Protecting Long-Term Care Residents from Sepsis

Long-term care (LTC) settings, such as nursing homes/skilled nursing facilities and assisted living, are home to individuals who are unable to live independently and who need a variety of services, including both medical and personal care. According to the National Center for Health Statistics, in 2015, there were 1.5 million residents living in nursing homes/skilled nursing facilities and almost 919,000 in assisted living.¹ The Centers for Disease Control and Prevention (CDC) estimates that 1 to 3 million serious infections occur in LTC settings every year. Many residents of LTC settings are older adults with chronic conditions. Older age and chronic conditions are both factors that can increase the risk of infection, as well as the risk of a life-threatening complication of infection called sepsis.^2,3 Sepsis is the body’s extreme response to an infection. Sepsis is a medical emergency; without timely treatment, sepsis can rapidly lead to tissue damage, organ failure, and death.

Challenges with Identifying Sepsis in LTC Settings

Over the years, there have been criteria, or tools, developed to help healthcare professionals know if a person has sepsis or an infection that cannot be stopped and is developing into sepsis.^3,4 Sepsis can be difficult to diagnose, even in residents who are in the hospital. There is not currently a single test that can diagnose sepsis. However, licensed healthcare professionals can diagnose sepsis using a combination of signs, symptoms, and test results to determine whether someone has sepsis. They should closely monitor the resident’s vital signs – blood pressure, heart rate, respiratory rate, and temperature – and look for other signs and symptoms that might indicate an infection is present or worsening. Tests, such as blood tests, can help determine whether tissue or organ damage is developing. Other testing can be done to look for infection and determine the germ that is causing the infection that has led to the development of sepsis.

The intensive testing and monitoring needed to diagnose and treat residents who are suspected to have sepsis can be difficult to implement in LTC settings. The use of sepsis tools can also bring challenges. Some criteria typically used to support a sepsis diagnosis might not be as effective in older adults due to normal physiologic changes that occur with aging. Changes can include cognitive changes, a normal decline in function, or the body’s inability to respond to infection (as it would have at a younger age),⁵ such as not developing a fever. These challenges can also be due to chronic conditions that can mimic signs or symptoms of an infection or sepsis and can make it difficult to know if the resident is experiencing a change in their average health status, or baseline.

Overcoming Challenges

Effective communication among the facility’s healthcare professionals, both clinical and non-clinical, and the residents and their loved ones is critical to ensure fast recognition and treatment of sepsis. Many LTC healthcare professionals are involved each day in providing care for their residents. These professionals and the resident’s loved ones might notice a change in the resident during one of these interactions. Think through these next scenarios, whether you are someone who works in an LTC setting, a family member, friend, or volunteer.

• Scenario 1: You enter a resident’s room and notice they are having trouble getting out of the bed. Usually, this resident doesn’t need anyone’s help, but today she needs help getting from the bed to the chair.
• Scenario 2: You are visiting during lunch hour, and you notice a resident who usually loves to eat doesn’t have an appetite.
• Scenario 3: You say hello to a long-time resident who knows you well, and realize they seem disoriented and can’t remember your name.

What should you do? If you are a family member, friend, or volunteer, it is best to alert a healthcare professional. This person could be the nurse, nurse practitioner, physician assistant, or doctor. Letting a healthcare professional know will allow for someone with clinical knowledge to assess the resident and determine the next steps. If you are the nurse or certified nursing assistant, alert the healthcare professional overseeing care of the resident about your concerns and ask them, “Could this infection be leading to sepsis?” If your facility does not have a plan for how to respond when a resident is suspected of having sepsis, consider talking with your supervisor or administration about developing a plan. If you are a loved one of a resident, ask the healthcare professional if there is a sepsis response plan in place at the facility.

Why Is This So Important?

Sepsis develops quickly and can cause irreversible damage, including death, if not treated early. With fast recognition and treatment, most residents survive.

• If a resident is developing sepsis, treatment will need to begin quickly and typically will include intravenous fluids and antibiotics. Other treatments could be needed to bring the resident’s blood pressure back to normal if it is too low, or to support breathing.⁶
• In most cases, a resident who is suspected to have sepsis, or who may be developing sepsis, will need to be transferred quickly to a hospital to receive intensive evaluation and treatment. This care should be consistent with the resident’s goals of care, which is one more important step to consider.
• Ensure residents have documentation at the facility detailing their goals of care for medical interventions. This care could include an advanced directive, living will, or state-specific portable medical orders, like a Medical Orders for Life-Sustaining Treatment (MOLST) or Physician Orders for Life-Sustaining Treatment (POLST). If the resident is unable to make their own decisions, make sure there is an appropriate Healthcare Power-of-Attorney document with the facility.

Working together as a team, LTC healthcare professionals and residents’ loved ones can improve the outcomes of residents with infections and sepsis. By knowing the risks, spotting the signs and symptoms, and acting fast, you can help stop an infection from developing into sepsis and save a life.

Dr. Heather Jones is a nurse consultant with the long-term care team within CDC’s Division of Healthcare Quality Promotion with a strong focus on infection prevention and control and has a clinical background in long-term care, acute care, and chronic care management including extensive work in containment and reduction of communicable infectious diseases in long-term care facilities.

References

1. Harris-Kojetin L, Sengupta M, Lendon JP, Rome V, Valverde R, Caffrey C. Long-term care providers and services users in the United States, 2015–2016. National Center for Health Statistics. Vital Health Stat 3(43). 2019.
2. Fay K, Sapiano MRP, Gokhale R, et al. Assessment of Health Care Exposures and Outcomes in Adult Patients With Sepsis and Septic Shock. JAMA Netw Open. 2020;3(7):e206004. doi:10.1001/jamanetworkopen.2020.6004.
3. Rowe TA, McKoy JM. Sepsis in Older Adults. Infect Dis Clin North Am. 2017 Dec;31(4):731-742. doi: 10.1016/j.idc.2017.07.010. PMID: 29079157.
4. Chakraborty RK, Burns B. Systemic Inflammatory Response Syndrome. [Updated 2022 May 30]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from NLM: https://www.ncbi.nlm.nih.gov/books/NBK547669/
5. Alvis BD, Hughes CG. Physiology Considerations in Geriatric Patients. Anesthesiol Clin. 2015 Sep;33(3):447-56. doi: 10.1016/j.anclin.2015.05.003. Epub 2015 Jul 3. PMID: 26315630; PMCID: PMC4556136.
6. Polat G, Ugan RA, Cadirci E, Halici Z. Sepsis and Septic Shock: Current Treatment Strategies and New Approaches. Eurasian J Med. 2017 Feb;49(1):53-58. doi: 10.5152/eurasianjmed.2017.17062. PMID: 28416934; PMCID: PMC5389495.