2011 quality systems assessment self assessment ...€¦ · 2011 quality systems assessment self...

2011 Quality Systems Assessment Self Assessment

Supplementary Report - Sepsis

Table of Contents

INTRODUCTION ........................................................................................................................................................ 4

HOW THE QSA WORKS ...................................................................................... ERROR! BOOKMARK NOT DEFINED.

NOTES ABOUT THE DATA: ................................................................................................................................... 35

MANAGEMENT OF SEPSIS ................................................................................ ERROR! BOOKMARK NOT DEFINED.

WHY IS THIS IMPORTANT? .................................................................................................. ERROR! BOOKMARK NOT DEFINED.

SUMMARY OF RESULTS ....................................................................................................... ERROR! BOOKMARK NOT DEFINED.

WHAT NEXT? ...................................................................................................................... ERROR! BOOKMARK NOT DEFINED.

STATEWIDE RECOMMENDATIONS ..................................................................................................................................... 6

May 2012

2

© Clinical Excellence Commission 2012

This work is copyright. Apart from any use as permitted under the Copyright Act 1968, no part may be reproduced

without prior written permission from the Clinical Excellence Commission. Requests and enquiries concerning

reproduction and rights should be directed to the Director, Corporate Services, Clinical Excellence Commission, GPO

Box 1614, Sydney NSW 2001.

This publication is part of the Clinical Excellence Commission’s Quality Systems Assessment Series. A complete list of

the CEC’s publications is available from the Director, Corporate Services, Clinical Excellence Commission, GPO Box 1614,

Sydney NSW 2001, or via the Institute’s web site (http://www.cec.health.nsw.gov.au).

Authors

Bernadette King, Roger Kerr, Jun Bai

Clinical Excellence Commission

Board Chair: Associate Professor Brian McCaughan AM

Chief Executive Officer: Professor Clifford F Hughes AO

Any enquiries about or comments on this publication should be directed to:

Dr Charles Pain Director Health Systems Improvement Clinical Excellence Commission Locked Bag A4062 Sydney South NSW 1235

Phone: (02) 9269 5500

Email: [email protected]

http://www.cec.health.nsw.gov.au/stocktake_request.html

mailto:[email protected]

3

Table or Contents

EXECUTIVE SUMMARY ............................................................................................................................. 4

INTRODUCTION ....................................................................................................................................... 5

UNDERSTANDING THE DATA ................................................................................................................................... 5

STATE-WIDE RECOMMENDATIONS ........................................................................................................................... 6

RESULTS .................................................................................................................................................. 7

APPENDIX 1: NOTES ABOUT THE DATA ................................................................................................... 35

4

Executive Summary Sepsis is a potentially deadly medical condition that is associated with high mortality. The key to improving sepsis

outcomes is implementation of pre-hospital and hospital-wide systems that assist early recognition of at-risk or septic

patients and lead to rapid administration of effective therapy.

This supplementary report provides more detailed information from the self assessment results undertaken from

September 2011 to November 2011 relating to the management of sepsis in both adult and paediatric patients

responded by those who work in the local health district and NSW Ambulance Service. The 2011 self-assessment was

completed by over 1,500 respondents across, and at various levels, of the health system. At the unit level the overall

response rate was 99%. All medical and surgical specialties; maternity; intensive care and high dependency units;

mental health; emergency medicine and allied health services were represented at the department/clinical unit level.

The results provided here, unless stated otherwise, reflect data provided at the department/ clinical unit level for the

local health districts and networks and the station / paramedic level for the Ambulance Service. Results are presented

in graph form to allow comparison of performance between each LHD/organisation.

Some of the main findings include:

At the clinical unit level there were 52% of respondents that manage adult patients only, 12% manage children or

young people only and 36% manage adults and children/young people.

At the clinical unit level 80% of respondents manage or treat patients at risk of sepsis often, sometimes or rarely

At the station / paramedic level 94% of respondents manage patients at risk of sepsis often, sometimes or rarely.

Of those departments/clinical units responding that patients with suspected or confirmed sepsis were assessed or

managed on a weekly or more frequent basis also responded that the patient management needed improvement.

34% of departments/clinical units responding that patients with suspected or confirmed sepsis were assessed or

managed on a weekly or more often did not have guidelines and or protocols.

At the clinical unit level in response to the question ‘we have a standardised approach to the management of

patients with confirmed or suspected sepsis’ 29% responded always

At the clinical unit level 42% of respondents monitor some aspects of sepsis incident care and management and

38% routinely review sepsis cases at their local M&M meetings.

5

Introduction A critical element of the QSA is the reporting of findings of the assessment activities to relevant stakeholders. The initial

rationale for the development of the QSA was to provide NSW Health with assurance about the quality of health

services and assist the CEC in identifying areas for improvement and promotion of better practice in patient safety

management. Analysis of the findings of the QSA and reporting these findings to all levels of the health system is key to

achieving the objectives of the QSA.

This supplementary is the third reporting obligation the CEC has completed since the 2011 self assessment.

Two weeks following assessment closure the raw data (labelled and coded) was returned to each LHD / Network /

Organisation and facilities

Four weeks following assessment a ‘results’ report for each facility-level respondent (~198) was generated and

sent out to facilitate follow-up and action at facility level. These reports contained aggregated / comparative data

based on the LHD / Network

Thematic supplementary reports – Paediatrics, Sepsis, Delirium and Mental Health

It is expected that the above resources will be used by the LHD / Networks to identify areas with greatest risk and

vulnerability that apply to them and develop improvement plans to address them. Where appropriate they should also

be used by individual departments to review their data and respond to issues raised. For example, 34% of

departments/clinical units responding that patients with suspected or confirmed sepsis were assessed or managed on a

weekly or more often did not have guidelines and or protocols. This issue has an impact across the whole district so it is

likely the district will need to work at each level (i.e. facility and department / clinical unit) to address this issue.

While it is expected that action is taken in response to the results the CEC acknowledge that the timeline of the QSA

assessment was for September / November 2011 and it is probable that in some cases policy / programs have already

been implemented / completed by the time this report is published.

Understanding the data

In this report, charts and tables are used to provide information on department/clinical unit responses to the questions

from the 2011 QSA self assessment compared to the aggregated NSW results.

Except where noted the charts illustrate the responses for departments/clinical units from LHDs.

The report uses pie charts, summary graphs for multiple questions and tables summarising the statistical analysis

of the results.

Charts are also used to compare the responses for departments/clinical units from each peer hospital group and

the overall NSW proportion. The Peer Hospital Groups are collapsed to the main letter designation with the

exception of:

F2 Nursing Home & F3 Multi-Purpose Services facilities are mapped to F2-3

F1 – Psychiatric facilities that are mapped to F1 – MH

6

F4 Sub Acute, F6 Rehabilitation, F7 Mothercraft & F8 Ungrouped Non-Acute facilities are mapped to

“F4-8”

State-wide recommendations

In May 2012 the Statewide report will be released. This report will provide an overview of results and makes

recommendation on a system wide perspective. These recommendations come from the aggregated analysis of all data

from the self assessments.

All LHDs and facility executive support the implementation of the Sepsis Kills initiative as it is implemented

including:

o introducing guidelines

o data collection and regular reporting to facility and LHD quality / safety committees

o integrate the program into the quality and safety systems

All LHDs and facilities further develop the links between the Between the Flags and Sepsis Kills initiatives to

promote clinical uptake and sustainability

Clinical units that manage patients who have had an episode of severe sepsis or septic shock review the patients

management as part of the regular Mortality and Morbidity meeting

7

Results

At the clinical unit level 80% of respondents manage or treat patients at risk of sepsis; at the station / paramedic

level 94% of respondents manage patients at risk of sepsis (often, sometimes or rarely).

At the clinical unit level 80% of respondents manage or treat patients at risk of sepsis often, sometimes or rarely

Figure 1: % of Departments/clinical units reporting frequency of management of patients at risk of sepsis

Table 1: Count and % of Departments/clinical units reporting frequency of management of patients at risk of sepsis by LHD.

Description LHD Often (weekly or

more often)

Sometimes (at least

monthly but less often

than weekly)

Rarely (once every three

to twelve months) Never

Metropolitan

LHDs CCLHD 23 47.9% 8 16.7% 10 20.8% 7 14.6%

ISLHD 26 41.3% 14 22.2% 12 19.0% 11 17.5%

NBMLHD 21 60.0% 6 17.1% 4 11.4% 4 11.4%

NSLHD 36 36.7% 18 18.4% 18 18.4% 26 26.5%

SCHN 26 29.9% 20 23.0% 16 18.4% 25 28.7%

SESLHD 38 30.4% 33 26.4% 29 23.2% 25 20.0%

SVHN 11 52.4% 4 19.0% 4 19.0% 2 9.5%

SWSLHD 47 41.6% 23 20.4% 17 15.0% 26 23.0%

SYDLHD 50 50.0% 14 14.0% 17 17.0% 19 19.0%

WSLHD 23 37.1% 18 29.0% 10 16.1% 11 17.7%

Metro 301 40.0% 158 21.0% 137 18.2% 156 20.7%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

CC

LHD

ISLH

D

NB

MLH

D

NSL

HD

SCH

N

SESL

HD

SVH

N

SWSL

HD

SYD

LHD

WSL

HD

FWLH

D

HN

ELH

D

MLH

D

MN

CLH

D

NN

SWLH

D

SNSW

LHD

WN

SWLH

D

ASN

SW

Metropolitan LHDs Rural & Regional LHDs Other

Often (weekly or more often) Sometimes (at least monthly but less often than weekly)

Rarely (once every three to twelve months) Never

Please indicate the frequency that you assess or manage adults, children or young people with suspected or confirmed sepsis

__ Often (weekly or more often)

__ Sometimes (at least monthly but less often than weekly) -

__ Rarely (once every three to twelve months)

__ Never (answer no more questions in relation to sepsis)

8

Description LHD Often (weekly or

more often)

Sometimes (at least

monthly but less often

than weekly)

Rarely (once every three

to twelve months) Never

Total

Rural & Regional

LHDs FWLHD 2 16.7% 1 8.3% 7 58.3% 2 16.7%

HNELHD 50 38.8% 35 27.1% 29 22.5% 15 11.6%

MLHD 11 16.4% 10 14.9% 31 46.3% 15 22.4%

MNCLHD 15 40.5% 6 16.2% 10 27.0% 6 16.2%

NNSWLHD 17 30.4% 12 21.4% 17 30.4% 10 17.9%

SNSWLHD 17 31.5% 10 18.5% 16 29.6% 11 20.4%

WNSWLHD 20 21.1% 23 24.2% 27 28.4% 25 26.3%

R&R Total 132 29.3% 97 21.6% 137 30.4% 84 18.7%

NSW LHDs

433 36.0% 255 21.2% 274 22.8% 240 20.0%

ASNSW 17 10.2% 43 25.9% 95 57.2% 11 6.6%

45% of departments/clinical units from hospitals in Peer Group A and B reported that patients with suspected or

confirmed sepsis were assessed or managed on a weekly or more frequent basis.

Figure 2: % of Departments/clinical units reporting frequency of management of patients at risk of sepsis by Peer group

Table 2: Count and % of Departments/clinical units reporting frequency of management of patients at risk of sepsis by Peer group

Peer Group Often (weekly or more often) Sometimes (at least monthly

but less often than weekly)

Rarely (once every three to

twelve months) Never

A 231 44.8% 104 20.2% 88 17.1% 93 18.0%

B 121 44.6% 61 22.5% 53 19.6% 36 13.3%

C 64 29.6% 43 19.9% 59 27.3% 50 23.1%

D 6 9.4% 23 35.9% 28 43.8% 7 10.9%

F2-3 4 8.3% 10 20.8% 27 56.3% 7 14.6%

F1-MH 0 N/A 2 3.8% 14 26.9% 36 69.2%

F4-7 7 20.0% 12 34.3% 5 14.3% 11 31.4%

0%

20%

40%

60%

80%

100%

A B C D F2-3 F1-MH F4-7



9

Intensive Care (79%), Emergency (68%) and Oncology (66%) departments/clinical units reported assessing or

managing adults, children or young people with suspected or confirmed sepsis at least weekly or more often.


managed on a weekly or more frequent basis also responded that the patient management needed improvement.


managed on a weekly or more often did not have guidelines and or protocols. Facility level self assessment results

illustrate a differential perception to department/clinical unit self assessment level results on the frequency of

assessing or managing adults, children or young people with suspected or confirmed sepsis.

Figure 3: % of Departments/clinical units reporting frequency of management of patients at risk of sepsis

Table 3: Count and % of Departments/clinical units reporting frequency of management of patients at risk of sepsis

Service type Often (weekly or more

often) Sometimes (at least monthly but less often than weekly)

Rarely (once every three to twelve months)

Never

Medical 84 35.7% 59 25.1% 62 26.4% 30 12.8%

Surgical 69 35.0% 51 25.9% 45 22.8% 32 16.2%

MH 0 N/A 2 2.2% 25 27.8% 63 70.0%

Obs & Gyn 12 14.3% 14 16.7% 40 47.6% 18 21.4%

ED 56 67.5% 19 22.9% 8 9.6% 0 N/A

Other 23 28.4% 10 12.3% 17 21.0% 31 38.3%

Aged Care 27 35.1% 13 16.9% 16 20.8% 21 27.3%

Paediatric 23 35.4% 15 23.1% 15 23.1% 12 18.5%

ICU 44 78.6% 11 19.6% 0 N/A 1 1.8%

Oncology 27 65.9% 7 17.1% 5 12.2% 2 4.9%

Imaging 9 25.0% 4 11.1% 6 16.7% 17 47.2%

Nephrology 14 40.0% 8 22.9% 11 31.4% 2 5.7%

Rehabilitation 7 21.2% 13 39.4% 8 24.2% 5 15.2%

Orthopaedic 13 50.0% 6 23.1% 7 26.9% 0 N/A

Cardiac/ Cardiology

13 50.0% 10 38.5% 2 7.7% 1 3.8%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Med

ical

Surg

ical

MH

Ob

s &

Gyn

ED

Oth

er

Age

d C

are

Pae

dia

tric

ICU

On

colo

gy

Imag

ing

Nep

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Reh

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tati

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Ort

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pae

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Car

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c/C

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Pal

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10

Service type Often (weekly or more

often) Sometimes (at least monthly but less often than weekly)


Never

Palliative Care 5 25.0% 6 30.0% 5 25.0% 4 20.0%

Microbiology 7 41.2% 7 41.2% 2 11.8% 1 5.9%

Table 4: Count and % of Departments/clinical units reporting frequency of management of patients at risk of sepsis by how

managed

Managed Often (weekly or more often) Sometimes (at least monthly but

less often than weekly) Rarely (once every three to

twelve months)

Managed optimally - needs no improvement

29.6% 33.3% 39.4%

Managed variably - needs some improvement

70.2% 66.3% 58.4%

Managed poorly - needs considerable improvement

0.2% 0.4% 2.2%

Table 5: Count and % of Departments/clinical units reporting frequency of management of patients at risk of sepsis by having

guidelines / protocols in place

Guidelines & Protocols exist Often (weekly or

more often) Sometimes (at least monthly but less often

than weekly) Rarely (once every three to

twelve months)

Yes, for adults only 43.2% 31.4% 23.7%

Yes, for children and/or young people only

9.5% 10.2% 6.2%

Yes, for both (adults and children/young people)

13.9% 18.4% 19.7%

No 33.5% 40.0% 50.4%

Table 6: Comparison of facility and department response by LHD to question frequency of management of patients at risk of

sepsis

LHD Self assessment Level

Often (weekly or more often)

Sometimes (at least monthly but less often

than weekly)


Never

CCLHD Service/ Unit 48% 17% 21% 15%

Facility 67% 33% 0% 0%

ISLHD Service/ Unit 41% 22% 19% 17%

Facility 60% 20% 0% 20%

NBMLHD Service/ Unit 60% 17% 11% 11%

Facility 75% 0% 25% 0%

NSLHD Service/ Unit 37% 18% 18% 27%

Facility 67% 17% 17% 0%

SCHN Service/ Unit 30% 23% 18% 29%

Facility 100% 0% 0% 0%

SESLHD Service/ Unit 30% 26% 23% 20%

Facility 43% 14% 43% 0%

SVHN Service/ Unit 52% 19% 19% 10%

Facility 50% 0% 50% 0%

SWSLHD Service/ Unit 42% 20% 15% 23%

Facility 50% 13% 13% 25%

SYDLHD Service/ Unit 50% 14% 17% 19%

Facility 33% 17% 33% 17%

WSLHD Service/ Unit 37% 29% 16% 18%

11

LHD Self assessment Level

Often (weekly or more often)

Sometimes (at least monthly but less often

than weekly)


Never

Facility 75% 0% 25% 0%

FWLHD Service/ Unit 17% 8% 58% 17%

Facility 0% 100% 0% 0%

HNELHD Service/ Unit 39% 27% 22% 12%

Facility 38% 19% 41% 3%

MLHD Service/ Unit 16% 15% 46% 22%

Facility 40% 20% 20% 20%

MNCLHD Service/ Unit 41% 16% 27% 16%

Facility 67% 33% 0% 0%

NNSWLHD Service/ Unit 30% 21% 30% 18%

Facility 40% 60% 0% 0%

SNSWLHD Service/ Unit 31% 19% 30% 20%

Facility 30% 40% 20% 10%

WNSWLHD Service/ Unit 21% 24% 28% 26%

Facility 56% 0% 22% 22%

Table 7 shows that respondents in metropolitan facilities assessed that they have sufficient skills and knowledge in

managing sepsis compared to rural and regional respondents (p<0.001). Metropolitan facilities were more likely to

be aware of sepsis campaign (p<0.001); and more often managed sepsis patients than the rural and regional ones

(p<0.001). However, there was no significant difference of having standard approach for sepsis management

between metropolitan and rural areas (p=0.35).

Table 7 Comparison of Metropolitan and Rural & Regional responses

Metropolitan Rural & Regional P-Value

Sepsis skills and knowledge are sufficient % 79.0 69.1 <0.001

Awareness of sepsis campaign by all/most % 94.0 87.2 <0.001

Having standard approach for sepsis % 74.3 62.8 0.35

Managing sepsis often/sometimes % 61.0 50.9 <0.001

Table 8 shows comparison between the facility peer groups. It has demonstrated a clear trend that the higher

tertiary level of the facility the more likely to have sufficient skills and knowledge of managing sepsis (p<0.001), the

more likely to be aware of the sepsis campaign (p<0.001), the more likely to have standard approach for managing

sepsis (p=0.03), and the more often to manage sepsis patients (p<0.001).

Table 8 Comparison between facility peer groups re skills and knowledge and standard approach to sepsis management

Facility Peer Group (Tertiary Level) P-Value for

trend A B C D & F

Sepsis skills and knowledge are sufficient % 82.0 76.6 66.3 62.2 <0.001

Awareness of sepsis campaign by all/most % 94.6 94.0 88.0 80.6 <0.001

Having standard approach for sepsis % 75.9 74.5 69.3 67.4 0.03

Managing sepsis often/sometimes % 64.9 67.2 49.5 38.4 <0.001

12

Management of Sepsis

Across NSW 67% of departments/clinical units responding to the self assessment indicated that management of

sepsis in their departments/clinical units needed improvement. This response was reasonably consistent across all

LHDs.

Figure 4: % of Departments/clinical units reporting how well is sepsis managed by LHD

Table 9 Count and % of Departments/clinical units reporting how well is sepsis managed by LHD

Description LHD Managed optimally - needs no

improvement

Managed variably - needs some

improvement

Managed poorly - needs

considerable improvement

Metropolitan

LHDs CCLHD 11 26.8% 30 73.2% 0 N/A

ISLHD 17 32.7% 33 63.5% 2 3.8%

NBMLHD 11 35.5% 20 64.5% 0 N/A

NSLHD 20 27.8% 51 70.8% 1 1.4%

SCHN 33 53.2% 29 46.8% 0 N/A

SESLHD 40 40.0% 60 60.0% 0 N/A

SVHN 4 21.1% 15 78.9% 0 N/A

SWSLHD 33 37.9% 51 58.6% 3 3.4%

SYDLHD 33 40.7% 48 59.3% 0 N/A

WSLHD 23 45.1% 28 54.9% 0 N/A

Metro Total 225 37.8% 365 61.2% 6 1.0%

Rural &

Regional LHDs FWLHD 2 20.0% 8 80.0% 0 N/A

HNELHD 33 28.9% 81 71.1% 0 N/A

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

CC

LHD

ISLH

D

NB

MLH

D

NSL

HD

SCH

N

SESL

HD

SVH

N

SWSL

HD

SYD

LHD

WSL

HD

Met

ro T

ota

l

FWLH

D

HN

ELH

D

MLH

D

MN

CLH

D

NN

SWLH

D

SNSW

LHD

WN

SWLH

D

R&

R T

ota

l

ASN

SW

Metropolitan Rural & Regional Other

LHD - Managed optimally Management Needs Improvement

NSW - Managed optimally

13

Description LHD Managed optimally - needs no

improvement


improvement



MLHD 11 21.2% 40 76.9% 1 1.9%

MNCLHD 7 22.6% 24 77.4% 0 N/A

NNSWLHD 16 34.8% 30 65.2% 0 N/A

SNSWLHD 10 23.3% 32 74.4% 1 2.3%

WNSWLHD 17 24.3% 53 75.7% 0 N/A

R&R Total 96 26.2% 268 73.2% 2 0.5%

NSW NSW 321 33.4% 633 65.8% 8 0.8%

ASNSW 10 6.5% 107 69.0% 38 24.5%

60% of departments/clinical units in hospitals in Peer Group A responded that management of sepsis in their

departments/clinical units needed improvement while the corresponding figure for Peer Group D was 81%.

Figure 5: % of Departments/clinical units reporting how sepsis is managed by peer group

Table 10: Count and % of Departments/clinical units reporting how sepsis is managed by peer group

Peer Group Managed optimally - needs no

improvement


improvement

Managed poorly - needs considerable

improvement

A 171 40.4% 252 59.6% 0 N/A

B 80 34.0% 153 65.1% 2 0.9%

C 40 24.1% 122 73.5% 4 2.4%

D 11 19.3% 46 80.7% 0 N/A

F2-3 7 17.1% 34 82.9% 0 N/A

F1-MH 3 18.8% 11 68.8% 2 12.5%

F4-7 9 37.5% 15 62.5% 0 N/A

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

A B C D F2-3 F1-MH F4-7

Peer group - Managed optimally Management Needs Improvement


14

Figure 6: % of Departments/clinical units reporting how sepsis is managed by service type

Table 11: Count and % of Departments/clinical units reporting how sepsis is managed by service type

Service type Managed optimally - needs no

improvement


improvement

Managed poorly - needs considerable

improvement

Medical 48 23.4% 157 76.6% 0 N/A

Surgical 63 38.2% 101 61.2% 1 0.6%

ED 7 8.4% 76 91.6% 0 N/A

Obs &

Gynaecology 33 50.0% 32 48.5% 1 1.5%

Aged Care 9 16.1% 47 83.9% 0 N/A

ICU 25 45.5% 30 54.5% 0 N/A

Paediatric 21 39.6% 31 58.5% 1 1.9%

Other 24 48.0% 25 50.0% 1 2.0%

Oncology 19 48.7% 20 51.3% 0 N/A

Nephrology 14 42.4% 18 54.5% 1 3.0%

Rehabilitation 13 46.4% 15 53.6% 0 N/A

MH 6 22.2% 18 66.7% 3 11.1%

Orthopaedic 7 26.9% 19 73.1% 0 N/A

Cardiac/Cardiol

ogy 6 24.0% 19 76.0% 0 N/A

Imaging 10 52.6% 9 47.4% 0 N/A

Palliative Care 7 43.8% 9 56.3% 0 N/A

Microbiology 9 56.3% 7 43.8% 0 N/A

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100% M

edic

al

Surg

ical

ED

Ob

s &

Gyn

Age

d C

are

ICU

Pae

dia

tric

Oth

er

On

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Nep

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Reh

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Ort

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Managed optimally - needs no improvement Management Needs Improvement


15

Table 12: Count and % of Departments/clinical units reporting how well sepsis is managed compared to facility by LHD.

LHD Self assessment

Level

Managed optimally - needs no

improvement


improvement



CCLHD Service/ Unit 27% 73% 0%

Facility 0% 100% 0%

ISLHD Service/ Unit 33% 63% 4%

Facility 25% 75% 0%

NBMLHD Service/ Unit 35% 65% 0%

Facility 0% 100% 0%

NSLHD Service/ Unit 28% 71% 1%

Facility 33% 67% 0%

SCHN Service/ Unit 53% 47% 0%

Facility 100% 0% 0%

SESLHD Service/ Unit 40% 60% 0%

Facility 0% 100% 0%

SVHN Service/ Unit 21% 79% 0%

Facility 50% 50% 0%

SWSLHD Service/ Unit 38% 59% 3%

Facility 0% 100% 0%

SYDLHD Service/ Unit 41% 59% 0%

Facility 20% 80% 0%

WSLHD Service/ Unit 45% 55% 0%

Facility 25% 75% 0%

FWLHD Service/ Unit 20% 80% 0%

Facility 0% 100% 0%

HNELHD Service/ Unit 29% 71% 0%

Facility 6% 90% 3%

MLHD Service/ Unit 21% 77% 2%

Facility 25% 75% 0%

MNCLHD Service/ Unit 23% 77% 0%

Facility 0% 100% 0%

NNSWLHD Service/ Unit 35% 65% 0%

Facility 20% 80% 0%

SNSWLHD Service/ Unit 23% 74% 2%

Facility 22% 78% 0%

WNSWLHD Service/ Unit 24% 76% 0%

Facility 0% 100% 0%

16

Always (100%)

Often (67%-99%)

Sometimes (34% – 66%)

Rarely (1% - 33%)

Never (0%)

Our staff are aware of sepsis __ __ __ __ __

Results for this question demonstrated a high level of awareness for staff of sepsis across all LHDs participating in

the self assessment. At the state level the facility level self assessment results were consistent with the

department/clinical unit level.

Figure 7: % of Departments/clinical units reporting that their staff were aware of sepsis

Table 13: Count and % of Departments/clinical units reporting that that their staff were aware of sepsis by LHD.

Description LHD Always (100%) Often (67%-99%) Sometimes (34%–66%) Rarely (1%-33%)

Metropolitan LHDs CCLHD 11 26.8% 28 68.3% 2 4.9% 0 N/A

ISLHD 19 36.5% 31 59.6% 1 1.9% 1 1.9%

NBMLHD 9 29.0% 18 58.1% 3 9.7% 1 3.2%

NSLHD 23 31.9% 45 62.5% 4 5.6% 0 N/A

SCHN 35 56.5% 25 40.3% 2 3.2% 0 N/A

SESLHD 47 47.0% 45 45.0% 7 7.0% 1 1.0%

SVHN 6 31.6% 9 47.4% 3 15.8% 1 5.3%

SWSLHD 26 29.9% 57 65.5% 2 2.3% 2 2.3%

SYDLHD 43 53.1% 36 44.4% 2 2.5% 0 N/A

WSLHD 22 43.1% 25 49.0% 3 5.9% 1 2.0%

Metro Total 241 40.4% 319 53.5% 29 4.9% 7 1.2%

Rural & Regional LHDs FWLHD 1 10.0% 8 80.0% 1 10.0% 0 N/A

HNELHD 35 30.7% 64 56.1% 13 11.4% 2 1.8%

MLHD 14 26.9% 29 55.8% 9 17.3% 0 N/A

MNCLHD 8 25.8% 20 64.5% 3 9.7% 0 N/A

NNSWLHD 8 17.4% 34 73.9% 4 8.7% 0 N/A

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

CC

LHD

ISLH

D

NB

MLH

D

NSL

HD

SCH

N

SESL

HD

SVH

N

SWSL

HD

SYD

LHD

WSL

HD

Met

ro T

ota

l

FWLH

D

HN

ELH

D

MLH

D

MN

CLH

D

NN

SWLH

D

SNSW

LHD

WN

SWLH

D

R&

R T

ota

l

Metropolitan LHDs Rural & Regional LHDs

LHD - Always or Often NSW - Always or Often

17

Description LHD Always (100%) Often (67%-99%) Sometimes (34%–66%) Rarely (1%-33%)

SNSWLHD 10 23.3% 30 69.8% 3 7.0% 0 N/A

WNSWLHD 17 24.3% 41 58.6% 10 14.3% 2 2.9%

R&R Total 93 25.4% 226 61.7% 43 11.7% 4 1.1%

NSW NSW 334 34.7% 545 56.7% 72 7.5% 11 1.1%

Table 14: Count and % of Departments/clinical units and Ambulance station / paramedics reporting that that their staff are aware

of sepsis

Strongly agree Agree Neutral Disagree Strongly disagree

ASNSW 36 23.2% 84 54.2% 23 14.8% 10 6.5% 2 1.3%

LHD Department 334 34.7% 545 56.7% 72 7.5% 11 1.1% 0 N/A

18

N/A Always

(100%)

Often (67%-99%)


Rarely (1% - 33%)

Never (0%)

We have a standardised approach to the

management of patients with confirmed or

suspected, sepsis

__ __ __ __ __ __

While the overall NSW average was 73% of respondents having a standardised approach to sepsis management

there was some variability in responses from Metropolitan LHDs with results between 42% and 85%.

Figure 8: % of Departments/clinical units reporting that there was a standardised approach to the management of patients with

confirmed or suspected sepsis by LHD

Table 15 Count and % of Departments/clinical units reporting that there was a standardised approach to the management of

patients with confirmed or suspected sepsis by LHD

Description LHD Always (100%) Often (67%-99%) Sometimes (34%–

66%) Rarely (1%-33%) Never (0%)

Metropolitan

LHDs CCLHD 13 31.7% 11 26.8% 14 34.1% 1 2.4% 2 4.9%

ISLHD 10 19.2% 34 65.4% 5 9.6% 3 5.8% 0 N/A

NBMLHD 6 19.4% 14 45.2% 6 19.4% 3 9.7% 2 6.5%

NSLHD 18 25.0% 29 40.3% 13 18.1% 8 11.1% 4 5.6%

SCHN 24 38.7% 29 46.8% 6 9.7% 2 3.2% 1 1.6%

SESLHD 37 37.0% 42 42.0% 13 13.0% 7 7.0% 1 1.0%

SVHN 4 21.1% 4 21.1% 6 31.6% 5 26.3% 0 N/A

SWSLHD 27 31.0% 35 40.2% 22 25.3% 2 2.3% 1 1.1%

SYDLHD 36 44.4% 33 40.7% 10 12.3% 2 2.5% 0 N/A

WSLHD 17 33.3% 20 39.2% 10 19.6% 4 7.8% 0 N/A

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

CC

LHD

ISLH

D

NB

MLH

D

NSL

HD

SCH

N

SESL

HD

SVH

N

SWSL

HD

SYD

LHD

WSL

HD

Met

ro T

ota

l

FWLH

D

HN

ELH

D

MLH

D

MN

CLH

D

NN

SWLH

D

SNSW

LHD

WN

SWLH

D

R&

R T

ota

l Metropolitan LHDs Rural & Regional LHDs


19


66%) Rarely (1%-33%) Never (0%)

Metro Total 192 32.2% 251 42.1% 105 17.6% 37 6.2% 11 1.8%

Rural &

Regional LHDs FWLHD 1 10.0% 5 50.0% 3 30.0% 1 10.0% 0 N/A

HNELHD 30 26.3% 54 47.4% 22 19.3% 6 5.3% 2 1.8%

MLHD 12 23.1% 27 51.9% 5 9.6% 5 9.6% 3 5.8%

MNCLHD 9 29.0% 13 41.9% 9 29.0% 0 N/A 0 N/A

NNSWLHD 10 21.7% 27 58.7% 5 10.9% 3 6.5% 1 2.2%

SNSWLHD 9 20.9% 22 51.2% 10 23.3% 0 N/A 2 4.7%

WNSWLHD 15 21.4% 28 40.0% 16 22.9% 6 8.6% 5 7.1%

R&R Total 86 23.5% 176 48.1% 70 19.1% 21 5.7% 13 3.6%

NSW NSW 278 28.9% 427 44.4% 175 18.2% 58 6.0% 24 2.5%

Surgical (63%), Emergency (68%) and Intensive Care (68%) departments/clinical units reported lower than the NSW

average. At the state level the facility level self assessment results were consistent with the department/clinical

unit level.

Table 16: Count and % of Departments/clinical units, facilities and Ambulance station / paramedics reporting that there was a

standardised approach to the management of patients with confirmed or suspected sepsis


ASNSW 9 5.8% 53 34.2% 46 29.7% 40 25.8% 7 4.5%

LHD Department 278 28.9% 427 44.4% 175 18.2% 58 6.0% 24 2.5%

LHD Facility 24 23.3% 45 43.7% 23 22.3% 11 10.7% 0 N/A

20

N/A Always

(100%)

Often (67%-99%)


Rarely (1% - 33%)

Never (0%)

The skills and knowledge of staff are sufficient to

manage the identification and optimal

management of sepsis

__ __ __ __ __ __

Across NSW 75% of departments/clinical units “Strongly Agreed” or “Agreed” with the statement “The skills

and knowledge of staff are sufficient to manage the identification and optimal management of sepsis”.

Figure 9: % of Departments/clinical units reporting that skills and knowledge of staff are sufficient to manage the identification

and optimal management of sepsis

Table 17: Count and % of Departments/clinical units reporting that skills and knowledge of staff are sufficient to manage the

identification and optimal management of sepsis by LHD.


66%) Rarely (1%-33%) Never (0%)

Metropolitan

LHDs CCLHD 11 26.8% 20 48.8% 8 19.5% 2 4.9% 0 N/A

ISLHD 6 11.5% 35 67.3% 10 19.2% 1 1.9% 0 N/A

NBMLHD 3 9.7% 16 51.6% 7 22.6% 4 12.9% 1 3.2%

NSLHD 15 20.8% 38 52.8% 16 22.2% 1 1.4% 2 2.8%

SCHN 21 33.9% 35 56.5% 4 6.5% 1 1.6% 1 1.6%

SESLHD 26 26.0% 52 52.0% 19 19.0% 3 3.0% 0 N/A

SVHN 2 10.5% 5 26.3% 10 52.6% 2 10.5% 0 N/A

SWSLHD 16 18.4% 55 63.2% 14 16.1% 1 1.1% 1 1.1%

SYDLHD 36 44.4% 40 49.4% 5 6.2% 0 N/A 0 N/A

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

CC

LHD

ISLH

D

NB

MLH

D

NSL

HD

SCH

N

SESL

HD

SVH

N

SWSL

HD

SYD

LHD

WSL

HD

Met

ro T

ota

l

FWLH

D

HN

ELH

D

MLH

D

MN

CLH

D

NN

SWLH

D

SNSW

LHD

WN

SWLH

D

R&

R T

ota

l Metropolitan LHDs Rural & Regional LHDs


21


66%) Rarely (1%-33%) Never (0%)

WSLHD 14 27.5% 25 49.0% 7 13.7% 5 9.8% 0 N/A

Metro Total 150 25.2% 321 53.9% 100 16.8% 20 3.4% 5 0.8%

Rural &

Regional LHDs FWLHD 1 10.0% 7 70.0% 1 10.0% 1 10.0% 0 N/A

HNELHD 25 21.9% 56 49.1% 29 25.4% 4 3.5% 0 N/A

MLHD 4 7.7% 30 57.7% 16 30.8% 2 3.8% 0 N/A

MNCLHD 4 12.9% 14 45.2% 12 38.7% 1 3.2% 0 N/A

NNSWLHD 5 10.9% 32 69.6% 7 15.2% 2 4.3% 0 N/A

SNSWLHD 10 23.3% 23 53.5% 10 23.3% 0 N/A 0 N/A

WNSWLHD 11 15.7% 31 44.3% 23 32.9% 4 5.7% 1 1.4%

R&R Total 60 16.4% 193 52.7% 98 26.8% 14 3.8% 1 0.3%

NSW NSW 210 21.8% 514 53.4% 198 20.6% 34 3.5% 6 0.6%

Table 18: Count and % of Departments/clinical units, facilities and Ambulance station / paramedics reporting that there was a

standardised approach to the management of patients with confirmed or suspected sepsis


ASNSW 10 6.5% 46 29.7% 52 33.5% 42 27.1% 5 3.2%

LHD

Department 210 21.8% 514 53.4% 198 20.6% 34 3.5% 6 0.6%

LHD Facility 13 12.6% 41 39.8% 37 35.9% 12 11.7% 0 N/A

22

Figure 10: % of Departments/clinical units reporting that Paramedics alert triage staff if sepsis is suspected by LHD

Table 19: Count and % of Departments/clinical units reporting that Paramedics alert triage staff if sepsis is suspected by LHD.

Description LHD Always (100%) Often (67%-99%) Sometimes (34%-

66%) Rarely (1%-33%) Never (0%)

Metropolitan LHD

CCLHD 0 N/A 1 25.0% 0 N/A 3 75.0% 0 N/A

ISLHD 2 20.0% 3 30.0% 1 10.0% 2 20.0% 2 20.0%

NBMLHD 0 N/A 1 16.7% 2 33.3% 2 33.3% 1 16.7%

NSLHD 0 N/A 5 31.3% 7 43.8% 4 25.0% 0 N/A

SCHN 2 28.6% 2 28.6% 1 14.3% 2 28.6% 0 N/A

SESLHD 1 9.1% 2 18.2% 2 18.2% 6 54.5% 0 N/A

SVHN 0 N/A 0 N/A 0 N/A 0 N/A 1 100.0%

SWSLHD 1 4.8% 9 42.9% 5 23.8% 4 19.0% 2 9.5%

SYDLHD 3 20.0% 7 46.7% 3 20.0% 0 N/A 2 13.3%

WSLHD 2 11.1% 6 33.3% 8 44.4% 1 5.6% 1 5.6%

Rural & Regional LHD

FWLHD 1 50.0% 0 N/A 1 50.0% 0 N/A 0 N/A

HNELHD 1 2.6% 12 31.6% 13 34.2% 8 21.1% 4 10.5%

MLHD 1 3.3% 9 30.0% 9 30.0% 7 23.3% 4 13.3%

MNCLHD 1 12.5% 3 37.5% 2 25.0% 1 12.5% 1 12.5%

NNSWLHD 1 5.6% 4 22.2% 8 44.4% 2 11.1% 3 16.7%

SNSWLHD 2 11.8% 3 17.6% 8 47.1% 2 11.8% 2 11.8%

WNSWLHD 0 N/A 10 29.4% 9 26.5% 13 38.2% 2 5.9%

ASNSW ASNSW 15 9.7% 58 37.4% 63 40.6% 18 11.6% 1 0.6%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

CC

LHD

ISLH

D

NB

MLH

D

NSL

HD

SCH

N

SESL

HD

SVH

N

SWSL

HD

SYD

LHD

WSL

HD

FWLH

D

HN

ELH

D

MLH

D

MN

CLH

D

NN

SWLH

D

SNSW

LHD

WN

SWLH

D

Metropolitan Rural & Regional

LHD - Always or Often ASNSW - Always or Often

Paramedics alert triage staff if sepsis is suspected

__ Always (100%)

__ Often (67%-99%)

__ Sometimes (34% – 66%)

__ Rarely (1% - 33%)

__ Never (0%)

__ Not applicable

23

Challenges in management of Sepsis

Figure 11: Count of most challenging issues when managing patients with suspected or confirmed sepsis identified by

department / clinical unit

49%

33%

31%

27%

25%

19%

14%

10%

16%

0% 10% 20% 30% 40% 50% 60%

Deficits in skill and knowledge e.g. lack of familiarity with assessment/screening tools

Time/workload constraints

Issues relating to referrals/consultation

Multiple physicians admit to the unit, such that care processes and teams are fragmented

Absent or unclear procedures/protocols

Lack of supervision of junior clinicians

Other

Access to relevant information, assistance or other resources

Nothing

NSW - % of Departments/Clinical Units responding

From the following list please indicate the most challenging issues when managing patients with suspected or

confirmed sepsis (tick a maximum of three and provide additional details as necessary)

__ None

__ Deficits in skill and knowledge e.g. lack of familiarity with assessment / screening tools

__ Absent or unclear procedures / protocols

__ Issues relating to referrals / consultation

__ Access to relevant information, assistance or other resources

__ Multiple physicians admit to the unit, such that care processes are fragmented

__ Lack of supervision of junior clinicians

__ Time / workload constraints

__ Other

24

Table 20: Count of most challenging issues when managing patients with suspected or confirmed sepsis identified by department / clinical unit by LHD.

Description LHD

Deficits in skill

and knowledge

Time/workload

constraints

Issues relating to

referrals/consultat

ion

Multiple physicians

admit to the unit, such

that care processes and

teams are fragmented

Absent or

unclear

procedures/

protocols

Lack of

supervision of

junior clinicians Other

Access to

relevant

information,

assistance or

other resources Nothing

Metropolitan CCLHD 23 56% 17 41% 9 22% 17 41% 12 29% 13 32% 3 7% 2 5% 8 20%

ISLHD 25 48% 12 23% 17 33% 19 37% 10 19% 10 19% 9 17% 3 6% 7 13%

NBMLHD 17 55% 13 42% 10 32% 5 16% 14 45% 12 39% 4 13% 6 19% 5 16%

NSLHD 29 40% 23 32% 23 32% 14 19% 13 18% 16 22% 13 18% 7 10% 8 11%

SCHN 11 18% 16 26% 10 16% 14 23% 2 3% 5 8% 12 19% 1 2% 16 26%

SESLHD 36 36% 33 33% 26 26% 26 26% 12 12% 18 18% 11 11% 9 9% 25 25%

SVHN 11 58% 8 42% 5 26% 6 32% 10 53% 6 32% 6 32% 4 21% 1 5%

SWSLHD 31 36% 30 34% 31 36% 27 31% 14 16% 22 25% 10 11% 6 7% 18 21%

SYDLHD 9 11% 31 38% 19 23% 12 15% 7 9% 10 12% 15 19% 6 7% 23 28%

WSLHD 20 39% 17 33% 18 35% 11 22% 16 31% 10 20% 6 12% 6 12% 14 27%

Rural &

Regional FWLHD

5 50% 3 30% 3 30% 5 50% 1 10% 2 20% 1 10% 0% 0%

HNELHD 73 64% 49 43% 47 41% 48 42% 26 23% 35 31% 13 11% 16 14% 17 15%

MLHD 31 60% 14 27% 20 38% 11 21% 10 19% 4 8% 7 13% 5 10% 5 10%

MNCLHD 15 48% 13 42% 12 39% 15 48% 7 23% 5 16% 5 16% 2 6% 3 10%

NNSWLHD 25 54% 21 46% 20 43% 14 30% 8 17% 9 20% 10 22% 5 11% 3 7%

SNSWLHD 27 63% 20 47% 14 33% 16 37% 12 28% 9 21% 5 12% 5 12% 8 19%

WNSWLHD 49 70% 23 33% 32 46% 25 36% 26 37% 17 24% 11 16% 11 16% 4 6%

Other ASNSW 105 68% 30 19% 26 17% 14 9% 83 54% 11 7% 10 6% 18 12% 10 6%

NSW 542 49% 373 33% 342 31% 299 27% 283 25% 214 19%

15

1 14% 112 10% 175 16%

25 2011 Quality Systems Assessment - Sepsis

Guidelines / protocols

For NSW 60% of departments/clinical units responding to the self assessment reported that guidelines and / or

local protocols were in place that were specifically developed for the management of patients identified with, or

suspected of, sepsis.

At the LHD level 96% reported having guidelines and at the facility level 79% reported have guidelines / protocols

in place specifically developed for the management of patients identified with, or suspected of, sepsis

Figure 12: % of Departments/clinical units reporting that they have guidelines and / or local protocols in place specifically

developed for the management of patients identified with, or suspected of, sepsis

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

CC

LHD

ISLH

D

NB

MLH

D

NSL

HD

SCH

N

SESL

HD

SVH

N

SWSL

HD

SYD

LHD

WSL

HD

Met

ro T

ota

l

FWLH

D

HN

ELH

D

MLH

D

MN

CLH

D

NN

SWLH

D

SNSW

LHD

WN

SWLH

D

R&

R T

ota

l


LHD - Yes NSW Yes

Do you have guidelines and / or local protocols in place specifically developed for the management of

patients identified with, or suspected of, sepsis?

__ Yes, for adults only

__ Yes, for children and / or young people only

__ Yes, for both (adults and children / young people)

__ No


Table 21: Count and % of Departments/clinical units reporting that they have guidelines and / or local protocols in place

specifically developed for the management of patients identified with, or suspected of, sepsis by LHD.

Description LHD Yes, for adults only Yes, for children and/or

young people only

Yes, for both (adults and

children/young people) No

Metropolitan

LHDs CCLHD 13 31.7% 4 9.8% 0 N/A 24 58.5%

ISLHD 20 38.5% 2 3.8% 10 19.2% 20 38.5%

NBMLHD 6 19.4% 3 9.7% 4 12.9% 18 58.1%

NSLHD 27 37.5% 6 8.3% 9 12.5% 30 41.7%

SCHN 0 N/A 35 56.5% 3 4.8% 24 38.7%

SESLHD 33 33.0% 4 4.0% 13 13.0% 50 50.0%

SVHN 8 42.1% 0 N/A 0 N/A 11 57.9%

SWSLHD 32 36.8% 2 2.3% 13 14.9% 40 46.0%

SYDLHD 46 56.8% 3 3.7% 9 11.1% 23 28.4%

WSLHD 22 43.1% 3 5.9% 2 3.9% 24 47.1%

Metro Total 207 34.7% 62 10.4% 63 10.6% 264 44.3%

Rural &

Regional LHDs FWLHD 5 50.0% 1 10.0% 2 20.0% 2 20.0%

HNELHD 43 37.7% 9 7.9% 34 29.8% 28 24.6%

MLHD 17 32.7% 3 5.8% 15 28.8% 17 32.7%

MNCLHD 16 51.6% 0 N/A 7 22.6% 8 25.8%

NNSWLHD 17 37.0% 3 6.5% 10 21.7% 16 34.8%

SNSWLHD 13 30.2% 2 4.7% 11 25.6% 17 39.5%

WNSWLHD 14 20.0% 4 5.7% 19 27.1% 33 47.1%

R&R Total 125 34.2% 22 6.0% 98 26.8% 121 33.1%

NSW NSW 332 34.5% 84 8.7% 161 16.7% 385 40.0%

The rate for six of the seven Rural & Regional LHDs was higher than the NSW average. 81% of Departments/clinical

units from Rural & Regional LHDs that indicated that there were guidelines and / or local protocols in place for

“children and/or young people only” also reported that “All (100%)” or “Most (67%-99%)” staff were trained in

their use.

Table 22 % of Departments/clinical units reporting that they have guidelines and / or local protocols in place specifically

developed for the management of patients identified with, or suspected of, sepsis by Metropolitan and Rural & Regional LHD.

Description Guidelines & Protocols exist All or Most Some, Few, None or Don't know

Metropolitan LHDs Yes, for adults only 68.4% 31.6%

Yes, for both (adults and children/young

people) 73.0% 27.0%

Yes, for children and/or young people only 71.7% 28.3%

Rural & Regional LHDs Yes, for adults only 52.0% 48.0%

Yes, for both (adults and children/young

people) 53.1% 46.9%

Yes, for children and/or young people only 81.0% 19.0%


Across NSW 64% of departments/clinical units responding to the self assessment indicated that “All (100%)” or

“Most (67%-99%)” relevant clinical staff who have been orientated to and / or trained in the use of, the guidelines /

protocols.

Figure 13: % of Departments/clinical units reporting that relevant clinical staff who have been orientated to and / or trained in the

use of, the guidelines / protocols.

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

CC

LHD

ISLH

D

NB

MLH

D

NSL

HD

SCH

N

SESL

HD

SVH

N

SWSL

HD

SYD

LHD

WSL

HD

Met

ro T

ota

l

FWLH

D

HN

ELH

D

MLH

D

MN

CLH

D

NN

SWLH

D

SNSW

LHD

WN

SWLH

D

R&

R T

ota

l


LHD - All or Most NSW - All or Most

Please estimate the percentage of relevant clinical staff who have been orientated to and / or trained in the

use of, the guidelines / protocols

__ All (100%)

__ Most(67%-99%)

__ Some (34% – 66%)

__ Few (1% - 33%)

__ None (0%)

__ Don’t know


Table 23: Count and % of Departments/clinical units reporting that relevant clinical staff who have been orientated to and / or

trained in the use of, the guidelines / protocols by LHD.

Description LHD All (100%) Most (67%-99%) Some (34%–

66%) Few (1%-33%) None (0%) Don't know

Metropolitan

LHDs CCLHD 4 23.5% 5 29.4% 3 17.6% 2 11.8% 1 5.9% 2 11.8%

ISLHD 5 15.6% 15 46.9% 6 18.8% 3 9.4% 1 3.1% 2 6.3%

NBMLHD 2 15.4% 9 69.2% 0 N/A 0 N/A 0 N/A 2 15.4%

NSLHD 6 14.6% 25 61.0% 7 17.1% 1 2.4% 0 N/A 2 4.9%

SCHN 8 21.6% 15 40.5% 6 16.2% 1 2.7% 0 N/A 7 18.9%

SESLHD 10 20.0% 30 60.0% 5 10.0% 2 4.0% 1 2.0% 2 4.0%

SVHN 1 12.5% 1 12.5% 3 37.5% 0 N/A 0 N/A 3 37.5%

SWSLHD 6 13.0% 24 52.2% 3 6.5% 5 10.9% 1 2.2% 7 15.2%

SYDLHD 19 32.8% 29 50.0% 3 5.2% 1 1.7% 2 3.4% 4 6.9%

WSLHD 7 25.9% 9 33.3% 5 18.5% 1 3.7% 0 N/A 5 18.5%

Metro Total 68 20.7% 162 49.2% 41 12.5% 16 4.9% 6 1.8% 36 10.9%

Rural &

Regional LHDs FWLHD 2 25.0% 3 37.5% 1 12.5% 1 12.5% 1 12.5% 0 N/A

HNELHD 10 12.0% 40 48.2% 22 26.5% 4 4.8% 2 2.4% 5 6.0%

MLHD 1 2.9% 12 34.3% 12 34.3% 6 17.1% 1 2.9% 3 8.6%

MNCLHD 3 13.0% 8 34.8% 6 26.1% 3 13.0% 1 4.3% 2 8.7%

NNSWLHD 4 13.3% 15 50.0% 6 20.0% 3 10.0% 0 N/A 2 6.7%

SNSWLHD 3 11.5% 11 42.3% 7 26.9% 4 15.4% 1 3.8% 0 N/A

WNSWLHD 3 8.1% 18 48.6% 11 29.7% 3 8.1% 0 N/A 2 5.4%

R&R Total 26 10.7% 107 44.2% 65 26.9% 24 9.9% 6 2.5% 14 5.8%

NSW NSW 94 16.5% 269 47.1% 106 18.6% 40 7.0% 12 2.1% 50 8.8%


Figure 14: Count of sepsis management issues explicitly covered in guidelines / protocols identified by department / clinical unit

0% 5% 10% 15% 20% 25% 30% 35% 40%

Clear guidelines for response and escalation when sepsis is identified/suspected

A standardised sepsis screening protocol which includes criteria/parameters for recognition/identification

Treatment pathway/resuscitation protocol/algorithm with early goal directed therapy (EGDT) measures included

Standardised septic shock order set for IV fluids/antibiotic etc

Referral/discharge/transfer protocol/s

Other

NSW - % of Departments/Clinical Units responding

Please indicate which of the following sepsis management issues are explicitly covered in your guidelines /

protocols: (tick all that apply)

__ Clear guidelines for response and escalation when sepsis is identified / suspected

__ A standardised sepsis screening protocol (adult and paediatric) which includes criteria / parameters for

recognition / identification

__ Treatment / Resuscitation protocol / algorithm with early goal directed therapy (EGDT) measures including

Monitoring, airway management, fluid resuscitation blood cultures, BGL monitoring and antibiotic

administration.

__ A standardised septic shock order set for IV fluids/antibiotic etc

__ Referral /discharge / transfer protocol/s

__ Other


Monitoring and Reporting

Rural & Regional LHDs (33%) reported a lower % of departments/clinical units monitoring aspects of sepsis

incidence, care and management than Metropolitan LHDs (49%). Emergency (28%), Aged Care (31%), Medical

(31%) and Surgical (38%) departments/clinical units reported lower overall rates than the NSW average (43%).

Figure 15: % of Departments/clinical units reporting that they monitor any aspects of sepsis incidence, care and management

Table 24: Count and % of Departments/clinical units reporting that they monitor any aspects of sepsis incidence, care and

management by LHD.

Description LHD Yes Yes - LHD No No

Metropolitan LHDs CCLHD 12 29.3% 29 70.7%

ISLHD 19 36.5% 33 63.5%

NBMLHD 18 58.1% 13 41.9%

NSLHD 36 50.0% 36 50.0%

SCHN 25 40.3% 37 59.7%

SESLHD 45 46.4% 52 53.6%

SVHN 12 63.2% 7 36.8%

SWSLHD 49 57.6% 36 42.4%

SYDLHD 48 63.2% 28 36.8%

0%

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100%

CC

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ISLH

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NB

MLH

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HD

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Yes - LHD Yes - NSW

Do you monitor any aspects of sepsis incidence, care and management?

__ Yes

__ No


Description LHD Yes Yes - LHD No No

WSLHD 24 48.0% 26 52.0%

Metro Total 288 49.2% 297 50.8%

Rural & Regional

LHDs FWLHD 4 40.0% 6 60.0%

HNELHD 41 36.6% 71 63.4%

MLHD 17 32.7% 35 67.3%

MNCLHD 7 23.3% 23 76.7%

NNSWLHD 11 24.4% 34 75.6%

SNSWLHD 20 46.5% 23 53.5%

WNSWLHD 18 25.7% 52 74.3%

R&R Total 118 32.6% 244 67.4%

NSW NSW 406 42.9% 541 57.1%

Figure 16: % of Departments/clinical units reporting that monitor any aspects of sepsis incidence, care and management

0%

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30%

40%

50%

60%

70%

80%

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100%

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Yes Yes - NSW


Figure 17: Count of sepsis performance measures utilised identified by department / clinical unit

Analysis of ‘other’ responses showed that most departments are reviewing their own specific infection

data / rates suchs as hip repleacement prosthesis; intravascular line / CLAB incidence and wound

infection or have only just commenced using the data collection set from sepsis project.

0

0% 5% 10% 15% 20% 25% 30% 35% 40%

Other

Rapid Response/Medical Emergency Team (MET) …

Time to antibiotics (delay)

Admissions to Intensive Care (ICU) due to sepsis

Serum lactate measure taken

Delay in blood cultures

Time to commencement of 2nd litre of IV fluid

Time to completion of 1st litre of IV fluids

None

NSW - % of Departments/Clinical Units responding "Yes" that aspects of sepsis incidence, care and management are monitored

Please indicate what performance measures you utilise (tick all that apply)

__ None

__ Delay in blood cultures

__ Time to antibiotics (delay)

__ Admissions to ICU due to sepsis

__ Time to completion of 1st

litre of IV fluids

__ Time to commencement of 2nd litre of IV fluid

__ Serum lactate measure taken

__ Rapid Response / Medical Emergency Team (MET) calls related to sepsis

__ other


For NSW, 57% of departments/clinical units responding to the self assessment reviewed all sepsis cases at local

morbidity and mortality meetings.

Departments/clinical units from hospital peer groups B & C reported rates lower than the NSW average.

Figure 18: % of Departments/clinical units reporting that all sepsis cases are reviewed at local morbidity and mortality meetings,

including those patients transferred to ICU and / or transferred to another facility

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

CC

LHD

ISLH

D

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SCH

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Yes - LHD Yes - NSW

All sepsis cases are reviewed at local morbidity and mortality meetings, including those patients transferred to ICU and / or transferred to another facility

__ Yes, routinely

__ Yes, occasionally but not routine

__ No

__ Not applicable


Table 25: Count and % of Departments/clinical units reporting that all sepsis cases are reviewed at local morbidity and mortality

meetings, including those patients transferred to ICU and / or transferred to another facility by LHD.

Description LHD Yes, routinely Yes, occasionally but not

routine No Not applicable

Metropolitan LHDs

CCLHD 4 9.8% 10 24.4% 13 31.7% 14 34.1%

ISLHD 15 28.8% 18 34.6% 5 9.6% 14 26.9%

NBMLHD 9 29.0% 8 25.8% 8 25.8% 6 19.4%

NSLHD 25 34.7% 32 44.4% 6 8.3% 9 12.5%

SCHN 14 22.6% 19 30.6% 10 16.1% 19 30.6%

SESLHD 33 34.0% 24 24.7% 13 13.4% 27 27.8%

SVHN 5 26.3% 6 31.6% 6 31.6% 2 10.5%

SWSLHD 32 37.6% 29 34.1% 14 16.5% 10 11.8%

SYDLHD 42 55.3% 17 22.4% 7 9.2% 10 13.2%

WSLHD 13 26.0% 12 24.0% 16 32.0% 9 18.0%

Metro Total 192 32.8% 175 29.9% 98 16.8% 120 20.5%

Rural & Regional LHDs

FWLHD 1 10.0% 4 40.0% 2 20.0% 3 30.0%

HNELHD 18 16.1% 40 35.7% 26 23.2% 28 25.0%

MLHD 5 9.6% 13 25.0% 14 26.9% 20 38.5%

MNCLHD 4 13.3% 5 16.7% 10 33.3% 11 36.7%

NNSWLHD 10 22.2% 18 40.0% 6 13.3% 11 24.4%

SNSWLHD 11 25.6% 12 27.9% 8 18.6% 12 27.9%

WNSWLHD 8 11.4% 19 27.1% 22 31.4% 21 30.0%

R&R Total 57 15.7% 111 30.7% 88 24.3% 106 29.3%

NSW NSW 249 26.3% 286 30.2% 186 19.6% 226 23.9%

Figure 19 % department / clinical units reporting that all sepsis cases are reviewed at local morbidity and mortality meetings,

including those patients transferred to ICU and / or transferred to another facility by service type

0%

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Service Type - Yes Yes - NSW


Appendix 1: Notes about the data

In this report, charts and tables are used to provide information on department/clinical unit responses to the questions from the

2011 QSA self assessment compared to the aggregated NSW results.

Except where noted the charts illustrate the responses for departments/clinical units from LHDs.

The report uses pie charts, summary graphs for multiple questions and tables summarising the statistical analysis of the results.

In the chart below, responses for the block of six questions on the paediatric Between the Flags program for all NSW are summarised.

.

Figure X: % of “Strongly agree” or “Agree” responses to questions on the Paediatric Between the Flags Program for

departments/clinical units reporting that children/young people were assessed and treated (Q.7x; NSW).

The section of the report that reviews each question in detail makes use of 3 types of chart to summarise the

department/clinical unit responses. The chart below is used to compare the responses for departments/clinical units from

each LHD, Metropolitan and Rural based LHDs and the overall NSW proportion. A list of Metropolitan and Rural & Remote

LHDs is available at http://www.health.nsw.gov.au/services/index.asp

Figure X: % of Departments/clinical units responding “Strongly agree” or “Agree” by LHD.

0% 10% 20% 30% 40% 50% 60% 70% 80% 90%

100%

Q7a. Executive support

important part of success

Q7b. Clinical lead critical to

uptake & acceptance

Q7c. Blue zone assists early

detection

Q7d. Yellow zone assists

early detection

Q7e. Red zone assists rapid

response

Q7f. Overall BTF Benefits patient

safety

0%

20%

40%

60%

80%

100%

CC

LHD

ISLH

D

NB

MLH

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SCH

N

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ota

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FWLH

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MN

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Metropolitan Rural & Regional

LHD - Strongly agree or Agree NSW - Strongly agree or Agree

1

This chart summarises the responses to the group of statements from Question 7

in the 2011QSA, LHD Department/Clinical Unit self assessment. The results are

aggregated at the NSW level.

2

Aggregate result for Rural &

Regional based LHDs.

Aggregate result for Metropolitan

based LHDs.

http://www.health.nsw.gov.au/services/index.asp


The chart below is used to compare the responses for departments/clinical units from each peer hospital

group and the overall NSW proportion. The Peer Hospital Groups are collapsed to the main letter designation

with the exception of:

F2 Nursing Home & F3 Multi-Purpose Services facilities are mapped to F - Other

F1 – Psychiatric facilities that are mapped to F1 – MH

F4 Sub Acute, F6 Rehabilitation, F7 Mothercraft & F8 Ungrouped Non-Acute facilities are mapped to

“Other”

A list of NSW Peer Hospital Groups 2011/12 is available at http://www.health.nsw.gov.au/hospitals/peer_groups.asp

Figure X: % of Departments/clinical units responding “Strongly agree” or “Agree” by Peer Hospital Group.

The chart below is used to compare the responses for departments/clinical units from each aggregated service

type and the overall NSW proportion. The aggregated service types are derived from the response to Question

88 from the Department/Clinical Unit Self assessment. The primary respondent for the self assessment was

asked to indicate the main type of service their department/clinical unit provides. A table showing the

mapping of these responses is provided in Appendix A of this document.

Figure X: % of Departments/clinical units responding “Strongly agree” or “Agree” by Service type.

0%

20%

40%

60%

80%

100%

A B C D F - Other F1 - MH Other

Peer group - Strongly agree or Agree NSW - Strongly agree or Agree

0% 10% 20% 30% 40% 50% 60% 70% 80% 90%

100%

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Service type - Strongly agree or Agree NSW - Strongly agree or Agree

3

4

This line shows the

aggregate result for

all NSW (77%)

http://www.health.nsw.gov.au/hospitals/peer_groups.asp


Tables used in the report.

This table summarises the statistical analysis made for a group of questions.

The P-Value indicates if there is a statistically significant association between the variables (in this case) of LHD

location and response to the question. Using an -level of 0.05 for this test, the conclusion is the variables are

associated.

Table X: Summary of metropolitan and rural/regional Department/clinical unit self assessment responses regarding

the level of agreement with the SPOC/BTF statements.

Metropolitan Rural & Regional P-Value

BTF SPOC implemented % 70.3 91.3 <0.001

Agree on BTF clinical leader benefits % 64.7 66.2 0.78

Agree on BTF blue zone benefits % 53.9 73.7 <0.001

Agree on BTF yellow zone benefits % 72.9 81.3 0.06

Agree on BTF red zone benefits % 68.6 79.7 0.02

Agree on BTF benefits % 71.7 81.8 0.02

BTF NSW CPGs utilised always/often % 42.9 77.3 <0.001

This table summarises the responses for LHDs or clinical units to a single question. The responses for the

question are arranged across the top of the table with the values arranged in columns.

Table X: Count and % of Departments/clinical units reporting that children/young people were assessed and treated

and the SPOC implantation status by LHD.

Description LHD Yes

No Not applicable - our department

does not manage or treat children

Metropolitan CCLHD 5 41.7% 3 25.0% 4 33.3%

ISLHD 7 41.2% 6 35.3% 4 23.5%

NBMLHD 11 73.3% 3 20.0% 1 6.7%

NSLHD 18 47.4% 8 21.1% 12 31.6%

SCHN 66 75.9% 9 10.3% 12 13.8%

SESLHD 14 33.3% 15 35.7% 13 31.0%

SVHN 0 N/A 1 100.0% 0 N/A

SWSLHD 18 42.9% 8 19.0% 16 38.1%

SYDLHD 10 43.5% 4 17.4% 9 39.1%

WSLHD 11 64.7% 2 11.8% 4 23.5%

Metro Total 160 54.4% 59 20.1% 75 25.5%

Rural & Regional FWLHD 8 100.0% 0 N/A 0 N/A

HNELHD 61 82.4% 5 6.8% 8 10.8%

MLHD 40 97.6% 1 2.4% 0 N/A

MNCLHD 10 71.4% 0 N/A 4 28.6%

NNSWLHD 28 84.8% 5 15.2% 0 N/A

SNSWLHD 23 59.0% 4 10.3% 12 30.8%

WNSWLHD 52 77.6% 6 9.0% 9 13.4%

R&R Total 222 80.4% 21 7.6% 33 12.0%

NSW 382 67.0% 80 14.0% 108 18.9%

Similar tables have been provided for peer hospital groups and aggregated service types where applicable.

5

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39

Offices

Level 13, 227 Elizabeth Street

SYDNEY NSW 2000

Correspondence

Bernadette King

QSA Program leader

Locked Bag A4062,

Sydney South NSW 1235

Tel 61 2 9269 5500

Fax 61 2 9269 5599

[email protected]

www.cec.health.nsw.gov.au

mailto:[email protected]

http://www.cec.health.nsw.gov.au/

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