Septic shock, which occurs when a sepsis patient experiences a significant drop in blood pressure, is both difficult and expensive for hospitals to treat.
The estimated average cost to treat a septic shock patient is $87,282 — roughly two to three times more than other acute conditions requiring hospitalization, according to data from CMS. Mortality rates for septic shock also exceed those of most other conditions. A 2014 study in the Journal of Critical Care found septic shock patients in the intensive care unit had a 30-day mortality rate of about 50 percent, compared to a 14 percent mortality rate for heart attack patients and a 12 percent mortality rate for congestive heart failure patients over the same period.
This article is sponsored by La Jolla Pharmaceutical Company.
The Society of Critical Care Medicine launched the Surviving Sepsis Campaign in 2002 to improve the quality of sepsis care in the U.S. by releasing sepsis treatment guidelines every four years. The guidelines are organized into one-, three- and six-hour bundles, which contain a set of care elements clinicians should implement after a patient presents with symptoms of severe sepsis or septic shock.
Individual state mandates also ensure hospitals follow best practices when identifying sepsis patients. New York became the first state to implement Rory's Regulations in 2013, named after 12-year-old Rory Staunton who died from sepsis in 2012. The regulations require every hospital in New York to follow evidence-based clinical practice protocols for timely sepsis identification and management.
While these interventions have helped hospitals nationwide improve initial sepsis identification and resuscitation, current protocols offer limited guidance on the entire sepsis care process, especially for sepsis patients who develop shock, according to Annette N. Chavez, PharmD, director of medical affairs for La Jolla Pharmaceutical Company.
"Existing literature shows there is quite a bit of information about severe sepsis, but there is not a consensus on treatment conventions [for shock]," she said during a May 10 presentation at Becker's Hospital Review Health IT + Clinical Leadership 2018 conference in Chicago.
Septic shock care in the real world
The Surviving Sepsis Campaign recommends physicians keep septic shock patients' mean arterial pressure at 65 mmHg or higher. It is one of the few quality measures addressing septic shock care. However, few studies have investigated MAP control in a real-world setting.
La Jolla assessed how well hospitals can control MAP —its relationship to sepsis mortality rates — by analyzing data from the Medical Information Mart for Intensive Care, also known as MIMIC III. The public database contains detailed information for 61,532 ICU admissions at Boston-based Beth Israel Deaconess Medical Center from 2001 to 2012.
La Jolla identified 5,725 admissions in which adult septic shock patients were treated with vasopressors for more than six hours. Additional patient selection parameters mirrored the clinical trial entry criteria for La Jolla's own vasopressor GIAPREZATM (angiotensin II), which the FDA approved in December 2017.
La Jolla looked at the ICU admissions data to identify periods of time in which patients' MAP fell below the recommended level. A majority (93.8 percent) of patients had MAP drop below the recommended threshold of 65 mmHg for any period of time. Nearly 62.3 percent of patients' MAP fell below the target level for over two continuous hours, and 22.1 percent of patients saw this reading fall below the threshold for six continuous hours. Nearly 70 percent of patients fell below 55 mmHg at least once during their hospital stay.
"You might say, 'MAP is just a number. It doesn't matter,'" Dr. Chavez said. "But when you start to look at these figures in relation to mortality, you realize MAP does matter."
Patients whose MAP fell below the 65 mmHg threshold for two continuous hours had a 22.1 percent ICU mortality rate. This figure skyrocketed to 57.4 percent for patients whose MAP fell below the threshold for 12 continuous hours.
"The longer you're under a threshold for MAP, the higher your mortality risk," said Dr. Chavez, adding that MAP may be a valuable quality indicator for hospitals to adopt when tracking septic shock care.