Knowledge is key to better outcomes for post-sepsis patients.
In the past, I have written a fair bit about sepsis, so this column will have some familiar elements. But there is a lot that is new, including an update on diagnostic methods and new information on the incidence of sepsis in the general population, how often it is initially diagnosed in primary care, and some updates on the cost to the healthcare system. In addition, I want to again reinforce that treatment of post-sepsis patients falls directly onto primary care. We need to know and understand sepsis well, and be prepared to have meaningful discussions with our key physician practices, to understand their experience with sepsis diagnosis, as well as their needs to manage post-sepsis patients. As a practical matter, since patients who have survived sepsis experience a broad range of both physical and psychological symptoms, the more you and your customers know, the better the outcomes for the patient post-sepsis.
I plan to tread some familiar ground in this column to provide a review of what sepsis is and what causes it. The reason is that there continues to be a lot of misconceptions about sepsis. For instance, while 72% of the American public can identify the symptoms of stroke, only 12% of the public can do so for sepsis. In addition, 39% of all Americans believe sepsis is contagious. Clearly education about sepsis is needed. The better informed we are, the greater our ability to convey needed knowledge to our customers as their consultants. So here goes.
What is sepsis?
It may start as an infection, but sepsis is not an infection at all. As we have learned, sepsis is not a disease and it is not contagious. It typically results from an infection, some that seem trivial and easily treated, but sepsis is actually the body’s overly aggressive reaction to the infection. Sepsis is defined as “the body’s overwhelming and life-threatening response to infection which can lead to tissue damage, organ failure, and death.” It results from our immune system becoming over-stimulated and the creation of a feedback loop keeping the immune system highly active. From a metabolic standpoint, sepsis typically unleashes a powerful immune response, resulting in what is described as a “cytokine storm.” Cytokines are a part of the immune system that pass messages to the immune system to attack a foreign substance and rid the body of it. In healthy conditions, their signaling stays in control and results in the removal of the infecting substance. But in sepsis, their signal goes out of control and unleashes a far greater immune response than is appropriate.
What causes sepsis?
Sepsis causes include respiratory infections such as COVID, pneumonia, group A strep and influenza urinary tract infections, enteric diseases including C. difficile and skin infections including MRSA. While we think of respiratory infections and skin infections as relatively minor issues which are usually easily treatable, this is not the case for everyone. Our recent experience with COVID and patients who experience lingering symptoms well after their initial diagnosis (long COVID) showcases how complicated some of these seemingly innocuous clinical conditions can be.
Risk factors for sepsis/who is most likely to develop sepsis
Unfortunately, sepsis risk factors target those most likely to develop several other serious adverse health outcomes. Those at risk include adults over 65, people with compromised immune systems, those with chronic medical conditions, those who recently experienced a serious illness or hospitalization, former sepsis survivors and children younger than one. As we help create awareness of sepsis and patients most at risk, the situation regarding chronic illnesses is important to consider at greater length. We know that heart disease, diabetes and chronic lower lung disease factor into the ten leading causes of death (now along with COVID at number five) but consider the chronic conditions of the patients our customers see frequently. Nineteen percent of U.S. adults 55 years or older have three or more chronic conditions. For adults older than 65, the percentage rises to over 23% according to CDC data. This leaves a substantial percentage of the patients our customers see every day in a high-risk group for sepsis and other conditions.
Incidence of sepsis and costs to the health care system
So, knowing all this, what is the current incidence of sepsis? According to the Sepsis Alliance, there are 1.7 million sepsis cases diagnosed annually in the U.S., with 350,000 fatalities annually. Sepsis has a 20% fatality rate, and over 30% of sepsis survivors go on to have “post-sepsis syndrome” with a range of physical symptoms including fatigue, shortness of breath and difficulty sleeping. Psychological symptoms include panic attacks, flashbacks, depression, memory loss and others. Management of the “post-sepsis syndrome” patient largely falls to primary care practices except in seriously acute conditions where hospitalization will be required.
The most recent estimates of the impact of sepsis on the health care system make it clear that sepsis’s impact is growing, not declining. Latest cost estimates show the annual cost of sepsis to hospitals at $27 billion according to the Sepsis Alliance. This does not take into account primary care visit costs. Sepsis continues to be the leading cause of death in hospitals as well as the leading cause of readmissions. It is estimated that the cost of sepsis has increased by 20% from 2015 to 2018. While our understanding of means to diagnose and treat sepsis have improved significantly in the past 20 years, the burden on the health care system continues to grow. Most experts believe faster, more accurate diagnosis and more targeted treatment methods are the keys to improving outcomes and reducing costs. There is a lot of work to be done to achieve these goals.
Sepsis diagnosis
This brings us to try to understand current diagnostic tools for sepsis and to what extent out customers encounter sepsis in their practices. First, we need to know that 10% of all initial diagnoses of sepsis take place outside of the hospital. These diagnoses are made in primary care practices, urgent care centers and free-standing emergency facilities.
Unfortunately, there is no single biomarker that can rapidly diagnose sepsis definitively today. Typically, a combination of “signs and symptoms” are evaluated along with lab data. Signs and symptoms include high heart rate, weak pulse, fever, shortness of breath, mental confusion, clammy or sweaty skin, and extreme pain or discomfort.
Lab diagnostic tools include complete blood counts (CBC), lactate, coagulation tests including prothrombin time, d-dimer and platelet counts, as well as procalcitonin. Microbiology tests can assist in determining the type of infection and the most likely antibiotics to counter it. Presumptive positives for sepsis require reflex testing for ALT, AST, BUN and creatinine to determine whether there is also organ damage taking place. Between developing more experience with COVID patients who may develop sepsis as well as increased focus on early detection of sepsis, a greater understanding of CBC interpretation is developing. It is well known that infections create an increase in while cells, but other patterns are emerging. As white cell production increases dramatically, the white blood cell differential shifts resulting in an increase in bands (immature neutrophils) and immature granulocytes. Monocyte distribution width also changes, with monocyte distribution width greater than 20 indicative of sepsis. A normal monocyte distribution width indicates a six-fold decrease in the likelihood that the patient has sepsis. Each of these changes are red flags that the patient may be experiencing sepsis. As our knowledge of how to interpret CBC data to help diagnose sepsis continues to grow, this area of lab diagnosis is growing in importance. Stay in close touch with your key hematology manufacturers to take advantage of their expertise as these findings continue to evolve.
As dangerous as sepsis can be, if diagnosed and treated early and aggressively, the patient outcome is usually favorable. More than 70% of those who suffer from sepsis will recover fully if treated promptly. The key is recognizing the symptoms of sepsis and rapidly taking action to overcome it. The classic symptoms of sepsis include:
- Temperature: elevated or below normal.
- Infection: sepsis typically presents as a result of an infection.
- Mental confusion/decline: the patient may be sleepy, easily confused, or difficult to rouse.
- Extremely ill: patients frequently state that they are concerned they may die.
Clinicians frequently use the acronym TIME when they describe the symptoms of sepsis. It’s worth putting into your vocabulary.
Once the sepsis patient becomes ill enough to be hospitalized, the patient management includes assessment of blood gases and electrolyte values and also shifts to developing and following the patient’s SOFA (sequential organ failure assessment) score. This score helps determine the prognosis of the patient; the higher the score, the more serious the prognosis. There are six elements of the SOFA scoring system: respiration, platelet count, bilirubin, hypotension (low blood pressure), Central Nervous System Glasgow Coma score and creatinine. Each has a value from zero to 4. Scores above 11 are associated with a very high risk of death. As you can see, lab results continue to be important both in the primary care realm as well as the hospital, since these specific lab results point to impending organ failure, which is a serious complication of sepsis and development of septic shock.
Patient treatment and management in the hospital setting includes therapeutic measures including aggressive antibiotic treatment, supportive therapy including supplemental oxygen, pain management and IV fluid replacement.
Post sepsis management: back to the community
About 1.4 million Americans survive sepsis annually and return for ongoing care. Their needs are special and require physician practices to understand the trauma they have recently undergone and develop a care plan to deal with both physical and psychological elements of their recovery. They will need to have routine monitoring of their lab tests including organ tests (ALT, AST, BUN, creatinine, electrolytes and CBC at a minimum). They may also require counseling and physical rehabilitation to resume normal activities and return to health. Their treatment plan is likely to involve far more health care practices and personnel than the average patient upon hospital discharge. Understand your role as consultant and work to understand the network of health care professionals needed to complete the patient’s successful recovery.
Sepsis resources
There have been several organizations working diligently to develop awareness of sepsis, effective diagnostic
and treatment tools and the need to treat it with the urgency required to assure patient recovery. Key among them are the Sepsis Alliance and the Society of Critical Care Medicine. Both organizations post a wealth of information on their web sites to assist you and your customers in learning far more than can be delivered in this column. I recommend you spend the time to review their resources, think with your key lab manufacturers about how to integrate this information into your customer consultation, and become more well informed. In addition, September is Sepsis Awareness Month, a time for you, your key lab manufacturers and our customers to focus our thinking on sepsis and how to effectively manage it. This complex disorder requires exceptional knowledge and coordination between you, a large number of our manufacturers for lab and other products, and the health care professionals in your community. Commit to make a difference. It will save lives.
Sidebar:
The classic symptoms of sepsis include:
- Temperature: elevated or below normal.
- Infection: sepsis typically presents as a result of an infection.
- Mental confusion/decline: the patient may be sleepy, easily confused, or difficult to rouse.
- Extremely ill: patients frequently state that they are concerned they may die.