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Disrupting the Cycle of Sepsis A Sepsis-Specific Approach to Reduce Readmissions
Mark E. Mikkelsen, MD, MSCE Chief, Section of Medical Critical Care Perelman School of Medicine September 2018 Mark.mikkelsen@uphs.upenn.edu
2
Disclosures
Co-Chair of the SCCM Thrive Supporting Survivors after Critical Illness Initiative
Physician advisor, The Hospital and Healthsystem Association of Pennsylvania, Hospital Improvement and Innovation Network HAP-HIIN ExSEPSIS (Exiting with Excellent Care) Initiative
– Thank you to Maggie Miller, Sandy Abnett, and Lisa Lesko for supporting sharing ExSEPSIS resources today
NIH Support – NIH Loan Repayment Program Awardee – NIH NINR R01 Co-investigator to study hospital readmissions after sepsis in
patients discharged to home with home health services
3
Objectives Apply readmission reduction strategies to the sepsis survivor Review the enduring consequences of sepsis that increase
rehospitalization risk and fuel the cycle of sepsis
Review the timing and causes of hospital readmissions after sepsis
RECOGNITION “Could this be sepsis?” “Could this be a sepsis survivor?”
READMISSION
ADHERENCE
4
A Readmission Reduction Roadmap “Begin [An Admission] with the End [↓ Hospital Readmissions] in Mind”
Courtesy of The Hospital and Healthsystem Association of Pennsylvania
5
Our Goal: Less Cycle, More Forward
Angus et al Intensive Care Med 2003
6
Neuropsychological impairment
Physical impairment Sepsis-induced inflammation and cardiovascular risk Sepsis-induced immunosuppression Long-term health-related quality of life Healthcare resource utilization Long-term mortality
Maley et al Clin Chest Med 2016
Long-Term Consequences of Sepsis
7
Sepsis Drives Hospital Readmissions
HCUP Statistical Brief #196 https://www.hcup-us.ahrq.gov/reports/statbriefs/sb_readmission.jsp
Courtesy of Hallie Prescott
8
Readmissions after Sepsis Across NYS
19.89 20.81 21.47 20.34 21.26 20.59 20.87 20.62 21.60 21.07 21.51 22.0320.51 21.46 21.03 19.94 20.05
21.47 20.76 19.91 19.84
0.00
5.00
10.00
15.00
20.00
25.00
30 D
ay A
ll Ca
use
Read
mis
sion
Rat
e
Year and Month
30 Day All Cause Readmission Rates by MonthInitial Admission WITH Sepsis Initial Admission WITHOUT Sepsis
Step 1: Measure 7- and 30-day hospital readmission after sepsis
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Patient Initial Hospitalization
Infection
Readmission Infection (Chart)
New or Recurrent/ Unresolved
1 C. difficile Culture negative sepsis New
2 Intraabdominal abscess and bowel perforation
Pneumonia New
3 Neutropenic sepsis, c. difficile
Hepatic abscess New
4 Culture negative sepsis
Urinary tract infection and C. difficile
New
5 MSSA and VRE CLABSI Klebsiella CLABSI
New
• 69% of unplanned readmissions attributable to infection via chart review
• 51% of infection-related readmissions were categorized as recurrent/unresolved
• 19% are same site and same organism Sun et al CCM 2016
DeMerle et al CCM 2017
WHY? INFECTION
36 C. difficile, hospital-acquired pneumonia
C. difficile
Recurrent/ unresolved
37 Pneumonia Pneumonia
Recurrent/ unresolved
38 Pneumonia (fungal)
Pneumonia (fungal)
Recurrent/ unresolved
39 Pseudomonal bacteremia
Citrobacter bacteremia (cultures from discharge of initial hospitalization)
Recurrent/ unresolved
40 Pneumonia Pneumonia
Recurrent/ Unresolved
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Most Frequent Readmission Diagnoses After Sepsis
Sepsis 15.0%
Congestive heart failure 12.9%
Pneumonia 8.2%
Acute renal failure 7.8%
Rehabilitation 6.6%
Respiratory failure 5.8%
Complication of device, implant, or graft 4.7%
COPD exacerbation 4.4%
Aspiration pneumonitis 4.2%
Urinary tract infection 3.9%
Prescott et al JAMA 2015
42% of readmission diagnoses were for Ambulatory Care Sensitive Conditions
The Big 3:
Infection/Sepsis Fluid Balance (Heart failure/Renal failure)
Respiratory (Aspiration pneumonia, COPD)
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Readmission Outcomes Are Worse After Sepsis
13-16% of readmissions after sepsis result in death or transition to hospice - Maley et al Clin Chest Med 2016 Highlight the importance of timely recognition and the potential role of targeted early palliative care
Jones et al Annals ATS 2015
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Prescott et al JAMA 2018
Management & Self-Management
Are these symptoms
factored into your discharge
planning?
13
Getting Started
• Identify a physician champion to help address barriers and assist peers • Multidisciplinary team and unit champions across multiple care settings • Meet monthly (minimum) to discuss progress, barriers, and challenges • Team reports to hospital Quality and/or Critical Care Committee • May align work with existing sepsis or readmission teams already in place
Sepsis Readmissions
Team
• Successful hospitals have a dedicated sepsis navigator role • Round daily on sepsis patients to ensure successful discharge • Analyze and share sepsis data in real-time • Communicate quality issues with frontline staff and leadership • Connect with pre- and post- hospital partners • Educate patients, families/caregivers on post-discharge care • Join the Sepsis Alliance Sepsis Coordinator Network for support
Sepsis Coordinator
• Define a real-time method to identify patients readmitted within 30-days following a sepsis discharge
• Interview readmitted patient/caregiver to understand reason for readmission following a sepsis discharge - use a consistent approach
• Determine the top diagnoses for patients readmitted following a sepsis discharge at your hospital - focus efforts on these populations
Finding Sepsis Readmissions
Courtesy of Maggie Miller, HAP
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Getting Started (Continued)
• Align team goals with organizational goals • Simplify goals into action items with specific deadlines and task owners • Collect baseline sepsis data • Identify process and outcome data elements to be collected • Follow trends including SEP-1 compliance during patients' initial
hospitalization
Sepsis Readmission
Data
• Use PDSA Cycle for learning and Improvement • Prioritize process/area/unit to work on first - start small and celebrate wins! • Communicate opportunities for improvement in detail • Process in place to address deviations from evidence based care for sepsis
and/or hospital sepsis protocol • Standardize approach and processes as much as possible
Continuous Process
Improvement
• Educate team, staff, patients, family, pre-and post-hospital staff on sepsis signs & symptoms
• Ensure sepsis language is used • Provide tools to assist staff (pocket cards, videos, fact sheets) • Consider using simulation training for sepsis care • Provide real-time feedback to team
Sepsis Education
Courtesy of Maggie Miller, HAP
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AHRQ Re-Engineered Discharge (RED) Strategy
RED Component Ascertain need for / obtain language assistance.
Make appointments for follow-up care. Plan for the follow-up pending tests.
Organize post-discharge outpatient services and medical equipment.
Medication reconciliation, including a plan for the patient to obtain them.
Teach a discharge plan the patient can understand.
Educate the patient about his/her diagnosis and medications.
Review with the patient what to do if a problem arises (Action Plan).
Assess patient’s understanding of the d/c plan.
Expedite transmission of discharge summary to clinicians accepting care of the patient.
Provide telephone reinforcement of the d/c plan.
16 Jack et al AHRQ, March 2013, Pub. No. 12(13)-0084
Advantages of Adopting a RED Approach Why Should Hospitals Use the RED?
Improves Clinical Outcomes• Decreases 30-day readmission by 25 percent.• Decreases ED use from 24 percent to 16 percent.• Improves patient "readiness for discharge."• Improves primary care provider followup.
Meets Safety Standards and Improves Documentation• Accepted as NQF Safe Practice and endorsed by Institute for Healthcare Improvement,
The Leapfrog Group for Patient Safety, and CMS.• Meets Joint Commission standards.• Documents the discharge preparation.• Documents understanding of the discharge plan.
Improves Return on Investment• Reduces costs by $412 per patient.• Allows higher level physician billing for discharge.• May reduce diversion and creates greater capacity for higher revenue patients.• May improve market share as "preferred provider."• Improves relationships with ambulatory providers.• Prepares for changes in CMS rules regarding readmission reimbursement.
Improves Patient Centeredness and Hospital's Community Image• Brands the hospital as high-quality facility.• Improves patient and family satisfaction.
17
AHRQ Re-Engineered Discharge (RED) Strategy Applied to Sepsis RED Component Sepsis-Specific
Ascertain need for / obtain language assistance. Given cognitive impairment, engage family.
Make appointments for follow-up care. Mission critical in sepsis survivor.
Organize post-discharge outpatient services and medical equipment.
Be mindful of physical impairment. Be mindful of behavioral health conditions.
Medication reconciliation, including a plan for the patient to obtain them.
Be mindful of aspiration risk amongst survivors. Focus on antibiotic plan.
Teach a discharge plan the patient can understand.
Given cognitive impairment, engage family.
Educate the patient about his/her diagnosis and medications.
Educate the patient and caregiver. Leverage ExSEPSIS, Sepsis Alliance, CDC, and SCCM resources. Use visual tools (Sepsis Alliance video).
Review with the patient what to do if a problem arises (Action Plan).
Incorporate surveillance into discharge action plan to facilitate timely recognition.
Assess patient’s understanding of the d/c plan.
Expedite transmission of discharge summary to clinicians accepting care of the patient.
Partner with post-acute care locations.
Provide telephone reinforcement of the d/c plan.
18 Iwashyna et al JAMA 2010
Cognitive Impairment after Sepsis
19
The Perfect Storm of Sepsis
Annane et al Lancet Resp Med 2015
20
Sepsis, Depression, and Recovery
Davydow et al Amer J Geri Psych 2013
21 Iwashyna et al JAMA 2010
Functional Impairment after Sepsis
Functional impairment associated with hospital
readmission in dose-dependent manner
Greyson et al JAMA IM 2015
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AHRQ Re-Engineered Discharge (RED) Strategy Applied to Sepsis RED Component Sepsis-Specific
Ascertain need for / obtain language assistance. Given cognitive impairment, engage family.
Make appointments for follow-up care. Mission critical in sepsis survivor.
Organize post-discharge outpatient services and medical equipment.
Be mindful of physical impairment. Be mindful of behavioral health conditions.
Medication reconciliation, including a plan for the patient to obtain them.
Be mindful of aspiration risk amongst survivors. Focus on antibiotic plan.
Teach a discharge plan the patient can understand.
Given cognitive impairment, engage family.
Educate the patient about his/her diagnosis and medications.
Educate the patient and caregiver. Leverage ExSEPSIS, Sepsis Alliance, CDC, and SCCM resources. Use visual tools (Sepsis Alliance video).
Review with the patient what to do if a problem arises (Action Plan).
Incorporate surveillance into discharge action plan to facilitate timely recognition.
Assess patient’s understanding of the d/c plan.
Expedite transmission of discharge summary to clinicians accepting care of the patient.
Partner with post-acute care locations.
Provide telephone reinforcement of the d/c plan.
23
02
46
Per
cent
0 5 10 15 20 25 30Days To 30-Day Hospital Readmission
Timing of 30-Day Readmission after Sepsis
• Coordination of follow-up
was absent or too late in two-thirds of UPHS septic shock survivors who were readmitted within 30 days
- Ortego et al Crit Care Med 2014
Jones et al Annals ATS 2015
Median 12 days, IQR: 6, 19
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Discharge Planning: Room for Improvement
Qutulqutub Lumpkin BSN,CCRN, Julie Rogan MSN, CNS ExSEPSIS chart review at Penn Presbyterian Medical Center
• Sepsis was rarely listed on the hospital discharge summary
• 76% of patients/caregivers were not provided instructions about what to do should the patient’s condition worsens
• 90% of sepsis survivors readmitted within 30 days had no follow-up appointment scheduled or follow-up was scheduled > 10 days post-discharge
• 96% of patients/caregivers were not provided specific contact information to call if problems arose after hospital discharge
25
AHRQ Re-Engineered Discharge (RED) Strategy Applied to Sepsis RED Component Sepsis-Specific
Ascertain need for / obtain language assistance. Given cognitive impairment, engage family.
Make appointments for follow-up care. Mission critical in sepsis survivor.
Organize post-discharge outpatient services and medical equipment.
Be mindful of physical impairment. Be mindful of behavioral health conditions.
Medication reconciliation, including a plan for the patient to obtain them.
Be mindful of aspiration risk amongst survivors. Focus on antibiotic plan.
Teach a discharge plan the patient can understand.
Given cognitive impairment, engage family.
Educate the patient about his/her diagnosis and medications.
Educate the patient and caregiver. Leverage ExSEPSIS, Sepsis Alliance, CDC, and SCCM resources. Use visual tools (Sepsis Alliance video).
Review with the patient what to do if a problem arises (Action Plan).
Incorporate surveillance into discharge action plan to facilitate timely recognition.
Assess patient’s understanding of the d/c plan.
Expedite transmission of discharge summary to clinicians accepting care of the patient.
Partner with post-acute care locations.
Provide telephone reinforcement of the d/c plan.
26
Optimize Care Coordination Through Discharge
0
5
10
15
20
25
30
35
40
Home Home health services Skilled care facility Acute rehabilitation
%
%
UPHS Data 2010 – 2015 for Sepsis Survivors: Discharge Destination
Readmission risk, and cause, may differ by discharge location • 36% readmitted within 90 days among those discharged home • 46% among those discharged to a nursing facility
Prescott AnnalsATS 2017
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Partner to Optimize Care Coordination Leverage ExSEPSIS Resources
28
AHRQ Re-Engineered Discharge (RED) Strategy Applied to Sepsis RED Component Sepsis-Specific
Ascertain need for / obtain language assistance. Given cognitive impairment, engage family.
Make appointments for follow-up care. Mission critical in sepsis survivor.
Organize post-discharge outpatient services and medical equipment.
Be mindful of physical impairment. Be mindful of behavioral health conditions.
Medication reconciliation, including a plan for the patient to obtain them.
Be mindful of aspiration risk amongst survivors. Focus on antibiotic plan.
Teach a discharge plan the patient can understand.
Given cognitive impairment, engage family.
Educate the patient about his/her diagnosis and medications.
Educate the patient and caregiver. Leverage ExSEPSIS, Sepsis Alliance, CDC, and SCCM resources. Use visual tools (Sepsis Alliance video).
Review with the patient what to do if a problem arises (Action Plan).
Incorporate surveillance into discharge action plan to facilitate timely recognition.
Assess patient’s understanding of the d/c plan.
Expedite transmission of discharge summary to clinicians accepting care of the patient.
Partner with post-acute care locations.
Provide telephone reinforcement of the d/c plan.
29
Hospitalization Risk Factors
Sun et al Crit Care Med 2016
Duration of antibiotics was the lone risk factor associated with infection-related readmission Two-thirds of patients were discharged on antibiotics
30
Pay Attention to Discharge Medications
Too often, chronic medications are discontinued (e.g. synthroid, gastric acid suppression, anticoagulants, and statins)
Acute, potentially harmful, medications are continued (eg. antipsychotics, antidepressants, benzodiazepines)
Antibiotics are not taken as prescribed post-discharge
Bell, et al. JAMA. 2009. Morandi, et al. J Am Geriatric Soc. 2013.
Scales, et al. J Gen Intern Med. 2016. Courtesy of Hallie Prescott
31
Most Frequent Readmission Diagnoses After Sepsis
Sepsis 15.0%
Congestive heart failure 12.9%
Pneumonia 8.2%
Acute renal failure 7.8%
Rehabilitation 6.6%
Respiratory failure 5.8%
Complication of device, implant, or graft 4.7%
COPD exacerbation 4.4%
Aspiration pneumonitis 4.2%
Urinary tract infection 3.9%
Prescott et al JAMA 2015
The Big 3 (Purposeful Reminder):
Infection/Sepsis Fluid Balance (Heart failure/Renal failure)
Respiratory (Aspiration pneumonia, COPD)
32
AHRQ Re-Engineered Discharge (RED) Strategy Applied to Sepsis RED Component Sepsis-Specific
Ascertain need for / obtain language assistance. Given cognitive impairment, engage family.
Make appointments for follow-up care. Mission critical in sepsis survivor.
Organize post-discharge outpatient services and medical equipment.
Be mindful of physical impairment. Be mindful of behavioral health conditions.
Medication reconciliation, including a plan for the patient to obtain them.
Be mindful of aspiration risk amongst survivors. Focus on antibiotic plan.
Teach a discharge plan the patient can understand.
Given cognitive impairment, engage family.
Educate the patient about his/her diagnosis and medications.
Educate the patient and caregiver. Leverage ExSEPSIS, Sepsis Alliance, CDC, and SCCM resources. Use visual tools (Sepsis Alliance video).
Review with the patient what to do if a problem arises (Action Plan).
Incorporate surveillance into discharge action plan to facilitate timely recognition.
Assess patient’s understanding of the d/c plan.
Expedite transmission of discharge summary to clinicians accepting care of the patient.
Partner with post-acute care locations.
Provide telephone reinforcement of the d/c plan.
33
Moving Forward: Forge The Alliance
Empower survivors, their caregivers, and their providers Start by calling it what it is: sepsis
Maley et al CCM 2014
Increase awareness of the diagnosis
of severe sepsis
Educatepatients
andcaregivers
Coordinate in-hospital and post-discharge
care and follow-up Foster a supportive
environment that spans the
continuum of care
Mitigate the risk
of physical and neuropsychological
impairment
Prioritize early and sustained
rehabilitation
34
Leverage Resources
35
https://youtu.be/HIk64wdy44Q
Leverage Audiovisual Resources
Life After Sepsis video, available at: www.sepsis.org/life-after-sepsis/
36
Provider and Patient/Family Education
37
AHRQ Re-Engineered Discharge (RED) Strategy Applied to Sepsis RED Component Sepsis-Specific
Ascertain need for / obtain language assistance. Given cognitive impairment, engage family.
Make appointments for follow-up care. Mission critical in sepsis survivor.
Organize post-discharge outpatient services and medical equipment.
Be mindful of physical impairment. Be mindful of behavioral health conditions.
Medication reconciliation, including a plan for the patient to obtain them.
Be mindful of aspiration risk amongst survivors. Focus on antibiotic plan.
Teach a discharge plan the patient can understand.
Given cognitive impairment, engage family.
Educate the patient about his/her diagnosis and medications.
Educate the patient and caregiver. Leverage ExSEPSIS, Sepsis Alliance, CDC, and SCCM resources. Use visual tools (Sepsis Alliance video).
Review with the patient what to do if a problem arises (Action Plan).
Incorporate surveillance into discharge action plan to facilitate timely recognition.
Assess patient’s understanding of the d/c plan.
Expedite transmission of discharge summary to clinicians accepting care of the patient.
Partner with post-acute care locations.
Provide telephone reinforcement of the d/c plan.
38
ED Presentation of Unplanned Hospital Readmissions “Could This Be Sepsis?”
Fever upon presentation 25.0%
White blood cell count, initial 10 (7 – 14)
Respiratory rate, initial 18 (16 – 20)
Heart rate, initial 106 (88 – 116)
Sepsis 63.8%
Sun et al CCM 2016
What Do Patients Look Like At Readmission?
Half of sepsis patients are seen by a clinician in the week before sepsis, supporting the “ambulatory-care sensitive condition” designation
Liu et al Crit Care Med 2018
39
From Surveillance to Action
40
Penn Medicine Sepsis Alliance: The Cycle of Sepsis
An abstract presented by Reddy et al, from the Cleveland Clinic, at the Society of Critical Care Medicine’s annual Congress found that
SEP-1 adherence was associated with improved in-hospital mortality and reduced hospital readmission.
RECOGNITION: Maximize recognition of sepsis-associated end organ dysfunction.
ADHERENCE: Improve adherence to the 3 hour SEP-1 bundle for inpatients and in the ED.
READMISSIONS: Reduce the number of 7 day and 30 day readmissions after a hospitalization for sepsis.
41
AHRQ Re-Engineered Discharge (RED) Strategy: Apply It to Sepsis Survivors
RED Component Ascertain need for / obtain language assistance.
Make appointments for follow-up care. Plan for the follow-up pending tests.
Organize post-discharge outpatient services and medical equipment.
Medication reconciliation, including a plan for the patient to obtain them.
Teach a discharge plan the patient can understand.
Educate the patient about his/her diagnosis and medications.
Review with the patient what to do if a problem arises (Action Plan).
Assess patient’s understanding of the d/c plan.
Expedite transmission of discharge summary to clinicians accepting care of the patient.
Provide telephone reinforcement of the d/c plan.
42
Acknowledgments Collaborators & Co-Investigators
Jack Iwashyna Hallie Prescott David Gaieski Alexandra Ortego Barry Fuchs Tiffanie Jones Scott Halpern S. Cham Sante Byron Drumheller Jason Christie Dylan Small Asaf Hanish Craig Umscheid Meeta Kerlin Alexander Sun Brett Dietz Jason Maley Giora Netzer
Penn Sepsis Alliance Bill Schweickert Julie Jablonski Sean Foster Nikhil Mull Stephanie Kindt Elains Desantis HAP ExSEPSIS Team Maggie Miller Sandy Abnett Lisa Lesko Julie Rogan SCCM & Thrive Team Jack Iwashyna Hallie Prescott Adair Andrews And many others
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Questions?
Please feel free to contact me at mark.mikkelsen@uphs.upenn.edu
For questions re: HAP HIIN’s ExSEPSIS Initiative, please contact Maggie Miller at mmiller@haponline.org
Life After Sepsis video, available at: www.sepsis.org/life-after-sepsis/
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