Quality statement 7 – Care after hospital and survivorship

A patient who has survived sepsis receives individualised follow-up care to optimise functional outcomes, minimise recurrence, reduce rehospitalisation and manage the ongoing health effects of sepsis. This requires structured, holistic and coordinated post-discharge care and education that involves the patient, their family, carer, general practitioner and other clinicians.

Support and information are provided to the family or carer of a patient who has died from sepsis.

Purpose

To support ongoing individualised care after discharge for patients who had sepsis. To ensure that appropriate support and care are provided to bereaved families and carers.

For patients

A member of your healthcare team in hospital will provide you with information and education about the diagnosis of sepsis and the type of treatment you will need after you leave hospital. Sepsis can affect many organs in your body and affects everyone differently. You or your family member may need a range of follow-up treatments, depending on your situation.

When you leave hospital, your regular doctor (general practitioner, or GP) will play an important role in managing your health. Information about your care in hospital and your ongoing care needs should be provided to your GP so they can help manage your care. For Aboriginal or Torres Strait Islander people, your GP care may be provided through your Aboriginal medical service.

Sepsis can have long-lasting effects. It is important that you are given information about these, as well as how to manage your health in the future. It takes time to recover from hospitalisation and treatment for sepsis, and you may not be able to go back to your usual activities for some time. Some people’s lives change significantly because of sepsis.

Your immune system can take time to recover, and this can mean you are more likely to get infections. It is important to talk with your doctor, nurse or pharmacist about medicines you need to keep taking, and what you need to do to prevent infection, including staying up to date with vaccinations and maintaining good hygiene.

Sepsis can affect your ability to function socially, emotionally and cognitively (how well you can think and understand) while you are recovering, even after you leave hospital. It is important to discuss any issues with your doctor and seek help for symptoms such as fatigue, anxiety and trouble concentrating.

If your relative or someone close to you has died from sepsis, the healthcare service should give you information about what happened. They should also answer any questions you have about the events and treatment provided to the person leading up to their death.

For clinicians

After sepsis treatment in hospital, consider the patient’s ongoing care needs and how these will be managed.

When discharging a patient from hospital, communicate the ongoing care plan to the patient’s general practitioner (GP). Ensure that the patient is aware of any follow-up appointments required and communicate these to the patient’s GP as part of their discharge documentation. Arrange access to appropriate services, support and contacts for patients who have been transferred from remote locations.

In general practice or other primary or community healthcare services, be aware of the specific needs for ongoing care of a patient who has had sepsis, and coordinate care between specialist medical, nursing, rehabilitation and allied healthcare professionals.

Discuss the diagnosis of sepsis with the patient and family member or carer, and how this may affect their health and wellbeing in the short and long term. Tailor your advice to the individual patient, and discuss treatment and rehabilitation goals together with the patient.

Discuss the potential effects on cognitive, social and emotional wellbeing that may occur after diagnosis and treatment for sepsis, including fatigue and anxiety. Provide information on the support available for people who have survived sepsis. Refer Aboriginal and Torres Strait Islander people to culturally safe services.

Ensure that the patient confirms any medicines they have been prescribed, including antimicrobials, and has access to these medicines. Ensure continuation of antimicrobial therapy when required, on discharge from hospital and at regular healthcare appointments. Communicate to the patient, in a way they understand, about:

  • How to take their antimicrobials
  • The duration of treatment
  • Why this is important
  • Where they can access antimicrobials.

In addition, the patient should be informed about, and understand the need for infection prevention and control, the impact of their medical history on their risk for future infection, and the importance of keeping their immunisations up to date.

If there has been a sepsis-related death during the episode of care, ensure that this is recorded in the incident management system. Ensure that the extended family (where appropriate) and carers have the opportunity to discuss the care that was given and what happened. Address any questions that arise using the principles of open disclosure, and direct them to patient support organisations such as the Australian Sepsis Network and bereavement organisations for ongoing support. Ensure that the support is accessible and appropriate for culturally and linguistically diverse communities.

If there has been a neonatal sepsis-related death, refer to the Stillbirth Clinical Care Standard for further information about bereavement care and support.

For healthcare services

Ensure that processes are in place to support patients, families and carers after hospital discharge for acute management of sepsis. This can include rehabilitation, access to emotional and social wellbeing supports, and allied health care. Consider using a centralised computer system to coordinate the patient’s post-acute care.

Before discharge, a patient should be referred to their general practitioner (GP), who can coordinate their care after hospital discharge. The GP and any other clinician to whom the patient is referred should be provided with:

  • A comprehensive plan on follow-up requirements to optimise functional outcomes, minimise recurrence, reduce rehospitalisation and manage the ongoing health effects of sepsis
  • Details of the hospital clinician with expertise in managing sepsis or care coordinator to support the transition of care and facilitate communication between the community and hospital care providers
  • Education materials about sepsis and patient care needs.

Discharge summaries should include all the relevant information as described in Quality statement 6 – Transitions of care and clinical documentation and NSQHS Communicating for Safety Action 6.11.

Healthcare services discharging patients on antimicrobial therapy should have systems in place to ensure that the patient can continue antimicrobial therapy post-discharge and address potential barriers to access, including cost. In some cases, antimicrobials may need to be supplied to the patient.

Review the death of any patient due to sepsis in the absence of a pre-existing life-limiting condition, or where death was unexpected. Offer the family an explanation, information and discussion in line with the principles of open disclosure. This may involve a follow‑up appointment at a later date and referral to bereavement care and support services as required. Ensure that all sepsis deaths are documented in a risk management system, reviewed, and reported to and monitored by a governing body (such as a patient safety or deteriorating patient committee, or similar) to identify opportunities for continued improvement.

For patients

A member of your healthcare team in hospital will provide you with information and education about the diagnosis of sepsis and the type of treatment you will need after you leave hospital. Sepsis can affect many organs in your body and affects everyone differently. You or your family member may need a range of follow-up treatments, depending on your situation.

When you leave hospital, your regular doctor (general practitioner, or GP) will play an important role in managing your health. Information about your care in hospital and your ongoing care needs should be provided to your GP so they can help manage your care. For Aboriginal or Torres Strait Islander people, your GP care may be provided through your Aboriginal medical service.

Sepsis can have long-lasting effects. It is important that you are given information about these, as well as how to manage your health in the future. It takes time to recover from hospitalisation and treatment for sepsis, and you may not be able to go back to your usual activities for some time. Some people’s lives change significantly because of sepsis.

Your immune system can take time to recover, and this can mean you are more likely to get infections. It is important to talk with your doctor, nurse or pharmacist about medicines you need to keep taking, and what you need to do to prevent infection, including staying up to date with vaccinations and maintaining good hygiene.

Sepsis can affect your ability to function socially, emotionally and cognitively (how well you can think and understand) while you are recovering, even after you leave hospital. It is important to discuss any issues with your doctor and seek help for symptoms such as fatigue, anxiety and trouble concentrating.

If your relative or someone close to you has died from sepsis, the healthcare service should give you information about what happened. They should also answer any questions you have about the events and treatment provided to the person leading up to their death.

For clinicians

After sepsis treatment in hospital, consider the patient’s ongoing care needs and how these will be managed.

When discharging a patient from hospital, communicate the ongoing care plan to the patient’s general practitioner (GP). Ensure that the patient is aware of any follow-up appointments required and communicate these to the patient’s GP as part of their discharge documentation. Arrange access to appropriate services, support and contacts for patients who have been transferred from remote locations.

In general practice or other primary or community healthcare services, be aware of the specific needs for ongoing care of a patient who has had sepsis, and coordinate care between specialist medical, nursing, rehabilitation and allied healthcare professionals.

Discuss the diagnosis of sepsis with the patient and family member or carer, and how this may affect their health and wellbeing in the short and long term. Tailor your advice to the individual patient, and discuss treatment and rehabilitation goals together with the patient.

Discuss the potential effects on cognitive, social and emotional wellbeing that may occur after diagnosis and treatment for sepsis, including fatigue and anxiety. Provide information on the support available for people who have survived sepsis. Refer Aboriginal and Torres Strait Islander people to culturally safe services.

Ensure that the patient confirms any medicines they have been prescribed, including antimicrobials, and has access to these medicines. Ensure continuation of antimicrobial therapy when required, on discharge from hospital and at regular healthcare appointments. Communicate to the patient, in a way they understand, about:

  • How to take their antimicrobials
  • The duration of treatment
  • Why this is important
  • Where they can access antimicrobials.

In addition, the patient should be informed about, and understand the need for infection prevention and control, the impact of their medical history on their risk for future infection, and the importance of keeping their immunisations up to date.

If there has been a sepsis-related death during the episode of care, ensure that this is recorded in the incident management system. Ensure that the extended family (where appropriate) and carers have the opportunity to discuss the care that was given and what happened. Address any questions that arise using the principles of open disclosure, and direct them to patient support organisations such as the Australian Sepsis Network and bereavement organisations for ongoing support. Ensure that the support is accessible and appropriate for culturally and linguistically diverse communities.

If there has been a neonatal sepsis-related death, refer to the Stillbirth Clinical Care Standard for further information about bereavement care and support.

For healthcare services

Ensure that processes are in place to support patients, families and carers after hospital discharge for acute management of sepsis. This can include rehabilitation, access to emotional and social wellbeing supports, and allied health care. Consider using a centralised computer system to coordinate the patient’s post-acute care.

Before discharge, a patient should be referred to their general practitioner (GP), who can coordinate their care after hospital discharge. The GP and any other clinician to whom the patient is referred should be provided with:

  • A comprehensive plan on follow-up requirements to optimise functional outcomes, minimise recurrence, reduce rehospitalisation and manage the ongoing health effects of sepsis
  • Details of the hospital clinician with expertise in managing sepsis or care coordinator to support the transition of care and facilitate communication between the community and hospital care providers
  • Education materials about sepsis and patient care needs.

Discharge summaries should include all the relevant information as described in Quality statement 6 – Transitions of care and clinical documentation and NSQHS Communicating for Safety Action 6.11.

Healthcare services discharging patients on antimicrobial therapy should have systems in place to ensure that the patient can continue antimicrobial therapy post-discharge and address potential barriers to access, including cost. In some cases, antimicrobials may need to be supplied to the patient.

Review the death of any patient due to sepsis in the absence of a pre-existing life-limiting condition, or where death was unexpected. Offer the family an explanation, information and discussion in line with the principles of open disclosure. This may involve a follow‑up appointment at a later date and referral to bereavement care and support services as required. Ensure that all sepsis deaths are documented in a risk management system, reviewed, and reported to and monitored by a governing body (such as a patient safety or deteriorating patient committee, or similar) to identify opportunities for continued improvement.

Equity and cultural safety

Resources

Related resources have been identified which are relevant to the quality statements, including:

  • Decision support tools and sepsis pathways and other guidance about sepsis - including state and territory resources
  • Guidelines and tools for recognising and responding to acute deterioration, including patient escalation pathways for each state and territory
  • Resources to support management of antimicrobial therapy
  • Education and information for patients and carers during hospitalisation for sepsis, on discharge and through survivorship.

A range of implementation resources have also been developed by the Commission including guidance, factsheets and tools for healthcare services and clinicians, and resources for consumers. 

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