3 Need-to-Know Leaps in Sepsis Care

Best practices and innovations in sepsis can drop mortality rates and lead to earlier detection.

Sepsis is deadly, it's expensive, and there are abundant initiatives under way that could lead to earlier detection, lowering costs, and saving lives.

In May 2016, the Healthcare Cost and Utilization Project (HCUP) and the Agency for Healthcare Research and Quality released a report about the impact of sepsis on U.S. inpatient hospital costs. As published by The Sepsis Alliance, the study, which analyzed billings from 2013, revealed:

• Sepsis accounts for nearly $24 billion in annual costs, making it the most expensive condition to treat in the U.S. healthcare system
   
• Sepsis was responsible for 6.2% of all hospital costs across the country
   
• Sepsis also was the most expensive hospital condition billed to Medicare, accounting for 8.2% of all Medicare costs
   
• The condition accounted for nearly 1.3 million hospital stays

The Sepsis Alliance estimates that 258,000 patients die from the condition each year in the U.S. To save lives and improve the bottom line, hospitals across the nation are trying different approaches to reduce sepsis morbidity and mortality. At the same time, innovators strive to create ways to identify the condition earlier.

Below is a look at best practices from Nemours Children's Hospital in Orlando, which instituted a program that reduced its pediatric morality rate to zero, as well as two promising innovations on the horizon.

1. Nemours Drops Mortality to Zero With Remote Monitoring

In 2015 Nemours Children's Hospital decided to take an aggressive, multifacted approach to sepsis that dropped sepsis mortality rates from 12.5% in 2016 to zero during the first six months of 2018. While there were numerous factors that contributed to the decrease, remote monitoring was one of the primary drivers behind the improvement, according to one of the physicians involved in the project.

Jennifer Setlik, MD, pediatric emergency physician at Nemours Children's Hospital, says, "The way we have improved our sepsis results is through a bundle of care. We've educated nurses on administering IV fluids in a faster way. We also worked on pharmacy processes to have antibiotics delivered faster to a patient with sepsis. There are many different mechanisms we have used to help this process, but the key starting point—or the gun that starts the race—is [remote monitoring from] the Logistic Center. Logistics really gives us a head start in the race to treat patients with sepsis."

The initiative began in November 2015 in the emergency department, then rolled out to the rest of the hospital. Nemours also participates in a national collaborative with the Children's Hospital Association, which is working to reach consensus on appropriate mechanisms of action related to sepsis.

How It Works

• The Nemours Clinical Logistics Center, a facility located in the hospital, provides 24/7 remote monitoring by paramedics who observe all patients in the emergency department and every bed in the hospital, except the NICU, which uses separate protocols
   
• Vital signs and other data are aggregated into a shock/sepsis score
   
• Nemours designed the scoring system, which contains a unique feature that gives greater weight to blood pressure changes
   
• The team tweaks the scoring system over time to further improve its sensitivity
   
• If the score reaches a threshold value of 25 or more points, paramedics receive a visual cue and prompt a bedside nurse (who also receives the score on her monitor) to gather additional information
   
• Additional inputs include assessments for a shock/sepsis state, which may raise the score
   
• If the child has a score of 45 points or higher, a rapid response team is deployed as the child is at an elevated risk of shock, a precursor to sepsis

Results

• Average length of stay dropped from 10 days in 2016 to 7 days throughout 2017 and the first six months of 2018
   
• Mortality rates decreased from 12.5% in 2016, to 4.5% in 2017, to zero through June 2018 (However, physicians note that figures can be artificially inflated due to the small size of the 100-bed hospital)
   
• Mortality rates for medically complex children saw a similar decline from 21% in 2016, to 6% in 2017, and zero in 2018 through June

On the Horizon

There are numerous innovative approaches to sepsis in development. Here's a look at two:

2.  Artificial Intelligence Tool in Development at Emory

Predictive analytics already play a role in early sepsis detection in models introduced by Mayo Clinic, Penn Medicine, and other places. But it's only a matter of time before artificial intelligence speeds up the detection process even further.  

Using real-time data, Emory University innovators are testing their Artificial Intelligence Sepsis Expert. It already can accurately predict the onset of sepsis in an ICU patient four to 12 hours prior to clinical recognition, according to an article published April 2018 in Critical Care Medicine.

The accuracy rate is 85% to 90%, says Timothy Buchman, MD, PhD, FACS, FCCP, MCCM, professor of surgery and anesthesiology at the Emory University School of Medicine, who also serves as director of the Emory Critical Care Center and chief of critical care services at Emory Healthcare.

In addition to predicting sepsis, the developers want the model, which is still in development, to explain why the patient is likely to become septic.

"The novelty of this algorithm is that it [will tell clinicians] that among hundreds of tests, you need to pay attention to these five labs right now," says Shamim Nemati, PhD, assistant professor of biomedical informatics at Emory University's School of Medicine. This information will not only help providers build trust in the device, it will offer more precise opportunities for action.

It may be up to five years before the device is commercially available, although initial forms of the Sepsis Expert may be available for testing in academic health environments as soon as next year.

3.  Test Immune Response Rather than Pathogens

Seattle-based Immunexpress has taken a different approach to the sepsis battle. Currently, no definitive test exists to diagnose sepsis.

Clinicians rely on detecting pathogens in blood cultures, a process that takes time and still doesn't offer a conclusive diagnosis. Minutes are precious in the sepsis battle; each hour without treatment increases mortality by 8%, says Rolland Carlson, PhD, CEO of Immunexpress.   

Rather than passively chasing pathogens, Immunexpress developed a test to measure the body's specific immune response to infection by examining biomarkers in the patient's blood.

According to Carlson, these biomarkers may hold the key to the early and accurate detection of infection, as well as assist in guiding the use and timing of drugs and other therapies.

"SeptiCyte is the first FDA-cleared diagnostic to test for a gene signature that differentiates between positive systemic inflammation, which would be sepsis, or negative systemic inflammation, which would be indicative of SIRS (systemic inflammatory response syndrome)," says Carlson.

The latter diagnosis is treated much differently from sepsis and usually doesn't require admission to the ICU. Up to 43% of patients treated for sepsis were unlikely to have had a sepsis infection, according to a study published September 7, 2015, in Critical Care.

SeptiCyte has received FDA approval and conducted some of its clinical trials at Seattle Children's Hospital in Seattle, Washington. The company is now testing SeptiCyte on a different platform that could produce results in less than 90 minutes. Immunexpress expects to have a product commercially available during 2019.

Learn More

• Hospital sepsis scores are now publicly available on Medicare's Hospital Compare website (select a hospital, then “Timely & Effective Care,” then “Sepsis Care").
   
• Learn how the U.S. Department of Health and Human Services aims to accelerate sepsis innovation.
   
• Preliminary findings from an Intermountain Healthcare study found no difference in 30-day mortality among sepsis patients treated as inpatients versus outpatients.