In Sepsis, An ‘Excellent Diagnosis’ Means Keeping Patients at the Center
Feature Story
By Stephanie Miceli
Last update October 5, 2020
Each year, more than 1.7 million adults in the United States develop sepsis, and 270,000 people die as a result. It’s a dangerous medical complication that occurs when an existing infection — such as pneumonia, a bladder infection, or a skin infection — triggers an extreme reaction throughout the body that can rapidly lead to tissue damage, organ failure, and even death. This extreme reaction can also occur in patients who become seriously ill with COVID-19. Accumulating data indicate that patients with severe COVID-19 illness are at high risk for developing sepsis — an issue the World Health Organization raised in the lead up to Sepsis Awareness Month.
Most Americans know the signs of a heart attack and strokes, thanks to consumer-friendly educational campaigns (such as the “FAST” campaign for stroke detection). However, there’s currently no well-known equivalent for recognizing sepsis, said panelists at a recent National Academies workshop called Achieving Excellence in Sepsis Diagnosis, part of a series on diagnostic excellence.
The symptoms of sepsis — such as chills, fever or low body temperature, pain, difficulty breathing, and disorientation — vary among patients, and there’s no gold standard test available to confirm the diagnosis. Sometimes, clinicians may not recognize that a patient is experiencing sepsis until it’s too late to prevent complications. Workshop panelist Helen Haskell lost her son, Lewis, in 2000 because his sepsis and internal bleeding were not diagnosed until it was too late to effectively treat him. Delayed diagnosis is not always considered a diagnostic error, but it is a leading cause of death among septic patients, she said.
Panelists discussed challenges and opportunities in sepsis diagnosis, technologies in the pipeline, and a vision for how the health care system can achieve “diagnostic excellence.”
What is Diagnostic Excellence?
Diagnostic excellence goes beyond avoiding errors or making accurate diagnoses, said Harvey Fineberg, president of the Gordon and Betty Moore Foundation, and a former president of the Institute of Medicine. “It looks at the question of the efficiency and the appropriateness of the testing strategy. It asks questions about the cost — financially and in terms of safety. It is concerned with redundancy and over-testing,” he said.
Quality metrics to assess diagnostic excellence should not only consider missed or delayed diagnoses but also address the challenges of over-testing that leads to unnecessary costs and treatments, added Jeremy Kahn, professor of critical care medicine and health policy and management at the University of Pittsburgh School of Medicine and Graduate School of Public Health. “If we measure diagnostic quality along all these domains, we can have a more holistic approach,” he said.
Emerging Technologies
Tests to identify infection-causing pathogens, a key step in diagnosing and treating sepsis, used to take several days — a long time when every second counts. In the last few years, however, hospitals have begun using rapid detection systems to turn around test results within hours. This means patients can receive more targeted therapy sooner. For example, by tailoring antibiotics to specific pathogens, clinicians can more effectively treat infection while avoiding overuse of antibiotics that may contribute to drug resistance.
Panelists also discussed the promise of biomarker panels to identify sepsis, particularly in early stages before the development of organ dysfunction. But the key question is whether these biomarkers will be broadly applicable for diverse patient populations in different settings of care.
Hospitals are also using machine learning and artificial intelligence (AI) tools to predict and identify the onset of sepsis, but they’re not always intuitively built into clinical decision support tools. Clinicians may get 10 to 15 alerts per hour on an individual patient — so those alerts have to provide the right information at the right time, said Christopher Seymour, associate professor of critical care and emergency medicine at the University of Pittsburgh.
“If a patient is in the ICU, any time we give a clinician a piece of information or a new prediction — it needs to be clear how this should be changing their reasoning and decision-making,” said Seymour. “Every new piece of information should feel like a value-add.”
Part of diagnostic excellence is also knowing when it’s safe to send a patient home, said Daniel Yang, program officer at the Gordon and Betty Moore Foundation and a practicing physician in San Francisco.
“As a clinician, what keeps me up at night are not the patients that I admit to the hospital or the ICU. It’s the patients I send home,” said Yang. “We need reliable strategies to monitor these patients — whether that’s an automated AI system or a nurse on the phone calling the patient in 24 hours to make sure that they are actually doing better.”
Several panelists said the next frontier of diagnostic excellence in sepsis is identifying it in settings outside of the emergency department and ICU (for example, in people’s homes and in ambulatory care settings).
Haskell, the patient advocate who is now president of the nonprofits Mothers Against Medical Error and Consumers Advancing Patient Safety, agreed, and said the patient voice will be pivotal to make that a reality. “We live in a data-driven world,” she said. “People are increasingly monitoring their own health and vital signs with personal equipment and wearables. So there is a lot patients can contribute, but they need to know how to apply it to sepsis.”
‘Hear my story, not my symptoms’
New technologies are important for advancing sepsis diagnosis, “but sometimes they take us away from the most obvious things that are right before our eyes,” said Abraham Verghese, a physician at Stanford Medicine and critically acclaimed author.
Knowing the signs of sepsis could have been transformative for Haskell while she was at her son’s bedside. “I couldn’t protect him because I lacked the knowledge in medicine that I needed to save him,” she said. Haskell’s guiding mantra today is “follow the patients.”
“Find out what the patients and families think went wrong in their missed sepsis diagnoses and what the communication issues were, because they are almost always there,” she concluded. “Then find out what it would take to teach families to recognize sepsis, to teach respectful, empathic communication to health care providers, and to give nurses and families the confidence to speak up even when they feel uncertain.”
Christine Goeschel, assistant vice president at the MedStar Institute for Quality and Safety, recalls a recent conversation with a patient who said, “What I dream of is an interaction with a care provider who wants to hear my story, not just my symptoms.”
“In that space between the story and the symptoms is the opportunity to make our health systems improve and keep sepsis diagnosis as a real priority.”
Future workshops in this webinar series will focus on advancing diagnostic excellence in acute cardiovascular events and cancer.
