Effect of a Multicomponent Sepsis Transition and Recovery Program on Mortality and Readmissions After Sepsis: The Improving Morbidity During Post-Acute Care Transitions for Sepsis Randomized Clinical Trial*

Abstract

PATIENTS:Eligible patients hospitalized for suspected sepsis and deemed highrisk for mortality or readmission by validated internal risk models. INTERVENTIONS:Patients were randomized to receive usual care alone (i.e., routine transition support, outpatient care; n = 342) or additional Sepsis Transition And Recovery support (n = 349). The 30-day intervention involved a multicomponent transition service led by a nurse navigator through telephone and electronic health record communication to facilitate best practice postsepsis care strategies during and after hospitalization including: postdischarge medication review, evaluation for new impairments or symptoms, monitoring comorbidities, and palliative care approach when appropriate. Clinical oversight was provided by a Hospital Medicine Transition Services team. MEASUREMENTS AND MAIN RESULTS:The primary outcome was a composite of mortality or hospital readmission at 30 days. Logistic regression models were constructed to evaluate marginal and conditional odds ratios (adjusted for prognostic covariates: age, comorbidity, and organ dysfunction at enrollment). Among 691 randomized patients (mean age = 63.7 ± 15.1 yr; 52% female), a lower percentage of patients in the Sepsis Transition And Recovery group experienced the primary outcome compared with the usual care group (28.7% vs 33.3%; risk difference, 4.7%; odds ratio, 0.80; 95% CI, 0.58-1.11; adjusted odds ratio, 0.80; 95% CI, 0.64-0.98). There were 74 deaths (Sepsis Transition And Recovery: 33 [9.5%] vs usual care: 41 [12.0%]) and 155 rehospitalizations (Sepsis Transition And Recovery: 71 [20.3%] vs usual care: 84 [24.6%]). CONCLUSIONS:In a multisite randomized clinical trial of patients hospitalized with sepsis, patients provided with a 30-day program using a nurse navigator to provide best practices for postsepsis care experienced a lower proportion of either mortality or rehospitalization within 30 days after discharge. Further research is needed to understand the contextual factors associated with successful implementation.

Blood count derangements after sepsis and association with post-hospital outcomes

“…To understand the incremental predictive value of discharge CBCD parameters, we fit multivariable logistic regression models and used the area under the receiver operating characteristics (AUROC) and likelihood ratio tests to determine significant improvement over a base model using clinical variables alone. Clinical variables selected for inclusion in the base model were all previously associated with risk of post-hospitalization death or rehospitalization in other publications (7)(8)(9)37). Additionally, we fit a full model using clinical variables and all eight CBCD parameters.…”

“…While there has been increased attention to longerterm morbidity and mortality after sepsis, targeted therapies to prevent these sequelae are lacking (4)(5)(6). In addition, predicting post-acute sequelae, particularly rehospitalization, remains challenging with predictive models performing only modestly (7)(8)(9)(10). Heterogeneity in sepsis and sepsis survivorship is a major factor complicating the development of predictive models and application of therapies directed at improving long-term outcomes (4,11).…”

“…Prior studies assessing risk factors for post-sepsis morbidity have largely focused on non-modifiable factors such as age, comorbidities, and pre-hospitalization healthcare utilization (2, 8, 16). Biological variables, including measures of persistent inflammation at hospital discharge, have been infrequently evaluated in sepsis survivors and are not currently incorporated into predictive models (7,8,12). A hallmark of the acute inflammatory response of sepsis is dramatic changes in complete blood count and leukocyte differential (CBCD) parameters as a result of altered production, consumption, and death of blood cells (17,18).…”

New and Progressive Medical Conditions After Pediatric Sepsis Hospitalization Requiring Critical Care

“…The 2021 adult Surviving Sepsis Campaign guidelines recommend routine follow-up and assessment for new sepsis-related sequelae after hospital discharge, but no similar recommendation exists for children . Structured postsepsis follow-up programs incorporating telephone follow-up, patient and family education, care coordination, screening, and communication with outpatient health care professionals have been feasible in high-resource settings, but more work is needed to make such programs broadly accessible. Second, our study suggests that dedicated research is needed to better understand and mitigate the development and progression of comorbid conditions.…”

Association between unmet medication needs after hospital discharge and readmission or death among acute respiratory failure survivors: the addressing post-intensive care syndrome (APICS-01) multicenter prospective cohort study

“…This model of support may miss an early window of vulnerability among ARF survivors, as suggested by a pilot randomized trial [47]. The pragmatic IMPACTS trial also suggested that a nurse navigator might improve outcomes among sepsis survivors [59]. The IMPACTS intervention included symptom monitoring, medication review, and targeted palliative care referrals.…”