Sepsis and Post-Sepsis Syndrome

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Sepsis and Post-Sepsis Syndrome Is your patient hospice-eligible? VITAS can help.
Sepsis and
Post-Sepsis Syndrome

Sepsis and Post-Sepsis Syndrome Is your patient hospice-eligible? VITAS can help. Confidential and Proprietary Content
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CE Provider Information

Goal
• 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

Objectives
• 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

1
US 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
3Rhee, 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.
• 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

Sepsis Incidence in US Hospitals, 2009 to 2014
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 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.
3Gluck, 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.
• 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

Case of HS
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

• 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)
What Is Sepsis?

• 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
SIRS: Systemic Inflammatory Response Syndrome

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

qSOFA: quick Sequential Organ Failure Assessment Score
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

©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
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
Resolution of
the acute septic
episode

Background: Dementia Epidemiology
©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

1
US Department of Health and Human Services. (2020). Solving Sepsis: Transforming Health Security. Retrieved from DRIVe.HHS.gov
2Prescott, H., et al. (2018). Enhancing Recovery from Sepsis: A Review. JAMA, 319(1), 62-75.
3Thompson, 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.
• 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
Sepsis Characteristics

Case of HS (cont.)
Day 1 Day 8
Day 5
48 hrs
Hospital
Admission
• 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
• Admitted to ICU from
ED; Sepsis Alert
System activated
– Multiple IV antibiotics
– Volume resuscitation
– Wound care

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.
• An estimated 25%-50% of hospital deaths are sepsis-related
– Sepsis was present on admission: 93%
– Developed sepsis during hospital stay: 7.5%
• 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
Sepsis and Hospital 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.
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
Hospital Deaths, Sepsis, and Hospice

• 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%
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
– Hyperlactatemia
– Acute kidney injury
– Hepatic injury
Sepsis and Hospice Eligibility: Hospital

Cause of Death in Patients With Sepsis
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
Hematologic Cancer
Dementia
Chronic Pulmonary Disease
Unknown
Chronic Liver Disease
Chronic Renal Disease
Stroke
Other
Cause of Death in Patients With Sepsis

Factors Associated With Hospital-Related Death
0 10 20 30 40 50 60
Thrombocytopenia
Hepatic injury
Acute kidney injury
Hyperlactatemia
Mechanical
ventilation initiation
Vasopressor
initiation
Organ Dysfunction or Associated Mortality
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
Proportion of sepsis cases with organ dysfunction Associated mortality

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: Sepsis Course

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

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

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 dUnsteady gait
– Dependent
– Status-post fall
Sepsis-associated organ dysfunction:
• Vasopressor initiation
• Mechanical ventilation initiation
• Hyperlactatemia
• Acute kidney injury
• Thrombocytopenia
Case of HS: Post-Sepsis Syndrome Course

Case of HS: Post-Sepsis Syndrome Course
Day 14
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
initiated for acute
respiratory failure,
secondary to
bilateral pneumonia
– Acute renal failure;
hemodialysis initiated
– IV vasopressors initiated
– Hyperlactatemia
Day 1 48 hrs

Hospice Care’s Impact on Caregiver Health
Day 1 Day 14
• 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
Day 10

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

Post-Sepsis Syndrome
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
Inflammatory and Immunosuppression Biomarker Values Collected at Each Scheduled Collection Time Point

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

Sepsis Cognitive and Functional Outcomes
Iwashyna, T., et al. (2010). Long-Term Cognitive Impairment and Functional Disability Among Survivors of Severe Sepsis. JAMA, 304(16), 1797-1794.

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

Hospice
Admission
• Same-day hospice admission and initial
Plan of Care 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
Day 1 Day 141
Day 4

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

Sepsis and Readmissions
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

Riester, M., et al. (2022). Causes and timing of 30-day rehospitalization from skilled nursing facilities after a hospital admission for pneumonia or sepsis. PloS one, 17(1), e0260664.
Daily Risk of 30-Day Unplanned Hospital
Readmission Among Older Adults
0
0.0001
0.0002
0.0003
0.0004
0.0005
0.0006
0 2 3 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
Infectious Circulatory Respiratory Genitourinary

• 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
Day 1 Day 141
Day 124 Day 127
Hospice
Admission
Day 4
• 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

Case of RA: Clinical Indicators of Poor Prognosis
• 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
Sepsis and Hospice Guidelines: Hospitals Discharge

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.
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

Inouye, S., et al. (1990). Clarifying Confusion: the Confusion Assessment Method: a New Method for Detection of Delirium. Annals of Internal Medicine, 113(12), 941-948.
• Two weeks later:
– HS continues to decline despite aggressive
respiratory symptom management
– She dies peacefully surrounded by family
Day 1 Day 141
Hospice
Admission
Day 4 Day 127
Day 124
– Hospice RN attends death, prepares
HS’s body for viewing and transport, and
supports her husband in the process

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

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

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

Goals of Care (GOC) Conversation
Develop
a collaborative plan
Understand
what patient and
caregiver know
Listen
to goals and
expectations
Inform
of evidence-based
information
Build
trust and respect
Post-Centric
Care

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

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:
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