Protocols improve detection & treatment, but transition of care remains a challenge
It’s the leading cause of death in U.S. hospitals, according to the Centers for Disease Control and Prevention (CDC). With every hour that passes before treatment begins, mortality risk jumps nearly 8%. These statistics demonstrate that sepsis continues to pose serious challenges for facilities across the country, specifically when it comes to effectively transitioning care from unit to unit and from hospital to home.
Sepsis care across the continuum was to be the focus of HealthTrust’s Collaboration Summit meeting in late April, but the two-day event was postponed due to the COVID-19 pandemic.
Despite public awareness campaigns drawing greater attention to sepsis, which strikes about 1.7 million adults each year and kills 270,000, many don’t realize the condition’s stark toll, experts say. But healthcare organizations across the nation have ramped up efforts in recent years to both cut the mortality rate and peel back some of the more than $24 billion in annual hospital expenses associated with sepsis care.
“In the last five years, various protocols for diagnosis and treatment have started to gain traction, and hospitals started looking closely at having a staff member specifically focused on sepsis,” explains Karen Bush, MSN, FNP, BC, NCRP, Director of Clinical Research & Education for HealthTrust. “Sepsis coordinators look at every case, when cases are triggered, what actions are taken and what appropriate actions would be, as well as the response.”
“The ability to bend the survival curve hinges on early detection and coordination of care,” says Jeffrey S. Guy, M.D., MS, MMHC, FACS, Vice President of Clinical Services for HCA Healthcare in Nashville, Tennessee, and a HealthTrust Physician Advisor. “Detecting when patients get infections and giving a few dollars’ worth of antibiotics and IV fluids can change outcomes dramatically,” Dr. Guy says. “It’s about getting the basics down well.”
Evolving diagnostic tools
Because cost and length of hospital stay rise progressively with the severity of sepsis, healthcare leaders have increasingly focused on protocols surrounding early detection and treatment. But varying definitions of sepsis itself have created a speed bump on the path toward standardizing treatment, Bush notes. U.S. clinicians currently can choose from three options to define patients presenting with suspected sepsis, including a version advanced by the Centers for Medicare & Medicaid Services (CMS).
Regardless of definition, diagnosing sepsis typically takes into account factors such as patient temperature; heart and respiration rate; white blood cell count; blood pressure; lactate levels, which can show a lack of oxygen; and creatinine levels, which can measure kidney function.
Meanwhile, the latest tool to identify poor outcomes in sepsis patients is known as the quick Sepsis Related Organ Failure Assessment, or qSOFA, Bush says. A bedside prompt that may identify patients with suspected infection at greater risk for a poor outcome without ICU care, the qSOFA score uses three criteria: low blood pressure, high respiratory rate or altered mentation.
Still, these tools don’t always provide the full picture. “Recognizing sepsis is going to take more than putting together criteria,” says HealthTrust Physician Advisor S. Shaefer Spires, M.D., an infectious disease specialist at Duke Health in Durham, North Carolina. “Research is burgeoning and people are thirsting for it, with revelations on new biomarkers and the understanding around which lab values mean more than others in detection and treatment.
“We’re all scrambling in situations where we’re not sure what’s causing sepsis,” he adds, “and we end up doing something—and everything—as physicians” to treat it.
HCA Healthcare was recently recognized for “SPOT,” its innovative approach to detecting sepsis using artificial intelligence. Learn more about SPOT in our upcoming Q4 issue.
Treatment protocols & dilemmas
As Dr. Spires notes, treating sepsis has not been an exact science. But, as with detection, treatment in recent years has progressively become more standardized.
Standard therapies include antibiotics—typically broad-spectrum versions that work against several of the more common bacteria—administered intravenously to work more quickly. Additional IV fluids can mitigate shock by keeping blood pressure from plummeting. Medications typically include corticosteroids to reduce systemic inflammation and vasopressors to boost blood pressure. Various equipment can also factor into treatment, including mechanical ventilation and kidney dialysis, among others.
But widespread antibiotic stewardship initiatives can sometimes clash with rapid sepsis treatment, Dr. Spires says.
“Trying to put these patients in a box and check off these items can have other downstream consequences, such as increased inappropriate broad-spectrum antibiotic use,” he explains. “If you’re someone who’s overly worried about meeting sepsis criteria, then you’re more likely to give someone antibiotics who doesn’t necessarily need them, just in case that patient does have an infection. Consequently, that can cause some harm as well.”
Still, the efforts surrounding standardized care have generally paid off in spades, with improved survival rates, Dr. Spires notes. “The critical care aspect of treating sepsis is largely why patients do better than they used to,” he says. “We end up causing patients less harm and have reduced hospital-acquired infections, so more patients improve.”
Strategic transition approaches
Even with the array of protocols now in place to streamline sepsis diagnosis and therapy, effectively transitioning patient care from unit to unit and hospital to home remains a particular challenge, experts say.
“Sepsis is not just a hospital condition,” Dr. Guy explains. “Even when you survive the initial illness, a typical sepsis patient accesses healthcare for a year afterward at a rate greater than if they’d not had sepsis. They’re more prone to additional infections and go to the ER more frequently afterward. It leaves them drained.”
Here are some guidelines to minimize the effects:
- Enact additional protocols to monitor sepsis patients as they enter step-down units or rehabilitation facilities, or after discharge. Bush says this should include educating patients and caregivers about issues such as following up with primary care physicians and understanding worrisome symptoms. “These are complicated patients,” she explains, “and sometimes their different comorbid conditions hinder their transition.”
- Manage patients’ antibiotic treatment. This is often not tracked accurately or effectively, Dr. Spires says. “We know from a study our group did a year ago that 40% of antibiotic utilization related to the hospitalization is after the hospital stay,” he explains. “That transition from hospital to long-term care facility or to the home is a huge risk for someone getting too much of an antibiotic.”
- Engage multidisciplinary efforts. A patient’s care should be coordinated among clinicians and pharmacists. This requires resource dedication from hospital leadership to address the issue, Dr. Spires says. “It ultimately benefits the hospital.”
- Track outcomes. CMS sepsis quality requirements provide a built-in reason to track outcomes well: The resulting data is publicly reported. Technology advances such as artificial intelligence promote these efforts, along with clinical analytics.
“The biggest thing is for us to understand how much antibiotics are given outside the hospital, long-term care or other facilities,” Dr. Spires says. “Then, we can impact that metric.”
Electronic medical records generally collect sepsis-related data and help trigger responses, as well as track the outcomes, Bush notes. “Then, it’s the detailed task of going back and examining the outcomes,” she says, “and getting data back to the right people so they can react appropriately.”
For assistance in reducing complications such as sepsis, consider HealthTrust Clinical Data Solutions Care Redesign services. Contact Kimberly Wright, RN, AVP, Clinical Data Solutions for additional information.