Downloaded from http://emj.bmj.com/ on March 12, 2015 - Published by group.bmj.com
PostScript
LETTER
Use of sepsis 6 raises some interesting questions Dear Sirs NHS Forth Valley, like other health boards in Scotland, has implemented the Scottish Patient Safety Programme (SPSP) sepsis workstream which started in January 2012 and aims to reduce mortality from sepsis in pilot sites by 10% by December 2014.1 One of the vehicles for this is reliable delivery of the sepsis 62 bundle (see table 1) within 1 h of recognition of sepsis. Locally, our guidance advises that where a patient is triggering on their NHS Early Warning Scoring chart (NEWS3) and is suspected of having an infection, they should be treated with the sepsis 6 bundle. This has led to a significant (25%) increase in the number of blood cultures (BCs) being taken. However, the number of positive BCs has remained relatively unchanged; thus, the proportion of positive BCs has fallen from 15% to 9% (see figure 1). This poses some interesting questions: ▸ Are we taking BCs from patients triggering NEWS but not due to sepsis? ▸ Are BCs being taken earlier in sepsis, prior to the development of bacteraemia? ▸ Given the sepsis 6 involves giving intravenous antibiotics as part of the bundle and given the relative decrease in positive BCs, do we end up with more cases of culture-negative sepsis treated with broad spectrum antibiotics? This last scenario is unsatisfactory
Table 1 The sepsis 62 Give oxygen Give intravenous fluid resuscitation Give appropriate antibiotics (intravenous)
Take Hb and lactate Take BCs Monitor urine output
BCs, blood cultures; Hb, haemoglobin.
948
Figure 1
Numbers of blood cultures (BCs) taken and numbers which were positive (by month).
for patients and treating health professionals, and from an antibiotic stewardship viewpoint is concerning, as it may promote antibiotic resistance. This observed trend also has implications for sepsis mortality statistics. If sepsis mortality is calculated using number of deaths/number of BCs taken (current SPSP methodology), then there is a risk that any fall in mortality may be largely due to an increase in the denominator, rather than a fall in the numerator. One way to mitigate against this might be to look at number of deaths/number of positive BCs (minus contaminants). Furthermore, if we are drawing BCs from patients with conditions other than sepsis which can present with pyrexia (eg, malignancy), then these deaths will be captured as ‘sepsis deaths’ making changes in mortality even harder to interpret. The sepsis 6 bundle is an effective and useful way of ensuring that patients with suspected sepsis get appropriate early interventions in a timely manner. These local data demonstrate the need for further consideration of how to measure the impact of widespread implementation on mortality from sepsis, since number of deaths/number of BCs taken is only one methodology, and other methods may offer greater insights.
Emerg Med J November 2014 Vol 31 No 11
David J Wright,1 Daniel J Beckett,2 Ben Cooke2 1
Department of Anaesthesia & Critical Care, NHS Forth Valley, Forth Valley Royal Hospital, Larbert, UK Forth Valley Royal Hospital, Larbert, UK
2
Correspondence to Dr David J Wright, Department of Anaesthesia & Critical Care, NHS Forth Valley, Forth Valley Royal Hospital, Stirling Road, Larbert FK5 4WR, UK; [email protected] Contributors BC collected the data on blood cultures. DJB and DJW had the idea for this letter. The letter was written by DJW. Competing interests None. Provenance and peer review Not commissioned; externally peer reviewed.
To cite Wright DJ, Beckett DJ, Cooke B. Emerg Med J 2014;31:948. Published Online First 1 September 2014 Emerg Med J 2014;31:948. doi:10.1136/emermed-2014-204065
REFERENCES 1
2 3
http://www.knowledge.scot.nhs.uk/media/CLT/ ResourceUploads/4007280/Sepsis%20Driver% 20Diagram0.10.doc (accessed 12 May 2014). http://survivesepsis.org/the-sepsis-six/ (accessed 13 May 2014). http://www.rcplondon.ac.uk/sites/default/files/documents/ national-early-warning-score-standardising-assessmentacute-illness-severity-nhs.pdf (accessed 2 Jun 2014).
Downloaded from http://emj.bmj.com/ on March 12, 2015 - Published by group.bmj.com
Use of sepsis 6 raises some interesting questions David J Wright, Daniel J Beckett and Ben Cooke Emerg Med J 2014 31: 948 originally published online September 1, 2014
doi: 10.1136/emermed-2014-204065 Updated information and services can be found at: http://emj.bmj.com/content/31/11/948
These include:
Email alerting service
Receive free email alerts when new articles cite this article. Sign up in the box at the top right corner of the online article.
Notes
To request permissions go to: http://group.bmj.com/group/rights-licensing/permissions To order reprints go to: http://journals.bmj.com/cgi/reprintform To subscribe to BMJ go to: http://group.bmj.com/subscribe/
PostScript
LETTER
Use of sepsis 6 raises some interesting questions Dear Sirs NHS Forth Valley, like other health boards in Scotland, has implemented the Scottish Patient Safety Programme (SPSP) sepsis workstream which started in January 2012 and aims to reduce mortality from sepsis in pilot sites by 10% by December 2014.1 One of the vehicles for this is reliable delivery of the sepsis 62 bundle (see table 1) within 1 h of recognition of sepsis. Locally, our guidance advises that where a patient is triggering on their NHS Early Warning Scoring chart (NEWS3) and is suspected of having an infection, they should be treated with the sepsis 6 bundle. This has led to a significant (25%) increase in the number of blood cultures (BCs) being taken. However, the number of positive BCs has remained relatively unchanged; thus, the proportion of positive BCs has fallen from 15% to 9% (see figure 1). This poses some interesting questions: ▸ Are we taking BCs from patients triggering NEWS but not due to sepsis? ▸ Are BCs being taken earlier in sepsis, prior to the development of bacteraemia? ▸ Given the sepsis 6 involves giving intravenous antibiotics as part of the bundle and given the relative decrease in positive BCs, do we end up with more cases of culture-negative sepsis treated with broad spectrum antibiotics? This last scenario is unsatisfactory
Table 1 The sepsis 62 Give oxygen Give intravenous fluid resuscitation Give appropriate antibiotics (intravenous)
Take Hb and lactate Take BCs Monitor urine output
BCs, blood cultures; Hb, haemoglobin.
948
Figure 1
Numbers of blood cultures (BCs) taken and numbers which were positive (by month).
for patients and treating health professionals, and from an antibiotic stewardship viewpoint is concerning, as it may promote antibiotic resistance. This observed trend also has implications for sepsis mortality statistics. If sepsis mortality is calculated using number of deaths/number of BCs taken (current SPSP methodology), then there is a risk that any fall in mortality may be largely due to an increase in the denominator, rather than a fall in the numerator. One way to mitigate against this might be to look at number of deaths/number of positive BCs (minus contaminants). Furthermore, if we are drawing BCs from patients with conditions other than sepsis which can present with pyrexia (eg, malignancy), then these deaths will be captured as ‘sepsis deaths’ making changes in mortality even harder to interpret. The sepsis 6 bundle is an effective and useful way of ensuring that patients with suspected sepsis get appropriate early interventions in a timely manner. These local data demonstrate the need for further consideration of how to measure the impact of widespread implementation on mortality from sepsis, since number of deaths/number of BCs taken is only one methodology, and other methods may offer greater insights.
Emerg Med J November 2014 Vol 31 No 11
David J Wright,1 Daniel J Beckett,2 Ben Cooke2 1
Department of Anaesthesia & Critical Care, NHS Forth Valley, Forth Valley Royal Hospital, Larbert, UK Forth Valley Royal Hospital, Larbert, UK
2
Correspondence to Dr David J Wright, Department of Anaesthesia & Critical Care, NHS Forth Valley, Forth Valley Royal Hospital, Stirling Road, Larbert FK5 4WR, UK; [email protected] Contributors BC collected the data on blood cultures. DJB and DJW had the idea for this letter. The letter was written by DJW. Competing interests None. Provenance and peer review Not commissioned; externally peer reviewed.
To cite Wright DJ, Beckett DJ, Cooke B. Emerg Med J 2014;31:948. Published Online First 1 September 2014 Emerg Med J 2014;31:948. doi:10.1136/emermed-2014-204065
REFERENCES 1
2 3
http://www.knowledge.scot.nhs.uk/media/CLT/ ResourceUploads/4007280/Sepsis%20Driver% 20Diagram0.10.doc (accessed 12 May 2014). http://survivesepsis.org/the-sepsis-six/ (accessed 13 May 2014). http://www.rcplondon.ac.uk/sites/default/files/documents/ national-early-warning-score-standardising-assessmentacute-illness-severity-nhs.pdf (accessed 2 Jun 2014).
Downloaded from http://emj.bmj.com/ on March 12, 2015 - Published by group.bmj.com
Use of sepsis 6 raises some interesting questions David J Wright, Daniel J Beckett and Ben Cooke Emerg Med J 2014 31: 948 originally published online September 1, 2014
doi: 10.1136/emermed-2014-204065 Updated information and services can be found at: http://emj.bmj.com/content/31/11/948
These include:
Email alerting service
Receive free email alerts when new articles cite this article. Sign up in the box at the top right corner of the online article.
Notes
To request permissions go to: http://group.bmj.com/group/rights-licensing/permissions To order reprints go to: http://journals.bmj.com/cgi/reprintform To subscribe to BMJ go to: http://group.bmj.com/subscribe/
