caring for sepsis survivors: from icu to post-hospital care · early hospital care: timely...

Caring for Sepsis Survivors: From ICU to post-hospital care

Speaker:Hallie Prescott, MD, MScAssistant Professor in Internal MedicineDivision of Pulmonary & Critical Care MedicineUniversity of Michigan Health System

Webinar seriesSepsis: Across the Continuum of Care

This webinar series is made possible with unrestricted educational support from bioMérieux, Inc.

Mission Statement:

Save lives and reduce suffering by raising awareness of sepsis as a medical emergency.

www.sepsis.org

Sepsis Survivor WeekFebruary 10 - 16

• 1.4 Million Survive Sepsis Each Year

• Up to 60% of sepsis survivors are left not only with physical challenges but mental and emotional challenges too

• Sepsis Survivor Week toolkit & Life After Sepsis resource page

www.sepsis.org

Hallie Prescott, MD, MScUniversity of Michigan

VA Ann Arbor CCMR

@HalliePrescott

Caring for sepsis survivors:From ICU to post-hospital care

February 12, 2019

Disclosures

• Funding:

– NIH/NIGMS K08 GM115859

– US Department of Veterans Affairs IIR 17-219

• Positions– VA employee. This talk does not represent views of US government or

Department of Veterans Affairs

– vice-chair of Surviving Sepsis Campaign Guidelines; this talk does not

necessarily represent views of SSC.

Fleischmann, et al. AJRCCM. 2016.

19.4 million cases 5.3 million deaths

An estimated 14.1 million patients survive

(severe) sepsis each year.

Outline

• The story of one such patient

• Life after sepsis

• What we can do now

• Follow-up on our patient

One patient’s story

49 year old female, mid-level manager at a large

corporation.

PMH: HTN, mild asthma

• Presented to ED with fevers, chills, sore throat, cough

• Admitted with community-acquired pneumonia

• Treated with IV antibiotics

• ARDS

• Septic Shock

• Day #36: extubated

• Day #43: to rehab

3 weeks of inpatient rehab

IQ Testing

Jackson et al. Southern Med J. 2009.

IQ Testing

Jackson et al. Southern Med J. 2009.

Interview with an ICU trialist, 2004

http://www.frontline.in/static/html/fl2120/stories/20041008001708600.html

Is there a residue in sepsis survivors who have had multi-

organ failures or dysfunctions?

Interview with an ICU trialist, 2004

http://www.frontline.in/static/html/fl2120/stories/20041008001708600.html

Is there a residue in sepsis survivors who have had multi-

organ failures or dysfunctions?

“Most people return to normal or near-normal lives even if

they have had severe organ failures…

Most surviving patients come back to being normal.”

Early cohort studies suggest a problem

Jackson et al. Crit Care Med. 2003.

In national sample with baseline

measurement, new and persistent

disability is common after sepsis.

Iwashyna, et al. JAMA. 2010.

Angus, et al. JAMA. 2010.

Moderate-Severe Cognitive Impairment

• 6% → 16%

• 3.5-fold increased odds

Iwashyna, et al. JAMA. 2010.

Functional Disability

• 1-2 new limitations

Iwashyna, et al. JAMA. 2010.

Increased healthcare use, post-acute mortality

Health

Care

Facility

Before Severe Sepsis After Severe Sepsis

Prescott, et al. AJRCCM. 2014.

Frequent hospital readmission

Health

Care

Facility

Prescott, et al. JAMA. 2015.

In matched cohort studies, sepsis

survivors are at increased risk for:

Prescott, et al. JAMA, 2015.

Shen, et al. Crit Care Med. 2016.

Zielske, et al. Eur Arch

Otorhinolaryngol. 2014.

Ou, et al. AJRCCM. 2016.

Yende, at al. AJRCCM. 2014.

Infection AspirationAcute kidney

injury

Cardiovascular

Events

Experimental Animal Data

Post-septic mice are

at increased risk for:

• Infection: succumb to bacterial or fungal challenge

• CV disease: accelerated atherosclerotic disease

• Cancer: accelerated tumor growth

Kaynar, et al. Crit Care. 2014.

Benjamim, et al. Am J Path. 2003.

Benjamim, et al. J Lekoc Biol. 2004.

Deng, et al. J Clin Invest. 2006.

Cavassani, et al. Blood, 2010.

Our current mechanistic framework

Hotchkiss, et al. Lancet Infectious Diseases. 2013.

Shankar-Hari, et al. Crit Care. 2016.

“Epidemiologic criteria for a causal relationship…

not consistently observed.”

Prescott, et al. BMJ. 2016.

Life after sepsis is scary

New Symptoms & Morbidity

Vulnerable to further health set-backs

https://jamanetwork.com/journals/jama/fullarticle/2667724

In summary, sepsis survivors experience

poor long-term outcomes

1 in 5 with

post-acute mortality

3-fold increase in

cognitive impairment

1-2 new functional limitations

(activities of daily living)

40% re-hospitalized

within 90 days

Iwashyna, et al. JAMA. 2010. Prescott, et al. JAMA. 2015.

Prescott, et al. BMJ. 2016.

Outline

• The story of one such patient

• Life after sepsis

• What we can do now

• Follow-up on our patient

But guidelines do not address

long-term outcomes

Rhodes, et al. Crit Care Med. 2017.

• 67 Pages

• 655 References

• 0 Mention of

Post-Hospital Care

Prescott and Angus, JAMA. 2018.

Early Hospital

Care

After DischargeTowards Discharge

Early Hospital Care: Timely antibiotics, source control, and

resuscitation

Lower-risk population:

Mortality difference non-significant,

but reduced readmissions

Seymour, et al. NEJM. 2017.

Oskam, et al. Lancet Resp Med. 2018.

Increased odds of in-hospital

with each hour delay

2.7% RRR / hr

0.7% ARR / hr2.9% RRR / hr

0.2% ARR / hr

Early Hospital Care: Timely antibiotics, source control, and resuscitation

Seymour, et al. NEJM. 2017.

The sicker the patient,

the more important

early antibiotics are.

For less ill patients

without clear infection,

ok to do more

diagnostic work-up.

Early Hospital Care: Timely antibiotics, source control, and resuscitation

Rhodes, et al. 2016 SSC Guidelines.

SCCM and ACEP Release Joint Statement About the SSC Hour-1 BundleThe Society of Critical Care Medicine (SCCM) and the American College of Emergency

Physicians (ACEP) acknowledge concerns expressed about the recently released Surviving

Sepsis Campaign (SSC) Hour-1 bundle and the appropriateness of implementation in the

United States. Both organizations understand the importance of prompt and optimal sepsis

diagnostics and treatment. SCCM and ACEP along with other involved international experts

are organizing a meeting as soon as possible to carefully review the recommendations, and

provide guidance on bundle implementation and care of potentially septic patients who

present to emergency departments in the United States. We recommend that hospitals not

implement the Hour-1 bundle in its present form in the United States at this time.

Early Hospital Care: Timely antibiotics, source control, and resuscitation

Devlin, et al. CCMed. 2018.

Early Hospital Care: Pain, Agitation, and Delirium Management

Schuler, et al. CCMed. 2018.

Early Hospital Care: Pain, Agitation, and Delirium Management

Schweickert, et al. Lancet. 2009.

Early Hospital Care: Early Mobility

Towards Discharge: De-escalation and De-resuscitation

Stop

Antibiotics

Target

“dry weight”

Prescott, et al. AJRCCM. 2015. Baggs, et al. Clin Infect Dis. 2018.

Lam, et al. Crit Care Med. 2018.

Wirtz, et al. Crit Care. 2018.

Mitchell, et al. AnnalsATS. 2015.

Towards Discharge: De-escalation and De-resuscitation

Towards Discharge: Medication reconciliation & titration

Chronic medications discontinued(e.g. synthroid, gastric acid suppression,

anticoagulants, and statins.)

Acute medications continued(eg. antipsychotics, antidepressants, benzodiazepines,

gastric acid suppression, inhalers)

Bell, et al. JAMA. 2009.

Morandi, et al. J Am Geriatric Soc. 2013.

Scales, et al. J Gen Intern Med. 2016.

Tomicek, et al. Crit Care, 2016.

Ravn-Nielsen, et al. JAMA IM. 2018.

Towards Discharge: Medication reconciliation & titration

23% reduction in composite outcome

(ER visits + re-hospitalization)

Govindan, et al. AnnalsATS. 2014.

Towards Discharge: Counseling, anticipatory guidance

27%

2%

37%

17%

17%Almost Never

Only for the Sickest Patients

It varies widely across practitioners

With many but not all patients

With almost every patient

“Do medical teams in your ICU have formal discussions with patients

or family members regarding challenges or changes to their lives after

ICU discharge?”

https://jamanetwork.com/journals/jama/fullarticle/2667724

Towards Discharge: Counseling, anticipatory guidance

Patient page on

post-sepsis

morbidity at

JAMA.

Towards Discharge: Counseling, anticipatory guidance

Towards Discharge: Counseling, anticipatory guidance

Towards Discharge: Counseling, anticipatory guidance

“When you don’t tell me what to expect, I feel

defeated every time I can’t do something.”

Towards Discharge: Counseling, anticipatory guidance

“When you don’t tell me what to expect, I feel

defeated every time I can’t do something.”

“My family, my doctor, everyone thinks I’m

okay. They tell me it is in my head… but I

don’t feel right.”

Towards Discharge: Counseling, anticipatory guidance

“When you don’t tell me what to expect, I feel

defeated every time I can’t do something.”

“My family, my doctor, everyone thinks I’m

okay. They tell me it is in my head… but I

don’t feel right.”

“No one told me I was going to be short of

breath. I’ve been sitting in my chair, waiting

for it [the dyspnea] to get better…”

After Discharge: Promote functional recovery

• Screen for functional impairment – E.g. ADL limitations, 6 minute walk, Timed Up and Go test

• Address new weakness and functional impairment– Structured exercise program

– Physical therapy

– Occupational therapy

– Cardiac or pulmonary rehabilitation

Graphic adapted from McSparron & Iwashyna in Deutschman and Neligan Evidence-Based Practice in Critical Care (3rd ed.)

Prescott, et al. JAMA. 2015.

After Discharge: Big 5 Potentially Preventable Readmissions

Infection

CHF Exacerbation

Acute Kidney Injury

COPD Exacerbation

Aspiration

• Reconcile and titrate medications

• De-resuscitate targeting new dry weight

• Consider lingering myocardial suppression

• Reconsider and titrate medications

• Consider residual injury and vulnerability, lingering

myocardial suppression

• Consider laboratory monitoring

• Address delirium, cognitive impairment,

swallowing muscle weakness

• Consider temporary Dobb-hoff

• Ensure optimal inhaler regimen and vaccines

• Physical rehabilitation

• De-resuscitate, diurese

• Optimize antibiotic course

• Remove lines, tubes, hardware

• Counsel patients, update vaccines

• Screen and treat promptly

Prescott and Angus. JAMA. 2018.

After Discharge: Big 5 Potentially Preventable Readmissions

Haines, et al. CCMed. 2018.

After Discharge: Peer Support

Enhancing survivorship

Early Hospital Care:• Timely antibiotics, resuscitation, source control

• Pain, agitation, delirium management

• Early mobility

Towards Discharge:• De-escalation and De-resuscitation

• Prepare patients about what to expect

• Reconcile and titrate discharge medications

After Discharge:• Promote functional recovery

• Focus on “Big 5” causes of preventable readmission

• Peer support

Our Patient

Our Patient

• Multiple readmissions for infection

• Returned to work, but never 100%

• Retired early

• Participates in peer-to-peer support group

• Mentor to new sepsis survivors

IQ Testing

Jackson, et al. Southern Med J. 2009.

IQ Testing

Jackson, et al. Southern Med J. 2009.

Early Hospital Care:

• Timely antibiotics, resuscitation, source control

• Pain, agitation, delirium management

• Early mobility

Towards Discharge:

• De-escalation and de-resuscitation

• Prepare patients about what to expect

• Reconcile and titrate discharge medications

After Discharge:

• Promote functional recovery

• Focus on “Big 5” causes of preventable readmission

• Peer support

QuestionsHallie Prescott, MD, MScUniversity of Michigan

VA Ann Arbor Center for Clinical Management Research

@HalliePrescott

• Information and tips to help navigate the ICU from a patient’s admission to discharge.

When A Loved One Has SepsisA Caregivers Guide

To download: www.sepsis.org/resources/caregivers

• Topics such as the different roles of ICU team members and what nurses are checking when they assess their patients.

• Encourages caregivers to take time to care for themselves.

Webinar seriesSepsis: Across the Continuum of Care

Fluid Management and SepsisMarch 28 at 2 pm ET

Register: www.sepsiswebinar.org

Heath Latham, MD, FCCP Mark Piehl, MD

This webinar is made possible with unrestricted educational support from bioMérieux, Inc. and Cheetah Medical

Children’s Hospital Association 2019 Sepsis Webcast Series

Pediatric Prehospital Sepsis Screening and Management

April 10 @ 1 pm ET

Kathleen Brown, MD

George Washington University

Children’s National Health System

Lynn Babcock, MD, MS

University of Cincinnati

Cincinnati Children's Hospital Medical Center

Webinar seriesSepsis: Across the Continuum of Care

The information in this webinar is intended for educational purposes only. The presentations and content are the opinions, experiences, views of the specific authors/presenters and are not statements of advice or opinion of Sepsis Alliance. The presentation has not been prepared, screened, approved, or endorsed by Sepsis Alliance.

This webinar series is made possible with unrestricted educational support from

bioMérieux, Inc.