The CDC acknowledges that sepsis is life-threatening, costly, and difficult to predict, diagnose, and treat. Providers agree. But consensus on how to address it remains elusive.
Sepsis has an image problem.
Is it a bacterial infection? Inflammation? A complication of surgery? A syndrome or disease in itself? If you're interested enough in the quality of healthcare delivery to be reading this column, you probably know what sepsis is.
But, a lot of people—both inside and outside of hospitals—don't know what is it, how to recognize it, or even how to define it.
And not only, as the CDC acknowledges, is the condition life-threatening, costly, "difficult to predict, diagnose, and treat," but no one sector of the health system owns it.
That makes sepsis exceptionally challenging.
"Whereas stroke is province of a neurologist and trauma is the province of a surgeon and asthma is the province of an pulmonologist, sepsis involves the emergency room, the acute patient floor, the infectious diseases practitioner, the ICU, and the surgeon," says Martin Doerfler, MD, senior vice president of clinical strategy and development at North Shore-LIJ Health System (soon to be renamed Northwell Health) in New York." [Sepsis] really falls through the cracks, and that is part of the problem."
Most consumers and providers are well aware that October is breast cancer awareness month and February is heart health awareness month. September has been designated "Sepsis Awareness Month." It's a start.
While sepsis is often cast as a hospital-acquired infection, Doefler says most people "walk in the door with it."
A Family's Response
Unfortunately for 12-year-old Rory Staunton, he walked back out of a New York hospital after he was treated for complications from an infected cut. By the time he returned to the hospital, it was too late.
Rory's father, Ciaran Staunton, said he had never heard of sepsis until a doctor walked into the hospital waiting room and told him and his wife that their 12-year-old son was dead.
Now, the two are devoting their time to making sure other people know about sepsis. They have founded the Rory Staunton Foundation for Sepsis Prevention, which sponsored its second forum on the condition on Wednesday morning in Washington DC, which was live-streamed.
"I want to welcome you to something that shouldn't be happening," Ciaran Staunton told those gathered. The panel included Doerfler (who is on the foundation's medical advisory board), as well as Amy Knight, COO of the Children's Hospital Association, and Jean Moody-Williams,deputy director of the Center for Clinic Standards and Quality at the Center for Medicare & Medicaid Services.
Staunton believes the Centers for Disease Control and other government agencies need to devote more resources to the condition, which he notes kills far more people in the US than much-publicized Ebola. He credits CMS, however, for taking steps to address sepsis by adding the condition to its Hospital Inpatient Quality Reporting Program.
Ciaran Staunton |
That rule, defined in CMS's sepsis bundle project—set to go into effect on Oct. 1—has generated some resistance. In August, the American Hospital Association and several other groups asked CMS to delay implementation. In a letter to the agency, the groups warned that the new rule is "overly complex and burdensome" and will lead to the overuse of antibiotics." Other have challenged whether the CMS guidelines are based on solid evidence.
The National Quality Forum has released a sepsis management bundle of its own, in a document called #0500.
Doerfler, whose hospital has cut sepsis deaths by 35% , is supportive of the CMS action concept, though he thinks it could be improved. "Having people have to report on it and pay attention to the incidence and treatment of sepsis is going to move things in the right direction," he said in a telephone interview before the forum.
Sepsis comes in three degrees of severity:
- Sepsis
- Severe sepsis
- Septic shock
Regardless of how CMS decides to handle sepsis, detection and treatment programs are moving forward. Like NS-LIJ, many hospitals are working to reduce the incidence of sepsis as a way of improving quality while cutting costs.
It accounted for 4.0% of all inpatient costs in 2008, making it the most costly reason for hospitalization that year, according to a 2011 study sponsored by the Agency for Health Quality Research: "Between 1997 and 2008, costs for this condition grew at almost three times the rate of costs for hospital stays overall (average annual growth of 11.9% versus average annual growth of 4.4 percent)."
Many Paths Forward
As the opposition to the CMS rules suggest, an evidence-based approaches will be key, if practitioners can agree on the evidence.
Or, maybe they can they disagree and still save lives. In 2013, the New York State Health Commission issued what are known as "Rory's Regulations," which give hospitals some leeway in dealing with the problem. The rules require that "hospitals shall have in place evidence-based protocols for the early recognition and treatment of patients with severe sepsis/septic shock that are based on generally accepted standards of care."
As a result, Doerfler said, "My protocol does not have to be the same as New York Presbyterian. It doesn't have to be the same as New York University hospital or SUNY Buffalo's."
Martin Doerfler, MD |
With programs such as the international Surviving Sepsis Campaign and the collaboration between the Institute or Health Improvement and NS-LIJ, hospitals now have an abundance of resources for preventing, identifying, and treating sepsis.
It remains to be seen how opposition to the new CMS guidance will play out. It is clear, however, that hospitals and the providers who work in them need to be more aware of how to identify sepsis, even if they disagree about how to treat it.
'He Could Have Been Saved'
Ciaran Staunton recently dismantled Rory's bed and went through his clothes to pack up for a move to a new home.He said in a phone interview that he feels a lot of anger over his son's death because he believes is could have been prevented.
"If it had happened from cancer, that would be bad," he said. "If it had happened in a car accident, that would be bad. But knowing that he could still be stretched out on that bed and alive is what haunts us. He could have been saved. If I sound angry, well I am angry. My big guy should be here today, as should most of the other quarter of a million who die every year.
CMS Sepsis Bundle Project(Sep)National Hospital Inpatient Quality Measures by HLMedit