Sepsis gets its measure taken
People die in hospitals, but how many from sepsis was unknown
There are a lot of things counted in hospitals, a lot of data collected. That’s why it might seem surprising that until very recently, there was no measure of sepsis as a proportion of hospital mortality. Not until Vincent Liu, MD, MS, and his colleagues as Kaiser Permanente decided to look at it. Their findings were published in a research letter in the Journal of the American Medical Association in August.1
"I do not know why it hadn’t been previously measured," says Liu, a research scientist in Kaiser’s Northern California region. "Most places focus on the absolute mortality rate, and haven’t focused on this related question: Of all those dying, how many died of this?"
They did a chart review of 21 hospitals and their findings were astounding: Of the patients with sepsis, most were admitted with it. Between a third and a half of all hospital deaths were as a result of sepsis, and those with less severe disease were more likely to die.
Given its prominence in inpatient death, Liu says it deserves a place among the things you measure. They looked for multiple indicators, including septic shock, septicemia, sepsis and severe sepsis. Given a known under-recognition of sepsis, the authors also looked for patients with multiple organ failure with infection as a stand-in for likely cases of sepsis.
"If you are not looking at this, you have no way to determine if you are improving, you have no way to gauge your care or to change practice," he says. While understanding that all hospitals are "operating under constrained resources," given how many hospital deaths are caused by this condition, it seems like a good place to put some of that limited time, money and manpower to figure out how many cases you have had, how they were treated and where you can improve.
Sepsis hasn’t captured the attention of the public, Liu says, and turning the number into a rate — 33%, 50% — is a way to gain attention for something that is underdiagnosed, and hasn’t been considered very worthy of study.
When they uncovered these results, Kaiser started a regional quality improvement project and has been working to implement some best practices that they hope will reduce mortality, he says. "They have done this in the intensive care units, and preliminary results show that mortality is down across all the hospitals."
The project involved implementing early goal-directed therapy, and aggressive early identification of patients with sepsis from the time they come into the emergency department.
"We are working on the report now, but so far, we know there has been a 25% decrease in all-cause mortality, and we think much of it is related to our sepsis practices. But we have other practices going on, too, so it will be hard to tease out," he says.
Liu says it will be another 12 months or so before they can figure out what is the result of the sepsis project and what is not.
"The bottom line is that everyone has many demands," Liu notes. "This is a worthy investment, and the weight of evidence, that as many as one in two deaths is caused by this, should drive that point home."
For more information on this topic, contact Vincent Liu, MD, MS, Research Scientist, Critical Care, Kaiser Permanente Northern California. Email: Vincent.X.Liu@kp.org
- Liu V, Escobar GJ, Greene JD, Soule J, Whippy A, Angus DC, Iwashyna TJ. Hospital deaths in patients with sepsis from 2 independent cohorts. JAMA. 2014 Jul 2;312(1):90-2.