A study in the Journal of the American Medical Association Vindicates a Family Who Lost a Loved One to Sepsis.
I want to open today with a mother talking about her son.
“Oh he was really very much an old soul. He was just very kind, he was always on the side of the underdog. He was the kid who threw his dirty towels around and wouldn’t do his homework as well but he had very strong empathy and was very considerate and really wanted to make a good change in this world”.
That was Orlaith Staunton speaking about her son Rory, who died of sepsis in April of 2012. Rory was a healthy 12-year-old boy when he fell in gym class, sustaining a small cut on his upper arm. The next day he developed a high fever and nausea and was sent by his pediatrician to the emergency room.
“His eyes still followed me around that emergency room the night I was there with him, trusting me. And my eyes were trusting the medical professionals who were there”.
He was sent home after some fluids. Labs drawn at the time were resulted after he had been discharged from the ER and, per the New York Times, showed a high white count with neutrophils and band cells present – signs of bacterial infection. According to the Staunton family and their pediatrician, no one followed up with them about these labs.
Rory was readmitted the following day and sent to the ICU. Despite the heroic efforts of the ICU team, He died two days later of Strep pyogenes sepsis.
The Staunton family grieved, but they also took action, lobbying the New York State Department of Health to institute mandates for the recognition and prompt treatment of sepsis throughout the state.
In 2013, Rory’s Regulations were passed – mandating that hospitals deliver a care bundle consisting of blood culture, broad-spectrum antibiotics, and IV fluids within 1 hour of sepsis recognition.
Now this article, appearing in the Journal of the American Medical Association, suggests that those regulations are making a difference.
Researchers led by Dr. Christopher Seymour from the University of Pittsburgh examined the outcomes of 1,179 children with sepsis admitted to 54 hospitals across New York State.
Of those kids, 294 or 25% received all 3 elements of the sepsis bundle within one hour while 75% took longer. There was a stark difference in mortality rate – 7.5% in the kids who got treated within an hour, 13.2% among those who didn’t.
This was, obviously, not a randomized trial. I would have assumed that the sicker kids would have been treated faster, but that didn’t appear to be the case. I asked lead author Chris Seymour about that finding:
“Sick patients often have a lot of other things going on, and so if there’s an urgent need for organ support like placing a patient on a mechanical ventilator or obtaining central access in order to administer vasopressors, these things may get in the way of doing the bundle.”
Dr. Seymour’s team adjusted for a slew of markers of severity of illness. Despite that, rapid receipt of the bundle was associated with more than a 40% reduction in mortality. In absolute terms, you’d need to treat 25 kids with the rapid sepsis bundle to save one life. That’s a pretty impressive effect.
The study is not without caveats though. In particular, we need to realize that sepsis had to be recognized to even get into the dataset – you could imagine that recognition of sepsis is more important than the rapid treatment of sepsis when it is recognized.
Still – the dose-response effect here is telling. For every hour longer it took to complete the bundle, the risk of death increased by 2%.
Now, this area of research has received some pushback.
Physicians note that the definition of sepsis has undergone a lot of revision, as well as the practical difficulties and potential errors that could occur when docs are pressured to get medications into children as fast as possible.
And of course there remains a persistent causality question – is giving the bundle within the hour a good thing in and of itself, or are hospitals that are capable of delivering care in this fashion just better hospitals period? Short of a randomized trial, we won’t have answers to those questions.
Despite the controversy, Orlaith Staunton is standing firm.
“I'm not a medical professional but I certainly believe that any medical professional would want their child to get the best medical care and I believe that these protocols and these regulations provide the best medical care for children. What we're hoping is nobody else has to go through the horrific tragedy that we went through and have to bury their child because of something that is completely preventable. I think what these regulations are showing is that we can make a difference and we should make a difference. If we don't make a difference, frankly we should be ashamed of ourselves.”
To find out more or to support the Rory Staunton foundation, click here.