Reducing Costs While Saving Lives: Appropriate Sepsis Recognition & Treatment

Cuts, scrapes, and acute wounds are some of the most common injuries that people of all ages will experience, whether they play sports, cook with sharp utensils, or work full-time in an office setting. While a casual cut on one’s finger may not seem life-threatening, any open wound runs the risk of becoming infected and proper care must be taken to ensure against an infection that may lead to a more serious syndrome. A tragic example of how important it is to properly treat any wound is demonstrated through the untimely death of Rory Staunton, 12-year-old boy from Queens, NY, who died in 2012 after scraping his arm while playing basketball during gym class and subsequently developing sepsis. However, Rory is only one example of millions of patients in this country who have been affected by the syndrome, which is also one of the most common syndromes experienced by patients across the globe that can often lead to life-altering consequences, organ failure, and, obviously, death. In an attempt to better educate wound care providers in the outpatient setting, this article will give an overview of the signs and symptoms, as well as appropriate treatment strategies, related to sepsis. 

SEPSIS: THE “OTHER” SILENT KILLER

Sepsis can present through many signs and symptoms, such as altered mental status, elevated pulse and respiratory rates, fever, and difficulty breathing. Because these symptoms are common to other diseases and syndromes, healthcare providers and/or family members may think that a patient is suffering from pneumonia or influenza. Through a misdiagnosis, incorrect therapies may be administered, potentially resulting in serious consequences. Perhaps what should perplex healthcare providers most about this syndrome is its preventability. Sepsis can be prevented by properly treating and cleaning wounds to avoid the risk of infection. If the syndrome is identified early enough, providers can administer appropriate treatment to prevent progression to septic shock. 

By definition, sepsis is a syndrome characterized by an overwhelming systemic, inflammatory response to infection.¹ When the human body reacts to an infection, inflammation is a natural response, but, in certain situations, the inflammation may get out of control and attack organs that were not originally infected. This whole-body inflammation may cause organ dysfunction that could result in death if not treated within an appropriate timeframe. General knowledge about sepsis is sorely lacking, including among healthcare providers, despite its being one of the most common medical syndromes in America, The 11th highest cause of death in the U.S.,¹ sepsis has been reported to be a more common killer than high-profile illnesses such as AIDS, prostate cancer, and breast cancer.² More than 18 million cases of sepsis are diagnosed annually,³ with more than 1 million of those cases resulting in the patient’s death. 

Specifically relevant for providers in the outpatient setting, early warning signs that could signal septic conditions include tachycardia and a feeling of doom. Additionally, those patients living with lymphedema who have experienced sepsis previously may be able to predict if sepsis could be on the horizon based on how they’re feeling  — so asking about past presence of sepsis in this population is key. Providers in the outpatient setting should also talk about increased risk for sepsis with their patients who live with diabetes and/or are prescribed steroids.

THE CMS SEPSIS CAMPAIGN

Aside from devastating mortality rates, sepsis is also one of the many factors contributing to the economic burdens faced by hospitals. In fact, sepsis was the most expensive hospital-acquired syndrome in 2013, with an aggregate price tag of more $23.6 billion.³ These costs are not always a result of patients developing sepsis during their stay; they can also stem from the commonality of readmissions due to complications resulting from the syndrome long after the patient has been discharged. Readmissions related to sepsis can also result in costly penalties from Medicare and Medicaid programs, which is why the Centers for Medicare & Medicaid Services (CMS) released a new sepsis payment bundle in 2016 in an attempt to reduce instances of the syndrome across U.S. hospitals and as a reimbursement strategy. These bundles incentivize hospitals to ensure patients are experiencing quality care throughout their stay by paying hospitals for the total package of care they provide. Prior to the implementation of bundled care, Medicare and Medicaid would pay hospitals for the individual components of care throughout a patient’s hospital stay, often resulting in weakened care coordination that may have led to a longer hospital stay or readmission before the 30-day mark. In other words, hospitals focused on the quantity of care they provided, which in turn may have affected the quality of care patients were receiving. Prior to 2016, CMS bundles were available for a number of widely recognized diseases and syndromes, such as diabetes, stroke, congestive heart failure, urinary tract infection, and pneumonia. The sepsis-focused CMS bundle aims to curb costs relating to sepsis recognition and treatment, and encourages providers to be more cognizant of the common medical syndrome and how it should be treated.

The CMS sepsis bundle is informed by the Surviving Sepsis Campaign,⁴ which has developed guidelines to reduce the risk of patients developing sepsis, or, if already present, to prevent the syndrome from worsening. All healthcare providers should remain diligent about identifying an infection in order to prevent it from worsening. However, if a patient does acquire sepsis, providers should follow these guidelines:

Within the first three hours of the syndrome being identified, providers should:

1. Measure lactate levels.
2. Obtain blood cultures prior to administration of antibiotics.
3. Administer broad-spectrum antibiotics. 
4. Administer 30mL/kg crystalloid for hypotension or lactate ≥ 4 mmol/L.

   Note: Time of presentation is defined as the time of triage in the emergency department or, if presenting from another care venue, from the earliest chart annotation consistent with all elements of severe sepsis or septic shock ascertained through chart review.

   Within the first six hours that sepsis presents, providers should:

5. Apply vasopressors (for hypotension that does not respond to initial fluid resuscitation) to maintain a mean arterial pressure (MAP) ≥ 65mmHg.
6. In the event of persistent hypotension after initial fluid administration (MAP < 65 mm Hg), or if initial lactate was ≥ 4 mmol/L, reassess volume status and tissue perfusion, and document findings according to the Table.
7. Re-measure lactate if initial lactate elevated.⁵

Lactate is a marker of malperfusion that helps measure the end-organ tissue perfusion of a patient. It also acts as a biomarker that can help a provider identify sepsis and gauge whether the syndrome is becoming better or worse, making lactate measurement one of the more crucial elements of the CMS bundle. Providers should continue to monitor lactate levels after the initial three hours, and CMS requires a retest in < 6 hours, to ensure a patient’s syndrome is not worsening. If lactate levels are decreasing, it typically means the patient may be experiencing better tissue perfusion. In conjunction with lactate, procalcitonin (PCT), a biomarker not included in the CMS sepsis bundle, can help determine whether a patient has a bacterial infection. Through kinetics, PCT acts as a sensitive and specific biomarker of the inflammatory response to bacterial infection⁶ because its accuracy can help determine both severity of illness and adequacy of source control.⁷ In some instances, lactate levels will decrease while PCT levels can rise, often leading providers to believe that a patient is no longer septic even when they still are. Since lactate is not specific to bacterial infections, using PCT and lactate together can help providers with a more accurate assessment of a patient’s risk of sepsis and death. Certain patients, such as wound care patients, are more vulnerable to developing an infection that may progress to sepsis. It is important that the providers who care for these patients are thinking about sepsis as a possibility. Because the illness is one of the most common and expensive syndromes to treat, providers who familiarize themselves with the warning signs of sepsis and the CMS bundle strategy will be able to better recognize and diagnose the syndrome, which will lead to enhanced care coordination, improved outcomes, and reduced healthcare costs. 

Amy Sprague is patient safety manager at Richard L. Roudebush Indianapolis VA Medical Center.

References

1. The Worldwide Market for Infectious Disease Diagnostic Tests. Kalorama Information. 2015. Accessed online: www.kaloramainformation.com/infectious-disease-diagnostic-9367616

2. Wood KA, Angus DC. Pharmacoeconomic implications of new therapies in sepsis. Pharmacoeconomics. 2004;22(14):895-906.

3. Torio CM, Moore BJ. National Inpatient Hospital Costs: The Most Expensive Conditions by Payer, 2013. Healthcare Cost and Utilization Project. 2016. Accessed online: www.hcup-us.ahrq.gov/reports/statbriefs/sb204-Most-Expensive-Hospital-Conditions.jsp

4. Surviving Sepsis Campaign. Society of Critical Care Medicine. Accessed online: www.survivingsepsis.org/pages/default.aspx

5. Updated Bundles in Response to New Evidence. Surviving Sepsis Campaign. 2015. Accessed online: www.survivingsepsis.org/
sitecollectiondocuments/ssc_bundle.pdf

6. Brunkhorst FM, Heinz U, Forycki ZF. Kinetics of procalcitonin in iatrogenic sepsis. Intensive Care Med. 1998;24(8):888-9.

7. Hausfater P, Juillien G, Madonna-Py B, Haroche J, Bernard M, Riou B. Serum procalcitonin measurement as diagnostic and prognostic marker in febrile adult patients presenting to the emergency department. Crit Care. 2007;11(3):R60.