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Sepsis

The development of sepsis is associated with a very high in-hospital mortality. In fact, 1 (or more) in 3 hospital deaths are sepsis-related.

Sepsis is one of the most serious conditions in the United States, with approximately 250,000 annual deaths. The estimated annual cost of sepsis readmissions is >$3.5 billion.
Additionally, post-acute care use and hospital readmissions are common after sepsis. The increased readmission risk after sepsis was observed regardless of sepsis severity and was associated with adverse readmission outcomes.
Sepsis 30-day readmissions are twice as likely to die or enroll into hospice compared to non-sepsis readmission.
Despite this, hospice is inadequately utilized for sepsis patients. In one study, 40% of sepsis deaths met hospice eligibility guidelines at the time of hospital admission.
Any patient with advanced illness and a clinical complication of sepsis is a candidate for a goals-of-care discussion and the consideration of hospice services.

Clinical Progression of Sepsis

The clinical course of sepsis can be divided into pre-sepsis, sepsis and post-sepsis, with patients generally following a trajectory based on underlying health status.

Important determinants of status pre-sepsis include:

Nutritional, functional and cognitive status
Symptom burden in conjunction with:
- Medical factors (multi-morbidity and advanced illness)
- Contextual factors (healthcare utilization and social determinants of health)
- Pathogenic factors (virulence, load and antibiotic susceptibility)

Sepsis-related determinants include clinical manifestations plus some degree of system dysregulation. Clinical manifestations:

Respiratory failure
Circulatory shock
Renal injury
Delirium
Metabolic changes
Coagulopathy
Liver injury
Increased lactate

The most common advanced illnesses associated with sepsis-related hospital deaths include:

Metastatic cancer
NYHA class III/IV heart failure
Advanced lung disease (defined as SOB at rest or with minimal exertion, with or without oxygen)
Dementia with any difficulty in ADLs

The more clinical factors or organ dysfunction present, the higher the in-hospital mortality due to sepsis. Clinical complications include:

Vasopressors
Mechanical ventilation
Hyperlactemia
Acute kidney injury
Hepatic injury
Thrombocytopenia

Hospice Eligibility:

Sepsis-related complications, particularly organ dysfunction, should trigger goals of care conversations, especially when the patient has an end-stage condition such as cancer (solid tumor or hematologic), heart disease, lung disease or dementia.

Patients with functional and cognitive impairments pre-sepsis are significantly more likely to die after hospital discharge than those patients who are functionally and cognitively intact—and should be referred to hospice.

Patients who survive hospital-incurred sepsis often develop decrements in health status along with disease exacerbation such as impaired cardiac or lung function, refractory delirium/cognitive impairment, or dysphagia. As noted above, ED utilization and hospital readmission are common upon hospital discharge.

It is incumbent upon the hospital to delineate the most appropriate post-acute care site: skilled nursing, home health or hospice. Those patients eligible for hospice have an underlying advanced illness or, prior to sepsis, had an underlying physical disability or cognitive impairment.

Hospital Inpatient:

Hospice eligible, not previously identified
- Cancer-solid tumor and hematologic
- Heart disease
- Lung disease
- Dementia

Clinical complications of sepsis
- Vasopressors
- Mechanical ventilation
- Hyperlactemia
- Acute kidney injury
- Hepatic injury
- Thrombocytopenia

At Hospital Discharge

Hospice eligible, not previously identified
- Cancer-solid tumor and hematologic
- Heart disease
- Lung disease
- Dementia

Pre-hospital functional ability
- Physical impairment
  - 1 or 6 ADL's or 1 or 5 ADL's
- Cognitive status
  - Any degree of dementia