Issue 2 / 25 January 2016

A NSW sepsis intervention program should be rolled out nationally, according to experts, after research published in the MJA found the approach was saving lives and improving patient care.

The SEPSIS KILLS program was developed by the Clinical Excellence Commission (CEC) and encourages intervention within 60 minutes of sepsis being recognised, including taking of blood cultures, measuring serum lactate levels, administering intravenous antibiotics, and fluid resuscitation.

Professor Mary-Louise McLaws, infection control expert at the University of NSW, told MJA InSight that “patients can often present with very mild and insidious symptoms, so sepsis can sometimes be overlooked”.

“But the message from SEPSIS KILLS is to recognise, resuscitate and refer patients with sepsis early on. As more patients get seen rapidly, the death rate falls.”

Related: MJA — Do death certificates accurately record deaths due to bloodstream infection?

Professor McLaws co-authored the MJA study, which assessed the effectiveness of the SEPSIS KILLS program, implemented in 97 NSW emergency departments (EDs) from 2011.

The hospitals recorded data for a total of 13 567 adult patients until the end of 2013. The authors compared mortality rates and length of stay in hospital, as well as the time to antibiotics and fluid resuscitation for patients before and after SEPSIS KILLS was adopted. 

The proportion of patients who received intravenous antibiotics within 60 minutes of triage increased from 29.3% in 2009–2011 to 52.2% in 2013, the authors found. The percentage for patients for whom a second litre of fluid was started within the hour rose from 10.6% to 27.5%.

The authors also found a decrease in mortality from 19.3% in 2009 – 2011 to 14.1% in 2013, and there was also a significant decline in time spent in intensive care and total length of stay in hospital. 

The mortality rates for patients with severe sepsis was 19.7%, which was consistent with the overall mortality rate in Australian and New Zealand intensive care units (ICUs).

The authors wrote that their findings demonstrated the SEPSIS KILLS program was effective in NSW EDs in promoting early recognition and management of sepsis within the first few hours.

“This program could be applied in other jurisdictions and its integration with antimicrobial stewardship requirements should be considered,” they said.

Related: MJA — Sepsis in the tropical Top End of Australia’s Northern Territory: disease burden and impact on Indigenous Australians

Ms Mary Fullick, sepsis program manager at the CEC, told MJA InSight that SEPSIS KILLS was meeting a vital need in the healthcare system. Sepsis was not being managed adequately and this was putting patients at risk.

“Sepsis is a medical emergency. We need to approach sepsis like we would a stroke or a trauma,” she said.

Associate Professor David Pilcher, an intensivist at the Alfred Hospital in Melbourne, agreed, adding that the program was an important step forward in improving how sepsis is managed.

“Sepsis is a problem that is not only not going away, but probably increasing due to more admissions to ICU and more antibiotic resistance,” he told MJA InSight.

Professor Pilcher said this research proved that it was possible to have a procedure in place that translates into better outcomes for ED patients with sepsis.

“It also demonstrated the value of tests such as lactate in identifying those at higher risk, and this appeared to be associated with overall better outcomes.”

Professor Pilcher said that the coordinated and consistent way the program was implemented across so many hospitals was “something that other hospitals and health departments could learn from”.

Related: MJA InSight — Rethinking sepsis

Professor McLaws was confident that SEPSIS KILLS could be successfully and cost-effectively implemented across the country.

“The program is a standardised bundle of care – serum lactate, administration of fluids and antibiotics, and rapid referral,” she said.

Ms Fullick explained that the CEC did not have the power to implement the program nationally, however.

“We would need another organisation to rollout the program in other jurisdictions.”

The CEC had a range of online tools that would make a national rollout easier, Ms Fullick said.

“Our primary tool is the sepsis pathway, a double page sheet that promotes the key points [of SEPSIS KILLS].”

Ms Fullick said while the results of this research were positive, the task of improving sepsis care in all areas of the hospital wasn’t over.

“Data from the EDs has now been collected, but the next phase is ongoing and focused on sepsis in the inpatient area.”

She said that the CEC’s fundamental priority was to “keep pushing for improvement in sepsis management through continuing education of nurses and clinicians”.

7 thoughts on “Act fast on sepsis

  1. Belinda Cochrane says:

    I have been involved in discussions and debate about “Sepsis Kills” in NSW for several years now and recently it has been decided that we will trial it on Respiratory Ward in my hospital. As Director of Respiratory Medicine, I was not included in the decision-making but just informed that this “was to be”. Like others I have reservations about the blind application of protocols and believe that protocolised care should not replace careful clinical judgement. However, how do we prevent this from occurring? The temptation is always there when there is a written protocol – relax, disengage brain and just follow like a sheep.

    If you consider the criteria for diagnosing sepsis, used in the Sepsis Kills protocol, it is very clear that most acute respiratory adimssions would meet the criteria, especailly in winter. Nearly all have rasied respiratory rate, tachycardia and low SpO2. Many have elevated lactate too, especially if they’ve been given high doses of short-acting beta-agonist, either in the ED or in the ambulance. So, it is equally clear that it is a far smaller proportion who actually have sepsis after careful consideration.

    Now comes to my main concern. Despite many requests, I have been unable to obtain reassurance that there would be meaningful monitoring and transparent reporting of complications. I remember a frail lady with end stage COPD who came in to our ED with AECOPD (no infective features), who received CPR and left the ED for ICU intubated after anaphylaxis to Ceftriaxone. A single case, but I will always remember her. How are we capturing the adverse drug reactions from this protocol, such as allergy, diarrhoea, Clostridium colits and antiobiotic resistance?

  2. Dr. Balaji Bikshandi says:

    Dear Sue leraci, +1 for your second paragraph; 0 tests available as a reliable ‘goal’ and EGDT is a failure; -1 for the ill thought of ‘lactate’ level which is non-specific (most shock states exhibit this and their push on this could alter resuscitative  fluids). ‘Recognise’ is ok but the terms ‘refer’ and ‘resuscitate’ override physician autonomy in my humble opinion. No this need not be ‘rolled out’ nationwide – every physician worth his or her salt already knows early recognition of sepsis is vital (credit goes to the surviving sepsis campaign). The ‘standard care’ at the physician discretion works well. Cheers. 

  3. Sue Ieraci says:

     “is that not a goal and ‘directed’ ‘early’?”. Of course it is. Don’t we need some sort of a goal for therapy, that measures whether the person is improving? For a simple infection, it’s easy. For systemic infection in the setting of multiple co-morbidities and poor cardiac function, not so much.

    Having said that, there is no protocol that substitutes for clinical judgement. These processes target identified gaps in the system. Without careful drafting, and ongoing review, there is a risk of side-stream harms from over-identification of conditions, and blunt-tool approach. Unless everyone gets seen early by experienced, competent clinicians, at all hours of the day, there will always be a fall-back to simplified procedures in an attempt to minimise risk.

  4. Dr. Balaji Bikshandi says:

    The sepsis bundle propaganda is the classic example of how mindless protocols fail. The ARISE and Process trials are testaments to this effect. That excellent editorial accompanying them which condemned protocolized therapies should be read by any thinking doctor. Now the propagandists have reduced themselves to ‘recognition’ only! Please don’t mistake me I am all for early recognition – they should have stopped at that. Oh the countless number of junior doctors bullied by nurses with this when they were only careful about fluid loading heart failure patients. There is an yet another protocol propaganda compromising patients lives – blood sugar ‘control’! By the way, citing lactate level, is that not a goal and ‘directed’ ‘early’? Cheers. 

  5. Sue Ieraci says:

    To the most recent “anonymous” – the CEC Sepsis Campaign is about early recognition, fluids and antibiotics. It doesn’t recommend the types of invasive monitoring that characterised the “Goal-Directed therapy” trials – it’s much more about early recognition and a clinical response. While these are sound principles, one criticism of the analysis might be that there is “over-recognition”, so that outcomes appear to improve when you include cases that would not previously have been defined as “sepsis”.

  6. Dr. Balaji Bikshandi says:

    Didn’t both the ARISE and Process trial refute the benefits of goal directed therapy? 

  7. Sue Ieraci says:

    INteresting data, including ” The proportion of patients with uncomplicated sepsis (SBP ≥ 90 mmHg, serum lactate < 4 mmol/L) transferred to a ward increased”. it can’t be disputed that early recognition and intervention for any acute illness is a good thing (so long as other patients are not disadvantaged), but it’s possible that at least a proportion of the outcome improvement here is from a widened definition and greater case-finding.

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