Critical access to quality care
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|June 19, 2012|
When a patient arrives at any hospital emergency room with a gunshot wound, the response is immediate, aggressive and choreographed to address the most critical aspects of the injury. Taking that same kind of approach to treating patients without obvious trauma or injury may seem overzealous but in cases of sepsis, it can often mean the difference between life and death.
A new protocol for sepsis treatment was developed in part at Penn Medicine and brought to Mount Desert Island Hospital through the groundbreaking partnership with the large urban academic medical center. MDI Hospital’s physicians and nurses, along with paramedics from all ambulance services on the Island, are learning the techniques and protocols as part of this year’s specialized training component of the MDI Hospital-Penn Medicine collaboration. The program enables MDI medical providers to receive training in highly specialized topics and new protocols that come out of evidence-based research at Penn Medicine.
Sepsis or septic shock is a systemic condition in which the body is fighting an infection that has spread via the bloodstream. The root cause may be bacterial or viral and treatment can often require lengthy intensive hospitalization.
“The similarities between trauma and sepsis care are really important,” said Rakesh Mistry, MD, a Penn Medicine pediatric emergency physician and researcher. “I think most of us recognize with trauma the sooner you get to it and the sooner you fix it, the better the outcome. Approaching sepsis in the same manner – we can improve outcomes if we get into treatment and get to certain goals.”
Nationally, as many as 25 percent of patients with sepsis die from the illness. In cases where patients are severely ill, mortality can be as high as 45 percent. By utilizing this latest protocol, the number of patients who die from sepsis can be reduced by half or more.
The crux of the new protocol is to begin aggressive treatment at the earliest indication of symptoms. Many EMS services on MDI are acquiring meters to test lactate levels, one indication of potential sepsis, as soon as a patient is on board an ambulance. That knowledge can help prepare ER staff so they can begin treatment as soon as the patient arrives. It’s also something that is at the leading edge of EMS practice. “That’s a step in a direction that we haven’t been able to do yet (at Penn),” said Sarah Perman, MD, a Penn emergency physician and research collaborator.
The goal-based treatment establishes a set of benchmarks for a patient’s vital signs such as blood pressure, oxygen saturation, and other blood chemistry and attaches appropriate actions to achieve and maintain those levels. It also calls for many patients to receive large amounts of intravenous fluids and antibiotics at the earliest indications of sepsis.
In some cases, this technique departs from conventional wisdom and training, especially when it comes to the extremely high volumes of fluids that are given. “It is a paradigm shift and change in mentality across all of medicine,” Dr. Mistry said. “I think that’s the fear you have to overcome is that it’s still the right thing to do even though it’s out of the usual spectrum of care that people have had ingrained in their memory for many many years. What you learned in medical school doesn’t apply anymore.”
A second component of the paradigm is to consider this type of treatment as a resuscitation as opposed to an evaluation. The protocol provides “an almost algorithmic approach so that the patient gets the care, the immediate care, they need versus in the past, they may wait a bit longer for interventions,” Dr. Perman said.
The importance of early intervention makes this advanced training especially valuable in rural areas that are distanced from a trauma center. At MDI Hospital, patients with varying degrees of sepsis are seen every week, according to JR Krevans, Jr., MD, MDI Hospital’s Emergency Department medical director. Starting this aggressive treatment early can have such a dramatic effect that it could be the difference between “walking out of the emergency room after a few hours or spending days in the hospital,” he said.
The MDI Hospital-Penn Medicine collaboration is a privately funded initiative that provides a direct link to leading-edge medical practices as they emerge from academia. Additionally, the program enables professional exchanges between staffs at both organizations. For July and August Penn physicians, resident physicians, and nurses travel to Bar Harbor to work in MDI Hospital’s Emergency Department to enhance their skills and knowledge of rural health care delivery. During the winter months, registered nurses join the Penn staff in one of their facilities in Philadelphia to advance their knowledge in topics such as trauma and emergency care in a high patient volume setting. The program is currently in year two of a three year pilot program.