Hi Fang I will try to answer your question, by telling you a little about what I do and I will also enter the time zero debate all in the one email! At present one of my roles as sepsis nurse is to collect data for audit purposes. Each month I get a list of patients coded A419 sepsis. I then retrospectively determine time zero. Then I review their notes until I find 20 patients from the list with severe sepsis. This is very labour intensive, but at present, I cannot find an easier way of identifying these patients. I also review patients admitted with pneumonia as diagnosis, yearly for 3 months April to June. I review each set of notes with pneumonia admission diagnosis over the 3 month period to see if the patient has triggered for severe sepsis. This again is very time consuming. Once I have the data of those patients triggering for severe sepsis from those 20 sets coded as A419 sepsis and for the pneumonia admission diagnosis, I examine the time to each element of the sepsis six, against patient outcome. As my main role as sepsis nurse is education we are interested to find out if education, screening tools and awareness of sepsis early diagnosis and management are improving in our organisation. For my masters dissertation I am also examining factors which influence time delays into antibiotic administration. Regarding time zero, I have interestingly read the debates on the sepsis groups over time zero. Here is how I determine time zero, which I believe most of the people in the UK follow (correct me if I am wrong) Time zero is the first point at which the patient fulfils the criteria for severe sepsis: SIRS + Infection + Organ dysfunction. This first point may be at triage in A & E or it may be on admission to the Acute Admission Units, however it may also occur anywhere at anytime within any area of the hospital. My general rules and which I pass onto our clinical staff is that: SIRS: for various reasons there may not be 2 SIRS criteria met, but do not wait for 2 SIRS criteria if a patient has/may have an infection and for e.g. a lactate of 8 TREAT NOW! The screening tool is a guide to help identify sepsis, not to replace clinical judgement. Infection is not dependant on a doctor's examination of the patient or imaging, lab results, etc; we must treat patients as soon as we suspect infection. If staff are sending a sample, suspected infection is part of the differential diagnosis. Organ dysfunction: once a patient has sepsis you must actively screen for severe sepsis to find it, you cannot rule out severe sepsis until you have completed all tests. By not doing a lactate is not assurance that a patient does not have severe sepsis, remember cryptic shock. Severe Sepsis diagnosis implies most of the times initiation of the sepsis six as soon as you know the diagnosis of sepsis because the sepsis six involves ruling out severe sepsis. For audit purposes we audit sepsis six timing against severe sepsis cases. We also use time of the investigation performed (time of blood taken from patient) for the purpose of time zero diagnosis; there could be delayed diagnosis of severe sepsis if you use time of awareness of results of blood test. We are assuming that blood test in particular are done as soon as possible from admission or, if in patient, as soon as suspected sepsis. My role as sepsis specialist nurse was funded to educate and promote the survive sepsis campaign. I have been in this role for almost 3 years. I now carry a pager and encourage areas to inform me when they have a patient with sepsis, and then I will deploy education at the bedside. I will audit these patients, prospectively and this will equate to approximately 50% of the audit. Ultimately, this prospective auditing does have an effect on the data as I will ensure the sepsis six is complete and within one hour as time allows. I have concentrated on the sepsis six predominantly, and not moved onto auditing further bundles because I believe we need to get the basics right first. Again, I have stressed here about cases of severe sepsis, I do not audit time to sepsis six from all cases of sepsis, simply because there would be too many and in cases of uncomplicated sepsis many go home. We do not discourage the sepsis six in sepsis. I now have data from about 900 sepsis cases and dramatic improvements have been made, but there is still so much work to be done and raising awareness is the forefront of my daily work. So although it is not research as such, I am well accustomed with data collection, I am GCP trained and have worked on the SPOT(light) and ProMISe study among others. I am very willing to collaborate and I have the support of my medical colleagues to use our trust as an extra site for your research. Regards Jacqui Jacqui Jones Sepsis Specialist Nurse South Tees Hospitals NHS Foundation Trust 01642 850850 ext 56969 bleep 1008 Email [email protected] Suspect Sepsis: save someone's life today. -----Original Message----- From: Fang Gao Smith [mailto:[email protected]] Sent: 04 February 2013 16:37 To: Jones Jacqui (RTR) South Tees NHS Trust Cc: Melody Teresa Subject: Re: [Sepsis Groups] Time Zero Thank you and what is your research question for this? Fang On 01/02/2013 13:40, "Jones Jacqui (RTR) South Tees NHS Trust" <[email protected]> wrote: >Hi Dr Fang Gao > >I would be very interested in participating in your next prospective >cohort study on behalf of South Tees NHS Trust. I currently collect data >on around 35 of our patients with severe sepsis each month. I look at >the time to each element of the sepsis six from time zero alongside >factors which influence the standards of care delivery. > > > >Regards > >Jacqui > >Jacqui Jones >Sepsis Specialist Nurse >South Tees Hospitals NHS Foundation Trust >01642 850850 ext 56969 bleep 1008 >email [email protected] > >Suspect Sepsis: save someone's life today. > > >Sign our e-petition at http://epetitions.direct.gov.uk/petitions/19602 > > > > >-----Original Message----- >From: [email protected] >[mailto:[email protected]] On Behalf Of Fang >Gao Smith >Sent: 31 January 2013 21:01 >To: Jessica Harkey; [email protected] >Cc: Melody Teresa >Subject: Re: [Sepsis Groups] Time Zero > >Dear Jessica >We did a prospective cohort study on determining 'time zero' of severe >sepsis amongst critical care team 3-4 years ago with very interesting >results. Teresa, our dept manage should be able to feed you with more >information. Your suggestion has prompted us to consider to repeat this >study after 3-4 years sepsis education. Would you be interested to >participate? > >Best wishes >Fang > > >Fang Gao >Professor in Anaesthesia, Critical Care and Pain >Perioperative, Critical Care and Trauma Trials Group >School of Clinical and Experimental Medicine >University of Birmingham > >Academic Department of Anaesthesia, Critical Care, Pain and >Resuscitation >MIDRU Building >Birmingham Heartlands Hospital >Heart of England NHS Foundation Trust > > >[email protected]; [email protected]<mailto:[email protected]>; >07711823212 > >Patricia Mponela: 0121 3713243; >[email protected]<mailto:[email protected]> > >Dawn Hill: 0121 424 2966; >[email protected]<mailto:[email protected]> > > > >From: Jessica Harkey <[email protected]<mailto:[email protected]>> >Date: Thu, 31 Jan 2013 17:10:03 +0000 >To: >"[email protected]<mailto:[email protected] o >ups.org>" ><[email protected]<mailto:[email protected] o >ups.org>> >Subject: [Sepsis Groups] Time Zero > >Hello, all- >We had some very good discussion at our last team meeting about defining >"time zero" for the bundle. Currently for the ED we use triage time. >Would anyone be willing to share what you use as time zero to begin >implementation of the bundle? >Thank you, > > >Jessica Harkey, RN, BSN, CCRN >Sepsis Program Coordinator >San Joaquin Community Hospital >2615 Chester Avenue >Bakersfield, CA 93303 >661-869-6874 >[email protected]<mailto:[email protected]> > >[cid:MBFOHERTDJDT.IMAGE_5.BMP]
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