The Need for Multidisciplinary Teams in Sepsis Care

By: Anne Sutherland, MD

September 26, 2017

I’ll never forget the first patient with septic shock for whom I assumed total responsibility. I was a new PCCM fellow taking one of my first nighttime calls in August. I received a call from my resident who told me about a previously healthy young woman, who had been dropped off in the ED after getting a “vitamin infusion” by a nonlicensed practitioner at a neighborhood botanica. It rapidly became apparent that the infusion had been contaminated by bacteria, as she was febrile, hypotensive, tachycardic, oliguric, and delirious.

I immediately became determined that this young, healthy woman with septic shock case would be handled “perfectly.” I made sure that the broad-spectrum antibiotics had been ordered and given, I ran in from home, got the central line in, got pressors started after the 4th liter of NS, and got my attending’s permission to start activated protein C – (this was 2005). Within 36 hours of her admission, she was urinating, off pressors, talking on her cell phone, and almost ready to be discharged to home.

I love the physiology and biology of sepsis – how an infectious insult can lead to the disordered response of all body’s systems – the patients are frequently delirious, hypotensive, not urinating, hypoxic. Watching the systems come back on line in patients with sepsis who do well is immensely satisfying – patients start to make sense, the blood pressure normalizes, and they start to produce liquid gold – urine. Of course, patients also die of sepsis. Sometimes this is okay, as the patient has multiple illnesses, and sepsis is the last stop on the way to death that is not unexpected. However, it is endlessly sad and frustrating when a patient dies of sepsis unexpectedly, and not at the end of a long illness.

As I started to mature into my role of an attending physician, and eventual MICU Director, I realized that I needed to work to improve the system of care in the hospitals that I work in, so patients with sepsis would have the best chance for survival. I began to see parallels to the body’s and hospital’s response to sepsis – a patient with sepsis calls all of a hospital’s systems into action.

A patient with sepsis on the general medical floor or the in the ED needs the nurse or patient care tech to recognize that they are sick. This then has to be communicated effectively to the physician, who needs to order fluids and antibiotics in a timely manner. The antibiotics need to be delivered expeditiously by pharmacy, and then the doctor and nurse need to work together to make sure that the therapies are delivered quickly, and then work together to monitor the patient’s response. If the response to fluids is not acceptable, that should trigger another whole “cytokine cascade” of interventions in a timely manner that will give a chance for a good outcome: pressors, stress dose steroids, transfer to an ICU setting.  

Sepsis has worse outcomes in a host who has underlying problems, like diabetes, cancer, kidney disease; patients with sepsis have worse outcomes in hospitals with underlying problems: bad communication between disciplines and services, and delays in recognition can lead to a patient with sepsis not getting timely care in a proper manner. This is why so many of the successful efforts in sepsis care have focused on bundles and a team approach to caring for these patients.

Hospitals that are striving to improve their sepsis care need to engage a multidisciplinary team. As this team works together, they can wind up finding solutions that lead to better efficiencies in recognizing all sick patients, delivering medications, having the nurses and the doctors communicate better, and having the different services – ED, ICU, General Medicine, Surgery, Pediatrics – all join together to help their patients. Hospitals who can care for patients with sepsis well are more likely to care for all patients well. The doctors, nurses, pharmacists, lab techs, and other services have easy pathways for communication, so they can work together and help to send their patients home.

Dr. Anne Sutherland is an Assistant Professor of Medicine at NJMS-Rutgers, where she is the MICU Director at University Hospital in Newark, NJ.