Recovery-Focused Practices and Discharge Planning - References

References

• 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.

• 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. Journal of Critical 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.

• 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.Critical Care Medicine 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, race, 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.

• 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
• 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. Ann Am Thorac Soc. 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.

• 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.

• 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.

• Coppa, K. et al. Examination of Post-discharge Follow-up Appointment Status and 30-Day ReadmissionJ 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 PopulationJAMA 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.

• 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.

• 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.

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