Bay Area hospitals sharply cut death rates
Victoria Colliver, Chronicle Staff Writer
April 21, 2011
By taking relatively simple steps and arming health care workers with greater knowledge, Bay Area medical centers have made dramatic strides in reducing death rates from sepsis, the leading preventable cause of deaths in hospitals.
Nine Bay Area hospitals participating in a two-year UCSF program saw a striking 40 percent average drop in death rates from the common but potentially deadly condition in which the bloodstream is overwhelmed by bacteria.
Sepsis typically begins as an ordinary infection, such as pneumonia or a urinary tract infection, but can develop into something more serious by overwhelming the body's immune system. It can turn deadly when the infection enters the bloodstream. An estimated 200,000 people reportedly die from it each year.
The nine Bay Area hospitals started with an average sepsis mortality rate of 27.7 percent of cases in the six months leading up to the start of the study in December 2008. By December 2010, the average across the hospitals had dropped to 16.6 percent, for a 40 percent difference in mortality.
The hospitals got the results by working with their nurses, doctors, laboratory technicians, pharmacists, specialists and administrators to get them to recognize that there was a problem. Then they taught them to better identify and screen patients most at risk of developing sepsis and to get them to follow existing protocols. As a result, patients were treated with antibiotics much faster.
Not fancy, just smart
"It's nothing fancy. We didn't buy a $20 million piece of equipment. We used the smart intelligence of frontline clinicians," said Julie Kliger, director of UCSF's Integrated Nurse Leadership Program, which developed the sepsis reduction program.
The hospitals officially released their results Wednesday during an event celebrating the end of the program, but not the end of their work. The hospitals showed a range of overall results, depending on the type of facility and patients, and the rates varied greatly from month to month.
But all the hospitals made strong improvements.
At San Mateo Medical Center, death rates from sepsis dropped by almost half from nearly 40 percent in December 2009 to about 21 percent. San Francisco General Hospital's mortality rate from sepsis fell from above the average - 42.4 percent - to its most recent level of 22.7 percent.
Both Contra Costa and Alameda counties' medical centers reported recent mortality levels as low as 13 percent. The smaller Sequoia Hospital in Redwood City started at a relatively low rate of 18.5 percent and managed to drop below 10 percent.
"The key issue here, in addition to having standardized workflow and screening, is really about educating the medical staff," said Dr. Susan Ehrlich, chief executive officer of San Mateo Medical Center. "It's helping them understand why we worry about sepsis ... and what we can do to change those outcomes."
The sepsis project is the second set of impressive results produced by UCSF's Integrated Nurse Leadership Program, which is funded by the Gordon and Betty Moore Foundation. Medication errors dropped 88 percent as the result of a 36-month program that ended in 2009 and involved many of the same nine hospitals.
What both the sepsis and medication programs have in common are low-tech, seemingly commonsense approaches. For example, in the medication study some of the hospitals reduced errors by having nurses wear special sashes or vests to remind other staff members not to interrupt them while they were administering medications.
In the sepsis program, hospitals used various methods such as having nurses more thoroughly screen patients for sepsis as they arrived in the emergency room.
While many of the tests - blood pressure, heart rate, temperature - are routine in emergency care, nurses found that doing them while being vigilant about the clinical signs of sepsis helped identify those patients earlier. Because the condition progresses rapidly, hours or even minutes can save lives.
The program gave the hospitals latitude to develop techniques tailored to their facility and patients. Some of the hospitals gave ER nurses the ability to order lactate blood tests, a key way to identify the existence of sepsis, rather than waiting for those high-risk patients to see a doctor.
San Francisco General Hospital changed protocols to require all patients in the medical-surgical and critical care units to be screened every
12-hour shift for sepsis. Previously, patients were tested when they appeared to be at risk, but the protocols have now become more standardized.
"It brought the subjectivity out of it and made it more objective," said Terry Dentoni, a nursing director at the hospital. Dentoni said the emergency department now screens all patients with any sign of possible infection - be it a cough or a cut.
Andrea Kabcenell, a vice president with the Institute for Healthcare Improvement in Cambridge, Mass., said other projects for reducing sepsis have produced similar results, but she said the strong showing of the hospitals and the empowerment of nurses makes this program exciting.
"For the average across the nine hospitals to be that good is really quite stunning," she said.
Project: UCSF's Integrated Nurse Leadership Program worked with nine Bay Area hospitals over two years with the goal of reducing deaths from sepsis, or blood poisoning.
Key components: Better screening for patients at risk of developing sepsis; quicker testing; improved adherence to a series of "best practices."
Results: A 40 percent average reduction in sepsis mortality rates.
Participating hospitals: Alameda County Medical Center, Contra Costa County Medical Center, El Camino Hospital in Mountain View, Kaiser Fremont, Kaiser Hayward, St. Rose Hospital in Hayward, San Francisco General Hospital, San Mateo Medical Center and Sequoia Hospital in Redwood City.
Source: Integrated Nurse Leadership
Program Potentially fatal blood poisoning
What is sepsis?
It is a bad response by the body to an infection. Typically, the potentially deadly condition is caused when bacteria invades and spreads in the bloodstream (often called "septicemia" or "blood poisoning").
Normally, the body's defense system fights infection, but in severe sepsis, that reaction kicks into overdrive and can lead to organ failure and death.
How deadly is it?
About 750,000 people in the United States develop sepsis each year, and more than 200,000 people die from it. Studies suggest an overall mortality rate of 28 to 50 percent. Because patients usually die from sepsis during an illness, mortality rates may be underreported.
Who's at risk?
Although anyone can develop sepsis even from common infections, those most at risk are the very old, the very young, hospital patients, people with pre-existing medical conditions, and those with invasive devices such as tubes and catheters.
What are the symptoms?
Fever or chills; confusion; nausea and vomiting; diarrhea; increased heart rate and respiration; high or low white blood cell count; low blood pressure; altered kidney or liver functions.
How is it treated?
Patients are typically hospitalized and given a combination of intravenous antibiotics.
Source: Surviving Sepsis Campaign
Reprinted with approval of Victoria Colliver
© 2011 SF Chronicle
Read statement below from G.
Umberto Meduri, MD, who is
investigating the effects of steroid
treatment in ARDS
This is a brief
update on the global impact achieved
by research steroids in ARDS (most
sepsis-induced). The randomized
trial investigating prolonged
low-dose glucocorticoid treatment in
ARDS that we published two years ago
in Chest (1) has had an impact in
medical practice. This trial won a
national research award and was one
of the most read articles by
Pulmonologists in 2007. The 2008
edition of the Washington Manual of
Critical Care states that “with the
exception of glucocorticoids, no
pharmacological therapy has yet been
shown to decrease the mortality of
ARDS independent of treating the
underlying cause”. Both the
Washington Manual and the 2008
International Task Force by the
American College of Critical Care
Medicine recommended our protocol
for the treatment of ARDS.(2)
Most importantly a new comprehensive
review of the literature and
meta-analysis, published in the
current issue of Critical Care
Medicine (enclosed), concluded that
prolonged low-dose glucocorticoid
treatment in ARDS is safe and will
save one of four treated patients –
translating into 50,000 lives saved
per year in the United States
Click here to read the recently
published commentary in Critical Care Medicine.
Moreover, all nine reviewed studies consistently reported that treatment-associated reduction in inflammation was associated with a significant reduction in duration of mechanical ventilation and ICU stay. Overall, treatment achieved a seven-day reduction in duration of ICU stay translating into tens of thousands of dollars saved per patient.
Physicians all around the globe now have a treatment that is safe (when used in combination with secondary prevention),(4) inexpensive ($200 for 1 month treatment), and highly effective.
Click here to read the recently
published commentary in Critical Care Medicine.
G. Umberto Meduri MD
Memphis VA Medical Center
Professor of Medicine
1. Meduri GU,
Golden E , Freire AX, et al.
Methylprednisolone infusion in early
severe ARDS: results of a randomized
2007; 131: 954-963.
2. Marik PE, Pastores S, Annane D,
et al. Clinical practice guidelines
for the diagnosis and management of
corticosteroid insufficiency in
critical illness: Recommendations of
an international task force.
3. Tang B, Craig J, Eslick G, et al.
Use of corticosteroids in acute lung
injury and acute respiratory
distress syndrome: a systematic
review and meta-analysis.
4. Meduri GU, Marik PE, Annane D.
Prolonged glucocorticoid treatment
in ARDS: Evidence supporting
effectiveness and safety. Crit Care
Med. 2009; 39: 1800-1803.
Steroid treatment in ARDS: a critical
appraisal of the ARDS network trial
and the recent literature>
of this commentary was to compare the design and results
of randomized trials investigating prolonged glucocorticoid treatment (≥ 7 days) in patients with ARDS, and review factors affecting response to therapy, including
the role of secondary prevention. They concluded that prolonged glucocorticoid treatment
substantially and significantly improves meaningful patient-centered outcome variables, and has a distinct
survival benefit when initiated before day 14 of ARDS.
Click here to read the recently
published commentary in Intensive Care Medicine.
Meduri GU, Marik PE, Chrousos GP et
al. Steroid treatment in ARDS: a critical appraisal of the ARDS network trial
and the recent literature.
Intensive Care Med. 2008; 34:61–69.
Methylprednisolone May Save One in
Six Treated Patients (Approximately
35,000 patients in the U.S. a Year)
of the recently released study was
to determine the effects of low-dose
infusion on lung function in patients with early
severe ARDS. Dr. Meduri and the
other investigators concluded that
down-regulation of systemic
inflammation was associated with
significant improvement in pulmonary
and extrapulmonary organ dysfunction
and reduction in duration of
mechanical ventilation and ICU
length of stay.
Click here to read the recently
published study in Chest Journal.
Click here to read an editorial
from Dr. Djillali Annane on the use
of certain steroids in ARDS
Meduri GU, Golden E, Freire AX et
al. Methylprednisolone Infusion in
Early Severe ARDS - Results of a
Randomized Controlled Trial.
Chest. 2007; 131:954-963.
Acute Respiratory Distress
Education, care, support, and communication
for patients, survivors, families, friends, medical personnel, and
others affected by and/or interested in ARDS.
Acute Respiratory Distress Syndrome (ARDS) is
an acute, severe injury to most or all of both lungs. Patients with
ARDS experience severe shortness of breath and often require
mechanical ventilation (life support) because of respiratory
failure. ARDS is not a specific disease; instead, it is a type of
severe, acute lung dysfunction that is associated with a variety of
diseases, such as pneumonia, shock, sepsis (a severe infection in
the body) and trauma. ARDS can be confused with congestive heart
failure, which is another common condition that can also cause acute
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I am writing you because my wife
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My wife's doctors say she has
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SARS (Severe Acute Respiratory Syndrome)
Much about the virus is a mystery. Here’s what’s known.
“What is my risk of catching it?”
Low, so far. In the United States 55 of the 69 victims have been recent visitors to China, Hong Kong, Vietnam or Singaporethe centers of the epidemic. The rest have been family members of those travelers or medical personnel who treated them.
“How can I tell if I’ve got it?”
If you suspect you’ve been exposed and have a fever over 100.4 degrees, difficulty breathing, a dry cough, aches and malaise, call your doctor immediately.
“Is this a brand new disease?”
Apparently so. Researchers believe a mutant member of a virus family that also causes some forms of the common cold causes it.
“How contagious is it?”
Sneezing and coughing, experts say, can pass the virus and it has an incubation period of up to ten days. It may also linger on objects handled by a person with SARS.
“How can I avoid it?”
The surest way is to stay out of the most affected countries. Frequent hand-washing may also help. Though Hong Kong merchants nearly sold out of surgical masks, doctors say these are of limited help if not properly used.
“How is it treated?”
At this point, doctors can only treat the symptoms, not the disease itself. The good news: SARS’s mortality rate is relatively low. If you get it, you have a 96.5 percent chance of surviving.
“Is SARS related to ARDS?”
NO!! There is absolutely no connection between ARDS and SARS. If you are a surviving ARDS patient, you should have absolutely no concern that you are a prime candidate for SARS.
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