Title: Digital alerting to improve sepsis detection and patient outcomes in NHS Trusts
Funder: Department of Health and Social Care

Abstract: Sepsis is a serious disease, most commonly caused by a bacterial infection and treatable with antibiotics. If patients don’t get antibiotics quickly enough the infection can cause vital organs, such as the liver and kidneys, to shut down. This can result in death. Identifying patients with sepsis as early as possible means treatment with antibiotics is started quickly._x000D_ _x000D_ There are lots of ways of identifying patients who may have sepsis based on their clinical condition. For example, high or low temperature and fast breathing rate. Most of these measurements can be combined to create a score – if the score is high sepsis should be considered. The introduction of electronic health records in hospitals in the UK has meant that these scores can be included in the system and doctors and nurses can be digitally ‘alerted’ to sepsis. _x000D_ _x000D_ Our research in a busy London hospital has already shown that the introduction of a digital sepsis alert is associated with more patients receiving antibiotics in the target of one hour after identification and fewer patients dying. We want to expand this work to include sites from other areas of the UK. Different hospitals have used different methods of creating a score and introduced the digital alerting systems in different ways, some of which include details on a patient’s clinical history. We want to establish which method works best, and how. This research will assess whether different digital alerts, and the way in which they were introduced results in better outcomes for patients. _x000D_ _x000D_ The research will have two parts. In the first part we will use statistical methods to analyse patient digital health records. This will allow us to find out if patients are doing better in hospitals when a digital alert is present and whether different alerting systems perform better than others. We will focus on whether or not patients have received the recommended care and whether they have better health outcomes. For example, do they have shorter hospital stays? are they less likely to return to hospital? and are they less likely to die? _x000D_ _x000D_ In the second part of the research we will use interviews and discussions, as well as studying hospital paperwork, to understand how the digital alert was introduced in different hospitals and what people, including doctors, nurses, pharmacists and patients, think of the alert. We will also understand whether the alert was introduced alongside changes in treatment plans for patients with sepsis._x000D_ _x000D_ Our team has experience of working with hospital staff to ensure the findings of our research are useful to clinicians and inform practice and policy. We will develop these close working links with other hospitals and feedback our findings to support ongoing work with patients with sepsis. We will work closely with NHS and doctors organisations to ensure that the introduction of alerts in UK NHS hospitals has the maximum impact.

Lay abstract: Background_x000D_ Identifying clinical deterioration in order to prevent death is a major focus for health systems across the world. Sepsis is a specific cause of clinical deterioration with an estimated 46,000 deaths in the UK each year. Early Warning Scores, based on patients’ vital signs, can be embedded into patient electronic health records to digitally alert clinicians to patients at risk. Rapid identification is imperative for patients with sepsis as rapid treatment, including appropriately targeted intravenous (IV) antibiotics have been shown to be effective in improving patient outcomes._x000D_ _x000D_ Research question_x000D_ How effective are the introduction of digital alerts to improve outcomes of patients with sepsis?_x000D_ Using routine clinical datasets, across six UK NHS acute trusts, the mechanisms and mediators of effectiveness and consequences of digital alerting in outcomes for patients with sepsis will be assessed. This project focuses on digital alerts used to identify clinical deterioration due to sepsis or serious infectious disease. _x000D_ _x000D_ Objectives_x000D_ _x000D_ 1. Map the digital alerts currently in use in multiple UK hospitals to identify patients at risk of having sepsis (WS1)_x000D_ _x000D_ 2. Evaluate the impact of digital alerts on outcomes for patients at risk of sepsis (WS2)_x000D_ _x000D_ 3. Examine the impact of the implementation process on digital alert performance, guided by the consolidated framework for implementation research (WS3)_x000D_ _x000D_ 4. Make recommendations on the effectiveness of different digital alerts and the most effective method of implementation using a systems modelling approach to assess causality of effects, including a mediation analysis (WS4)_x000D_ _x000D_ Methods_x000D_ This research has four workstreams, and will use a range of qualitative and quantitative approaches. Document analysis will be used to map digital alerts used across NHS Trusts (WS1). Qualitative approaches, including interviews and focus groups, will allow us to examine the implementation process and its impact on digital alert performance (WS3). A natural experiment will assess impact of the digital alerts on patient outcomes and use approaches including multi-level interrupted time series (WS2). The primary outcome will be in-hospital mortality. Secondary outcomes will include administration of IV-antibiotics, length of stay and transfer to intensive care. We will examine unintended outcomes associated with the alerts. Mediation analysis will be conducted in WS4 and will consolidate learning from WS1 to 3. This will allow us to describe the relationship between implementation, the implementation process and changes in patient outcomes. Routinely collected clinical data will be used for this research, processed in line with NIHR-Health Information Collaborative protocols. All Trusts have agreed to share data and specific local ethical and governance approval will be sought at each site. The research will be completed in 36 months._x000D_ _x000D_ Anticipated impact and dissemination_x000D_ This research is in collaboration with five NHS Trusts and the UK Sepsis Trust. Our study will impact on patients, hospital staff and policy makers. Our methodologies will be applicable to the introduction of other digital innovations in NHS hospitals. We will use innovative methods to disseminate out findings including a Goldilocks Ward which will enable people to engage with simulated sepsis patients and digital alerts, and the ‘Sepsis Big Room on Tour’.

Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: INFECTION;INFLAMMATORY AND IMMUNE SYSTEM