Stamping Out Sepsis: A Global Goal

By Michelle Beaver

In late 2010, a global group called out sepsis for what it is: a medical emergency beyond national boarders. The Global Sepsis Alliance (GSA) which represents about 250,000 intensive and critical care physicians around the world is urging healthcare providers, patients and policymakers in every nation to treat sepsis as a medical priority.

"Tens of millions of people die from sepsis each year, making it the likely leading cause of death worldwide," says Konrad Reinhart, MD, chairman of GSA and director of the Department of Anesthesiology and Intensive Care Medicine at the University of Jena in Germany. Sepsis can kill anyone but occurs more frequently in the young and elderly.

"It's imperative that we come together as a global community to address this enormous public health problem," adds Mark Lambert, executive director of GSA.

But what does this mean? At a fall symposium in Manhasset, N.Y., more than 150 sepsis experts from 18 countries declared that part of the mitigation plan is to properly define sepsis, recognize it, and administer fluids, antibiotics and other efficacious treatments within one hour of suspecting sepsis.

Sepsis is the body's life-threatening response to infection. It afflicts about 750,000 Americans annually and costs the U.S. healthcare system nearly $17 billion, according to GSA data. Globally, the statistics are even more staggering: an estimated 18 million cases of sepsis occur each year. According to GSA, sepsis experts believe the condition is responsible for the majority of the deaths associated with HIV/AIDS, malaria, tuberculosis, pneumonia and other infections.

Part of the problem in tackling this condition is the shadowy nature of its definition. To address this, Manhasset symposium attendees created a new public definition as follows: "Sepsis is a life-threatening condition that arises when the body's response to an infection injures its own tissues and organs. Sepsis may lead to shock, multiple organ failure and death, especially if not recognized early and treated promptly. Sepsis remains the primary cause of death from infection despite advances in modern medicine, including vaccines, antibiotics and acute care. Millions of people die of sepsis every year worldwide."

Multiple surveys show that as high as 60 percent of people around the world do not know what sepsis is, according to Edgar Jimenez, MD, president of the World Federation of Societies of Intensive and Critical Care Medicine and director of the Medical Critical Care at Orlando Regional Medical Center.

"In order to make sepsis a global health priority, the first step is to define it in terms the public can understand," Jimenez says. "This definition achieves this goal."

In the United States, 1 in 4 hospital deaths is caused by sepsis, yet most Americans have never heard of the condition, says Kevin J. Tracey, MD, president of the Feinstein Institute. "Sepsis is a mystery to most Americans," he adds. Would caregivers prefer that patients not know sepsis cases are sometimes acquired from improper healthcare techniques?

Definitely not, according to Mitchell M. Levy, MD, professor of medicine at Brown University School of Medicine. "I do think that patients should demand that their caregivers be held accountable for adherence to known quality metrics," Levy says. "I do think that many clinicians are worried about public reporting, but I dont think that there are advocates of keeping patients in the dark."

It would certainly help if patients and family members better understood sepsis and its causes, Levy believes. "Public awareness is an important component of facilitating earlier diagnosis in sepsis," he says.

The core problem though, is that many healthcare providers do not realize how serious sepsis prevention is to health and the bottom line.

"I think many providers believe that it is only a matter of providing appropriate antibiotics," Levy says. "They do not appreciate the urgent nature of the illness and the need to apply all appropriate therapies in a timely fashion."

Even among healthcare providers, the definition of sepsis varies. This is a problem, but according to Levy, definition ambiguity is not nearly the biggest perpetrator.

"I think it is the lack of vigilance, especially on the medical wards, of tracking patient vital signs and following the course of infection, that is the major problem," he says.

Physicians and nurses in intensive care units are more likely to be aware of and respond to sepsis than healthcare professionals in other settings, GSA claims. Awareness issues are not exclusive to the United States, or the rest of the developed world. They are rampant in the undeveloped world too, and are worse there, says Niranjan Kissoon, MD, president-elect of the World Federation of Pediatric Intensive and Critical Care Societies.

There is hope, however. A reduction in hospital mortality from severe sepsis and septic shock was associated with participation in the Surviving Sepsis Campaign performance improvement initiative, according to an article published simultaneously in the February issues of Critical Care Medicine and Intensive Care Medicine.

"A multifaceted performance improvement initiative was successful in changing treatment behavior as evidenced by a significant increase in compliance with sepsis performance measures," says Levy, the lead author. "These results should encourage similar efforts with other evidence-based guidelines as a means of improving patient care and outcomes."

"Application of two time-related bundles of care based on the Surviving Sepsis Campaign guidelines in a performance improvement program results in measurable behavior change in the care of patients with severe sepsis and septic shock," adds Levy. A "bundle" is a group of therapeutic actions, which applied together and measured for compliance, improve outcomes as compared to being applied individually.

In an attempt to decrease sepsis through standardized care, the Society of Critical Care Medicine, European Society of Intensive Care Medicine, and the International Sepsis Forum launched the Surviving Sepsis Campaign in 2002 and in 2008 updated the guidelines.

In order for a majority of healthcare providers to be aware of this campaign and proper guidelines, and to carry them out, mandated accountability by regulatory agencies and the government will be necessary, Levy believes. That is easier said that done, however.

"Clinical behaviors changes very slowly, and I believe that clinicians will need to be forced to the table, unfortunately," Levy says.

Obviously the ultimate goal is for zero sepsis cases a year, but this is probably not attainable.

"People get infections: pneumonia, urinary tract infections, skin infections it is very unlikely we can reduce this to zero," Levy says. "However, we can reduce deaths from sepsis, through rapid identification and management. I think an attainable, positive goal is exactly that laid out by the Surviving Sepsis Campaign: 25 percent reduction in mortality from sepsis over the next five years. I believe remains a positive, attainable goal."