HMS Sepsis Toolkit 

HMS Bundle Measures on Data Reports – Recovery Practices

• Baseline functional status was assessed(≥4 I/ADLs documented)
• PT/OT consultation
• Assessment and documentation of goals of care

HMS Bundle Measures on Data Reports – Discharge Planning

• Post-discharge phone call made to patient within 3 calendar days
• Anticipatory guidance for symptom monitoring
• Hospital contact provided for issues post discharge
• Scheduled for PCP follow-up within 2 weeks
• Appropriate continuation of medications for chronic disease management on discharge
• Appropriate discontinuation/non-use of controlled substances on discharge

Strategies to Achieve Measures

• Implement practices to reduce post sepsis and post ICU syndrome
• Sepsis team evaluates current state of discharge process and recovery focused practices
• Consider implementing Project RED discharge process

General

• HMS site reports (hard copy distributed at collaborative wide meetings and live reports available daily via the HMS data entry system)
• AHRQ Sepsis in the United States Data Visualization
  • This visualization presents data from the Healthcare Cost and Utilization Project on:
    • Morbidity and in-hospital mortality related to sepsis
    • Outcomes of sepsis hospitalizations, by patient characteristics

Recovery-Focused Practices

• The Hospital + Health System Association of Pennsylvania Suite of Sepsis Fact Sheets
  • Patient Post-Discharge
  • Patient Post-Discharge Action Plan
  • Patient Discharge Checklist-For Staff Discharging a Sepsis Patient
  • Patient and Family Education
  • Hand-Off Communication – Acute Care Hospital to Post-Acute Care Facility
  • Health Care Providers
  • Post-Acute Care Facilities
  • Home Care Staff
• AHRQ: Care Transitions from Hospital to Home: IDEAL Discharge Planning Implementation Handbook
  • This resource is designed to help hospitals develop effective partnerships with patients and family members with the goal of improving multiple aspects of hospital quality and safety.
• Michigan Medicine COVID-19 Resources for Patients and Families

Baseline Functional Status Assessment

• Geriatric Assessment Toolkit – Functional Status Questionnaire
• North East Specialized Geriatric Centre – Baseline Functional Status Fact Sheet and Example Assessment

PT/OT Consultation

• AHRQ – Tool 3K: Algorithm for Mobilizing Patients

Assessment/Documentation of Goals of Care

• Center to Advance Palliative Care: Honoring Previously Determined Preferences for Care
• Oregon Portable Orders for Life-Sustaining Treatment (POLST) Conversations for ED Physicians with a Capable Patient
  • From: The Center to Advance Palliative Care
  • This five-minute video demonstrates a physician talking with a capable patient about wishes for care and treatment.
• Key Elements of a Goals of Care Discussion (Dunlay, S.M. et al, Trends in Cardiovascular Medicine)
• SPIKES Mnemonic Framework for Approaching Difficult Conversations with Patients (Dunlay, S.M. et al, Trends in Cardiovascular Medicine)

Discharge Planning

• Henry Ford Health Sepsis: Patient Education Guide
• UpToDate: Hospital Discharge and Readmission
• Project RED (Re-Engineered Discharge): Toolkit
• Patient Education: AHRQ. Taking Care of Myself: A Guide for when I leave the hospital
• Global Sepsis Alliance: Life After Sepsis Guide for Sepsis Survivors and Families
• Society of Critical Care Medicine Patient and Family Resources
• Australian Commission on Safety and Quality in Healthcare: Sepsis Clinical Care Standard – Information for People with Sepsis and Their Families
• JAMA Patient Page on Post-Sepsis Morbidity
• SCCM – Recovery After a Hospitalization for Sepsis (Video)
• Indiana Patient Safety Center – IHA Sepsis Patient and Family Discharge Education
• Michigan Value Collaborative Sepsis Workgroup: An Overview of HMS’s Sepsis Work
  • Meeting Recording (48:46 mins)
  • Meeting Slides

HMS Collaborative-Wide Meeting Resources (Authentication May Be Required)

• HMS Sepsis Abstractor Breakfast Education Session (July 2023) – Optimizing Transition for Sepsis Patients(link is external)(Speaker: Pat Posa, RN, BSN, MSA, CCRN-K, FAAN)
• October 10, 2020, HMS/MHA Sepsis Symposium – Post-Hospital Management(link is external)

Post-Discharge Phone Call Made to Patient within 3 Calendar Days

• Project Re-Engineered Discharge (RED) – How to Conduct a Post-Discharge Follow Up Phone Call
• AHRQ Post Discharge Follow-up Phone Call Script
• University of Michigan-West Transition of Care Phone Call Documentation Template (for EPIC)
• Discharge Checklist and Follow-up Phone Calls: The Foundation to an Effective Discharge Process; Parker Adventist Hospital Presentation
• Kentucky Hospital Association – Post Discharge Follow-Up Call Script

Hospital Contact Provided for Issues Post-Discharge

• IMPACT – Reduce Readmissions with 3 Simple Items When Discharging to a SNF
• Sepsis Alliance Hospital Discharge List – Post-Sepsis or Septic Shock
• AHRQ Re-Engineered Discharge Toolkit – Components of After Hospital Care Plan (AHCP)
• UpToDate – Ideal Discharge of the Older Adult Patient: A Hospital Checklist
• HMS Member Hospital Examples

Scheduled for PCP Follow-Up with 2 Weeks

• IMPACT – Physician Conversation Guide: Scheduling 7-day Follow-up Appointments
• The University of Kansas Health System: Ready, Set, CALL: Improving Follow-Up Appointments Post Hospital Discharge (Examples of Discharge Checklist and Appointment Order Set)
• AHRQ – Discharge Process Checklist
• IMPACT Patient Conversation Guide: Do you want to avoid another hospital stay? (EN)
  • IMPACT Patient Conversation Guide: Do you want to avoid another hospital stay? (SP)

Appropriate Continuation of Medications on Discharge

• CDC – MyMedications List (for patients)
• National Transition of Care Coalition – Medication Reconciliation Elements

Appropriate Discontinuation/Non-Use of Controlled Substances on Discharge

• Society of Hospital Medicine Implementation Guide – Improving Pain Management for Hospitalized Medical Patients

• Communicating with Sepsis Patients: A Survivor’s Story (53:22)
  • From: Sepsis Alliance Institute
  • Presenters: Angel Coz, MD, FCCP; Darrell Raikes
  • CE Information: 1.6 CNE, 1.25 CE for other healthcare professionals
  • Session Overview: Hear firsthand from Darrell Raikes, a sepsis survivor and 2019 Erin Kay Flatley Spirit Award Winner, as he discusses his 32-day ICU stay and ensuing recovery. Participants will learn about post-sepsis physical, cognitive, and emotional challenges faced by many sepsis survivors. A Critical Care specialist will review the importance of early sepsis recognition to improve patient outcomes.
• Transitions of Care: Out of the Hospital
  • From: Society of Hospital Medicine(SHM)
  • Presenters: Amit Bansal, MD, MBA, CPE, FHM; Amy Baughman, MD, MPH; Catherine Lau, MD; Nidhi Rohatgi, MD, MS, FACP, FHM
  • CE Information:  0.25 CE for healthcare professionals
  • Session Overview:  This series will feature three transitions of care subtopics that will describe various types of transitions of care with respective best practices.
• Empowering Sepsis Survivors: Developing Patient & Family Education and Discharge Plans (1:00:58)
  • From: Sepsis Alliance Institute
  • Presenters: Stephanie Parks Taylor, MD, MS; Sandra Kleier, RN; Don Smith; Kaitlin Walden
  • CE Information: 1.7 CNE, 1.25 CE for other healthcare professionals
  • Session Overview: During this presentation, participants will learn about the long-term outcomes and risks faced by sepsis survivors. Additionally, there will be information on strategies and resources for championing best practice, evidence-based discharge planning, and education protocols for sepsis survivors and their families.
• Transitions of Care After Sepsis Hospitalization (57:15)
  • From: Sepsis Alliance Institute
  • Presenter: Stephanie Parks Taylor, MD, MS
  • CE Information: 1.7 CNE, 1.25 CE for other healthcare professionals
  • Session Overview: Dr. Stephanie Parks Taylor addresses what is known about the post-acute care needs of sepsis survivors and discuss evidence-based approaches to meet these needs.
• Enhancing Recovery from Sepsis and COVID-19 (55:13)
  • From: Sepsis Alliance Institute
  • Presenter: Hallie Prescott, MD, MSc
  • CE Information: 1.6 CNE, 1.25 CE for other healthcare professionals
  • Session Overview: This webinar reviews the current understanding of long-term outcomes from sepsis, reviews best practices for enhancing recovery from sepsis, and discusses current trials underway to enhance recovery from sepsis.
• Improving Sepsis Survivorship: A Multidisciplinary Approach to Optimize Post-Sepsis Care (59:51)
  • From: Sepsis Alliance Institute
  • Presenters: Jakob McSparron, MD; Rima Mohammad, PharmD; Mari Pitcher, MSW, MBA
  • CE Information: 1.7 CNE, 1.25 CE for other healthcare professionals
  • Session Overview: This course discusses a multidisciplinary approach for the care of patients after hospitalization for sepsis and is presented by the clinicians working at the Michigan Medicine UM PULSE(Post-ICU Longitudinal Survivor Experience) Clinic. Learn the resources you need to care for sepsis survivors and delve into the value brought by the interdisciplinary clinical team to improve sepsis survivorship and quality of life.
• Post-Sepsis Syndrome: Recognition and Management (56:03)
  • From: Sepsis Alliance Institute
  • Presenters: Cairn Ruhumuliza, RN, MS, CPHQ; Catherine(Terri) Hough, MD, MSc
  • CE Information: 1.6 CNE, 1.25 CE for other healthcare professionals
  • Session Overview: This webinar reviews signs and symptoms of post-sepsis syndrome and their relationship to sepsis and identify how to determine a post-sepsis patient’s pre-sepsis function and goals of care.
• Caring for Sepsis Survivors (57:47)
  • From: Sepsis Alliance Institute
  • Presenter: Hallie Prescott, MD, MSc
  • CE Information: 1.7 CNE, 1.25 CE for other healthcare professionals
  • Session Overview: This presentation revies best practices to mitigate and/or recover from post-sepsis sequelae, as well as reviews discharge and post-discharge medical care to enhance survivorship.
• Sepsis and Opioid Use Disorder: The Intersection of Two Public Health Crises (58:56)
  • From: Sepsis Alliance Institute
  • Presenters: Simeon Kimmel, MD, MA; Chanu Rhee, MD, MPH, FIDSA
  • CE Information: 1.6 CNE, 1.25 CEs for other healthcare providers
  • Session Overview: Sepsis and opioid use disorders are major sources of morbidity, mortality, and costs to the healthcare system. While most of the national focus has been on the rising number of fatal opioid overdoses, less attention has been paid to the serious infectious complications of opioid use disorders, including sepsis.  In this presentation, Drs. Rhee and Kimmel will review recent data elucidating the epidemiology of sepsis and opioid-related hospitalizations and discuss potential strategies for reducing the harms associated with the intersection of these two public health emergencies.

Baseline Functional Status Assessment

• Iwashyna, T.J. et. al. Long-term cognitive impairment and functional disability among survivors of severe sepsis. JAMA 2010
  • Severe sepsis in this older population was independently associated with substantial and persistent new cognitive impairment and functional disability among survivors. The magnitude of these new deficits was large, likely resulting in a pivotal downturn in patients’ ability to live independently.
• Odden, A.J. et al. Functional outcomes of general medical patients with severe sepsis. BMC Infec Dis 2013.
  • New physical debility is a common feature of severe sepsis in patients initially cared for on the general medical floor. Debility occurs even in those with good baseline physical function. Interventions to improve the poor functional outcomes of this population are urgently needed.

PT/OT Consultation

• Rousseau, A.F. et al. Long-term Outcomes After Critical Illness: Recent Insights. Crit Care 2021.
  • This article summarized the benefits of a variety of interventions on post-intensive care syndrome (PICS) and the long-term health status of ICU survivors. One intervention outlined is promoting exercise in these patients.
• Sakai, Y. et al. Effects of Early Rehabilitation in Sepsis Patients by a Specialized Physical Therapist in an Emergency Center on the Return to Activities of Daily Living Independence: A Retrospective Cohort Study. PloS One 2022.
  • This study investigated how early rehabilitation provided by a specialized physical therapist affects ADL in patients with sepsis. Assigning a specialized physical therapist to sepsis patients at an advanced emergency critical care center significantly shortened the number of days until a patient can begin rehabilitation after hospital admittance and improved activities of daily living after hospital discharge.
• Schweickert, W.D. et al. Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomized controlled trial. Lancet 2009.
  • A strategy for whole-body rehabilitation – consisting of interruption of sedation and physical and occupational therapy in the earliest days of critical illness – was safe and well tolerated and resulted in better functional outcomes at hospital discharge, a shorter duration of delirium, and more ventilator-free days compared with standard care.
• Sossdorf, M. et al. Potential Effect of Physiotherapeutic Treatment on Mortality Rate in Patients with Severe Sepsis and Septic Shock: A Retrospective Cohort Analysis. Journ of Crit Care 2013.
  • The aim of the study was to examine the onset and frequency of physiotherapeutic interventions (PTI) and their potential effects on the intensive care unit mortality rate in patients with severe sepsis or septic shock. This study found that the frequency of PTI was associated with improved outcomes.
• Uthup, B.R. et al. Evaluating the benefits of early intensive rehabilitation for patients with sepsis in the medical intensive care unit: A retrospective study. Journ Acute Care PT 2021.
  • Patients who received early rehabilitation intervention in the MICU had significantly higher level of mobility at discharge and a better discharge disposition than those who received a standard rehabilitation intervention.
• Walsh, T.S. et al. Increased Hospital-Based Physical Rehabilitation and Information Provision After Intensive Care Unit Discharge: The RECOVER Randomized Clinical Trial. JAMA Intern Med 2015.
  • In a randomized clinical trial at two hospitals in Scotland, 240 patients who received at least 48 hours of mechanical ventilation while hospitalized received a variety of interventions, including physiotherapy. Post-ICU hospital-based rehabilitation, including increased physical and nutritional therapy plus information provision, did not improve physical recovery or health related quality of life, but improved patient satisfaction with many aspects of recovery.

Assessment of Goals of Care

• Bernacki, R.E. et al. Communication About Serious Illness Care Goals: A Review and Synthesis of Best Practices. JAMA Internal Medicine 2014.
  • This article (1) reviews the evidence and describes best practices in conversations about serious illness care goals and (2) offers practical advice for clinicians and health care systems about quality and timing of such communication. The authors conclude that communication about serious illness care goals is an intervention that should be systematically integrated into our clinical care structures and processes.
• Black, M.D. et al. A Multifaceted Intervention to Improve Compliance with Process Measures for ICU Clinician Communication with ICU Patients and Families. Crit Care Med 2013.
  • This study found that a multifaceted intervention to improve communications between families and clinicians in the ICU improved compliance with process measures.
• Cagino, L. et al. Goals of care assessment during hospitalization for sepsis. Annals ATS 2025.
  • This study investigates how frequently goals of care (GoC) are assessed during sepsis hospitalizations across 66 Michigan hospitals between 2020 and 2023. Among 18,711 patients, GoC discussions and assessments occurred in 35.7% and 45.3% of cases, respectively, with notable variation across hospitals. Factors like advanced age, chronic conditions, intensive care admission, and life support were associated with higher rates of GoC assessments. Despite these associations, significant inconsistencies remain, highlighting the need for further research to understand and improve practices for assessing GoC during sepsis hospitalization.
• Curtis, J.R. et al. Intervention to Promote Communication About Goals of Care for Hospitalized Patients with Serious Illness. JAMA 2023.
  • Among hospitalized older adults with serious illness, a pragmatic clinician facing communication-priming intervention significantly improved documentation of goals of care discussions, with a greater effect size in racially or ethnically minoritized patients.
• Dunlay, S. et al. How to Discuss Goals of Care with Patients. Trends in Cardiovascular Medicine 2016.
  • This framework is meant to enable clinicians to feel impowered to discuss goals of care with their patients. These conversations are essential to aligning care delivery with patient preferences.
• Pronovost P, et al. Improving communication in the IC using daily goals. Journ of Crit Care 2003.
  • Implementation of a daily goals form resulted in a significant improvement in the percent of residents and nurses who understood the goals of care for the day and a reduction in ICU length of stay.

General Discharge Planning

• Becker, C. et al. Interventions to Improve Communication at Hospital Discharge and Rates of Readmission: A Systematic Review and Meta-analysis. JAMA Netw Open 2021.
  • Communication interventions at discharge are significantly associated with fewer hospital readmissions, higher treatment adherence, and higher patient satisfaction and thus are important to facilitate the transition of care.
• Chao, P. et al. Association of Postdischarge rehabilitation with mortality in intensive care unit survivors of sepsis. Am J Respir Crit Care Med 2014.
  • Post-discharge rehabilitation may be associated with a reduced risk of 10-year mortality in the subset of patients with particularly long ICU courses.
• Kowalkowski, M.A. et al. Effect of a transitional care intervention on rehospitalization and mortality after sepsis: A 12-month follow-up of a randomized clinical trial. Am J Resp Crit Care Med 2025.
  • Details the 12-month outcomes of a randomized clinical trial demonstrating that proactive and sepsis-specific multicomponent transitional support improved 30-day outcomes after sepsis hospitalization.
• Prescott, H.C. et al. Enhancing Recovery from Sepsis: A Review. JAMA 2018.
  • In the months after hospital discharge for sepsis, management should focus on (1) identifying new physical, mental, and cognitive problems and referring for appropriate treatment, (2) reviewing and adjusting long-term medications, and (3) evaluating for treatable conditions that commonly result in hospitalization, such as infection, heart failure, renal failure, and aspiration. For patients with poor or declining health prior to sepsis who experience further deterioration after sepsis, it may be appropriate to focus on palliation of symptoms.
• Prescott, H.C. et al. Readmission diagnoses after hospitalization for severe sepsis and other acute medical conditions. JAMA 2015.
  • Readmissions within 90 days after hospitalization for severe sepsis were common, and 42% occurred for diagnoses that could potentially be prevented or treated early to avoid hospitalization. The high prevalence and concentration of specific diagnoses during the early post discharge period suggests that further study is warranted of the benefit of post discharge interventions.
• Taylor, S.P. et al. Clinical Subtypes of Sepsis Survivors Predict Readmission and Mortality after Hospital Discharge. Annals ATS. 2022.
  • Sepsis survivors constitute distinct clinical subtypes and future interventions may be targeted to the unique needs of each subtype.
• Trivedi, S.P. et al. Assessment of Patient Education Delivered at the time of Hospital Discharge. JAMA 2023.
  • In this QI study, patients infrequently received discharge education in key domains, leaving gaps in patient knowledge. Interventions to improve the hospital discharge process should address the content, method of delivery, and transparency among team members regarding patient education.

Post-Discharge Phone Call Made to Patient within 3 Calendar Days

• Dudas, V. et al. The impact of follow-up telephone calls to patients after hospitalization. Am J Med 2001.
  • A follow-up phone call by a pharmacist involved in the hospital care of patients was associated with increased patient satisfaction, resolution of medication-related problems, and fewer return visits to the emergency department.
• Jack, B.W. et al. A re-engineered hospital discharge program to decrease rehospitalization: a randomized trial. Ann Intern Med 2009.
  • A package of discharge services reduced hospital utilization within 30 days of discharge. These discharge services included a nurse discharge advocate working with patients during hospitalization to facilitate discharge planning and a follow-up call from a clinical pharmacist post-discharge to reinforce discharge plan.
• Taylor, S.P. et al. Effect of a Multicomponent Sepsis Transition and Recovery Program on Mortality and Readmissions After Sepsis: The Improving Morbidity During Post-Acute Care Transitions for Sepsis Randomized Clinical Trial. Crit Care Med 2022.
  • Patients provided a 30-day program using a nurse navigator to provide best practices for post-sepsis care experienced a lower proportion of either mortality or rehospitalization within 30 days after discharge.

Hospital Contact Provided for Issues Post-Discharge

• Harrison, J.D. et al. Developing a Patient and Family-Centered Research Agenda for Hospital Medicine: The Improving Hospital Outcomes through Patient Engagement (i-HOPE) Study. J Hosp Med 2020.
  • A group of patients, caregivers, healthcare providers, and researchers from 39 organizations identified questions that were high priority to improve care of hospitalized adult patients. Knowing who to call if there are questions/issues post-discharge was identified as a high-priority issue.

Scheduled for PCP Follow-Up Within 2 Weeks

• Coppa, K. et al. Examination of Post-discharge Follow-up Appointment Status and 30-Day Readmission. J Gen Intern Med 2021.
  • The benefit of patients arriving to their post-discharge appointments compared with patients who missed their follow-up visits or had no follow-up scheduled, is only significant during first week post-discharge, suggesting that coordination within 1 week of discharge is critical in reducing 30-day readmissions.
• Misky, G.J. et al. Post-hospitalization Transitions: Examining the Effects of Timing of Primary Care Provider Follow-up. J Hosp Med 2010.
  • Patients admitted to a Colorado hospital that did not have timely follow-up with their primary care provider were 10 times more likely to be readmitted to the hospital than those who did receive timely follow-up with their PCP.
• Prescott, H.C. et al. Variation in Scheduling and Receipt of Primary Care Follow-up After Hospitalization for COVID-19 in Michigan. J Gen Intern Med 2021.
  • In a cohort of patients discharged alive from hospitalization during wave 1 of COVID-19 at 38 hospitals across Michigan, only 9 percent were scheduled for follow-up within 14 days of discharge. During wave two of COVID-19, only 25% were scheduled for a 14-day follow-up prior to discharge. At both timepoints, scheduling practices varied widely across hospitals. Enhanced policies and programs to facilitate post-hospitalization follow-up appear necessary.
• Shen, E. et al. Association of a Dedicated Post–Hospital Discharge Follow-up Visit and 30-Day Readmission Risk in a Medicare Advantage Population. JAMA Intern Med 2017.
  • Any follow-up visit with a primary care clinician within 7 days of discharge was associated with a lower risk for 30-day readmission for patients on the medicine service.

Appropriate Continuation of Medications on Discharge

• Bell, C.M. et al. Discontinuity of Chronic Medications in Patients Discharge from the Intensive Care Unit. J Gen Intern Med. 2006.
  • Patients discharged from the ICU often leave the hospital without note of their previously prescribed chronic medications. Careful review of medication lists at ICU discharge could avoid potential adverse outcomes related to unintentional discontinuation of chronic medications at hospital discharge.
• Coleman, E.A. et al. Posthospital medication discrepancies: Prevalence and contributing factors. JAMA IM 2005.
  • A total of 14.1% of studied patients (community-dwelling adults aged 65 and older) experienced one or more medication discrepancies between what older patients reported taking post discharge in comparison with their prehospital medication regimen. Both patient-associated and system-associated solutions may be needed to ensure medication safety during the discharge process.
• Pronovost, P. et al. Medication reconciliation: A practical tool to reduce the risk of medication errors. J of Crit Care 2003.
  • Estimates reveal that 46% of medication errors occur on admission or discharge from a hospital when patient orders are written. Use of a medication reconciliation discharge survey in an adult surgical ICU resulted in a dramatic drop in medication errors for patients discharged from the ICU.

Appropriate Discontinuation/Non-Use of Controlled Substances on Discharge

• Delaney, L. et al. Opioid and benzodiazepine prescribing after COVID-19 hospitalization. J of Hosp Med 2022.
  • In the studied cohort of patients across hospitals in Michigan, new exposure to opioids and/or benzodiazepines is common and discharge prescriptions are correlated with inpatient admission. Future efforts should aim to ensure that discharge prescriptions adhere to best practices in safe opioid stewardship, and that strong care transitions with consistent follow-up are prioritized.