In 2011, the Penn Transplant Institute performed its first bilateral hand transplant on a young woman. Four years later, the transplant team successfully completed the world’s first pediatric bilateral hand transplant. But the patients had more in common than the transplant. Both had lost their limbs — and almost their lives — to sepsis.
While these cases captured worldwide attention, sepsis is actually more common than people think. “It contributes to one out of every two to three deaths in hospitals nationwide,” said William Schweickert, MD, director of Medical Critical Care Operations for UPHS. In fact, more people die from sepsis than from prostate cancer, breast cancer and AIDS combined. It also represents the single biggest cost to hospitals nationwide — nearly $24 billion is spent each year in caring for these patients.
The Penn Sepsis Alliance is aiming to reverse these numbers. Clinicians from throughout Penn Medicine are collaborating to develop strategies that help providers quickly and accurately recognize and manage sepsis … and prevent the leading cause of readmissions.
Is it Sepsis?
Sepsis is the body’s overwhelming response to infection. It can result in tissue damage, organ failure and, ultimately, death. The risks are higher for people with compromised immune systems (such as cancer patients), the elderly and the young, but according to the National Sepsis Alliance, sepsis is an “equal-opportunity killer impacting people of all ages and levels of health.”
“There are a million ways to get sepsis,” said Sean Foster, MD, director of Quality Control for the Penn Presbyterian ED, “from a skin infection that becomes severe to an untreated urinary tract infection.”
And the signs of sepsis are subtle … and can be missed, especially among consumers. “People don’t know the risks, can’t spot the signs. They wait, thinking ‘It’ll pass.’ But it only gets worse,” said Juliana Jablonski, DNP, Critical Care RN Systems strategist.
Because a majority of sepsis case — 85 percent or more — enter through emergency departments, the Penn Sepsis Alliance turned to Foster and other ED providers from throughout Penn Medicine to create targeted strategies to help providers quickly identify and manage sepsis. In 2017, the ED team rolled out a custom-built “sepsis alert system” aimed at promoting timely recognition of possible sepsis cases and establishing “sepsis care pathways,” which aligned with the recently released core measures from the Centers for Medicare and Medicaid Services (CMS).
A key component of the pathways are “care bundles” or small sets of evidence-based practices that, when performed together, have been shown to improve patient outcomes. As Schweickert noted, timing is key when it comes to sepsis. “Each hour of delay in treatment is associated with a four percent rise in mortality.” When sepsis is suspected, these order sets facilitate the simultaneous ordering of tests necessary to support the diagnosis, as well as antibiotics and fluids necessary for treatment. The pathways also include alerts which “nudge” both the triage nurse and then the provider to think about the possibility of the patient having sepsis and to act accordingly. “Recognizing that it could be sepsis — as early as possible — is the biggest issue in the ED,” Foster said. “Once you decide, management is pretty straight forward.”
Other measures are aimed at raising team awareness of a patient’s sepsis status, including a colored banner across a patient’s medical electronic chart clearly showing that “this patient is on the sepsis pathway” and a clock on the track board (which lists all patients receiving treatment in the ED) that keeps track of how much time has passed since the patient was identified as possibly having sepsis. “It’s a time-oriented mindset,” Foster said. “We want to keep it visible.”
This ED Sepsis Alert System is now live at four Penn Medicine hospitals, with the goal of further expansion. “We now have systems in place to help providers do the right thing — a care pathway that steers them to an order set for the ED and for hospitalized patients,” Schweickert said. “No matter which hospital you go to, you will get the same evidence-based care.”
Although the care is the same, the antibiotic prescribed is a “careful recipe” based on the hospital the patient is in. As Schweickert explained, “Every home has a different garden of bacteria, some more resistant than others. HUP has a population with more resistance so we use stronger and broader antibiotics on the front end, before we know what infection we’re dealing with.” In the order set, patients in Penn’s “community” hospitals (CCH, PAH, and Princeton) receive one antibiotic pathway while another is used for the tertiary care hospitals (HUP and PPMC). (LGH has developed its own sepsis pathway.)
While the sepsis care pathways are lowering sepsis mortality, fighting hospital-acquired sepsis remains a challenge. According to Schweickert, nationally, nearly one-fourth of these patients die versus only about 10 percent of those who present with sepsis on admission. “These are patients who develop an infection despite ongoing hospital care,” he said. “That’s why there’s so much emphasis on recognizing a new onset of infection. We need to make sure these patients get timely antibiotics and a timely transfer to ICU.” The Alliance is working with Penn Medicine’s data scientists to improve early warning detection system algorithms to not only to predict which patients might develop sepsis, but also hasten detection of patients who are deteriorating from sepsis.
Pharmacists have also played a key role in the fight against sepsis, focusing on opportunities to improve and expedite the swift preparation and delivery of antibiotics. In collaboration with nursing and the Penn Sepsis Alliance, Pharmacy is starting a new pilot at HUP in the fall. “We are piloting a new multidisciplinary pathway that aims to guarantee patients are always administered antibiotics within the quickest time frame possible,” said Lauren Simonds, PharmD, unit based clinical pharmacist on Silverstein 11, who is leading the pilot.
A Better Quality of Life
Efforts to improve sepsis outcomes, which date back several years, have decreased mortality rates. Before, patients were simply discharged and sent home after completing acute treatment, on the road to recovery. “We thought the patient got better and there were no long-term consequences,” said Mark Mikkelsen, MD, chief of Medical Critical Care at Penn Medicine. But that’s not the case.
One in four sepsis survivors is readmitted to the hospital within 30 days, often with a new or recurrent infection. Indeed, it is the leading cause of readmissions to hospitals. “The body’s inability to handle infection can linger for months after discharge,” Mikkelsen said. And sepsis survivors can also suffer cognitive impairment issues that impact memory and executive function (the ability to do simple chores) as well as physical impairment that leaves them weak and with reduced stamina.
To help educate patients and families about these risks, Mikkelsen created a “Life After Sepsis” video, in partnership with the Society of Critical Care Thrive initiative and the Sepsis Alliance. (The video is accessible on the Sepsis Alliance website). “The patient will have paper discharge instructions but also the ability to see the video and learn what to expect,” he said. “It’s a first step towards being better prepared.”
The educational video will be part of a sepsis discharge checklist being developed. A pilot in the MICU at Penn Presbyterian, led by Julie Rogan, MSN, clinical nurse specialist, is refining this “readmission reduction bundle,” filling in any gaps in the current process and “winnowing it down to what’s necessary versus a wish list,” Mikkelsen said. Raising awareness for both providers and patients and families of the increased risk of readmission and long-term issues that result from sepsis is a priority. So is recognizing the signs of sepsis. According to Sepsis.Org, nearly two-thirds of the population can identify stroke symptoms, yet less than 1 percent know common symptoms of sepsis. “We want to empower patients to do their own surveillance. If a person is not feeling well and has a fever, he or she will know to seek medical attention quickly. This knowledge makes them more vigilant.”
Another key point on the checklist: The discharge summary “needs to reflect that the patient had sepsis, its cause, and how it was treated,” Mikkelsen said. Other reminders will include post-discharge follow-up appointments as well as referrals (if needed) for outpatient PT/OT, and home care, to leverage the soon-to-launch Penn Home Health pathway designed specifically for sepsis survivors.
The Penn Sepsis Alliance is having a huge education rollout this month to celebrate World Sepsis Day on September 13. “We’re trying to get clinicians to be as aware as possible,” Schweickert said.
“We have great interventions but we need clinicians to always ask ‘Could this be sepsis?’ because we know it’s a killer among our ranks.”