By Melinda Young
EXECUTIVE SUMMARY
Sepsis takes a huge toll on Americans and hospitals each year. There are about 1 million related hospitalizations annually, and recovery for survivors can be challenging.
- Sepsis often presents as difficulty breathing and requiring respiratory support. Patients also might experience delirium or confusion.
- Coding issues involving sepsis can make it difficult for post-acute providers to realize their patients are sepsis survivors and need special attention to prevent recurrence of infection.
- Sepsis survivors can face a long recovery period and experience weakness, fatigue, and reinfection.
For the more than 1.7 million Americans who develop sepsis each year — including about 1 million who are hospitalized — survival can be a long and difficult road. Sepsis management in hospitals costs more than $20 billion per year — the highest cost among all disease states.1-3 Sepsis survivors are at high risk of illness and functional impairment and need support services after their hospitalization.4
Post-acute care is crucial for sepsis survivors. It helps patients with functional recovery and can prevent readmissions. Research suggests post-acute care services may be underused. Fewer than half the patients discharged from the hospital receive care in skilled nursing facilities, with home health services, or in long-term care facilities.3-7
“Sepsis, broadly speaking, is defined as life-threatening, acute organ dysfunction due to infection. In the process of your body fighting off a severe infection, there is collateral damage,” says Hallie C. Prescott, MD, MSc, an associate professor in the University of Michigan Department of Medicine. “It often shows up as difficulty breathing and needing respiratory support. There may be an altered mental status — delirium or confusion — and acute renal shock — cardiovascular dysfunction.”
Any type of dysfunction can progress to sepsis, but the most common are respiratory infections infections (e.g., pneumonia, intra-abdominal infections) and urinary infections (e.g., bladder infections and kidney infections). People also can acquire maternal sepsis because of problems in pregnancy, including miscarriage, Prescott explains.
The disease is especially dangerous if not diagnosed quickly. While it chiefly affects older people, it can be deadly to young people who develop it and are not diagnosed immediately.
The sepsis-related death rate for older adults has declined in the past two decades, from 298.8 per 100,000 people in 2000 to 277.4 per 100,000 in 2019, according to the CDC.8
This means more people are surviving sepsis and more will need post-acute care but there are obstacles to providing survivors of sepsis the post-acute care they need.
On Sept. 11, 2023, Sepsis Alliance asked the Biden administration to create a National Sepsis Action Plan to address the nation’s leading cause of death in U.S. hospitals. The plan would lead to the construction of a national sepsis research center and the development of a sepsis data trust. Experts would provide guidelines for all healthcare providers and create national education and awareness programs.9
Documentation Is an Issue
One obstacle involves the way these cases are coded at discharge. There has been no ICD-10 code for post-acute sepsis care.
It is a problem that a team of healthcare professionals recognized. In March 2023, they petitioned the CDC for a new ICD-10 code for that purpose, says Kathryn Bowles, PhD, RN, FAAN, FACMI, a professor of nursing and van Ameringen chair in nursing excellence at the University of Pennsylvania School of Nursing.
For example, when clinicians document why a sepsis patient was in the hospital and was referred to home healthcare, the coding often indicates the source of the patient’s original infection, such as pneumonia or urinary tract infection. When post-acute providers see these charts, they may not realize the patient developed sepsis, which requires more monitoring and attention than infections that were resolved without long-term problems.
“We have seen that referral documents may not use the word ‘sepsis,’ and the discharge summary may not have ‘sepsis’ on it if the physician marks the sepsis as resolved, which it often is,” says Bowles, director of research at the Center for Home Care Policy & Research at VNS Health in New York City. “It falls into the history, so the next level of care will not see sepsis listed on the active problem list, and post-acute care may not think they can put it on their record as an active problem.”
Everyone involved in post-acute care of a recovering sepsis patient needs to know about the diagnosis so they can monitor the patient for signs of recurring infection.
“The treatment and recognition of sepsis has improved, and more people are surviving sepsis,” Bowles says. “My work is focused on home healthcare, and we’re studying people’s transition from the hospital into home health services.”
Sepsis is common among older patients — more common than heart attack and stroke combined. “Many cases of sepsis present straightforwardly with signs and symptoms of infection progressing,” Prescott says. “They get confused, and their blood pressure is low.”
Those types of cases are easily identified. The more difficult-to-diagnose cases include patients with baseline impairment, such as someone in a nursing home. They may not be able to explain their signs and symptoms to clinicians, and their infection is only identified when they become more confused, stop eating, and are brought to the ED. “There is not one highly sensitive test for sepsis like there is for a heart attack. Sepsis can present in different ways,” Prescott says.
Sepsis survivors are prone to long recovery periods. They may experience weakness, fatigue, and are at high risk of reinfection and recurrence of sepsis, Bowles says. “It’s critical that post-acute care is received so people can be monitored for sepsis,” she adds.
Emotional Support Often Overlooked
Prescott and colleagues performed an electronic survey of hospitals’ best practices for recovery of sepsis. They found clinical leaders rated emotional support as the lowest and social support and medication management as the highest.3
When investigators followed up on why clinical leaders did not rate emotional support higher, the leaders said they did not think it was always (or nearly always) needed and was only important for a subset of patients. Prescott and colleagues did not ask about care coordination, although it is an important topic in sepsis care.
Patients Refuse Services
Another problem is that about three in five sepsis patients discharged from the hospital go home with no post-acute services, Bowles says. Smaller percentages are discharged to skilled nursing facilities (SNFs) and to home health services. Some patients also receive physical therapy and occupational therapy because their mobility could be limited for weeks or months.
“But a large proportion are not receiving services. That’s the group that worries me,” Bowles notes.
It is not that case managers and clinicians are not recommending these services to hospitalized sepsis patients. Often, they do suggest home health and other services for those who are not sent to a SNF.
“Often times, services are offered but patient education is needed to make people realize the importance of having those services,” Bowles explains. “Papers show that even though services are ordered, people don’t always get those services. One reason is patient refusal.”
This problem was exacerbated by the COVID-19 pandemic when discharged patients were reluctant for healthcare professionals to visit their home. Another reason for the refusal is that patients and their families might hold misconceptions about what home healthcare is. They may think it involves personal aide services, such as helping a person with dressing, eating, or using the bathroom. They may not realize that home health is a nurse visit to their home to check for health improvement and signs and symptoms of medical problems. It also is about sending physical therapists and other professionals into the home to help the person with mobility and returning to activities of daily living, Bowles explains.
Hospital case managers and discharge planners can help these patients by educating them about post-acute care for sepsis and why home health services can help them stay healthy and prevent readmission. “It is really important to educate patients and their caregivers,” Bowles says.
Home health nurses can monitor patients for reinfection and make sure they are taking their antibiotics. If the patient’s chronic illnesses flare up, home health nurses can treat these.
“Sepsis patients are debilitated and weak after a long stay. For those reasons, they need to be educated on what happened to them and why they need a professional set of eyes watching them,” Bowles explains. “We found that the first week of home healthcare is critical.”
When patients receive early attention and are admitted to home healthcare quickly, they can improve. For example, patients who are seen by home health within two days of hospital discharge, and have one more nursing visit that first week, and are seen by an outpatient provider within seven days, record 7% lower readmission rates than for sepsis survivors who did not receive that attention.1
Typically, people recovering from sepsis are prone to recurrence because they are older adults with multiple chronic conditions. Their kidney function is not as efficient as it was when they were younger. Ways to prevent readmissions include post-acute care, monitoring, and thorough patient education about the disease and why they need to be careful in the weeks after discharge. (For more information, see the story in this issue on how to prevent sepsis patient readmissions.)
Nine out of 10 sepsis cases develop in the community and not in the hospital when a patient is hospitalized for another condition, Prescott notes. “Ten to 15% of cases develop in the hospital after chemotherapy or surgery, but the bulk of time it’s people coming into the hospital with evidence of sepsis already present,” she says.
REFERENCES
- Deb P, Murtaugh CM, Bowles KH, et al. Does early follow-up improve the outcomes of sepsis survivors discharged to home health care? Med Care 2019;57:633-640.
- National Institute of General Medical Sciences. Sepsis. Page last reviewed Sept. 10, 2021.
- Paoli CJ, Reynolds MA, Sinha M, 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;46:1889-1897.
- Hechtman RK, Cano J, Whittington T, et al. A multi-hospital survey of current practices for supporting recovery from sepsis. Crit Care Explor 2023;5:e0926.
- Lee JT, Mikkelsen ME, Qi M, Werner RM. Trends in post-acute care use after admissions for sepsis. Ann Am Thorac Soc 2020;17:118-121.
- Burgdorf JG, Chase JD, Whitehouse C, Bowles KH. Unmet caregiving needs among sepsis survivors receiving home health care: The need for caregiver training. J Appl Gerontol 2022;41:2180-2186.
- O’Connor M, Kennedy EE, Hirschman KB, et al. Improving transitions and outcomes of sepsis survivors (I-TRANSFER): A type 1 hybrid protocol. BMC Palliat Care 2022;21:98.
- Kramarow EA. Sepsis-related mortality among adults aged 65 and over: United States, 2019. NCHS Data Brief 2021;422:1-8.
- Sepsis Alliance. Sepsis Alliance calls on Biden-Harris administration for a National Sepsis Action Plan. Sept. 11, 2023.
Post-acute care is crucial for sepsis survivors. It helps patients with functional recovery and can prevent readmissions. Research suggests post-acute care services may be underused. Fewer than half the patients discharged from the hospital receive care in skilled nursing facilities, with home health services, or in long-term care facilities.
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