As September is National Sepsis Month, we want to discuss an aspect of sepsis called Post Sepsis Syndrome (PSS). During this article, we provide background on PSS and strategies providers are leveraging to improve outcomes.

Going to the hospital can be an overwhelming experience for any patient and their loved ones. For healthcare providers, patient safety is a top priority; however, sometimes adverse events happen and patients may experience life-threatening obstacles during their course of care. One of the most common issues patients may face is hospital-acquired infections. These infections can develop for various reasons, but one of the most-life threatening reactions to an infection is if a patient develops sepsis.

While contracting sepsis is possible in the hospital or nursing home, it is even more common in the community. Of the 307,491 hospitalizations for sepsis, 63% of the underlying infections are community-acquired and only 11% were hospital acquired. Additionally, 26% of these hospitalizations were healthcare-associated, meaning the patient had a recent association with a nursing home or was a hemodialysis patient.

According to a recent article in the Journal of the American Medical Association, Enhancing Recovery From Sepsis A Review, most of the current research on sepsis is directed towards prevention and treatment of sepsis in the acute care setting. The article mentioned there has been limited research about a patient’s course after returning home from a prolonged hospitalization with a diagnosis of sepsis. In another article, the author asked if the lingering consequences of sepsis might be described as a public health disaster. As we explore in this article, treating sepsis extends beyond the four walls of the hospital and there are opportunities for providers to help improve the outcomes for sepsis patients.

What is sepsis?
According to the Sepsis Alliance, sepsis is defined as “the body’s overwhelming and life-threatening response to an infection, which can lead to tissue damage, organ failure, and death. It can be caused by any type of infection that is anywhere in your body – including infections of the skin, lungs – such as pneumonia- a urinary tract infection, or abdomen – such as appendicitis.

While sepsis can impact patients across the care continuum, one statistic to note is that the in-hospital mortality has declined from 35% in 2000 to 18% in 2012, showcasing improvement in care within the hospital, but signals that there may be a higher number of sepsis survivors needing follow-up care. Dr. Prescott, in the JAMA review article, quotes a study that rehospitalizations after sepsis accounts for 12.5% of all US hospital readmissions and 14.5% of readmission costs. The Sepsis Alliance reports that in 2014, sepsis was named the most expensive in-patient hospitalization, averaging more than $18,000 per hospital stay. With over 1.5 million hospital admissions, that is over $27 billion of hospital costs per year. and 50% of the survivors suffer from Post Sepsis Syndrome.

Approximately 50% of sepsis survivors suffer from Post Sepsis Syndrome and patients who are diagnosed with sepsis can experience long-term effects, such as:

• Insomnia
• Nightmares, vivid hallucinations, and panic attacks
• Disabling muscle and joint pain
• Extreme fatigue
• Poor concentration
• Decreased mental (cognitive) functioning
• Loss of self-esteem and self-belief

The Emotional Impact of Sepsis and the Need for Support
These long-term effects can have a large impact on patients. Some patients even report symptoms associated with Post Traumatic Stress Disorder and require ongoing support for emotional and psychological support. On the Sepsis Alliance webpage, Julie Osenton, a sepsis survivor describes how most survivors feel “You never feel safe. Every time some little thing happens, you think, “Do I need to go to the hospital or is this nothing?”

Sepsis not only impacts patients on an emotional level, but it can also have a lingering impact on a patient’s physical ability. According to Iwashyna in a 2010 article in JAMA, among patients who had no limitations before their diagnosis of sepsis, more than 40% developed trouble with walking and nearly 20% of sepsis patients developed new problems with shopping or preparing a meal.

The emotional and physical impact of sepsis can also translate into societal costs of healthcare. In a 2017 study of Medicare patients with a discharge diagnosis of sepsis, Prescott and Iwashyna found that 40% of them were readmitted were readmitted within 90 days. Using their research findings, they provide a framework for the redesign of care after sepsis. Dr. Iwashyna says, “We need to make sure families have the resources they need to care for survivors of sepsis when they get home.”

It is easy to see how sepsis affects patients and the larger healthcare system. The question begs, how can healthcare providers better care for sepsis patient post-discharge?

Called to action: How United Regional Health Care System is Tackling Post Sepsis Syndrome Head On
Understanding the importance of ensuring patients make a safe transition home, United Regional Health Care System in Wichita Falls, TX, has re-engineered its outpatient sepsis program. Jennifer Wilson, Sepsis Coordinator and Zach Kast, Practice and Quality Program Manager for Chronic Disease Management at United Regional Health Care System in Wichita Falls, TX, recently shared their experiences in uncovering the opportunity to provide better care to sepsis survivors.

Jennifer Wilson, in her new position as the hospital’s Sepsis Coordinator, said, “United Regional is constantly seeking ways to further reduce readmissions and improve care. One opportunity we found was to enhance the support we were providing to sepsis patients.”

With a goal of reducing readmissions and improving mortality rates, leaders at United Regional Health Care System created an ad-hoc team to improve the care to sepsis patients, both in and out of the hospital.

The team created a Symptom Zone Card with green, yellow, and red symptoms that inform the patient and family of what they should do when experiencing a symptom. For example, if the patient has a symptom that is in the yellow zone, such as feeling cold, shivering, thinking “feels slow”, or developing a new cough, they need to call their doctor immediately. This empowers the patient and family and gives them a sense of control to prevent potential adverse events.

Before the patient is discharged, nursing staff educates the patient on the symptom zone card and explains the post-discharge follow up program designed to help patients as they transition home. The Symptom Zone Card and proactive follow up showcase two strategies United Regional is leveraging to improve the outcomes and experiences of sepsis patients and their families – both inside and outside of the hospital.

In addition to a nurse conducting follow-up within 48 hours of discharge, the team at United Regional Health Care System wanted to extend the follow-up monitoring to 30 days. By utilizing CipherHealth Outreach, the team is able to scale their follow-up program to include multiple calls post-discharge. With CipherHealth Outreach, the patient receives two automated calls on days nine and 16 post-discharge, and should a patient need additional assistance, the chronic care team is alerted immediately. The chronic care team then has a goal of responding to alerts within two hours and completely resolving the concerns within 24 hours.

The CipherHealth Outreach calls ask about follow-up appointments, check for an understanding of discharge instructions, address symptom management and prescription understanding, and ask if the patient is taking the medications as directed. Since the program’s inception in August 2017, calls have been made to 248 patients and 76% have engaged with the calls. In 46 of the calls, patients indicated they had a concern that was subsequently resolved by the chronic care team.

This program is showcasing how impactful follow up can be in resolving concerns for patients who were discharged with a diagnosis of sepsis. For United Regional Health Care System, the readmission rate for patients who engaged with the outreach calls was 16.7% lower than for patients who did not engage. This difference translates to reduced utilization of hospital resources.

Echoing Wilson’s earlier point of seeking ways to improve patient care, United Regional Health Care System is looking to further enhance the program. Future plans, according to Kast, include looking at readmissions after 60 and 90 days following the index admission and incorporating questions about how the patient is functioning at home.

Taking the Next Step in Helping Sepsis Patients
CipherHealth is a technology company dedicated to improving patient outcomes and experiences across the care continuum. For those who are a part of our client community, we encourage you to reach out to your Client Success Manager who can help you and your team re-engineer your own post-discharge care process for Sepsis patients. Specifically, your team may want to consider asking specific questions to engage sepsis patients at-risk for PSS or other sepsis complications.

Other steps your organization can take would be to implement a similar tool as the Symptom Zone Card to educate patients and families and help ensure they know what to expect as they transition home.

Finally, we encourage you to monitor the readmissions of sepsis patients to determine if there is a readmission that could have been prevented through education, symptom assessment, and intervention. By analyzing your data to uncover trends and improvement opportunities, it is possible to create life-saving interventions that positively impact future outcomes.

For more information about PSS, we encourage you to access these resources:

• Post Sepsis Syndrome; Sepsis Alliance https://www.sepsis.org
• Fred Shulte, Elizabeth Lecs and Joe Hamr. Chicago Tribune. “Avoidable sepsis infections send thousands of seniors to gruesome deaths” September 6, 2016
• Iwashyna, Theodore. “Sepsis survivors more than three times as likely to have cognitive issues”Journal of the American Medical Association, 2010: 304 (16): 1787-1794.
• Prescott, Hallie, Angus, Derek. Enhancing Recovery from Sepsis: A Review. JAMA, 2018: 319 (1): 62-75.