Presented by : Joshua Muthuiru (CCN).

1. Subject :The Impact of Sepsis Among Patients Admitted In Public Hospital ICU.A study done at Machakos Level Five . Presented by : Joshua Muthuiru (CCN).

2. INTRODUCTION In Kenya, approximately 14000 admissions occur in ICU (MOH, 2016). Machakos L5 hospital has 6 bed ICU and is a leading public hospitals in service delivery. Patient in ICU are severely ill and undergo multiple complex interventions at the same time, these patients are extremely vulnerable to experiencing adverse outcomes. In addition to its impact on mortality, critical care is a costly component of the national health care budget, with costs estimated to be $81.7 billion by 2005, accounting for 13.7% of hospital costs,4.1% of national health expenditures, and 0.066% of the gross domestic product (NHS-2009). These costs are largely explained by the length of stay (LOS) in the ICU (IHI, 2011).

3. Intro’ ctd. • Sepsis Definition. • Sepsis is a growing worldwide threat. “ Preventing infection and fighting sepsis saves 800,000 lives a year (WSD, 2017) .10-15% deaths are avoidable by vaccination, hygiene measures, early recognation &treatment . • Sepsis is a major cause of deaths in developed nations, Sub-Saharan African data is lacking due to “garbage Codes”& lack research. • Sepsis (new def;) Life threatening organ dysfunction due to dyseregulated host response to infection.

4. Sepsis is a clinical syndrome with a continuum of increasingly severe manifestation of symptoms. • It is body’s response to an infection that has moved beyond localized tissue to become systemic inflammatory response syndrome (SIRS). • SIRS: Signs; tachycardia, tachypnea/hyperventilation, Temp. changes, Leukocytosis, Leukopenia. • No early Rxt; SIRS progresses to severe Sepsis-presence of end organ dysfunction or tissue hypo perfusion; then to- • Septic Shock; persistent hypotension even after fluid resuscitation. threating organ failure due to dyseregulated host response to infection

5. Sepsis has a mortality rate of 10% or higher, making the condition already severe • New sepsis definition-organ dysfunction- threshold that elevates uncomplicated infection to sepsis. • Assessment method organ dysfunction-sequential (sepsis related) organ failure assessment (SOFA). • New clinical criteria-quickSOFA (qSOFA); 3 simple tests identity patients at risk of sepsis • Alteration on mental status. • Decrease in SBP of less than 100mmhg. • Respiration rate greater than 22 breaths/min.

6. Methodology. Audit of the impact of Sepsis on patients admitted in ICU at Machakos Level 5 Hospital over a12 month retrospective Cross-sectional study for the year 2015/2016. Data was extracted from the case notes and the ICU records of the patients by use of questionnaires and analyzed for the care and the outcome of the patient, and other variables.

7. RESULTS • Male 73 Females -65 • Number of beds 6, with only 4 in use. • Total Number of patients discharged to the wards 71 (52%), referrals to higher facilities ( ) 27% (23). Mortality rescued for the year 31%. Medical condition 53% (73) surgical including obs ( ) 47% (64)

8. CONDITIONS • TBI (12%) - 16 • SEPSIS 9% - 12 • CVDs 7% - 10 • MENEGITIS 5% - 7 • OTHER (Tetanus, Gullaine Borne, obs, Lymes, AE’s) 67% - 92

10. DEATHS BY CONDITION • SEPSIS 36% (16) • TBI 30% (13) • CVDs 03% (2) • MENGITIS 10% (4) • AE’S 10% (4) • OTHERS 11% (5)

11. DEATH BY CONDITION

12. DISCUSSION • Total admissions 137: Medical conditions (73) 53%, surgical (64) 47%, Mortality accounted for 31% (43) and discharges to wards 52% (71). Referrals for higher care 17%. Leading cause of admissions, Traumatic brain injury (TBI) 12%, Sepsis 9%, Cardiovascular conditions (CVD’s) 7%, Meningitis 5%, others 67%. Leading cause of death: Sepsis 36%, TBI 30%, CVD’s 13%, Meningitis 10%, AEs: theatre related 10%, others 20%. Patients assessment used Glasgow Coma Scale (GCS); APACHE I or II unaffordable due to cost of investigations . • Other constrains included; lack of antibiotics, inotropes and shortage of ICU nurses, and doctors.

13. DISCUSSION • Burden of diseases from sepsis in Africa & Kenya remains unknown. • lack of data on sepsis Rxt. Due to “garbage codes” . • There need to improve coding of sepsis and proper accounting for statistics • Health workers to increase awareness on sepsis by using the term “sepsis” in communication. • 70% of sepsis cases are community acquired (wsd,2017). • Notable is, progression from infection to sepsis can be insidious and is unpredictable • Need to recognize perceived conflict between rapid administrations of antibiotics to sepsis and efforts to combat Antimicrobial resistance • Sepsis; leading cause of death from infection and reported in incidence is on the rise

14. Recommendation • Promulgation of clear, comprehensive treatment guidelines, e.g., surviving sepsis campaign applicable to LMIC. • Recognition of Key Role of Prevention –Through vaccination, clean child birth & surgical practice, hand hygiene • Increased awareness to health workers, relatives and patients. • WHA resolution – include politician, policymaker healthcare administrators, clinicians among others • Global/Local action plan on antimicrobial resistantance • Timely and appropriate to clinical management of sepsis • Promote research & data Collection on sepsis

15. Recommendation ct’d • Early recognation & appropriate Rxt of Sepsis, in areas such as A&E, clinics, OPD, wards. • Antimicrobial stewardship. • Appropriate Sepsis Codes-ICD9/10. • NB: Severe Sepsis has been left out from the new Sepsis definition.

16. CONCLUSION • With respect to the challenges facing public hospitals in Kenya, it need to recognize that the sorry state of affair of public healthcare is not for want of policies or managerial skills or for want of latest technologies rather resource allocation in areas such as IPC programs. • There is little or no data on precise incidences ,Etiology & onset of sepsis in Public hospitals. • Simple interventions have effective Such; IPC measures like, Hands hygiene, Antimicrobial stewardship among others.