Tim Nutbeam

The sepsis six and the severe sepsis resuscitation bundle: a prospective observational cohort study

Background Severe sepsis is likely to account for around 37 000 deaths annually in the UK. Five years after the international Surviving Sepsis Campaign (SSC) care bundles were published, care standards in the management of patients with severe sepsis are achieved in fewer than one in seven patients. Methods This was a prospective observational cohort study across a 500-bed acute general hospital, to assess the delivery and impact of two interventions: the SSC resuscitation bundle and a new intervention designed to facilitate delivery, the sepsis six. Process measures included compliance with the bundle and the sepsis six; the outcome measure was mortality at hospital discharge. Results Data from 567 patients were suitable for analysis. Compliance with the bundle increased from baseline. 84.6% of those receiving the sepsis six (n=220) achieved the resuscitation bundle compared with only 5.8% of others. Delivery of the interventions had an association with reduced mortality: for the sepsis six (n=220), 20.0% compared with 44.1% (p<0.001); for the resuscitation bundle (n=204), 5.9% compared with 51% (p<0.001). Those receiving the sepsis six were much more likely to receive the full bundle. Those seen by the sepsis team had improved compliance with bundles and reduced mortality. Conclusions This study supports the SSC resuscitation bundle, and is suggestive of an association with reduced mortality although does not demonstrate causation. It demonstrates that simplified pathways, such as the sepsis six, and education programmes such as survive sepsis can contribute to improving the rate of delivery of these life-saving interventions.

Sepsis: a need for prehospital intervention?

Prehospital staff have made a significant contribution in recent years to improving care for patients with acute coronary syndrome, multiple trauma and stroke. There is, however, another group of patients that is not currently being targeted, with a similar time-critical condition. This group of patients is those with severe sepsis and septic shock and they could also benefit greatly from timely prehospital care. This article will consider how prehospital staff can improve the outcome of patients with severe sepsis, and in particular how they can aid emergency departments in identifying and initiating treatment in patients with severe sepsis.

Recognizing and managing sepsis: what needs to be done?

Sepsis is associated with significant morbidity and mortality if not promptly recognized and treated. Since the development of early goal-directed therapy, mortality rates have decreased, but sepsis remains a major cause of death in patients arriving at the emergency department or staying in hospital. In this forum article, we asked clinicians and researchers with expertise in sepsis care to discuss the importance of rapid detection and treatment of the condition, as well as special considerations in different patient groups.

Clinical governance and prehospital care in the UK

Throughout the United Kingdom, doctors and other healthcare professionals respond to requests for assistance from the ambulance service on a voluntary basis. These practitioners respond to a wide variety of incidents both medical and traumatic. West Midlands Ambulance Services (WMAS) catchment area covers approximately 5.3 million people: from April 2009 to April 2010, doctors tasked by WMAS responded to 953 incidents. The role of such practitioners in the prehospital environment has yet to be fully defined: no formal skill set is established, with practitioners coming from a wide range of medical and nursing backgrounds. This variation in base clinical competencies can lead to disparities in the standard of care delivered, as well as leading to practitioners working outside of their established clinical skill set. Clinical governance is a framework used to maintain and improve standards of medical care, and it provides a mechanism whereby the quality of care in the prehospital setting can be assured. Eight years ago Robertson-Steele et al 1 indicated how clinical governance techniques should be applied to prehospital care, but it is clear that much remains to be done. Many prehospital practitioners partake in mandatory clinical governance activity as part of their paid National Health Service (NHS) commitments; however, this governance does not cover the service they provide within the prehospital environment. Furthermore, …

Trauma systems and medical helicopters in the UK

Abstract A system of trauma centres is being established in the UK, and it is generally assumed that trauma patients in rural areas will be transported to the trauma centres by helicopter. However helicopters are often unable to fly, for example at night and in adverse weather conditions. The purpose of this article is to describe these restrictions, and to consider how they might affect trauma care in outlying regions.

Transporting major trauma patients from the margins of a UK trauma system.

Objective For serious motor vehicle crashes (MVC) occurring in a rural area to quantify: how many occur more than 45 min by road to a major trauma centre (MTC); how many occur more than 45 min by helicopter to an MTC; and how many patients might have to be taken to a local trauma unit if their incident occurs more than 45 min by road from an MTC and when the helicopter cannot fly. Methods MVC occurring in Shropshire, in which patients were killed or seriously injured during 2006–9 (inclusive) were analysed using the following parameters: distance from MTC by road; distance from MTC by air; weather and visibility-related factors that affect the operation of a helicopter emergency medical service. Results 722 serious MVC occurred, of which 626 (87%) occurred more than 45 min by road from the MTC. Of these 626 incidents, 408 occurred in conditions in which the helicopter could fly. There were 218 incidents (30%), which were more than 45 min by road from the MTC and which occurred when the helicopter could not fly. Conclusions The transportation of patients from remote and rural areas to MTC remains problematical. Further work is required to develop more efficient systems of retrieval and transfer, and in particular to consider how emergency medical helicopters might operate safely at night.

Extrication time prediction tool

Background Many patients will require extrication following a motor vehicle collision (MVC). Little information exists on the time taken for extrication or the factors which affect this time. Objective To derive a tool to predict the time taken to extricate patients from MVCs. Methods A prospective, observational derivation study was carried out in the West Midland Fire Services metropolitan area. An expert group identified factors that may predict extrication time—the presence and absence of these factors was prospectively recorded at eligible extrications for the study period. A step-down multiple regression method was used to identify important contributing factors. Results Factors that increased extrication times by a statistically significant extent were: a physical obstruction (10 min), patients medically trapped (10 min per patient) and any patient physically trapped (7 min). Factors that shortened extrication time were rapid access (−7 min) and the car being on its roof (−12 min). All these times were calculated from an arbitrary time (which assumes zero patients) of 8 min. Conclusions This paper describes the development of a tool to predict extrication time for a trapped patient. A number of factors were identified which significantly contributed to the overall extrication time.

Paediatric traumatic cardiac arrest: a Delphi study to establish consensus on definition and management

Aims Paediatric traumatic cardiac arrest (TCA) is associated with low survival and poor outcomes. The mechanisms that underlie TCA are different from medical cardiac arrest; the approach to treatment of TCA may therefore also need to differ to optimise outcomes. The aim of this study was to explore the opinion of subject matter experts regarding the diagnosis and treatment of paediatric TCA, and to reach consensus on how best to manage this group of patients. Methods An online Delphi study was conducted over three rounds, with the aim of achieving consensus (defined as 70% agreement) on statements related to the diagnosis and management of paediatric TCA. Participants were invited from paediatric and adult emergency medicine, paediatric anaesthetics, paediatric ICU and paediatric surgery, as well as Paediatric Major Trauma Centre leads and representatives from the Resuscitation Council UK. Statements were informed by literature reviews and were based on elements of APLS resuscitation algorithms as well as some concepts used in the management of adult TCA; they ranged from confirmation of cardiac arrest to the indications for thoracotomy. Results 73 experts completed all three rounds between June and November 2016. Consensus was reached on 14 statements regarding the diagnosis and management of paediatric TCA; oxygenation and ventilatory support, along with rapid volume replacement with warmed blood, improve survival. The duration of cardiac arrest and the lack of a response to intervention, along with cardiac standstill on ultrasound, help to guide the decision to terminate resuscitation. Conclusion This study has given a consensus-based framework to guide protocol development in the management of paediatric TCA, though further work is required in other key areas including its acceptability to clinicians.

The stages of extrication: a prospective study

Background Many patients will require extrication following a motor vehicle collision (MVC). Little information exists on the time taken for the various stages of extrication. Objective To report the time taken for the various stages of extrication. Methods A prospective, observational study carried out in the West Midland Fire Services metropolitan area. Time points related to extrication were collected ‘live’ by two-way radio broadcast. Any missing data were actively gathered by fire control within 1 h of completion of extrication. This paper reports an interim analysis conducted after 1 year of data collection following a 3-month run-in and training period: data were analysed from 1 January 2011 to 31 December 2011 inclusive. Results During the study period 228 incidents were identified. Seventy-nine were excluded as they met the predetermined exclusion criteria or had incomplete data collection. This left 158 extrications that were suitable for analysis. The median time for extrication was 30 min, IQR 24–38 min. Conclusions In patients requiring extrication following an MVC a median time of 8 min is typically required before initial limited patient assessment and intervention. A further 22 min is typically required before full extrication. Prehospital personnel should be aware of these times when planning their approach to a trapped patient.

1 Simultaneous trauma patients in emergency departments: a difference in mortality?

Background The presentation of multiple simultaneous trauma patients to an Emergency Department is likely to place significant stress and strain on trauma care resources. Currently there is limited literature and no UK or multicentre data available to understand this impact. The aim of this study was to identify patient outcomes when there are simultaneous major trauma patients. We hypothesised that with increasing numbers of simultaneous trauma patients an increase in mortality may be seen. Methods The Trauma Audit and Research Network (TARN) database was interrogated from 2010–2015 to identify simultaneous major trauma patients. We defined simultaneous trauma as occurring when there was more than one trauma patient within an Emergency Department at any one time. Patient age, sex, Glasgow Coma Scale and Injury Severity Score (ISS) were recorded. A standardised comparison using a stratified Ws statistic was conducted to compare mortality between groups. Secondary outcomes included length of hospital and intensive care (ICU) stay. Results Of 2 07 094 patients, 33.7% were eligible simultaneous trauma patients. 55.7% of patients were male, median age was 61 and median ISS was 9. No increase in mortality was seen with increasing patient numbers (table 1).Abstract 1 Table 1 Ws statistic with increasing simultaneous patient numbers Isolated 2 patients 3 patients 4 patients 5 patients 6+ patients Total 1 37 360 51 466 13 820 3539 671 185 Ws statistic 0.05 0.38 0.72 0.53 0.39 2.70 A statistically significant increase in length of ICU stay was observed for the 6+patient category (p=0.047) but no difference was reported in hospital stay. Conclusion The impact of simultaneous trauma patients on patient outcomes within the UK has not been previously defined. Simultaneous trauma patients do not appear to have an impact on mortality (as measured by Ws statistic).