By Joseph Shega, MD, Chief Medical Officer, VITAS Healthcare

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.¹

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.²

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.³

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.⁴

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
• Hyperlactatemia
• 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.⁵

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
  • Hyperlactatemia
  • 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 of 6 ADL or 1 of 5 IADL
  • Cognitive status
    • Any degree of dementia

VITAS provides these guidelines as a convenient tool. They do not take the place of a physician's professional judgment.

¹Centers for Disease Control and Prevention Data Reports. Available at: https://www.cdc.gov/sepsis/datareports/index.html

²Gadre, SK et al. Epidemiology and Predictors of 30-Day Readmission in Patients With Sepsis. CHEST 2019; 155(3):483-490

³Jones TK, et al. “Post-Acute Care Use and Hospital Readmission after Sepsis.” Ann Am Thorac Soc 2015 (12); 904–913

⁴Rhee C., et al. “Prevalence, Underlying Causes and Preventability of Sepsis-Associated Mortality in US Acute Care Hospitals.” JAMA Network Open. 2019;2(2):e187571

⁵Iwashyna TJ, et al. “Long-term Cognitive Impairment and Functional Disability Among Survivors of Severe Sepsis.” JAMA 2010;304(16):1787-1794]