An estimated 1.7 million people in the U.S. develop sepsis in any given year, according to a Sepsis Alliance release, and up to one-third of survivors are re-hospitalized within three months of discharge from the hospital. This makes up about 12 percent of hospital readmissions overall – far more than readmissions related to patients diagnosed with other conditions, such as heart failure (7 percent) or pneumonia (5 percent). And what is particularly concerning, said the Alliance, is researchers believe that almost half of readmissions due to sepsis could be prevented. The most common reason for readmission is new or recurrent (returning) infections.
Researchers working with the Center for Home Care Policy & Research at the Visiting Nurse Service of New York, and the University of Pennsylvania School of Nursing, did a study to determine if early home health interventions could lower the number of sepsis-related re-hospitalizations. The findings were published in the August 2019 issue of Medical Care.
“I had been collaborating on some projects with the Visiting Nurse Service of New York,” said co-author Partha Deb, PhD, from Hunter College in New York City. “In conversations, the issue of how “early and intensive” home nursing care and physician care might prevent bad outcomes post a hospital stay would come up often. It was a tricky issue to study in a statistical sense and I thought we could develop appropriate methods to get around issues of unobserved confounding if we did study it. We studied this issue following heart failure hospitalizations to, but that seemed like a pretty “clear cut” condition with a well-established recovery protocol. Sepsis, on the other hand, was arguably poorly defined, and definitely poorly recognized. We thought we could make a difference in patient care by identifying the potential value of post-discharge care for these patients.”
The researchers looked at records of over 170,000 severe sepsis or septic shock survivors from across the United States. About 57 percent were women, most were seniors, and many had other health problems aside from having survived sepsis. Almost half of the study group (44.7 percent) were visited by a nurse the day they were discharged from the hospital or the day after. They were visited again by a nurse at least once within their first week at home. This was the nursing protocol. Eleven percent of the study group had the doctor-only protocol. This included seeing a doctor once within the week of discharge. Just over 28 percent received both protocols and over 16 percent had neither the nursing nor the doctor protocols.
At the end of the study, the researchers didn’t see any marked improvement among patients who only saw the nurses or only the doctor. However, the group that was part of both protocols, seeing a nurse and a doctor, saw a drop in hospital readmissions, by 7 percentage points.
Why is the combination of protocols more successful than one or the other? Home health nurses are the eyes and ears that can detect problems before they escalate. Among many other things, nurses check the medications and prescriptions patients take home from the hospital, reconciling them with medications the patients took before their hospitalization, ensuring that all necessary medications have been restarted and conflicting medications addressed.
Nurses can also detect signs of infections, deterioration in health, and problems in the home environment, often in the early stages. However, without a quick follow-up with a doctor, the problems may take longer to manage than they should, resulting in more complications. Doctor-only follow-ups may miss things that a nurse may detect. So, combining the two protocols gives patients the benefit of nursing and doctor expertise and experience.
Preventing hospital readmissions also helps reign in healthcare costs. Re-hospitalizations related to sepsis cost more than $2 billion a year. And in reality, costs are higher as the amount doesn’t represent lost wages for the patient, costs to families as they rally around their loved one, and continued rehabilitation costs after discharge from the second hospitalization.
More work must be done to understand and prevent most readmissions following hospital discharge. “I plan to continue work on post-discharge care with a focus on home care in the context of my continuing collaboration with VNSNY,” Deb said. “We also plan to study other aspects of patient care for sepsis patients, e.g., hospital lengths of stay, that have implications for future outcomes.”
