PP26 Missed opportunities in ambulance sepsis care

Background Two-thirds of severe sepsispatients are initially seen in the emergency department, with the majority arriving via ambulance. Since early sepsisrecognition, diagnosis and clinical management are considered key for optimal patient outcomes, ambulance clinicians are well placed to have a key role in sepsiscare. This study aims to identify key patient, clinician and organisation-derived factors which lead to missed sepsisrecognition and delayed access to definitive care in the ambulance setting. Methods The East of England Ambulance Service NHS Trust declares any missed cases of sepsisas a Serious Incident (SI; NHS England Serious Incident Framework 2015) to support clinician and service learningand prevent reoccurrence. A qualitative thematic review, based on the Yorkshire Contributory Factors Framework, has being conducted using seventeen sepsis-related SI reports generated between March 2014 and March 2016. Results SIs were usually associated with emergency/999 calls resulting in non-conveyance. Breathing/respiratory problems were the most prevalent chief complaint. Perceived contributory factors to these incidences were: ‘Patient-derived’: unwell patients with capacity choosing to remain at home, despite advice to attend hospital; presence of co-morbidities and other medical conditions. ‘Clinician-derived’: inadequate patient assessment and triage; failure to recognise sepsismarkers and use screening tools; low index of suspicion for sepsisand rapid patient deterioration; insufficient safety-nettingand documentation; communication errors. ‘Organisation-derived’: increasing service demands; mismatch between clinician and vehicle response allocation; lower acuity calls receiving delayed responses at peak demand; variable provision of staff training; lack of clinical practice monitoring; lack of safety culture; promotion of alternative care pathways. Conclusions Errors in pre-hospital sepsiscare occur at all service levels. SI reports provide invaluable systems-based analyses of healthcare episodes and offer concise guidance to prevent error reoccurrence and improve future care. The study findings will inform the development of a prospective sepsisrisk assessment tool using prospective hazards analysismethodologies.