In the fight against sepsis, time means everything
In the world of sepsis treatment, the scale is vast and the cost is staggering.
In the world of sepsis treatment, the scale is vast and the cost is staggering. Every year, 258,000 people in the United States die from sepsis. Hundreds of thousands of others recover with treatment. Treating sepsis costs more than $20 billion a year, according to a 2013 federal report.
Still, the most startling figure is a singular one: Mortality among sepsis patients increases dramatically every hour without antibiotic treatment.
At UF Health, teams of researchers and health care professionals are attacking sepsis with vigor. Physicians and nurses at UF Health Shands have new tools and procedures to identify sepsis and respond quickly with treatment. A review committee probes sepsis cases to improve care. Scientists at the UF Sepsis and Critical Illness Research Center are focused on preventing sepsis, minimizing its damage and improving long-term survival.
The effort is intense because the stakes are high: UF Health Shands treats about 3,300 patients with a sepsis diagnosis each year.
“Sepsis is one of the top killers in every hospital. It’s also far and away the most expensive condition that we treat,” said Nicole M. Iovine, M.D., Ph.D., a hospital epidemiologist who leads the Sepsis Committee.
As part of the response to the federal government’s sepsis reporting requirements instituted last fall, UF Health chose to use the Modified Early Warning Score/Sepsis Recognition Score tool to help identify patients at risk for sepsis. Patients are monitored continuously and their Modified Early Warning Score changes along with their condition. When a patient begins to show signs of sepsis, the Modified Early Warning Score system alerts a dedicated team that responds immediately. Physicians, specialty nurses and a respiratory therapist arrive to determine if the patient is septic.
“The goal is to treat the patient early in the course of the infection to reduce complications and mortality,” said Janet M. Gerner, R.N., a UF Health Sebastian Ferrero Office of Clinical Quality and Patient Safety senior quality improvement specialist.
The systematic federal reporting requirements have already benefited sepsis patients, according to Iovine. Minute, myriad details — the first blood test of a lactate level, delivery of an initial antibiotic and a first blood culture — become part of an overall benchmark of appropriate care.
“What’s being required by the government is really what is also best for the care of a septic patient,” Iovine said.
In the E.R., sepsis can be especially pernicious. A patient might arrive with little more than a general complaint and abnormal vital signs. If it’s sepsis, time is the enemy. Meanwhile, physicians have to sift through a host of conditions that can mimic sepsis, including diabetic emergencies, dehydration and stroke.
“When people wait, they become worse or decompensate. We had to design other tools to be able to recognize sepsis cases quickly and utilize our resources,” said Brandon Allen, M.D., assistant medical director of the UF Health Shands E.R. and a clinical professor in the UF College of Medicine’s department of emergency medicine.
Those resources include an interdisciplinary team of about a dozen people who meet monthly to talk about anti-sepsis strategies.
The group includes nurses from the E.R. and ICUs, physicians and representatives from pharmacy and quality control. Discussion often focuses on a crucial anti-sepsis metric: delivery time for the first antibiotic.
“We break down every part of that process to see how it can be improved,” said Lara Thompson, R.N., a clinical leader in the E.R.
The federal government’s standard for a sepsis patient receiving his or her first antibiotic is three hours. As of late March, the median delivery time at UF Health Shands Hospital was 67 minutes — a figure Allen said can and will be improved.
The E.R. has several new measures that are helping in the fight against sepsis. A sepsis tool has helped to streamline nurses’ documentation and made the sharing of patients’ lab results and vital signs easier, Thompson said. Also, the system that alerts physicians, nurses and other health professionals about sepsis cases has been restructured. Sepsis alerts were often issued hospitalwide, leading to “alert fatigue.” Now, a tiered system directs crucial information to specific people and makes the sepsis response more efficient, Allen said.
Elsewhere, other UF Health professionals are equally immersed in the anti-sepsis effort. After sepsis patients are discharged, a hospital employee scrutinizes randomly selected cases, then brings them back to the Sepsis Committee. The idea is to spark a discussion about how patient management can be improved.
“When we don’t pass a core measure, we want to know where that’s occurring. We look hard at the barriers and challenges, and find solutions,” said Iovine.
For their part, UF Health researchers are focused on preventing sepsis and mitigating its effects. Among premature infants, that is particularly crucial: They have the highest incidence of sepsis and the worst mortality, said Lyle L. Moldawer, Ph.D., a professor and vice chairman of research in the UF College of Medicine’s Department of Surgery.
Shawn Larson, M.D., and James Wynn, M.D., are working on a vaccine to prevent sepsis in premature infants. Sepsis can kill or disable 40 percent of premature babies who become infected.
Larson is an assistant professor in the division of pediatric surgery. Wynn serves as an associate professor of pediatrics in the division of neonatalperinatal medicine.
Their research team believes that stimulating a baby’s immune system can help fight — and even prevent — sepsis.
In neonatal mouse models, introducing components of bacteria into the bloodstream can prompt neutrophils — a type of white blood cell — to seek and destroy the invading organisms, Larson and Wynn found.
“Once these cells find and attack the invaders, for example viruses or bacteria, they signal other immune cells to join the fight,” Larson explained.
Another potential bright spot is an ongoing clinical trial at UF Health and other sites that uses anti-cancer drugs against sepsis. The same drugs that prompt the immune system to attack lung and kidney cancer have shown some effectiveness against secondary infections in sepsis patients, Moldawer said.
While attacking sepsis with research and new clinical tactics is important, it’s also the little things that matter. For hospital workers, good personal hygiene and taking the time to slip on gloves or a mask can make a difference.
“Sepsis requires a team effort,” said Iovine. “The admitted patients are already fragile, so keeping them from getting an infection is extremely important.”
