A year ago, a study published in the Journal of the American Medical Association (JAMA) reported that more patients than ever are surviving after treatment for severe sepsis (2014;311:1295-1297).
But now, research shows that the finding only tells one part of the story. A spate of recent studies shows the immense burden of sepsis survivorship in the United States.
Four studies and two editorials revealed that people who are treated for and survive severe sepsis and septic shock are frequently rehospitalized within a few months, often for potentially preventable conditions, and they remain at higher risk for death. The national burden of readmissions among sepsis survivors may approach $3 billion in the United States, based on estimates that approximately 91,300 survivors of sepsis will be readmitted to hospital within 30 days of discharge.
“These studies argue convincingly that any construct of severe sepsis as an acute illness that, if survived, has few ongoing issues for patients is incorrect,” James O’Brien, MD, MSc, medical director of quality and patient safety at Riverside Methodist Hospital, Columbus, Ohio, wrote in an editorial in the April edition of the journal Critical Care Medicine (2015;43:906-907).
“Instead, hospitalization for severe sepsis should be a trigger for clinicians to identify patients as an at-risk population for new limitations of functional capacity and significant morbidities, such as cognitive dysfunction and ongoing health care utilization.”
The studies consistently demonstrate that sepsis patients treated in this country are likely to return to hospital within months.
In a research letter published in the March 10 issue of JAMA, investigators reported that 42.6% of people who were treated in the hospital for severe sepsis and then discharged were rehospitalized within 90 days (2015;313:1055-1057). The investigators analyzed data from the U.S. Health and Retirement Study, a sample of households including adults aged at least 50 years that is linked to Medicare claims from 1998 to 2010. They matched almost 2,600 hospitalizations for severe sepsis to hospitalizations for other acute medical conditions.
In both groups, 42% of patients were readmitted to hospital within three months. When researchers looked at the reasons for the readmissions, patients who survived sepsis were significantly more likely to be readmitted for a condition that could have been prevented or treated early. In all, nearly 42% of readmissions among sepsis survivors were due to preventable conditions, according to an expanded definition that the team used. Those conditions included a second bout of sepsis, kidney failure, heart failure and other infections.
Hallie Prescott, MD, MSc, the lead author of the paper and a critical care physician at the University of Michigan Health System, in Ann Arbor, said these conditions could be managed if patients could see a doctor at the start of their illness.
“We need to assess their vulnerability and design a better landing pad for patients when they leave the hospital, and avoid the second hit that derails a recovery,” she said.
Two recent studies in Critical Care Medicine also emphasize the need for better discharge care for sepsis patients. One study from investigators at the Medical University of South Carolina used administrative data from California, Florida and New York over a six-month period in 2011, and another study from researchers at the University of Pennsylvania, Philadelphia, described the experience of septic shock survivors at a tertiary, academic hospital (43:729-737; 43:738-746). In both reports, a significant percentage of index admissions resulted in death during hospitalization, at 23% and 32%, respectively. Around one-fourth of survivors were readmitted within 30 days of discharge, 23% and 26%. Both studies found that readmissions were often related to the index admission for sepsis instead of a new diagnosis, although there was a significant gap between the two, at 78% and 22%.
A fourth study, published in Annals of the American Thoracic Society, found the readmission risk to be 1.51 times greater (95% confidence interval, 1.38-1.66) than non-sepsis hospitalizations, in a comparison of post-acute care use at discharge and hospital readmission after 3,620 sepsis hospitalizations and 108,958 non-sepsis hospitalizations (Ann Am Thorac Soc 2015 March 9 [Epub ahead of print]). After controlling for pre-sepsis characteristics, readmissions after sepsis were more likely to result in death or transition to hospice care (6.1% vs. 13.3% after sepsis; P<0.001). Independent risk factors associated with 30-day readmissions after sepsis hospitalizations included age, cancer diagnosis, hospitalizations in the year before the index hospitalization, non-elective index admission type, one or more procedures during the index hospitalization, and low hemoglobin and high red-cell distribution width at discharge.
Jose L. Pascual, MD, PhD, surgical ICU co-medical director at the Hospital of Pennsylvania, Philadelphia, said the past five years mark a significant shift in thinking about sepsis and critical care, with a growing awareness of the difficulties these patients face after they leave the ICU.
“We’re just starting to understand that patients are significantly different in terms of post-ICU needs if they are septic patients,” he said.
Unfortunately, he noted, there is still little understanding of how to improve ICU and post-ICU care in ways that will reduce the difficulties that survivors face in the months after discharge.
“For now, vigilance is going to be what we can add to these ICU patients’ care until we have more information. We may need to really cross the t’s and dot the i’s on the patient who was septic in the ICU to make sure that before discharge, we’ve got the antibiotics, the follow-up cultures and follow-up visits teed up much more vigilantly.”
Lewis J. Kaplan, MD, interim chief of surgery and section chief for surgical critical care at the Philadelphia VA Medical Center and associate professor of surgery at the Perelman School of Medicine, University of Pennsylvania, said post-ICU care for septic patients should be considered a national health issue.
“This is a national problem rather than one exclusively for individual centers. Severe sepsis and septic shock are labor-intensive, financially costly, and they consume resources. You would expect to have as good an outcome as possible after directing all that toward the patient and their underlying disease processes. But you see rates of rehospitalization of 26% to 27% after sepsis,” he said.
The problem, he pointed out, is that the studies do not answer the question of why patients are readmitted at such high rates. The studies relied on administrative databases, which lack details on discharge regimens, patient compliance with follow-up care and specifics on antibiotic use.
Dr. Kaplan called for prospective studies that examine patient care in the outpatient sector. Innovative programs, such as a post-discharge ICU clinic, may be helpful, he said.
“Its impact on readmission after ICU care for severe sepsis or septic shock has never been studied, but it would seem, based upon these ICU readmission rates, that there’s a real opportunity and a need for an outpatient intervention like that,” he noted.
As the critical care medicine field waits for further research, Dr. O’Brien said surgeons, who often maintain a longer-term relationship with their patients than most intensivists, are more likely to care for sepsis survivors after discharge.
“They could help to connect the dots for patients that the post-sepsis symptoms they suffer are real and due to the sepsis, more than the trauma or surgery,” he said.
He emphasized the need for robust hand hygiene and judicious use of antibiotics for infections or prophylaxis, rather than noninfectious systemic inflammatory response syndrome.
“Sepsis is a major cause of death after surgery and after trauma. Surgical mortality and morbidity would be reduced with rapid identification and treatment of sepsis in postsurgical patients. Preoperative counseling of patients and their families to be partners in avoiding infections in the hospital by ensuring that anyone that touches the patient washes his or her hands first [is recommended],” he said.
Editor-in-chief of Critical Care Medicine, Timothy G. Buchman, MD, PhD, wrote an elegant and emotional foreword to the April 2015 issue, describing the immense toll that sepsis takes on patients, their families and friends. He recounts the way his English teacher, who later went on to become executive editor-in-chief at Random House, was pulled out of class to go to his brother who was dying of severe staphylococcal sepsis.
“The phone call came, his teacher left, and his life changed. Science and medicine replaced journalism as the goal,” he wrote, speaking about himself. “Half a century later, he’s rescuing septic patients. Writing forewords for Critical Care Medicine. Was he touched by the one case of fatal staphylococcal sepsis? Does he belong on the map?”
“You tell me.”