Eric J. Reines, M.D.,is a practicing internist at Element Care in Lynn, Massachusetts. He specializes in geriatric medicine and sees patients enrolled in the Massachusetts Program of All-inclusive Care for the Elderly (PACE). The goal of PACE is to allow eligible patients who would otherwise need to live in skilled nursing facilities to remain in their homes and receive needed medical, social, recreational and wellness services. Dr. Reines serves as an advisor to the Massachusetts Medical Society’s Committee on Geriatric Medicine and on the Steering Committee that developed recommendations and toolkits recently released by the Massachusetts Sepsis Consortium.
The Betsy Lehman Center: Thanks to you and others, the Massachusetts Sepsis Consortium has developed recommendations for sepsis prevention and early recognition in post-acute care. There is now a great deal of focus on preventing and recognizing COVID-19. When it comes to long term health care settings, in what ways do the two concerns align?
Dr. Reines: Indeed, there is synergy between practices to address both sepsis and COVID-19. The basic premise for people in long term care — the elderly, disabled or younger patients with multiple diseases — is to do all you can to prevent them from getting infections, such as influenza, pneumonia, pertussis and certainly COVID-19, on top of the health problems they already face. Everyone should take advantage of available vaccines and practice good health habits: washing our hands and coughing into our elbow, for example. Remember that sepsis is the body’s overreaction to infection. It’s not an infection itself, but avoiding infection also helps prevent sepsis.
To address COVID-19, nursing facilities must screen all professionals and visitors, if any, for travel history and current illness. At my practice and at PACE sites, we’ve been screening people at the door for flu symptoms every winter season. Prevention is best; you want to do everything you can to avoid giving infections to people who are already ill.
The Betsy Lehman Center: There are some overlaps in the symptoms of COVID-19 and sepsis. When educating providers and staff about the need for quick action, is it important to draw distinctions between the two?
Dr. Reines: The most important thing we can do is to encourage all caregivers to speak up when they notice changes that may signal infection or sepsis. Elderly patients often do not give the same signs that we see in younger people. It’s critical for direct care workers to be alert to changes in behavior or eating habits, to report what they observe to other clinicians and to feel confident that they’ll be heard. Whether changes signal early sepsis, COVID-19 or a different infection, caregivers who are in close interaction with patients — changing diapers, helping them eat and get dressed — are often the first to know. We must pay attention to our direct care workers who know our patients well, whether they be aides, nurses, family members or close friends; we must value them and listen to them. Changes in behavior may or may not be due to infection or sepsis; that's up to a clinician to decide after evaluating the patient. The earlier we know there may be a problem, the better.
The Betsy Lehman Center: Collecting meaningful data on the prevalence and progression of sepsis has proved a challenge in all settings, which can make it more difficult to focus resources on improving sepsis outcomes. Do you have thoughts on ways to underscore the importance of advancing sepsis care?
Dr. Reines: I will say again that for patients in long term care it’s most important to recognize a change in condition and then evaluate the patient appropriately. Defining sepsis — which we must do to collect meaningful data — gets technical and arcane, even for physicians. Direct care workers, who play a critical role, don’t need to know how to diagnose and treat sepsis, which evolves along a continuum. It starts with an initial infection — say, in the bladder — that may spread to the kidneys and into the bloodstream. The body’s automatic response is sometimes helpful and sometimes, when uncontrolled, can result in sepsis.
Recognizing and responding to signs of change early can help, but in the case of advanced sepsis, not always. It is not always possible to save people, especially if they have serious underlying health problems. There seems to be an acceptance of death when it follows a heart attack or cancer, but not following infection, which brings up another important topic.
Everyone and especially those near the end of life should talk with their loved ones about what they would like done when they are not able to make their own decisions. As a physician, I want to be able to make the right decisions for patients and families. It helps to know the patient’s priorities and wishes. We should do everything possible to prevent and treat sepsis and also prepare for the difficult decisions that we sometimes face.
The Betsy Lehman Center: You served on the Steering Committee for the Sepsis Consortium that produced the new report, recommendations and toolkit for sepsis identification. What are the most important takeaways from that work for your peers? Where should they start?
Dr. Reines: First, I want to acknowledge the Betsy Lehman Center, and our project leader, Lisa Conley, for bringing the Post-Acute Steering Committee together and for polling providers to understand current practices. It’s an important topic, and I’m glad we were able to address it together.
I come back again to supporting direct care workers, at home as well as in nursing facilities. They are the ones who will first notice that something is “off.” If they don’t understand the significance of their observations or don’t feel empowered to say something to a nurse or another clinician, we miss an opportunity to address problems early, when we can be most effective.
The Betsy Lehman Center: The post-acute care provider community has also faced challenges when it comes to ensuring that all staff members get their annual flu shots. Do you see any signs that the current COVID-19 outbreak is raising greater awareness of the need for vaccination or infection control in general?
Dr. Reines: The families and friends of my patients in nursing homes have accepted the order not to visit. This is heartbreaking, but they realize the necessity. All staff at our hospital are required to wear a surgical mask throughout their shift, and this rule may soon come to our nursing homes. The clamor for a vaccine against the coronavirus is making many rethink their objections to the flu vaccine. Regarding flu vaccine, I think we should work to better understand the socioeconomic factors that influence health and help our direct care workforce make good decisions for their own well-being, as well as the health of their family members, coworkers and patients. Long term care facilities are often understaffed, which is a big problem. Direct care workers receive low pay and often not much respect. They may feel they need to work while sick or have trouble accessing childcare during this difficult time. These are societal issues that impact health for everyone.
