Q&A: The next step in sepsis care

Patients with severe sepsis and septic shock get the best care that hospitals have to offer: rapid, intensive, protocol-based treatment.

Patients with severe sepsis and septic shock get the best care that hospitals have to offer—rapid, intensive, protocol-based treatment.

But some patients with milder cases of sepsis might be slipping through the cracks of inpatient care, according to a new study. Researchers from Kaiser Permanente Northern California (KPNC) recently looked at outcomes in patients diagnosed with sepsis and others who weren't coded as sepsis patients but had both infection and acute organ failure.

They found that these others actually made up a larger proportion of hospital patients than those with diagnosed sepsis, in both their own KPNC patient database and a patient cohort from the Healthcare Cost and Utilization Project Nationwide Inpatient Sample, according to results published as a research letter by the Journal of the American Medical Association on May 18.

In addition to being common, these apparently less severe sepsis cases appeared to be deadly. In the KPNC patients, the majority of sepsis deaths occurred in patients with normal blood pressure and lactate levels below 4 mmol/L. Only 32.6% of the patients who died of sepsis were sick enough to qualify for early, goal-directed therapy (EGDT).

ACP Hospitalist recently spoke to lead study author Vincent Liu, MD, MS, a research scientist and critical care physician for KPNC, about what his findings mean and how hospitalists can improve care for this vulnerable patient population.

Q: Should there be more explicit identification of patients who are at high risk of hospital death but don't fit the criteria for severe sepsis and septic shock?

A: I believe there should be. A large number of patients with sepsis are not going to the ICU. They're going out to the hospital wards, where the protocols for care are not well established. How can we take the principles of what we've learned from treating the most severely ill patients and disseminate that to patients with less severe illness? We've been engaged in an effort trying to roll out a protocol that's based on the Surviving Sepsis guidelines (the 3-hour bundle treatment for sepsis) for less severe patients to see if we can improve their outcomes in the hospital. There's a lot of potential to not only increase our awareness about these patients, but to begin to understand how we [should] treat them more effectively.

Q: Should less severe patients get the same treatment protocol as severe sepsis patients?

A: The overarching principles of all the treatment are earliest identification, source control (including surgery and prompt antibiotics for their infection), and fluid resuscitation.

Q: How much mortality do you think can be prevented by improving care for these patients?

A: Historically, mortality in septic shock and very severe sepsis (the EGDT-eligible patients) was 30% to 50%. And now multiple studies suggest that it's in the high teens or low 20%. There's been a halving of mortality.

Q: What lessons should hospitalists take from your study?

A: What our study suggests is that most of these patients with less severe sepsis are treated on the wards. They are admitted by hospitalists who give them their best care. However, sometimes we think, “Oh, we don't really have to worry about these patients, they look fine.” I don't think it turns out that's entirely true. Clearly the sickest patients have a much higher mortality rate, but what we're finding is these less sick patients, even those who go to the ward, have a substantial mortality rate, much higher than other non-sepsis hospitalized patients.