A Sepsis Transition Program to Reduce Morbidity and Mortality in High Risk Individuals

PROJECT SUMMARY
Sepsis survivors and healthcare systems are burdened by high mortality, morbidity, and utilization following
hospitalization for sepsis. While many complications post-sepsis result from preventable causes, healthcare
systems lack efficient strategies to deliver evidence-based care recommendations targeted to specific deficits
experienced by sepsis survivors. There is urgent need to determine successful implementation strategies for
post-sepsis care to improve patient outcomes. The overarching goal of our work is to reduce hospital
readmissions and post-discharge mortality for patients admitted to an acute care facility for sepsis. The
objective of this study is to evaluate the effectiveness and cost-effectiveness of implementing an evidence-
based Sepsis Transition And Recovery (STAR) program to develop broadly generalizable knowledge on best
practices for post-sepsis care. To achieve this objective, we will: 1) link EHR based data to risk prediction
algorithms to identify at the point of care patients who are high risk for post-sepsis mortality and readmission;
and 2) implement evidence-based post-sepsis care recommendations, directed to high-risk sepsis survivors,
and delivered using a proactive, nurse navigation process. The STAR program will focus on adults aged 18
and older hospitalized for sepsis. Effectiveness of the STAR program is assessed using a stepped-wedge,
cluster randomized controlled study design. Eight acute care hospitals from diverse geographic regions of
western and central North Carolina will be randomized to a staggered sequence (i.e., steps 1 to 8) of
transitioning from Usual Care to STAR group assignment. The two intervention conditions are: Arm 1) Usual
care in which hospitals and their providers have no access to intervention-related post-sepsis care support;
and Arm 2) STAR program intervention in which a centrally located nurse navigator facilitates the application of
four evidence-based core components of post-sepsis care (i.e., review of medications, new impairments,
comorbidities, and palliative care), to patients prior to and during the 90 days after hospital discharge. With
eight hospital sites and 4400 potentially eligible patients, this study will formally test the hypothesis that STAR
program implementation is superior to usual care with respect to significantly lower rate of combined death or
hospital readmission, at 90 days. We further hypothesize that STAR will have lower healthcare and societal
costs than usual care. We will use the Consolidated Framework for Implementation Research processes to
guide implementation planning, organization, conduct, and impact evaluation of this complex intervention into a
large, diverse healthcare system. We will apply focused ethnography to obtain an intensive and nuanced
understanding of the nurse navigator’s important role in the execution of the STAR program. The proposed
project will engage a heterogeneous population with substantial morbidity and mortality and gaps in the
delivery of evidence-based post-sepsis care. Results will advance dissemination and implementation research
methods that can improve the immense long-term healthcare burden of sepsis.