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Hospital Harm: Sepsis

Sepsis is defined as: "life-threatening organ dysfunction caused by dysregulated host response to infection" (Singer et al., 2016). It affects neonatal, pediatric, and adult patients worldwide. Differentiated from an uncomplicated infection by virtue of the dysregulated host response and acute organ dysfunction, sepsis can present as or progress to septic shock, recently redefined as: "a subset of sepsis in which particularly profound circulatory, cellular and metabolic abnormalities are associated with a greater risk of mortality than with sepsis alone." (Singer et al., 2016). Maternal sepsis is a life-threatening condition defined as an organ dysfunction caused by an infection during pregnancy, delivery, puerperium, or after an abortion (Escobar et al., 2020).

Topics
  • Patient safety
  • Hospital harm
Audience

  • Point of care provider

  • Quality or safety improvement lead

  • Policy advisor or analyst

Goal

To decrease the morbidity and mortality from sepsis and to prevent nosocomial sepsis in the hospitalized pediatric and adult population.

Overview

Healthcare Excellence Canada has developed this Hospital Harm Improvement Resource – a compilation of resources to support patient safety and improvement efforts.

Healthcare-associated infections (HAIs) can lead to sepsis and its deleterious outcomes (Riley & Wheeler, 2012). Failure to comply with evidence-based infection preventive practices for HAIs increases the incidence of hospital-acquired sepsis.

HAIs account for a large proportion of patient safety incidents in Canada. Every year, it is estimated that 220,000 Canadian patients (approximately one in nine) will develop an infection during their stay in hospital. Complicating the problem is the fact that many HAIs are caused by antimicrobial-resistant organisms (AROs), which make them difficult to treat. Although progress has been made to prevent and control ARO-related HAIs, much work remains to be done. Globally and in Canada, the steps taken to mitigate antimicrobial resistance (AMR) are relatively limited (MacLaurin et al., 2020). The Public Health Agency of Canada (PHAC) estimates that approximately two per cent of patients admitted to large, academic Canadian hospitals will have acquired an infection with an ARO during the course of their hospital stay (Mitchell et al., 2019) and that at any given time, three to 10 per cent of patients who are hospitalized in Canada will either be infected or be a carrier of an ARO (Martin et al., 2019).

Canada continues to lag behind other OECD countries on sepsis following abdominal surgery (CIHI, 2019b). In 2019, the Canadian in-hospital sepsis rate was 3.9 per 1,000 patients (CIHI, 2019a). Sepsis affects approximately 1.7 million adults in the United States each year and potentially contributes to more than 250,000 deaths. Various studies estimate that sepsis is present in 30 to 50 per cent of hospitalizations that culminate in death. The high burden of sepsis and the perception that most sepsis-associated deaths are preventable with better care has catalyzed numerous sepsis performance improvement initiatives in hospitals around the world (Rhee et al., 2019).

It has been reported in a recent study that hospital-onset sepsis preferentially afflicted ill patients but even after risk-adjustment, they were twice as likely to die as community-onset sepsis patients; in patients admitted without sepsis, hospital-onset sepsis tripled the risk of death. Hospital-onset sepsis is an important target for surveillance, prevention, and quality improvement initiatives (Rhee et al., 2019).

Recommendations for guiding care for adults with critical or severe Coronavirus associated sepsis have been developed by the Surviving Sepsis Campaign Coronavirus Disease 2019 panel and will be updated as necessary (Alhazzani et al., 2020).

Risk Factors

  • Examples of risk factors are:

  • Age (higher risk in neonates and elderly persons than in other age groups).

  • Chronic diseases with/without severe organ dysfunction.

  • Immunodeficiency.

  • Immunosuppressive agents.

  • Inappropriate use of antibiotics.

  • The presence of implanted medical devices (intravascular or other).

  • Pregnancy.

  • Prematurity.

  • Infection is more likely to occur when the normal anatomy is altered by a process – benign or malignant - that either obstructs a normal passage (e.g., calculous cholecystitis, prostatitis) or breaks and enters a previously sterile system (e.g., skin breakdown by trauma, dermatological conditions).

  • Patients unable to communicate their symptoms often present later in their illness (i.e., often with sepsis) (CPSI et al., 2015).

Importance to Patients and Families

Patient Stories

Julie's Story

This short documentary accompanies "Julie's Story". In 2008, Julie Carman was involved in a road traffic accident whilst on a cycling holiday. She suffered injuries to her face, jaw and legs but made a good initial recovery and expected to be back at work within three months. Three years later she was still having treatment having experienced two further emergency admissions to hospital due to acute cellulitis and sepsis. In this short film, Julie explains how a series of "everyday" communication failures conspired to create delays in her receiving effective treatment (Patient Stories, 2013).

Additional Sepsis Survival Stories

https://bcpsqc.ca/improve-care/sepsis/sepsis-survival-stories/

Clinical and System Reviews, Incident Analyses

Given the broad range of potential causes of Sepsis, in addition to recommendations listed above, we recommend conducting clinical and system reviews to identify latent causes and determine appropriate recommendations.

Occurrences of harm are often complex with many contributing factors. Organizations need to:

  1. Measure and monitor the types and frequency of these occurrences.

  2. Use appropriate analytical methods to understand the contributing factors.

  3. Identify and implement solutions or interventions that are designed to prevent recurrence and reduce risk of harm.

  4. Have mechanisms in place to mitigate consequences of harm when it occurs.

Measures

Vital to quality improvement is measurement, and this applies specifically to implementation of interventions. The chosen measures will help to determine whether an impact is being made (primary outcome), whether the intervention is actually being carried out (process measures), and whether any unintended consequences ensue (balancing measures). In selecting your measures, consider the following:

You may use different measures or modify the measures described below to make them more appropriate and/or useful to your particular setting. However, be aware that modifying measures may limit the comparability of your results to others.

Evaluate your choice of measures in terms of the usefulness of the final results and the resources required to obtain them; try to maximize the former while minimizing the latter.

Whenever possible, use measures you are already collecting for other programs.

Try to include both process and outcome measures in your measurement scheme.

Discharge Abstract Database

Discharge Abstract Database (DAD) Codes included in this clinical category: B17: Sepsis

Concept: Sepsis identified during a hospital stay, excluding neonatal sepsis.

Notes: This clinical group includes an episode of sepsis that developed in hospital; however, the infection which led to sepsis might have been acquired in the community or hospital.

Success Stories

PatientStories.org and the Winchester and Eastleigh Healthcare NHS Trust in the UK have created Surviving Sepsis: A Human Factors Approach, a short film documenting their innovative human factors approach to identify and manage sepsis (Patient Stories, 2013).

The World Sepsis Declaration is a call to action: To reduce sepsis incidence by 20 per cent by 2020. Internationally, over 4,200 organizations and individuals have signed this declaration to show their support. This includes organizations and individuals from across Canada. The pledge supports increasing awareness, implementing best practice, and tracking the positive impact of sepsis care and management.

References

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