Implementation and Effectiveness of Engagement and Collaborative Management to Proactively Advance Sepsis Survivorship (ENCOMPASS)

Implementation and Effectiveness of Engagement and Collaborative Management to Proactively Advance Sepsis Survivorship

Implementation and Effectiveness of Engagement and Collaborative Management to Proactively Advance Sepsis Survivorship: A Hybrid Effectiveness-Implementation Randomized Controlled Trial

The purpose of this study is to evaluate if implementation of the Sepsis Transition and Recovery (STAR) program within a large healthcare system will improve outcomes for high-risk patients with suspected sepsis, while concurrently examining contextual factors related to STAR program delivery within routine care to generate knowledge of best practices for implementation and dissemination of post sepsis transitions of care. To address persistent morbidity and mortality for sepsis survivors, Atrium Health developed the Sepsis Treatment and Recovery (STAR) program which uses a nurse navigator to deliver a bundle of best-practice care elements for the delivery of longitudinal post-sepsis care for up to 90 days. These care elements are directed towards the specific challenges and sequelae following a sepsis hospitalization and include: 1) identification and treatment of new physical, mental, and cognitive deficits; 2) review and adjustment of medications; 3) surveillance of treatable conditions that commonly lead to poor outcomes including chronic conditions that may de-stabilize during sepsis and recovery; and 4) focus on palliative care when appropriate. ENCOMPASS (Engagement and Collaborative Management to Proactively Advance Sepsis Survivorship) is an effectiveness-implementation hybrid type I trial, with the evaluation designed as a two-arm, pragmatic, stepped-wedge cluster randomized controlled trial conducted at eight regional hospitals in which each participating hospital begins in a usual care control phase and transitions to the STAR program intervention in a randomly assigned sequence. Patients are allocated to receive the treatment condition (i.e., usual care or STAR) assigned to their admission hospital at time of enrollment. ENCOMPASS will test the hypothesis that patients who receive care through the STAR program will have reduced mortality and hospital readmission assessed 90 days post index hospital discharge compared to patients who receive usual care.

BACKGROUND Sepsis is a common and life-threatening condition defined by organ dysfunction due to a dysregulated response to infection (Fleischmann, 2016). Aggressive early sepsis identification and treatment initiatives have decreased hospital mortality for patients with sepsis (Rhodes, 2017; Kaukonen, 2014). However, sepsis survivors continue to face challenges after the acute illness episode, experiencing new functional, cognitive, and psychological deficits, and high rates of hospital readmission and mortality in the 90-days after hospital discharge (Iwashyna, 2010; Borges, 2015; Annane, 2015; Prescott, 2015; Mayr, 2017). To address persistent morbidity and mortality for sepsis survivors, Atrium Health developed the Sepsis Treatment and Recovery (STAR) program which uses a nurse navigator to deliver a bundle of best-practice care elements for the delivery of longitudinal post-sepsis care for up to 90 days. These care elements are directed towards the specific challenges and sequelae following a sepsis hospitalization and include: 1) identification and treatment of new physical, mental, and cognitive deficits; 2) review and adjustment of medications; 3) surveillance of treatable conditions that commonly lead to poor outcomes including chronic conditions that may destabilize during sepsis and recovery; and 4) focus on palliative care when appropriate (Prescott, 2018) These care elements have good face-validity and have shown to be associated with improved outcomes for sepsis survivors in observational data (Taylor, 2020). However, they are not widely applied in real-world settings for this vulnerable population, likely hindered by a gap in understanding key contextual factors underlying how to best integrate this bundle of care elements into the complex and fragmented post-discharge setting (Brownson, 2012; Bodenheimer, 2008; Coleman, 2004; Kim, 2013) RATIONALE In randomized controlled trials (RCTs), successfully implemented care transition programs using nurse navigators have been shown to reduce hospital readmission and costs. To better enhance transitions of care for the highest risk, complex patients with suspected sepsis, the investigators propose extending this evidence using a nurse-facilitated care transition program for patients in the post-sepsis transition period to improve the implementation of recommended care practices and bridge care gaps. This approach, called the Sepsis Transition and Recovery (STAR) program, is the next step in the progression of the investigator team's work on improving discharge transitions and sepsis processes of care. A key aspect of this initiative includes the ability to identify sepsis survivors at the greatest risk for poor outcomes. For example, one-quarter of sepsis survivors account for three-quarters of hospital readmission and costs, indicating that identifying high-risk sepsis patients for targeted facilitation of best-practice care could efficiently impact quality and cost. The STAR program uses near real-time risk modeling to identify high-risk patients and a centrally located nurse, virtually connected to participating hospitals, to coordinate the application of evidence-based recommendations for post-sepsis care, overcome barriers to recommended care, and bridge gaps in service that can serve as points of failure for complex patients. During hospitalization, high-risk patients enter into a transition pathway integrated within Atrium Health Hospital Medicine's Transition Services program and includes the following core components: i) Introduction to STAR process prior to discharge (confirm provider consults e.g., PT, ID, palliative); ii) Disease-specific education and discharge "playbook"; iii) Virtual hospital follow-up evaluation within 48 hours including medication reconciliation; iv) Second, post-acute virtual follow-up within 72-96 hours (symptom monitoring, confirm provider follow-up); v) Weekly contact with STAR team; vi) Referral to provider follow-up (e.g., primary care provider, transition clinic) as appropriate; vii) Coordinated transition to the next appropriate care location after 90 days from time of discharge. The STAR navigator also meets weekly with the Medical Director of the Atrium Health Transition Services program who provides additional clinical oversight of ongoing cases. The ENCOMPASS (Engagement and Collaborative Management to Proactively Advance Sepsis Survivorship) evaluation will examine if implementation of the STAR program within a large healthcare system will improve outcomes for high-risk sepsis patients. This cluster randomized program evaluation is designed to be a seamless part of routine care in a real-world setting to generate knowledge of best practices for implementation and dissemination of post-sepsis transitions of care. INVESTIGATIONAL PLAN Overall Study Design ENCOMPASS is an effectiveness-implementation hybrid type I trial. The evaluation component is designed as a two-arm, pragmatic, stepped-wedge cluster randomized controlled trial conducted at eight regional hospitals in which each participating hospital begins in a usual care control phase and transitions to the STAR program intervention in a randomly assigned sequence, with one of eight hospitals assigned to transition at each four-month interval (i.e., step). During the time that a hospital is allocated to usual care, all eligible patients will receive usual care. Once a hospital has been allocated to the STAR arm, all eligible patients will receive STAR during their index hospitalization and extending through 90 days from discharge or date of death. The ENCOMPASS trial will compare the effectiveness of the Sepsis Transition And Recovery (STAR) program versus usual care on post-sepsis care and patient outcomes. The STAR program is informed by existing evidence and designed using the Chronic Care Model to increase best-practice adherence and care coordination, resulting in improved transitions between hospitals and post-acute care during sepsis recovery. ENCOMPASS will test the STAR program intervention within the course of providing usual care among a large and diverse population of post-sepsis patients admitted to eight hospitals within Atrium Health, one of the largest, vertically integrated health systems in the US. The eight acute care hospitals participating in this study use the same EHR, which connects across all points of care, including outpatient practices, urgent care locations, emergency departments and hospitals. Consistent with the pragmatic study design concept, eligibility criteria are broad, the sample size is large and diverse, and study procedures are embedded into the context of routine care. To be objective in patient selection and allow for program evaluation, a data driven approach will be used to identify patients as eligible for program referral. Each weekday morning actively admitted patients at eight study hospitals will be identified from the electronic health record and Enterprise Data Warehouse and output into daily eligibility lists based on the study's inclusion/exclusion criteria. Primary analyses will be conducted using an intent-to-treat approach such that all eligible patients will be included. Planned enrollment is 4032 patients and STAR program follow-up will be completed 90 days after hospital discharge. Outcomes data will be tracked for 90 days and captured from routinely collected data from the Atrium Health Enterprise Data Warehouse. Given this evaluation protocol relies on using evidence-based interventions, only utilizes data collected as part of routine care, and is minimal risk to patients, the institutional review board granted the request for waiver of informed consent.

evidence based medicine, transition care, critical care, implementation science, pragmatic clinical trial

Standard of care received through Atrium Health facilities for patients hospitalized with sepsis. Aspects of usual care will be determined by treating clinicians independent of trial assignment.

In the STAR program intervention, 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. The STAR navigator will provide telephone and EHR-based support within the hospitalization and to patients across all discharge settings with remote monitoring at specified intervals following hospital discharge. Patients will continue to receive STAR directed services for 90 days following their discharge and then will be transitioned back to the next appropriate care location.

Hospitals and their patients will not have access to the STAR program. Patients will continue to receive usual care throughout their stay and discharge, consisting of: patient education and follow-up instructions at discharge, which are not specific to sepsis; routine recommendations for follow-up visits with primary care providers; arrangements for home health services or care management follow-up based on each patient's needs but not specifically tailored to the sepsis population; discharge to post-acute setting with no sepsis-specific follow-up. All aspects of usual care will be determined by treating clinicians independent of trial assignment.

Binary composite endpoint of mortality and hospital readmission assessed 90 days post index hospital discharge

Continuous composite endpoint of days alive and outside of the hospital assessed 90 days post index hospital discharge

Binary endpoint of all-cause hospital readmission rate assessed 90 days post index hospital discharge

Binary endpoint of cause-specific readmission rate for infection, chronic lung disease, heart failure, acute renal failure, and ambulatory care sensitive conditions assessed 90 days post index hospital discharge

A comparison of the STAR and usual care strategies based on the incremental cost-effectiveness ratio (ICER). The ICER is defined as the difference in costs between interventions, divided by the difference in combined mortality and readmission rates

Open-ended, qualitative assessment guided by the Consolidated Framework for Implementation Research to identify perceived barriers to implementing the STAR program into the peri-discharge setting. Themes will be categorized and reported as percentages of participants.

Open-ended, qualitative assessment guided by the Consolidated Framework for Implementation Research to identify perceived facilitators to implementing the STAR program into the peri-discharge setting. Themes will be categorized and reported as percentages of participants.

Inclusion Criteria: At least 18 years of age upon admission Suspected infection Oral/parenteral antibiotic or bacterial culture order within 24 hours of emergency department presentation; and Evidence of systemic inflammatory response (i.e., at least two abnormal of temperature; heart rate; respiratory rate; and WBC count or bands) Evidence of organ dysfunction (i.e., at least two points on either Quick Sepsis-related Organ Failure Assessment or Sepsis-related Organ Failure Assessment risk tools) Deemed as high risk for 90-day readmission using risk-scoring models Not discharged at the time of patient list generation Exclusion Criteria: Patients with a change in code status (i.e., do not resuscitate, do not intubate) within 24 hours after infection onset due to presumed limitation of aggressive treatment Patients who reside > 2.5 hours drive time from the treating hospital Patients actively enrolled in a different care management program at time of admission Patient has been randomized previously.

Fleischmann C, Scherag A, Adhikari NK, Hartog CS, Tsaganos T, Schlattmann P, Angus DC, Reinhart K; International Forum of Acute Care Trialists. Assessment of Global Incidence and Mortality of Hospital-treated Sepsis. Current Estimates and Limitations. Am J Respir Crit Care Med. 2016 Feb 1;193(3):259-72. doi: 10.1164/rccm.201504-0781OC.

Rhodes A, Evans LE, Alhazzani W, Levy MM, Antonelli M, Ferrer R, Kumar A, Sevransky JE, Sprung CL, Nunnally ME, Rochwerg B, Rubenfeld GD, Angus DC, Annane D, Beale RJ, Bellinghan GJ, Bernard GR, Chiche JD, Coopersmith C, De Backer DP, French CJ, Fujishima S, Gerlach H, Hidalgo JL, Hollenberg SM, Jones AE, Karnad DR, Kleinpell RM, Koh Y, Lisboa TC, Machado FR, Marini JJ, Marshall JC, Mazuski JE, McIntyre LA, McLean AS, Mehta S, Moreno RP, Myburgh J, Navalesi P, Nishida O, Osborn TM, Perner A, Plunkett CM, Ranieri M, Schorr CA, Seckel MA, Seymour CW, Shieh L, Shukri KA, Simpson SQ, Singer M, Thompson BT, Townsend SR, Van der Poll T, Vincent JL, Wiersinga WJ, Zimmerman JL, Dellinger RP. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Intensive Care Med. 2017 Mar;43(3):304-377. doi: 10.1007/s00134-017-4683-6. Epub 2017 Jan 18.

Kaukonen KM, Bailey M, Suzuki S, Pilcher D, Bellomo R. Mortality related to severe sepsis and septic shock among critically ill patients in Australia and New Zealand, 2000-2012. JAMA. 2014 Apr 2;311(13):1308-16. doi: 10.1001/jama.2014.2637.

Iwashyna TJ, Ely EW, Smith DM, Langa KM. Long-term cognitive impairment and functional disability among survivors of severe sepsis. JAMA. 2010 Oct 27;304(16):1787-94. doi: 10.1001/jama.2010.1553.

Borges RC, Carvalho CR, Colombo AS, da Silva Borges MP, Soriano FG. Physical activity, muscle strength, and exercise capacity 3 months after severe sepsis and septic shock. Intensive Care Med. 2015 Aug;41(8):1433-44. doi: 10.1007/s00134-015-3914-y. Epub 2015 Jun 25.

Annane D, Sharshar T. Cognitive decline after sepsis. Lancet Respir Med. 2015 Jan;3(1):61-9. doi: 10.1016/S2213-2600(14)70246-2. Epub 2014 Nov 28.

Prescott HC, Langa KM, Iwashyna TJ. Readmission diagnoses after hospitalization for severe sepsis and other acute medical conditions. JAMA. 2015 Mar 10;313(10):1055-7. doi: 10.1001/jama.2015.1410. No abstract available.

Mayr FB, Talisa VB, Balakumar V, Chang CH, Fine M, Yende S. Proportion and Cost of Unplanned 30-Day Readmissions After Sepsis Compared With Other Medical Conditions. JAMA. 2017 Feb 7;317(5):530-531. doi: 10.1001/jama.2016.20468. No abstract available.

Prescott HC, Angus DC. Enhancing Recovery From Sepsis: A Review. JAMA. 2018 Jan 2;319(1):62-75. doi: 10.1001/jama.2017.17687.

Taylor SP, Chou SH, Sierra MF, Shuman TP, McWilliams AD, Taylor BT, Russo M, Evans SL, Rossman W, Murphy S, Cunningham K, Kowalkowski MA. Association between Adherence to Recommended Care and Outcomes for Adult Survivors of Sepsis. Ann Am Thorac Soc. 2020 Jan;17(1):89-97. doi: 10.1513/AnnalsATS.201907-514OC.

Brownson RC, Allen P, Duggan K, Stamatakis KA, Erwin PC. Fostering more-effective public health by identifying administrative evidence-based practices: a review of the literature. Am J Prev Med. 2012 Sep;43(3):309-19. doi: 10.1016/j.amepre.2012.06.006.

Bodenheimer T. Coordinating care--a perilous journey through the health care system. N Engl J Med. 2008 Mar 6;358(10):1064-71. doi: 10.1056/NEJMhpr0706165. No abstract available.

Coleman EA, Berenson RA. Lost in transition: challenges and opportunities for improving the quality of transitional care. Ann Intern Med. 2004 Oct 5;141(7):533-6. doi: 10.7326/0003-4819-141-7-200410050-00009.

Kim CS, Flanders SA. In the Clinic. Transitions of care. Ann Intern Med. 2013 Mar 5;158(5 Pt 1):ITC3-1. doi: 10.7326/0003-4819-158-5-201303050-01003. No abstract available.

Kowalkowski M, Eaton T, McWilliams A, Tapp H, Rios A, Murphy S, Burns R, Gutnik B, O'Hare K, McCurdy L, Dulin M, Blanchette C, Chou SH, Halpern S, Angus DC, Taylor SP. Protocol for a two-arm pragmatic stepped-wedge hybrid effectiveness-implementation trial evaluating Engagement and Collaborative Management to Proactively Advance Sepsis Survivorship (ENCOMPASS). BMC Health Serv Res. 2021 Jun 2;21(1):544. doi: 10.1186/s12913-021-06521-1.