By JUDITH EVANS
Early identification and aggressive treatment are keys to controlling sepsis and reducing sepsis-related deaths, experts say. Humility of Mary Health Partners, the Daughters of Charity Health System, Mercy and Trinity Health are among ministry systems focusing on just that, with significant success.
Serious infection is the underlying trigger for sepsis, but not all infections progress to sepsis. Dr. Robert W. Taylor, who has researched sepsis for nearly two decades and serves as chair of critical care medicine at Mercy Hospital St. Louis, said that before patients become septic they develop systemic inflammatory response syndrome in response to the underlying infection. "This systemic response suggests the body's immune system has gone into overdrive and is the beginning of some people going into severe sepsis," which can progress into life-threatening septic shock, he said.
Warning signs include fever, accelerated heart rate, a fast respiratory rate and an elevated or depressed white blood cell count. When two of the four are present, and the clinician believes the systemic response is secondary to an infection, the patient has sepsis, Taylor said. There is no specific blood test to confirm sepsis. "It's a clinical diagnosis."
Rhonda Gluckner, sepsis coordinator for Humility of Mary Health Partners, said the condition can progress quickly to severe sepsis, which is marked by organ failure, and then to septic shock, with low blood pressure that cannot be reversed with fluids.
The goal for clinicians, said Taylor, is to be on guard for the warning signs and respond fast with broad spectrum antibiotics and fluids, refining the treatment over hours and days as lab tests reveal more specific information about the type and source of the underlying infection. "Time is critical. If I wait to start my therapy until a lab test or a blood culture comes back, I've waited 24 to 48 hours too long," he said.
"It's very apparent that this disease process is a killer," Taylor said. "You've got to treat it quickly, and if you do, the mortality just plummets."
Growing risk
Pope John Paul II, Superman actor Christopher Reeve and Muppets creator Jim Henson are among those whose deaths were attributed to sepsis. According to figures compiled by the Institute for Healthcare Improvement, the U.S. sees approximately 750,000 cases of sepsis annually, resulting in at least 210,000 deaths, a mortality rate of 28 percent. Estimates for the mortality rate for severe sepsis and septic shock are as high as 50 percent. "As medicine becomes more aggressive, with invasive procedures and immunosuppression, the incidence of sepsis is likely to increase even more," the institute predicts.
"Everybody knows breast cancer, everybody knows stroke and heart attack," Gluckner said. "I think sepsis is the next disease people are going to focus on."
In its early stages, sepsis can be hard to recognize. Gluckner uses a computer system to monitor patients at Youngstown, Ohio-based Humility of Mary's three hospitals, two free-standing emergency centers and two urgent care centers. When she suspects a patient has developed sepsis, she alerts a physician. When sepsis is diagnosed, she assures that the medical team is providing appropriate treatment.
Since her job was created in 2010, Humility of Mary has seen the average length of stay for patients with severe sepsis or septic shock drop from 13.7 days in 2009 to 8.7 days in 2012 and the mortality rate fall from 19.6 percent to 16.7 percent.
Ask a nurse
At Daughters of Charity, nurses have taken the lead in designing systems to screen patients for sepsis, said Nancy Carragee. She is vice president of quality for the Los Altos Hills, Calif.-based system. Those nurses head multidisciplinary teams that study quality-improvement methods, data analysis, communication and peer coaching. Since 2008, sepsis mortality at the system's five hospitals has fallen from 18.5 percent to 14.2 percent, which she estimates has saved more than 300 lives.
"We have a lot of partners. I think that's the key," she said. The Gordon and Betty Moore Foundation and the UniHealth Foundation awarded grants. The University of California-San Francisco's Center for the Health Professions and the Altos Group provided training, faculty and curriculum, and Paul E. Plsek and Associates, which teaches creative thinking, provided senior team coaching.
Flagging patients
About three years ago, Taylor headed a Mercy team that evaluated how well three of the Chesterfield, Mo.-based system's large hospitals and one of its smaller hospitals were complying with guidelines for responding to sepsis and septic shock. "We found that we weren't doing as well as we'd hoped," said Taylor. "There were significant time delays in diagnosis and treatment."
To address the problem, Mercy put together an action committee in St. Louis comprised of doctors, nurses and other clinical staff.
The committee's effort includes teaching employees and other emergency room clinicians about the imperative to promptly screen patients for sepsis risk. "Many patients come from home fairly advanced down this pathway; if that is the case, you want to fast track them to the ICU," Taylor said.
Mercy St. Louis' electronic medical records program now is nimble enough to flag patients at-risk for sepsis before symptoms raise concerns for doctors or nurses. A high or low temperature, fast respiration, high or low blood pressure and white blood count are taken into account, as is indirect evidence of an underlying infection such as a doctor having ordered a urine culture, blood culture or antibiotic.
If the analysis points to sepsis or its precursor syndrome, the software places the patient in a "virtual sepsis unit" and alerts the sepsis nurse at Mercy's control center for its systemwide telemedicine intensive care service, based at Mercy St. Louis. She confers with a physician in the virtual ICU unit then calls the bedside caregivers to alert them to the risk or presence of sepsis in a patient.
Mercy will begin incorporating the sepsis-detecting software in all 32 of its hospitals this year.
"Many of our hospitals are rural facilities, and they don't have 24-7 expertise in the management of septic shock," Taylor said. "Because of today's technology, we can see which patients are at greatest risk, begin treatment and save lives."
Mercy St. Louis has cut the mortality rate for septic shock in half, to 18.5 percent, and Taylor predicts similar results across Mercy. This month Mercy will bring together 60 to 80 clinicians from across the system for a two-day sepsis summit.
Vigilance
Trinity Health also has put computer power behind its clinicians in the fight against sepsis. When vital signs and lab values suggest sepsis, a computer sends out an alert. "It's kind of like the warning lights we have on our car when we have low tire pressure," said Paul Conlon, senior vice president for clinical quality and patient safety for the Livonia, Mich.-based system.
In October 2010, Trinity Health formed a collaborative effort on sepsis. More than 225 participants represent every ministry organization in the system: 47 hospitals, over 30 long-term care facilities and home health care. With the focused effort, Trinity's mortality rate has fallen from 15.7 percent to 12.9 percent of all sepsis patients, sparing 406 lives in fiscal year 2012.
Margaret A. Reynolds is Trinity's director of evidence-based practice. She said that the recommended sepsis treatments may seem counterintuitive. "Fluid volume is probably the toughest one to get people to buy into," she said. The standard is 1 to 2 liters of fluid per hour. "That's scary for patients with renal failure, heart failure — but that's what saves lives." Treating patients with appropriate antibiotics also is vital, she said. "Sometimes people are hesitant to pull out these big-gun antibiotics when they don't know what the organism is." But those aggressive treatments keep many patients from progressing to septic shock. As a result, Trinity saw a $16.6 million reduction last year in the cost of caring for sepsis patients.
Still, saving lives is more important than saving money, Conlon said. "Our mission says we're going to improve the health of the community we serve," he said. "There are 406 people walking around who might not have been … We do this together. It's in the spirit of the Gospel that we do this."
Scientists publish revised guidelines on sepsis treatment
Newly revised guidelines from the Surviving Sepsis Campaign advise that doctors who suspect a patient has sepsis start antibiotics within 45 minutes, even if that doesn't allow time for diagnostic tests to be performed first.
"We figured out that it's really important to get the antibiotics in very early," Dr. Clifford S. Deutschman said. "The best of all possible worlds is to get the diagnosis first, but you don't want to wait to get them on something that should be lifesaving." He is a coauthor of the guidelines, which were published jointly in the February issues of Critical Care Medicine, the journal of the Society of Critical Care Medicine, and Intensive Care Medicine, the journal of the European Society of Intensive Care Medicine.
Doctors from North America, South America, Europe and Israel drew up the revised guidelines, which originally were written in 2004 and previously revised in 2008. "We got the experts, the best people we could find to review the data," said Deutschman, professor of anesthesiology and critical care and director of the Sepsis Research Program at Perelman School of Medicine at the University of Pennsylvania and a past president of the Society of Critical Care Medicine. That society launched the Surviving Sepsis Campaign.
The revised guidelines also include these key changes:
Administering 30 cc of fluid per kilogram of body weight, up from 20 cc in the previous guidelines.
Employing norepinephrine as the first-line drug when a vasopressor is required to increase blood pressure. Vasopressin is no longer the second-line drug. Dopamine should not be used for renal protection.
Treating elevated glucose above 180 mg/dl. Previous guidelines recommended keeping glucose between 80 mg/dl and 110 mg/dl.
No longer using Recombinant Activated Protein C.