Supporting the Survivors of Sepsis

"The first hurdle is knowledge-based: knowing a patient experienced a recent sepsis diagnosis and sepsis hospitalization," says Benjamin A. Zaniello, MD, MPH.

This article was originally published August 26, 2020 on PSQH by John Palmer

Editor’s note: The following Q&A resulted from a conversation with Benjamin A. Zaniello, MD, MPH, chief medical officer at Salt Lake City–based Collective Medical. The company recently rolled out an event notification and care collaboration platform that identifies patients with a history of sepsis so that care teams may more quickly intervene to address these patients’ unique needs.

Sepsis is the number one driver of hospital costs in the United States and—according to the CDC—accounts for more than one-third of hospital deaths and more than $24 billion in hospital expenses. Sepsis is the most expensive all-payer condition in the United States.

PSQH: Why is sepsis such a prevalent problem in U.S. hospitals? Why are survivors rehospitalized so often? What are the factors that put them at such high risk?

Benjamin Zaniello: Sepsis is prevalent in U.S. hospitals for a variety of reasons—from the fact that it’s not always easy to identify sepsis before it becomes life-threatening to the high number of seniors living in the U.S. with multiple comorbidities such as heart disease and kidney failure. One recent study indicated that sepsis is associated with one in five deaths globally, twice the amount that some previous estimates indicated. That’s not surprising, considering how insidious it is.

The main problem is that sepsis is hard to identify because it has multiple signs. In an elderly patient, sepsis could originate from an untreated or undertreated UTI. In a pregnant woman, it could manifest from the flu. In a child, it could escalate from a skin infection.

It is a problem of sensitivity versus specificity. It’s very easy to be specific—to know a patient has sepsis when it’s too late. It’s hard to be sensitive in sepsis identification when the potential at-risk population is so large.

PSQH: What do you think is the biggest hurdle to overcome when it comes to preventing the rehospitalization of a sepsis patient?

Zaniello: The first hurdle is knowledge-based: knowing a patient experienced a recent sepsis diagnosis and sepsis hospitalization. Often physicians have no idea that someone who arrives in their ED or clinic had a recent history of sepsis. We know from the statistics that only half of all patients fully recover post-sepsis and the other half needs very, very close follow-up—but they aren’t usually getting the level of close follow-up care that they need.

With sepsis you often see comorbidities like congestive heart failure, which requires close follow-up to monitor weight and manage edema and medication. Another common side effect of sepsis is acute renal failure, which, if not addressed by a specialist post-discharge, can turn into chronic renal failure (and a higher risk of rehospitalization).

The second biggest hurdle is the fragmentation of our healthcare system. Sepsis patients are often managed in one hospital, but their follow-up is in another—we frequently see the patient transferred from their community hospital to a Level I trauma center or an academic hospital, but when they’re transferred back to their community hospital, information isn’t shared between facilities and providers.

Until recently, sharing that kind of information across a network—between disparate health systems, even in the same state—was next to impossible.

PSQH: What is the intent of rolling out the sepsis history alerting functionality on the Collective platform, and how does it work?

Zaniello: A study published by JAMA found 42.6% of severe sepsis survivors were rehospitalized within 90 days—so it’s absolutely essential for care teams to know these patients are at high risk. To do this, hospitals and healthcare systems need to be able to address the gaps in care coordination that affect the outcomes of their patients. Sepsis patients or those with history of sepsis are high-risk and high-needs patients that benefit from careful, close collaboration post-discharge.

The highest-risk patients are geriatric patients, discharged from postacute facilities, who require more intensive care collaboration and monitoring. By flagging patients with history of sepsis in our system, care providers on the Collective Medical network can intervene much more quickly. Health plans, ACOs, and relevant healthcare providers are notified as soon as their patients are discharged with a recent history of sepsis, allowing them to collaborate with critical providers notified at point of care. Likewise, when a sepsis survivor presents at an ED, physicians and nurses are notified in real time of the patient’s history with sepsis, allowing them to act more quickly and with better context.

PSQH: Is there an area of the country where sepsis rehospitalization seems to be a bigger problem than others? Why?

Zaniello: From what I’ve seen, states that have a stronger managed care network tend to have a slightly lower risk of sepsis, while more urban areas with higher concentrations of patients will have a higher rate of sepsis per capita. The states with an older population like Florida are going to have a higher rate because they have a larger geriatric population.

But it is a risk everywhere—even in the most highly-rated hospitals staffed with the best care providers in the world. The best way to effectively lower our risk of rehospitalization is to address sepsis before it exacerbates by identifying risk factors early, intervening on a timely basis, and using the technology and resources at our disposal to coordinate care.

PSQH: What results have you seen in the short time the alert system has been rolled out?

Zaniello: Prior to the national rollout, the states that used the Collective Medical platform saw significant reduction in various outcomes, including avoidable ED visits. In Oregon, for example, use of the Collective platform contributed to a statewide reduction in potentially avoidable ED visits from patients with patterns of high utilization by 11.2% across 2018. As an example of another outcome supported by our platform, during that same time period, comorbid substance use disorder–related visits fell by 4%, while visits within 90 days following development of an initial care guideline fell 31%.

We’re really encouraged by these figures. With sepsis, ultimately, you’re dealing with something that is hard to identify [until] it arrives and presents an emergency that is frequently fatal.

By improving our identification of patients with high risk factors (e.g., those with previous incidents of sepsis) and notification process, it’s possible to change the scope of care and potential outcomes for those patients.

John Palmer is a freelance writer who has covered healthcare safety for numerous publications. Palmer can be reached at johnpalmer@palmereditorial.com.