Understanding Sepsis

Podcast Transcript

Raed Dweik, MD (00:04):

Hello, and welcome to The Respiratory Inspirations Podcast. I'm Raed Dweik, Chairman of the Respiratory Institute at the Cleveland Clinic. This Podcast series of short, digestible episodes is intended for patients and families, and covers topics related to respiratory health and disease. My colleagues and I will be interviewing experts about timely and timeless topics in the areas of pulmonary, critical illness, sleep, infectious disease, and related disciplines. We will share with you information that will help you take better care of yourself and your loved ones. I hope you enjoy today's episode.

Hassan Khouli, MD (00:39):

Hello everyone and welcome to The Respiratory Inspirations Podcast. I am your guest host, Doctor Hassan Khouli, Director of the Critical Care Center and Chair of Critical Care Medicine in the Integrated Hospital Care Institute at the Cleveland Clinic. My guests today are Doctor James Morrison, Staff Physician in Critical Care Medicine and Emergency Medicine and the Chair of the Enterprise Sepsis Committee at the Cleveland Clinic... Also joining us today is Doctor Matthew Dettmer, Staff Physician in the Critical Care Medicine and Emergency Medicine and Co-Medical Director of the Sepsis Emergency Response Team at the Cleveland Clinic main campus. Today we will be talking about sepsis. James and Matt, welcome to the program.

James Morrison, MD (01:24):

Thanks, Hassan.

Matthew Dettmer, MD (01:24):

Thanks, very much.

Hassan Khouli, MD (01:25):

We have a lot to talk about today in the area of significant interest really to many of us, including our public, really, who are interested in this, and learning more about it, and learning maybe about what the implications are for this too. So, I'm going to start with you, James. If you can let our audience maybe understand better, what is really sepsis?

James Morrison, MD (01:49):

Thanks, Hassan. It can be a tough thing to tackle, and so, I think we approach it pretty broadly to just understand that sepsis is related to infection. So, sepsis is a life-threatening medical emergency, and it's caused by the body's response to an infection. And we care about sepsis 'cause it can lead to damage to the tissues and the organs, and it can kill people, especially if not treated quickly.

(02:12):

So, while not every infection leads to sepsis, when it does occur, the risks to patients is often higher than other conditions that we often think of as medical emergencies. So, heart attacks or strokes. And we know that it's... Sepsis is a leading cause of death in hospitals worldwide. So, to summarize, sepsis is related to infection and the body's response, and it's a life-threatening medical emergency that needs to be treated promptly.

Hassan Khouli, MD (02:37):

Thank you, James. And I know our audience want to hear about sepsis, and in the context of strokes, in the context of heart attacks, and, and how you really put it at the same level of an emergency and life-threatening disease is going to be quite focusing for them there. So, you know, when you put it in that perspective, why is it such an important priority, above and beyond what you mentioned to us?

James Morrison, MD (03:05):

Yeah. I think the key is what we said, which is that it's a leading cause of death. We know that it causes two out of five hospital deaths at the Cleveland Clinic, and this fits with the picture throughout the rest of the country, and actually globally. So, we know that sepsis is a leading killer, and very important to address for that reason, and it also causes harm to people that survive sepsis. That's the cornerstone of the importance of it.

Hassan Khouli, MD (03:29):

Thank you, James, and these are a lot of lives that we can save by preventing sepsis and by treating it appropriately too. Uh, Matt, I'm going to switch to you at this point, and if you can, really give us the broad clinical criterias. You know, some of these criterias by which we say, "Yeah, we think this patient possibly has sepsis."

Matthew Dettmer, MD (03:49):

That's a great question, and in reality there's a couple different ways that clinicians can define sepsis at the bedside. And one of the ways to sort of put those in context is to think about sort of the historical evolution of how we've come to understand sepsis, how we've come to understand how to manage sepsis. And a lot of that's happened in the last about 25 years, and, you know, in the '90s and probably before then, sepsis was certainly going on, it carried a really high mortality, and prompted a fair amount of research interest. And since 2001 moving forward, there've been a number of really important studies that've taught us important lessons about not only how to define sepsis, but also the things that are important to do to prevent deaths from sepsis.

(04:40):

In parallel with that, the government in the U.S. has become obviously aware of the risks posed by sepsis to patients, and has become very instrumental in developing a metric that helps to grade hospitals with respect to how they take care of patients with sepsis, again, with an effort to sort of standardize care nationally. So, if... Thinking about maybe those sort of two tracks of development over the last 25 years that sort of, which have informed each other, but are a little bit distinct, the sort of scientific investigation of sepsis, and then sort of the regulatory efforts to standardize care... as a result, there are a number of different ways to define sepsis.

(05:25):

And I'm speaking, you know, fairly broadly, but there's from that sort of scientific effort the consensus definition released in 2016. It's called Sepsis-3. And then a different definition criteria that uses SIRS criteria, which is Systemic Inflammatory Response Syndrome criteria, that informs the regulatory efforts for sepsis. So, two different ways to define sepsis, and then some of the history as to why those two exist.

Hassan Khouli, MD (05:55):

Thank you, Matt. You know, a nice really history of sepsis, and how it really evolved, and how it really guided the clinicians and how we care for these patients when they come to our doors in the emergency rooms, or they develop that type of serious infection, sepsis on the floor here. James, you know, would you like to add to this in terms of maybe, maybe a bit more specificity or, things to share with our audience, please?

James Morrison, MD (06:21):

Yeah. I think Matt broke it down into the two big things. We have an international, agreed-upon definition which is focused on how likely, you know, sepsis is to lead to death, and it's kind of defined that way. And we have an interplay between that and some more rules-based criteria. So, the general definition is related to, you know, knowing that you have an infection with the body's response harming the body, and we know that that leads to mortality or a chance of dying of up to ten percent. And we have a sub-definition of patients at particularly high risk that we call "septic shock", and those patients have profound disturbances that lead to an increased risk of dying, as high as thirty or forty percent, and that's kind of how we defined it.

(07:04):

We also use in clinical practice definitions that are based on rules and numbers that are discreet, so that we can kind of look at the record and see it and define it. And the reality is if you're a community member, or a patient, or you have a family member who's a patient, your provider's going to use different definitions. But what's important is that they're sitting down thinking about sepsis and engaging in kind of like, identifying sepsis and taking care of patients that they think are at risk. And so, they do that through a number of pathways, but what the real key is is your provider sitting down and thinking about infection, treating it as an emergency if there's signs of danger and doing it quickly.

Hassan Khouli, MD (07:44):

Okay. Thank you, James, for sharing this. And I'm sure it's reassuring, really, to our audience who are here that medical teams are guided by specific criteria, protocols, that they tend to refer to that allow them to identify these patients, these complex issues in a life-threatening disease like sepsis.

(08:09):

Matt, I'm going to come back to you and ask you... Are there certain patient populations that are at a high risk of developing sepsis? Or maybe they don't do as well when they develop this life-threatening disease?

Matthew Dettmer, MD (08:23):

Yeah. I think that's a really important question, and I think that there's a couple ways to think about sub-populations. One way is to think about, patients who develop sepsis, what are their sort of underlying diseases that are being managed at the same time? Because sometimes, you know, those underlying diseases can promote worse outcomes from sepsis. So, for example, patients who have cancer, who are being treated with chemotherapy that would suppress their immune system, one can imagine that if they develop an infection that leads to sepsis, that their outcomes can be worse. Which is the case versus patients who have other underlying diseases or, or none at all. And so, I think that's one way to sort of start to sub-divide some of those populations.

(09:10):

Another way to do it would be to think about where the patient develops sepsis and where they are initially managed for sepsis. So, the vast majority of sepsis in the U.S. is developed in the community or outside of the hospital, and those patients based on their symptoms come to the emergency department and receive their initial care there. And that's a population we can refer to potentially as "community onset sepsis", because that's where it's developed, or "present on admission sepsis" in the sense that as they are admitted to the hospital, that's when their disease state is present.

(09:46):

The opposite side of that population is patients who are already in the hospital with another disease process. Maybe they're undergoing care for cancer or for heart failure management, or something like that, and they develop an infection and sepsis there. And that population we refer to as "hospital onset sepsis" or "not present on admission" because it develops after their admission. So, and that population tends to be somewhat smaller, but also carries with it a higher mortality. More people are likely to die who develop it in that fashion. So, it's an important target for us to understand even better.

Hassan Khouli, MD (10:24):

Thank you, Matt, for sharing this. James, I'm going to come back to you. Matt had mentioned previously in that historic perspective, and how sepsis' definition evolved, is that some government regulatory agencies got involved in this. Can you maybe elaborate a little bit more on this, and what's the intention of this, and how we really measure, how they measure performance of hospitals in the area of sepsis care?

James Morrison, MD (10:49):

Yeah. I think rooted in that understanding that it's such an important driver of patient harm and death, you know, it is a regulatory interest to make sure that you're providing a standard of care. And I think, to give feedback, I think that there's actually a kind of complex web of interested groups, in community groups that are interested in this and the government.

And CMS actually does have a specific measure for sepsis, and this is publicly-related data that's available for everyone to access and kind of understand some facts about how sepsis is taken care of at a hospital. And it gives information about some core key measure of sepsis treatment, such as antibiotic timing, such as administration of fluids, and other interventions that we think makes better outcomes. So, yes, this is actually measured and reported and available to people to see.

Hassan Khouli, MD (11:41):

That's good to see for such an important disease and how serious it is, the lights being shed on by different really areas. Certainly the most important one, from within our own hospitals, and how we care for these patients and put together these kind of protocols around it too. I'm going to stay with you, James, and ask you about, what are some of the maybe best practices? Things that we aim to do and that it's important for our audience to hear about?

James Morrison, MD (12:09):

Yeah. That's a good question, and I think we anchor it in this understanding of we want to measure the outcomes for our patients. We want to know what happens to our community members, our friends, our family. So, we measure how we're doing with sepsis death or sepsis mortality, and then we give our providers some things that we have known from outcomes that make an impact.

(12:29):

So, we measure antibiotic timing, and some measure related to standardized care, making sure that you get kind of an appropriate, evidence-based spectrum of care as kind of like our base... As our regular care. We measure that though order set usage and other standardization that we're kind of aware of, track, and help our providers know how they're performing compared to other people in, both in our system and then nationally compare to other groups like us and across the country.

Hassan Khouli, MD (12:59):

That’s good. I can imagine families or patients or future patients unfortunately who are in a hospital and maybe have been told that they have sepsis, how now they can be more engaged in their care and talk about antibiotics and, and also on how soon it can be delivered there. So, it's a teamwork and families and patients can join in on this there.

(13:23):

Matt, there are several programs that we have alluded to that are being implemented here at the Cleveland Clinic. One of them is what's called SERT. Can you share a bit more information about this? Things that would be of interest to our audience?

Matthew Dettmer, MD (13:38):

Sure. SERT stands for Sepsis Emergency Response Team, and just broadly it's a team whose focus is to identify and manage patients who have early signs of sepsis on the regular nursing floors at main campus. So, as I was mentioning before, you know, a way to think about different populations that develop sepsis is sort of where they are, whether they develop sepsis, and where they're managed for that. And at a hospital of our size, each of those sort of populations is, is quite large. So, there's a lot of septic management that happens in the emergency department, there's a lot that happens on the floor, there's a lot that happens in the intensive care unit.

And, and given how big those, those clinical areas are, I think it's valuable to have dedicated sort of workflows to make sure that some of the metrics that James was mentioning about are effectively executed in those like, different kinds of environments. You can imagine that, you know, the emergency department is a little bit different venue than the floor, a little bit different than the ICU.

(14:43):

So, our team is geared really to that population that, that is showing early signs of sepsis on the floor. We identify that by using an electronic screening mechanism primarily, and then our APBs, our physician assistants, and nurse practitioners go and look at those patients and talk to the primary care teams taking care of them to decide whether their, you know, symptoms that they're developing are really from sepsis or maybe from some other condition, perhaps the one that they're hospitalized with and then work up a plan of care to make sure that if it is sepsis that we're doing some of the evidence-based measures that will improve their outcome moving forward.

Hassan Khouli, MD (15:22):

Thank you, Matt, and we'll stay on this point. You did mention that these two patient populations, the one who presents through the emergency room or who develop sepsis on the floor, tend to differ in their symptoms, in how they present, and how we identify them there. Are they also different in terms of how well they do as they leave the hospital, or as their course of hospitalization continues?

Matthew Dettmer, MD (15:49):

Sure. And one of the things that's become really clear again over the last decades of research is that hospital onset patient population that develop sepsis is at risk... is more likely to die than those that come in from the community. Which again emphasizes, despite that that population is relatively small, that it's an important one to not only have a team that helps manage it, but also for it to be a specific focus of research to understand what are the things that contribute to that higher death rate? And what are things that, that maybe need to be done differently in that population versus a community onset one?

Hassan Khouli, MD (16:31):

Thank you. And one last question for you, Matt, about SERT is, who are the people? Who are the caregivers, who are usually on a team like the SERT?

Matthew Dettmer, MD (16:42):

Yeah. I think, you know, team is built into the name of the program, and I think that that is really important. And certainly there's the actual SERT members. So, our APPs. Again, physician assistants and nurse practitioners that help assess these patients and get interventions going. We have dedicated nursing as well, which is a really vital part of the management for any patient, certainly a septic patient. We also have folks from phlebotomy that help us with lab draws that are indicated.

(17:14):

But that's, you know, members of the SERT program. But really the team globally is really important, and I think we like to think about the primary teams that we're engaging with as part of that team as well, as well as the patients and their families. Because talking to them and seeing how they've changed over the course of a hospital stay is a really valuable way to assess these patients. So, the team is quite broad.

Hassan Khouli, MD (17:39):

Thank you, Matt. I'll come back to you, James, and maybe ask you a little bit about from a broad perspective, many hospitals seem to have good programs, strong programs to care for patients with sepsis. And, here at the Cleveland Clinic, you know, both of you have alluded to a few things. Best practices also, there, too. Can you share some of that with us? Some of the best practices, and how our teams, our providers, and caregivers are engaged in that?

James Morrison, MD (18:08):

Listening to Matt, I was kind of inspired to think that, you know, we're focused on SERT, but we believe in this across the board, and it's not like the sepsis emergency response in one place or another. We really believe that no matter where you are in the Cleveland Clinic, you deserve that level of care, and we've made sure that we have a system that provides that to patients across the board.

(18:28):

we've motivated our providers... We've empowered them to act when they are concerned about sepsis, and they have tools that help them provide good sepsis care. And really we've found that, you know, when our providers are engaged like that, they come to us with improvements and innovations. And so, we've seen from within our own system and asking people to engage in sepsis care, our providers and, and sometimes our family and community members bring us ideas that have really been brought from one very local, specific thing to the entire enterprise.

(18:56):

So, you know, we've seen changes in how we measure antibiotic timing coming out of our cancer institute. We've seen actually like, providers having within a unit competitions between nursing groups to get antibiotics in as quickly and timely as possible. And you know, we've seen providers go out and, and have good impacts and communicate with teams, and these are all things that then we've seen the impact and incorporated it into our standard response. So, it's really about that global picture of like, recognizing the importance of sepsis, empowering our providers, and making sure that we provide standard care across the spectrum so that no matter where you are, you're getting high-quality care.

Hassan Khouli, MD (19:34):

Thank you, James. It's really a continuum of care, and you've focused these best practices, these resources, you know, in every area where we can make a difference in the care of these patients and, and really make their outcomes better. Any future initiatives in the care of patients with sepsis, James, that you can think of and you can share with us today too, please?

Matthew Dettmer, MD (19:57):

Yeah. You know, I think we talked about the challenges of defining exactly when patients have sepsis, and we've had to work with the balance between having enough sensitivity to find the cases, but also balance that with, if we alert on too many cases, it's not specific enough, and we end up wasting resources or burning people out. So, some of our work has really been on focusing on how we can find these patients, and you know, we have teams that are dedicated to looking at the data, and we're deploying new technologies like artificial intelligence to screen and put providers into the loop. So, instead of just a rule that tells you, "This number's bad," really understanding the whole context of the patient and, and using that technology to help us deliver that care to who needs it most.

Hassan Khouli, MD (20:42):

Thank you, James. And I'm sure our audience actually are interested in hearing that. Especially new technology, a lot of people are talking these days about artificial intelligence that is being explored to see if this can enhance how we care for patients with sepsis, or how we identify patients with sepsis, as soon as possible even in the hospital. Looking forward to hear more about that. So, we're going to close, and I want to ask you Matt and James, if you can really share with us, brief closing remarks here. And I'll start with you, Matt.

Matthew Dettmer, MD (21:15):

Sure. You know, I'd say I think James and I are both excited to be here and talk about this topic, but that we're representatives of much broader teams and so appreciative to all the work that everybody does for the groups that we're parts of. We’ve learned a lot about sepsis historically. We've done a lot of good work translating those lessons to the bedside. I think that there's a lot of opportunities for us to continue to be vigilant and aggressive about different ways that we can learn about how to continue to improve, again, on, maybe on some of these sub-populations, is a mechanism for that...

(21:59):

But to continue to improve and put those lessons into place as well. So, I think the struggle against sepsis continues, and continuing to be innovative and thoughtful about how we're working against the disease process is really important.

Hassan Khouli, MD (22:16):

Thank you, Matt. James? Closing remarks, please.

James Morrison, MD (22:18):

Yeah. I want to bring it back to that thought that sepsis is a life-threatening medical emergency, that it's related to the body's response to infection. Not all infections cause sepsis, but when it does, it's really a medical emergency that's as bad as anything else we know. So, both the vigilance, and treating sepsis as an emergency is important for patients to recognize it and for our providers to recognize it. And we've come to learn that treating it like that, we actually have tools and protocols that help us make it less deadly.

(22:49):

So, my take-home message is also a grateful one to appreciate the community and our providers caring about this, and to recognize that they are making a difference. And I think that's what drives us here, is really get the engagement to prevent this from hurting our patients, our friends, our family, our community.

Hassan Khouli, MD (23:10):

Thank you. And with these closing thoughts, our podcast comes to a close as well. I want to thank again Doctor Morrison and Doctor Dettmer. Thanks really everyone who's listening to our podcast today.

(23:23):

I am your host, Doctor Hassan Khouli, Director of the Critical Care Center and Chair of Critical Care Medicine in the Integrated Hospital Care Institute at the Cleveland Clinic. My guests today were Doctor James Morrison, Staff Physician in Critical Care Medicine and Emergency Medicine and the Chair of the Enterprise Sepsis Committee at the Cleveland Clinic... Also, Doctor Matt Dettmer, a Staff Physician in Critical Care Medicine and Emergency Medicine and Co-Medical Director of the Sepsis Emergency Response Team, SERT, at the Cleveland Clinic main campus. Today, we talked about sepsis. Thank you.

Raed Dweik, MD (23:59):

Thank you for listening to this episode of The Respiratory Inspirations Podcast. For more stories and information from the Cleveland Clinic Respiratory Institute, you can follow me on Twitter @RaedDweikMD.