Structured, proactive care coordination versus usual care for Improving Morbidity during Post-Acute Care Transitions for Sepsis (IMPACTS): a pragmatic, randomized controlled trial

Abstract

AbstractsBackgroundHospital mortality for patients with sepsis has recently declined, but sepsis survivors still suffer from significant long-term mortality and morbidity. There are limited data that support effective strategies to address post-discharge management of patients hospitalized with sepsis.MethodsThe Improving Morbidity during Post-Acute Care Transitions for Sepsis (IMPACTS) study is a pragmatic, randomized controlled trial at three hospitals within a single healthcare delivery system comparing clinical outcomes between sepsis survivors who receive usual care versus care delivered through the Sepsis Transition and Recovery (STAR) program. The STAR program includes a centrally located nurse navigator using telephone counseling and electronic health record-based support to facilitate best-practice post-sepsis care strategies for patients during hospitalization and the 30 days after hospital discharge, including post-discharge review of medications, evaluation for new impairments or symptoms, monitoring existing comorbidities, and palliative care referral when appropriate. Adults admitted through the Emergency Department with suspected infection (i.e., antibiotics initiated, bacterial cultures drawn) and deemed, by previously developed risk-stratification models, high risk for readmission or death are included. Eligible patients are randomly allocated 1:1 to either Arm 1, usual care or Arm 2, STAR. Planned enrollment is 708 patients during a 6-month period. The primary outcome is the composite of all-cause hospital readmissions and mortality assessed 30 days post discharge. Secondary outcomes include 30- and 90-day hospital readmissions, mortality, emergency department visits, acute care-free days alive, and acute care and total costs.DiscussionThis pragmatic evaluation provides the most comprehensive assessment to date of a strategy to improve delivery of recommended post-sepsis care.Trial registrationClinicalTrials.gov, NCT03865602. Registered retrospectively on 6 March 2019.

Insights From Rapid Deployment of a “Virtual Hospital” as Standard Care During the COVID-19 Pandemic

“…To overcome this implementation barrier, we embedded evidence-based scoring algorithms directly within the electronic health record (EHR) workflow for COVID-19 testing. This point-of-care decision support created a standardized process, which allowed every patien t tested at Atrium Health's mobile COVID-19 test sites, urgent cares, and emergency departments to be evaluated for AH-HaH eligibility ( 23 , 24 ) ( Appendix Table , available at Annals.org).…”

Protocol for a two-arm pragmatic stepped-wedge hybrid effectiveness-implementation trial evaluating Engagement and Collaborative Management to Proactively Advance Sepsis Survivorship (ENCOMPASS)

“…The navigator contacts eligible patients at intervention hospitals by telephone and introduces the STAR process before discharge. Our team has successfully deployed these same processes during prior transitions interventions [ 49 ]. In this real-world implementation study, patients, clinicians, and investigators are not blinded to group assignments; but, primary outcomes are collected from objective data, minimizing bias introduced by the lack of blinding.…”

“…3 ). The STAR program is described in detail elsewhere [ 49 ]. Broadly, STAR applies the Chronic Care Model organizational framework [ 28 ], which promotes care planning, active follow-up, and patient, provider, and community engagement, to increase adherence to best-practice recommendations and improve care coordination between hospital and post-acute care transitions during sepsis recovery.…”

Risk of Adverse Clinical Outcomes in Hyponatremic Adult Patients Hospitalized for Acute Medical Conditions: A Population-Based Cohort Study

“…We have chosen this composite outcome because both end points are clinically relevant for patients and because it is in line with an ongoing randomized controlled trial investigating the impact of hyponatremia and its treatment on different patient outcomes ( 13 ). In addition, previous studies in the multimorbid and frail medical patient setting have also chosen such a composite outcome ( 14 , 15 ), indicating the importance of measuring mortality and readmission rates in combination.…”