Welcome to UAB MedCast, a continuing education podcast for medical professionals. Here's Melanie Cole.
Melanie Cole, MS (Host): Welcome to UAB MedCast. I'm Melanie Cole. And today, we're highlighting sepsis mortality in preterm infants. Joining me is Dr. Colm Travers. He's a neonatologist at UAB Medicine. Dr. Travers, thank you so much for joining us today. And despite advances in screening and treatment, why does sepsis remain one of the leading causes of hospital mortality for preterm infants?
Dr. Colm Travers: Thanks, Melanie. Preterm infants are especially vulnerable to late-onset sepsis, which in our field we define as babies who are more than three days old who develop a bacterial infection. The reasons for this is that the preterm babies have a relatively immature immune system, and also that their skin, their lungs, and their intestinal barriers are also immature and can let bacteria get inside their bodies and into their bloodstream.
On top of that, we also often have to use intravenous lines and central lines for nutrition and different medications that the babies are receiving. And whenever you have any plastic in the body, that also can increase the risk of getting a bloodstream infection or sepsis.
Melanie Cole, MS: Well, that's so interesting. And Dr. Travers, what are some of the most critical factors that influence sepsis mortality outcomes across this continuum of care?
Dr. Colm Travers: So, I think the first thing is knowledge about extremely preterm infants and their risk of having sepsis and their risk of mortality from sepsis. Recognizing that when babies are in that first period after they're born, that first four to six weeks, that they are especially at high risk of developing a bloodstream infection or sepsis.
Other important factors would include things like the difficulty in recognizing sepsis. Because these babies tend to be quite sick, sometimes it can be hard for people to recognize when they're getting sicker because they're already unwell, and they may already be on ventilators and on oxygen and on medications, that we think of being associated with being unwell. So sometimes, it's hard to recognize when they're actually getting sicker. And then, last factor is probably treating infants, once sepsis is suspected, as quickly as possible.
Melanie Cole, MS: Tell us a little bit about that, Dr. Travers. What happens for treatment?
Dr. Colm Travers: So at UAB, we're lucky that we do have a special system that is constantly working in the background to try to alert us to when babies are getting sicker and deteriorating. And what that system does looks at heart rate variability, and it brings us to the bedside of babies that might be getting sicker.
And then, we can assess and decide whether this baby is at risk of sepsis. And then, if they're at risk of sepsis, we borrowed the code sepsis philosophy from adult medicine, and we create an algorithm where doctors will place all of their orders stat. And then, the nurses will work together to obtain access if the baby doesn't already have an intravenous line. And pharmacy will send a first dose of antibiotics, as quickly as possible so that it can be given immediately.
So at UAB, by using that code sepsis algorithm in the neonatal intensive care unit, we were able to decrease the time for antibiotics from around about an hour to less than 30 minutes after placing those orders.
Melanie Cole, MS: Dr. Travers, after you telling us that, as you speak to other healthcare organizations, how can they create similar to the culture you've created with that code sepsis at UAB? How can they create a culture where sepsis in preterm infants is recognized and treated as a true medical emergency?
Dr. Colm Travers: One of the things that we wanted to change based on evidence was that we felt strongly that when a baby might have sepsis, that it's best not to send screening labs, because that might just waste critical time. And so, we decided that if we suspect sepsis, we should go ahead and, as we said, treat it like an emergency. Send blood cultures and the usual labs that we might send and start antibiotics immediately, rather than sending screening labs, which might delay that process. And by doing that, we were able to halve the number of deaths due to sepsis in extremely preterm infants in our unit.
Melanie Cole, MS: Wow. That's so interesting. So, you're really just jumping to the heart of the matter.
Dr. Colm Travers: Yeah. Unfortunately, one of the things that we're missing in neonatology is a good way to screen babies for sepsis. And because sepsis happens quite quickly in these babies. And so, sometimes even if the labs are normal, it doesn't mean that the baby doesn't have sepsis. And so, recognizing that and realizing that we couldn't wait for that information to come back before we had started antibiotics. Because if we did, we might be too late.
Melanie Cole, MS: Well then, how do high-performing organizations sustain those kinds of sepsis improvements after the initial success to hear what you're doing? And then, if they initiate this type of code system, how do they sustain that if they've seen that initial success?
Dr. Colm Travers: I think it's important for all the staff to be really vigilant in this population and to know that these babies' number one cause of death is sepsis. And then, to share the data of our success to kind of help sustain that and motivate people to continue to be vigilant. The other changes that we made to try and bake it into our system was to create those new order sets using the electronic medical record that helped us to develop that kind of code sepsis and having all of our orders as stat.
Melanie Cole, MS: Dr. Travers, this is such important information that you are speaking to other providers that really may not encounter this or have this kind of up-to-date information. Where do you see the greatest opportunities to reduce preventable sepsis deaths in preterm infants over the next few years? Give us your best advice here. Speak to those providers.
Dr. Colm Travers: Well, currently with the lack of screening tools, I think it's really important to treat infants quickly who may have sepsis. But ultimately, we do need new ways of preventing sepsis from happening in the first place. Currently, we lack good tools to reduce the overall rate of sepsis in these babies.
And so, I think that it's in some ways going to be a research question, but also a quality improvement work in the future to figure out ways to prevent the infants from developing sepsis in the first place. And we also need new tools to be able to screen babies and improve our recognition of when babies are actually developing sepsis. So, I think there's still a lot of really important work ahead of us in this population of babies that are at such high risk of sepsis.
Melanie Cole, MS: Thank you so much, Dr. Travers, for joining us today and sharing your very unique experience for these other providers. Thank you so much. And for more information, please visit our website at uabmedicine.org/physician. That concludes this episode of UAB MedCast. I'm Melanie Cole.
Melanie Cole, MS (Host): Welcome to UAB MedCast. I'm Melanie Cole. And today, we're highlighting sepsis mortality in preterm infants. Joining me is Dr. Colm Travers. He's a neonatologist at UAB Medicine. Dr. Travers, thank you so much for joining us today. And despite advances in screening and treatment, why does sepsis remain one of the leading causes of hospital mortality for preterm infants?
Dr. Colm Travers: Thanks, Melanie. Preterm infants are especially vulnerable to late-onset sepsis, which in our field we define as babies who are more than three days old who develop a bacterial infection. The reasons for this is that the preterm babies have a relatively immature immune system, and also that their skin, their lungs, and their intestinal barriers are also immature and can let bacteria get inside their bodies and into their bloodstream.
On top of that, we also often have to use intravenous lines and central lines for nutrition and different medications that the babies are receiving. And whenever you have any plastic in the body, that also can increase the risk of getting a bloodstream infection or sepsis.
Melanie Cole, MS: Well, that's so interesting. And Dr. Travers, what are some of the most critical factors that influence sepsis mortality outcomes across this continuum of care?
Dr. Colm Travers: So, I think the first thing is knowledge about extremely preterm infants and their risk of having sepsis and their risk of mortality from sepsis. Recognizing that when babies are in that first period after they're born, that first four to six weeks, that they are especially at high risk of developing a bloodstream infection or sepsis.
Other important factors would include things like the difficulty in recognizing sepsis. Because these babies tend to be quite sick, sometimes it can be hard for people to recognize when they're getting sicker because they're already unwell, and they may already be on ventilators and on oxygen and on medications, that we think of being associated with being unwell. So sometimes, it's hard to recognize when they're actually getting sicker. And then, last factor is probably treating infants, once sepsis is suspected, as quickly as possible.
Melanie Cole, MS: Tell us a little bit about that, Dr. Travers. What happens for treatment?
Dr. Colm Travers: So at UAB, we're lucky that we do have a special system that is constantly working in the background to try to alert us to when babies are getting sicker and deteriorating. And what that system does looks at heart rate variability, and it brings us to the bedside of babies that might be getting sicker.
And then, we can assess and decide whether this baby is at risk of sepsis. And then, if they're at risk of sepsis, we borrowed the code sepsis philosophy from adult medicine, and we create an algorithm where doctors will place all of their orders stat. And then, the nurses will work together to obtain access if the baby doesn't already have an intravenous line. And pharmacy will send a first dose of antibiotics, as quickly as possible so that it can be given immediately.
So at UAB, by using that code sepsis algorithm in the neonatal intensive care unit, we were able to decrease the time for antibiotics from around about an hour to less than 30 minutes after placing those orders.
Melanie Cole, MS: Dr. Travers, after you telling us that, as you speak to other healthcare organizations, how can they create similar to the culture you've created with that code sepsis at UAB? How can they create a culture where sepsis in preterm infants is recognized and treated as a true medical emergency?
Dr. Colm Travers: One of the things that we wanted to change based on evidence was that we felt strongly that when a baby might have sepsis, that it's best not to send screening labs, because that might just waste critical time. And so, we decided that if we suspect sepsis, we should go ahead and, as we said, treat it like an emergency. Send blood cultures and the usual labs that we might send and start antibiotics immediately, rather than sending screening labs, which might delay that process. And by doing that, we were able to halve the number of deaths due to sepsis in extremely preterm infants in our unit.
Melanie Cole, MS: Wow. That's so interesting. So, you're really just jumping to the heart of the matter.
Dr. Colm Travers: Yeah. Unfortunately, one of the things that we're missing in neonatology is a good way to screen babies for sepsis. And because sepsis happens quite quickly in these babies. And so, sometimes even if the labs are normal, it doesn't mean that the baby doesn't have sepsis. And so, recognizing that and realizing that we couldn't wait for that information to come back before we had started antibiotics. Because if we did, we might be too late.
Melanie Cole, MS: Well then, how do high-performing organizations sustain those kinds of sepsis improvements after the initial success to hear what you're doing? And then, if they initiate this type of code system, how do they sustain that if they've seen that initial success?
Dr. Colm Travers: I think it's important for all the staff to be really vigilant in this population and to know that these babies' number one cause of death is sepsis. And then, to share the data of our success to kind of help sustain that and motivate people to continue to be vigilant. The other changes that we made to try and bake it into our system was to create those new order sets using the electronic medical record that helped us to develop that kind of code sepsis and having all of our orders as stat.
Melanie Cole, MS: Dr. Travers, this is such important information that you are speaking to other providers that really may not encounter this or have this kind of up-to-date information. Where do you see the greatest opportunities to reduce preventable sepsis deaths in preterm infants over the next few years? Give us your best advice here. Speak to those providers.
Dr. Colm Travers: Well, currently with the lack of screening tools, I think it's really important to treat infants quickly who may have sepsis. But ultimately, we do need new ways of preventing sepsis from happening in the first place. Currently, we lack good tools to reduce the overall rate of sepsis in these babies.
And so, I think that it's in some ways going to be a research question, but also a quality improvement work in the future to figure out ways to prevent the infants from developing sepsis in the first place. And we also need new tools to be able to screen babies and improve our recognition of when babies are actually developing sepsis. So, I think there's still a lot of really important work ahead of us in this population of babies that are at such high risk of sepsis.
Melanie Cole, MS: Thank you so much, Dr. Travers, for joining us today and sharing your very unique experience for these other providers. Thank you so much. And for more information, please visit our website at uabmedicine.org/physician. That concludes this episode of UAB MedCast. I'm Melanie Cole.
