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Showing results for tags 'Sepsis'.
Found 38 results
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Content Article
CQUIN for deteriorating patients: proforma (February 2020)
PatientSafetyLearning Team posted an article in CQUIN
CQUIN.pptx CQUIN.pdf- Posted
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Content ArticleThis webinar explores NHS acute sector experiences during the peak of COVID-19 in Spring and Summer of 2020, reflects on global figures and sequalae and contrast with sepsis on a national and global scale including the importance of AMR. 5 key learning points: Understanding of the impact of COVID-19. Learn about after effects of C-19 and sepsis in survivors. Remind ourselves about the global scale of sepsis. Understand this in the context of AMR. Reflect on global and national policy strategies.
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News ArticleAn investigation into the outbreak of a bacterial infection that killed 15 people has found there were several “missed opportunities” in their care. Mid Essex Clinical Commissioning Group has released the outcome of a 10-month investigation into a Strep A outbreak in 2019, which killed 15 people and affected a further 24. The final report was critical of Provide, a community interest company based in Colchester, as well as the former Mid Essex Hospital Services Trust (now part of Mid and South Essex Foundation Trust). It said: “This investigation has identified that in some cases there were missed opportunities where treatment should have been more proactive, holistic and timely. These do not definitively indicate that their outcomes would have been different.” Investigators found that 13 of the 15 people that died had received poor wound care from Provide CIC. They reported that inappropriate wound dressings were used and record keeping was so poor that deterioration of wounds was not recognised. Even wounds that had not improved over 22 days were not escalated to senior team members for help or referred to the tissue viability service for specialist advice, with investigators told this was often due to concerns over team capacity. The report, commissioned by the CCG and conducted by consultancy firm Facere Melius, said: “[Some] individuals became increasingly unwell over a period of time in the community, yet their deterioration either went unnoticed or was not acted upon promptly. Sometimes their condition had become so serious that they were very ill before acute medical intervention was sought”. Other findings included delays in the community in the taking of wound swabs to determine if the wound was infected and by which bacteria. It said in one case nine days elapsed before the requested swab took place. Even after Public Health England asked for all wounds to be swabbed following the initial outbreak, this was only conducted on a single patient. In other cases there were delays in patients being given antibiotics and this “could have had an adverse impact on the treatment for infection”. It also found that sepsis guidelines were not accurately followed, wounds were not uncovered for inspection in A&E, and some patients were given penicillin-based antibiotics despite penicillin allergies being listed in their health records. Read full story (paywalled) Source: HSJ, 17 September 2020
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EventThis year’s programme brings together highly ranked representatives of international and national healthcare authorities, NGOs, policymakers, clinical scientists, researchers, and pioneers in healthcare improvement with the unified goal of improving AMR and sepsis healthcare around the world. The objectives of this free Spotlight online congress are to review achievements, challenges, and potential solutions to combat the threats posed by AMR and sepsis globally. Speakers will describe the current global epidemiology and burden of sepsis and AMR, explore a future research agenda, provide an overview of lessons and challenges from the COVID-19 pandemic and recent Ebola outbreaks, and ultimately explore innovative and cost-effective approaches to preventing and combating sepsis and AMR. The WSC Spotlight is a free online congress and is attended by a large number of clinicians, health decision-makers, and other health workers. For example, more than 40,000 people from 160 countries tuned in to the 2017 WSC Spotlight on maternal and neonatal sepsis (and accessed more than 300,000 times on YouTube and Apple Podcasts in the following weeks). Moreover, at the occasion of this congress, WHO will launch the first Global report on the epidemiology and burden of sepsis. The report describes results from original research and existing published evidence, the methodologies and limitations of the studies, and identifies gaps and priorities for future research. Programme and registration
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Take, test and treat - The critical future in diagnostics and blood culture
Patient Safety Learning posted a calendar event in Community Calendar
untilA FREE and LIVE virtual event made up of five educational webinars, Tuesday 8th - Thursday 10th September 2020. Co-produced by BD and Health Plus Care. Looking at the blood culture pathway is relevant to all of us right now. The crossover in symptoms between coronavirus and sepsis, means early diagnosis is even more urgent. We are all moving away from the mentality of 'just in time' to 'just in case'. Our speakers have been handpicked for their expertise in diagnostics, in clinical settings, and as known advocates for patient safety. They will examine what methods and best practices are available, as well as reflecting on the current mood and change in priorities within healthcare. This is against a backdrop of UKI guidelines, the UK’s diagnostic strategy and what the future of blood cultures could look like. You will have the chance to hear real life UK customer stories, and our final session will end with a panel discussion chaired by Ed Jones, former Chief of Staff to the UK Foreign Secretary, Jeremy Hunt MP. The panel features Lord O’Shaughnessy, and Dr Ron Daniels, and will tackle the issues around blood cultures and testing in the current COVID-19 climate. Further information and registration -
Content Article
Antibiotic Resistance & Patient Safety Portal
Claire Cox posted an article in International patient safety
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News Article
Coronavirus: Thousands of COVID-19 survivors could be diagnosed with sepsis, charity warns
Clive Flashman posted a news article in News
People are being warned to familiarise themselves with the symptoms of sepsis after a study found that as many as 20,000 COVID-19 survivors could be diagnosed with the condition within a year. One in five people who receive hospital treatment for the coronavirus are at risk, according to the UK Sepsis Trust. Sepsis is triggered when the body overreacts to an infection, causing the immune system to turn on itself - leading to tissue damage, organ failure and potentially death. If spotted quickly, it can be treated with antibiotics before it turns into septic shock and damages vital organs. Read the full article here. -
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Sepsis: A decade of change (May 2020)
Claire Cox posted an article in Deterioration and sepsis
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Content ArticleThe US observance of ’Groundhog Day‘ is more than just the annual emergence of Punxsutawney Phil – the rodent soothsayer who ceremoniously predicts the timing of the arrival of Spring. It is the name of a popular film that represents how the repetition of unwanted experiences can contribute to scepticism, callousness and burnout for the primary character – weatherman Phil. However, he emerges from the darkness by applying what he learns over time to arrive at a new brighter day. Patient safety leaders are apt to feel like weatherman Phil. Repetitiveness – the feeling that something been done over and over again without change – can decrease engagement but it can also lead to experiential knowledge that can be applied to future efforts. Community engagement is paramount to patient safety success but it can be challenging if people feel like they wake to the same problem every day despite efforts to make a difference. The Boston-based Betsy Lehman Center has developed Including the Patient Voice: A Guide to Engaging the Public in Programmes and Policy Development. The Guide shares a six-element approach to involving members of the public as partners to reduce reoccurrence of poor care. Strategies focus on enabling community members to succeed as partners and contribute as experts to designing health services that are evidence based and accessible to all. This includes leadership-led mini-workshops for staff to inform their engagement programmes and patient correspondence reviews to identify the right consumers to invite as participants. Similarly lessons have been shared by MedStar Health, a large regional healthcare system that sought to engage patients and design strategies that engage patients and families in safety improvement. Organisational structures such as Patient and Family Advisory Councils (PFAC) served as the focal point of the shared learning effort. The system developed a network of courses that shared best practices to foster innovation and sustain realised improvements in event reporting, disclosure (the CANDOR Toolkit), after-incident support and sepsis reduction. The tactics used include board and leadership activation activities, a mentorship programme for new community leaders and public awareness campaigns. For example, the system launched a collaborative to share information to improve early detection of sepsis. Patients who had contracted sepsis along with PFAC members and in-house quality experts were brought together to design an educational video to reduce sepsis that highlighted symptom identification and response. The programme contributed to marked sepsis treatment improvement. The City of Philadelphia recently launched a prescription monitoring strategy to curtail the overprescribing of opioids in their region. Because this programme identifies by name the 10% of physician that overprescribe, these individuals can be offered targeted training and, if necessary, legal interventions to address their behaviour. Home-grown programmes can also be proactive to prevent overprescribing. One Boston-based family medicine clinic described their five-year change management effort to reduce opioid overuse. The authors reported their focus on developing “shared general principles”; communication mechanisms to connect clinicians with in-house addiction experts, patient registries, targeted training, certification opportunities and centralised leadership were all instrumental in embedding improved prescribing practices throughout the organisation. Consistent unremitting workload pressure perpetuates stress and fatigue. Its presence degrades staff relations, performance and the safety of care delivery. It’s a common problem that medical residents are burnt out: no news there. What conveys great promise are programmes like what the Virginia Mason Medical Center in Kirkland Washington has done to address burnout by implementing workflow changes and fostering a culture of “collegiality, respect and innovation”. The Center changed workflow by standardising clinical tasks, defining staff roles and carving out protected time for staff to recharge, self-educate and participate in improvement efforts. The Center has enhanced its culture and improved staff morale through leadership efforts to lower hierarchy, welcome and respond to feedback, and address inefficiencies that can discourage staff and derail efforts. Ninety percent of staff at Kirkland reported in a 2018 internal survey feeling content and engaged about their work. Medical residents can also find support through programmes like the ACGME Aware initiative. This set of tools targets strategies that junior doctors can use to build resilience and embrace their professional community through a mobile phone app to find support as they need it. Personal tactics to protect against burnout for more experienced healthcare professionals are also in demand. A news story in Medical Economics highlights what doctors and hospital administrators can do to minimise burnout, such as making time to socialise with peers and using the opportunity to share stories, rethinking their roles to bring joy back to medicine, and to listen. For 2020, Phil has told us that Spring is due to arrive early. Will the application of the successes reviewed in this month’s Letter reduce the recurrence of opioid overprescribing and staff burntout? We need more than a rodent to speculate on that for us. But given efforts by patient safety champions in the US and UK, improvements optimism is in the air.
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Sepsis screening tool telephone triage for the under 5s
Claire Cox posted an article in Paediatrics
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Content ArticleThe resources include peer-reviewed content on identifying and managing sepsis in the community, in older people and in children from Emergency Nurse, Nursing Children and Young People, Nursing Older People and Primary Health Care.
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Content ArticleKey learning points Maternal sepsis remains a significant cause of morbidity and mortality in the UK. Improving prevention and care of sepsis is highlighted in the latest Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries in the UK (MBRRACE UK) report: Saving Lives, Improving Mothers’ Care 2017. One of the actions suggested is a ‘declaring sepsis’ alert as described below. Where sepsis is suspected a sepsis care bundle, applied in a structured and systematic way with urgency, can save lives.
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News Article
'My baby died of sepsis - we can stop more deaths'
Patient Safety Learning posted a news article in News
New monitors that can detect the deadly blood condition sepsis are being fitted at a Scottish children's hospital. The equipment will be installed at the Royal Hospital for Children in Glasgow. Charlotte Cooper, who lost her nine-month-old daughter Heidi to sepsis last year, said she had "no doubt" the monitors would help save babies' lives. She told BBC Scotland: "You don't have time to come to terms with the fact that someone you love is dying from sepsis because it happens so quickly." Ms Cooper now wants to see the monitors installed in every paediatric ward in Scotland. "We need to do whatever we can to stop preventable deaths from sepsis in Scotland," she said. The monitors record and track changes in heart rate, temperature and blood pressure, and can pick up early sepsis symptoms. The machines, which have been installed in a critical care area, use the Paediatric Early Warning Scores to monitor the children for any signs of deterioration in their condition. Sepsis Research said early warning of the changes would mean sepsis being diagnosed and treated faster. The monitors were accepted on behalf of the hospital by senior staff nurse Sharon Pate, who said: "In a very busy paediatric word it is vital all our patients are monitored regularly and closely for signs of deterioration. The addition of these new monitors will greatly improve our ability to monitor patients and provide vital care." Read full story Source: BBC News, 4 February 2020 -
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Bawa-Garba - Implications and the BMA's response (April 2018)
Claire Cox posted an article in Systems
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Patient Stories: Julie’s story (22 August 2013)
Claire Cox posted an article in Patient stories
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Content ArticleWhat will I learn? History of sepsis guidance Oxford AHSN approach to implementation of the guidance Care bundles (resource) Regional pathway for sepsis How to measure surveillance Limitations of coding sepsis Patient outcomes
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News Article
Baby boy died from sepsis after doctors’ delay giving antibiotics
Patient Safety Learning posted a news article in News
A three-month-old boy died from sepsis after ‘gross failures’ by medics to give him antibiotics until it was too late, an inquest ruled. Lewys Crawford died a day after he was admitted to the University Hospital of Wales in Cardiff with a high temperature last March. Jurors at Pontypridd Coroner’s Court said the failure of doctors to treat his illness with antibiotics until seven hours after his arrival had ‘significantly contributed’ to his death. They found the little boy died from natural causes contributed to by neglect in his care. Read full story Source: The Metro, 15 February 2020
