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The Evolution of Sepsis Care During COVID-19 and Other Key Lessons for Sepsis Awareness Month

Rory Staunton was a young, active, healthy 12-year-old boy who scraped his arm while playing basketball during school in Queens, New York. He continued playing ball and his wound was not seen as critical or urgent. Later that evening, he began having fever along with leg and abdominal pain. Over the next two days his parents took him to both his primary care provider and a major New York City emergency department for evaluation. He was diagnosed as having a stomach virus. It was not until his second visit to the emergency department where he was finally diagnosed with sepsis. He died 24 hours later.

What happened to Staunton was one of the most pivotal cases in recent history. The disease that killed him could potentially affect any person and is all too common in hospital settings around the world, where early recognition and treatment can be lifesaving.

Sepsis is the body’s overwhelming and life-threatening response to infection, and can lead to tissue damage, organ failure and death. About 270,000 people die from sepsis every year in the United States — more than prostate cancer, breast cancer, and opioid overdose combined. Worldwide, sepsis effects an estimated 49 million people  each year, including more than 20 million children under age 5, and nearly 5 million older children and adolescents.

Penn Medicine Systems Nursing Strategist Julie Jablonski, DNP, RN, co-leads the Penn Sepsis Alliance along with William Schweickert, MD, an associate professor of Clinical Medicine in the Perelman School of Medicine at the University of Pennsylvania and director of Medical Critical Care Operations for the University of Pennsylvania Health System. The Penn Sepsis Alliance is a system-wide workgroup that develops programs that direct clinicians to always consider the possibility of sepsis early and often with patients, and to use the health system’s best-practice approach to sepsis care including critical laboratory tests, antibiotic guidelines, and intravenous fluid resuscitation recommendations.

September is Sepsis Awareness Month and World Sepsis Day is September 13 — allowing for people worldwide to unite in the fight against sepsis. In a Q&A, Jablonski discussed the importance of knowing the signs of sepsis and when to seek care, the impact of COVID-19, racial disparities in the treatment of sepsis, and the work of the Penn Sepsis Alliance.

signs of sepsis

Why should everyone know about sepsis?

Every 20 seconds someone is diagnosed with sepsis in the United States. Every member of the care team has a responsibility to understand the basics about sepsis because early recognition and treatment can save lives. The signs of sepsis are subtle and can be missed, especially among consumers. People don’t know the risks. They can’t spot the signs and they wait for it to pass. But it only gets worse.

It’s not only for doctors, nurses, and other care providers to know what sepsis is and how to identify the early signs — patients, family members, and caregivers should be informed to stay vigilant.

Based on the 2020 national Sepsis Alliance yearly online survey results, while 71 percent of were aware of the word “sepsis” — an all-time high for the annual survey — only 15 percent can describe the four most common symptoms. Whereas most Americans know that facial droop and slurred speech are signs of a stroke, and chest and left arm pain are signs of a heart attack. More work is needed to increase the awareness that sepsis is a medical emergency that requires immediate response like stroke and heart attacks.

Multiple tools with mnemonics are available to help remember the signs of sepsis, for example, “TIME” and “SEPSIS” are some of the most common. TIME stands for temperature, infection, mental decline, and extremely ill, while SEPSIS denotes shivering, extreme pain, pale skin, sleepiness, I feel like I might die, and shortness of breath.

How is COVID-19 impacting patients with sepsis and vice versa?

The clinical definition of sepsis is when a person experiences life-threatening organ dysfunction caused by their body’s response to an infection. For example, if someone has bacteria in their blood that enters through an open wound, and the bacterial infection causes the lungs, kidney, or liver to shut down, this is sepsis. COVID-19 is a virus, and if the COVID-19 virus causes organ dysfunction this too is sepsis. Sepsis is a common complication observed in severe cases of COVID-19.

There are treatment bundles — a recommended combination of treatments — that clinicians use for patients with sepsis. These bundles include drawing blood and checking for bacteria and viruses, giving medication to treat the infection, and infusing fluids to support blood circulation and resuscitation. There are unique aspects that health care providers must consider when treating sepsis that is caused by COVID-19. Unlike bacterial types of sepsis, COVID-19 is a virus and does not have a standard antibiotic to use for its treatment. More research is needed to evaluate if the standard practices of care for sepsis are as effective with COVID-19.

The most important way to prevent sepsis is to recognize and treat the infection as quickly as possible before it leads to life threatening complications.

Over the last year, COVID-19 has shined a brighter light on health disparities. Can you talk about the racial disparities in sepsis outcomes and how Penn Medicine is addressing that?

The COVID-19 pandemic has highlighted health inequities across the nation. Prior to the pandemic, published literature on non-COVID sepsis has described racial disparities in the management of sepsis with several underlying factors such as socioeconomic status, access to healthcare, environmental factors, and quality of care contributing to the differences in patient outcomes.

By addressing the complex interaction between race and these factors, health systems can enact policies and improvement initiatives that effectively addresses these disparities to improve care for all patients. Elimination of disparities based on racial and social determinants of health — like socioeconomic status, gender, age, or sexual orientation — is a top priority for Penn Medicine. Currently, the Penn Sepsis Alliance is using organizational data on race, ethnicity, language preference, and other sociodemographic factors to improve quality and safety related to sepsis care at Penn Medicine.

patient post discharge

How did the Penn Sepsis Alliance come about and how does it function today?

As a large academic health system, we collaborate and align practices across all of our hospitals and outpatient facilities. The Penn Sepsis Alliance first formed in March 2017. The Alliance governs health system sepsis activities with the goal of improving the early recognition of sepsis and optimizing care management. We recently released a standardized practice protocol called the Penn Sepsis Recognition Tool, which serves as an important resource for clinicians in making a diagnosis and asking the question, “Could this be sepsis?” This practice standard is based on the science around sepsis diagnosis and care.

The Penn Sepsis Alliance also creates patient educational materials that are provided to patients who were treated for sepsis during a hospital admission (sepsis survivors). It is important to assess daily the signs of becoming re-infected after being discharged from the hospital.

You serve as Penn Medicine Systems Nursing Strategist, which includes overseeing the Penn Sepsis Alliance. What does that role entail and what’s next for the alliance?

I serve on the Penn Sepsis Alliance as a nurse expert and health systems leader. The alliance framework includes a dyad (two-element) model of nursing and physician leadership to build an infrastructure for performance improvement and the achievement of strategic goals around sepsis care. I lead interdisciplinary teams across all six Penn Medicine hospitals in designing and implementing evidence-based programs to help clinical teams quickly and accurately recognize and manage sepsis. The patient is the highest priority and the center of all sepsis care.

One example of an evidence based sepsis program at Penn is the sepsis surveillance system being used at each emergency department in the health system. Our data shows that most patients come to the emergency department first before being admitted to the hospital for treatment of sepsis. As a result, it is important for emergency care clinicians to always ask the question: “Could this be Sepsis?” Penn Medicine uses a computerized health record that is programmed to analyze patient data for signs and symptoms of sepsis. If sepsis criteria are identified, electronic alerts are sent to the care team for quick evaluation. Then, if sepsis is confirmed by the provider, a sepsis practice pathway and checklist is used to ensure every patient receives the best care. 

The Penn Sepsis Alliance is committed to the continuum of patient care. National data show that about 20 percent of patients who survive a hospitalization for sepsis are readmitted to the hospital within 30 days. In the months ahead, we will be creating more programs with collaborative relationships to home care, skilled nursing facilities, and community organization to support patients after being discharged from the hospital with a diagnosis of sepsis.

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