Sepsis and Post-Sepsis Syndrome | VITAS Healthcare

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Sepsis and Post-Sepsis Syndrome Is yourpatient hospice-eligible? VITAS can help.
Sepsis and Post-Sepsis Syndrome Is your patient hospice-eligible? VITAS can help.
Sepsis and
Post-Sepsis Syndrome

Sepsis and Post-Sepsis Syndrome Is your patient hospice-eligible? VITAS can help. Confidential and Proprietary Content
CME Provider Information
Satisfactory Completion
Learners must complete an evaluation form to receive a certificate of completion. You must participate
in the entire activity as partial credit is not available. If you are seeking continuing education credit for a
specialty not listed below, it is your responsibility to contact your licensing/certification board to determine
course eligibility for your licensing/certification requirement.
Physicians
In support of improving patient care, this activity has been planned and implemented by Amedco LLC and
VITAS®
Healthcare. Amedco LLC is jointly accredited by the Accreditation Council for Continuing Medical
Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses
Credentialing Center (ANCC), to provide continuing education for the healthcare team. Credit Designation
Statement – Amedco LLC designates this live activity for a maximum of 1 AMA PRA Category 1 CreditTM
.
Physicians should claim only the credit commensurate with the extent of their participation in the activity.

VITAS Healthcare programs are provided CE credits for their Nurses/Social Workers and Nursing Home Administrators through:
VITAS Healthcare Corporation of Florida, Inc./CE Broker Number: 50-2135. Approved By: Florida Board of Nursing/Florida Board
of Nursing Home Administrators/Florida Board of Clinical Social Workers, Marriage and Family Therapy & Mental Health Counseling.
VITAS Healthcare programs in Illinois are provided CE credit for their Nursing Home Administrators and Respiratory Therapists through:
VITAS Healthcare Corporation of Illinois, Inc./8525 West 183 Street, Tinley Park, IL 60487/NHA CE Provider Number: 139000207/RT CE
Provider Number: 195000028/Approved By the Illinois Division of Profession Regulation for: Licensed Nursing Home Administrato
rs and
Illinois Respiratory Care Practitioner.
VITAS Healthcare, #1222, is approved to offer social work continuing education by the Association of Social Work Boards (ASWB)
Approved Continuing Education (ACE) program. Organizations, not individual courses, are approved as ACE providers. State and
provincial regulatory boards have the final authority to determine whether an individual course may be accepted for continuin
g
education credit. VITAS Healthcare maintains responsibility for this course. ACE provider approval period: 06/06/2024– 06/06/2027.
Social workers completing this course receive 1.0 ethics continuing education credits.
VITAS Healthcare Corporation of California, 310 Commerce, Suite 200, Irvine, CA 92602. Provider approved by the California
Board of Registered Nursing, Provider Number 10517, expiring 01/31/2027.
Exceptions to the above are as follows: AL: No NHAs, DE: No NHAs, DC: No NHAs, GA: No NHAs, KS: No NHAs, NJ: No NHAs,
OH: No NHAs, PA: No NHAs, TX: No NHAs, VA: No NHAs, WI: No NHAs and Nurses are not required – RT only receive CE Credit
in Illinois
CE Provider Information

Goal
• Appreciate the role of hospice in the care of patients
who develop sepsis in acute-care hospital and
post-acute care settings
• Discuss the role of post-sepsis syndrome and
characteristics that support hospice eligibility

Objectives
• Appreciate the identification and
natural history of post-sepsis syndrome
• Describe hospice eligibility for sepsis
– Hospitalization
– Post-acute
• Understand indicators of poor
prognosis in sepsis
• Incorporate a care model for
sepsis in hospice
• Apply a clinician's mnemonic for sensitive
discussions and how to address common
misconceptions through an example of an
effective goals-of-care conversation

1US Centers for Disease Control and Prevention. Data and Reports, retrieved from: https://www.cdc.gov/sepsis/datareports/index.html. Retrieved June 13, 2024.
2World Health Organization. (2021). WHO calls for global action on sepsis: cause of 1 in 5 deaths worldwide. Retrieved from: https://www.who.int/news/item/08-09-2020-who-calls-for-global-action-on-sepsis---cause-of-1-in-5-deaths-worldwide
3Rhee, C., et al. (2017). Incidence and trends of sepsis in US hospitals using clinical vs claim data, 2009 to 2014. JAMA, 318(13), 1241-1249.
4Thompson, K., et al. (2018). Health-related outcomes of critically ill patients with and without sepsis.Intensive Care Med, 44(8):1249-1257.
• Sepsis affects 1.7 million people
per year in the US and 270,000
die from it1
– 50 million worldwide and
11 million deaths2
• About 1 in 3 patients or more who
die in a hospital have sepsis; many
are hospice-eligible at admission3
• Recommendations exist for
inpatient hospital care
– Standard/rapid identification
and management
• 30% of sepsis survivors suffer
from post-sepsis syndrome4
• No consensus recommendations
exist on best post-acute care
– New symptom burden
– Pain, fatigue, dysphagia, poor
attention, shortness of breath
– Long-term disability:
cognitive and physical function
• Higher risk of hospital readmission and
death compared to other conditions
Background

Sepsis and Healthcare Costs
• The cost of sepsis and post-sepsis
care continues to be a serious
healthcare burden
• Sepsis costs accounted for
$62 billion in 2019 (including
inpatient and skilled nursing
admissions), making it the most
expensive condition treated in
US hospitals1
• Sepsis cost of care:2
– Hospital-acquired: $51,000
– Community-acquired: $18,000
• The comparative cost
of care by disease states:3
– Diabetes: $32,000 vs.
non-diabetes: $13,000
• Readmission cost
averaged $25,0004
1Buchman, T., et al. (2020). Sepsis Among Medicare Beneficiaries: 3. The Methods, Models, and Forecasts of Sepsis, 2012-2018. Critical Care Medicine; 48:302-318.
2Paoli, CJ et al. Epidemiology and Costs of Sepsis in the United States—An Analysis Based on Timing of Diagnosis and Severity Level. Crit Care Med 2018; 46:1889-97.
3Hajj, J., et al., The “centrality of sepsis”: a review on incidence, mortality, and cost of care. In Healthcare (Vol. 6, No. 3, p. 90). Multidisciplinary Digital Publishing Institute.
4Gluck, T. (2019). Epidemiology and Costs of Sepsis in the U.S. NEMJ Journal Watch. Retrieved from: https://www.jwatch.org/na48114/2019/01/02/epidemiology-and-costs-sepsis-us.

Case of HS
HPI: 66 y/o female presents to
ED with multiple infected 1st- and
2nd-degree burn wounds to 60%
of TBSA after she slipped/fell
on hot cooking oil 7 days ago
PMHx: COPD with previous
hospitalization for exacerbation and
pneumonia. Worsening SOB with
optimal medical management.
Controlled IDDM, severe PVD,
obesity. Unsteady gait s/p fall,
1/6 ADL dependency
Treatments: Spiriva and Advair,
oxygen-dependent 2L NC with
SOB on minimal exertion
Exam: Poor attention, temp.
104ºF, pulse 120 bpm, RR
28/min, BP 90/60, WBC 15 and
15% bands, lung sounds with
bilateral congestion and wheezing
to bases, grossly infected 1st-
and 2nd-degree oil burn wounds

• Sepsis is a life-threatening illness with host dysregulation
brought on by the body’s response to an infection
• Sepsis can lead to:
– Severe sepsis (acute organ dysfunction secondary
to documented or suspected infection)
– Septic shock (severe sepsis plus hypotension not
reversed with fluid resuscitation)
– Post-sepsis syndrome (immune, inflammatory, and
endocrine changes resulting in cognitive and
physical impairments)
What Is Sepsis?

Background: Sepsis Epidemiology
©2019 VITAS
®
Healthcare Corporation Adapted from Prescott, H. & Angus, D. (2018). Enhancing Recovery from Sepsis: A Review. JAMA, 319(1), 62-75.
• 41% of patients
admitted with
sepsis die within
90 days
• 42% of patients
who survive are
readmitted within
90 days
1 in 2-3 dies 1 in 3 hospital deaths are sepsis related Fewer than 1 in 5 admitted to hospice

Pre-hospitalization conditions:
• Hospice-eligible:
– COPD with optimal
medical management
– SOB with minimal exertion
on 2L NC for SOB
– Hospitalization for COPD
exacerbation and pneumonia
• Functional decline:
– 1 of 6 ADL dependent
– Unsteady gait
– Status-post fall
Sepsis-associated organ dysfunction:
• Vasopressor initiation
• Mechanical ventilation initiation
• Hyperlactatemia
• Acute kidney injury
• Thrombocytopenia
Case of HS: Post-Sepsis Syndrome Course

Case of HS: Post-Sepsis Syndrome Course
Day 14
Day 10
Hospital
Admission
• Admitted to ICU from
ED; Sepsis Alert
System activated
– Multiple IV antibiotics
– Volume resuscitation
– Wound care
• 48 hours post-admission, condition worsened
– Mechanical ventilation
initiated for acute
respiratory failure,
secondary to
bilateral pneumonia
– Acute renal failure;
hemodialysis initiated
– IV vasopressors initiated
– Thrombocytopenia
– Hyperlactatemia
Day 1 48 hrs

Hospice Care’s Impact on Caregiver Health
Day 1 Day 14
• 10 days post-admission:
– HS is weaned off ventilator;
kidney function improves
– Vital signs are stable;
labs normalize
– Mild delirium persists after
HS is discharged home
with home health care
48 hrs
Hospital
Admission
Day 10

Case of HS: Post-Sepsis Syndrome Course (cont.)
• 14 days post-admission
– HS continues to decline,
marked by 20-lb. weight
loss, and functional decline
in 4/6 ADLs
– HS visits PCP for follow-up and
is diagnosed with aspiration
pneumonia; PCP recommends
HS readmit to hospital
– GOC conversation reveals
HS’ request for comfort care
– PCP initiates hospice referral
Day 1 Day 14
48 hrs
Hospital
Admission
Day 10

Relationship of Pre-Sepsis Function and Cognition on
Post-Hospital Survival
Iwashyna, T. J., Ely, E. W., Smith, D. M., & Langa, K. M. (2010). Long-term Cognitive Impairment and
Functional Disability Among Survivors of Severe Sepsis. JAMA, 304(16), 1787-1794.
Patients with functional
and cognitive impairment
prior to sepsis that
survive hospitalization
have a high 6-month
mortality that supports
hospice as a relevant
and important post-acute
care option.
Severe Limits
No Limits
Moderate/Severe
Impairment
Normal

Prescott, H., et al. (2018). Enhancing Recovery from Sepsis: A Review. JAMA, 319(1), 62-75.
• New functional limitations
– 1-2 new ADL limitations
on average
• Physical weakness
• Myopathy and neuropathy
• Increased cognitive impairment (CI)
– Persistent delirium
– Moderate to severe CI increased
from 6.1% before hospitalization
to 16.7% post-hospitalization
• Difficulty swallowing
– 63% aspiration on fiberoptic
endoscopic evaluation
– Muscular weakness
or damage
Post-Sepsis Syndrome (cont.)

Prescott, H., et al. (2018). Enhancing Recovery from Sepsis: A Review. JAMA, 319(1), 62-75.
• Cardiovascular events occurred
in 29.5% of patients in the year
after sepsis
– Persistent myocardial dysfunction
• Increased risk of recurring sepsis
– 9-fold elevated risk
• Increased depression and anxiety
– About 33% prevalent 2-3
months later
• Exacerbation of chronic
medical conditions
– Heart failure, acute renal
failure, and COPD
Post-Sepsis Syndrome (cont.)

Hospice
Admission
• Same-day hospice admission and initial
Plan of Care implemented:
– Medication and treatments ordered and delivered
in coordination with PCP and hospice physician
– Continuous care level of care initiated for symptoms
of pain, SOB, congestion, wound care, and delirium
– Short-acting and long-acting opioids optimized
for pain
• Agitation addressed with pain control plus
Ativan PRN
• Respiratory:
– Oral antibiotics x 10 days for pneumonia
– O2 at 6L (previously 2L)
– Respiratory treatments ATC
– Opioids for SOB
• Wound care:
– TID dressing changes
– Electric hospital bed with low-air-loss mattress
• 4 days later, HS’ symptoms improve; continuous
care is discontinued, and HS returns to routine
level of hospice care
Day 124 Day 127
Day 1 Day 141
Day 4

Sepsis and Readmissions
Jones, T., et al. (2015). Post–acute care use and hospital readmission after sepsis. Annals of the American Thoracic Society, 12(6), 904-913.
0
5
10
15
20
25
30
Cohort (N=112,578) AMI (N=2,597) Heart Failure
(N=19,723)
Pneumonia
(N=4,949)
Sepsis (N=3,620)
7-Day Hospital Readmission 30-Day Hospital Readmission
• Patients who have
survived sepsis are at
increased risk of
readmission within 7
days and at higher
risk of readmission
within 30 days.

• Four months later:
– Over a weekend,
HS’ husband notices
increased congestion and
SOB and contacts hospice
provider, who dispatches
after-hours clinician
– Hospice on-call physician
contacted
– Continuous care LOC for
SOB, congestion, fever,
and presumed pneumonia
• Husband indicates
he wants symptom
management only:
ATC Tylenol for fever,
opioids for dyspnea, and
respiratory treatments
to manage SOB
Day 1 Day 141
Day 124 Day 127
Hospice
Admission
Day 4
• 3 days later, HS is
discharged from
continuous care with
return to routine LOC
– Hospice increases
nurse and SW
visits to assist in
LOC transition

Inouye, S., et al. (1990). Clarifying Confusion: the Confusion Assessment Method: a New Method for Detection of Delirium.Annals of Internal Medicine, 113(12), 941-948.
• Two weeks later:
– HS continues to decline despite aggressive
respiratory symptom management
– She dies peacefully surrounded by family
Day 1 Day 141
Hospice
Admission
Day 4 Day 127
Day 124
– Hospice RN attends death, prepares
HS’s body for viewing and transport, and
supports her husband in the process

Disease
Group
No
Hospice
Hospice
< 15 Days 15 – 30 31 – 60 61 – 90 91 – 180 181 – 266 > 266
ALL $67,192 4% -5% -9% -12% -14% -10% -12%
Circulatory $66,041 7% -4% -8% -10% -11% -8% -10%
Cancer $76,625 10% -1% -6% -9% -13% -14% -20%
Neuro-
degenerative
$61,004 12% -6% -9% -11% -11% -5% -4%
Respiratory $77,892 -2% -11% -14% -17% -19% -18% -22%
CKD/ESRD $82,781 1% -14% -21% -24% -24% -23% -27%
Comparison of Total Cost of Care by Disease Group and
Hospice Episodes in the 12-Month Period Before Death
*To be eligible to elect hospice care under Medicare, an individual must be entitled to Part A of Medicare and be certified as being terminally ill. An individual is considered
to be terminally ill if the medical prognosis is that the individual’s life expectancy is 6 months or less if the illness runs its normal course. Only care provided by (or under
arrangements made by) a Medicare certified hospice is covered under the Medicare hospice benefit. The hospice admits a patien
t only on the recommendation of the
medical director in consultation with, or with input from, the patient's attending physician (if any).
NORC at the University of Chicago (2023). Value of Hospice in Medicare. Available at: https://www.nhpco.org/wp-content/uploads/Value_Hospice_in_Medicare.pdf
• Hospice care saved Medicare
approximately $3.5 billion for
patients in their last year of life
• Those patients with hospice
stays of ≥ 6 months* yielded
the highest percentage
of savings
– For patients whose hospice
stays were between 181-266
days, total cost of care
was almost $7K less
than non-hospice users
– Hospice patients with stays
of > 266 days spent
approximately $8K less
than non-hospice users
Spending is greater than Spending is less than
non-hospice users non-hospice users
No Difference / Not
Statistically Significant

Benefits of Early Identification of Hospice-Eligible Sepsis
Patients and Alignment With Care Goals
Quality
• Hospital
readmissions
• Advance care
planning
• Symptom
management
• Patient experience
• Hospital mortality
• Medicare spend
per-beneficiary
• Bereavement
HME and Supplies
• Oxygen
• Non-invasive
ventilation
• Hospital bed
• Specialized mattress
• ADL assist devices
• Incontinence
supplies
• Wound care supplies
Complex Modalities
• Antibiotics
• IV hydration
• Parenteral opioids
• Respiratory therapist
• Therapy services:
PT, OT, speech
• Nutritional counseling
• Goals-of-care
conversations
High-Acuity Care
• Telecare
• Intensive
Comfort Care®
• General
inpatient care
• Visits after
hours and on
weekends/holidays
• Visit frequency
• Physician support
Levels of Care
• Home/routine
• Respite
• Continuous
• Inpatient

Goals-of-Care (GOC) Conversation
Develop
a collaborative plan
Understand
what patient and
caregiver know
Listen
to goals and
expectations
Inform
of evidence-based
information
Build
trust and respect
Post-Centric
Care

Advance Care Planning
Baile, W.F. Buckman, et al. (2000). SPIKES- a six-step protocol for delivering bad news: application to the patient with cancer. The oncologist, 5(4), 302-311.

ACACT
C A C T
Acknowledge Clarify Answer Confirm Transition
A

Advance Care Planning
Baile, W.F. Buckman, et al. (2000). SPIKES- a six-step protocol for delivering bad news: application to the patient with cancer. The oncologist, 5(4), 302-311.
ACACT
ACACT
ACACT
ACACT

Patient & Family: “I want to bring my wife home with me. I
want things to go back to how they were.”
Clinician: “I understand how difficult it can be to have your
spouse experience critical illness. Tell me about how she was
before this hospitalization.”
Acknowledge
A

Clinician: “I hear that what matters most to you is getting your wife back
to her definition of an acceptable quality of life. Please share what you
understand about her condition.”
Patient & Family: “We were so happy when she came home from the
ICU. That was so awful, but she is such a fighter! Once we got her
home, though, she’s just been SO sick. She can’t really get up and move
around, and she’s been really confused and acting funny, especially in
the evenings. I’m really worried about what’s going on, and I definitely
don’t want to go back to the hospital. She wouldn’t want that.”
Clarify
C

Clinician: “Thank you for sharing that with me. It is so
helpful to understand what you are experiencing and that it
is important to stay out of the hospital. We can help achieve
that goal and keep her at home and comfortable while also
supporting you—her care has required a lot of you, and you
have done a wonderful job.”
Answer
A

Clinician: “Based on our conversation, it sounds like
we need your wife’s medical team to focus on keeping
her comfortable and keeping her out of the hospital?"
Confirm
C

Patient & Family: “Yes. This has been so hard on all of
us, and we just want mom to be comfortable.”
Clinician: “I would like to work with your mom’s doctors to
get additional support in place in your home to keep her
comfortable. I’m going to call VITAS and ask for an RN to
contact you and coordinate a time to meet you at your
home to get services in place to help as soon as possible."
Transition
T

Confidential and Proprietary Content
Sepsis and Post-Sepsis Syndrome Is your patient hospice-eligible? VITAS can help.
Questions

Adapted from Prescott, H. & Angus, D. (2018). Enhancing recovery from sepsis: a review. JAMA, 319(1), 62-75.
Baile, W.F. Buckman, et al. (2000). SPIKES- a six-step protocol for delivering bad news: application to the patient with cancer. The
oncologist, 5(4), 302-311.
Buchman, T., et al. (2020). Sepsis among Medicare beneficiaries: 3. The methods, Models, and Forecasts of Sepsis, 2012 -2018.
Critical Care Medicine; 48:302-318.
US Centers for Disease Control and Prevention. (2020). Data and Reports, Available at:
https://www.cdc.gov/sepsis/datareports/index.html
US Centers for Disease Control and Prevention (2022). What is Sepsis? Available at: https://www.cdc.gov/sepsis/what-is-sepsis.html
Gluck, T. (2019). Epidemiology and Costs of Sepsis in the U.S. NEMJ Journal Watch. Retrieved from:
https://www.jwatch.org/na48114/2019/01/02/epidemiology-and-costs-sepsis-us
Hajj, J., et al. (2018). The “centrality of sepsis”: a review on incidence, mortality, and cost of care. In Healthcare (Vol. 6, No. 3, p. 90).
Multidisciplinary Digital Publishing Institute.
Inouye, S., et al. (1990). Clarifying Confusion: the Confusion Assessment Method: a New Method for Detection of Delirium. Annals of
Internal Medicine, 113(12), 941-948.
Iwashyna, T. J., Ely, E. W., Smith, D. M., & Langa, K. M. (2010). Long-term Cognitive Impairment and
Functional Disability Among Survivors of Severe Sepsis. JAMA, 304(16), 1787-1794.
Jones, T., et al. (2015). Post–acute care use and hospital readmission after sepsis. Annals of the American Thoracic Society,
12(6), 904-913.
Marik, P., et al. (2017). SIRS, qSOFA and new sepsis definition. Journal of Thoracic Disease, 9(4), 943.
References

NORC at the University of Chicago (2023). Value of Hospice in Medicare. Available at: https://www.nhpco.org/wp-
content/uploads/Value_Hospice_in_Medicare.pdf
Paoli, CJ et al. Epidemiology and Costs of Sepsis in the United States—An Analysis Based on Timing of Diagnosis and Severity Level. Crit
Care Med 2018; 46:1889-97.
Prescott, H. & Angus, D. (2018). Enhancing recovery from sepsis: a review. JAMA, 319(1), 62-75.
Rhee, C., et al. (2017). Incidence and trends of sepsis in US hospitals using clinical vs claim data, 2009 to 2014. JAMA, 318(13), 1241-1249.
Rhee, C., et al. (2019). Prevalence, underlying causes, and preventability of sepsis-associated mortality in US acute care hospitals.
JAMA Network Open, 2(2), e187571-e187571.
Thompson, K., et al. (2018). Health-related outcomes of critically ill patients with and without sepsis. Intensive Care Med. 44(8):1249-1257.
US Centers for Disease Control and Prevention. (2020). Data and Reports, retrieved from: https://www.cdc.gov/sepsis/datareports/index.html
US Department of Health and Human Services. (2020). Solving Sepsis: Transforming Health Security. Retrieved fromDRIVe.HHS.gov
World Health Organization. 2021. WHO calls for global action on sepsis: cause of 1 in 5 deaths worldwide. Retrieved from:
https://www.who.int/news/item/08-09-2020-who-calls-for-global-action-on-sepsis---cause-of-1-in-5-deaths-worldwide
References

This document contains confidential and proprietary business information
and may not be further distributed in any way, including but not limited to
email. This presentation is designed for clinicians. While it cannot replace
professional clinical judgment, it is intended to guide clinicians and
healthcare professionals in establishing hospice eligibility for patients
with sepsis and post-sepsis syndrome. It is provided for general
educational and informational purposes only, without a guarantee of the
correctness or completeness of the material presented.
Rev. 02/25

Sepsis and Post-Sepsis Syndrome | VITAS Healthcare

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