Disrupting the Cycle of Sepsis - NYSPFP · 3 Objectives Apply readmission ... • Join the Sepsis...

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 [email protected]

mailto:[email protected]

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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

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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

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A Readmission Reduction Roadmap “Begin [An Admission] with the End [↓ Hospital Readmissions] in Mind”

Courtesy of The Hospital and Healthsystem Association of Pennsylvania

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Our Goal: Less Cycle, More Forward

Angus et al Intensive Care Med 2003

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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

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Sepsis Drives Hospital Readmissions

HCUP Statistical Brief #196 https://www.hcup-us.ahrq.gov/reports/statbriefs/sb_readmission.jsp

Courtesy of Hallie Prescott

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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


38 Pneumonia (fungal)

Pneumonia (fungal)


39 Pseudomonal bacteremia

Citrobacter bacteremia (cultures from discharge of initial hospitalization)


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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Management & Self-Management

Are these symptoms

factored into your discharge

planning?

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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.

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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.


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.



Partner with post-acute care locations.


18 Iwashyna et al JAMA 2010

Cognitive Impairment after Sepsis

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The Perfect Storm of Sepsis

Annane et al Lancet Resp Med 2015

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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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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

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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

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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

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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

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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%


The Big 3 (Purposeful Reminder):

Infection/Sepsis Fluid Balance (Heart failure/Renal failure)

Respiratory (Aspiration pneumonia, COPD)

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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

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Leverage Resources

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https://youtu.be/HIk64wdy44Q

Leverage Audiovisual Resources

Life After Sepsis video, available at: www.sepsis.org/life-after-sepsis/

http://www.sepsis.org/life-after-sepsis/

https://youtu.be/HIk64wdy44Q

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Provider and Patient/Family Education

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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

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From Surveillance to Action

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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.

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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.









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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 [email protected]

For questions re: HAP HIIN’s ExSEPSIS Initiative, please contact Maggie Miller at [email protected]

Life After Sepsis video, available at: www.sepsis.org/life-after-sepsis/



http://www.sepsis.org/life-after-sepsis/

Disrupting the Cycle of Sepsis - NYSPFP · 3 Objectives Apply readmission ... • Join the Sepsis...

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