While COVID raged, another deadly threat was on the rise

As COVID-19 began sweeping through California, hospitals were inundated with sick patients. Medical staff struggled to cope with the onslaught.

Amid the new coronavirus threat, an old one has also been on the rise: More people have contracted severe sepsis in California hospitals in recent years — including a worrying rise in patients contracting sepsis in the hospital, state data show.

Sepsis occurs when the body tries to fight off an infection, putting itself at risk. Chemicals and proteins released by the body to fight infection can damage both healthy and infected cells, causing inflammation, leaking blood vessels, and blood clots, according to the National Institutes of Health.

It’s a dangerous condition that can damage tissues and trigger organ failure. Across the country, sepsis kills more people each year than breast cancer, HIV/AIDS and opioid overdose combined, said Dr. Kedar Mate, President and CEO of the Institute for Healthcare Improvement.

“Sepsis is one of the leading causes of death in hospitals. That’s been true for a long time — and it’s become even truer during the pandemic,” Mate said.

The majority of sepsis cases begin outside of hospitals, but people are also at risk of contracting sepsis while they are hospitalized for other illnesses or medical procedures. And that danger only grew during the pandemic, according to government data: In California, the number of “hospital-acquired” cases of severe sepsis increased by more than 46% between 2019 and 2021.

Experts say the pandemic has exacerbated an ongoing threat to patients, raising concerns about both the dangers of the coronavirus itself and the strains hospitals have faced during the pandemic. California’s rise in sepsis came as hospital-acquired infections surged across the country — a problem researchers say has worsened as COVID hospitalizations surged.

“This setback can and must be temporary,” said Lindsey Lastinger, a public health scientist with the CDC’s Division of Health Care Quality Promotion.

Doctors describe sepsis as difficult to recognize and easy to treat in its earliest stages, but more difficult to treat when it becomes obvious. It can present in a number of ways, and recognizing it is complicated by the fact that its symptoms — which can include confusion, shortness of breath, clammy skin, and fever — are not unique to sepsis.

There is no “gold standard test to tell whether or not you have sepsis,” said Dr. Santhi Kumar, interim chief of pulmonology, critical care medicine and sleep medicine at USC’s Keck Medicine. “It’s a constellation of symptoms.”

Christopher Lin, 28, endured excruciating pain and a boiling 102.9-degree Fahrenheit fever at home before heading to Kaiser Permanente Los Angeles Medical Center. It was October 2020 and the hospital looked “surreal,” Lin said, with a tent pitched outside and chairs sparsely spaced in the waiting room.

His fever raised concerns about COVID-19, but Lin tested negative. At one point in the ER, his blood pressure dropped abruptly, Lin said, and “it felt like my soul had left my body.”

Lin, who suffered from sepsis related to a bacterial infection, is not sure where he first contracted it. Days before he went to the hospital, he had undergone a quick emergency room procedure to drain a painful abscess on his chest, and the gauze was changed by a nurse the next day, he said. Such outpatient procedures are not included in government data on “hospital-acquired” sepsis.

Someone with sepsis may have a high or low temperature, an accelerated or slowed heart rate, a fast or slow respiratory rate.

It can be caused by bacteria, fungal infections, viruses, or even parasites — “and the challenge is that when someone comes into the ER with a fever, we don’t know which of those four things they have,” said Dr. Karin Molander, emergency doctor and former CEO the Sepsis Alliance. Treatment can vary, depending on what’s driving the infection that triggered the sepsis. Antibiotics are common, however, as many cases are associated with bacterial infections.

The pandemic has increased risks: Coronavirus infection can itself lead to sepsis, and the virus has also drawn more elderly and medically vulnerable people to hospitals who are at greater risk of the dangerous condition, experts said. According to government data, nearly 40% of patients with severe sepsis who died in California hospitals in 2021 were diagnosed with COVID-19. Some COVID-19 patients have been hospitalized for weeks, increasing their risk of other complications that can lead to sepsis.

“The longer you’re in the hospital, the more things happen to you,” said Dr. Maita Kuvhenguhwa, Infectious Diseases Physician, MLK Community Healthcare. “You’re immobilized, so you’re at risk of developing pressure sores” — not just on the back, but possibly your face under an oxygen machine — “and the wound can become infected.”

“Lines, pipes, being here for a long time — all of that puts them at risk of infection,” Kuvhenguhwa said.

Experts said the pandemic may have diverted attention from other types of infection control as well, with staff strained and hospital routines disrupted. California, which is unusual statewide when it comes to mandating minimum quotas for nurse staff, allowed some hospitals to relax those requirements amid the pandemic.

Nurses juggling more patients may not check and clean patients’ mouths as often to prevent bacterial infections, Kumar said. Mate said hospital patients may not change their catheters as often due to staff shortages, which can increase the risk of UTIs.

Hospitals may have brought in traveling nurses to fill the gaps, but “if they don’t know the same systems, it becomes harder for them to follow the same processes” to prevent infection, said Catherine Cohen, a policy researcher at the RAND Corp.

Armando Nahum, one of the founding members of Patients for Patient Safety US, said the pandemic restrictions on hospital visitors may have also made the problem worse, preventing family members from realizing that a relative is behaving unusually and raising concerns.

Molander reiterated that point, saying it’s important for patients to have someone who knows them well and could alert doctors: “My mother has dementia, but she’s usually very talkative.”

Sepsis has long been a battle for hospitals: A third of people who die in US hospitals had sepsis while they were hospitalized, according to a study cited by the CDC. But Mate argued that deaths from sepsis could be significantly reduced “with the right actions that we know how to take.”

In Pennsylvania and New Jersey, Jefferson Health began rolling out new efforts to fight sepsis in the fall of 2021 — just before the first Omicron wave began hitting hospitals.

The system includes predictive modeling that uses information from electronic medical records to alert clinicians that someone may have sepsis. A “standard workflow” for sepsis patients has also been established to ensure that important steps such as the prescription of antibiotics are carried out as quickly as possible, said hospital officials.

The goal is to reduce the psychological burden on doctors and nurses, which is being pulled in many directions, said Dr. Patricia Henwood, Chief Clinical Officer. “Clinicians across the country are strained, and we don’t necessarily need better clinicians — we need better systems,” she said.

Jefferson Health credits the new system with helping reduce deaths from severe sepsis by 15% in one year.

In upstate New York, the uproar over the death of 12-year-old Rory Staunton led to new requirements for hospitals to adopt protocols to quickly detect and treat sepsis, and to report data to the state. State officials said the effort saved more than 16,000 lives between 2015 and 2019, and researchers found that deaths from sepsis fell more in New York than in states without such requirements.

If your child gets sick, you shouldn’t have to wonder if the hospital on the right has sepsis protocols and the one on the left doesn’t,” said Ciaran Staunton, who co-founded the organization End Sepsis after his son’s death. His group hailed the news as federal agencies were recently directed to develop “hospital quality measures” for sepsis.

Such a move could meet resistance. Robert Imhoff, President and CEO of the Hospital Quality Institute – a subsidiary of California Hospital Assn. — claimed that extending the type of requirements in force in New York was unnecessary.

“I don’t think hospitals need to be required to provide safe, quality care,” Imhoff said.

State data shows that severe sepsis — including cases that arose both out-of-hospital and in-hospital — has been increasing in California over the past decade, but Molander said the long-term increase may be related to changes in reporting requirements that led to it that more cases have occurred followed. California has yet to release new data on severe sepsis acquired in hospitals last year and is unlikely to do so until this fall.

For Lin, surviving sepsis was determined to make sepsis known—and not just in English. In the hospital, he struggled to explain what had happened to his mother, who speaks Cantonese. After his recovery, Lin worked with local officials to translate Sepsis Alliance materials into Mandarin.

“I can’t imagine my parents being in the hospital,” he said, “going through what I went through.”