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The Tragedy of Sepsis and the Collaborative Work to Combat It

09/10/19

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Marilyn Sherrill, RN, MBA, CNOR, CPHQ, Knowledge Transfer Director

Maybe you’ve heard of blood poisoning, which is a common lay term for sepsis. The Centers for Disease Control and Prevention (CDC) answers the question “What is sepsis?” in simple and easy-to-understand language:

“Sepsis is the body’s extreme response to an infection. It is a life-threatening medical emergency. Sepsis happens when an infection you already have — in your skin, lungs, urinary tract, or somewhere else — triggers a chain reaction throughout your body. Without timely treatment, sepsis can rapidly lead to tissue damage, organ failure, and death."

At least 1.7 million adults in America develop sepsis every year and nearly 270,000 die as a result. My friend’s son was one of them.

Josh’s story

Josh was a successful, healthy 27-year old man who had decided to return to school to become a child psychologist. He loved working with children and the feeling was mutual. Just before beginning this journey, Josh experienced an equipment malfunction while skydiving that sent him plummeting to the ground at 60 miles per hour. Incredibly, he survived, but the fall resulted in a fractured femur and a fracture to the back of his skull.

Surgery reduced the pressure in his brain from the trauma and repaired his leg fracture. The recovery required a very difficult six-week stay in the intensive care unit, but Josh was on a good path to recovery. There was reason to hope as he transitioned into a rehabilitation facility for a full recovery, but when he went into cardio-pulmonary arrest after spiking a fever, and his brain again swelled, a medical error caused permanent injury to his cervical spine. Paralyzed and ventilator-dependent, Josh endured agonizing pain over the next five days as his organs slowly yet steadily shut down.

No one knew what or why it had happened until an investigation discovered “sepsis” written on the very last statement of Josh’s medical record.

An organization’s efforts

The most common, costly and deadly diagnosis in U.S. hospitals, sepsis is also time-sensitive: For every hour that passes, the risk of patient mortality increases. Research shows that 80 percent of sepsis deaths can be prevented with rapid diagnosis and treatment.

The facts and industry data surrounding sepsis are well known to Vizient and our members. For the last decade, sepsis has been part of the Vizient Performance Improvement Collaboratives program, where network members bring together clinical, operational and quality leaders to work on the most critical aspects of health care performance. Through collaboration and the sharing of leading practices, participants are able to improve quality of care, lower costs and increase efficiency. In 2017, 72 network organizations joined an Early Recognition and Intervention for Sepsis Management collaborative, reducing their total sepsis mortality rate by 4 percent, which translates to 283 lives saved during the nine-month project.                           

Vizient is currently in the middle of a three-part sepsis Early Recognition collaborative, which will address the unique aspects of early identification in three sites of care, from the perspective of clinicians as well as patient and family advisers. This project will conclude in 2020.

Increasing awareness

September is Sepsis Awareness Month and ironically, Josh’s skydiving accident occurred on a Labor Day weekend. Josh’s parents have never looked to point blame but only wish to prevent this from happening to anyone else. They have worked closely with various organizations such as CDC and the Centers for Medicare & Medicaid Services to heighten the awareness and prevalence of sepsis in our communities. They also work with health care organizations to develop patient and family councils to support hearing from patients and their families about ways to enhance care delivery, reduce medical errors and improve the patient experience overall. 

For more information, CDC provides numerous sepsis-related resources, including basic facts, data and reports, and life after sepsis.

About the author. Marilyn Sherrill is a knowledge transfer director on the Vizient Knowledge Transfer team and works with the PI Collaboratives Program. She provides research on various clinical topics to support the case for change, while developing the resources to share the work performed by members who participate in the various PI collaborative projects. Sherrill previously served as a collaborative advisor for the PI Collaboratives Program. Before this, Sherrill was a senior consultant on the Vizient Advisory Services team.

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