EXECUTIVE SUMMARY

Although much of the research on sepsis has focused on early recognition and treatment, the CDC issued a new report highlighting opportunities to prevent the condition from developing. To facilitate improvements in this area, investigators highlighted data showing which infections and healthcare factors are associated most commonly with sepsis so that providers can improve their efforts.

  • Investigators reviewed the medical records of 246 adult patients diagnosed with severe sepsis or septic shock at four New York hospitals, finding that the most common types of infections associated with sepsis were respiratory tract, urinary tract, gastrointestinal, and skin and soft tissue.
  • Among 79 pediatric cases, the most common infections included respiratory tract, gastrointestinal, and bloodstream.
  • Investigators found that sepsis occurred most often in patients with one or more comorbidities and that most developed infections that led to sepsis outside the hospital.
  • Given that many patients at highest risk for sepsis frequently encounter the healthcare system, providers have opportunities to better educate patients about prevention and early warning signs.

Healthcare providers understand the importance of picking up on signs of sepsis at the earliest possible stage. The condition is associated with a high mortality rate, so accelerating treatment obviously is critical to achieving a positive outcome. Further, a new report from the CDC suggests that a clear majority of patients diagnosed with sepsis experience onset of the disease before entering the hospital.1 What this means is that emergency providers have both a big opportunity and a responsibility to recognize sepsis in patients, and to start patients on evidence-based treatment protocols quickly.

Although early recognition and treatment must remain a top priority, the CDC report highlights another big opportunity for frontline providers in the battle against sepsis: preventing the condition from occurring in the first place. To help with this task, investigators have begun pinpointing what types of infections, patient characteristics, and other factors are associated most closely with the development of sepsis.

In addition to arming the medical profession with this information, investigators note that patients also can move the needle on sepsis care by recognizing the signs and symptoms so that they can act on these indicators at an early stage. Investigators note that frontline providers are ideally positioned to pass this information along to patients who are most at risk.

Understand Risks

To gather data for the report, CDC investigators performed a retrospective medical record review at four acute care hospitals in New York to isolate patients who received diagnoses of severe sepsis or septic shock between 2013 and 2015. Investigators then reviewed these records to identify factors and characteristics associated with the diagnoses.

Out of 246 adult patients, investigators found that the most common types of infections associated with sepsis were respiratory tract (35%), urinary tract (62%), gastrointestinal (11%), and skin and soft tissue (11%). Among 79 pediatric cases, the most common infections included respiratory tract (29%), gastrointestinal (23%), and bloodstream (13%).

Investigators found that sepsis occurred most often in patients presenting with one or more comorbidities and that most (79.4%) developed infections that led to sepsis outside the hospital. The authors also noted that the majority of these patients had interacted recently with healthcare providers prior to their admission for sepsis — perhaps revealing a key opportunity for providers to educate patients about their risks for sepsis.

“This goes for EDs, but also primary care practitioners [PCPs] and acute care clinics — people on the front line who are seeing patients diagnosed with an infection,” explains Shannon Novosad, MD, the lead author of the review and an epidemic intelligence service officer at the CDC. “It is really about educating patients and their families about what sepsis is and what they should look for to know if sepsis could be happening.”

Leverage Patient Encounters

Although some infections lead to sepsis more commonly than others, Novosad stresses that it is important for patients to understand that almost any infection can lead to the condition. “Keep this in the forefront — that even something that doesn’t seem that serious at the start could develop into something serious,” she explains. “Educate [patients] on the signs and symptoms, and how to know when their infection is getting worse. That is very important.”

In addition, Novosad stresses that patients must feel comfortable and unafraid about asking providers if they might have sepsis, and that providers play a role in helping patients feel empowered to pose these questions.

The study findings show that patients suffering from chronic diseases are more at risk for contracting infections and are at greater risk of developing sepsis. This association was particularly strong with respect to diabetes, Novosad observes. “That disease was common [in the patients who developed sepsis]. Between 30% and 40% had diabetes,” she says. “Also, there was a lot of cardiovascular disease that ranged from coronary artery disease to peripheral vascular disease and some heart failure. Chronic kidney disease was common, and then lung diseases as well, such as COPD.”

One thing that ties these chronic diseases together is the fact that patients presenting with these conditions tend to encounter healthcare providers frequently, Novosad observes. “We are highlighting these chronic diseases for two reasons: Having these chronic diseases puts people at higher risk. But also people who have these chronic diseases are seeing healthcare providers more frequently, and that provides an opportunity to educate them about sepsis,” she explains.

Focus on Prevention

By identifying at-risk groups and documenting factors and conditions that are most associated with sepsis, the CDC hopes to move the conversation beyond the early recognition of sepsis. “One thing that we are really striving to work on is preventing infections. We think that is one really important way to prevent sepsis,” Novosad says. “So efforts here and future work to better understand what patients are getting sepsis and what diseases they have could really inform some of these prevention efforts.”

For example, vaccines to prevent respiratory disease such as influenza and pneumonia also can prevent sepsis because they prevent specific types of infections, Novosad observes. Similarly, decreases in certain behaviors such as smoking will result in lower rates of lung disease, which also leads to a diminished risk of sepsis. “We are trying to take a broad view of prevention for these different types of infections, and not just focus on preventing the infections themselves, but better manage chronic diseases that can increase the risk of infections,” she says.

One component of this work involves developing better surveillance methods so that healthcare policymakers and providers understand better what the true burden of sepsis actually is, Novosad offers. “Everyone can tell that sepsis is a big public health problem,” she says, but getting exact numbers is difficult. “The way we track sepsis now is with billing data,” she notes.

With better definitions and tracking methodologies, healthcare providers will be able to more accurately measure not just the burden of sepsis, but also what interventions are proving most effective, Novosad explains.

Use a Systems Approach

Although moving toward prevention is important, the CDC report also makes clear that emergency providers carry a heavy burden in recognizing sepsis in patients who present for care, according to Manish Garg, MD, a professor of emergency medicine in the Lewis Katz School of Medicine at Temple University. Garg co-authored an accompanying editorial to the CDC report.2 In particular, he highlights the finding that the vast majority of patients in the report were identified as developing sepsis before they arrived at the hospital. This puts the responsibility of early recognition on front-line providers, and this task can be very challenging.

“We have to take a combination of the patient’s history, their risk factors, and their exam. We also have to think about different criteria that they might have,” he says. “Sometimes, we are lucky and we get an immune-compromised patient with a high fever who has a history of sepsis ... but a lot of times there are overlapping illnesses, and [arriving at a correct diagnosis] is very difficult.”

Garg says that early warning tools are helpful in alerting providers that sepsis should be considered, but these tools do not provide definitive answers. “I was working a shift last night and had three patients who were coming up positive for sepsis on our early warning detection score for sepsis. But only one of the three had sepsis,” he explains. “We have a lot to differentiate as the front-line providers in the ED. Sepsis can be very difficult to recognize.”

However, given the high mortality rate associated with sepsis, emergency providers must put the syndrome on their radar, along with a systematized approach for responding, Garg notes. “In our ED, we have ‘think sepsis’ signs plastered literally everywhere, so that is a way to help our providers think about it,” he says. He also emphasizes the importance of having care protocols and checklists, and using early warning scores and triage alerts. “We have systems set up for trauma, so really having a system set up for sepsis that really leverages the entire ED system, from the nurses to the techs to the physicians — that is probably your most effective approach and probably your biggest opportunity for improvement.”

Think Beyond Current Problem

Garg explains that the electronic medical record he uses will prompt providers to consider sepsis automatically when a patient’s vital signs fit the criteria for systemic inflammatory response syndrome. He acknowledges that false positives can frustrate providers but says that the prompt is helpful in the long run. “When we are seeing patients we are always thinking about the worst possibility first — and sepsis carries the highest mortality.”

These types of early warning tools also serve an important role in educating emergency staff about the signs and symptoms of sepsis. “If you have an educated group from the front door of the ED to the provider, you are in the best possible shape to help patients,” Garg observes.

In fact, Garg notes that flu season is when providers really need to be thinking about sepsis. “Patients are staying home longer because it is colder outside and they don’t want to come to the hospital,” he says. “In my experience, this is the time when we see the highest morbidity and mortality from sepsis.”

Garg notes that it is difficult for emergency providers to make a big difference on prevention, but they have opportunities. “In our department, we screen patients when they come in on whether they have received a flu or pneumonia shot. If they haven’t, then they are automatically offered the shots,” he says. “And this is not just for people with respiratory illness.”

Garg stresses that providers should not underestimate the effect flu shots can have on preventing illness and downstream complications such as sepsis. “Right now, the flu strain that is going through our ED is actually covered by this year’s flu shot ... and it is unbelievable what a difference we see in terms of volume,” he says. “The one year I remember when the flu shot didn’t work, it was just non-stop flu. And all these patients with comorbid illnesses were just having horrendous outcomes. So a little bit of prevention goes a long way.”

Further, Garg notes that he reminds residents that they are on the front lines and have an opportunity to teach patients. For example, he often sees patients from nursing homes who are in and out of the hospital frequently. “We really try to talk to them about ways they can prevent the need to come back,” he says. “I always try to put myself in the patient’s or the family’s shoes and say, ‘OK, the current problem is what I am here for, but let’s make sure there is not a future problem.’”

REFERENCES

  1. Novosad SA, Sapiano MR, Grigg C, et al. Vital signs: Epidemiology of sepsis: Prevalence of health care factors and opportunities for prevention. MMWR Morb Mortal Wkly Rep 2016;65:864-869.
  2. Garg M, Otter J, Healy M. Commentary. Ann Emerg Med 2017;69:135-136.

SOURCES

  • Manish Garg, MD, Professor, Emergency Medicine, Lewis Katz School of Medicine, Temple University, Philadelphia. Email: manish.garg@tuhs.temple.edu.
  • Shannon Novosad, MD, Epidemic Intelligence Service Officer, CDC, Atlanta. Email: snovosad@cdc.gov.