What is the follow-up management for patients hospitalized for sepsis?

Follow-Up Management for Sepsis Survivors

All sepsis survivors should receive structured post-discharge follow-up that includes screening for new physical, cognitive, and emotional problems, medication reconciliation, written and verbal education about sepsis sequelae, and assessment of economic and social support needs. 1

Immediate Post-Discharge Actions (Within 1 Week)

Early Outpatient Follow-Up

• Schedule physician follow-up within the first week after hospital discharge, as early combined medical and nursing follow-up reduces 30-day readmissions by 7 percentage points in sepsis survivors. 2
• For patients discharged to home health care, ensure the first nursing visit occurs within 2 days of discharge with at least one additional visit in the first week. 2

Medication Management

• Perform comprehensive medication reconciliation at both ICU and hospital discharge to prevent adverse drug events and ensure appropriate continuation or discontinuation of therapies initiated during acute illness. 1

Screening and Assessment Requirements

Physical Function Screening

• Screen all sepsis survivors for new physical morbidities including weakness, mobility limitations, and need for physical or occupational therapy. 3
• Patients with new functional limitations should be referred promptly to rehabilitation services. 3

Cognitive and Psychological Assessment

• Evaluate for new cognitive impairments including attention deficits, memory problems, and executive dysfunction that commonly develop after sepsis. 3, 1
• Screen for emotional problems including depression, anxiety, and post-traumatic stress disorder. 1
• Refer patients with cognitive or behavioral concerns for expedited neuropsychological evaluation. 3

Structured Telephone Assessment

• For patients with low-to-moderate medical complexity, conduct a telephone-based health assessment 2-3 months after discharge to screen for new physical or psychosocial morbidity. 3
• This approach efficiently identifies patients requiring additional intervention without overwhelming subspecialty services. 3

Patient and Family Education

Discharge Information

• Provide both written and verbal information about sepsis and its potential long-term sequelae at hospital discharge. 1
• Educate families about warning signs of recurrent infection and when to seek medical attention. 3

Shared Decision-Making

• Use shared decision-making in post-ICU and hospital discharge planning to align care plans with patient values and goals. 1

Social and Economic Support

Resource Assessment

• Screen all sepsis survivors for economic and social support needs and make appropriate referrals where available. 1
• This is a strong recommendation recognizing that sepsis often creates significant financial burden and social disruption. 1

Risk-Stratified Follow-Up Approach

High Medical Complexity Patients

• Patients with pre-existing high medical complexity or established subspecialty care should be referred for follow-up through existing care coordination or subspecialty services. 3
• Provide guidance to these specialists to monitor specifically for post-sepsis morbidity. 3

Low-to-Moderate Complexity Patients

• These patients benefit from structured sepsis survivorship program follow-up with telephone screening and targeted referrals as needed. 3
• Flag patients with new concerns for referral to their primary care physician and/or expedited specialty evaluation. 3

Common Pitfalls to Avoid

• Do not assume that clinical recovery at hospital discharge means full recovery - new morbidities often emerge weeks to months after sepsis. 3
• Do not rely solely on patients to self-identify problems - proactive screening is necessary as patients may not recognize subtle cognitive changes or attribute symptoms to sepsis. 3
• Do not delay follow-up beyond the first week - early intervention reduces readmissions and may prevent progression of new morbidities. 2
• Do not neglect patients with pre-existing conditions - these patients are at highest risk for deterioration and require close monitoring through their established care systems. 3

Implementation Considerations

Program Structure

• Utilize a nurse coordinator-led model to efficiently manage sepsis survivor follow-up and triage patients to appropriate services. 3
• Leverage existing care coordination systems, subspecialty services, and rehabilitation programs rather than creating entirely parallel systems. 3
• This approach is cost-effective and sustainable in most healthcare settings. 3