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Spotlighting sepsis: How one journalist reported on 'dirty little hospital horror' Date: 07/16/15

As senior quality editor for HealthLeaders Media for more than six years, Cheryl Clark wrote more than 1,300 stories about hospitals' efforts to improve quality and safety and related issues. The story she wrote for the June 2014 issue of HealthLeaders' print magazine, on how U.S. hospitals are improving recognition and treatment of sepsis — which is diagnosed in 750,000 patients a year and kills 40 percent — won the 2015 National Institute of Health Care Management prize in the trade print category. They said the story was "most likely to save a life." Clark now is a contributing writer for MedPage Today, and is helping launch a new investigative journalism organization called Hashtag30. She includes links to her work and practical tips at the end of her “How I did it” essay.

Cheryl Clark

By Cheryl Clark

When I was very young, we had to drive from our home in Washington, D.C. to East Orange, N.J., because my grandmother was very sick. We entered her darkened living room to find about 20 crying Italian relatives all wearing black.

We were too late.

My grandmother had died in the hospital from "sepsis," a word the family seemed to whisper because they didn't quite know what it meant. They said that just before she died, she deliriously saw the Virgin Mary who, she cried, "has come to take me away."

My grandmother was 53.

When spoken by physicians, the word sepsis can carry a tone of resignation that death is likely imminent, or has already occurred. Often, sepsis takes the old and frail, after pneumonia, organ failure and system breakdown. When doctors say someone is "circling the drain," they are likely talking about sepsis because nothing more can be done.

Fast forward to June 11, 2012, and a story in The New York Times. Sepsis had ambushed someone who was hardly old and frail. Rory Staunton, 12 years old, sought help in NYU Langone's emergency room where he was diagnosed with a stomach bug and sent home. Three days later he returned and died in the ICU. Of sepsis. The story said no one in the ED had read the test result in time.

Hospital executives all over the country realized this could happen to any one of their organizations.

Misdiagnosis and hospital harm get my attention. As senior quality editor for HealthLeaders' monthly print magazine, it was my task to find stories that hospital executives — the magazine's targeted audience — should feel compelled to read to make their systems safer. The best topics are hospital horrors, which many chiefs would rather not acknowledge occur in their organizations, (think schadenfreude) but know full well they can — and do. My stories were to help them learn how they might tailor other hospitals' solutions to address problems in their own.

For each 1,700-2,300-word HLM magazine piece, I had to find three or four hospitals that tackled the problem in unusual or interesting ways, persuade their doctors and others to explain what worked and what didn't, and share their data for publication. What they told me had to hold up when an independent fact checker called.

These stories require multiple interviews with each hospital's front-line staffers, the ones who conceptualized and executed improvement programs, and who could discuss how they overcame resistance from staff, budget constraints or other obstacles. It's time consuming, because one often gets interviews with people who aren't clear on the specifics, and you have to go deeper in the organization to find the right expert. It also requires getting executive leaders to say why and how they prioritized the issue — without puffery.

In November 2013, the task was to anticipate a new topic for the June 2014 issue, and present it to our team's approval during a teleconference on Dec. 10.

Sepsis, an immune system cascade usually stemming from infections acquired outside of the hospital, seemed perfect. The federal government was starting to penalize hospitals with higher 30-day mortality rates and more sepsis research was underway in several multi-center studies. And no one wanted a repeat of the publicity that NYU Langone got after Staunton's death.

Rates of sepsis seemed to be one more dirty little hospital horror to explore, one that the Joint Commission said cost hospitals about $16.7 billion annually. Yet hospitals' efforts to tackle it seemed hidden behind improvement initiatives attracting more attention, such as reducing hospital-acquired infections, and preventable readmissions, lowering emergency room wait times and raising patient experience scores.

Often to find the right organizations for my stories, I would go to the data, to Hospital Compare, sort a spreadsheet for a type of adverse event, such as pressure ulcers, and see which hospitals seemed to have the best numbers. But sepsis was a tough one because there were no publicly reported hospital sepsis data comparable across the country. The problem usually wasn't hospital practices that caused sepsis, but the failure of the hospital teams to recognize it quickly enough to rescue patients because symptoms are so easily confused with other illnesses.

I tried to talk to officials with NYU Langone to ask what they had learned after Staunton, but they declined because of pending litigation. Henry Ford officials, who had pioneered a special catheter and protocol that had been endorsed by the National Quality Forum, declined after a New England Journal of Medicine paper this spring found that Henry Ford’s "early goal-directed therapy" wasn't superior to standard treatment.

So I went back to New York, to NYU Langone's competitors. North Shore Long Island Jewish had implemented a number of strategies and its leaders were eager to discuss them. For instance, they had a new emergency room system to make sure patients with possible sepsis were given antibiotics as soon as possible.

Also eager to talk about sepsis prevention was the huge Kaiser Permanente system, which several years earlier had discovered that sepsis was the biggest killer of patients in its hospitals. Kaiser had made sepsis detection and treatment in its emergency departments a top priority.

My third source was the 42-hospital Carolinas HealthCare System in North Carolina, which had developed a mock system to train physicians and nurses on recognizing complex sepsis systems with high-tech mannequins in a simulation center.

My reporting included several interviews with key officials for the Centers for Disease Control and Prevention, whose antibiotic stewardship campaign was said to be at odds with strategies to prevent sepsis, which might require more liberal use of antibiotics in people suspected of sepsis in the ED.

The CDC A-Z Index website didn't have a listing for sepsis, and wouldn't until March 20, 2014, just before the June issue's deadline. The CDC also provided valuable information on reporting laws in numerous states and interviews helped craft several subsequent columns and news stories.

More stories await. New federal reporting rules will soon clarify when patients coded as having sepsis really have pneumonia, and should be calculated with hospital readmission rates when they are readmitted. Disease investigators are challenged to distinguish when sepsis occurs from infections that are acquired during hospitalization, as opposed to those that are community-acquired, such as in Staunton's case. He was infected after getting a cut on his arm while playing basketball.

All in all, I interviewed more than 30 people for the story and consulted several organizations such as the Stop Sepsis Collaborative, the American College of Critical Care Medicine's and the Society of Critical Care Medicine's Surviving Sepsis Campaign, the New York State Department of Health for their new regulations on sepsis. I also read dozens of journal articles for background and sources.

Coverage tips

If you can't convince officials at a hospital that had an adverse event to talk about what happened and how it fixed a problem, go to its regional competitors to find what they would have done.

• Interview researchers. Even if their papers seem arcane and off point, the scientists might know what new efforts are working or plausible.

• Convey to hospital representatives that you are trying to raise public awareness and help publicize success, not hurt a hospital's reputation.

• Stress that transparency is in the public interest as it is in the hospital's best interest too.

• The CDC, even though it has had some major fails in the past year, is an excellent resource. Get to know key people within the agency who will steer you to the right data sources. The CDC and the Centers for Medicare & Medicaid Services, which makes reporting rules and penalizes hospitals, are working much more closely now to formalize public reporting policy and hospital compliance standards for reimbursement.

• If possible, pick a topic that stirs your passion, one that you have some personal attachment to, for inspiration. I think my grandmother would be pleased.

Additional coverage at HealthLeaders Media:

March 20 - The Bad News on Sepsis is Really Good News
March 19 - Septic Shock Treatment Protocols Challenged
March 6 - Size Matters in Antibiotic Overuse
March 5 - CDC Warns of Antibiotic Overuse in Hospitals

Cheryl Clark (@CherClarHealth) was the senior quality editor for HealthLeaders Media for more than six years, writing about the Affordable Care Act, payment reform, quality reporting and measurement. She is a contributing writer for MedPage Today.