HSMR helps identify sepsis as an area of concern for Canadian hospitals

A new study shows that in 2008-2009 more than 9,300 patients died of sepsis, a condition resulting from the body's response to severe infection, in Canadian hospitals outside Quebec.

Hospital sepsis rates in Canada are the special focus of this year's public release of hospital standardized mortality ratios (or HSMRs) for Canadian hospitals by the Canadian Institute for Health Information (CIHI). First released publicly in 2007 by CIHI, the HSMR is a quality of care measure that allows Canadian hospitals to assess their mortality rates over time and identify areas for improvement.

When reviewing HSMR data from the past five years, many hospitals recognized that sepsis was a cause of death that required further investigation.

"While hospitals will never bring mortality rates to zero, many hospitals have made reducing their mortality rates a priority," says Indra Pulcins, Director of Indicators and Performance Measurement at CIHI. "Thanks to concerted efforts across the country to improve quality of care and patient safety, HSMRs appear to be decreasing overall in Canada. However, some conditions such as sepsis remain an important challenge for reducing mortality in hospitals."

A response to infection, sepsis can be a serious condition calling for immediate medical care. If sepsis becomes severe, it can result in extensive tissue damage, organ failure or death. Sepsis can be caused by a number of bacterial, fungal or viral infections that progress into the blood stream. While sepsis can develop from minor infections, such as the flu or a urinary tract infection, it is most likely to develop in people who have serious wounds, extremely weakened immune systems and open or exposed areas from catheters.

Mortality rates for sepsis patients three times as high as for heart attack patients

Every day, about 1,400 people around the world die from sepsis, and it is a growing health care concern in Canada. CIHI's study shows that in 2008-2009, more than 30,500 patients were hospitalized with sepsis in Canada outside of Quebec, about the same number as those hospitalized for new strokes, and fewer than those admitted for new heart attacks (49,000). Just over 30% of patients hospitalized with sepsis died, compared to 18.0% for stroke patients and 9.1% for heart attack patients. Globally, between 30% and 50% of all sepsis patients end up dying from it.

"Sepsis can be difficult to detect. However, studies have identified various factors that can reduce deaths from sepsis, in particular early recognition and treatment," says Dr. Claudio Martin, a critical care physician at London Health Sciences Centre, who performs sepsis research. "More importantly, there is lots of evidence that hospital-acquired infections that lead to sepsis can be prevented. Instituting these best practices should be a priority for reducing sepsis and mortality rates."

CIHI's study found that sepsis patients were at higher risk of dying if they were elderly, if they had pre-existing health conditions and if they were female.

In 2008-2009, almost one-quarter (23.6%) of all sepsis patients were diagnosed with sepsis after being admitted to hospitals. CIHI's data found these patients were 56% more likely to die than patients diagnosed with sepsis before their admission to hospital.

Sepsis results in more time spent in hospital

Patients diagnosed with sepsis generally require aggressive treatment and end up using more hospital resources than other patients. The median length of stay for a sepsis patient in an acute care hospital is nine days longer than for the average patient admitted with other conditions. Close to half (45.1%) of all sepsis patients are admitted to the intensive care unit during their stay.

Combating sepsis on the front lines

Through the Surviving Sepsis Campaign and Safer Healthcare Now!--two patient safety initiatives that aim to reduce preventable adverse events and deaths--sepsis mortality can be reduced. With the recognition of the high mortality rates associated with sepsis, hospitals have been focusing their efforts on controlling the disease and are using the HSMR to monitor improvements over time.

For example, at Southlake Regional Health Centre in Newmarket, Ontario, early HSMR results steered staff to look more closely at sepsis. Although sepsis mortality rates were lower than the national average, the facility questioned whether deaths due to other diagnoses, which were above average, might also be attributable to sepsis. A review of all sepsis cases at Southlake confirmed that there might be a delay in identifying the disease, as protocols were not consistent across the hospital.

A task force was created to adopt known best practices and draft standardized orders for early recognition and treatment on the wards and in the emergency room. The hospital also turned to its rapid response team, which is an outreach of its intensive care unit (ICU). Nurses were trained to recognize sepsis early and instructed to call in the team if they sensed a patient wasn't doing well. As a result, developing cases on the ward are being picked up more quickly and treatment started sooner, which has reduced ICU admissions and has led to a decrease in the hospital's HSMR.

"The HSMR was instrumental in providing us with a key starting point to assess our mortality rates," says Barbara Kendrick, Southlake's Director of Quality and Planning. "As a result of our work, we've seen a steady downward trend in our HSMR, and I think we've yet to see the full outcome of the work that we've done over the past year with sepsis."

This year's HSMR numbers

This year's HSMR report includes five years of HSMR results (from 2004-2005 to 2008-2009) for 75 hospitals and 38 health regions across Canada, excluding Quebec. The HSMR compares the actual number of deaths in a hospital or region with the average Canadian experience, after adjusting for several factors that may affect in-hospital mortality rates, such as the age, sex, diagnoses and admission status of patients. An HSMR equal to 100 suggests that there is no difference between a local mortality rate and the average national experience, given the types of patients cared for. An HSMR greater or less than 100 suggests that a local mortality rate is higher or lower than the national experience, respectively.

"One of the main objectives of the HSMR is to provide hospitals with a tool that demonstrates mortality trends because this information can help hospitals monitor changes over time and identify the strategies that work best in lowering their mortality rates," explains Dr. Eugene Wen, Manager of Health Indicators at CIHI. Comparing this year's numbers to previous years demonstrates that more Canadian hospitals now have HSMRs below 100. The proportion of hospitals whose HSMR is significantly below 100 is 47%, compared to 36% in 2008.

Source: CANADIAN INSTITUTE FOR HEALTH INFORMATION