There are proven best practices for care after sepsis that are associated with reduced readmission and mortality risk. However, that doesn't mean every patient gets them. “Our initial health services research indicated that recommended postsepsis care practices were inconsistently applied to sepsis survivors,” said Stephanie Parks Taylor, MD, a hospitalist in the department of internal medicine at Atrium Health in Charlotte, N.C.
One apparent obstacle to providing optimal care to these patients is the difficulty they have returning for in-person visits as they recover from their critical illnesses, a barrier even before the COVID-19 pandemic.
To develop a solution, a research team worked with a multidisciplinary group of clinicians (including Dr. Taylor and two other hospitalists) and administrative leaders. The result, the Sepsis Transition and Recovery (STAR) program, uses a virtual care model to implement best practices for sepsis patients.
How it works
A computerized risk model identifies sepsis patients early in their hospitalization who will be at high risk for readmission or death. These patients are then each assigned to one of the program's nurse navigators, who are currently working from home due to COVID-19 but were originally physically located in the health system's care management team facility. The nurse navigators use tools like the electronic health record, secure messaging, and phone calls to review patients' medications and identify any new physical, mental, or cognitive deficits; treatable conditions that commonly lead to poor outcomes; or need for palliative care. They then work with the treating clinicians or make new referrals as appropriate.
The team initially deployed the STAR program to Atrium Health's flagship, quaternary care center and two other hospitals in the Charlotte metropolitan area, said Dr. Taylor. “The STAR program's success in supporting those sites led to interest in implementing the program at eight additional hospitals,” she said. She added that the expansion to these sites is being studied as it is implemented, in a trial called ENCOMPASS.
Another randomized trial, IMPACTS, was done to study the effects of the program on 30-day mortality and readmissions at the original three hospitals. The results were still in peer review as of February, so Dr. Taylor, one of the principal investigators, could not yet share these data. However, she reported that the program has been well received by patients, clinicians, and hospital leadership.
“It's a low-cost, scalable intervention that aligns with many health system priorities—improving transitions of care, utilizing novel health care delivery mechanisms to improve access and equity of care, standardizing postsepsis care practices—and this is why there was enthusiastic buy-in for expanding the implementation to other sites across the system,” she said.
Anecdotally, Dr. Taylor said, there have been “countless examples” of when the STAR navigator proactively averted a near-miss (e.g., discovered a patient was not taking antibiotics due to cost and so found a lower-cost pharmacy nearby), provided infection-specific education to prevent adverse events (e.g., on proper catheter care for caregivers of a patient who had multiple hospitalizations for recurrent catheter-associated infection), or identified new functional decline that could be addressed by home physical therapy and support devices.
Dr. Taylor and colleagues proposed that the program could work for survivors of other serious illnesses, such as COVID-19, in a paper published online in February by Annals of the American Thoracic Society. “[I]t is presently reasonable to assume that COVID-19 survivors experience similar trajectories to patients surviving other serious illnesses, such as sepsis. Therefore, one approach to establishing a COVID-19 transition and recovery program might be to follow the example of sepsis survivorship programs,” they wrote.
Since the intervention has multiple components, a focus of the ENCOMPASS trial is identifying the keys to successful implementation, said Dr. Taylor. “A factor we focused on early on is improving communication pathways for patients discharged to skilled nursing facilities, because information exchange has traditionally been challenging in this setting and research tells us that these patients are particularly vulnerable to poor outcomes after discharge,” she said.
As the STAR program expands to more hospitals, the researchers are keeping a close eye on its effects, including on cost and outcomes. The stepped-wedge randomized ENCOMPASS trial is expected to be completed in 2023.
Words of wisdom
The growing number of sepsis survivors and the health problems that they face create an urgent public health challenge, Dr. Taylor said. “I think there is growing awareness that sepsis is both a life-threatening and life-changing event, but there is still of a lot of work to be done to identify and address the needs of sepsis survivors,” she said.