SCCM Pod-450 Surviving Sepsis Campaign: Long-Term Goals of Care

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Since the publication of the Surviving Sepsis Campaign guidelines, the focus has been on sepsis management, early identification, and treatment. (Evans L, et al. Crit Care Med. 2021;49:e1063-e1143). As more patients are surviving sepsis, they may be left with short- and long-term problems that need to be addressed. Host Ludwig H. Lin, MD, is joined by Christa A. Schorr, DNP, MSN, RN, FCCM, to discuss the implementation of initiatives for preventing impairments due to sepsis. They will also discuss the challenges faced by survivors of sepsis and the difficulties of matching care to the patient’s and family’s goals of care. In addition to the challenges of physical rehabilitation, patients often are uncertain about how care is coordinated to promote recovery and avoid complications and recurrence. Christa Schorr is a clinical nurse scientist at Cooper Hospital University Medical Center in Camden, New Jersey, USA.

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Transcript:

Dr. Lin: Hello and welcome to the Society of Critical Care Medicine’s iCritical Care podcast. I’m your host, Ludwig Lin, MD. Today, I’ll be speaking with Christa Schorr, DNP, MSN, RN, FCCM. We’ll be talking about the Surviving Sepsis Campaign International Guidelines for Management of Sepsis and Septic Shock 2021. To access the full article, visit ccmjournal.org. Dr. Schorr is a clinical nurse scientist at Cooper University Healthcare in Camden, New Jersey. She was instrumental as part of the panel that put together this version. I feel fortunate to be able to speak with her about this process and her thoughts about the content. Welcome, Dr. Schorr. Before we start, do you have any disclosures to report?

Dr. Schorr: No, Dr. Lin. Thank you so much.

Dr. Lin: It’s my pleasure. I think it’s amazing what SCCM has done with the Surviving Sepsis Campaign over the years. It probably was time for a new version to come out and to revisit the various points. Before Dr. Schorr and I start chatting, I just want to mention that this podcast cannot possibly cover all of it because it’s such a huge set of guidelines. We will be focusing today mostly on the long-term implications of critical illness and how to care for those patients. But I want to mention briefly that all the areas of the Surviving Sepsis Campaign have been revised in one way or another.

At first they might not seem very different but I think, for all of us who are so used to taking care of septic patients, any small change is probably quite seismic. So there are going to be differences in the fluid management recommendation. For antibiotic stewardship, there is a narrower choice of antibiotics, depending on your level of suspicion. There’s a shorter duration of antibiotic therapy if you can assess the patient for that. There is a different escalation of vasopressor therapy. Even little details such as how it’s now considered okay to use vasopressors through a peripheral line. Different recommendations about short steroid and bicarbonate administration. Thoughts about hemoperfusion therapy. Lots of little details throughout the guidelines. Make sure that you do get a chance to look through all of it.

We are so lucky today to be able to speak with Dr. Schorr about one of the new areas that is being emphasized in the Surviving Sepsis Campaign, which is about long-term outcomes and goals of care as well as subacute and long-term care for people surviving critical illness. I think what I’ll do is hand over the mic to Dr. Schorr and ask how you feel about the new additions. It’s one of the topics that you emphasized in your panel participation and why you feel they’re important.

Dr. Schorr: I’m super excited about the 2021 guidelines. The first iteration of the guidelines was in 2004, which was some time ago, and things have really changed. Literature has been making changes and over the years the focus was really on management, but now we see that patients are surviving sepsis. Some patients do fairly well and are discharged from the hospital quickly, whereas others may unfortunately become chronically critically ill, and patients experience challenges in recovery. 

Now is a good time to address that. We’re really fortunate to have this section expanded. I certainly did not do this alone. Seven other colleagues worked on this section with me, including physicians, nurses and, unique to this section, we had public members provide input—survivors of critical illness or family members of those who survived sepsis. Their insight really helped guide some of the recommendations in this iteration of the guidelines. 

Dr. Lin: What would you say are the biggest points that you would like all to take away from this version?

Dr. Schorr: I think the biggest point that we want to make is that patients are surviving. Some patients have physical challenges after surviving critical illness. Patients who are on mechanical ventilation for long periods of time or those who are on vasopressors for septic shock may have some severe weakness or even cognitive challenges that may go unnoticed when they’re in the ICU.

However, when they move to the general medical floors it’s important to know what this patient’s functional capacity was before illness. Hopefully our goals are to get them as close as we can back to their functional status prior to this sepsis insult. It’s important that we not only work with the patients but also work with their families because we’re focusing our attention on patient- and family-centered care.

It’s often the caregivers who need to be aware of the signs and symptoms, to be aware of changes and when to seek healthcare advice. There are a lot of little pieces that we need to do in order to help patients’ recoveries. It’s not just one element, there’s a multitude of things that we need to do. 

Not every facility has these resources. Some facilities may have the ability to have an ICU follow-up clinic where they can see these patients, but there are many, many facilities in the United States and internationally that would not have the capability of running that sort of facility. I think it’s important that we look at the resources that we have within our facility, whether it’s a teaching facility or a community hospital, and provide as much as we can to these patients and families so that they can continue the recovery process, not only in the hospital setting, but even afterward.

Dr. Lin: Great, thank you. I was thinking that we could talk about an ideal situation, where resources and the ability to have these resources were not issues for that particular institution. In that situation, what would your ideal workflow be for a patient and their family going through the Surviving Sepsis Campaign? Please describe for us how you would go about pulling together the various components of the care program.

Dr. Schorr: For instance, we can describe a patient who is admitted to the ICU with septic shock, was on vasopressors for a number of days, and also was on mechanical ventilation for seven days. At this particular point, the patient also had experienced some delirium while in the ICU. During the ICU stay, the patient was assessed to determine whether they were ready for physical rehab or even just mobility. The hope is that we would have initiated early mobility in these patients and also brought in occupational therapy just to see where the patient was at baseline before they were transferred to a general medical floor.

In this particular case, this patient we’re describing has had some challenges, some weakness, and also some difficulty swallowing at this point. They really need to be monitored a little bit more closely, so this patient we would send to a step-down unit. It’s important that, during the transitions of care, we share with the receiving team the patient’s clinical course so they have an understanding how long they were on the ventilator and vasopressors, and also what potential concerns we would have in order for them to continue on with their recovery.

In this process too we also want to include the family members so that they’re aware now that their family member is transitioning out of the ICU to a step-down unit and the care is going to be equally good; that’s important to share but sometimes they also need to understand that the nurse-patient ratio is different. Having the time to prepare the family is key. Educating the patient and the family throughout this process is important. The thought here too is that, during the ICU stay, there would have been a discussion of goals of care and that the family and the patient are participating in shared decision-making. 

We want to ensure that, as clinicians, we are caring for this patient and providing the level of care that they would deem acceptable because it’s not only that this patient is surviving sepsis, some of these patients have a multitude of comorbidities or chronic illnesses that are going to come into play. As clinicians, we need to understand where the patient and the family are as far as their goals of care and their choices. And we need to include families in that discussion.

So, now the patient is going to move to a step-down unit, and we need to begin that recovery process. The patient that we’re describing here is just on nasal cannula at this point. But most of the time patients will complain of weakness in their hands, which is going to certainly affect their ability to do activities of daily living such as brushing their teeth and combing their hair. Having therapy in there to help guide them in this process is really important in promoting mobility. 

Even if the patients are not able to walk right away, we can certainly sit them on the side of the bed or help them to the chair. Each day, we want to ensure that we are proceeding in the process of helping this patient recover. Not all patients are able to walk before they leave the institution. They may need physical rehab or long-term care. It depends on how debilitated they are from the sepsis episode. During hospitalization we really want to try to get them to a place that is going to help facilitate that recovery. 

One thing that we think we do all the time but may not do it a hundred percent of the time is that we need to assess the patient’s psychosocial aspects for anxiety and depression. Patients may have PTSD from their ICU experience. Sometimes that doesn’t come out right away in the hospital setting. Sometimes that doesn’t surface until they’re in rehab or even at home, but we need to ensure that we’re educating the patient and the family to those possibilities. That sometimes is called post-intensive care syndrome, or PICS. We want to be aware of those challenges and ensure that we educate the patient and the family that this is not uncommon; we want them to seek medical advice if they have any of those difficulties. 

Preparing the patient for discharge from the hospital, we also want to assess their financial situation and their social support because we certainly don’t want to send a patient home or to a rehab facility not knowing what their situation is. It’s not uncommon for patients to potentially have some financial challenges, especially patients who are younger and are still working. We need to ensure that the patients and the families have the resources that they need and the financial resources to be able to get the medication or the rehab that they need. Social work and transitional care navigators are certainly very, very helpful with that. But as clinicians, we can’t just assume that the patients have resources after discharge.

Most of the patients will go to physical rehab for a period of time, but they need to continue working on their cognitive function as well. It’s not uncommon for patients to feel a little foggy, their brain is just not clear. Even though they were perfectly functional before this illness, surviving sepsis and critical illness can certainly have a toll on patients. If the patient is discharged from the rehab facility and they go home, the thought is that they’re certainly ready to go home, but it doesn’t necessarily mean that they’re a hundred percent. Many survivors will tell us they still have a foggy brain, they still have muscle weakness, and strength in their hands is a big complaint that patients have. They need to continue working on those. What we’re hoping is that, if you have the capability to send or refer these patients to an ICU follow-up clinic, that would be ideal.

But unfortunately we know that that doesn’t exist in most facilities. Referring patients to their primary care physician who then can help link them with whatever it is they need, if they need physical therapy, where they maybe will go two or three times a week for strength and conditioning. If the patient is experiencing depression or anxiety, referring them to behavioral health would be certainly ideal. I think the most important thing here is that we let the patient and family know that some of the things that they’re going to experience are not unique to them and they should share that information with their healthcare providers so that they can get the resources that they need in a timely fashion.

Even after they recover, something else that may be helpful is support groups. There are a variety of peer supports. There could be a one-on-one. We may be able to link a patient with a previous survivor and they can share information as to recovery. There are support groups that are virtual. During COVID many support groups were done in a virtual setting. The goal here is to support one another and share stories. A lot of times patients become very friendly with one another, even outside of the support group meeting. They’re able to recognize changes in one another and offer some suggestions in seeking additional medical advice.

Support groups are super helpful. Providing education at this particular point is helpful. One area that I think some of us really don’t think about is the potential that these patients would get sepsis again. They are at high risk for another sepsis episode. Unfortunately, patients who experience a second episode requiring a readmission to the hospital tend not to do well and are more likely to have a poor outcome with that that second readmission. 

Educating our patients on the signs and symptoms so that they can access healthcare provider assistance as early as feasibly possible I think is a big plus. When you think about recovery, recovery from the ICU is just the first step. There are several steps along the clinical course that these patients have to go through. The challenge is that it may take months for some patients, it may be years before they’re able to feel like themselves again. As clinicians, I think we need to understand that and begin to provide care that puts patients on the road to recovery, when they’re presenting to us in critical illness, recognizing all the risks that are contributing to a delayed recovery.

I think that wraps it up for that particular patient. This is a unique patient, but I think that really gives a good picture of what recovery would look like for a patient surviving septic shock in the ICU. 

Dr. Lin: It does. Thank you. That very much is an archetypal patient. It brings up all the various issues that we need to think about. I think that was perfect. As you mentioned, there are so many different team members, and they’re all essential to getting a patient better. And better, as you pointed out, doesn’t mean just surviving the ICU stay, it means actually getting out of the hospital, getting through rehab and becoming a fulfilled member of society again. That involves physical therapists, occupational therapists, speech therapists, social workers, case managers, and maybe even a psychologist, which is what I’m hearing you talk about. It takes a village.

I want to ask you a couple of follow-up questions. One in particular is about the role of a psychologist or therapist. You talked about how sometimes later on in their recovery, the patient surviving septic shock can develop, or have come to the surface, psychological issues like PTSD or anxiety or depression. Is there a particular time point when the availability of a psychologist or behavior specialist would be most helpful? 

Dr. Schorr: I think it depends on the patient and when they begin to have these symptoms and where it’s actually disrupting their life. I think the challenge here is that there are patients who don’t verbalize that they’re experiencing these difficulties. Letting them know that it’s not uncommon and that if they do experience anxiety, depression, or PTSD, they should verbalize that because there are resources to help them through that process. Some patients experience these while they’re in the hospital, so we can intervene while they’re still hospitalized.

It’s not uncommon for patients who were in the ICU for a long period of time, once they get to the general medical floor, they feel hopeless because they’re not functioning at the same capacity as they were prior to this illness and tend to experience depression. We can bring behavioral health in at that point. They’re already in the system so we can set up a follow-up visit. It’s the patients who have gone to rehab, recovered physically, and look perfectly fine on the outside, but when it comes to having a conversation with them, they’ll say, I’m just not the same, I really don’t have the same drive, I can’t do what I used to do. It’s not uncommon for them to feel depressed. As long as we let them know and encourage them to seek medical advice and counseling perhaps, I think more patients will continue in that recovery.

It happens at all ages. So if you’re 25 years old with septic shock or you’re 80 years old with septic shock, age doesn’t matter. It’s just how patients feel. That’s really important for recovery. If patients are anxious and depressed, they’re less likely to attend the physical rehab that we have recommended for them. Unfortunately it’s a spiral because it really impacts their recovery. So, bringing this to the surface and letting patients know that healthcare providers are there for them to help them in this recovery process. When they hear in support groups that someone else has experienced these psychosocial issues, it really opens them up to say, this is happening to me and I really need to get some help. Just sometimes having a peer voice that information can be super helpful. 

Dr. Lin: Yes. I totally agree with that. I want to ask you about how to prioritize if an institution has a limited budget. I feel like that’s almost an unfair question because obviously every component is so important. Do you have any feelings about that at all? 

Dr. Schorr: In the guidelines for this particular section, long-term outcomes and goals of care, we address, in limited-resource settings, how some of these things can be accomplished. Education is something that’s very low cost. Educating our patients, providing them with the print material and verbal education, the public members stressed the importance of that, that we not only provide written information but we actually sit down and educate the patients verbally. It may require several sessions because they are overwhelmed with the amount of information that they’re receiving and they really want to understand what’s happening. We need to ensure that we take the time to spend with families. Education is key. Transitions of care in the hospital to ensure the patient is getting the right care at the right time and the right place, there are no real costs in that. It’s basically the continuum of care and having protocols in place to ensure that the patient is receiving the right care. It’s very low cost to do that.

Things that are expensive are to set up a post-ICU clinic. If you don’t have that capability, perhaps  we can make sure that patients follow up with their primary care provider, who can serve as a resource for them to find other resources that they may need. If they’re having issues with renal impairment, they can be referred to a nephrologist. If they’re having psychosocial issues, we can send them to behavioral health, but they need to see someone to manage their care. And I think that’s the correlate to having an ICU follow-up clinic. 

Dr. Lin: Yes. Thank you so much for reminding us that this is part of version 2021, to help us prioritize when there are limited resources. I think that’s going to be very helpful for a lot of people because of the healthcare environment being what it is. Thank you for saying that. One thing that you and I had talked about before we started recording was that you were hoping that the addition of these topics not only makes providers think about these issues more. I think this podcast has amply supported why we should, but that it will also spur some more studies to accumulate and present data, supporting the necessity of these different treatment and assessment measures. Is that right, Dr. Schorr? 

Dr. Schorr: Yes. Absolutely. When you look at the guidelines for long-term outcomes and goals of care, you’ll see that the recommendation, the strength of the evidence, most of the recommendations are best practice statements or weak with low quality of evidence. Best practice statements just aim to facilitate evidence-based practice and improve quality. Unfortunately, with many of these recommendations, there’s very little research available in the literature for us to include, although we recognize that each one of these elements is important to the recovery of patients with sepsis. Having additional literature and research in this area would be helpful, not only to have more robust recommendations but also to understand what patients and families need in the process of recovering from sepsis. 

Dr. Lin: Yes, I can totally see that. And I could also see us making different financial decisions because of those studies. For example, what are the outcomes of patients surviving septic shock who do not have efficient resources? What are the outcomes of people who get to have active management of their post-critical illness syndrome? If those outcome studies can show us some dramatic differences and suggest that our money could be efficiently spent in one particular way, I think that could really drive our healthcare forward in a constructive fashion. Hopefully we will be able to do that soon, and the Surviving Sepsis Campaign will have contributed to that. It’s been a great discussion. I feel like we should wrap up, although I could go on for hours about this topic. Thank you so much, Dr. Schorr for making time to talk about this topic and to raise the awareness of it for all of us. Before I conclude, would you like to say some other words of conclusion? 

Dr. Schorr: I certainly appreciate the time and allowing me to talk about this. I think many people are going to feel very strongly about what they can do for patients in recovery. It’s not only about the management, the financial cost of what’s going into helping patients’ recovery but also, if we continue to focus on the quality of life for these individuals, that’ll help us move the needle in how we’re caring for these patients in the hospital as well as after discharge. I really appreciate the opportunity and I hope clinicians are able to identify with the recommendations and move recovery from sepsis forward in their patient populations. 

Dr. Lin: Yes, that was a perfect way to wrap this up. This is the conclusion of this edition of the iCritical Care podcast. For the podcast team, I’m Dr. Ludwig Lin. Thank you so much for joining us. 

Ludwig H. Lin, MD, is an intensivist and anesthesiologist at Sutter Hospitals in San Francisco, California, and is a consulting professor at Stanford University School of Medicine, where he teaches a seminar on the psychosocial and economic ramifications of critical illness. Dr. Lin did his medical training, anesthesiology residency, and a critical care medicine fellowship at the University of California San Francisco. He has served as faculty at both Stanford University and the University of California San Francisco, where he has been a professor and the medical director of critical care at San Francisco General Hospital. His academic interests include patient and family communication and education. Being an SCCM podcast host reminds Dr. Lin of his undergraduate days as a news broadcaster for his college radio station, KZSU.

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