A devastating tragedy two decades ago has fueled a deeply personal mission: preventing sepsis deaths.
In 1997, sepsis killed Debra Malone’s father – a tragedy that his health care providers could have prevented if only they had recognized and acted on the signs of his rapidly escalating infection.
Back in the fall of that year, Malone’s father, Dr. Karl Shipman, was an internal medicine doctor in Denver. He was visiting a Vermont farmhouse that he owned when he fell from a ladder and broke his left wrist. A painful injury to be sure, but not one that should have threatened the life of a 64-year-old man who otherwise was in good health.
But a series of misdiagnoses and questionable treatment decisions by those caring for Shipman in both clinics and hospitals allowed a staph infection to take hold and spiral out of control. By the time intensive-care specialists took over his care – and did a superb job, Malone said – Shipman had deteriorated so much that his doctors couldn’t save him.
“I was outraged at the errors and mishaps,” said Malone, who at that time was working as a nurse in Vail.
Quickly spotting sepsis – Saving lives
Medical workers can use a quick monitoring system known as qSOFA to spot patients whose organs may be shutting down. It uses three criteria:
- Low blood pressure (systolic blood pressure less than 100 hg)
- High respiratory rate (22 or more breaths per minute)
- Altered mental status
Patients who meet two or more of these criteria have a greater risk of a poor outcome.
She discovered that the orthopedists treating her father had not taken his vital signs and treated pain he complained of in his neck and shoulders with physical therapy.
About two months after the original injury, he was in extreme physical and mental distress. He was hospitalized in the intensive care unit of a Denver hospital, but he lost precious time while his medical care team failed to recognize the infection that had entered his wrist and spine.
The sepsis resulted in multiple organ failures, Malone said. She traced the clinical collapse leading to her father’s death to entirely preventable human error.
“It’s still mind-boggling to me.”
Fighting sepsis in memory of her dad
Fast forward to March, 2016. Malone had become a nurse at UCHealth University of Colorado Hospital’s outpatient pre-op and post-anesthesia care units.
She attended an annual gathering of health professionals that UCHealth hosts called the Rocky Mountain Interprofessional and Evidence-based Practice Symposium.
The name is a mouthful. But the event features presentations from researchers throughout the Denver area. For Malone, one word stood out above all others: sepsis.
Among many people making presentations were UCHealth’s sepsis coordinators, who since 2015 have been working to raise awareness among hospital providers about the warning signs of sepsis – a powerful response to infection that can lead to severe organ damage and death.
The coordinators are part of UCHealth’s system-wide efforts to reduce sepsis deaths by identifying the warning signs quickly and appropriately administering an infection-fighting bundle of care within three hours.
After speaking to the coordinators, who presented data about their efforts to fight sepsis and save lives, Malone said she had a simple response. “I said, ‘I need to be a part of this.’”
Deadlier than heart attacks and strokes combined
Numbers alone might have explained Malone’s concern. In 2016, the federal Healthcare Cost and Utilization Project released data showing that sepsis cost the United States health care system $24 billion – more than any other condition. Sepsis also claimed more than a quarter-million lives annually.
Closer to home, Malone said University of Colorado Hospital had 2,644 sepsis cases in fiscal year 2017, which ended June 30, 2017 – making it more frequent than heart attacks and strokes combined, and deadlier.
“But people don’t realize the magnitude of sepsis,” she said.
In the two years since the symposium, Malone has made good on her promise to improve detection and treatment of sepsis. She launched sepsis screenings in outpatient clinics at University of Colorado Hospital – a first in the nation.
As part of her successful credentialing project for UEXCEL – the hospital’s clinical advancement ladder for nurses – she developed information kits and online learning modules to educate outpatient nurses and medical assistants about sepsis, its definitions, and the latest screen for gauging its risk, the Quick Sepsis Related Organ Failure Assessment.
Fighting for reform
Malone didn’t give the health care system a pass. She wrote the Colorado Medical Board to launch multiple state and federal regulatory investigations of her dad’s death and joined a national campaign backed by the Society for Critical Care Medicine to put patient care in large ICUs in the hands of teams led by critical care specialists – something that was not the case for a crucial period when her father’s infection raged through his body.
Her work didn’t stop there. Malone was determined to bring more transparency to a health care system she felt too often swept its errors and omissions under the rug. She began searching for others who had suffered harm from medical miscues. That eventually led to a meeting in Chicago attended by members of the American Medical Association who, Malone said, “were touched by the stories.”
That led to her joining the National Patient Safety Foundation, which formed in 1997 to prod hospitals and health systems to look at medical errors from a system perspective, bring them into the open and use the lessons to bolster protection for patients. Malone traveled all over the country for a decade, sharing her story on behalf of the NPSF. She became a founding member of the Patient and Family Advisory Council of the NPSF.
In 1999, she was living in Vail when she got a call from Washington, D.C. asking her to testify as part of a Senate subcommittee hearing on a landmark report by the Institute of Medicine (now the Health and Medicine Division) entitled “To Err Is Human: Building a Safer Health System.” The report concluded that as many as 98,000 people in the U.S. die each year because of preventable medical errors – just as Karl Shipman had.
Her advocacy work occurred as she continued her nursing career, which included stints in intensive care units and encounters with septic patients. That experience and the painful loss of her father delivered a simple but profound lesson, she said. “Anybody in any situation can get sepsis.”
Taking on sepsis in the clinics
Malone’s work is an important part of UCHealth’s ongoing effort to reduce sepsis mortality, which has focused on the inpatient and emergency department settings, said Nicole Huntley, a clinical nurse specialist who is sepsis coordinator for University of Colorado Hospital and co-chair of its Sepsis Steering Committee with Dr. Read Pierce. Pierce is also an assistant professor for the University of Colorado School of Medicine and has a strong interest in quality improvement projects.
“From the first day that we met, Deb wanted to do the outpatient project,” Huntley said. “It’s few and far between to see that level of passion.”
Huntley credited Malone’s “education blitz” – which included flyers, laminated cards, games, PowerPoint presentations, TED-style talks, learning modules and pre- and post-tests – for engaging outpatient nurses about their role in assessing sepsis risk and raising awareness among other staff, such as valets, of the danger signs, like elevated respiratory rates.
There is no debate about the importance of monitoring hospitalized patients for signs of sepsis, and the emphasis on inpatient protocols is one factor that has helped UCH reduce its septic mortality by about 10 percent, according to data Huntley compiles. But she noted that roughly three-quarters of patients diagnosed with the condition come through the emergency department. She called the screening processes and interventions “phenomenal,” but the volume highlights the elusive nature of sepsis.
“Those cases in the emergency department may originate at home or in nursing homes or another setting, not the acute-care hospital,” she said. “Were some of these also followed up in clinics? We haven’t been tracking that.” Screening patients during clinic visits and flagging those at risk could head off later emergency department visits, hospitalizations and deaths, Huntley said.
“We hope to see a further decline in mortality, and that is thanks to Debra Malone’s efforts,” she said.
‘Meant to be here’
Malone isn’t finished. Her original goal was to implement a “best practice advisory” alert that would automatically appear in a patient’s electronic medical record when a patient was at high risk for sepsis. That idea snagged over concerns that doctors and nurses already are coping with too many alerts.
As an alternative, Malone and Pierce requested permission from five outpatient medical directors to pilot the alerts in their clinics. These include the Cancer Center, the General Surgery, Infectious Disease and Urology clinics, and the A.F. Williams Family Medicine Clinic. As of mid-February, General Surgery, Urology and A.F. Williams had firmly committed to the six-month trial, Pierce said.
“Deb’s pilot is important to help us determine if we can reliably identify early sepsis in patients arriving to our clinics – not simply to our emergency department,” Pierce said. “While the number of sepsis cases in our clinics is likely to be low, as the health system works to improve access to ambulatory care – including an emphasis on increasing access to visits on the same day a patient calls with an urgent symptom – we are likely to catch more early sepsis in the ambulatory setting.”
Pierce added that the pilot will allow the hospital to test that hypothesis in a research framework that includes qSOFA as the standard screen and to collect data that reveals “if using that screening tool is worth the effort.”
For Malone, this latest phase is part of a steadily closing circle. In April, she will make a podium presentation about her project at the same symposium that reignited her interest two years earlier. Speaking of sepsis will be bittersweet, but her father’s memory demands it.
“It seems like I was meant to be here,” she said as she sat in her small office with a pile of clippings and photos from her long fight for patient safety at hand. “I shed many tears throughout this process, but I am working on something greater than myself. The sepsis project hit me in the heart. I knew I had to be part of it. There was no option to opt out.”