This document discusses sepsis, post-sepsis syndrome, and the benefits of early hospice referral. Key points include: - Sepsis affects millions worldwide each year and is a leading cause of death in hospitals. Survivors often experience post-sepsis syndrome with new physical and cognitive impairments. - Early identification of sepsis and standardized hospital treatment can improve outcomes, but there is no consensus on best post-acute care. Hospice may be appropriate for some patients. - Over 40% of sepsis patients who die in the hospital meet hospice eligibility guidelines upon admission due to underlying terminal conditions exacerbated by sepsis. Hospice referral rates for sepsis patients remain low compared to non-

1. Sepsis and
Post-Sepsis Syndrome
Natural history, determinants of prognosis, and
benefits of early hospice referral
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Healthcare Corporation to be confidential.

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4. • 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
Goal

5. • Appreciate the identification and
natural history of sepsis
• Describe hospice eligibility for sepsis
– Hospitalization
– Post-acute
• Understand indicators of poor
prognosis in sepsis
• Incorporate a care model for
sepsis in hospice
• Integrate ICD-10 coding for sepsis
Objectives

6. • 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
1US Centers for Disease Control and Prevention. (2020). Data and Reports, retrieved from: https://www.cdc.gov/sepsis/datareports/index.html
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
3
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.
4Thompson, K., et al. (2018). Health-related outcomes of critically ill patients with and without sepsis. Intensive Care Med, 44(8):1249-1257.

7. 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.
Sepsis Incidence in US Hospitals, 2000 to 2014

8. • 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
• The median hospital cost
was $16,0002
– Hospital-acquired: $38,000
– Community-acquired: $7,000
• The comparative cost
of care by disease states:
– Diabetes: $32,000 vs.
non-diabetes: $13,000
• Readmission cost
averaged $25,0003
Sepsis and Healthcare Costs
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.
2Hajj, 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.
3
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

9. 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. 104 ºF,
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
Case of HS

10. What Is Sepsis?
• 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)

11. SIRS: Systemic Inflammatory Response Syndrome
• In 1991, SIRS criteria consensus conference
established “Sepsis-1”
• Sepsis-1 diagnosis requires at least 2 of
the following:
– Tachycardia (heart rate > 90 beats/min)
– Tachypnea (respiratory rate > 20 breaths/min)
– Fever or hypothermia (temperature > 38ºC or < 36ºC)
– Leukocytosis, leukopenia, or bandemia (white blood cells
> 1,200/mm3, < 4,000/mm3, or bandemia ≥ 10%)
• Sepsis is infection or suspected infection leading to SIRS

12. Max SOFA
Score
Mortality,
%
0-6 < 10
7-9 15-20
10-12 40-50
13-14 50-60
15 > 80
15-24 > 90
Marik, P. & Taeb, A. (2017). SIRS, qSOFA and new sepsis definition. Journal of Thoracic Disease, 9(4), 943.
SOFA: Sequential Organ Failure Assessment Score

13. Sepsis Related Organ Failure Assessment: https://qsofa.org/
qSOFA (quick SOFA) Criteria Points
Respiratory rate ≥ 22/min 1
Change in mental status 1
Systolic blood pressure ≤ 100 mmHg 1
qSOFA: quick Sequential Organ Failure
Assessment Score

14. ©2019 VITAS®
Healthcare Corporation Adapted from Prescott, H. & Angus, D. (2018). Enhancing Recovery from Sepsis: A Review. JAMA, 319(1), 62-75.
Sepsis: Important Factors in Clinical Course
and Outcomes
Complex
interactions
among host,
medical conditions,
contextual, and
pathogen
factors
Complex
interactions
among
interaction among
host factors,
medical conditions,
manifestations
of sepsis, and
treatments
Pre-sepsis
(3 months)
Onset of sepsis Hospitalization
for sepsis
Resolution of
the acute septic
episode
Post-sepsis
(3 months)
Host risk factors
nutritional status,
functional status,
cognitive status,
uncontrolled symptoms
Medical conditions
advanced illness,
multimorbidity, frailty
Contextual features
recent hospitalizations,
ED visits, social
determinants of health
Pathogen factors
virulence, load,
antibiotic
susceptibility, other
Clinical manifestations
circulatory shock,
respiratory failure, renal
injury, delirium, coma,
coagulopathy, metabolic
changes and increased
lactate, other
System dysregulation
immune, inflammatory,
endocrine, microbiome,
other
Treatment considerations
sepsis protocol, manage
pain and agitation,
hospice care for
non-responders/declining
with treatment or
goals-of-care comfort
Clinical manifestations
progression of host factors
and/or medical conditions to
end stage, recurrent infections,
exacerbation of heart failure,
COPD or acute renal failure,
refractory delirium/cognitive
impairment, swallowing
dysfunction with dysphagia
Contextual factors
hospital readmission,
ED visits
Post-acute care
skilled facility, home health,
no post-acute care, hospice

15. ©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
Sepsis: Common Clinical Trajectories

16. 1US Department of Health and Human Services. (2020). Solving Sepsis: Transforming Health Security. Retrieved from DRIVe.HHS.gov
2Prescott, H. & Angus, D. (2018). Enhancing Recovery from Sepsis: A Review. JAMA, 319(1), 62-75.
3
Thompson, K., et al. (2018). Health outcomes of critically ill patients with and without sepsis. Intensive Care Medicine, 1249-1257. doi: 10.1007/s00134-018-5274-x.
Sepsis Characteristics
• Physical location
– 80% community-acquired1
– 26% healthcare-associated
(NH/recent hospital/dialysis)
– 7.5% hospital-acquired2
– 20% of all deaths
are sepsis-related
– 30% of sepsis
survivors experience
post-sepsis syndrome3
• Body location
– Pneumonia (40%)
– Abdominal
– Genitourinary
– Primary bacteremia
– Skin/soft tissue infection

17. Case of HS (cont.)
Day 1 Day 8
Day 5
48 hrs
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

18. 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.
Sepsis and Hospital Mortality
• An estimated 25%-50% of hospital deaths are sepsis-related
– 93% sepsis was present on admission
– 7.5% developed sepsis during hospital stay
• Compared to patients who died in the hospital without sepsis,
hospitalized patients who died of sepsis were more likely to:
– Be admitted from acute rehabilitation or long-term care
– Be admitted to the intensive care unit
– Die in the hospital than on hospice

19. 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.
Hospital Deaths, Sepsis, and Hospice
All Deaths
• 568 patients included in analysis
– 395 (69.5%) died in the hospital
– 173 (30.5%) discharged
to hospice
• Of the 173 patients discharged
to hospice
– 59 (34.1%) died within 1 week
Sepsis vs. Non-Sepsis Deaths
• 19% of sepsis deaths were
referred to hospice
• 43.3% non-sepsis deaths
were referred to hospice

20. 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.
Sepsis and Hospice Eligibility: Hospital
• 40% (121 of 300) of sepsis deaths
met hospice eligibility guidelines at
time of hospital admission
• Most common terminal
conditions are:
– Solid cancer 20%
– Hematologic cancer 5.3%
– Advanced cardiac disease 16%
– Dementia 5%
– Stroke 4%
– Advanced lung disease 4%

21. Sepsis and Hospice Eligibility: Hospital
• Hospice-eligible, not previously identified:
– Cancer, solid tumor, and hematologic
– Advanced cardiac disease
– Advanced lung disease
– Dementia
• Clinical complications of sepsis
associated with death:
– Vasopressors
– Mechanical ventilation
– Hyperlactemia
– Acute kidney injury
– Hepatic injury
– Thrombocytopenia

22. Causes of Death in Patients With Sepsis
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.
0 5 10 15 20 25 30 35 40
Sepsis
Progressive Cancer
Heart Failure
Hemorrhage
Cardiac Tamponade
Stroke
Myocardial Infarction
Infection Without Sepsis
Other Pulmonary
Unknown
Aspiration
Other
Immediate Cause of Death in All Patients
All Deaths (Immediate Cause), %
0 5 10 15 20 25
Solid Cancer
Chronic Heart Disease
Hermatologic Cancer
Dementia
Chronic Pulmonary Disease
Unknown
Chronic Liver Disease
Chronic Renal Disease
Stroke
Other
Cause of Death in Patients With Sepsis
Sepsis-Associated Deaths (Underlying Cause), %

23. 0 10 20 30 40 50 60
Thrombocytopenia
Hepatic injury
Acute kidney injury
Hyperlactatemia
Mechanical
ventilation initiation
Vasopressor
initiation
Organ Dysfunction or Associated Mortality
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.
A greater number
of organs with
dysfunction
increases the
likelihood of hospital
death and the need
for a goals-of-care
conversation.
Organ dysfunction or mortality, %
0 20 40 60 80 100
≥4
≥3
≥2
≥1
Associated Mortality by Number of
Organ Dysfunction Criteria Met
Organ dysfunction or mortality, %
Number
of
criteria
met
Factors Associated With Hospital-Related Death
Proportion of sepsis cases with organ dysfunction Associated mortality

24. Case of HS: Sepsis Course
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

25. Case of HS: Sepsis Course
• 5 days post-admission, condition
has not improved
– Ventilator-dependent
– Palliative care consult to discuss
goals of care (GOC), and
trach and PEG tube placement
– Husband reveals patient’s
specific request for DNR.
Trach and PEG tube deferred
– Referral for VITAS hospice
services with general inpatient
(GIP) level of care
Day 1 Day 8
Day 5
48 hrs
Hospital
Admission

26. Case of HS: Sepsis Course (cont.)
• 8 days post-admission
– Compassionate extubation
along with admission to
VITAS GIP level of care
for management of
SOB and restlessness
Day 1 Day 8
Day 5
48 hrs
Hospital
Admission
• During the night, HS’ vital signs deteriorate, and she shows
signs of restlessness:
– Hospital nurse calls VITAS Telecare
– VITAS Telecare clinician dispatches VITAS RN to hospital
– VITAS RN confirms that HS is actively dying and
administers medication for symptom management
– VITAS RN notifies on-call psychosocial staff member
to support husband at bedside
– HS responds to medication and is resting comfortably
• 6 hours later, HS passes peacefully with husband at bedside
• Bereavement support provided to family

27. 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

28. Case of HS: Post-Sepsis Syndrome Course
Day 1 Day 14
48 hrs 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

29. Day 1 Day 14
Day 10
Case of HS: Post-Sepsis Syndrome Course (cont.)
• 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

30. 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

31. Yende, S., et al. (2019). Long-term Host Immune Response Trajectories Among Hospitalized Patients With Sepsis. JAMA Network Open, August, 2(8), e198686.
• Inflammatory and immune changes persist in many patients
Post-Sepsis Syndrome
Inflammatory and Immunosuppression Biomarker Values Collected at Each Scheduled Collection Time Point

32. Prescott, H. & Angus, D. (2018). Enhancing Recovery from Sepsis: A Review. JAMA, 319(1), 62-75.
Post-Sepsis Syndrome (cont.)
• 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

33. Iwashyna, T., Ely, E., Smith, D., & Langa, K. (2010). Long-Term Cognitive Impairment and Functional Disability Among Survivors of Severe Sepsis. JAMA, 304(16), 1797-1794.
Sepsis Cognitive and Functional Outcomes

34. Prescott, H. & Angus, D. (2018). Enhancing Recovery from Sepsis: A Review. JAMA, 319(1), 62-75.
Post-Sepsis Syndrome (cont.)
• 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

35. Case of HS: Post-Sepsis Syndrome Course (cont.)
Day 1 Day 141
Day 4
Hospice
Admission
• Same-day hospice admission and
initial PoC 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

36. Buchman, T., et al. (2020). Sepsis Among Medicare Beneficiaries: 2. The Trajectories of Sepsis, 2012–2018. Critical Care Medicine, 48(3), 289.
Sepsis and Post-Acute Care Utilization

37. 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 are
readmitted to the
hospital within 30
days of an initial
sepsis episode are
twice as likely to die
or enroll in hospice
as patients not
admitted for sepsis
Sepsis and Readmissions

38. Prescott, H. (2017). Variation in post-sepsis readmission patterns: A cohort study of VA beneficiaries. Annals of the American Thoracic Society. February, 14(2), 220-237.
Sepsis and Readmissions (cont.)
2009 (N=15,836 readmissions) diagnosis
category (proportion of readmissions
that are for this diagnosis)
2010 (N=17,021 readmissions) diagnosis
category (proportion of readmissions
that are for this diagnosis)
2011 (N=16,844 readmissions) diagnosis
category (proportion of readmissions
that are for this diagnosis)
1 Congestive heart failure (7.0%) Congestive heart failure (7.6%) Congestive heart failure (7.4%)
2 Pneumonia (5.4%) Pneumonia (5.3%) Pneumonia (5.1%)
3 Sepsis (4.8%) Sepsis (4.9%) Sepsis (4.7%)
4 Urinary tract infection (4.6%) Urinary tract infection (4.6%) Urinary tract infection (4.5%)
5 Acute renal failure (4.3%) Chronic obstructive pulmonary disease (4.1%) Acute renal failure (4.4%)
6 Chronic obstructive pulmonary disease (3.9%) Acute renal failure (4.0%) Chronic obstructive pulmonary disease (4.0%)
7 Complication of device, implant, graft (2.8%) Acute respiratory failure (2.7%) Complication of surgical or medical care (2.8%)
8 Complication of surgical or medical care (2.7%) Fluid/electrolyte-disorder (2.7%) Complication of device, implant, or graft (2.7%)
9 Fluid/electrolyte disorder (2.6%) Complication of device, implant, or graft (2.4%) Acute respiratory failure (2.6%)
10 Acute respiratory failure (2.5%) Complication of surgical or medical care (2.4%) Fluid/electrolyte disorder (2.6%)

39. Case of HS: Post-Sepsis Syndrome Course (cont.)
• 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
• 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
Day 1 Day 141
Day 124 Day 127
Hospice
Admission
Day 4

40. Sepsis and Hospice Guidelines: Hospital Discharge
• Hospice-eligible, not previously identified
– Cancer, solid tumor, and hematologic
– Advanced cardiac disease
– Advanced lung disease
– Dementia
• Pre-hospital functional ability
– Physical impairment
• 1 of 6 ADL or 1 of 5 IADL
– Cognitive status
• Any degree of dementia

41. Pre-Sepsis Function and Cognition on Post-Hospital Survival
• Patients with functional
and cognitive impairment
prior to sepsis who
survive hospitalization
have a high 6-month
mortality that supports
hospice as a relevant
and important post-acute
care option
Iwashyna, T., Ely, E., Smith, D., & Langa, K. (2010). Long-Term Cognitive Impairment and Functional Disability Among Survivors of Severe Sepsis. JAMA, 304(16), 1797-1794.

42. Case of HS: Post-Sepsis Syndrome Course (cont.)
• Two weeks later:
– HS continues to decline
despite aggressive respiratory
symptom management
– She dies peacefully
surrounded by family
– Hospice RN attends death, prepares
HS’s body for viewing and transport, and
supports her husband in the process
Day 1 Day 141
Hospice
Admission
Day 4 Day 127
Day 124

43. 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
Benefits of Early Identification of Hospice-Eligible Sepsis
Patients and Alignment With Care Goals

44. Datta, R., et al. (2019). Increased Length of Stay Associated with Antibiotic Use in Older Adults with Advanced Cancer Transitioned to Comfort Measures.
American Journal of Hospice and Palliative Medicine, 37(1): 27-33. doi: 10.1177/1049909119855617
Antibiotics in Hospice
• Symptom benefits
– Urinary tract response up to 92%
– Respiratory infections symptom
response up to 53%
– Less symptomatic benefit to
bloodstream infection
• Unclear whether antibiotics in the last
week of life improve symptom burden
• Higher risk of medication toxicities
• Increased patient burden
(diagnosis and monitoring)
• Patient preferences
– Advanced cancer home hospice
population, 79% preferred no
antibiotics or for symptom
benefit only

45. Skin
Upper
Respiratory
Lower
Respiratory
UTI
• Erythema
• Malodor
• Fever
• Pain
Infections and Symptoms
• Frequency
• Dysuria
• Agitation
• Confusion
• Fever
• Short of breath
• Cough
• Chest/back pain
• Agitation
• Fever
• Fatigue
• Cough
• Sneeze
• Sore throat
• Fatigue
• Sinus pressure
• Fever

46. Infections and Management Consideration
• Symptom assessment
• Pharmacologic and
non-pharmacologic considerations
• Time of onset and duration of action
– Nebs/opioids vs. antibiotics
for SOB
• Adverse effects, including allergies
• Feasibility (ability to swallow,
route available, cost)
• Treatment schedule
– Scheduled vs. as-needed
• Prognosis
• Care goals

47. Goals-of-Care Conversation
Build
trust and
respect
Develop
a collaborative
plan
Understand
what patient
and caregiver
know
Patient-Centric
Care Inform
of evidence-
based
information
Listen
to goals and
expectations

48. ICD-10 Coding for Sepsis, SIRS, and Post-Sepsis Syndrome
(Acute Causes of Death Only)
ICD-10 Description
A41.9 Sepsis, unspecified organism
A41.52 Sepsis due to Pseudomonas
J69.0
Pneumonitis due to inhalation
of food and vomit
ICD-10 Description
R65.20
Severe sepsis without
septic shock
R65.21
Severe sepsis with septic
shock
R65.11
Systemic inflammatory
response syndrome (SIRS)
of non-infectious origin with
acute organ dysfunction
ICD-10 Description
J96.00
Acute respiratory failure,
unspecified
I50.9 Heart failure, unspecified
K72.00
Acute and subacute
hepatic failure
N17.9
Acute renal failure,
unspecified
G93.40 Encephalopathy, unspecified
Underlying Infection Sepsis/SIRS Organ Dysfunction

49. Questions?

50. Adapted from Prescott, H. & Angus, D. (2018). Enhancing recovery from sepsis: a review. JAMA, 319(1), 62-75.
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.
Datta, R., et al. (2019). Increased Length of Stay Associated with Antibiotic Use in Older Adults with Advanced Cancer Transitioned
to Comfort Measures. American Journal of Hospice and Palliative Medicine, 37(1): 27-33. doi: 10.1177/1049909119855617
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.
Iwashyna, T., Ely, E., Smith, D., & Langa, K. (2010). Long-term cognitive impairment and functional disability among survivors
of severe sepsis. JAMA, 304(16), 1797-1794.
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. & Taeb, A. (2017). SIRS, qSOFA and new sepsis definition. Journal of Thoracic Disease, 9(4), 943.
Prescott, H. & Angus, D. (2018). Enhancing recovery from sepsis: a review. JAMA, 319(1), 62-75.
References

51. Prescott, H. (2017). Variation in post-sepsis readmission patterns: A cohort study of VA beneficiaries. Annals of the American Thoracic
Society, 14(2), 220-237.
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 from DRIVe.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
Yende, S., et al. (2019). Long-term Host Immune Response Trajectories Among Hospitalized Patients With Sepsis. JAMA Network Open,
August, 2(8), e198686.
References

52. 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 and healthcare
professionals. While it cannot replace professional clinical judgment, it is
intended to guide clinicians and healthcare professionals in establishing
hospice eligibility for patients through evaluation and management of
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.