Hospitals fight costly war on sepsis

Dawn Nagel, a nurse at St. Joseph Hospital in Orange, Calif., knew she was going to have a busy day, with more than a dozen patients showing signs of sepsis. They included a 61-year-old mechanic with diabetes. An elderly man recovering from pneumonia. A new mom whose white blood cell count had shot up after she gave birth.

Nagel is among a new breed of nurses devoted to caring for patients with sepsis, a life-threatening condition that occurs when the body's attempt to fight an infection causes widespread inflammation. She has a clear mission: Identify and treat those patients quickly to minimize their chance of death. Nagel administers antibiotics, draws blood for testing, gives fluids and closely monitors her charges — all on an extremely tight timetable.

'We are the last line of defense,' Nagel said. 'We're here to save lives. If we are not closely monitoring them, they might get sicker and go into organ failure before you know it.'

High cost, Leading cause of death in U.S. hospitals

Sepsis is the leading cause of death in U.S. hospitals, according to Sepsis Alliance, a nationwide advocacy group based in San Diego. More than 1 million people get severe sepsis each year in the U.S., and up to 50 percent of them die from it. It also is one of the most expensive conditions for hospitals to treat, costing $24 billion annually.

Most hospitals in the U.S. have programs aimed at reducing sepsis, but few have designated sepsis nurses and coordinators as St. Joseph's does. That needs to change, said Tom Ahrens, who sits on the advisory board of Sepsis Alliance.

'From a clinical point of view, from a cost point of view, they make a huge impact,' said Ahrens, a research scientist at Barnes-Jewish Hospital in St. Louis.

Hospitals now must report on treatment efforts

Recent federal rules could help foster such a change: The Centers for Medicare & Medicaid Services began requiring hospitals in 2015 to measure and report on their sepsis treatment efforts. They must make sure certain steps are completed within the first three hours after sepsis is identified, including getting blood cultures, giving intravenous fluids and starting patients on a broad-spectrum antibiotic.

Sepsis is difficult to diagnose, but if it's caught early it can be treated effectively. If not, patients are at risk of septic shock, which can lead to organ failure and death.

St. Joseph Hoag Health, an integrated medical system in Orange County, Calif., that operates St. Joseph and six other hospitals, began employing dedicated sepsis nurses throughout the system in 2015. Hoag Hospital in Newport Beach and its namesake sister facility in Irvine were the first to try out the nurses about seven years ago, and four other hospitals have followed.

The hospitals in the St. Joseph Hoag Health system treat about 8,000 cases of sepsis each year, at a cost of $130 million, according to Andre Vovan, a critical care physician who oversees St. Joseph Hoag's antisepsis programs.

Nurses at center of effort to combat inflammation

The health system also created sepsis care checklists and a mobile app to help coordinate care for patients at risk. But the nurses are at the core of the initiative. They know how to treat sepsis like 'the back of their hands,' Vovan said. 'Their familiarity allows them to do it faster.'

Speed is critical in sepsis: evidence shows that patients who get treatment quickly are more likely to survive.

'It's so much easier to give someone salt water and antibiotics. It's a lot harder when they are in the ICU and you are trying to get them off a ventilator,' said Cecille Lamorena, who is in charge of the sepsis nurses at St. Joseph Hospital.

Sepsis nurses give families an idea of what to expect — both during the patients' hospital stay and after their discharge, Vovan said.

'We want the families to understand that just because you survive sepsis, it doesn't mean you can get home and run a marathon,' Vovan said. 'It can take weeks to months to recover.'

Sepsis nurses and coordinators also serve as on-site experts to ensure that required standards are followed by others, said Dr. David Carlbom, medical director at Harborview Medical Center in Seattle. The sepsis nurse coordinator there, Rosemary Mitchell Grant, educates staff and tracks data collected through the medical records. She also carries out projects to improve outcomes and helps organize an annual sepsis conference.

'Hospitals that don't have a systematic approach could have a delay in recognition of sepsis,' Carlbom said, noting that busy acute care nurses might miss its subtle signs.

The St. Joseph Hoag Health effort seems to be working. From 2015 to 2016, the death rate for all of its hospitals fell from 15 percent to 12 percent for severe sepsis/shock, and from 12 percent to 9 percent for all sepsis cases, Vovan said. The length of hospital stays also is dropping, he said.

At St. Joseph Hospital in Orange, the number of patients who went into septic shock dropped 50 percent in the same two-year period, Lamorena said.

The sepsis program has support from doctors, including Dr. Matthew Mullarky, an emergency room physician at St. Joseph, who said he relies on the hospital's sepsis nurses to help find and follow patients who are at risk.

'With the knowledge they have, they ensure we are moving in the right direction quickly,' he said. 'These patients are so overwhelmingly sick.'