Vol. 21 • Issue 11 • Page 40
Long before healthcare reform and accountable care initiatives, Blue Ridge Regional Hospital in Spruce Pine, N.C., was committed to “patient and family-centered care.” The goal in caring for patients at Blue Ridge Regional Hospital is the same for the physicians, medical staff and families – to provide the best care and outcome for the patient. It takes a combination of modern medicine, compassionate care, advanced technology, dedicated staff, as well as care provided by families to reach the best possible outcome.
Improving patient care is a never-ending process for us. Blue Ridge Regional Hospital was named a Thomson Top 100 Hospital for two consecutive years and recognized as a Community Value Five-Star Hospital® by Cleverley & Associates for six years, most recently in 2012. Early last year, the hospital decided to adopt a sepsis protocol to make sure we were diagnosing sepsis as early as possible and giving these patients the best possible chance for success.
As many as 750,000 patients progress to severe sepsis annually in U.S. hospitals. With a mortality rate of about 25%, sepsis is second only to heart attack as the most deadly acute conditions.1 Early detection and rapid treatment is vitally important to sepsis survival, but many of the most common symptoms of sepsis – fever, tachycardia and tachypnea – overlap with many other conditions.
In light of studies showing the impact of early intervention on sepsis patients and the development of tests like procalcitonin (PCT), which can provide a very early indication of bacterial sepsis, Blue Ridge formed our Sepsis Protocol development team and held our first meeting in October of 2011. Like all complex conditions, many clinicians play distinct but vital roles in the care of these patients. To develop a protocol that would work, we included all stakeholders on this multi-disciplinary team, including pharmacy, respiratory care, ICU, ED, nursing, surgical services and lab staff.
PCT is a biomarker released by nearly every organ in the body in response to a severe bacterial infection. Severe bacterial infections can be either quite manageable or lead to severe sepsis, depending on how early the patient receives appropriate treatment. Lactic acid is another common biomarker for sepsis and is part of the Early Goal Directed Therapy protocol, but this marker does not begin to spike until sepsis begins to damage organs.
We decided to use both lactic acid and PCT in our protocol because PCT spikes before organ damage occurs, giving us the ðearliest possible indication of potential sepsis.
PCT concentrations have been validated as a gauge for sepsis progression. In healthy people, PCT levels are typically below 0.05 ng/ml. Minor infections see a slight increase up to 0.5 ng/ml. Above 0.5 up to 2 ng/ml, the risk of severe sepsis exists, but is unlikely. Between 2 and 10 ng/ml, the risk of severe sepsis is high and levels above 10 ng/ml strongly indicate severe sepsis and possible progression to septic shock.
In addition to lactate testing, our protocol for patients entering the hospital through the ED was to run PCT tests at hours 1, 6 and 24 (VIDAS® B·R·A·H·M·S PCT®). In our first group of patients, of the 13 with positive blood cultures, six had elevated PCT scores. To help educate others in the hospital about the value of PCT, we created a Physician Oversee Response Team, which is basically a doctor-to-doctor education program about the value of PCT, what the test tells you and how to read the trends. Within four months, we converted all of our ICU and ED doctors and the PCT test sequence in our protocol is now universally practiced. We are approaching the one-year mark for this protocol and gathering data on patient outcomes, mortality, length of stay and other key metrics. The case studies below highlight some of the benefits seen so far.
Sepsis Protocol Case Studies
An elderly woman was admitted to the emergency room with a very high white blood cell count and fever. Luckily, she arrived when she did, as she was suffering from an infection that was beginning to cause a septic event. The patient’s initial PCT test gave a result of 1.19. As we continued to monitor the patient, we saw her PCT levels skyrocket to 71.42 at six hours, then to 93.4 at 24 hours. During this timeframe, both the patient’s blood and urine cultures returned positive for E. coli and she was diagnosed with a urinary tract infection and sepsis. By monitoring PCT levels, clinicians were able treat her aggressively with fluids and antibiotics.
In another case study, a 65-year-old male patient was admitted to the emergency room after an acute onset of pneumonia symptoms – shaking chills, productive coughing and trouble breathing. He did not have a fever. He had heightened WBC and we suspected pneumococcal pneumonia, but his blood cultures were negative. His PCT level was 1.68 at admission, then spiked to 8.84 at 6 hours. With pneumonia sepsis suspected, but initial blood cultures negative, we continued PCT testing. Later, sputum cultures confirmed pneumococcal pneumonia.
An 81-year-old man was admitted to the emergency room. He had dyspnea and weakness, but no fever. The patient had confirmed COPD and prostate cancer. CT scans show signs of necrotizing pneumonia in the patient’s right lung. Blood and urine cultures were ordered; the patient was not able to provide a sputum culture. The patient was prescribed antibiotics Zithromax and Rocephin. However, there was no improvement and the patient was taken off Zithromax and placed on Levaquin. PCT testing revealed that procalcitonin levels were increasing when they should have been decreasing, revealing that the patient was not being treated aggressively enough with the right antibiotic. Finally, with the patient’s condition worsening, his antibiotic was finally switched to Vancomycin, which began to effectively fight the infection.
A good sepsis protocol includes multiple measures, including PCT. The biomarker provides a vital piece of the puzzle in diagnosing these hard-to-diagnose patients and provides clues that allow treating physicians to make critical decisions faster.
Marcia M Geiser is Chemistry Lead Technologist, Blue Ridge Regional Hospital.
Angus DC, Linde-Zwirble WT, Lidicker J, et al. Epidemiology of severe sepsis in the United States: Analysis of incidence, outcome, and associated costs of care. Crit Care Med 2001;29:1303-1310.