By Gary Evans, Senior Staff Writer
With everything else they are tasked to do, infection preventionists may question why they are now being called upon as key collaborators in the national effort to reduce sepsis, a syndrome traditionally more associated with critical care than infection control.
The short answer — proven by the IPs who have joined sepsis prevention collaborative teams — is that they can make a difference. An IP speaking at a sepsis session recently in Charlotte at the annual APIC conference summed up the current situation for the audience.
“For those of you sitting here thinking, ‘I’m an IP. I know nothing about sepsis. My quality, ICU, and ID teams lead sepsis at my hospital.’ Two years ago I was where you are, [but] you learn as you go the vital role we can play,” says Laura Anderson, RN, MSN, CIC, manager of infection prevention at Newton Medical Center in Denville, NJ. “As IPs, we know that we are collaborative and very interdisciplinary. I am the only IP in my facility, so I very much rely on the people I work with to get the job done.”
Getting the job done against sepsis means saving lives and dollars, as the deadly but poorly understood condition has become one of healthcare’s most dreaded outcomes. The increasing use of rapid detection and intervention strategies have lowered mortality to some degree, but sepsis still takes a staggering toll.
“I think it’s important to remember that sepsis is the single most expensive condition treated in the United States — about $20.3 billion in 2011,” Mitchell Levy, MD, MCCM, FCCP, chief of the division of critical care at Brown University in Providence, RI, recently noted at a press conference at the CDC. “The mortality rate, although going down, still remains quite high — it’s 15% to 25% or so. That’s a significant number. About 300,000 people in the U.S. die of sepsis every year. So, although the mortality rate seems to be going down based on appropriate treatment, we still have a long way to go.”
Thus, IPs are being drafted to join a national effort to prevent, detect, and rapidly treat sepsis before it becomes the fatal sequelae of what could begin as a simple infection. Sepsis is essentially a systematic inflammatory immune response to an infection that can quickly become life-threatening. In severe cases, organs begin to fail as blood pressure drops, affecting the heart and leading to septic shock. At that point, the patient’s life hangs in the balance and rapid interventions must be brought to bear to avert death.
Giving hospitals a sense of urgency in responding to sepsis, CMS issued regulations last year that define severe sepsis and require intervention bundles at three hours and six hours. The definition includes a temperature of more than 100.9 F or less than 96.8 F, pulse exceeding 90 beats per minute, respiration rate at more than 20 breaths per minute, and signs of organ failure. Interventions include measurement of lactate, obtaining blood cultures, administering broad spectrum antibiotics, fluid resuscitation, and vasopressor administration. The new sepsis regulations have not been without controversy, particularly among emergency care providers, some of whom say the CMS sepsis “reporting rules are rigid and onerous and may not always reflect best clinical care for all patients.”1 In addition, the CMS has established measures for Sequential Organ Failure Assessment for diagnosing sepsis.2
Some 20% of sepsis infections have hospital onset, so enforcing basic infection control principles like hand hygiene remain critically important. However, the CDC is finding that the majority of the remaining cases are community onset, though the key caveat is that most of these patients have recently received healthcare or they a have chronic condition that requires frequent medical care. When these patients present in the ED or develop sepsis after admission, time is of the absolute essence.
To respond quickly, Anderson and colleagues at Newton Hospital formed a Code Sepsis Team to get all critical hands on deck once a patient with suspected septic shock is identified.
“Ours is a silent alert, not a code that is called overhead,” she says. “It’s a page that goes to the cell phones of certain key members of the sepsis team, including myself, the ED medical director, and our ICU manager. It lets the ICU know we have a patient they need to get a bed ready for. It alerts our critical care physician who is on call so they know they have an admission, and the same for the hospitalist. It alerts the pharmacy so we will have the antibiotics we need. It also triggers the lab so they know we need to have the blood work run STAT.”
The patient record goes into a bright red folder that stays with the patient and documents the various aspects of sepsis response, she notes.
Also speaking at the APIC sepsis session was Shannon Davila, RN, MSN, CIC, CPHQ, a former hospital IP now with the American Hospital Association. A look at some of the skills in collaboration described in the APIC competency model for IPs underscores their valuable role on sepsis teams.
“Certainly in our roles we are collaborating all the time with medical staff, ID, nurses, environmental service,” she says. “We are really skilled at that, and that is one of the things we can pride ourselves on. And when you think of sepsis, it is no different. It really takes a collaborative approach and involves many of the same key stakeholders that are at the table for HAI prevention.”
IPs also have experience in dealing with electronic medical records, and “sepsis is all about building alerts, looking for those signs and symptoms of when the patients are deteriorating,” Davila says. “I know when I worked in a hospital, my IT department became my best friends when we were building tracking systems and running reports.”
Another IP competency that applies to sepsis is performance improvement and implementation science.
“I think this may be one of the most important parts of our role, and certainly over time we have really looked at how we can advance implementation of HAI prevention and really build those teams including the folks at the bedside,” she says. “With sepsis it is no different. You need to engage physicians, ED, and senior leadership to provide the support that you need to really do some of these interventions.”
While many sepsis cases will come in with the condition, it is important to remain alert for sepsis developing in the hospital, Davila says.
“When patients on a medical-surgical ward develop sepsis and end up going to the ICU, they have a higher mortality rate than a patient coming in through the emergency department,” she says. “So we really had a big push to engage nurses and hospitalists and physicians in the med-surg area to say, ‘We need to identify sepsis early and [begin] those treatment bundles quickly.’”
Though sepsis usually strikes the elderly, a case that drew national attention to the problem was the shocking death of 12-year-old Rory Staunton of Queens, NY, in 2012.
“After this really tragic case, his parents have gone on to be national and international patient advocates for sepsis,” Davila says. “I believe New York was the first state to legislate and mandate that all hospitals have treatment protocols in place for all pediatric and adult cases of sepsis. All New York hospitals have to report every case of sepsis and adhere to the [state] protocols in addition to the CMS bundle.”
Adding a personal emotional context to the clinical discussions at the recent press conference, CDC Director Tom Frieden, MD, described the time he faced sepsis as a father.
“Twenty-two years ago when our older son was just 4 months old, I came home from work one day to find him near death,” he said. “He was completely pale, I didn’t know if he was breathing or not, and it turned out he had bacteria in his blood. We were able to recognize it rapidly, treat it rapidly and he did fine and recovered completely. But he could have died from it. And far too many people do die from sepsis today.”
Some of the general signs that herald sepsis onset include shivering or feeling cold, pain or discomfort, clammy or sweaty skin, being confused or disoriented, shortness of breath, and rapid heartbeat, he said.
“Sepsis most often occurs in people over the age of 65, or infants under the age of one,” Frieden said. “People with chronic diseases such as diabetes, or weakened immune systems from things like tobacco use, are at higher risk of sepsis. But even healthy people can develop sepsis from an infection especially if it’s not treated properly and promptly.”
The CDC is finding that the four infection sites most likely to lead to sepsis are the lungs, urinary tract, skin, and the gut. Basic prevention measures include increasing immunization rates for pneumococcal disease and for influenza, and improving handwashing in healthcare facilities and the community, he says. Heightened awareness by providers and education of the public can also improve detection of sepsis.
“For example, if a patient with diabetes goes to their regular doctor and is found to have increased blood sugar and a small wound on their foot, this is a prime opportunity to think about infections and reduce the risk of sepsis,” Frieden said. “In addition to treating the infection, the clinician can inform the patient and family members about how to care for the wound, how to recognize signs that the infection may be getting worse, and when to seek additional medical care.”
No Simple Test
Since sepsis is caused by a variety of bacteria, there is no single test to make the diagnosis. Thus, clinicians look at the panoply of symptoms and begin antibiotics if they suspect a bacterial infection.
“Some published reports estimate that there are between one and three million people a year in the U.S. diagnosed with sepsis, and between 15% and 30% of these patients will die,” Frieden said. “[But sepsis] is challenging in terms of both its recognition and enumeration. We expect that doctors will draw blood cultures if they think someone has sepsis and then, if clinically appropriate, start them on board spectrum antibiotics, and then reassess 24 to 48 hours later to determine whether they need any antibiotics or more narrowly targeted antibiotics.”
Though given these unknowns it may be a surveillance artifact, the general trend points to an increase in sepsis, but also a diminishment in mortality in those with the syndrome.
“We know that there are certain trends that are very positive,” Frieden said. “For example, Haemophilus influenzae sepsis has been dramatically reduced. We know that, for example, staph or MRSA in intensive care units has come down by half. But in terms of the overall numbers, it’s challenging because there is no standard definition of sepsis or reporting of sepsis, and that’s one of the things that we will be working on to improve going forward. What we know is that, however much there is, it’s too much and we can do a better job preventing it, recognizing it early, treating it effectively, and preventing deaths.”
- Klompas M, Rhee C. The CMS Sepsis Mandate: Right Disease, Wrong Measure. Ann Intern Med 2016 Jun 14. doi:10.7326/M16-0588. [Epub ahead of print].
- Singer M, Deutschman CS, Seymour CW, et al. Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) JAMA. 2016;315(8):801-810.