Sepsis? What Sepsis, and What Else Can We Do?
- sflevac
- Apr 4, 2021
- 6 min read
An awareness of sepsis helps us to commit to focusing on the needs of the patient. Sepsis is the body’s extreme response to an infection, and without timely treatment, sepsis can rapidly lead to tissue damage, organ failure, and death. According to the World Health Organization (WHO), there were nearly 49 million cases and 11 million sepsis-related deaths globally in 2017, accounting for almost 20% of all deaths worldwide.
Infographic from WHO
During these challenging times we are facing because of the COVID-19 pandemic, it is important to reflect on the connections with sepsis. It is known that a patient with COVID-19 infection can have sepsis as a complication. But it is also important to highlight that because of the disruption of the healthcare system, it is possible that patients with sepsis have avoided seeking timely care due to fear of COVID-19. The COVID-19 pandemic has also uncovered valuable opportunities to improve the quality of care and patient safety that will help even after the pandemic ends: from improving patient education, addressing racial and ethnic health disparities, and improving diagnostic testing and infection control.
We are also reminded of the critical need to protect patients throughout their health journey - before a patient gets to the hospital, when they are receiving care, and in the time period after they receive care when follow up may be needed. We know that around 80 percent of adult patients with sepsis, regardless of the cause started having signs and symptoms prior to being hospitalized and many sepsis survivors continue with devastating complications after being discharged. Focusing on the needs of the patient at every healthcare encounter and developing innovative strategies and tools for timely diagnoses and adequate management of sepsis tailored to each healthcare setting are critical needs that must addressed. In addition, we need to promote initiatives to educate healthcare professionals and patients about the importance of infection prevention, as well as early sepsis detection and management integrated with existing and new strategies for care delivery, such as Telemedicine.
2020 - A New Problem
The COVID-19 response has shown that transparency and accountability with clear goals and better connections between public health and healthcare professionals focusing on infection prevention and addressing patient needs are critical to improve healthcare for all. It is a challenging time, but also an opportunity to address racial and ethnic health disparities and gaps in our healthcare delivery system that are not only critical for COVID-19, but also important factors for addressing sepsis in Canada.
Sepsis remains a priority for health care. It is important identify and develop innovative ways to prevent, recognize, and treat sepsis. We all have a role to play, and we must work together—across healthcare, government, research, public health, and more—to protect patients. This past year and always, we want to quantify the impact of each life lost to this life-threatening condition and its long-lasting effects.
A Local Perspective and a Possible Opportunity
An example of this is in Sudbury with health professionals wanting to support People Who Inject Drugs (PWID) to prevent additional health complications, including sepsis. Safe injection sites have been developed in other jurisdictions, yet there is not yet one site in Sudbury that has been approved. Collaboration has been key and community engagement is ongoing.
Calgary is an example of this collaboration and engagement, decided to provide safe injections within one hospital. Studies show that PWID use unsterile supplies and are infecting themselves, and allowing safe injections in an acute care setting will help decrease infections (Wituik, 2019, Sharma et al, 2017). Occupation Health services require notice of exposures of staff who were not wearing the appropriate personal protective equipment (PPE). Increasingly, notifications are for infectious Group A Streptococcus (iGAS). Many patients are repeatedly admitted for this and other infections which include, but are not limited to bacterial endocarditis, Methicillin-resistant Staphylococcus aureus (MRSA), Methicillin-sensitive Staphylococcus aureus (MSSA), Hepatitis C, and HIV. Research has shown that patients who inject IV drugs prior to admission continue to use IV drugs while in hospital. Abstinence-based approaches such as the one at many acute care facilities are known to be ineffective at prohibiting drug consumption.
The SEM - Socio-Economic Model
From A review of Frameworks on the Determinants of Health, (2015), the socioeconomic model is most commonly used.
This model refers to the capabilities of the members of society to comprehend economic and social issues and to solve these problems by social cooperation.
Utilizing this model, one tries to understand and subsequently support an initiative such as the one in the Calgary hospital. Supporting PWID in a safe environment, however does not get to the root of the issue. Socioeconomics can help understand why some people turn to using drugs:
· Individual lifestyle factors: sex (males) and heredity (individuals have shown to have addictive tendencies) are more likely to use drugs.
· Social and community networks: friends/relatives supportive or not?
General socio-economic, cultural and environmental conditions are further broken down as below:
· Agriculture and food production: easy/close access to healthy food
· Education: generally those with higher education are less likely to use drugs to the extent of requiring multiple admissions for infections from intravenous drug use (Jarrin et al, 2007)
· Work environment: stress/co-workers who use drugs
· Living and working conditions
· Unemployment: higher levels of unemployment may lead to housing insecurity (see below)
· Water sanitation
· Health Services: safe injection sites/mental health support/support in the local emergency department, or are they considered “frequent flyers”?
· Housing: If inadequate low income housing, do they “couch surf” with others? Are they living on the streets?
Professor Sir Michael Marmot, from the National Health Service in Great Britain in an interview discussed this model (2018) utilizes the following terms: "proportionate universalism", that "some need it more than others", and that the "effort is proportionate to the need". PWID need support to first help prevent infections. Safe injection sites, whether within a hospital or in a community-approved building are required. Once this support is initiated, other supports can be provided to understand the circumstances that lead to PWID using, and then look at how the community can improve.
This program can be utilized within the safe injection site framework developed by the community. Public Health Sudbury and Districts is the lead on developing their Community Drug Strategy and their work along with data on overdoses, naloxone can be found on their website. If we can understand the various factors that can lead to individuals turning to drug use, we may be able to help mitigate the risks of unsanitary intravenous drug use and support them to do so safely. Using this information may help make the cultural changes within health care facilities to support safe injections for PWID while admitted, decrease their days of stay and decrease their admissions due to infections. Within the community, understanding how to support PWID using this framework may eventually decrease the amount of PWID.
Next Steps - Technological Advances
Looking to the future, an integrated single health record would be supportive of PWID who are home-insecure. eHealth and eVisits, real-time video visits with patients can support the review of wounds, as well as the adoption of a virtual emergency room visit program in December in Sudbury. Funding was available from the Ontario government and additional sites in Southern Ontario were already set up. Forte (2020) wrote a blog before the pandemic started, suggesting just this program. While he wrote about severity and cost savings, lower rates of visits from patients perceiving the risks of attending the ED during the first wave did not force the transformation. As ED visits started to increase again, the transformation of waiting rooms due to physical distancing requirements was the main impetus. There has been much appetite for digital transformation of health, not only in Canada but around the world. The COVID-19 pandemic has expedited some of this transformation, as well as highlighting some of the limitations and ethical considerations that are involved with the decision-making processes by those in power, whether by politicians and their political parties, bureaucrats, or businesses. To support PWID, and others with sepsis, transformation of our health system is required.
References
Canadian Council on Social Determinants of Health (20150. A review of Frameworks on the Determinants of Health, retrieved from
Community Drug Strategy for the Greater City of Sudbury, retrieved from
Institute of Health Equity (2018). The NHS, health inequalities, and the Social determinants of
health.
Institute of Health Equity (2018). Reducing Health Inequalities Through New Models of Care - Interview with Michael Marmot. [Video]. YouTube.
Jarrin, I., Lumbreras, B. ,Ferreros, I., Pérez-Hoyos, S., Hurtado, I., & Hernández-Aguado, I. Effect of education on overall and cause-specific mortality in injecting drug users, according to HIV and introduction of HAART, International Journal of
Epidemiology, Volume 36, Issue 1, February 2007, Pages 187–194, retrieved from
Sharma, M., Lamba, W., Cauderella, A., Guimond, T., & Bayoumi, A. (2017). Harm reduction in
hospitals. Harm Reduction Journal, 14(32), 1-4.
Wituik, C. A case for integrating substance use harm reduction into IPAC practice in acute care settings. Canadian Journal of Infection Control, Fall 2019, Volume 34, Issue 3,
pp. 146-147.
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