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The strengthening of protocols for close monitoring, active surveillance, and goals of care (GOC) discussions during the pandemic have likely positioned more nursing facilities to confidently recognize and initiate early management for residents with sepsis or suspected sepsis.
“The positive of COVID is that facilities that might have questioned their ability to create such a standard of care and manage sick patients in accordance with their wishes have realized they’re capable of doing it,” said Swati Gaur, MD, MBA, CMD, chair of AMDA – The Society for Post-Acute and Long-Term Care Medicine’s Infection Advisory Committee and medical director of New Horizons Nursing Facilities with the Northeast Georgia Health System. “The protocols and frameworks that facilities put in place to manage COVID were not one-off functions,” she said. “We can use the competencies we had to develop for COVID to do well in other areas of patient care.”
Dr. Gaur has advocated at the Society’s conferences for PALTC providers to embrace feasible elements of the “hour-1 bundle” introduced by the Society of Critical Care’s Surviving Sepsis Campaign (SSC) in 2018, such as obtaining blood samples to send for culture, administering crystalloid fluids in residents who are hypotensive, and administering broad-spectrum antibiotics when indicated.
In a 2018 JAMDA editorial, Robin L.P. Jump, MD, PhD; Susan M. Levy, MD, CMD; and Wayne S. Saltsman, MD, PhD, CMD, urged nursing homes to serve as first responders by developing a sepsis protocol tailored to its institution and by stocking an “S-Kit” with pertinent supplies (J Am Med Dir Assoc 2019;20:275–278).
Now, updated international guidelines from the SSC will further shape early management in long-term care (Intensive Care Med 2021;47:1181–1247; Crit Care Med 2021;49:e1063–e1143). Issued in October 2021 as an update to 2016 recommendations, the new guidance draws a distinction between sepsis and septic shock in addressing treatment and allows for a “more thoughtful approach” to decision-making and management of suspected or early sepsis, Dr. Gaur told Caring.
The guidance also recognizes the long-term morbidity and mortality of sepsis and calls for a handoff process of key information during transitions of care, early GOC discussions, and an assessment of physical, cognitive, and emotional symptoms after hospital discharge. Additionally, it addresses equity, recommending that patients be screened before discharge for economic and social support.
“For all this to appear in the Surviving Sepsis Campaign, as geriatricians it’s very heartening to see,” Dr. Gaur said.
More “Thoughtful” Management, Important Downstream Issues
Prior guidelines recommended the initiation of broad-spectrum intravenous antimicrobials as soon as possible after recognition or within 1 hour for both septic shock and sepsis without shock. The 2021 guidelines present a more stratified framework for approaching antibiotics; they recommend immediate administration in cases of “possible septic shock or a high likelihood for sepsis” but advise rapid assessment of infectious versus noninfectious causes of acute illness in cases of “possible sepsis without shock.”
“For adults with possible sepsis without shock, we suggest a time-limited course of rapid investigation and if concern for infection persists, the administration of antimicrobials within 3 hours from the time when sepsis was first recognized,” the new guidelines say. “For adults with a low likelihood of infection and without shock, we suggest deferring antimicrobials while continuing to closely monitor the patient.”
The guidelines also recommend basing antibiotic selection on whether patients are at high risk of methicillin-resistant Staphylococcus aureus (MRSA), multidrug-resistant organisms, or fungal infections. The new guidance “gives space to investigate while monitoring,” Dr. Gaur said. “We’ve gone from being asked to do it all ... to now assess the likelihood of these infections and treat accordingly.”
The guidance is “still saying time is of the essence, but they’re allowing for the thoughtfulness that we hope and expect with our good antimicrobial stewardship programs,” she said.
In a section on long-term outcomes and GOC, the SSC recommends addressing GOC within 72 hours for patients with sepsis or septic shock and integrating the principles of palliative care into the treatment plan if appropriate. “They’re recognizing the high-risk nature of critical illness and the fact that outcomes are poor ... and that, in addition to treating the condition, we need to be able to also treat the patient,” Dr. Gaur said.
The new recommendation to assess survivors of sepsis or septic shock for physical, cognitive, and emotional symptoms after hospital discharge “is a nod to trauma-informed care and has bearing on what we [see and do] in long-term care,” she said. “We have to be able to screen for and understand the complications ... and how to manage them appropriately.”
Another pertinent item is the suggestion that survivors who have received mechanical ventilation for more than 48 hours or had an intensive care unit stay of more than 72 hours be referred to a posthospital rehabilitation program. This sometimes will be a nursing home, Dr. Gaur said. “We need to be prepared,” she said, “to provide comprehensive care for these patients.”
Screening for Sepsis
Screening for sepsis remains a challenge, particularly for long-term care facilities.
The updated SSC guidelines take a twist and recommend against using the quick Sequential Organ Failure Assessment (qSOFA) compared with the Systemic Inflammatory Response Syndrome (SIRS) criteria, the Modified Early Warning System (MEWS), or the National Early Warning Score (NEWS) as a single-screening tool for sepsis or septic shock. (The latter two are used commonly in the United Kingdom.) The qSOFA, a tool employed in some long-term care facilities, is less sensitive than the SIRS criteria.
More important for nursing facilities, said Bernardo J. Reyes, MD, CMD, AGSF, of the Charles E. Schmidt College of Medicine at Florida Atlantic University, will be the development of new ways to screen for sepsis using changes in vital signs and other measures rather than set published values. “We need to create scoring systems that work for older people in nursing homes,” he said.
The concept of “vital parameters” was first discussed in a 2019 paper by Dr. Reyes and colleagues (J Am Geriatr Soc 2019;67:2234–2239), and it is currently under discussion by a group from the Florida Medical Directors Association (FMDA) Quality Advocacy Coalition. The group aims to develop goals and guidance on sepsis identification and early management.
“With [electronic medical records], we have access to an enormous amount of data that we didn’t have before,” Dr. Reyes told Caring. “And current technology allows us to do machine learning [so we can know] what is abnormal for specific individuals.”
A growing number of facilities have the capability to treat patients with suspected sepsis in-house, he said, noting that point-of-care technology has changed the equation along with on-site nursing and in-house intravenous fluids and antibiotics.
Dr. Levy, coauthor of the first-responders editorial in JAMDA, agreed. “Many facilities have upped their clinical ability,” she said; but even facilities with limited resources can still “get the ball rolling” with frequent monitoring and other aspects of early management. “It’s not all or none,” she said.
Christine Kilgore is a freelance writer based in Falls Church, VA.
In this episode Karl Steinberg and Elizabeth Galik discuss updates in sepsis management, the new California regulations that require all skilled nursing facility medical directors to be certified, nursing assistants and workforce concerns, and our editor-in-chief’s recent personal experience with the health care system and what she learned about giving care.