Death in disguise: A broad campaign targets sepsis, which often mimics minor ills

By The Orange County Register

Categories: Featured News

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.

TRICKY DIAGNOSIS

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 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 Feb. 3, his 32nd birthday.

‘SNEAKY SEPSIS’

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 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 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 that day.”

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,” Perrott said.

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