When he started feeling sick one Sunday last year, 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 hospitals and kills
about 150,000 of them. The annual tab exceeds $20 billion. It is the biggest,
deadliest, costliest illness 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
be docked on their payments 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.”
Sepsis in essence is an overreaction by the body’s immune system
to an infection. Instead of just attacking the infection, the body releases
chemicals that also attack healthy cells.
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 state
in the past three years.
In recent years the death rate in hospitals from sepsis has declined,
but 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.
In early stages of sepsis, patients “can look incredibly well,”
said Dr. Christopher Fee, an associate professor of emergency medicine
at UC San Francisco.
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, which can damage one or more organs.
And finally comes what nearly killed Stan Tkaczyk: septic shock –
severe sepsis plus critically low blood pressure, damaging tissues throughout
the body and 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. 16, four days after
taking his last dose, he got what he thought was a fever. His doctor suggested
Motrin. His mother, Kay, got worried and took him to an emergency room.
This time it was severe sepsis. He was in a 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
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 Feb. 3, his 32nd birthday.
Health care workers have long recognized sepsis as an insidious and particularly
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, screen immediately for sepsis
using a once rare and now routine lactate test.
• If sepsis is confirmed, start broad-spectrum antibiotics within
• If blood pressure falls critically low, quickly begin intravenous therapy.
“The best strategy is to treat these patients rapidly and aggressively,”
Delay and denial escalated Tkaczyk’s illness. The retired businessman,
an OC 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, and that painful infection was triggering
sepsis. Over several days his condition worsened. After a week he shivered
so uncontrollably that he called paramedics. He decided he didn’t
need to go to a hospital.
The next morning, when he began shivering again, he relented. His wife
drove him to the emergency room at Hoag Hospital. 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.”
At Hoag, Dr. Andre Vovan, director of critical care medicine, said the
hospital’s approach includes a recently created sepsis specialty
floor to ensure consistent care.
“More than 10 years ago, we focused our program on the sickest patients
who were admitted to the critical care units,” Vovan said in an
email. “After realizing a double-digit decrease in sepsis mortality,
we expanded the efforts to the rest of the hospital.
“Additional advances to our program include creating a rapid response
team, appointing a dedicated sepsis nurse, and concentrating on early
recognition and initiation of treatment in the emergency room.”
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 reducing 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 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.”
At the four Global Medical Center hospitals in Orange County, staff formed
a multidisciplinary sepsis task force this year to develop a standardized
order set for all hospitals to follow, according to Shela Kaneshiro, chief
nursing officer for Orange County and Anaheim Global Medical Centers.
She said the Medicare change will result in greater transparency in patient care.
“We learn from the data to improve care and reduce mortality,”
Kaneshiro said in an email.
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 Northern California.
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. Like Tkaczyk, a kidney stone was the trigger.
“When I look back,” Banahasky said, “I should have died
The medical staff started pushing intravenous fluid into her – 30
pounds in the next three days – “so I’m like the Michelin
man,” Banahasky said.
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.
When it was her turn to speak in a meeting at work, “the words totally
escaped my brain, and (my supervisor) said, ‘It’s OK, 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,”
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