Strategies for Enhancing Sepsis Survivorship
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1 Strategies for Enhancing Sepsis Survivorship Hallie Prescott, MD, MSc Ohio Hospital Association August 16, 2016
2 Disclosures I have no relevant financial conflicts of interest Key Funding NIH/NIGMS American Thoracic Society Foundation This talk does not necessarily represent the views of the U.S. Government or Department of Veterans Affairs
3 Last Time
4 July Conclusions Sepsis survivors face heightened risk for death. 1 in 5 sepsis survivors with a late death attributable to sepsis. Over half of patients acquire new physical disability. Cognitive decline common; ~15% with mod-severe impairment Anxiety, depression, PTSD each affect ~1/3 of survivors but not necessarily worse after sepsis. Healthcare use and readmission are common. Often due to the same usual suspects that we know how to treat: infection, CHF, AKI, COPD, aspiration. Risk for Infection, AKI, aspiration, and CV events are increased in sepsis survivors.
5 Question What can we do to improve long-term survivorship after sepsis?
6 Outline Review the (small) evidence base of post-hospital interventions for survivors of sepsis / critical illness. My Top 8 list
7 SMOOTH Study RCT of a primary care-based intervention 291 Sepsis survivors, recruited from 9 ICUs in Germany Intervention: PCP & patient education Case management by critical care nurses, focusing on symptoms Clinical decision support by intensivist Primary Outcome: Mental Healthrelated QOL at 6 months Secondary: 32 measures as 6 and 12 months.
8 SMOOTH Study Results Primary Outcome (Mental Health) no difference Secondary Outcomes Survival QOL (SF-36 Subscales) Mental Health (depression, PTSD, cognition) Self health-assessment Healthcare Utilization Functional outcomes 5 measures with significant treatment effect Median ADL capabilities at 6 and 12 months, ~1 ADL better Lower disability and better physical function at 6 months Less insomnia at 12 months
9 RCTs of Post-Discharge Rehab Improvements are generally small and not sustained. Studies were all <200 patients. Study Intervention Control Outcome Jones, et al Elliot, et al Jackson, et al wk self-help rehabilitation manual 8-wk home PT (3 visits) and rehabilitation manual. 12-wk home cognitive, physical, and functional rehab. ICU follow-up program with 2 ward visits, 3 calls, and ICU follow-up clinic visit at 2 and 6 mos. Routine PCP follow-up. Usual care. Faster improvement in physical function (SF- 36). No significant treatment effect, but post-hoc analysis showed possible benefit. Improved executive and physical function (Tower test, functional activities questionnaire). Batterham, et al wk PT program Usual care Improved anaerboic threshold at 9 weeks.
10 RCTs of ICU Follow-up, Case Mgmt No treatment effect. Study Intervention Control Outcome Daly, et al Douglas, et al Cuthbertson, et al month disease mgmt program including care coordination, family support, education, and treatment monitoring by APRN, with geriatrician and pulmonary support. RN-led ICU follow-up clinic at 3 and 9 mos Jensen, et al RN-led ICU follow-up clinic at 1-3 mos. and 2 phone calls. Usual care Usual care Usual care. No difference in readmission or time to readmission. Fewer days spent readmitted 11.4, vs 16.7, p=0.03. No significant treatment effect for mortality, QOL, anxiety, or depression. No significant treatment effect for QOL, anxiety, depression, or sense of coherence.
11 Association of Post-Discharge Rehabilitation with Mortality in Intensive Care Unit Survivors of Sepsis observational study of over 30,000 sepsis survivors rehabilitation associated with a survival benefit to 10- years (ahr=0.94, p<0.001) Chao, et al. Crit Care Med
12 Interim Conclusions Existing studies show possible, small benefits, largely isolated to functional outcomes. Best practices for enhancing sepsis survivorship have not been defined.
13 My Top 8 List for enhancing survivorship after sepsis
14 1. Timely and Effective Sepsis Treatment Broad-spectrum Abx 30ml/kf IVF if SBP<90 or lactate>2 Source control Evidence: Time to treatment associated with mortality. Seymour, et al. NEJM Liu, et al. AJRCCM. 2017
15 1. Timely and Effective Sepsis Treatment, cont d Broad-spectrum Abx 30ml/kf IVF if SBP<90 or lactate>2 Source control Evidence: Health system-wide QI targeting these elements is associated with reduced mortality. Miller, et al. AJRCCM Liu, et al. AJRCCM. 2016
16 More information at ICUliberation.org. 2. Avoidance of Iatrogenic Harms A: Assess and treat pain B: Both SAT and SBT C: Choice of sedation / analgesia D: Delirium screening and prevention E: Early mobility F: Family Engagement and Empowerment Evidence: Girard, et al. Lancet Combined SAT & SBT; NNT= 7 patients.
17 3. Early Mobility Early mobility, to the goal of ambulation on mechanical ventilation, should be initiated as early as possible. Evidence: Schweickert, et al. Lancet Indep fxn in 58% vs 35%, p=0.02
18 4. Pay Attention to Discharge Medications
19 4. Pay Attention to Discharge Medications, 2 Chronic medications discontinued (e.g. synthroid, gastric acid suppression, anticoagulants, and statins.) Bell, et al. JAMA
20 4. Pay Attention to Discharge Medications, 3 Chronic medications discontinued (e.g. synthroid, gastric acid suppression, anticoagulants, and statins.) Acute medications continued (eg. antipsychotics, antidepressants, benzodiazepines, gastric acid suppression, inhalers) Bell, et al. JAMA Morandi, et al. J Am Geriatric Soc Scales, et al. J Gen Intern Med
21 5. Prepare Patients Do medical teams in your ICU have formal discussions with patients or family members regarding challenges or changes to their lives after ICU discharge? Almost Never Only for the Sickest Patients 17% 27% It varies widely across practitioners With many but not all patients 17% 2% With almost every patient 37% Govindan, et al. AnnalsATS
22 5. Prepare Patients, cont d Available videos on SCCM site: THRIVE: Redefining Recovery Discharge from the ICU Pediatric Post-Intensive Care Syndrome Pediatric PICS and Family Wellness after the ICU Available at myicucare.org.
23 5. Prepare Patients: Other resources Available at
24 5. Prepare Patients: Other resources, cont d Patient education websites: Post-Sepsis: Sepsis Alliance home page ( Hundreds of patient profiles, indexed by key words. Post-Critical Illness: Health Talk home page ( 27 video profiles and 87 articles on critical illness ICUsteps home page ( informational site and ICU and common illnesses
25 6. Focus on the Big 5 after discharge
26 6. Focus on the Big 5 after discharge, 2
27 6. Focus on the Big 5 after discharge, 3 Infection CHF Exacerbation Acute Renal Failure COPD Exacerbation Aspiration Pneumonitis
28 6. Focus on the Big 5 after discharge, 4 Infection confirm/update vaccines, council patients, eval s/s of infection CHF Exacerbation Acute Renal Failure COPD Exacerbation Aspiration Pneumonitis
29 6. Focus on the Big 5 after discharge, 5 Infection confirm/update vaccines, council patients, eval s/s of infection CHF Exacerbation med rec/titration, consider change to gfr, LVEF Acute Renal Failure COPD Exacerbation Aspiration Pneumonitis
30 6. Focus on the Big 5 after discharge, 6 Infection confirm/update vaccines, council patients, eval s/s of infection CHF Exacerbation med rec/titration, consider change to gfr, LVEF Acute Renal Failure med rec/titration, monitoring COPD Exacerbation Aspiration Pneumonitis
31 6. Focus on the Big 5 after discharge, 7 Infection confirm/update vaccines, council patients, eval s/s of infection CHF Exacerbation med rec/titration, consider change to gfr, LVEF Acute Renal Failure med rec/titration, monitoring COPD Exacerbation med rec/titration of inhalers, respiratory suppressants Aspiration Pneumonitis
32 6. Focus on the Big 5 after discharge, 8 Infection confirm/update vaccines, council patients, eval s/s of infection CHF Exacerbation med rec/titration, consider change to gfr, LVEF Acute Renal Failure med rec/titration, monitoring COPD Exacerbation med rec/titration of inhalers, respiratory suppressants Aspiration Pneumonitis consider formal SLP eval/tx for dysphagia, weakness, cognitive impairment, and/or recurrent pneumonia
33 7. Empower Patients to Help Each Other Peer Support Groups
34 7. Empower Patients to Help Each Other, 2 Closed group: THRIVE for ICU patients/families
35 8. Increase Function: Use It or Lose It Screen for functional impairment at hospital discharge and first outpatient follow-up: E.g. ADL limitations, 6 minute walk, Timed Up and Go test Address new weakness and functional impairment Structured exercise program Physical therapy Occupational therapy Cardiac or pulmonary rehabilitation
36 Top 8 List for Enhancing Survivorship 1. Timely and effective inpatient sepsis treatment 2. Avoidance of iatrogenic harms 3. Early mobility 4. Attention to discharge meds (reconcile and titrate) 5. Prepare patients about what to expect 6. Focus on Big 5 causes of preventable readmission 7. Peer Support 8. Promote functional recovery
37 Other Things to Keep in Mind. For patients declining prior to sepsis, it may be appropriate to focus on palliation.
38 Other Things to Keep in Mind 2 Be weary of the kitchen sink approach Plan: New psychotropic medications Referral to mental health professionals ICU follow-up Clinic Cognitive Therapy Physical Therapy Occupational Therapy Speech Therapy Pulmonologist PCP Cardiologist Nephrologist Endocrinologist
39 Other Things to Keep in Mind 3 Workload: all the work of being a patient; efforts to understand and plan care, enroll support of others, access and use healthcare services Capacity: quality and availability of resources to carry out the work of being a patient. Leppin, et al. JAMA Internal Med
40 Top 8 List for Enhancing Survivorship, 2 1. Timely and effective inpatient sepsis treatment 2. Avoidance of iatrogenic harms 3. Early mobility 4. Attention to discharge meds (reconcile and titrate) 5. Prepare patients about what to expect 6. Focus on Big 5 causes of preventable readmission 7. Peer Support 8. Promote functional recovery 9. Consider palliative approach 10. Avoid the kitchen sink approach
41 Top 8 List for Enhancing Survivorship, 3 1. Timely and effective inpatient sepsis treatment 2. Avoidance of iatrogenic harms 3. Early mobility 4. Attention to discharge meds (reconcile and titrate) 5. Prepare patients about what to expect 6. Focus on Big 5 causes of preventable readmission 7. Peer Support 8. Promote functional recovery Questions 9. Consider palliative approach 10. Avoid the kitchen sink hprescot@med.umich.edu
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