Disrupting the Cycle of Sepsis A Sepsis-Specific Approach to Reduce Readmissions

Transcription

1 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 2

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 READMISSION RECOGNITION Could this be sepsis? Could this be a sepsis survivor? ADHERENCE Review the timing and causes of hospital readmissions after sepsis 3

4 A Readmission Reduction Roadmap Begin [An Admission] with the End [ Hospital Readmissions] in Mind Courtesy of The Hospital and Healthsystem Association of Pennsylvania 4

5 Our Goal: Less Cycle, More Forward Angus et al Intensive Care Med

6 Long-Term Consequences of Sepsis 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

7 Sepsis Drives Hospital Readmissions Courtesy of Hallie Prescott HCUP Statistical Brief #

8 Readmissions after Sepsis Across NYS 30 Day All Cause Readmission Rates by Month Initial Admission WITH Sepsis Initial Admission WITHOUT Sepsis 30 Day All Cause Readmission Rate Year and Month Step 1: Measure 7- and 30-day hospital readmission after sepsis 8

9 WHY? INFECTION Patient Initial Hospitalization Infection Readmission Infection (Chart) New or Recurrent/ Unresolved 1 C. difficile Culture negative sepsis New 2 Intraabdominal abscess and bowel perforation 3 Neutropenic sepsis, c. difficile Pneumonia Hepatic abscess New New 36 C. difficile, hospitalacquired pneumonia C. difficile Recurrent/ unresolved 37 Pneumonia Pneumonia Recurrent/ unresolved 4 Culture negative sepsis 5 MSSA and VRE CLABSI Urinary tract infection and C. difficile Klebsiella CLABSI New New 38 Pneumonia (fungal) 39 Pseudomonal bacteremia Pneumonia (fungal) Citrobacter bacteremia (cultures from discharge of initial hospitalization) Recurrent/ unresolved Recurrent/ unresolved 40 Pneumonia Pneumonia Recurrent/ Unresolved 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

10 Most Frequent Readmission Diagnoses After Sepsis Sepsis 15.0% Congestive heart failure 12.9% 42% of readmission diagnoses were for Ambulatory Care Sensitive Conditions Pneumonia 8.2% Acute renal failure 7.8% Rehabilitation 6.6% The Big 3: Infection/Sepsis Fluid Balance (Heart failure/renal failure) Respiratory (Aspiration pneumonia, COPD) 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

11 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

12 Management & Self-Management Are these symptoms factored into your discharge planning? Prescott et al JAMA

13 Getting Started Sepsis Readmissions Team 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 Coordinator 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 Finding Sepsis Readmissions 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 Courtesy of Maggie Miller, HAP 13

14 Getting Started (Continued) Sepsis Readmission Data 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 Continuous Process Improvement 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 Sepsis Education 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 Courtesy of Maggie Miller, HAP 14

15 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. 15

16 Advantages of Adopting a RED Approach 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. Why Should Hospitals Use the RED? 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. Jack et al AHRQ, March 2013, Pub. No. 12(13)

17 AHRQ Re-Engineered Discharge (RED) Strategy Applied to Sepsis RED Component Ascertain need for / obtain language assistance. Make appointments for follow-up care. 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. Sepsis-Specific Given cognitive impairment, engage family. Mission critical in sepsis survivor. Be mindful of physical impairment. Be mindful of behavioral health conditions. Be mindful of aspiration risk amongst survivors. Focus on antibiotic plan. Given cognitive impairment, engage family. Educate the patient and caregiver. Leverage ExSEPSIS, Sepsis Alliance, CDC, and SCCM resources. Use visual tools (Sepsis Alliance video). Incorporate surveillance into discharge action plan to facilitate timely recognition. 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. 17

18 Cognitive Impairment after Sepsis Iwashyna et al JAMA

19 The Perfect Storm of Sepsis Annane et al Lancet Resp Med

20 Sepsis, Depression, and Recovery Davydow et al Amer J Geri Psych

21 Functional Impairment after Sepsis Functional impairment associated with hospital readmission in dosedependent manner Greyson et al JAMA IM 2015 Iwashyna et al JAMA

22 AHRQ Re-Engineered Discharge (RED) Strategy Applied to Sepsis RED Component Ascertain need for / obtain language assistance. Make appointments for follow-up care. 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. Sepsis-Specific Given cognitive impairment, engage family. Mission critical in sepsis survivor. Be mindful of physical impairment. Be mindful of behavioral health conditions. Be mindful of aspiration risk amongst survivors. Focus on antibiotic plan. Given cognitive impairment, engage family. Educate the patient and caregiver. Leverage ExSEPSIS, Sepsis Alliance, CDC, and SCCM resources. Use visual tools (Sepsis Alliance video). Incorporate surveillance into discharge action plan to facilitate timely recognition. 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. 22

23 Timing of 30-Day Readmission after Sepsis Percent Median 12 days, IQR: 6, Days To 30-Day Hospital Readmission 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

24 Discharge Planning: Room for Improvement 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 Qutulqutub Lumpkin BSN,CCRN, Julie Rogan MSN, CNS ExSEPSIS chart review at Penn Presbyterian Medical Center 24

25 AHRQ Re-Engineered Discharge (RED) Strategy Applied to Sepsis RED Component Ascertain need for / obtain language assistance. Make appointments for follow-up care. 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. Sepsis-Specific Given cognitive impairment, engage family. Mission critical in sepsis survivor. Be mindful of physical impairment. Be mindful of behavioral health conditions. Be mindful of aspiration risk amongst survivors. Focus on antibiotic plan. Given cognitive impairment, engage family. Educate the patient and caregiver. Leverage ExSEPSIS, Sepsis Alliance, CDC, and SCCM resources. Use visual tools (Sepsis Alliance video). Incorporate surveillance into discharge action plan to facilitate timely recognition. 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. 25

26 Optimize Care Coordination Through Discharge 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 % % Home Home health services Skilled care facility Acute rehabilitation UPHS Data for Sepsis Survivors: Discharge Destination 26

27 Partner to Optimize Care Coordination Leverage ExSEPSIS Resources 27

28 AHRQ Re-Engineered Discharge (RED) Strategy Applied to Sepsis RED Component Ascertain need for / obtain language assistance. Make appointments for follow-up care. 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. Sepsis-Specific Given cognitive impairment, engage family. Mission critical in sepsis survivor. Be mindful of physical impairment. Be mindful of behavioral health conditions. Be mindful of aspiration risk amongst survivors. Focus on antibiotic plan. Given cognitive impairment, engage family. Educate the patient and caregiver. Leverage ExSEPSIS, Sepsis Alliance, CDC, and SCCM resources. Use visual tools (Sepsis Alliance video). Incorporate surveillance into discharge action plan to facilitate timely recognition. 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. 28

29 Hospitalization Risk Factors Duration of antibiotics was the lone risk factor associated with infection-related readmission Two-thirds of patients were discharged on antibiotics Sun et al Crit Care Med

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 Courtesy of Hallie Prescott Bell, et al. JAMA Morandi, et al. J Am Geriatric Soc Scales, et al. J Gen Intern Med

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% The Big 3 (Purposeful Reminder): Infection/Sepsis Fluid Balance (Heart failure/renal failure) Respiratory (Aspiration pneumonia, COPD) 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

32 AHRQ Re-Engineered Discharge (RED) Strategy Applied to Sepsis RED Component Ascertain need for / obtain language assistance. Make appointments for follow-up care. 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. Sepsis-Specific Given cognitive impairment, engage family. Mission critical in sepsis survivor. Be mindful of physical impairment. Be mindful of behavioral health conditions. Be mindful of aspiration risk amongst survivors. Focus on antibiotic plan. Given cognitive impairment, engage family. Educate the patient and caregiver. Leverage ExSEPSIS, Sepsis Alliance, CDC, and SCCM resources. Use visual tools (Sepsis Alliance video). Incorporate surveillance into discharge action plan to facilitate timely recognition. 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. 32

33 Moving Forward: Forge The Alliance Coordinate in-hospital and post-discharge care and follow-up Increase awareness of the diagnosis of severe sepsis Foster a supportive environment that spans the continuum of care Educate patients and caregivers Prioritize early and sustained rehabilitation Mitigate the risk of physical and neuropsychological impairment Maley et al CCM 2014 Empower survivors, their caregivers, and their providers Start by calling it what it is: sepsis 33

34 Leverage Resources 34

35 Leverage Audiovisual Resources Life After Sepsis video, available at:

36 Provider and Patient/Family Education 36

37 AHRQ Re-Engineered Discharge (RED) Strategy Applied to Sepsis RED Component Ascertain need for / obtain language assistance. Make appointments for follow-up care. 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. Sepsis-Specific Given cognitive impairment, engage family. Mission critical in sepsis survivor. Be mindful of physical impairment. Be mindful of behavioral health conditions. Be mindful of aspiration risk amongst survivors. Focus on antibiotic plan. Given cognitive impairment, engage family. Educate the patient and caregiver. Leverage ExSEPSIS, Sepsis Alliance, CDC, and SCCM resources. Use visual tools (Sepsis Alliance video). Incorporate surveillance into discharge action plan to facilitate timely recognition. 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. 37

38 What Do Patients Look Like At Readmission? 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% 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 Sun et al CCM

39 From Surveillance to Action 39

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. READMISSIONS: Reduce the number of 7 day and 30 day readmissions after a hospitalization for sepsis. RECOGNITION: Maximize recognition of sepsisassociated end organ dysfunction. ADHERENCE: Improve adherence to the 3 hour SEP-1 bundle for inpatients and in the ED. 40

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. 41

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 42

43 Questions? Please feel free to contact me at For questions re: HAP HIIN s ExSEPSIS Initiative, please contact Maggie Miller at mmiller@haponline.org Life After Sepsis video, available at: 43