Terry P. Clemmer, MD, Director of Critical Care Medicine, LDS Hospital, Intermountain Healthcare, was one of the key contributors to the development of the Severe Sepsis Bundles. In this interview, he describes the results of increased scrutiny related to sepsis (from CMS and the media, for example).
What is important for people to understand about sepsis?
Severe sepsis and septic shock are major contributors to intensive care unit (ICU) morbidity and mortality. Mortality rates from these conditions are estimated between 12 and 42 percent, and hospitalization rates for sepsis rose by approximately 6 percent annually from 1993 through 2009.
Mortality is decreasing in many institutions because of early identification and adoption of aggressive treatment of severe sepsis and septic shock. In addition, research publications are helping to better define the standard of care that produces better outcomes. Much of this increased focus on sepsis in the health care community resulted from the Surviving Sepsis Campaign, the creation of the Severe Sepsis Bundles, and many major medical societies adopting these efforts.
On the public side, families and the media brought valuable attention to sepsis. Public attention can change medical practice. When they ask questions about sepsis, patients and their families influence health care providers, not to mention legislators and payers. For example, New York has passed very specific legislation regarding sepsis care, and the Centers for Medicare & Medicaid Services (CMS) has clearly focused on it with the development of their sepsis measures.
If recommended practices for sepsis identification and care exist, why is sepsis still so prevalent?
Despite this increased attention, the biggest challenge in the war on sepsis is raising awareness in all health care organizations about the new standards and then implementing the standards reliably. Scientific societies, regulatory bodies, and health care payers are all in support of implementing evidence-based standards in common practice.
However, implementation of these sepsis care standards is complex and requires effective communication and handoffs across individuals and departments, integration of care across disciplines, meeting rigid treatment timelines in our care processes, and using metrics to collect data on processes and provide timely feedback to clinicians.
What are some keys to successful early detection of sepsis?
Education: Clinicians who are not familiar with the sepsis literature often do not feel the urgency of early therapy, and may be more lax about early diagnosis.
Experience: Unfortunately, some clinicians become more aware of sepsis after caring for a patient who initially does not look very ill, but who then becomes very sick or even dies as a result of sepsis.
Real-Time Feedback: One of the best ways to raise awareness about the importance of early detection is to give feedback to clinicians whose patients become septic. Even though these clinicians may not be directly responsible for the patient once he or she is admitted to the ICU for sepsis care, it’s important for them to understand the longer-term outcomes and implications for septic patients.
Some organizations have developed early warning and alert systems to increase sepsis awareness among clinicians. The widespread use of electronic medical records makes this sounds easy, but implementation has proven to be much harder than anticipated.
Are you concerned that the CMS sepsis measures may contribute to overtreatment?
At this point, the harm of under-recognition and under-treatment is so overwhelming that we have not recognized the issues of over-treatment. As we mature and awareness increases, the over-treatment issue will become more prominent, and we will have to design processes and protocols to reduce the harms of over-treatment and find the right fit for sepsis therapy.
Dartmouth-Hitchcock recently reported reducing their sepsis mortality by over 75 percent. They apparently credit this dramatic improvement to reliable use of the sepsis bundles. What is your response to this news, considering you were one of the pioneers who originally developed those bundles?
We have known for many years that outcome results are directly related to our ability to implement evidence-based best practices at a high level of reliability. We have seen this in many areas of care with sepsis mortality reduction being one of the most rewarding. However, we still have doubters regarding the importance of reliable execution to reduce mortality. Replication of the methodology in various institutions is part of the scientific evidence assuring the validity of the original experiment. I am thrilled to see that highly reliable execution of the sepsis bundle is being duplicated in other institutions as it adds credibility to the methodology of reducing sepsis mortality.
Terry P. Clemmer, MD, is faculty for IHI’s Reliably Reducing Sepsis Mortality virtual training.
You may also be interested in:
Severe Sepsis Bundles
Evaluation for Severe Sepsis Screening Tool
Surmounting Sepsis: An Interview with Dr. Sean Townsend
WIHI: A Partnership to Reduce Deaths from Sepsis