Life After Sepsis:Post-Sepsis Syndrome

Sepsis Virtual Event July 6, 2017

12:00 – 1:00 p.m. CT

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WELCOME AND INTRODUCTIONSMallory Bender, LCSW| Program Manager, HRET

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Today’s Agenda

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WEBINAR PLATFORM QUICK REFERENCE

How Did You Hear About Today’s Virtual Event?

A) HRET HIIN flyerB) HRET HIIN websiteC) HRET LISTSERV D) State hospital associationE) QIN-QIO F) Your organization/colleagueG) Other, please specify.

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Data Updates

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Post-Sepsis Care Syndrome-Surviving Sepsis is Just the

Beginning

Elizabeth Scruth PhD MPH RN CCNS CCRN FCCMClinical Practice Consultant

Clinical Effectiveness Team- Quality DivisionKaiser Permanente NCAL

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Objectives

• Describe the sequelae most common in sepsis survivors

• Identify risk factors that contribute to post sepsis care syndrome

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Background

• Sepsis is an increasing burden in the USA• Sepsis management has led to decreased

mortality rates • Increased number of survivors• Little known about survivors of sepsis• Sepsis survivors have increased healthcare

utilization post survival• Ongoing mortality up to 2 years post sepsis

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Sun, et al. Critical Care Medicine. 2016: Dick, Liu, Zwanziger et al.BMC Health Services Research. 2012

• Sepsis survivors – increased healthcare usage in the first year

• Increased 30 day readmission rates– RBC transfusion, TPN and longer duration of

antibiotics ( main risk factors)– Insurance status, hospitalizations in prior year,

length of stay– Study showed 50% of the readmissions –

unresolved or recurrent infections

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Sun et al. Crit Care Med. 2016

• Long term care admissions and home healthcare– Two times more likely to be admitted to SNF in the

five years after a sepsis admission

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Dick et al. BMC Health Services Research. 2012

Beneath Our Understanding of Sepsis

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Sepsis and Chronic Health

• Chronic conditions increase risk of sepsis• Most common infectious disease of

hospitalization – pneumonia leading to severe sepsis

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Chronic Health Conditions Diabetes

Heart failure

Cardiovascular disease

Reduced lung function-severe

Cognitive impairments

Chronic kidney disease

Yende, Iwashyna, Angus. Trends Mol Med. 2015

• Severe reduction in lung function and or diabetes increases risk of pneumonia by over six fold- common cause of severe sepsis

• Unmeasured subclinical changes thought to play a role– Circulating interleukin (IL)- 6, tumor necrosis

factor ( TNF) and C-reactive protein ( CRP)

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Yende, Iwashyna, Angus., Trends Mol Med, 2015

The Sequelae of Sepsis

• Severe sepsis/septic shock worsens– Cognitive function– Physical impairment– Chronic kidney disease– Cardiovascular disease– Sleep patterns ( Common up to one year after

sepsis)May persist for several years and accelerate

underlying chronic diseases

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Shah et al. Am J Resp Crit Care Med.2013; Wunsch et al. JAMA. 2010: Iwashyna et al. JAMA. 2010: Altman et al. Ann Amer Thorac Soc. 2017

• During the sepsis event the following may affect the long term recovery:– Interventions- medications, early rehabilitation– Immobilization– Delirium– Depression/anxiety– Magnitude of host immune response

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Shah et al. Am J Resp Crit Care Med. 2013; Kellum et al. Arch Intern Med. 2007; Wunsch et al. JAMA. 2010

Impaired Immune Response• Septic shock- tissue damage• Preserving organ function during sepsis- effect

on chronic health- complex• Impaired immune response from sepsis-

deaths up to 1 year post index event• Sepsis survivors- more susceptible to

infections reducing their quality of life (herpes zoster, lower airway infections)

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Medzhitov et al. Science. 2012; Kellum et al. Arch Intern Med. 2007; Arens et al. Critical Care. 2016

Social and Environmental Factors

• Both influence the development of severe sepsis and its outcomes

• Race and marital status• Exposure to infection and health behaviors• Health systems and family environment

– restoration of function– family involvement/equipment needed

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Cox et al. Intensive Care Med. 2012

Preventing Sequelae from Sepsis?

We know how to prevent mortality-but what about mitigating morbidity in sepsis?

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• Our actions/inactions/delays – have long-term effects on the lives of our patients

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Next Steps for Patients with Post Sepsis Syndrome

Suzie Fletcher BSN, RN, CMSRNSepsis CoordinatorWesley Healthcare

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ABOUT US

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Wesley HealthcareWichita, Kansas

• Tertiary hospital licensed for 850 beds• Teaching Hospital• Children’s Hospital• Women’s Hospital• Over 500 babies delivered per month• Smaller 85 bed hospital (Wesley Woodlawn Hospital and ER)• 3 Emergency departments• Pediatric emergency department• 2 free standing emergency departments

Post- Discharge Clinic Planning

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• Need for clinic 30 for days post-discharge transitional care

• Health Promotion Model (Kessler, Renggli, & Swiss Centre for International Health, 2011)

• Almost 20 percent of all Medicare patients are readmitted within 30 days (Alper, O’Malley, and Greenwald, 2017)

• The cost of unplanned readmissions is 15 to 20 billion dollars annually (Beresford, 2011)

• Reduction in readmits• Reduction in mortalities

Post- Discharge Clinic Planning

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• Resources for:o

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Assessment of current medical status

Medication review and education

Disease management education

Focus on social environment and other non-medical issues

Next Steps

• Resources• Data gathering• Finance• Written Proposal• ?

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Contact Information

Suzie Fletcher BSN, RN, CMSRNSepsis Coordinator

Wesley Medical Center550 N. Hillside

Wichita, Kansas 67214Phone: (316) 962-7007

Cell: (316) 765-2071Fax: (316) 962-7467

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References

Alper, E., O’Malley, T.A., & Greenwald, J. (2017, April 3). Hospital discharge and readmission. Beresford, L. (2011, December). Is a post-discharge clinic in your hospital’s future? The

Hospitalist Retrieved from http://www.the-hospitalist.org/hospitalist/article/124553/qi-initiatives/post-discharge-clinic-your-hospitals-future

Kessler, C., Renggli, V., & Swiss Centre for International Health. (2011, March 21). Health promotion: Concepts and practices. Retrieved from https://www.google.com/search?q=swiss+center+for+international+health+health+promotion+model&rlz=1C1GGRV_enUS751US751&oq=swiss+center+for+international+health+health+promotion+model&aqs=chrome..69i57.16959j0j9&sourceid=chrome&ie=UTF-8

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Its Not Just About Mortality

Tools for Prevention & RecognitionMaryanne Whitney

Steve Tremain

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• Our actions/inactions/delays – have long-term effects on the lives of our patients

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Back to Basics• Early Recognition

– Screening all ED patients at triage – Screening all seriously ill inpatient– Use BPA’s

• Create action with a (+) sepsis screen– Alerts, rapid response teams

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Decrease Morbidity & Mortality

• Treat with urgency– Blood cultures and lactate– Antibiotics within the “golden hour”– Fluid 30ml/kg for patients who are hypotensive of

lactate >4mmol/L

• Early source identification and control

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Resources

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http://www.sepsis.org/files/SA_Infographic1_Square3_8.5x11_PrintReady.pdf

36http://www.sepsis.org/files/sig/lifeaftersepsis.pdf

Open the Lines• Let’s hear from you!

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Bring It Home

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Mallory Bender, Program Manager, HRET

THANK YOU!

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