Sepsis is an injury to the body resulting from the immune system’s attempt to eradicate an infection. “Think of it as collateral damage in a military sense, where you’re trying to get the enemy but, in the meantime, you are destroying whatever else is in town because it just happens to be in the same area,” says Martin Doerfler, M.D., senior vice president of clinical strategy and development at North Shore-LIJ Health System in New York.
Sepsis is a tricky topic because there are three stages of the condition, diagnosis can be difficult and definitions may be changing. At the moment:
• Sepsis is defined as infection plus the presence of at least two systemic inflammatory response syndrome criteria, such as rapid heart rate, high or low body temperature, low blood pressure, unexplained altered mental state and others.
• Severe sepsis means there is organ dysfunction caused by sepsis.
• Septic shock is severe sepsis plus low blood pressure or high serum lactate not reversed with fluid resuscitation.
The definition of basic sepsis is under attack by some specialists who think it is too broad, prompting patients to be treated unnecessarily, and by others who think the definition misses some patients who should be treated immediately. A debate about the definition is playing out in medical literature.
Nevertheless, everyone agrees that early diagnosis and treatment are essential to prevent a patient’s condition from deteriorating to the more advanced stages, where death is common. More than 220,000 people in the United States die from sepsis each year, and it is the most expensive disease to treat in the hospital, costing about $24 billion annually, according to the Agency for Healthcare Research and Quality.
Despite its burden on patients and the health care system, sepsis has not received as much attention as some other treatable conditions. That is because it is more challenging in a few ways.
Surgical-site infections, for example, can be targeted by interventions along the well-defined path from preoperative evaluation through rehabilitation that every surgery patient travels. By contrast, sepsis can attack anyone, but is most common in patients who are very young or very old, have a compromised immune system, have wounds or injuries, have serious comorbidities or have invasive devices. That means that just about every acute inpatient throughout a hospital is at risk.
“I think many people thought for a long time that sepsis was such a big, hairy problem that we might not have the capacity to deal with it using traditional process improvement methods,” says Todd Allen, M.D., an emergency physician who has helped to spearhead sepsis protocols at Intermountain Healthcare. “That turns out not to be the case, but I think it took the culture of medicine a while to come to that.”
It's fairly obvious who should be part of the clinical team responsible for tackling surgical-site infections because of the patients they serve. The team to address sepsis, on the other hand, needs to include emergency department and critical care physicians, hospitalists, nurses and others who might not immediately come to mind. “One of the most important lessons that I learned leading this effort was that I had to have a phlebotomist on all of my teams if I really wanted to maximize our ability to make a difference,” Allen says.
Another challenge: Because there is little awareness of sepsis among the public, patients and family members rarely recognize symptoms that might point to that diagnosis in a more timely fashion.
And, while treatment guidelines do exist, the knowledge base about sepsis includes major gaps. For example, there is no consensus definition for septic shock in different care settings, and there is uncertainty about optimal treatment. For more on this, see Septic Shock: Advances in Diagnosis and Treatment from the Journal of the American Medical Association.