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Sepsis: how one ED has achieved a 70% rise in patients receiving life-saving treatment within the hour

Cambridge hospital trust uses digital technology to provide faster access to sepsis care in the emergency department 

Cambridge hospital trust uses digital technology to provide faster access to sepsis care in the emergency department 


Picture: iStock

Cambridge University Hospitals (CUH) NHS Foundation Trust has been lauded by NHS England for its use of an electronic alert system to identify, and provide faster access to treatment for, patients with sepsis.

The trust rolled out an electronic patient record (EPR) system, Epic, in October 2014, as part of its digital transformation programme at its Addenbrooke’s and The Rosie hospitals. The sepsis alert was set up as a part of Epic and launched in July last year.

CUH was one of the first trusts in the UK to use Epic; patient medical information is kept in the system with clinicians using handheld and mobile devices to record care at the bedside. This means that when a patient arrives as an emergency or is admitted, the clinical team caring for that patient can see their record in its entirety – wherever and whenever they need to – so they are all looking at the same information. This, the trust says, is vital for patient safety.

40% 

of people admitted to an ED with sepsis did not have a timely review by a senior clinician
(Source: National Confidential Enquiry into Patient Outcome and Death 2015)

 

Avoidable delays 

A report from the National Confidential Enquiry into Patient Outcome and Death published in 2015 found that 40% of people admitted to an emergency department (ED) with sepsis did not have a timely review by a senior clinician. It also reported avoidable delays in administering antibiotics in more than one quarter of cases and inconsistencies in early use of intravenous fluid.

‘Nurses on our wards and in our ED also scan patient wristbands and medication simultaneously to ensure that the correct medications are given to the correct patients each and every time’

The National Institute for Health and Care Excellence recommends that once someone is classed as high-risk they should be seen by senior staff and given the right treatment within an hour to avoid debilitating problems and, in the worst cases, death.

As a result of the NCEPOD report, a CUH sepsis action group – consisting of clinicians from the emergency department (ED), acute medicine, infectious diseases, rapid response and the eHospital digital team – developed the electronic alert and set of actions to add into the Epic system in a bid to help staff identify and treat sepsis quickly.

Dedicated sepsis nurse role

70%

increase in the proportion of patients diagnosed with sepsis receiving antibiotics within the recommended national time frame 

The organisation views the treatment of sepsis as a priority – a dedicated sepsis nurse role has recently been created to liaise with staff across the trust about the infection. Since the launch of the alert, there has been a 70% increase in the proportion of patients diagnosed with sepsis receiving antibiotics within the recommended national time frame when presenting at the ED.

There has also been a 50% increase across adult inpatient areas at the trust’s hospitals.

The statistics have been welcomed by the trust as the organisation was rated as inadequate in 2015 by the Care Quality Commission (CQC) and placed in special measures by Monitor, which stated that the multi-million pound eHospital programme had resulted in significant cost increases.

Outstanding care rating

However, a January 2017 CQC report rated the trust as good overall, with an outstanding rating for care. The report stated that many of the concerns they had identified at previous inspections about Epic had been addressed and staff were more familiar with the system.

‘The Epic electronic patient record system has been a real boon for us in terms of treating sepsis, which has always been significant for the ED’

Andrew Scott-Donkin is a senior ED charge nurse and educational lead for the department. He says that any implementation of a system as large as Epic was always going to cause some issues, but the reality of using it is that it has allowed better communication in the ED and across the trust.


Senior ED charge nurse and educational
department lead Andrew Scott-Donkin

‘Epic has been a real boon for us in terms of treating sepsis, which has always been significant for the ED. A patient could arrive in an ambulance bay and a full set of observations will be taken through Epic regardless of why they came in.’

National Early Warning Score

Mr Scott-Donkin says an elevated National Early Warning Score (NEWS) will prompt Epic to display a field suggesting escalation mechanisms including:

  • Informing the nurse in charge.
  • Contacting the medical team.
  • Consider sepsis.
  • Consider calling the rapid response team for advice.

He adds that if sepsis is suspected, Epic will prompt ordering of appropriate investigations such as cannulation, blood cultures and bloods including lactate: ‘ED attendances have been up year on year and we have had a number of challenges getting sepsis action achieved within an hour. We now have trained healthcare support workers (HCSW) who are able to cannulate and take blood.

‘There is a sepsis trolley based in the ambulance bay with cannulation equipment.’

‘The alert system has been a game-changer for all of us and is simple to follow’

Mr Scott-Donkin says staff at the ED have been working hard to make sure the busy nature of the department does not impact on the speed of them treating sepsis and for the past month nurses have been carrying timers and using them for severely septic patients.

‘It can sometimes get so busy that you turn around and it is 45 or 50 minutes later. The timer is good to keep you aware of the timeframe, to keep the momentum going and make sure the patient gets treatment with antibiotics within an hour.’

50%

reduction in medication adminstration errors

He explains that the demographic of patients attending the ED is generally older and due to comorbidities they may be less able to fight sepsis infection, making the alert system invaluable.

Recognise risk factors

Mr Scott-Donkin says the ED uses material from charity the UK Sepsis Trust within clinical areas as an additional prompt to assist nursing staff to recognise risk factors for sepsis. As educational lead for the department he is involved in continuing professional development for staff and will be supporting future work on sepsis treatment and care.

Lisa Wood is a senior sister in the rapid response team of specialised nurses who respond via a bleep system if a patient becomes acutely unwell on a ward or if another professional becomes concerned about them.

Ms Wood is part of the trust’s sepsis action group that meets quarterly: ‘We are also in regular email contact and learn from each other.

‘You can’t argue with the figures that tell you we are looking after people better’

‘The alert system has been a game-changer for all of us. It is simple to follow and it is important to remember that for every hour’s delay in giving a septic patient antibiotics you can significantly increase their chance of mortality.

‘Proved its worth’

‘Of course, anything to do with computers and change generally is going to be stressful and you will always have people questioning why things have to change, but it has opened up a whole new world.

‘If you look at statistics across the trust it has proved its worth. You can’t argue with the figures that tell you we are looking after people better.

‘One example that stands out to me is when a man in his mid-60s came through an outpatient clinic, a HCSW did all his observations and the Epic system showed he had a high NEWS and alerted the nurse in the clinic, who then opened the sepsis alert system and they contacted the rapid response team.

‘By the time we got there they had done five of the Sepsis Six checks and treatments within an hour. He went home a week later. They were not treating him blindly and his sepsis was recognised by a team of people who knew exactly what to do and how to action his plan of treatment.’

The Sepsis Six check

Sepsis, also known as blood poisoning, affects more than 250,000 people in the UK every year. It is a potentially life-threatening condition and the reaction to an infection in which the body attacks its own organs and tissues. However, it can be easily treated if caught early.

The Sepsis Trust recommends clinicians check for amber and red flag criteria to assess a patient’s sepsis risk and implement the Sepsis Six treatment if necessary. The Sepsis Six check was developed in 2005 and in 2011 the charity published evidence showing it to be associated with a 50% reduction in mortality of septic patients. 

The Sepsis Six check is now being used in 30 countries around the world:

  1. Administer oxygen to maintain SpO2 >94% 
  2. Take blood cultures and consider infective source 
  3. Administer intravenous antibiotics 
  4. Consider intravenous fluid resuscitation 
  5. Check serial lactates 
  6. Commence hourly urine output measurement

(Source: The Sepsis Trust)

‘In addition, we share information directly with our patients through Epic’s integrated MyChart patient portal feature’

Afzal Chaudhry is a renal consultant and chief clinical information officer at CUH and says that the wider use of the Epic system has reduced the use of paper patient records by 99% and has halved the time it takes to prepare discharge medications by integrating Epic with the trust’s medication dispensing robot.


Afzal Chaudhry, renal consultant
and chief clinical information
officer at Cambridge University
Hospitals trust

Real-time recording of bedside care

All patients on wards wear barcode wristbands which, when scanned, bring up their medical record in the Epic system to enable the real-time recording of care at their bedside.

He says: ‘Nurses on our wards and in our ED also scan patient wristbands and medication simultaneously to ensure that the correct medications are given to the correct patients each and every time.

‘This is improving safety and has reduced medication administration errors by 50%.

‘In addition, we share information directly with our patients through Epic’s integrated MyChart patient portal feature. In April we connected our Epic system to West Suffolk Hospital’s Cerner EPR system in a UK first, to enable our ED clinicians to access clinical records for shared patients to improve safety and prevent the unnecessary repeat of tests or procedures.

‘As a global digital exemplar, we are looking forward to extending the capabilities of our Epic EPR system even further to benefit our patients.’


Petra Kendall-Raynor is a freelance health journalist

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