A broad campaign targets sepsis, which often mimics minor ills

Sepsis, a complication of infection, nearly killed Stan Tkaczyk of Newport Beach. Cases have tripled in the past decade in the U.S., and about 150,000 per year are fatal./Paul E. Rodriguez, The Orange County Register

This story originally appeared in The Orange County Register.

When he started feeling sick one Sunday in early January 2014, Stan Tkaczyk “was mad at myself” for not getting a flu shot.

It wasn’t until weeks later -- after he got severe shakes and called paramedics, after a trip to the emergency room and after his wife Barbara told him he’d been unconscious for five days –- that he learned it wasn’t flu. The 69-year-old Newport Beach resident nearly died from sepsis, a virulent response to infection.

Each year sepsis lands more than 1 million people in the hospital and kills about 150,000 of them. The annual tab exceeds $20 billion. It is the biggest, deadliest, costliest bug in U.S. hospitals.

That helps explain why, beginning Oct. 1, Medicare will require hospitals across the nation to follow a standard treatment for sepsis – or lose money the following year if they don’t.

Sepsis is so deadly because, in its early stages, it resembles minor complaints.

“It’s an indolent killer,” said Dr. Sean R. Townsend, a critical care specialist at California Pacific Medical Center in San Francisco and a leader of the international Surviving Sepsis Campaign. “Patients don’t arrive in extremis… Yet the clock is ticking for them.”

Over the past decade the number of sepsis cases has tripled while the number of deaths has more than doubled.

Hospitals are trying to come to grips with it. The Hospital Quality Institute, an affiliate of the California Hospital Association, has conducted sepsis simulations for 1,600 doctors and nurses from 90 hospitals in the past three years.

But while the death rate in hospitals from sepsis has declined it remains seven times higher than the rate for all other conditions combined. And many of those who survive are never the same. They lose limbs, require organ transplants or suffer memory loss.

Source: Agency for Healthcare Research and Quality Healthcare Cost and Utilization Project

TRICKY DIAGNOSIS

“Nobody’s going to miss septic shock” when blood pressure crashes and several organs are failing, said Dr. Christopher Fee, an associate professor of emergency medicine at the University of California San Francisco. But in earlier stages of sepsis, patients “can look incredibly well.”

In its initial stage, sepsis consists of an infection plus two or more signs of inflammation: a fever or low temperature, elevated pulse, elevated breathing, a high white blood cell count.

Next comes severe sepsis: sepsis plus damage to one or more organs.

And finally comes what nearly killed Stan Tkaczyk: septic shock -- severe sepsis plus critically low blood pressure, causing damage to tissues throughout the body and to the brain.

Anyone, of course, can get an infection and thus, potentially, sepsis. But some are more sepsis-prone than others: infants, the elderly, cancer patients and people with compromised immune systems.

Greg Mulligan was in that last category. In 2009, while the Folsom resident was still in his mid-20s, his doctor detected an enlarged spleen and removed it. That impaired his immune system.

In November 2013, his doctor diagnosed him with sepsis – a relatively mild case, treated at home with antibiotics. On Dec. 14, two days after taking his last dose, he joined in a family ritual as old as he was – the annual trek to a Christmas tree farm in the Gold Country.

Two days later he got what he thought was a fever. His doctor suggested Motrin. His mother Kay got worried and took him to the emergency room.

This time it was severe sepsis. He was in the hospital for a week.

By mid-January 2014, Mulligan was back at work and feeling fine. On Sunday, Jan. 19, he watched the NFL playoffs with family and friends.

The next morning he felt sick. On Tuesday at 10 a.m. he and his mom talked briefly by phone.

“He just didn’t seem very coherent,” Kay Mulligan recalled. “I thought we were still talking, and it was like he hung up on me.”

He didn’t answer when his mother called back, or when she drove to his house and pounded on the door. By the time paramedics reached him he was in the throes of septic shock.

His memorial service was held on Feb. 3, his 32nd birthday.

‘SNEAKY SEPSIS’

Health care workers have long recognized sepsis as an insidious and particuarly deadly opponent. Hospital Quality Initiative President Julie Morath remembers a phrase from her early days as a registered nurse: “sneaky sepsis.”

While the national death rate from sepsis in hospitals today is around 13 percent, it appears to have been much higher – close to 50 percent at some hospitals – around the year 2000.

The turnaround came because of the adoption of a few standardized treatments and an emphasis on speed.

Over the past 15 years, doctors have developed a standard strategy against sepsis:

If there are signs of infection, then screen immediately for sepsis using a once rare and now routine lactate test.

If sepsis is confirmed, start broad-spectrum antibiotics within three hours.

If blood pressure falls critically low, quickly begin intravenous therapy.

“The best strategy is to treat these patients rapidly and aggressively,” Townsend said.

Delay and denial nearly killed Stan Tkaczyk. The retired businessman, an Orange County Fair Board member, thought he had the flu. He also thought he’d pulled a muscle while exercising.

The reality: He had a kidney stone. That painful infection triggered sepsis. Over several days it got worse until, after a week he shivered so uncontrollably that he called paramedics. He decided he didn’t need to go to the hospital.

The next morning, when he began shivering again, he relented. His wife drove him to the emergency room at Hoag Memorial Hospital Presbyterian. Minutes later he collapsed.

When he woke up five days later, “my body was like they sucked everything out of it,” Tkaczyk said. “I was just very weak and had to work very hard to build my body back.”

Sepsis “disguises itself so many ways that you don’t know you’re circling the drain,” Tkaczyk said. “That’s the scary thing.”

The need for speed has driven hospitals to innovate.

In an experiment organized by UCSF, several Bay area hospitals allowed emergency room nurses rather than doctors to order the lactate test if they suspect sepsis. In rural Amador County, Sutter Health, one of the largest health care systems in Northern California, taught paramedics to recognize signs of sepsis and begin treatment on the way to the ER.

Meanwhile, 49 California hospitals working together in the Patient Safety First initiative reduced their average sepsis fatality rate from 22.6 percent in 2009 to 16.6 percent in 2012. By last year the average fatality rate among participating hospitals had dropped to 13.6 percent.

Beginning in October Medicare will require hospitals to measure how closely they follow standards of care for patients with severe sepsis or septic shock. Next year Medicare will start docking payments to hospitals that fail to hit the standard.

The standard is strict – 28 specific steps kicking in three hours after a patient arrives.

If anything, Fee said, the standard is too strict. In a 2014 study of 505 patients with sepsis at two emergency rooms, 10 percent to 15 percent did not display symptoms in the first three hours.

Fee said that the new Medicare rule could prompt doctors to overtreat patients, giving them powerful antibiotics when the doctors merely suspect sepsis.

Still, Fee generally supports the Medicare rule.

“The idea is a noble one,” he said. “They want to standardize care or elevate care all across the country, raise the bar for those hospitals that aren’t performing well.”

Source: Agency for Healthcare Research and Quality Healthcare Cost and Utilization Project

A PATIENT’S VIEW

Even when patients get the right care in time, sepsis can leave them diminished for months, for years, for life.

Mary Banahasky, 54, is a registered nurse and a manager in the emergency room at Mills-Peninsula Medical Center in Burlingame.

In early January 2014 she came down with what she thought was a bad cold or flu. Then she began wheezing and got diarrhea. By the fifth day she could barely get out of bed

Her adult daughter Melodie drove her to the ER where Mary worked. She was in septic shock.

“When I look back retrospectively,” Banahasky said, “I should have died that day.”

Her blood pressure was critically low, her white blood cell count very high – both signs that sepsis was raging.

Doctors told Banahasky her kidneys were failing. Melodie was distraught.

Ever the practical nurse, “I told my daughter, ‘You can’t worry about my kidneys right now. Got to worry about my blood pressure.’”

The medical staff started pushing intravenous fluid into her – 30 lbs. in the next three days – “so I’m like the Michelin man.”

Two days after she arrived doctors found the infection that had sent her into sepsis, an 8-millimeter kidney stone, but decided it was unsafe to operate.

The next day, her white blood cell count still rising and her blood pressure still very low, they could wait no longer. They removed the stone.

The following day her blood pressure slowly began rising. She left the hospital four days later.

For months afterward, Banahasky suffered from “septic fog.” Days of low blood pressure had deprived her muscles and brain of circulation. Taking a shower exhausted her. She had no appetite and quickly shed 40 lbs. over and above the 30 lbs. of IV fluid. She returned to work after a month.

“I was in a meeting once, and they got to me and the words totally escaped my brain, and (my supervisor) said, ‘It’s okay, Mary,’ and I started crying. … That whole crying in front of everybody, I’ve never done that before.”

She had another milder episode of sepsis in February 2015. This time she realized she had a kidney stone and used a home remedy to pass it. When her illness intensified, she drove herself to the ER and was hospitalized for four days.

Banahasky now has twice survived an illness that at some hospitals two decades ago carried a 50 percent fatality rate.

A standard treatment has driven down the fatality rate at many hospitals into the teens. Medicare, with its giant checkbook, will force virtually all hospitals to adopt the standard.

David Perrott, chief medical officer of the California Hospital Association, said sepsis care may be on the verge of a breakthrough similar to what occurred over the past 20 years with heart attacks (52 percent decline in death rate) or stroke (39 percent decline).

“I think this is an exciting time in the world of sepsis care,” Perrott said. 

Comments

Other Articles

Stress case: What’s behind the increased demand for mental health counseling from SoCal college students?

On February 7, author Claudia Boyd-Barrett appeared on Southern California Public Radio's Air Talk with Larry Mantle to discuss her project about...

At some schools, mental health battle includes the Bible

This article originally appeared in the Orange County Register. All kinds of colleges are dealing with unprecedented student demand for mental health...

California colleges, like USC, are in the midst of a mental health care crisis. Can help come fast enough?

This article originally appeared in the Los Angeles Daily News. “Are you actually going to kill yourself?” Sociology Professor...
  • 1 of 254

Other Audio

Ronald Campbell

Ronald Campbell analyzes health care data and costs. Before joining the Center he was a staff writer at the Orange County Register for more than 25 years. He founded the Register’s program in computer-assisted reporting. He has written extensively about the census, immigration, white-collar crime and the trade in human body parts. He has won the Gerald Loeb Award, the IRE Award and placed third in the Philip Meyer Award. He lives in Orange County, Calif. In his spare time he hikes and rock climbs.

© 2018 Center for Health Reporting

Login