Tennessee healthcare professionals are seeking solutions for rising sepsis rates throughout the state.
In 2021, Tennessee surpassed 1,000 sepsis-related deaths, the highest the state has ever seen. The state’s 12.5% death rate for sepsis patients also increased by 2.1% compared to the prior year.
“Sepsis is an equal opportunity syndrome or condition,” said Rhonda Dickman, director of the Tennessee Hospital Association. “It can affect healthy young people who otherwise don't have any chronic health conditions to older people, or people who are fighting a chronic health condition.”
Infections with the highest risk of developing sepsis include respiratory and urinary tract infections (UTIs). However, any infection, whether bacterial, viral, or fungal, carries the risk of sepsis.
Dr. Edward Qian, assistant director of Quality and Education of the Medical ICU at Vanderbilt Medical Center, said that each type of infection carries different treatment needs, and depends on both the patient and the type of infection. Qian said the future of effective sepsis treatment lies in “individualized care,” something he noticed during the COVID-19 pandemic.
Because COVID-19 causes a “massive immune response” in the lungs, Qian said patients who developed sepsis from a COVID infection needed unique care.
“Antibacterial agents weren’t the answer,” he said.
What’s unique about Tennessee?
Statistically, the Southeast sees significantly higher rates of sepsis and sepsis mortality compared to the rest of the U.S.
Currently, about 58% of sepsis patients in the U.S. receive timely and adequate care, compared with 55% in Tennessee.
Dickman said that these rates don’t always tell the whole story, though. When a patient with sepsis enters the hospital, medical professionals issue a “sepsis bundle” - a list of criteria that must be met within just a few hours to provide adequate and timely care to the patient. Since sepsis can become fatal so quickly, time is of the essence when it comes to the bundle.
While this treatment criteria may apply to most sepsis patients, Dickman notes that following the bundle isn’t always in the best interest of every patient.
“For example, one of the elements is that the person receives a certain volume of intravenous fluids within a time period. But we have patients, particularly in Tennessee and the southeast region, who have end-stage kidney disease, or congestive heart failure, which are conditions in which it is not appropriate to give a large volume of IV fluids.”
Because of this, Dickman said that these publicly reported measures can be somewhat misleading.
“It may sometimes appear, ‘Oh, we missed the bundle.’ When the ultimate question is, did we do the best for this patient? And that's where hospitals are. Did we do the best for the patient?” Dickman said.
Qian added that prior versions of the bundle “came under a lot of criticism.”
To combat this, many hospitals record their own metrics for effectively treating sepsis patients.
“I think within hospitals, many of them, in addition to tracking their performance with this publicly reported sepsis bundle data, they have their own internal metrics that they track that is more appropriate for the patient population that they serve, to ensure that they are giving the best care for the patient above and beyond what the bundle elements are. So efforts to standardize care are important,” Dickman said.
Current data shows that local Knoxville hospitals perform higher in overall sepsis care than several other regions in the state. Some 71.4% of hospitals within a 25-mile radius of Knoxville perform above the state and national average for appropriate care for severe sepsis and/or septic shock, according to the Centers for Medicare & Medicaid Services.
This data changes when looking at sepsis treatment after surgery. According to Leapfrog Hospital Safety Grades, some 50% of hospitals within 25 miles of Knoxville perform above average for sepsis treatment after surgery.
Finding solutions through technology
Medical professionals across the state have been seeking and implementing solutions to reduce sepsis rates through knowledge sharing and new technologies.
One of the most recent technologies introduced to treat sepsis is an award-winning sepsis detection algorithm, developed by a team at the University of Tennessee’s Department of System and Industrial Engineering last year.
This innovative algorithm, created through a partnership with clinicians at UT Health Science Center and Emory University, was developed to address “alert fatigue,” a common phenomenon among healthcare workers.
“You have this concept of alert fatigue, where there's just too many alerts, and too many alerts that are wrong. And so the couple of times that it is right, the clinician has already been trained to ignore that alert, because there's just so many false positives,” Qian said. “There's a lot of work that needs to be done in this early detection space.”
Qian said that earlier, more specific detection is key to identifying sepsis cases more quickly. The more rare the alert is, the more a clinician is likely to pay attention to it when it pops up.
Another potential solution comes from the recent wave of telehealth providers, according to Dickman.
“We're seeing some innovations with virtual healthcare providers, or telehealth. So maybe breaking down some of those access barriers because through telehealth, a small rural hospital can have access to an intensivist, a pulmonologist, or others who can evaluate the patient situation and advise care,” she said.
Addressing the root cause of sepsis
Pinpointing the reasons for rising sepsis rates in the region is challenging, but could include factors such as an aging population, and a rise in chronic health conditions.
Dickman also noted that an increase in awareness over time may have led to an increase in reported cases.
“There has been a greater movement to raise awareness. So I think some of our older data actually missed sepsis patients and that we are better now at recognizing capturing these sepsis cases,” she said.
Qian said that implantable devices may be another driver.
“Invasive devices, implantable devices that live in a person’s body that are inherently from the outside world, and you put it in and those are at risk of getting infected,” he said. Higher obesity rates in the Southeast are also a contributing factor, he said.
“Obesity is associated with a lot of comorbidities that can increase the risk of sepsis. So obesity in and of itself, but then you think about the extra weight you're carrying around and what that does to your joints. And so then you have more joint replacements, hip replacements, knee replacements, those are implantable devices, those are at risk of getting infected always,” Qian said.
Both Dickman and Qion agree that sepsis rates won’t decrease until Tennesseeans address chronic health conditions.
“I don't know if we will see a lower prevalence of sepsis until we start solving some of our chronic health issues in Tennessee,” Dickman said. “What I do hope is that we see reduced mortality, that we see people coming for care sooner in their sepsis process because they're more educated and aware, and that the care is delivered efficiently and quickly.”
Education saves lives
The THA Sepsis Collaborative, a group formed in 2017 in response to THA’s goal to reduce sepsis mortality in the state, is trying to raise awareness about sepsis among Tennesseans.
The collaborative enables healthcare professionals to share new strategies across the state to address sepsis needs.
For now, Dickman encourages Tennesseans to learn more about sepsis by recognizing its symptoms. Because the rate of survival decreases by 7% for every hour treatment is delayed, education is essential in reducing rates.
“We've been making greater collective effort to raise public awareness and educate people about sepsis. Most people have never heard of it or don't know exactly what it is,” she said. “There's never anything wrong with a person saying, Could I have sepsis? You know, I see these signs, could this be sepsis? I think they should always feel empowered and encouraged to advocate for themselves in that respect,” Dickman said.
Qian said recent booms in sepsis research have the potential to help physicians give more effective care to their patients in the coming years.
“My hope is that over time, our ability to care for our patients and improve their outcomes will improve,” he said.
To learn more, see the Tennessee Center for Patient Safety.
(This story was co-produced with students from the University of Tennessee's Department of Journalism and Media.)