We have all heard the saying “beating a dead horse.” One imagines a cavalry commander in battle needing his horse to do more than it can. He frantically whips his horse until it is dead.
A sepsis bundle is not a dead horse. A sepsis bundle was a dead horse about three years ago (and it is not clear that it ever really was a horse, maybe something closer to a mule). For three years, this dead horse has been decomposing in the muddy field—flies around the bloated, desiccating carrion—you get the picture.
Many bright, well-respected experts in our medical battalion have illustrated in detail just how decomposed this horse is. (West J Emerg Med. 2019;20:185; http://bit.ly/30c5z5O; PulmCrit. Feb. 12, 2019; http://bit.ly/306HhKd.) Here is the brief autopsy report:
- There is no clear definition of sepsis.
- The one-hour antibiotic rule has been disproven (as has the three-hour rule) because sepsis does not start at the door or with recognition.
- No defined cutoff for lactate and trending lactates have been found to be unhelpful.
- No good science supports 30 cc/kg, and it can harm.
- Bundle compliance does not improve outcomes.
- Regardless of approach, 88 percent of sepsis mortality is not preventable. (West J Emerg Med. 2019:20:185, http://bit.ly/30c5z5O; EMCrit.org. 30 Jan 2017, http://bit.ly/2lTx6X0; JAMA Netw Open. 2019;2:e187571, http://bit.ly/304qGGX.)
This is not a scientific debate. There is no one leading in the trenches who believes in any of the stuff we are doing. From the very beginning, all strategies have failed: Xigris, steroids, tight glucose control, transfusions, central venous pressure, early goal-directed therapy, 30 cc/kg fluids, lactates, one-hour antibiotics, etc. We are the cavalry asked to fight this battle, but there is nothing that even resembles an animal left to ride. The sepsis bundle is a carcass.
But the Centers for Medicare & Medicaid Services is using our hospitals to demand that we mount these carcasses and ride them into battle. There are many voices in our battalion that say, “I know this is stupid, but we don't have a choice. If we don't mount the carcass and pretend we are riding into battle, our hospital won't get paid. And I might not have a job.”
I would charge that this is the hill to die on. It is unlikely you will lose your job from a poor metric on sepsis. But let's say that because the hospital administration is upset with its sepsis quality metrics that you think your contract is at risk. What kind of job are you risking? One in which you will knowingly harm patients (without benefit) for a corporation to make its financial bonus? One in which you will sit atop a carcass and pretend you are riding into a battle to make a salary? That is not a noble job; that is a farce. That is not fitting of a physician; it is mercenary.
We must abandon the strategy of asking CMS to reconsider the lack of evidence behind its decisions. This battle requires offense. We must fight or die for the soul of our profession. We need the names of the people behind the walls of CMS and to call them out publicly. We need to shame them for their lack of knowledge and the harm they cause to our profession, our hospitals, and especially our patients. We must expose to the public the lack of science behind these decisions and the names of the people who make them.
We need to stop agreeing to automatic sepsis alerts, sepsis bundles, 30 cc/kg, blood cultures on every SIRS, lactates, antibiotics before we even see the patient, and restore professional integrity and the strategy of a thoughtful pause before ordering and treating. If we get a nastygram from quality coordinators, it should be a badge of bravery to save the nobility of our profession. If we believe we are battling for the lives of our patients, then let us fight the good fight.
Dr. Mosleyis the medical director for student and resident education at Wesley Medical Center in Wichita, KS.