Core component / Evidence | Recommendation | STAR Task |
---|---|---|
Screen for new physical, mental, and cognitive deficits after sepsis | ||
 Functional disability: Patients aged ≥65 years develop 1 to 2 new functional limitations | -Prescribe structured exercise program -Referral to Physical/ Cardiac/ Pulmonary rehab as needed | Confirm functional assessment (Physical Therapy). Refer as needed. |
 Swallowing impairment: Of patients aged ≥65 years, 1.8% readmitted < 90 days for aspiration pneumonitis | -Screen for cough, dysphagia, weak voice -Referral to speech therapy as needed | Confirm screen and team aware. Refer as needed. |
 Mental Health impairment: Prevalence for clinically significant anxiety 32%, depression 29%, and PTSD 44% | -Review details of hospital course (e.g., ICU diary) -Depression screen -Referral to peer support or Behavioral Health as needed | Mental health screen. Refer as needed. |
Review and Adjust Long-term Medications | ||
 Medication errors: Errors of omission and commission occur in up to 25% of patients, depending on medication | -Review antibiotic choice, dose, duration. -Start/continue meds for comorbidities; adjust for BMI, etc. -Discontinue hospital meds without ongoing indication | Antibiotic Stewardship Medication Reconciliation Vitals/Weight |
Anticipate and Mitigate risk for Common and Preventable Causes of Health Deterioration | Â | Routine virtual follow up. Schedule provider visits |
 Infection: Of patients aged ≥65 years, 11.9% readmitted < 90 days for infection (6.4% for sepsis) | -Patient education about symptoms of sepsis, recurrence -Appropriate vaccination -Monitor for symptomatic improvement in index infection | Education Medication Reconciliation Monitor symptoms |
 Heart failure exacerbation: Of patients aged ≥65 years, 5.5% readmitted < 90 days for CHF | -Reassess beta-blocker, diuretic, ACE-inhibitor dosing -Monitor volume status (fluid balance) - recognizing dry weight may be decreased if muscle mass lost | Medication Reconciliation Vitals/Weight Monitor symptoms |
 Acute Renal Failure: Of patients aged ≥65 years, 3.3% readmitted < 90 days for acute renal failure | -Monitor renal function; lab testing as needed -Reassess need and dosages for renally cleared, nephrotoxic agents | Monitor symptoms Confirm CBC/BMP Medication Reconciliation |
 COPD exacerbation: Of patients aged ≥65 years, 1.9% readmitted < 90 days for COPD exacerbation | -Confirm/initiate appropriate controller inhalers -Appropriate vaccination -Review use of benzodiazepines/opioids | Monitor symptoms Medication Reconciliation |
Assess appropriateness for palliative care | -Palliative Care screen/consult as indicated -Goals of care. Educate on disease progression/ terminal | Discuss Palliative Care consult. Goals of Care |