Sepsis & Hospice Eligibility: Natural History, Prognosis & Role of Hospice

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, #1222, is approved to offer social work continuing education by the Association of Social Work Boards (ASWB) Approved Continuing Education (ACE) program. Organizations, not individual courses, are approved as ACE providers. State and provincial regulatory boards have the final authority to determine whether an individual course may be accepted for continuing education credit. VITAS Healthcare maintains responsibility for this course. ACE provider approval period: 06/06/2018 – 06/06/2021. Social workers completing this course receive 1.0 ethics continuing education credits. 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 01/31/2021. 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 06-2019

3. CME Provider Information Satisfactory Completion - Learners must complete an evaluation form to receive a certificate of completion. You must participate in the entire activity as partial credit is not available. If you are seeking continuing education credit for a specialty not listed below, it is your responsibility to contact your licensing/certification board to determine course eligibility for your licensing/certification requirement. Physicians - In support of improving patient care, this activity has been planned and implemented by Amedco LLC and VITAS® Healthcare. Amedco LLC is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team. Credit Designation Statement – Amedco LLC designates this live activity for a maximum of 1.00 AMA PRA Category 1 Credit(s)TM. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

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

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 1.5 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

7. 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

8. • 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.)

9. 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

10. 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)

11. 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.

12. 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

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 • Severe sepsis is complicated by organ dysfunction • Septic shock is a sepsis-induced hypotension persisting despite adequate fluid resuscitation

14. 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

15. 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

16. 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

17. Sepsis and Septic Shock for Common Patients

18. • 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

19. 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.

21. 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

22. 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

23. 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

24. 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

25. 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

26. 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

27. 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

28. • 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

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 Cause of Death in Patients with Sepsis

30. 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

31. • 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.)

32. 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

33. 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.)

34. 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

35. 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.

36. • 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.)

37. 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%

38. 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

39. 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

40. 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

41. 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

42. 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

43. 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

44. 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

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

46. 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

47. 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

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

49. 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

50. • 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

51. • 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

52. Questions?

53. 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.

Sepsis & Hospice Eligibility: Natural History, Prognosis & Role of Hospice

Sepsis & Hospice Eligibility: Natural History, Prognosis & Role of Hospice

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