Improving Morbidity During Post-Acute Care Transitions for Sepsis (IMPACTS): A Pragmatic Randomized Evaluation of Implementing Best Practice Care for Sepsis Survivors to Reduce Morbidity and Mortality

BACKGROUND

Sepsis is a common and life-threatening condition defined by organ dysfunction due to a dysregulated response to infection (Fleischmann, 2016). Aggressive early sepsis identification and treatment initiatives have decreased hospital mortality for patients with sepsis (Rhodes, 2017). As mortality rates have improved, there has been a growing recognition of the downstream effects of sepsis for the approximately 14 million annual sepsis survivors who encounter increased long-term mortality and morbidity across functional, cognitive, and psychological domains (Iwashyna, 2010; Shah, 2013; Schuler, 2018; Borges, 2015; Annane, 2015; Prescott, 2015). Currently, there is a disconnect between the post-acute care needs of sepsis survivors and the resources available to these patients (Huang, 2016; Ortego, 2015; Winters, 2010; Nesseler, 2013). Inadequate post-sepsis care strategies are reflected by adverse outcomes post-sepsis including increased mortality risk and strikingly high rates of healthcare utilization, including a 90-day hospital readmission rate of 40% and over 3 billion dollars in preventable costs (Prescott, 2016; Goodwin, 2015; Prescott, 2014; Jones, 2015). To address the specific gaps in treatment for sepsis survivors, international experts developed best-practice recommendations to guide delivery of post-sepsis care (Prescott, 2018). These best-practice recommendations are directed towards the specific challenges and sequelae following a sepsis hospitalization and include: i) identification and treatment of new physical, mental, and cognitive deficits; ii) review and adjustment of medications; iii) surveillance of treatable conditions that commonly lead to poor outcomes; and iv) focus on palliative care when appropriate. However, implementation of recommended post-sepsis practices is hindered by a gap in understanding how to best integrate interventions into the complex and fragmented post discharge setting (e.g., lack of provider time and patient engagement, limited access to care management, and insufficient institutional support) (Taylor, 2019; Brownson, 2012; Bodenheimer, 2008; Coleman, 2004).

RATIONALE

In randomized controlled trials (RCTs), including our previous work, successfully implemented care transition programs using nurse navigators have been shown to reduce hospital readmissions and costs. To better enhance transitions of care for the highest risk, complex patients with suspected sepsis, we propose extending this evidence using a nurse-facilitated care transition program for patients in the post-sepsis transition period to improve the implementation of recommended care practices and bridge care gaps. This approach, called the Sepsis Transition and Recovery (STAR) program, is the next step in the progression of our group's work on improving discharge transitions and sepsis processes of care. A key aspect of this initiative includes the ability to identify sepsis survivors at the greatest risk for poor outcomes. For example, one-quarter of sepsis survivors account for three-quarters of hospital readmissions and costs, indicating that identifying high-risk sepsis patients for targeted facilitation of best-practice care could efficiently impact quality and cost.

Our STAR program uses near real-time risk modeling to identify high-risk patients and a centrally located nurse, virtually connected to participating hospitals, to coordinate the application of evidence-based recommendations for post-sepsis care, overcome barriers to recommended care, and bridge gaps in service that can serve as points of failure for complex patients. During their hospitalization, high-risk patients enter into a transition pathway integrated within Atrium Health Hospital Medicine's Transition Services program and includes the following core components: i) Introduction to STAR process prior to discharge (confirm provider consults e.g., PT, ID, palliative); ii) Disease-specific education and discharge "playbook"; iii) Virtual hospital follow-up evaluation within 48 hours including medication reconciliation; iv) Second, post-acute virtual follow-up within 72 hours (symptom monitoring, confirm provider follow-up); v) Weekly contact with care management team; vi) Referral to provider follow-up (e.g., primary care provider, transition clinic) as appropriate; vii) Coordinated transition to the next appropriate care location after 30 days from time of discharge. The STAR navigator also meets weekly with the Medical Director of the Atrium Health Transition Services program who provides additional clinical oversight of ongoing cases.