 2009). Patients presenting to the ED within this period were assessed for likelihood of SS/SS by the computerised diagnostic code (DC) given to each patient upon leaving the ED. For those without a DC, the presenting complaint (PC) was assessed instead. Data were analysed using MSS (a computerised ED patient registry), which stores a scanned copy of the ED clerking.

Exclusion criteria were as follows:

  1. patients with a DC or PC highly unlikely to be associated with sepsis—for example, minor finger injury;

  2. age <18 years;

  3. patients discharged home from the ED.

The remaining patients were divided into the following groups:

  • Sepsis diagnosed—patients with a DC of sepsis;

  • Not diagnosed sepsis: wards—patients with a DC or PC suggestive of sepsis who were admitted to a general ward;

  • Not diagnosed sepsis: ITU/HDU—patients with a DC or PC suggestive of sepsis who were admitted to an intensive therapy unit/high-dependency unit (ITU/HDU);

  • ‘RIP in ED’—patients who died in the ED.

Two doctors at each hospital collected data and completed an Excel spreadsheet. Before starting, they received verbal and written instruction to ensure consistency of data collection across the three sites. Each patient had their scanned ED clerking notes assessed individually. Initially, their charted observations were checked for the presence of any two systemic inflammatory response syndrome (SIRS) criteria. Then their clerking was checked for any symptoms or signs of new infection. If the above criteria were met and they had evidence of organ dysfunction then they were included in the audit (table 1). Blood results were not available in the ED in a large majority of cases therefore these could not be used for diagnostic criteria as they would on the wards.

Table 1

Definitions used to identify patients with severe sepsis/septic shock. These are adapted from Dellinger RP, Levy MM, Carlet JM, et al Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2008. Crit Care Med 2008;36:296–32711

All Sepsis diagnosed, Not diagnosed septic: ITU/HDU and RIP in ED patient notes were assessed for the presence of SS/SS using the trust sepsis screening tool and if they met the criteria they were included in the audit. The Not diagnosed septic: ward patients were randomised as this was a large group, and as many were assessed for SS/SS as time constraints allowed.

The records of patients with suspected severe sepsis were screened for the following information:

  • compliance with the CEM guidelines, including referral to intensive care staff;

  • signs of organ dysfunction;

  • average frequency of assessment of ‘modified early warning score’ (MEWS);

  • use of the trust sepsis proforma.

For patients admitted to the ITU/HDU from the ED a number of physiological parameters were collected, including age, temperature, heart rate, respiratory rate, blood glucose, haemoglobin oxygen saturation (SATS), systolic blood pressure (SBP), lactate, MEWS and altered mental state.

Results

This audit collected data for 255 severely septic patients presenting between 1 January and 31 March 2009 over the three ED sites. Of these, 44 (17%) patients were recognised as septic by their computerised DC. A further 211 (83%) severely septic patients were identified using the sepsis screening tool during this audit. The numbers of eligible patients in each clinical group at each site are shown in figure 1.

Figure 1

A flow chart outlining the details of patient inclusion and exclusion from the audit (site 1: Birmingham Heartlands Hospital; site 2: Good Hope Hospital; site 3: Solihull Hospital. DC, diagnostic code; ED, emergency department; HDU, high-dependency unit; ITU, intensive therapy unit; MSS, a computerised ED patient registry; PC, presenting complaint; RIP died; SoS, symptom of sepsis). The boxes with writing in italics were excluded from the audit.

Completion of CEM standards

Table 2 gives the numbers of patients who received each CEM standard of care, according to their hospital site and whether they had been recognised as having a diagnosis of SS/SS.

Table 2

Numbers of patients who received each College of Emergency Medicine standard of care at each hospital site (site 1: Birmingham Heartlands, site 2: Good Hope, site 3: Solihull) according to whether they were diagnosed as having severe sepsis/septic shock or not

Figure 2 illustrates the percentage of patients who received each individual aspect of care for SS/SS in the ED within the 4 h time limit. Figure 3 subdivides patients into those with a DC of SS/SS and those without.

Figure 2

The percentage of patients who received the individual aspects of the College of Emergency Medicine (CEM) standards across the three emergency department sites within the 4 h target. ABG, arterial blood gas; UO, urine output.

Figure 3

Demonstrates completion of the College of Emergency Medicine (CEM) standards in the diagnosed sepsis group compared with the undiagnosed group within the 4 h target. ABG, arterial blood gas; UO, urine output.

Twenty-nine per cent of patients were either referred to ITU staff, considered not suitable for ITU or had a ‘do not attempt resuscitation’ status recorded within the ED. The remaining patients (71%) with severe sepsis had no documented discussion or consideration of referral to ITU.

Signs of organ dysfunction

Figure 4 illustrates the marker of organ dysfunction that resulted in patients being classified as severely septic according to criteria defined in the 2008 updated SSC guidelines adapted from the international sepsis definitions conference.11 17 This is not a complete analysis as approximately one-third of patients did not have lactate levels measured and less than half the patients had a fluid balance chart completed.

Figure 4

Percentage of patients with the four different markers of organ dysfunction. MAP, mean arterial pressure; SBP, systolic blood pressure.

Hypoxia was the commonest marker of organ dysfunction (44%) but this may reflect how frequently it was documented. A raised lactate level was present in nearly one-third of patients where it was measured. Twelve per cent of patients had a raised lactate level as their only criterion for organ dysfunction. All patients with a raised lactate level and low BP combined, or an isolated low BP without a raised lactate level, received fluid resuscitation. However, 12 patients with a recorded raised lactate level without a drop in BP (‘cryptic shock’) failed to receive fluid resuscitation.

Predicting ITU/HDU admission from severe sepsis

The average age of patient admitted to ITU/HDU was 52.5, 70 and 60 years at sites 1, 2 and 3, respectively. This may reflect the average age of the local demographics. Table 3 illustrates the type of physiological derangement present among patients admitted to the ITU or HDU. Overall, their average MEWS score was 6. Certain parameters failed to be measured in a number of patients. These are included in the table, to avoid underestimating the percentage of patients with each physiological derangement. A high proportion of patients had a raised heart rate, respiratory rate and low haemoglobin oxygen saturation. It is difficult to comment on lactate levels and urine output as insufficient data were available.

Table 3

Percentage of patients admitted to the intensive care unit or high-dependency unit with each systemic inflammatory response syndrome (SIRS) criterion/sign of organ dysfunction, together with the patients for whom these data were unavailable

The above assessment of physiological parameters only involves the patients who were actually referred to ITU/HDU from the ED, not all the patients who might have needed referral.

Discussion

The mortality rate from severe sepsis has been estimated as ranging between 28% and 50%.1–3 The recent SOAP study in Europe observed an overall hospital mortality of 36%.18 Data from the intensive care National Audit and Research Centre shows that patients admitted to intensive care in the UK with severe sepsis have a 39.8% risk of death. There are few disease processes with such a high mortality. An admission with severe sepsis places the patient at a level of risk around six times greater than if a patient were admitted with an acute myocardial infarction, and four to five times greater than if a patient had had an acute stroke.

The SSC has recently published the results of an international performance improvement initiative.19 This large study looked at 15 022 patients with severe sepsis from 165 sites (Europe, South America and the USA) and found a compliance improvement from 10.9% to 31.3% after 2 years. Methods of screening were ultimately established locally and it looked at patients from the ED, clinical wards and intensive care units. The sepsis launch within our trust was equally organised and publicised, with ‘sepsis six’ used as a mnemonic alliteration to help improve initial sepsis management. This audit looks at the outcome of a launch within a trust in the UK, with an individual but easily transferable screening tool, purely for patients presenting to the ED with SS/SS. This study highlights deficiencies in the delivery of care at a local level and the challenges of achieving CEM standards of care in the ED.

Early recognition of SS/SS is the first target of the SSC, yet only 17% of the patients in this audit were diagnosed as having SS/SS in the ED. Without this early recognition there is little hope of the CEM standards being instituted in a timely fashion. Overall, the CEM standards were completed in only 23% of patients with SS/SS during the audit period, and 41% of those diagnosed as severely septic. Early recognition and diagnosis of SS/SS seem to correlate positively with compliance with CEM standards in the ED. This highlights the importance of early recognition of this condition.

Despite the low overall compliance with CEM standards, 89% of the patients did receive the ‘treatment’ aspects of the CEM standards: oxygen, IV antibiotics and fluid resuscitation. This audit adds to existing research which states that early completion of all interventions is associated with reduced hospital mortality—thus the other elements of the CEM standards are also of importance. Taking blood cultures before starting antibiotics in the ED will help guide antibiotic treatment after the first 48 h and may restrict excessive use of broad-spectrum agents. A serum lactate measurement will identify those patients with poor tissue perfusion despite a normal BP. A mandate to accurately record urine output can avoid transfer of a patient with threatened renal failure to a ward, without appropriate fluid resuscitation.

In severely septic patients there relative and absolute hypovolaemia exist owing to vasodilatation, capillary network shunting and increased capillary permeability. This is compounded by reduced myocardial contractility and reduced cardiac output. Circulating volume is essential for oxygen delivery and for this reason intravenous fluid resuscitation should be administered to all severely septic patients. A high proportion of patients received fluid resuscitation (84%), although the CEM standard is 95%.

Seventy-one per cent of severely septic attendees had arterial blood gas assessment with lactate measurement. A low blood pressure triggered the use of resuscitation fluid in all patients with or without a raised lactate level; however, in 12 patients with a raised lactate level in the absence of hypotension, fluids were not administered despite their poor end-organ perfusion. The term ‘cryptic shock’ has been used to describe patients with a raised lactate level in the absence of hypotension, and it has been suggested that these patients need to be treated as aggressively as those with hypotensive shock. These patients may comprise up to 20% of septic patients with a normal blood pressure.20 Lactate measurement has also been shown to be useful in stratifying the risk of mortality.21 22 Serial measurements are used to direct fluid resuscitation.

A reduction in urine output is strongly suggestive of inadequate end-organ perfusion, and helps to guide fluid resuscitation. During this audit 47% of patients received formal urine output assessment. The relatively small proportion of patients who had their urine output monitored despite the severity of their illness may reflect the time constraints within the ED setting. It takes two consecutive hours with a urine output <0.5 ml/kg/h before the consensus definition for organ dysfunction is achieved, assuming no other evidence of end-organ dysfunction. The CEM standard just requires that urine output measurements be instituted in 90% of patients before leaving the ED.

The CEM recommends that 100% of patients receive antibiotics before leaving the ED and that 50% receive them within 1 h and 90% within 2 h. Mortality increases by 7.6% for each hour that antibiotic treatment is delayed for patients in septic shock.4 Seventy-eight per cent of patients received antibiotics before leaving the ED in our audit. The lack of early antibiotic administration provides a definite future goal for sepsis management within the ED. A further audit looking at the prescription of antibiotics for sepsis within the ED would hopefully help identify problems and guide a future campaign.

Diagnostic difficulties—for example, distinguishing between pneumonia with sepsis and acute heart failure in the absence of a temperature, may delay treatment. Patient waiting times to see a doctor often exceed an hour in the ED. If those with severe sepsis are not recognised at triage, there will often be a delay in antibiotic administration. There is a current view that the initiation of sepsis diagnosis and initial management should occur in the pre-hospital setting, with the subsequent mobilisation of a dedicated team at the receiving hospital with the expertise to make such decisions and avoid treatment delays.23

The CEM standards require blood cultures to be taken before administering antibiotics in 95% of cases (with the exception of patients with purpura fulminans seen in meningococcal or streptococcal septicaemia). Administering antibiotics first is poor practice as it reduces the sensitivity of the blood culture, making directed antibiotic treatment more difficult. A minority of our patients who received intravenous antibiotics were not bled for a diagnostic culture, which is encouraging and represents a tangible change in practice.

Inconsistent communication with intensive care staff about sick ED patients was evident from this audit. Those not requiring intensive care input at the time of discharge from the ED, but who may deteriorate, are not well provided for within our current referral system. There would appear to be scope for a formal system of referral to intensive care outreach from our ED nursing/clinical staff to allow ongoing monitoring of the need for formal intensive care evaluation.

Limitations

Owing to the enormity of the task, physically searching through all admission proformas in a 3-month period was not feasible with the resources available. Measures were taken, therefore, to reduce the sample size. Patients excluded using their ED exit diagnoses or presenting complaint, and those excluded because they were discharged home from the ED were unlikely to have had severe sepsis and therefore incorrectly excluded. Patients were only included in the audit if they had by definition ‘severe’ sepsis—that is, sepsis with organ dysfunction. Patients without all the investigations/measurements performed to diagnose severe sepsis—for example, lactate and urine output, may have been incorrectly excluded.

All the notes could not be examined under time constraints, but despite this we had a large sample of severely septic patients (255). The adopted methodology and exclusion criteria mean that we cannot accurately quote the total number of severely septic patients presenting to the three ED sites within a 3-month period but it does not affect our assessment of the completion of CEM standards for selected patients.

The CEM guidance (May 2009) states that all interventions should be performed before leaving the ED in 95% of patients as standard, except for the administration of IV fluids and IV antibiotics, which should be completed in 100% before leaving the ED.15 In addition, it does specify 1 h and 2 h targets for antibiotics and fluids but owing to the inconsistency of documentation of intervention timings and poor clarity on scanned ED clerking, we did not clarify the exact timings of these interventions. We did, however, identify whether they were completed during a patient's time in the ED. There is a space for these timings on the sepsis proforma but this was only used for 10% of patients.

Conclusion

The SSC has been well publicised; however, there is still a way to go to ensure full implementation.

We are good at providing most of the correctly identified patients with adequate resuscitation (oxygen, IV antibiotics and fluids) but this should occur at an earlier stage of presentation. We need to improve our triage and identification of these patients to enable earlier management. All the recommended measurements need to be performed to enable diagnosis of the more severely septic individuals and their relevance identified—that is, raised lactate level/normal BP in ‘cryptic’ shock. We highlight the difficulties in assessing the timings of interventions in a retrospective audit, especially with poor use of a dedicated proforma. Communication between ED and intensive care colleagues needs to develop to facilitate escalation of care for these patients if required. We assume that there may be a similar situation in other UK hospitals; highlighting the need to reinforce the CEM guidance. These recommendations for the emergency medicine community come at an appropriate time in view of the proposed mandatory CEM sepsis audit.

Acknowledgments

We thank Dr Christopher Stewart and Dr Sarah Davies for data collection; Ms Joanne Flowers and Mrs Rachel Mahay-Goodrich for data collection and technical help.

References

Footnotes

  • Competing interests None.

  • Provenance and peer review Not commissioned; externally peer reviewed.