The frightening syndrome known as sepsis has been a target of Minnesota hospital officials for months, even before last week’s $20 million malpractice award over a Maple Grove woman who died just days after giving birth.
The condition, triggered by an overwhelming immune response to infection, was the primary cause of 439 deaths in Minnesota in 2015. That’s up from 261 deaths a decade earlier, according to a Star Tribune review of a federal death records database.
Three-fourths of the deaths occurred while the patients were admitted to hospitals, records show.
Exactly how many of those deaths could have been prevented is unclear, but state hospital leaders have been pressing practitioners to spot the condition sooner, because the death rate increases 8 percent for every hour that a patient with severe sepsis goes untreated. In less than one day, patients can go from mild symptoms to septic shock, when their blood pressure plummets and their organs stop working properly.
“Sepsis is a time-critical emergency,” said Dr. David Larson, medical director of emergency medical services for Ridgeview Medical Center in Waconia, one of the first hospitals in Minnesota to develop a sepsis-reduction plan. “It is just like somebody having a stroke or heart attack; we have to act quickly.”
A Minneapolis jury concluded Monday that a nurse practitioner at Abbott Northwestern Hospital in Minneapolis failed to heed the signs of sepsis in Nicole Bermingham, a 30-year-old who went to the ER with fever and nausea three days after giving birth.
Bermingham was sent home, but fainted 12 hours later. She was taken back to Abbott by ambulance and died on Aug. 26, 2013.
The tragedy is a warning to hospitals, Larson said. Only one in four hospitals had sepsis response plans in place, according to a 2014 survey by the Minnesota Hospital Association.
The association has since launched a campaign called “Seeing Sepsis,” which advises hospitals on treatment “bundles” that improve a patient’s chance of recovery.
It also promotes a simple memory trick for caregivers: If patients have temperatures or pulse readings above 100, or blood pressure readings below 100, they need to be tested for sepsis.
Even two of the three signs should prompt a test for lactate, a compound released in the blood when tissues aren’t receiving enough oxygen, which serves as a predictor of septic shock.
“If you see 100s, think sepsis,” said Tania Daniels, the state hospital association’s vice president for quality and patient safety.
Thirty-five hospitals have now adopted all of the association’s sepsis treatment recommendations, and many others have taken steps to improve detection of the condition, Daniels said.
The U.S. Centers for Medicare & Medicaid Services plans to report later this year how often hospitals follow treatment guidelines in the first three to six hours of sepsis cases.
Getting antibiotics faster
Understanding the full menu of early sepsis symptoms is important, because they can vary from patient to patient.
A third of septic patients arrive at hospital emergency rooms without fevers, Larson said, and many just complain of “not feeling right.”
Infections in combination with fainting episodes or memory or cognitive problems are key warning signs, he added.
Fairview Health Services has updated its electronic medical record systems to alert doctors and nurses to sepsis risks based on their patients’ vital signs.
The goal is to hasten detection and automate the process of ordering antibiotics, said Beth Thomas, Fairview’s chief quality and patient safety officer. Antibiotics are administered to eliminate the underlying infection.
“We’ve definitely shaved time off,” Thomas said. “We want these antibiotics in within an hour of being [ordered].”
Fairview also is researching how to detect sepsis in tricky cases, such as pregnant women or patients recovering from surgery, Thomas said.
“It’s harder in cases of people where their physiology is already altered,” she said. “Take a patient in post-op. If I just took out your gallbladder, your vitals are already going to be altered.”
Ridgeview was among the first hospitals in the state to target sepsis, in 2007.
Through training and the creation of a treatment response team, the hospital cut the death rate of its sepsis cases from 39 percent to 24 percent as of 2013.
Larson said many of those cases involved patients in palliative care who were dying from other conditions. The death rate of patients admitted to the hospital with treatable cases is now under 6 percent.
‘They go in too late’
The infections that trigger a septic overreaction can vary, but the U.S. Centers for Disease Control and Prevention attribute 35 percent of cases to lung infections such as pneumonia, and 25 percent to kidney or urinary tract infections.
Another 11 percent involve skin infections, such as a rare instance detailed this year in the journal BMJ Case Reports in which a man died after getting a tattoo that became infected when he swam in the ocean.
Death records indicate that Bermingham probably suffered endometritis, an infection of the uterus that is more common after childbirth.
Blood tests during Bermingham’s first ER visit pointed toward sepsis or another life-threatening condition that should have resulted in hospital admission, said Chris Messerly, the attorney who represented her family.
Instead, she was sent home with a weak antibiotic for a presumed urinary tract infection.
Messerly said he hopes the judgment, entered against the nurse practitioner and her practice, not Abbott, would increase awareness among doctors and nurses — but also among patients — to the signs of sepsis.
“Patients oftentimes sit at home thinking they will get better, when they have symptoms of sepsis, and many times they go in after it’s too late,” Messerly said.
Minnesota’s aging population is one reason why deaths from sepsis are increasing. Thomas said the condition can be harsher in people who are frail or have chronic conditions such as diabetes.
The CDC’s main database on causes of deaths doesn’t list data for 2016 yet, but a Star Tribune review of Minnesota death certificates last year found only 376 listing sepsis as a primary cause, and state officials hope their efforts have caused a decline in fatalities.
For patients at the University of Minnesota Medical Center, odds are getting better, said Elizabeth Parr, an inpatient nurse.
She recalled sepsis cases in the past that weren’t detected until after patients suffered organ damage or dangerous drops in blood pressure.
Now, Parr said, patients often get treatment before those problems emerge.
“We just need to be on top of things,” she said, “before they go south.”