Protocol for a two-arm pragmatic stepped-wedge hybrid effectiveness-implementation trial evaluating Engagement and Collaborative Management to Proactively Advance Sepsis Survivorship (ENCOMPASS)

Leveraging inter-organizational networks to scale up a sepsis recovery program: results from an application of the Making Optimal Decisions for Intervention Flexibility during Implementation (MODIFI) method

BACKGROUND

Nearly two million adults in the United States are hospitalized with sepsis yearly, with survivors facing complications that result in high rates of hospital readmission and mortality after discharge. We demonstrated improved outcomes following discharge among sepsis survivors who participated in the Sepsis Transition And Recovery (STAR) program; however, important differences among hospitals require STAR's adaptation to facilitate its implementation and ensure its effectiveness in new settings.

PURPOSE

The purpose of this study was to adapt STAR to hospitals with diverse characteristics.

METHODS

We used the Making Optimal Decisions for Intervention Flexibility during Implementation (MODIFI) approach. We identified STAR core functions (i.e., effectiveness-driving features) using semi-structured key informant interviews (n = 7). We identified adaptations using semi-structured interviews with clinicians and leaders with expertise and oversight of resources related to transitions of care after sepsis hospitalization (n = 7) from four hospitals that systematically differed from the hospitals in which we originally found STAR to be effective.

RESULTS

Network theory, which proposes that performance improves with more efficient flow of information within and across hospitals, underlays STAR's eleven core functions. Adaptation included specific points-of-contact, communication preferences, and methods for achieving buy-in. We used proposed adaptations to tailor STAR protocols to each hospital.

CONCLUSIONS

We used MODIFI, a state-of-the-science method, to adapt a program that was effective in promoting transition and recovery in sepsis survivors to facilitate its scale-up to diverse hospitals. Future studies will assess STAR's implementation and effectiveness in diverse hospitals.

Care Transitions After Critical Illness

Patients and their caregivers navigate multiple transitions of care across the health system as they recover from their critical illness. Current research supports the development of integrated models of care to improve patient outcomes after critical illness. Future research to ensure the development of integrated models across different regions and to understand the optimal mode of delivery of these is required.

Pre-implementation planning for a sepsis intervention in a large learning health system: a qualitative study

BACKGROUND

Sepsis survivors experience high morbidity and mortality. Though recommended best practices have been established to address the transition and early post hospital needs and promote recovery for sepsis survivors, few patients receive recommended post-sepsis care. Our team developed the Sepsis Transition and Recovery (STAR) program, a multicomponent transition intervention that leverages virtually-connected nurses to coordinate the application of evidence-based recommendations for post-sepsis care with additional clinical support from hospitalist and primary care physicians. In this paper, we present findings from a qualitative pre-implementation study, guided by the Consolidated Framework for Implementation Research (CFIR), of factors to inform successful STAR implementation at a large learning health system prior to effectiveness testing as part of a Type I Hybrid trial.

METHODS

We conducted semi-structured qualitative interviews (n = 16) with 8 administrative leaders and 8 clinicians. Interviews were transcribed and analyzed in ATLAS.ti using a combination deductive/inductive strategy based on CFIR domains and constructs and the Constant Comparison Method.

RESULTS

Six facilitators and five implementation barriers were identified spanning all five CFIR domains (Intervention Characteristics, Outer Setting, Inner Setting, Characteristics of Individuals and Process). Facilitators of STAR included alignment with health system goals, fostering stakeholder engagement, sharing STAR outcomes data, good communication between STAR navigators and patient care teams/PCPs, clinician promotion of STAR with patients, and good rapport and effective communication between STAR navigators and patients, caregivers, and family members. Barriers of STAR included competing demands for staff time and resources, insufficient communication and education of STAR's value and effectiveness, underlying informational and technology gaps among patients, lack of patient access to community resources, and patient distrust of the program and/or health care.

CONCLUSIONS

CFIR proved to be a robust framework for examining facilitators and barriers for pre-implementation planning of post-sepsis care programs within diverse hospital and community settings in a large LHS. Conducting a structured pre-implementation evaluation helps researchers design with implementation in mind prior to effectiveness studies and should be considered a key component of Type I hybrid trials when feasible.

TRIAL REGISTRATION

Clinicaltrials.gov, NCT04495946 . Registered August 3, 2020.

Health system approaches to providing posthospital care for survivors of sepsis and critical illness

PURPOSE OF REVIEW

In the current review, we highlight developing strategies taken by healthcare systems to improve posthospital outcomes for sepsis and critical illness.

RECENT FINDINGS

Multiple studies conducted in the adult population over the last 18 months have advanced current knowledge on postdischarge care after sepsis and critical illness. Effective interventions are complex and multicomponent, targeting the multilevel challenges that survivors face. Health systems can leverage existing care models such as primary care or invest in specialty programs to deliver postdischarge care. Qualitative and implementation science studies provide insights into important contextual factors for program success. Several studies demonstrate successful application of telehealth to improve reach of postdischarge support. Research is beginning to identify subtypes of survivors that may respond to tailored intervention strategies.

SUMMARY

Several successful critical illness survivor models of care have been implemented and knowledge about effectiveness, cost, and implementation factors of these strategies is growing. Further innovation is needed in intervention development and evaluation to advance the field.

Passing the SNF Test: A Secondary Analysis of a Sepsis Transition Intervention Trial Among Patients Discharged to Post-Acute Care

OBJECTIVES

Sepsis survivors discharged to post-acute care facilities experience high rates of mortality and hospital readmission. This study compared the effects of a Sepsis Transition and Recovery (STAR) program vs usual care (UC) on 30-day mortality and hospital readmission among sepsis survivors discharged to post-acute care.

DESIGN

Secondary analysis of a multisite pragmatic randomized clinical trial.

SETTING AND PARTICIPANTS

Sepsis survivors discharged to post-acute care.

METHODS

We conducted a secondary analysis of patients from the IMPACTS (Improving Morbidity During Post-Acute Care Transitions for Sepsis) randomized clinical trial who were discharged to post-acute care. IMPACTS evaluated the effectiveness of STAR, a nurse-navigator-led program to deliver best practice post-sepsis care. Subjects were randomized to receive either STAR or UC. The primary outcome was 30-day readmission and mortality. We also evaluated hospital-free days alive as a secondary outcome.

RESULTS

Of 691 patients enrolled in IMPACTS, 175 (25%) were discharged to post-acute care [143 (82%) to skilled nursing facilities, 12 (7%) to long-term acute care hospitals, and 20 (11%) to inpatient rehabilitation]. Of these, 87 received UC and 88 received the STAR intervention. The composite 30-day all-cause mortality and readmission endpoint occurred in 26 (29.9%) patients in the UC group vs 18 (20.5%) in the STAR group [risk difference -9.4% (95% CI -22.2 to 3.4); adjusted odds ratio 0.58 (95% CI 0.28 to 1.17)]. Separately, 30-day all-cause mortality was 8.1% in the UC group compared with 5.7% in the STAR group [risk difference -2.4% (95% CI -9.9 to 5.1)] and 30-day all-cause readmission was 26.4% in the UC group compared with 17.1% in the STAR program [risk difference -9.4% (95% CI -21.5 to 2.8)].

CONCLUSIONS AND IMPLICATIONS

There are few proven interventions to reduce readmission among patients discharged to post-acute care facilities. These results suggest the STAR program may reduce 30-day mortality and readmission rates among sepsis survivors discharged to post-acute care facilities.