View Article PDF

“Some very important clinical issues, some of them affecting life and death, stay largely in a backwater which is inhabited by academics and professionals and enthusiasts, dealt with very well at the clinical and scientific level but not visible to the public, political leaders, leaders of healthcare systems… The public and political space is the space in which [sepsis] needs to be in order for things to change.” ¬– Sir Liam Donaldson

Sepsis is the syndrome connecting infection to acute multi-organ failure and death. It is a clinical diagnosis, resting on the identification of “life threatening organ failure due to a dysregulated host response to infection.” [[1]] Common causes include pneumonia, invasive bacterial infection (eg, Staphylococcus aureus bacteraemia), urinary tract and soft-tissue infection. Almost a quarter of a century ago, Finfer et al estimated that the incidence of sepsis requiring ICU admission in Australia and New Zealand was 0.77 per 1,000 population per year.[[2]] It was subsequently demonstrated that this approach missed 30% of the cases identified using consensus clinical criteria.[[3]] Added to this, the population with sepsis in intensive care is only a fraction of the total. Local audit at Waikato Hospital suggests that the true population of adults in hospital with sepsis is five-times the number admitted to ICU.[[4]] Is it plausible to suggest that around 1 in 200 people are being admitted to hospital with sepsis each year in New Zealand?

Sepsis admissions can be expected to reveal wicked interactions between deprivation, ageing, frailty and morbidity. New Zealand already has very high rates of bacterial infection, most notably revealed in epidemics of meningococcal disease and rheumatic fever.[[5,6]] Michael Baker and colleagues have shown that the risk of infection-related hospitalisation is 2.8-times higher comparing the highest quintile of socioeconomic deprivation with the lowest. [[7]] Socioeconomic deprivation is more commonly experienced by Māori and Pacific people. To further indict the conditions which give rise to it, sepsis is at least twice as common in these populations.[[8]] Adding to this, chronic medical conditions greatly increase the risk of infection and sepsis, as does population aging.[[9,10]] Is it surprising, then, that infectious disease hospitalisations have risen faster than any other cause over the past three decades, or that sepsis admissions doubled at Waikato Hospital in the five years leading to 2012?[[7,8]]

With these questions in mind, the first National Sepsis Conference was held from 18 to 20 November 2021. As a collaboration between the New Zealand Sepsis Trust (NZST), the Australasian Society for Infectious Disease (ASID) and Te Ohu Rata o Aotearoa (Te ORA), the conference brought together over 200 delegates to consider “challenges for New Zealand.” Prominent clinicians and researchers from the USA, Australia and New Zealand considered topics ranging from acute management of sepsis, to the evidence-informed design of systems to improve quality of sepsis care. In one session, three apparently disparate topics (the Whakaari volcanic eruption, the antimicrobial resistance crisis and the rise in healthcare-associated S. aureus bacteraemia) demonstrated the adversity facing patients and front-line providers. Professors spoke alongside medical students and postgraduate trainees; nurses with interests in sepsis gathered for a workshop to discuss their findings; survivors of sepsis and of COVID-19 shared their stories of hardship and discovery. Prominent Māori academics explained the origin of prevailing inequities revealed by investigation and audit. It was easy to agree that “New Zealand needs a plan.”

The conference was therefore an ideal launchpad for the Aotearoa New Zealand National Sepsis Action Plan. With support from ACC, this work arose from a 2017 World Health Assembly resolution urging member states to invest in sepsis care. The benefits of implementing the plan are nothing compared with the long-term benefits of poverty reduction and action to close gaps in health outcomes. However, the health system needs to lead short-term changes which can lead to quick improvements, so these are the plan’s focus (find out more at www.sepsis.org.nz/action):

  1. Create a National Sepsis Network to drive quality improvement in the acute health sector.
  2. Increase Public Awareness by investing in community infection and sepsis awareness campaigns.
  3. Improve recognition of sepsis in all healthcare settings by ensuring providers can recognise and manage cases of suspected sepsis.
  4. Collect data to drive quality improvement.
  5. Support sepsis survivors by investing in programmes of enhanced recovery and rehabilitation for people leaving hospital after a sepsis event.

Conceived in the pre-COVID era, and concentrating on a response based within the health system, the plan nevertheless reinforces the need to learn from the COVID-19 pandemic and to ensure that the investments made to endure and recover from COVID-19 provide long-lasting benefits. For example, sepsis care should be integrated into antimicrobial stewardship programmes (Recommendation 3). Ninety-five percent of human antimicrobial consumption is in the community. The non-pharmacologic measures deployed to manage COVID-19 were associated with reduced community antimicrobial consumption by over a third without evidence of harm.[[11]] In hospitals, investment in antimicrobial stewardship to improve care for patients with sepsis would start with ensuring urgent treatment but extend to de-escalating and de-prescribing during recovery. Reporting on measures of sepsis outcome in relation to antimicrobial selection, delivery, duration and de-escalation corresponds with the plan’s recommendation to gather and report data (Recommendation 4) and to network the sharing of best practice in relation to quality improvement (Recommendation 1).

It is already known that enormous benefits can be realised by investing in the prevention and mitigation of infectious disease. The British Columbia (BC) Sepsis Network was established in 2012 with a cumulative spend of $500,000 through to 2018. By that time, Khowaja and colleagues estimate that the network’s activities had led to the prevention of 172 deaths and savings of $112 for every dollar invested.[[12]] In New South Wales, a state-wide programme promoting early recognition and treatment of sepsis led to a 20% increase in the proportion of patients with sepsis receiving antibiotics within an hour of emergency department triage. This accompanied a 5% reduction in hospital mortality and a two-day reduction in mean length of stay.[[13]] Also in Australia, a whole-of-hospital sepsis pathway in a specialist cancer hospital halved the average time to antimicrobial therapy, reduced hospital mortality and saw an 18% reduction in the proportion of patients admitted to intensive care.[[14]]

This and other evidence has been used to fund a national sepsis plan for Australia coordinated by the Australian Commission on Quality and Safety in Health Care. In contrast, at the time of writing, a search for “sepsis” on the Ministry of Health website returned only one link, which was to a brief Official Information Act response. Why are we so far behind here? Did late twentieth century models of health investment focus too much on the management of non-communicable disease? Has sepsis fallen into the trap of being everyone’s problem but nobody’s business? Or is the failure to prioritise the prevention and management of severe infection the expected response to a problem which disproportionately affects Māori and Pacific people? Regardless of distal causation, we will not navigate a way forward without coordinated action. So saying, we commend the National Sepsis Action Plan to the leadership of our new health agencies.

Summary

Abstract

Aim

Method

Results

Conclusion

Author Information

Paul Huggan: FRACP. Infectious Disease Physician, Waikato Hospital. Trustee, New Zealand Sepsis Trust. Dan Dobbins: FACEM. Emergency Medicine Physician, Waikato Hospital. Trustee, New Zealand Sepsis Trust. Robert Martynoga: FANZCA FCICM. Intensivist and Amaesthetist, Waikato Hospital. Trustee, New Zealand Sepsis Trust. Chris Hopkins: FRACP. Infectious Disease Physician, Middlemore Hospital. ORCID ID: 0000-0003-3285-3481. Nigel Raymond: FRACP. Infection Service and General Medicine Department, Capital & Coast District Health Board. ORCID ID: 0000-0001-9519-5215.

Acknowledgements

Correspondence

Dr Paul Huggan, FRACP, Infectious Disease Physician, Waikato Hospital. Trustee, New Zealand Sepsis Trust

Correspondence Email

paul.huggan@waikatodhb.health.nz

Competing Interests

Nil.

1. Singer M, Deutschman CS, Seymour C, et al. The third international consensus definitions for sepsis and septic shock (sepsis-3). JAMA - Journal of the American Medical Association. 2016;315(8):801-810. doi:10.1001/jama.2016.0287

2. Finfer S, Bellomo R, Lipman J, French C, Dobb G, Myburgh J. Adult-population incidence of severe sepsis in Australian and New Zealand intensive care units. Intensive care medicine. 2004;30(4):589-596. doi:10.1007/s00134-004-2157-0

3. Heldens M, Schout M, Hammond NE, Bass F, Delaney A, Finfer SR. Sepsis incidence and mortality are underestimated in Australian intensive care unit administrative data. The Medical Journal of Australia. 2018;209(6):255-260. doi:10.5694/MJA18.00168

4. Linde-Zwirble WT, Angus DC. Severe sepsis epidemiology: Sampling, selection, and society. Critical Care. 2004;8(4):222-226. doi:10.1186/cc2917

5. Baker MG, Martin DR, Kieft CEM, Lennon D. A 10-year serogroup B meningococcal disease epidemic in New Zealand: Descriptive epidemiology, 1991-2000. Journal of Paediatrics and Child Health 2001. doi:10.1046/j.1440-1754.2001.00722.x

6. Webb R, Wilson N. Rheumatic fever in New Zealand. J Paediatr Child Health, 2013; 49(3): 179-84.

7. Baker MG, Barnard LT, Kvalsvig A, et al. Increasing incidence of serious infectious diseases and inequalities in New Zealand: a national epidemiological study. Lancet. 2012;379(9821):1112-1119. doi:10.1016/S0140-6736(11)61780-7

8. Huggan PJ, Bell A, Waetford J, Obertova Z, Lawrenson R. Evidence of High Mortality and Increasing Burden of Sepsis in a Regional Sample of the New Zealand Population. Open Forum Infectious Diseases. 2017;4(3). doi:10.1093/ofid/ofx106

9. Wang HE, Griffin R, Judd S, Shapiro NI, Safford MM. Obesity and risk of sepsis: A population-based cohort study. Obesity. 2013;21(12):E762-E769. doi:10.1002/oby.20468

10. Wang HE, Shapiro NI, Griffin R, Safford MM, Judd S, Howard G. Chronic Medical Conditions and Risk of Sepsis. PLOS ONE. 2012;7(10):e48307. doi:10.1371/JOURNAL.PONE.0048307

11. Duffy E, Thomas M, Hills T, Ritchie S. The impacts of New Zealand’s COVID-19 epidemic response on community antibiotic use and hospitalisation for pneumonia, peritonsillar abscess and rheumatic fever. The Lancet Regional Health - Western Pacific. 2021;12:100162. doi:10.1016/J.LANWPC.2021.100162/ATTACHMENT/8ED71F93-DDBC-4EF3-B8C5-59A4533AC84B/MMC1.DOCX

12. Khowaja, A, Willms, AJ, Krause, CM et al. The Return on Investment of a Province-Wide Quality Improvement Initiative for Reducing In-Hospital Sepsis Rates and Mortality in British Columbia, Canada, Critical Care Medicine. doi: 10.1097/CCM.0000000000005353

13. Burrell AR, McLaws M, Fullick M, Sullivan RB, Sindhusake D. SEPSIS KILLS: early intervention saves lives. Med J Aust 2016; 204 (2): 73. || doi: 10.5694/mja15.00657

14. Thursky K, Lingaratnam S, Jayarajan J et al. Implementation of a whole of hospital sepsis clinical pathway in a cancer hospital: impact on sepsis management, outcomes and costs. BMJ Open Qual. 2018;7(3):e000355. doi: 10.1136/bmjoq-2018-000355. PMID: 30019016; PMCID: PMC6045757.

For the PDF of this article,
contact nzmj@nzma.org.nz

View Article PDF

“Some very important clinical issues, some of them affecting life and death, stay largely in a backwater which is inhabited by academics and professionals and enthusiasts, dealt with very well at the clinical and scientific level but not visible to the public, political leaders, leaders of healthcare systems… The public and political space is the space in which [sepsis] needs to be in order for things to change.” ¬– Sir Liam Donaldson

Sepsis is the syndrome connecting infection to acute multi-organ failure and death. It is a clinical diagnosis, resting on the identification of “life threatening organ failure due to a dysregulated host response to infection.” [[1]] Common causes include pneumonia, invasive bacterial infection (eg, Staphylococcus aureus bacteraemia), urinary tract and soft-tissue infection. Almost a quarter of a century ago, Finfer et al estimated that the incidence of sepsis requiring ICU admission in Australia and New Zealand was 0.77 per 1,000 population per year.[[2]] It was subsequently demonstrated that this approach missed 30% of the cases identified using consensus clinical criteria.[[3]] Added to this, the population with sepsis in intensive care is only a fraction of the total. Local audit at Waikato Hospital suggests that the true population of adults in hospital with sepsis is five-times the number admitted to ICU.[[4]] Is it plausible to suggest that around 1 in 200 people are being admitted to hospital with sepsis each year in New Zealand?

Sepsis admissions can be expected to reveal wicked interactions between deprivation, ageing, frailty and morbidity. New Zealand already has very high rates of bacterial infection, most notably revealed in epidemics of meningococcal disease and rheumatic fever.[[5,6]] Michael Baker and colleagues have shown that the risk of infection-related hospitalisation is 2.8-times higher comparing the highest quintile of socioeconomic deprivation with the lowest. [[7]] Socioeconomic deprivation is more commonly experienced by Māori and Pacific people. To further indict the conditions which give rise to it, sepsis is at least twice as common in these populations.[[8]] Adding to this, chronic medical conditions greatly increase the risk of infection and sepsis, as does population aging.[[9,10]] Is it surprising, then, that infectious disease hospitalisations have risen faster than any other cause over the past three decades, or that sepsis admissions doubled at Waikato Hospital in the five years leading to 2012?[[7,8]]

With these questions in mind, the first National Sepsis Conference was held from 18 to 20 November 2021. As a collaboration between the New Zealand Sepsis Trust (NZST), the Australasian Society for Infectious Disease (ASID) and Te Ohu Rata o Aotearoa (Te ORA), the conference brought together over 200 delegates to consider “challenges for New Zealand.” Prominent clinicians and researchers from the USA, Australia and New Zealand considered topics ranging from acute management of sepsis, to the evidence-informed design of systems to improve quality of sepsis care. In one session, three apparently disparate topics (the Whakaari volcanic eruption, the antimicrobial resistance crisis and the rise in healthcare-associated S. aureus bacteraemia) demonstrated the adversity facing patients and front-line providers. Professors spoke alongside medical students and postgraduate trainees; nurses with interests in sepsis gathered for a workshop to discuss their findings; survivors of sepsis and of COVID-19 shared their stories of hardship and discovery. Prominent Māori academics explained the origin of prevailing inequities revealed by investigation and audit. It was easy to agree that “New Zealand needs a plan.”

The conference was therefore an ideal launchpad for the Aotearoa New Zealand National Sepsis Action Plan. With support from ACC, this work arose from a 2017 World Health Assembly resolution urging member states to invest in sepsis care. The benefits of implementing the plan are nothing compared with the long-term benefits of poverty reduction and action to close gaps in health outcomes. However, the health system needs to lead short-term changes which can lead to quick improvements, so these are the plan’s focus (find out more at www.sepsis.org.nz/action):

  1. Create a National Sepsis Network to drive quality improvement in the acute health sector.
  2. Increase Public Awareness by investing in community infection and sepsis awareness campaigns.
  3. Improve recognition of sepsis in all healthcare settings by ensuring providers can recognise and manage cases of suspected sepsis.
  4. Collect data to drive quality improvement.
  5. Support sepsis survivors by investing in programmes of enhanced recovery and rehabilitation for people leaving hospital after a sepsis event.

Conceived in the pre-COVID era, and concentrating on a response based within the health system, the plan nevertheless reinforces the need to learn from the COVID-19 pandemic and to ensure that the investments made to endure and recover from COVID-19 provide long-lasting benefits. For example, sepsis care should be integrated into antimicrobial stewardship programmes (Recommendation 3). Ninety-five percent of human antimicrobial consumption is in the community. The non-pharmacologic measures deployed to manage COVID-19 were associated with reduced community antimicrobial consumption by over a third without evidence of harm.[[11]] In hospitals, investment in antimicrobial stewardship to improve care for patients with sepsis would start with ensuring urgent treatment but extend to de-escalating and de-prescribing during recovery. Reporting on measures of sepsis outcome in relation to antimicrobial selection, delivery, duration and de-escalation corresponds with the plan’s recommendation to gather and report data (Recommendation 4) and to network the sharing of best practice in relation to quality improvement (Recommendation 1).

It is already known that enormous benefits can be realised by investing in the prevention and mitigation of infectious disease. The British Columbia (BC) Sepsis Network was established in 2012 with a cumulative spend of $500,000 through to 2018. By that time, Khowaja and colleagues estimate that the network’s activities had led to the prevention of 172 deaths and savings of $112 for every dollar invested.[[12]] In New South Wales, a state-wide programme promoting early recognition and treatment of sepsis led to a 20% increase in the proportion of patients with sepsis receiving antibiotics within an hour of emergency department triage. This accompanied a 5% reduction in hospital mortality and a two-day reduction in mean length of stay.[[13]] Also in Australia, a whole-of-hospital sepsis pathway in a specialist cancer hospital halved the average time to antimicrobial therapy, reduced hospital mortality and saw an 18% reduction in the proportion of patients admitted to intensive care.[[14]]

This and other evidence has been used to fund a national sepsis plan for Australia coordinated by the Australian Commission on Quality and Safety in Health Care. In contrast, at the time of writing, a search for “sepsis” on the Ministry of Health website returned only one link, which was to a brief Official Information Act response. Why are we so far behind here? Did late twentieth century models of health investment focus too much on the management of non-communicable disease? Has sepsis fallen into the trap of being everyone’s problem but nobody’s business? Or is the failure to prioritise the prevention and management of severe infection the expected response to a problem which disproportionately affects Māori and Pacific people? Regardless of distal causation, we will not navigate a way forward without coordinated action. So saying, we commend the National Sepsis Action Plan to the leadership of our new health agencies.

Summary

Abstract

Aim

Method

Results

Conclusion

Author Information

Paul Huggan: FRACP. Infectious Disease Physician, Waikato Hospital. Trustee, New Zealand Sepsis Trust. Dan Dobbins: FACEM. Emergency Medicine Physician, Waikato Hospital. Trustee, New Zealand Sepsis Trust. Robert Martynoga: FANZCA FCICM. Intensivist and Amaesthetist, Waikato Hospital. Trustee, New Zealand Sepsis Trust. Chris Hopkins: FRACP. Infectious Disease Physician, Middlemore Hospital. ORCID ID: 0000-0003-3285-3481. Nigel Raymond: FRACP. Infection Service and General Medicine Department, Capital & Coast District Health Board. ORCID ID: 0000-0001-9519-5215.

Acknowledgements

Correspondence

Dr Paul Huggan, FRACP, Infectious Disease Physician, Waikato Hospital. Trustee, New Zealand Sepsis Trust

Correspondence Email

paul.huggan@waikatodhb.health.nz

Competing Interests

Nil.

1. Singer M, Deutschman CS, Seymour C, et al. The third international consensus definitions for sepsis and septic shock (sepsis-3). JAMA - Journal of the American Medical Association. 2016;315(8):801-810. doi:10.1001/jama.2016.0287

2. Finfer S, Bellomo R, Lipman J, French C, Dobb G, Myburgh J. Adult-population incidence of severe sepsis in Australian and New Zealand intensive care units. Intensive care medicine. 2004;30(4):589-596. doi:10.1007/s00134-004-2157-0

3. Heldens M, Schout M, Hammond NE, Bass F, Delaney A, Finfer SR. Sepsis incidence and mortality are underestimated in Australian intensive care unit administrative data. The Medical Journal of Australia. 2018;209(6):255-260. doi:10.5694/MJA18.00168

4. Linde-Zwirble WT, Angus DC. Severe sepsis epidemiology: Sampling, selection, and society. Critical Care. 2004;8(4):222-226. doi:10.1186/cc2917

5. Baker MG, Martin DR, Kieft CEM, Lennon D. A 10-year serogroup B meningococcal disease epidemic in New Zealand: Descriptive epidemiology, 1991-2000. Journal of Paediatrics and Child Health 2001. doi:10.1046/j.1440-1754.2001.00722.x

6. Webb R, Wilson N. Rheumatic fever in New Zealand. J Paediatr Child Health, 2013; 49(3): 179-84.

7. Baker MG, Barnard LT, Kvalsvig A, et al. Increasing incidence of serious infectious diseases and inequalities in New Zealand: a national epidemiological study. Lancet. 2012;379(9821):1112-1119. doi:10.1016/S0140-6736(11)61780-7

8. Huggan PJ, Bell A, Waetford J, Obertova Z, Lawrenson R. Evidence of High Mortality and Increasing Burden of Sepsis in a Regional Sample of the New Zealand Population. Open Forum Infectious Diseases. 2017;4(3). doi:10.1093/ofid/ofx106

9. Wang HE, Griffin R, Judd S, Shapiro NI, Safford MM. Obesity and risk of sepsis: A population-based cohort study. Obesity. 2013;21(12):E762-E769. doi:10.1002/oby.20468

10. Wang HE, Shapiro NI, Griffin R, Safford MM, Judd S, Howard G. Chronic Medical Conditions and Risk of Sepsis. PLOS ONE. 2012;7(10):e48307. doi:10.1371/JOURNAL.PONE.0048307

11. Duffy E, Thomas M, Hills T, Ritchie S. The impacts of New Zealand’s COVID-19 epidemic response on community antibiotic use and hospitalisation for pneumonia, peritonsillar abscess and rheumatic fever. The Lancet Regional Health - Western Pacific. 2021;12:100162. doi:10.1016/J.LANWPC.2021.100162/ATTACHMENT/8ED71F93-DDBC-4EF3-B8C5-59A4533AC84B/MMC1.DOCX

12. Khowaja, A, Willms, AJ, Krause, CM et al. The Return on Investment of a Province-Wide Quality Improvement Initiative for Reducing In-Hospital Sepsis Rates and Mortality in British Columbia, Canada, Critical Care Medicine. doi: 10.1097/CCM.0000000000005353

13. Burrell AR, McLaws M, Fullick M, Sullivan RB, Sindhusake D. SEPSIS KILLS: early intervention saves lives. Med J Aust 2016; 204 (2): 73. || doi: 10.5694/mja15.00657

14. Thursky K, Lingaratnam S, Jayarajan J et al. Implementation of a whole of hospital sepsis clinical pathway in a cancer hospital: impact on sepsis management, outcomes and costs. BMJ Open Qual. 2018;7(3):e000355. doi: 10.1136/bmjoq-2018-000355. PMID: 30019016; PMCID: PMC6045757.

For the PDF of this article,
contact nzmj@nzma.org.nz

View Article PDF

“Some very important clinical issues, some of them affecting life and death, stay largely in a backwater which is inhabited by academics and professionals and enthusiasts, dealt with very well at the clinical and scientific level but not visible to the public, political leaders, leaders of healthcare systems… The public and political space is the space in which [sepsis] needs to be in order for things to change.” ¬– Sir Liam Donaldson

Sepsis is the syndrome connecting infection to acute multi-organ failure and death. It is a clinical diagnosis, resting on the identification of “life threatening organ failure due to a dysregulated host response to infection.” [[1]] Common causes include pneumonia, invasive bacterial infection (eg, Staphylococcus aureus bacteraemia), urinary tract and soft-tissue infection. Almost a quarter of a century ago, Finfer et al estimated that the incidence of sepsis requiring ICU admission in Australia and New Zealand was 0.77 per 1,000 population per year.[[2]] It was subsequently demonstrated that this approach missed 30% of the cases identified using consensus clinical criteria.[[3]] Added to this, the population with sepsis in intensive care is only a fraction of the total. Local audit at Waikato Hospital suggests that the true population of adults in hospital with sepsis is five-times the number admitted to ICU.[[4]] Is it plausible to suggest that around 1 in 200 people are being admitted to hospital with sepsis each year in New Zealand?

Sepsis admissions can be expected to reveal wicked interactions between deprivation, ageing, frailty and morbidity. New Zealand already has very high rates of bacterial infection, most notably revealed in epidemics of meningococcal disease and rheumatic fever.[[5,6]] Michael Baker and colleagues have shown that the risk of infection-related hospitalisation is 2.8-times higher comparing the highest quintile of socioeconomic deprivation with the lowest. [[7]] Socioeconomic deprivation is more commonly experienced by Māori and Pacific people. To further indict the conditions which give rise to it, sepsis is at least twice as common in these populations.[[8]] Adding to this, chronic medical conditions greatly increase the risk of infection and sepsis, as does population aging.[[9,10]] Is it surprising, then, that infectious disease hospitalisations have risen faster than any other cause over the past three decades, or that sepsis admissions doubled at Waikato Hospital in the five years leading to 2012?[[7,8]]

With these questions in mind, the first National Sepsis Conference was held from 18 to 20 November 2021. As a collaboration between the New Zealand Sepsis Trust (NZST), the Australasian Society for Infectious Disease (ASID) and Te Ohu Rata o Aotearoa (Te ORA), the conference brought together over 200 delegates to consider “challenges for New Zealand.” Prominent clinicians and researchers from the USA, Australia and New Zealand considered topics ranging from acute management of sepsis, to the evidence-informed design of systems to improve quality of sepsis care. In one session, three apparently disparate topics (the Whakaari volcanic eruption, the antimicrobial resistance crisis and the rise in healthcare-associated S. aureus bacteraemia) demonstrated the adversity facing patients and front-line providers. Professors spoke alongside medical students and postgraduate trainees; nurses with interests in sepsis gathered for a workshop to discuss their findings; survivors of sepsis and of COVID-19 shared their stories of hardship and discovery. Prominent Māori academics explained the origin of prevailing inequities revealed by investigation and audit. It was easy to agree that “New Zealand needs a plan.”

The conference was therefore an ideal launchpad for the Aotearoa New Zealand National Sepsis Action Plan. With support from ACC, this work arose from a 2017 World Health Assembly resolution urging member states to invest in sepsis care. The benefits of implementing the plan are nothing compared with the long-term benefits of poverty reduction and action to close gaps in health outcomes. However, the health system needs to lead short-term changes which can lead to quick improvements, so these are the plan’s focus (find out more at www.sepsis.org.nz/action):

  1. Create a National Sepsis Network to drive quality improvement in the acute health sector.
  2. Increase Public Awareness by investing in community infection and sepsis awareness campaigns.
  3. Improve recognition of sepsis in all healthcare settings by ensuring providers can recognise and manage cases of suspected sepsis.
  4. Collect data to drive quality improvement.
  5. Support sepsis survivors by investing in programmes of enhanced recovery and rehabilitation for people leaving hospital after a sepsis event.

Conceived in the pre-COVID era, and concentrating on a response based within the health system, the plan nevertheless reinforces the need to learn from the COVID-19 pandemic and to ensure that the investments made to endure and recover from COVID-19 provide long-lasting benefits. For example, sepsis care should be integrated into antimicrobial stewardship programmes (Recommendation 3). Ninety-five percent of human antimicrobial consumption is in the community. The non-pharmacologic measures deployed to manage COVID-19 were associated with reduced community antimicrobial consumption by over a third without evidence of harm.[[11]] In hospitals, investment in antimicrobial stewardship to improve care for patients with sepsis would start with ensuring urgent treatment but extend to de-escalating and de-prescribing during recovery. Reporting on measures of sepsis outcome in relation to antimicrobial selection, delivery, duration and de-escalation corresponds with the plan’s recommendation to gather and report data (Recommendation 4) and to network the sharing of best practice in relation to quality improvement (Recommendation 1).

It is already known that enormous benefits can be realised by investing in the prevention and mitigation of infectious disease. The British Columbia (BC) Sepsis Network was established in 2012 with a cumulative spend of $500,000 through to 2018. By that time, Khowaja and colleagues estimate that the network’s activities had led to the prevention of 172 deaths and savings of $112 for every dollar invested.[[12]] In New South Wales, a state-wide programme promoting early recognition and treatment of sepsis led to a 20% increase in the proportion of patients with sepsis receiving antibiotics within an hour of emergency department triage. This accompanied a 5% reduction in hospital mortality and a two-day reduction in mean length of stay.[[13]] Also in Australia, a whole-of-hospital sepsis pathway in a specialist cancer hospital halved the average time to antimicrobial therapy, reduced hospital mortality and saw an 18% reduction in the proportion of patients admitted to intensive care.[[14]]

This and other evidence has been used to fund a national sepsis plan for Australia coordinated by the Australian Commission on Quality and Safety in Health Care. In contrast, at the time of writing, a search for “sepsis” on the Ministry of Health website returned only one link, which was to a brief Official Information Act response. Why are we so far behind here? Did late twentieth century models of health investment focus too much on the management of non-communicable disease? Has sepsis fallen into the trap of being everyone’s problem but nobody’s business? Or is the failure to prioritise the prevention and management of severe infection the expected response to a problem which disproportionately affects Māori and Pacific people? Regardless of distal causation, we will not navigate a way forward without coordinated action. So saying, we commend the National Sepsis Action Plan to the leadership of our new health agencies.

Summary

Abstract

Aim

Method

Results

Conclusion

Author Information

Paul Huggan: FRACP. Infectious Disease Physician, Waikato Hospital. Trustee, New Zealand Sepsis Trust. Dan Dobbins: FACEM. Emergency Medicine Physician, Waikato Hospital. Trustee, New Zealand Sepsis Trust. Robert Martynoga: FANZCA FCICM. Intensivist and Amaesthetist, Waikato Hospital. Trustee, New Zealand Sepsis Trust. Chris Hopkins: FRACP. Infectious Disease Physician, Middlemore Hospital. ORCID ID: 0000-0003-3285-3481. Nigel Raymond: FRACP. Infection Service and General Medicine Department, Capital & Coast District Health Board. ORCID ID: 0000-0001-9519-5215.

Acknowledgements

Correspondence

Dr Paul Huggan, FRACP, Infectious Disease Physician, Waikato Hospital. Trustee, New Zealand Sepsis Trust

Correspondence Email

paul.huggan@waikatodhb.health.nz

Competing Interests

Nil.

1. Singer M, Deutschman CS, Seymour C, et al. The third international consensus definitions for sepsis and septic shock (sepsis-3). JAMA - Journal of the American Medical Association. 2016;315(8):801-810. doi:10.1001/jama.2016.0287

2. Finfer S, Bellomo R, Lipman J, French C, Dobb G, Myburgh J. Adult-population incidence of severe sepsis in Australian and New Zealand intensive care units. Intensive care medicine. 2004;30(4):589-596. doi:10.1007/s00134-004-2157-0

3. Heldens M, Schout M, Hammond NE, Bass F, Delaney A, Finfer SR. Sepsis incidence and mortality are underestimated in Australian intensive care unit administrative data. The Medical Journal of Australia. 2018;209(6):255-260. doi:10.5694/MJA18.00168

4. Linde-Zwirble WT, Angus DC. Severe sepsis epidemiology: Sampling, selection, and society. Critical Care. 2004;8(4):222-226. doi:10.1186/cc2917

5. Baker MG, Martin DR, Kieft CEM, Lennon D. A 10-year serogroup B meningococcal disease epidemic in New Zealand: Descriptive epidemiology, 1991-2000. Journal of Paediatrics and Child Health 2001. doi:10.1046/j.1440-1754.2001.00722.x

6. Webb R, Wilson N. Rheumatic fever in New Zealand. J Paediatr Child Health, 2013; 49(3): 179-84.

7. Baker MG, Barnard LT, Kvalsvig A, et al. Increasing incidence of serious infectious diseases and inequalities in New Zealand: a national epidemiological study. Lancet. 2012;379(9821):1112-1119. doi:10.1016/S0140-6736(11)61780-7

8. Huggan PJ, Bell A, Waetford J, Obertova Z, Lawrenson R. Evidence of High Mortality and Increasing Burden of Sepsis in a Regional Sample of the New Zealand Population. Open Forum Infectious Diseases. 2017;4(3). doi:10.1093/ofid/ofx106

9. Wang HE, Griffin R, Judd S, Shapiro NI, Safford MM. Obesity and risk of sepsis: A population-based cohort study. Obesity. 2013;21(12):E762-E769. doi:10.1002/oby.20468

10. Wang HE, Shapiro NI, Griffin R, Safford MM, Judd S, Howard G. Chronic Medical Conditions and Risk of Sepsis. PLOS ONE. 2012;7(10):e48307. doi:10.1371/JOURNAL.PONE.0048307

11. Duffy E, Thomas M, Hills T, Ritchie S. The impacts of New Zealand’s COVID-19 epidemic response on community antibiotic use and hospitalisation for pneumonia, peritonsillar abscess and rheumatic fever. The Lancet Regional Health - Western Pacific. 2021;12:100162. doi:10.1016/J.LANWPC.2021.100162/ATTACHMENT/8ED71F93-DDBC-4EF3-B8C5-59A4533AC84B/MMC1.DOCX

12. Khowaja, A, Willms, AJ, Krause, CM et al. The Return on Investment of a Province-Wide Quality Improvement Initiative for Reducing In-Hospital Sepsis Rates and Mortality in British Columbia, Canada, Critical Care Medicine. doi: 10.1097/CCM.0000000000005353

13. Burrell AR, McLaws M, Fullick M, Sullivan RB, Sindhusake D. SEPSIS KILLS: early intervention saves lives. Med J Aust 2016; 204 (2): 73. || doi: 10.5694/mja15.00657

14. Thursky K, Lingaratnam S, Jayarajan J et al. Implementation of a whole of hospital sepsis clinical pathway in a cancer hospital: impact on sepsis management, outcomes and costs. BMJ Open Qual. 2018;7(3):e000355. doi: 10.1136/bmjoq-2018-000355. PMID: 30019016; PMCID: PMC6045757.

Contact diana@nzma.org.nz
for the PDF of this article

Subscriber Content

The full contents of this pages only available to subscribers.
Login, subscribe or email nzmj@nzma.org.nz to purchase this article.

LOGINSUBSCRIBE