Association between Adherence to Recommended Care and Outcomes for Adult Survivors of Sepsis

Abstract

Rationale: Postsepsis care recommendations target specific deficits experienced by sepsis survivors in elements such as optimization of medications, screening for functional impairments, monitoring for common and preventable causes of health deterioration, and consideration of palliative care. However, few data are available regarding the application of these elements in clinical practice.Objectives: To quantify the delivery of postsepsis care for patients discharged after hospital admission for sepsis and evaluate the association between receipt of postsepsis care elements and reduced mortality and hospital readmission within 90 days.Methods: We conducted a retrospective chart review of a random sample of patients who were discharged alive after an admission for sepsis (identified from International Classification of Diseases, 10th Revision discharge codes) at 10 hospitals during 2017. We used a structured chart abstraction to determine whether four elements of postsepsis care were provided within 90 days of hospital discharge, per expert recommendations. We used multivariable logistic regression to evaluate the association between receipt of care elements and 90-day hospital readmission and mortality, adjusted for age, comorbidity, length of stay, and discharge disposition.Results: Among 189 sepsis survivors, 117 (62%) had medications optimized, 123 (65%) had screening for functional or mental health impairments, 86 (46%) were monitored for common and preventable causes of health deterioration, and 110 (58%) had care alignment processes documented (i.e., assessed for palliative care or goals of care). Only 20 (11%) received all four care elements within 90 days. Within 90 days of discharge, 66 (35%) patients were readmitted and 33 (17%) died (total patients readmitted or died, n = 82). Receipt of two (odds ratio [OR], 0.26; 95% confidence interval [95% CI], 0.10-0.69) or more (three OR, 0.28; 95% CI, 0.11-0.72; four OR, 0.12; 95% CI, 0.03-0.50) care elements was associated with lower odds of 90-day readmission or 90-day mortality compared with zero or one element documented. Optimization of medications (no medication errors vs. one or more errors; OR, 0.44; 95% CI, 0.21-0.92), documented functional or mental health assessments (physical function plus swallowing/mental health assessments vs. no assessments; OR, 0.14; 95% CI, 0.05-0.40), and documented goals of care or palliative care screening (OR, 0.52; 95% CI, 0.25-1.05; not statistically significant) were associated with lower odds of 90-day readmission or 90-day mortality. Conclusions:In this retrospective cohort study of data from a single health system, we found variable delivery of recommended postsepsis care elements that were associated with reduced morbidity and mortality after hospitalization for sepsis. Implementation strategies to efficiently overcome barriers to adopting recommended postsepsis care may help improve outcomes for sepsis survivors.

Medication-related Problems in Intensive Care Unit Survivors: Learning from a Multicenter Program

“…These results are contextualized by evidence that providing a pharmacy review at transitions of care can improve safety and reduce 30-day hospital readmission in patients with heart failure and primary care patients ( 12 , 13 ). Similarly, a recent study has shown that a pharmacy review as part of a bundled approach to care may reduce long-term mortality in the group with sepsis ( 14 ). More research is required to understand the potential of this intervention and how to integrate it within the complexities of ICU care.…”

Development, Validation, and Clinical Utility Assessment of a Prognostic Score for 1-Year Unplanned Rehospitalization or Death of Adult Sepsis Survivors

“…More important, because DCA does not mandate information on the costs or effectiveness of treatment or how patients value different health states, 14 our analysis highlights that it is possible to intervene selectively for sepsis survivors, using a systematic risk-based approach. An example of the follow-up care that we envision would be ensuring better postdischarge adherence to recommended management for common comorbidities, as better adherence could improve sepsis survivor outcomes 32 , 33 because effective outpatient management exists for these common rehospitalization diagnoses. 18 We expect our score to be refined over time based on preliminary use because clinicians and researchers may identify what additional predictors could add value.…”

Evaluating the association between unmet healthcare needs and subsequent clinical outcomes: protocol for the Addressing Post-Intensive Care Syndrome-01 (APICS-01) multicentre cohort study

“… 57 Barriers to optimal implementation of the intended discharge plan are many, leading to substantial unmet healthcare needs. 19 40 56 The frequency and nature of such unmet needs after hospital discharge and their impact on patients’ clinical outcomes is not well understood. 58 The APICS-01 study will evaluate the frequency and character of unmet healthcare needs in the early post-discharge period, while exploring their association with mortality, readmission to an acute care hospital, healthcare resource use and other patient-centred outcomes, including quality of life, cognitive function and mental health impairments.…”

“… 23 A retrospective analysis of 189 patients who were discharged alive after admission for sepsis at 10 hospitals suggested an association between fragmented care after discharge and 90-day hospital readmission, with lower readmission rates (OR 0.12 to 0.28) observed among patients who received more components of recommended sepsis aftercare. 19 In contrast, a comparative effectiveness analysis of Medicare data demonstrated that beneficiaries who received both early home health nursing and early physician follow-up after a hospitalisation for sepsis were less likely to be readmitted for any cause. 24 …”

“… 6–18 Survivors also experience fragmented healthcare after hospital discharge and mismatches between the healthcare services needed and those received during the vulnerable weeks immediately after the hospital discharge. 19 …”