The goal of this webinar is to educate healthcare clinicians about the history, incidence, impact and identification of sepsis in the acute-care setting. Hospice care is inadequately utilized for patients with sepsis, a serious condition that results in 250,000 US deaths each year and an annual $3.5 billion in hospital readmission costs.

1. Sepsis & Hospice Eligibility
Natural History, Prognosis
&
Role of Hospice

2. CE Provider Information
VITAS Healthcare programs are provided CE credits for their Nurses/Social Workers and Nursing Home Administrators through: VITAS
Healthcare Corporation of Florida, Inc/CE Broker Number: 50-2135. Approved By: Florida Board of Nursing/Florida Board of Nursing
Home Administrators/Florida Board of Clinical Social Workers, Marriage and Family Therapy & Mental Health Counseling.
VITAS Healthcare programs in Illinois are provided CE credit for their Nursing Home Administrators and Respiratory Therapists
through: VITAS Healthcare Corporation of Illinois, Inc./8525 West 183 Street, Tinley Park, IL 60487/NHA CE Provider Number:
139000207/RT CE Provider Number: 195000028/Approved By the Illinois Division of Profession Regulation for: Licensed Nursing Home
Administrators and Illinois Respiratory Care Practitioner.
VITAS Healthcare programs in California/Connecticut/Delaware/Illinois/Northern Virginia/Ohio/Pennsylvania/Washington
DC/Wisconsin are provided CE credit for their Social Workers through VITAS Healthcare Corporation, provider #1222, is approved as a
provider for social work continuing education by the Association of Social Work Boards (ASWB) www.aswb.org, through the Approved
Continuing Education (ACE) program. VITAS Healthcare maintains responsibility for the program. ASWB Approval Period: (06/06/18 -
06/06/21). Social Workers participating in this course will receive 1 clinical continuing education clock hour(s). {Counselors/MFT/IMFT
are not eligible in Ohio}
VITAS Healthcare Corporation of California, 310 Commerce, Suite 200, Irvine, CA 92602. Provider approved by the California Board of
Registered Nursing, Provider Number 10517, expiring 01/31/2019.
Exceptions to the above are as follows: AL: No NHAs, DE: No NHAs, DC: No NHAs, GA: No NHAs, KS: No NHAs, NJ: No
NHAs, OH: No NHAs, PA: No NHAs, TX: No NHAs, VA: No NHAs, WI: No NHAs and Nurses are not required – RT only receive CE
Credit in Illinois.
01-2019

3. Goal
• Appreciate the role of hospice in the care of patients that develop
sepsis in the acute care hospital and post acute space

4. • 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

5. • Sepsis affects 1.5 million people per year in the US
– 19 million worldwide
• Recommendations exist for inpatient hospital care
– Standard/rapid identification and management
– About 1 in 3 die in the hospital; many hospice eligible at admission
• Inpatient mortality has declined over the last decade, but many still die in the hospital or
soon afterward
Background

6. Rhee C et al. Incidence and trends of sepsis in US hospitals using clinical vs claim data, 2009 to 2014. JAMA 2017; 318(13):1241-1249
Sepsis Incidence in US Hospitals, 2000 to 2014

7. • No consensus recommendations on best post-hospitalized care
– New symptom burden
• Pain, fatigue, dysphagia, poor attention, shortness of breath
- Long-term disability
• Cognitive
• Physical function
Background (cont.)

8. Iwashyna TJ et al. Long-term cognitive impairment and functional disability among survivors of severe sepsis. JAMA 2010;304(16):1787-1794.
Sepsis Cognitive and Functional Outcomes

9. Case of HS
HPI: 66 y/o female presents to ED with multiple infected 1st- and 2nd-degree burn
wounds to chest, abdomen, thighs and arms after she slipped/fell on hot cooking oil
seven days ago
PMH: COPD with SOB at minimal exertion/rest on oxygen, AODM, severe PVD,
obesity, s/p fall x 2, 1/6 ADL dependent
Treatments: Spiriva and Advair
Exam: Poor attention, temp. 104 ºF, pulse 120 bpm, RR 28/min, BP 90/60, WBC 15
& 15% bands, lung sounds with bilateral congestion & wheezing to bases, grossly
infected 1st- and 2nd-degree oil burn wounds (60% TBSA)

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) and septic shock (severe sepsis
plus hypotension not reversed with fluid resuscitation).
• Speed and appropriateness of therapy administered in the initial hours after severe
sepsis develops are likely to influence outcome.

11. What Is Sepsis?
• A life-threatening illness brought on by the body’s response to an infection
• Can lead to severe sepsis and septic shock
• Speed and appropriateness of therapy administered in the initial hours after severe
sepsis develops are likely to influence outcome

12. SIRS: Systemic Inflammatory Response Syndrome
• In 1991, SIRS criteria consensus conference established “Sepsis-1”
• Sepsis-1 diagnosis requires at least two of the following:
- Tachycardia (heart rate >90 beats/min)
- Tachypnea (respiratory rate >20 breaths/min)
- Fever or hypothermia (temperature >38 ºC or <36 ºC)
- Leukocytosis, leukopenia or bandemia (white blood cells >1,200/mm3,
<4,000/mm3 or bandemia ≥10%)
• Sepsis is an infection or suspected infection leading to SIRS
• Severe sepsis is complicated by organ dysfunction
• Septic shock is a sepsis-induced hypotension persisting despite adequate
fluid resuscitation

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

14. 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 PE, Taeb AM. SIRS, qSOFA and new sepsis definition. Chest 2017;151:586-596
SOFA: Sequential Organ Failure Assessment Score

15. Marik PE, Taeb AM. SIRS, qSOFA and new sepsis definition. Chest 2017;151:586-596
qSOFA: quick Sequential Organ Failure
Assessment Score
qSOFA (Quick SOFA) Criteria Points
Respiratory rate ≥22/min 1
Change in mental status 1
Systolic blood pressure ≤100 mmHg 1

16. Sepsis and Septic Shock for Common Patients

17. • Sepsis by physical location
– 63% community acquired
– 11% hospital acquired
– 26% health care associated (NH/recent hospital/dialysis)
• Sepsis by body location
– Pneumonia (40%)
– Abdominal
– Genitourinary
– Primary bacteremia
– Skin/soft tissue infection
Sepsis Characteristics
Prescott HC and Angus DC Enhancing recovery from sepsis: A review. JAMA. 2018; ;319(1):62-75

18. Sepsis: Important Factors in Clinical Course
and Outcomes
©2019 VITAS Healthcare Corporation
Adapted from H. C. Prescott, HC et al. “Enhancing Recovery From Sepsis: A Review,”
JAMA, vol. 319, no. 1, pp. 62-75, 2018.

19. Sepsis: Common Clinical Trajectories
©2019 VITAS Healthcare Corporation
Adapted from H. C. Prescott, HC et al. “Enhancing Recovery From Sepsis: A Review,”
JAMA, vol. 319, no. 1, pp. 62-75, 2018.

20. Jobes TK et al. Post–Acute Care Use and Hospital Readmission after Sepsis. Ann Am Thorac Soc 2015 (12); 904–913,
Sepsis, Rehospitalization and Post-Acute
Care Utilization
Outcome Non-sepsis Sepsis
Post-acute
Home Health 31.5% 30.1%
Acute Rehab 4.3% 8.7%
Skilled 10.6% 26.1%
LTAC 0.4% 8.6%
Hospital Readmission
7-Day 5.2% 10%
30-Day 15.6% 26%
90-Day 25.7% 42.4%
Inpatient Mortality or Hospice Discharge
Mortality 1.2% 32.8%
Hospice 1.6% 8.9% *Sepsis 30-day readmissions are twice as likely to die or enroll into
hospice compared to non-sepsis readmission
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

21. Hajj T, Natalie B, Salavaci J, Jacoby D. The “Centrality of Sepsis”: A Review on Incidence, Mortality, and Cost of Care.
Healthcare 2018, 6, 90
Sepsis and Health Care Costs
• The cost of sepsis and post-sepsis care continues to be a serious
healthcare burden
• Sepsis costs accounted for $23 billion, making it the most expensive
condition treated in US hospitals
• The median hospital cost was $16,000
– Hospital-acquired: $38,000
– Community-acquired: $7,000
• The cost of care by disease states
– Diabetes: $32,000 vs. non-diabetes: $13,000
• Readmission cost averaged around $25,000

22. Case of HS (cont.)
• 20 days prior to this hospitalization, HS had a previous hospitalization for pneumonia
exacerbation
– Follow up visit with pulmonologist for COPD
– Worsening SOB with optimal medical management
– PT initiated for unsteady gait s/p fall & dependence in 1 out of 6 ADLs
• On day 1 of hospital admission HS was admitted to ICU from ED, Sepsis Alert System
activated
– Multiple IV antibiotics
– Volume resuscitation
– Wound care

23. Case of HS (cont.)
• 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

24. Sepsis and Hospital Mortality
• Approximately 25 to 50% of hospital deaths are sepsis related
– 73.3% had sepsis present on admission
– 26.3% developed sepsis during hospital stay
• Patients with hospital sepsis deaths compared to non-sepsis deaths had the following:
– More likely admitted from acute rehabilitation or long-term care
– More likely to be admitted to the intensive care unit
– Death in the hospital as opposed to hospice

25. Rhee C. et al. Prevalence, Underlying Causes, and Preventability of Sepsis-Associated Mortality in US Acute Care Hospitals. JAMA
Network Open.2019;2(2):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 one week
Sepsis vs. Non-Sepsis Deaths
• 19% of sepsis deaths referred to
hospice
• 43.3% non-sepsis deaths referred
to hospice

26. Sepsis and Hospice Eligibility: Hospital
• Hospice eligible, not previously identified:
− Cancer, solid tumor and hematologic
− Heart disease
− Lung disease
− Dementia
• Clinical complications of sepsis associated
with death:
− Vasopressors
− Mechanical ventilation
− Hypercalcemia
− Acute kidney injury
− Hepatic injury
− Thrombocytopenia

27. • 40% (121 of 300) of sepsis deaths met hospice eligibility guidelines at time
of hospital admission
• Most common terminal conditions are as follows:
− Solid cancer 20%
− Hematologic cancer 5.3%
− Heart Disease 16%
− Dementia 5%
− Stroke 4%
− Advanced lung disease 4%
Hospice Eligible at Hospital Admission
Rhee C. et al. Prevalence, Underlying Causes, and Preventability of Sepsis-Associated Mortality in US Acute Care Hospitals. JAMA
Network Open.2019;2(2):e187571

28. Rhee C. et al. Prevalence, Underlying Causes, and Preventability of Sepsis-Associated Mortality in US Acute Care Hospitals. JAMA
Network Open. 2019;2(2):e187571
Cause of Death in Patients with Sepsis

29. Rhee C. et al. Prevalence, Underlying Causes, and Preventability of Sepsis-Associated Mortality in US Acute Care Hospitals. JAMA
Network Open 2019;2(2):e187571
Factors Associated with Hospital-Related Death
A greater number
of organs with
dysfunction
increases the
likelihood of
hospital death and
need for goals of
care conversation

30. • 23 days post admission
– Ventilator dependent, trach and peg tube placed
– 20 lb. weight loss
– Delirium is unresolved
– Dependence in 4/6 ADLs, PT initiated
• 30 days post admission
– Delirium continues
– GOC conversation with husband revealed patient’s specific request for DNR
– D/C to SNF with Hemodialysis, trach, peg and antibiotics
Case of HS (cont.)

31. Prescott HC and Angus DC Enhancing recovery from sepsis: A review. JAMA. 2018; ;319(1):62-75.
• Inflammatory and endocrine changes and immune suppression ongoing
• New functional limitations
– 1-2 new ADL limitations on average
• Physical weakness
• Myopathy and neuropathy
• Difficulty swallowing
– 63% aspiration on fiberoptic endoscopic evaluation
– Muscular weakness or damage
• Cardiovascular events occurred in 29.5% of patients in the year after sepsis.
– Persistent myocardial dysfunction
Post-Sepsis Syndrome

32. Prescott HC and Angus DC Enhancing recovery from sepsis: A review. JAMA.2018; ;319(1):62-75.
• Increased risk of recurring sepsis
– 9-fold elevated risk
• Increased cognitive impairment
– Persistent delirium
– Twice the risk of developing dementia
– Moderate to severe CI increased from 6.1% before hospitalization to 16.7% after
hospitalization
• 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.)

33. Sepsis and Hospice Guideline: 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

34. Iwashyna TJ et al. Long-term cognitive impairment and functional disability among survivors of severe sepsis. JAMA
2010;304(16):1787-1794.
Pre-Sepsis Function and Cognition on
Post-Hospital Survival
Patients with functional and
cognitive impairment prior
to sepsis who survive
hospitalization have a high
six-month mortality that
supports hospice as a
relevant and important
post-acute care option.

35. • 6 days after discharge to skilled (36 days later from sepsis):
– Congestion, fever and agitation
– SNF called 911; patient taken to ER
– Readmitted for DX of aspiration pneumonia
– Hospice referral initiated by hospital staff
– VITAS nurse met with patient and husband at hospital
• Discharge to home ICC:
– Symptoms of pain, SOB/congestion and wound care
– Antibiotics discussed and initiated
– 4 days later, symptoms improve and ICC is discontinued
– Renal failure somewhat improved and dialysis discontinued
HS Case (cont.)

36. Antibiotics and Hospice
• Hospice-based studies report overall antimicrobial use ranging
from 8-37%
• Hospitals or inpatient units prevalence of antimicrobial use for
hospice and palliative care patients is reported around 90%

37. Furuno et al, 2014 Servid et al, 2018
Antibiotic Tx 21.1% 17.6%
Documentation
Evaluated
70.8% associated
with infection during
current hospitalization
45% included a rationale
• Curative 37.5%
• Prophylaxis 26.4%
• Suppressive 22.2%
• Pt/family 19.4%
• Palliative 9.7%
Infection Source
Sepsis/Blood 40.3%
Pneumonia 38.9%
Pneumonia 19.5%
UTI 18.9%
Gastrointestinal 17%
Antibiotics Upon Hospice Admission

38. Antibiotics in Hospice
• Symptom benefits:
– Urinary tract infection response up to 92%
– Respiratory infection response up to 53%
– Least symptomatic benefit to bloodstream infection
• Patient preferences:
– Advanced cancer home hospice population, 79% preferred no antibiotics or
only for symptom benefit
• Unclear whether antibiotics in the last week of life improve symptom burden
• Higher risk of medication toxicities
• Increased patient burden

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

40. Infections and Management Considerations
• Symptom assessment
• Pharmacologic and non-pharmacologic considerations
• Time of onset and duration of action
− Nebs/opioid versus antibiotic for SOB
• Adverse effects including allergies
• Feasibility (ability to swallow, route available, cost)
• Treatment schedule
− Scheduled versus as-needed
• Prognosis
• Care goals

41. Build
Trust and
Respect
Understand
What patient
and caregiver
know
Develop
A collaborative
plan
Listen
To goals and
expectations
Inform
Of evidence
based
information
Patient
Centered
Care
Goals of Care Discussion

42. Case of HS (cont.)
• Benefited from IDT for 4 weeks, but over weekend increased secretions and SOB
• ICC initiated again at home for symptoms of SOB, secretions, fever and
presumed pneumonia
• Patient not tolerating peg tube feedings secondary to disease progression as
evidenced by 2nd aspiration pneumonia
• Goals of care conversation with husband re: treatment approach:
– Feedings – husband elected to d/c further peg tube feedings
– Antibiotics – husband did not want to initiate treatment, instead used
acetaminophen RCT and aggressive symptom management
• Patient passes several days later with family at bedside

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
• Nutritional
Counseling
• Goals of Care
Conversations
High Acuity
• Telecare®
• Intensive
Comfort Care®
• General
Inpatient Care
• Visits After
Hours and
Weekends
• Visit Frequency
• Physician
Support
Levels of Care
• Home/Routine
• Respite
• Continuous
• Inpatient
Benefits to Early Identification of Hospice-Appropriate
Patients

44. ICD Coding for Sepsis
Acute Causes
of
Death Only
(made easy)

45. Sepsis/SIRS
• Multi-organ system failure
• Can be due to infection or not
• Can involve shock or not
• These are secondary codes that require primary codes

46. ICD-10 Description
A419 Sepsis, unspecified organism
A4152 Sepsis due to Pseudomonas
J69.0 Pneumonitis due to inhalation of food and vomit
First: Code the Underlying Infection

47. Second: Code the Sepsis
ICD-10 Description
R65.20 Severe Sepsis without septic shock
R65.21 Severe Sepsis with septic shock

48. Third: Code Any Organ Dysfunctions
ICD-10 Description
J96.00 Acute respiratory failure, unspecified
I50.9 Heart failure unspec
K72.00 Acute and subacute hepatic failure
N17.9 Acute Renal Failure, unspec
G93.40 Encephalopathy unspecified

49. • Systemic Inflammatory Response Syndrome
• Just like Severe Sepsis
- First: Code the cause (e.g., heat stoke, trauma)
- Second: Code SIRS
ICD-10 Description
R65.11
Systemic inflammatory response
syndrome (SIRS) of non-infectious
origin with acute organ dysfunction
SIRS

50. • Third: Code any organ dysfunctions
ICD-10 Description
J96.00 Acute respiratory failure, unspecified
I50.9 Heart failure unspec
K72.00 Acute and subacute hepatic failure
N17.9 Acute Renal Failure, unspec
G93.40 Encephalopathy unspecified
SIRS

51. Questions?

52. References
Hajj, T., Natalie, B., Salavaci, J., & Jacoby, D. (2018). The “Centrality of Sepsis”: A Review on Incidence, Mortality, and Cost of
Care. Healthcare 6(3), 90.
Adapted from H. C. Prescott, H.C. et al. “Enhancing Recovery From Sepsis: A Review”, JAMA (319)1, 62-75, 2018.
Iwashyna, T.J. et al. (2010). Long-term cognitive impairment and functional disability among survivors of severe sepsis. JAMA
304(16), 1787-1794.
Jones, T.K. et al. (2015). Post–Acute Care Use and Hospital Readmission after Sepsis. Ann Am Thorac Soc. 12(6), 904–913.
Marik, P.E., Taeb, A.M. (2017). SIRS, qSOFA and new sepsis definition. Chest 151(), 586-596.
Prescott, H.C. & Angus, D.C. (2018). Enhancing recovery from sepsis: A review. JAMA 319(1), 62-75.
Prescott,H.C., & Angus, D.C. (2018). Enhancing recovery from sepsis: A review. JAMA 319(1):62-75.
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.