So, without further ado, I'd like to introduce
our first session of the day, which is entitled
Defining and Innovating Strategies. And we have
the pleasure of kicking off today with a live
viewing of the Canadian Breakpoint podcast, hosted
by Dr. Rupina Purwal. This podcast is designed
to create awareness of increasing AMR and our
fight against it, to focus on discussions around
new diagnostic methods, how to implement technology
in clinical and laboratory medicine, and review
emerging infectious diseases. The title of this
episode is Canadian Sepsis Strategies, Optimizing
Patient Management with Antimicrobial Stewardship.
Dr. Purewell is a pediatric infectious disease
physician. She was born and raised in Edmonton,
Alberta, and completed her medical school at
the University of H in Hungary. I did have to
look up how to say that. It is not spelled that
way. Thereafter, she moved to the United States
for a three -year pediatric residency program
at West Virginia University. She returned to
Canada in 2017 to start her Pediatric Infectious
Disease Fellowship at the University of Manitoba.
Dr. Pirol has been working in Saskatchewan since
2019 as a clinician and academic physician at
the University of Saskatchewan. On today's episode,
she will be hosting two members of the National
Sepsis Action Plan, Dr. Kelly Barrett and Fatima
Sheikh. Dr. Barrett has an M .D. from the Schulich
School of Medicine at the University of Western
Ontario and completed her training in internal
medicine and adult critical care medicine at
the University of Toronto. She is presently the
medical director of the Recover Home Ventilation
Program at the Toronto Grace Health Centre and
is an affiliate scientist with the Health Systems
and Policy Research Collaborative Centre at the
University Health Network. Her academic work
focuses on evidence to inform policy development.
She has real -world experience in this regard
in Ontario and is presently in her fourth term
as a member of the Ontario Health Technology
Advisory Committee at Ontario Health, and she
sits on several working groups with the Ontario
Provincial Long -Term Ventilation Strategy. Fatima
Sheikh is a PhD candidate at McMaster University
and a Canadian researcher focused on health equity
and the social determinants of health. Her research
focuses on understanding how social determinants
of health influence both the incidence and outcomes
of critical illnesses. She also explores how
these determinants shape healthcare delivery
with a goal of informing equitable health policies,
responsible evidence use, and inclusive care
practices. In addition to her academic work,
Fatima holds a role in equity, diversity, and
inclusion and human rights department at Hamilton
Health Sciences. And in this role, she leads
collaborative initiatives with communities, patients,
and regional partners to design and implement
processes for collecting social demographic data
and advancing equity, inclusion, and anti -racism
across the organization. So please welcome them
to the stand. Welcome everyone to another episode
of our podcast, The Canadian Breakpoint. Thank
you so much for tuning in. It's my pleasure to
be here today to actually come for the second
time and do a live podcast. And for our listeners
that are tuning in virtually, welcome as well.
And thank you to our guest speakers today. So
today we're going to be talking about a really
important topic and it's regarding sepsis. So
before I begin, I wanted to get a poll from the
audience to see kind of what we know about sepsis
and those that have encountered someone with
sepsis. So I don't have my ticker up here. I
have to advance the slide. Okay, so I think some
of you guys know how to enter into Slido. So
you can either use the QR code there or through
the app itself. And so the first question is,
what is sepsis? Perfect. Looks like everybody
pulled in. Okay, I think we'll close that poll.
So I think the majority of our listeners today
realize that it is an organ damage produced by
inappropriate inflammatory response to infection.
So that's a correct answer. Next question. So
which of the following of these is a sepsis warning?
Okay, perfect. So yes, all of the above would
be, thank you. All right, and then we'll talk
to Dr. Barrett more about elaborating on some
of those warning signs as well. Okay, and then
our last question is, has someone, so either
in this room or any of our online listeners,
has anyone in your life? like a close friend
or family member gone through sepsis? And so
our options here are yes or no, or I've never
seen or heard about it before. Okay, the majority
of our folks are going to know. All right, so
now we're going to begin by talking about sepsis
and really understanding the work that... both
Fatima and Dr. Barrett have done in this area.
So without further ado, I think I want to start
by asking both of you, how would you define sepsis?
And in which clinical setting does this really
occur in? And which healthcare professionals
are really best positioned to manage this condition
effectively? Yeah, so sepsis is sort of defined
as the body's sort of out of control over excessive
inflammatory response to an infection. And it's
interesting, some of the people who answered
in the poll said that it was a blood infection,
which is true in some ways. And so it's important
to know that any infection really can cause sepsis.
And it's often sort of thought of as either the
bacteria or the virus is sort of eating away
at the body or that there's bacteria in the blood.
And while there's sometimes bacteria in the blood.
It doesn't always have to be that. It can be
just a soft tissue infection. And it's really
the immune response, the body's immune system
gets so overwhelmed and so, not overwhelmed,
sorry, almost overactive that the inflammation
causes organ damage. And the main way that the
organ damage happens is actually through shock.
So people's blood pressure is low. So that's
why one of the... question where it was what
are the warning signs and the sort of signs and
symptoms of sepsis they're typically signs and
symptoms of an infection so fever off urinary
tract symptoms a wound infection um but then
also not enough blood flow and oxygen delivered
to the brain because the blood pressure is low
so dizziness confusion um sort of not feeling
like feeling foggy increased urine output because
there's not enough blood flow to the kidneys
um people develop sort of cold some people develop
cold fingers and then some people they're actually
they're red and they're hot like you're you're
everything is red and sort of inflamed because
you're of the inflammation um so it's it's not
necessarily the infection it's the body's response
to the infection um and really anyone in the
health system would see someone with sepsis and
that's I think a very important point that this
isn't something that should be just only sort
of the purview of people in acute care hospitals.
We know that the majority of cases of sepsis
actually originate in the community. And so any
sort of first point of contact with the health
system, that health provider needs to be aware
of sepsis, know what it looks like, because they
could be encountering it for the first time in
that person's case. Yeah, so it sounds like some
kind of the warning signs that you mentioned
that the public and others or health care providers
should be aware of are quite alarming and can
sometimes happen quick as well. So it sounds
like very devastating. And so is this a treatable
condition? And within kind of our health care
infrastructure, what types of resources do we
really need to treat such a condition? So the
first most important point is we need to be able
to recognize it. So the clinicians looking at
the patient need to be able to have the pattern
recognition or the infrastructure within their
system to have warnings or red flags in their
EMR to say this patient is developing shock,
they're developing organ dysfunction, and they
have an infection. This could be sepsis. And
then the most important thing, and we know there's
very clear evidence about this, you need to give
antibiotics as quickly as possible. And that's
where I'm sure in this room it's like, oh, but
that's actually an evidence -based recommendation.
If you can start to treat that infection early,
you can then prevent some of that later inflammation
and organ damage. So it's getting control of
the infection as quickly as possible. when individuals
have shock associated with sepsis, they need
to be treated at an acute care center because
they need volume resuscitation with intravenous
fluids. And so you can't really, I don't think.
A family physician would be able to do that in
their clinic or sort of community health centers.
That's sort of beyond the scope of what could
be done there. You need to be at a hospital where
you can have blood work drawn, repeat blood work
drawn, get IV fluids. You need to have appropriate
investigations done to be able to find the source
of the infection. And then also key, and I think
important to this room, is appropriate cultures
done so that we know what the infection is caused
from so that we can then narrow the antibiotics.
make sure that we're not delivering too broad
spectrum antibiotics. And that ties us back to
antimicrobial resistance and building resistance
if we're not doing that. So definitely going
kind of broad empirically, sounds like the approach
being a multidisciplinary team, definitely need
to be in a setting where there's enough resources
to manage kind of acute changes. And with that,
I mean, there comes the burden on the health
care system as well. And so what have you guys
seen or what are the effects or the economic
burdens of this on our health care system? I
think it's a really important point to highlight
there. I think just even in the description that
Callie provided in terms of the level of care
required, we know that sepsis is going to be
costly. And we even think about this from the
number of Canadians that are impacted or the
number of individuals worldwide impacted. So
we know in Ontario alone, we're looking at upwards
of a billion dollars associated. Yes, a billion
dollars in Ontario associated with treating sepsis.
And remember, that's sort of the hospital associated
costs. I mean, all the other piece to this is
that once individuals have had a sepsis case,
they are at risk of coming back into our hospital
systems, increased risk of diabetes, cardiovascular
disease, so on and so forth. And so all of the
costs associated with treating those downstream
sequelae. We did a study a few years back looking
at the concept of high cost users. So the individuals
that make up a small portion of the population,
but a disproportionate amount of health care
spending. And we know that sepsis is actually
a risk factor for becoming a high cost user.
And so really when we're thinking about this
in terms of prevention, prevention of a sepsis
case could potentially yield. cost savings for
the healthcare system. And this doesn't even
begin to touch the pieces associated with the
individual, their families, you know, not being
able to return to work, the psychosocial factors
associated caregiving costs and all the burdens
associated with that. So we're really focused
on some of those health system costs, but there
are also significant costs associated with some
of the downstream impacts of sepsis. Yeah. I
think. One of the things that I think maybe isn't
necessarily recognized unless you've experienced
sepsis yourself, a loved one has or you've treated
it, is the people who have really severe sepsis
and have shock need to be admitted to an intensive
care unit. And to treat that low blood pressure,
we have to give medications to increase the blood
pressure. And some of the complications associated
from that medication is we actually squeeze the
vessels to the point where the digits and the
toes. you don't have enough circulation. So you
hear about people requiring amputations when
they have sepsis. And that's as a result of the
blood flow being diminished blood flow to their
fingers and their toes and the people that survive
sepsis and have lost limbs. the the prolonged
course of critical illness we know that every
day in bed your muscles are just sort of atrophying
and the inflammation the muscles atrophy so then
people have incredible weakness um they get nerve
damage so they're surviving an episode of sepsis
but now they've maybe lost a limb or two they've
got residual kidney dysfunction they might need
dialysis for the rest of their lives they have
foot drop They have intractable nerve pain. They
need months and months and months and months
of rehab just to have the strength to be able
to sort of ambulate and toil with themselves.
So for people with severe sepsis, it is a catastrophic,
life -altering event. And even those who have
a milder case of sepsis, you know, we spoke with
someone yesterday or two days ago who had, I
would say, a mild to moderate case of sepsis,
needed vasopressors. continues to have sequelae
is back at work but is continuing to like in
and out of visits with the physician because
she's having recurrent infections and things
her body has just been so messed up from nine
hours of sepsis so it is it's really uh it is
really life -altering yeah and it sounds like
from the population that affects obviously i
mean there's certain risk factors for certain
conditions that we know of in medicine but it
can really affect you at any stage. So I know
that there's cases with childbirth, there's cases,
routine cases, like I work in pediatrics, so
we see it all the time there as well. And you
really can identify a lot of risk factors when
somebody's going to have a severe presentation
or milder presentation. And so I know that we
talked about key kind of prevention and education
around that. And I know you guys have done a
lot of work around the sepsis national action
plan. And so I wanted to kind of shift gears
to that now, because as we know that this is
a very devastating condition, we need to make
awareness. Want to kind of let our audience know,
and we just presented it last year as well, the
symposium. I think some of our listeners were
there. And so kind of what have things, what
really led you to do this work? Yeah, I feel
like it's worth taking a step back and going
into sort of 2017 when the World Health Assembly
put forward Resolution 70 .7, which really, you
know, required member states to implement protocols,
standards associated with, you know, survey detection,
management, and so on and so forth. And I think
that was really the impetus for a lot of this
work, at least in 2017. Since then, we've done
a lot of work sort of looking at existing policies
outside of Canada to understand, you know, why
they were implemented, how they were implemented,
so on and so forth. In most cases, these are
examples of reactive policies. So a tragedy occurs,
it hits the news media, and there are subsequent
efforts that are put in place. A good example
of this is looking to our counterparts in the
U .S., particularly in New York around Roy's
regulations. These are an example of one of the
first state -mandated sepsis policies that were
implemented after the tragic death of a young
child that could have potentially been prevented
through early detection and appropriate management
within the hospital setting. There are other
parallel examples of this. I think we've done
some work around foodborne pathogens where there
have been subsequent policy efforts. And so we
wanted to take a step back and think about what
would a reactive, what would a coordinated plan
look like for sepsis here in Canada? And so we
started with a jurisdictional policy review of
existing sepsis policies, guidelines, and health
professional training standards in Canada. and
this work is forthcoming and will hopefully be
published soon, but just sort of a few tidbits
from that review, we didn't identify a single
sort of national policy or framework in Canada
to guide what provinces and territories should
potentially be implementing. And I think in the
absence of that, we see a lack of policies and
guidelines. most provinces and territories in
Canada. And where it exists, they don't cover
the breadth of populations at increased risk
and limited integration of some of those international
guidelines in that work. I think we talk a lot
about early detection, early detection, early
detection, and it's so critical. But I think
in order to facilitate that, we really need to
think about training for health professional
training standards and whether or not this is
actually included as a competency. Are physicians,
nurses, or allied health professionals trained
to detect the signs and symptoms and escalate
care accordingly? When we look at the physician
training standards, in most cases, sepsis isn't
considered. And whether it is we feel that it
isn't considered, you know, in a way that is
appropriate for a medical emergency. And I think
for nurses, for our paramedics, for our allied
health professionals, I think Kelly had mentioned,
you know, everyone in the health system sort
of has a role to play in some of that early detection.
We see a lack of consideration. And so I think
that for us highlighted the opportunity to implement
a sepsis national action plan that considers
those important risk factors that facilitates
the implementation of sepsis as a core training
competency to facilitate some of those downstream
pieces that we were talking about. Okay. And
it sounds like other countries. As you mentioned,
the U .S. particularly have a sepsis national
action plan. Are the components of that, like
you touched on some of them, are the components,
some of those similar components that you guys
integrated into your action plan? Yeah, absolutely.
So other countries have implemented sepsis national
action plans, and I'll give some of those examples.
But I think when we're talking about that, the
components really boil down to some of the prevention
efforts. So thinking about vaccines and other
things that can help prevent infections and then
subsequent onset of sepsis, we're thinking about
awareness. So I think, you know, in this audience.
We saw the polls earlier, and the majority of
you had said that no one in this room was impacted
by sepsis. And we often hear that people learn
about sepsis when a loved one has had it or a
relative has had it. And we don't know, it's
not common to know sort of the signs and symptoms
in the same way that we know the signs and symptoms
of, for example, stroke. So if someone is having
a stroke, whether it's your family member, whether
it's someone on the street. Even if you can't
name off all of the signs and symptoms, you are
able to identify that something is wrong. It's
a medical emergency. You need to call 911 and
get this person care. When they get to the hospital
system, we have protocols and policies in place
in order to escalate that care. So I think the
prevention and awareness pieces are really important.
And then when individuals get into the hospital
system. You know, standards in the emergency
department, you know, it's such a complex environment.
We heard from a speaker yesterday about some
of those complexities and some of the challenges,
but an opportunity to protocolize some of that
care so that early detection and management becomes
routine. I talked a little bit about the training
standards for everyone in the health system,
so beyond the emergency department, what that
looks like. And then I think there's opportunity
for developing quality standards, quality improvement
initiatives, and through all of this, integrating
sort of those data pieces, our ability to understand
who in Canada is actually impacted by sepsis,
and whether the efforts that we're putting in
place, whether those are policies, whether those
are guidelines, whether that's inclusion in health
professional training standards, having the intended
impact. And so I think that's going to be a really,
really important piece going forward. And I think
the ability to report on those pieces so that
we can evaluate our efforts continuously. Sounds
like definitely looking at some multidisciplinary
or multifaceted kind of approach is really important.
And you talked about prevention, diagnostics,
education. I think those are all kind of the
key points. All of this, I would assume, requires
a lot of money, funding. And so when we're looking
at things that are burdening our health care
system, such as conditions like sepsis, has there
been measures by the Canadian health care system
to help us implement such action plans to kind
of fight or to create awareness in regards to
conditions like sepsis? As our jurisdiction review
identified, there isn't yet a national strategy
or provincial strategies, really. And I'm actually
going to, I'm not sure it would cost a ton of
money to actually address this issue. A lot of
the work involves just bringing together the
people that are already doing work in these given
areas and just ensuring that sepsis is a part
of a training standard, ensuring that, you know.
prioritized quality metrics for hospitals and
health care centers that sepsis is one of them
so this i don't think this requires a new line
item in any system's health budget it just requires
a bit of a reorganization maybe or re -prioritization
of sepsis and i think in terms of so what has
the canadian government done um you know i'll
say that the aml efforts Apply to sepsis. So
every person who dies of AMR is likely dying
of a sepsis -related death from a resistant pathogen.
So sepsis is sort of like the human face of AMR.
And the Canadian government funded the Sepsis
Canada, the research network. So they gave several
million dollars to scientists, which Fatima and
I, some of this work was supported by Sepsis
Canada. And so there's been a pool of money for
research. A pool of money is now spent. There's
no further funding. But there hasn't been a sort
of a policy research. And so that's really some
of the work that we're doing. It's very hard
for a single government entity to lead this work.
The federal government is not going to be able
to solve this problem. A provincial government
is not going to be able to solve this problem.
And it requires having... The key government
stakeholders and the decision makers and then
the clinicians and the patient partners. And
so what we're hoping to do and what we're starting
to bring those people together, we're laying
on the ground sort of the plan of here's what
we're going to do. We've mapped out what's missing.
We've mapped out what exists. And then we're
going to work on basically filling the holes,
filling the holes in the policy gaps together,
coordinated so that we're not all doing reinventing
the wheel in all the different provinces. Yeah,
that's fair. And I think when we, I mean, we
talked about this at one of yesterday's talks
in terms of the provincial healthcare differences
that we have as well. So again, that poses some
challenges when you're kind of coming from a
national front, just with having different provincial
healthcare systems. But it sounds like awareness
is probably... There's a key factor in this as
well, and why we're also here today to make people
aware of this condition, what your guys' plan
is, and that is a national plan. We talked about
some of the barriers that exist, but where do
you think the key kind of awareness gaps are
within, let's say, the public, within policymakers
or healthcare professionals? Maybe I can start
with the public piece because I think that is
so critical. So there was some work done by some
of our colleagues, also funded by Sepsis Canada.
They tried to understand, you know, how many
Canadians know what sepsis is, how many Canadians
know the signs and symptoms of sepsis and some
of those preventative efforts. And across the
board, the percentage is relatively low. I think
what's important, though, is that awareness differs
by region, by sex, by education and by ethnicity.
I think there's a critical piece to all of this
work, which is that ensuring our communication
about sepsis and ensuring who has that sort of
education is tailored to the populations that
are at increased risk, which is often influenced
by the social determinants of health, where you
live, what you have access to. And I think it's
really challenging because sepsis is a heterogeneous
condition. Everything from any infection can
lead to sepsis. Patient partners talked to us
about, you know, a paper cut that led them to
a sepsis incidence. You know, we've had individuals
who've had pneumonia and come into hospital and
there's been some downstream effects. So it is
a challenging condition in that sense. But I
think there's lots of opportunities to think
about what prevention strategies look like. And
it really starts with, you know, folks understanding
what sepsis is and understanding some of those
signs and symptoms. And so obviously we've talked
about the components of the Sepsis National Action
Plan. So what is kind of the future in this?
So what future initiatives does your team have
planned? I know it seems like you've definitely
looked at the data. We know where some of the
gaps and barriers exist. And so what does the
future hold for us? Yeah. So we're starting to
pull together the group. And to support this
work, we're applying for CIHR funding. If we
don't get the funding, we're going to still start
the work and then continue to try to find funding.
The first step that we're going to do is we're
going to do a sort of proper comparative health
system evaluation of what have other jurisdictions
done and what's worked, what hasn't worked, and
actually get the leaders of all the different
national action plans together, host a conference.
And then we're going to try to figure out what
can we learn from those different examples that
are applicable to Canada. The next step is we're
going to bring together the key stakeholders
and decision makers and health care providers
and sort of people who will be implementing and
map out how we are going to fill the gaps in
each area. And this is going to be very different.
There's going to be we need to address reporting.
You know, we only, Chi Phi only reports nosocomial
cases of sepsis. And I think this is one of the
sort of academic decision makers, political sort
of gaps is that sepsis is always viewed as an
acute care condition. And we consider, you know,
infection prevention and control in hospitals
and hospital acquired, you know, surgical site
infections and C. difficile. And those are very,
very important. I'm not saying they're not important
to you, but that actually that's a minority of
sepsis. 80 % are coming from the community. So
we're not measuring those, reporting those, tracking
those. We don't know what the outcomes are for
those people in sort of a comprehensive way.
So reporting metrics, quality improvement metrics,
making sure every hospital in the country within
each province has a clear standard for how are
they going to detect sepsis, how are they going
to treat it, making sure all healthcare professionals
know what sepsis is, making sure it's in... hospital
accreditation standards so is every emergency
department or recovery room medicine ward surgical
ward all the different areas where sepsis could
be developing and percolating in patients is
that part of an accreditation standard for the
hospital And then research, making sure that
we have good research. And then another little
point of this is going to be public awareness.
So we want people to know what sepsis is. And,
I mean, as a clinician, you know that so much
of what we do is pattern recognition, right?
And sometimes you can cognitively get down a
pathway where you stop asking, what else could
this be? What else could this be? What else could
this be? And, you know, if patients knew what
it was and they said... That's really powerful.
A family member of mine called. We get these
phone calls. I have this problem. What do you
think? And when she started to describe it, it
didn't sound that bad. And then she said, I'm
worried this might be sepsis. And it immediately
made me think, oh, it actually could be. You
should go to the hospital. And she ended up needing
to be admitted and have an abscess drained. So,
you know, it's that sort of. Powering patients
to be able to advocate for themselves, I think
also would be very, very important in this. And
so public awareness and awareness within health
systems and within decision makers is going to
be key. Yeah, and you bring up a lot of good
points. Like we talked about, stroke symptoms
and signs are very... We have advertisements
and recognition. So I think your initiative sounds
like creating some awareness around where the
public can identify that, I think is definitely
one of the key points. And it hasn't been done.
I mean, for sure, I think everybody in this group
probably understands that. But some of my listeners
out there, they might be hearing some of this
information for the first time. So thank you
so much. I do want to give you guys the opportunity
to kind of give one key message. I mean, there's
probably a lot of key messages out of today's
talk. But I think one key message that you want
our audience to kind of take home from today
to think about, to, you know, speak up or integrate
into their decision making. Yeah, that's a tough
question. I would say that my one key message
would be that, you know, sepsis is a medical
emergency and that, you know, a coordinated and
proactive national action plan could save lives.
And I think there's a role to play for everyone
in this room and for the listeners. And I think
we've highlighted some of those opportunities.
And so we welcome that collaboration as we move
forward in this work. I would say that. I think
we need to stop thinking about the barriers in
our health system as reasons for why we can't
address this problem. We just make sure that
people are working on the things that they have
jurisdiction over. And so this is doable and
we just need to all come to the table and work
on it. Awesome. It's a great message. Well, thank
you so much. I definitely, I know I learned a
lot about your guys' action plan in terms of
in general. I think it brought about awareness
to our group here, to our listeners internationally.
Maybe other centers or sites that have created
such a plan would speak up and bring up their
efforts. Thank you so much for doing such important
work. I think it's really important, like you
mentioned, to prepare to, you know, just need
action. And that's and we need to prevent, you
know, such devastating conditions for sure. I
think the work that you guys have done is fantastic.
And we look forward to hearing about more of
your work. continues in this area and so I'm
sure we'll have future episodes for that so thank
you so much for being guests on our podcast today
thank you everyone for listening and for our
listeners that are tuning in virtually or they'll
be able to find our podcast on Apple, Spotify
or Google they I'm sure can reach out to us if
there's any other comments or questions and I
want to thank all of the supporters and for AMR
Symposium for having us here today and being
able to discuss such an important topic. Thanks
so much. Thank you.