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For those trying to keep track of developments and news regarding the COVID-19 pandemic, there are constant updates as the situation is evolving rapidly. The leaders of AMDA – The Society for Post-Acute and Long-Term Care Medicine on the frontlines of the COVID-19 response came together virtually during the opening general session of the Society’s 2020 Annual Conference to provide updates, share stories and solutions, and offer encouragement and resources. “We are building this airplane as it goes down the runway and is taking off,” said David Nace, MD, MPH, CMD, the Society’s president. He and his fellow panelists cautioned their audience to buckle up for a bumpy ride, but they also offered valuable guidance, support, and hope.
Test Access, Accuracy Failures
Several panelists addressed the challenges with testing. Swati Gaur, MD, MBA, AGSF, CMD, said, “We have six COVID-positive patients so far. Hospitals couldn’t do tests prior to discharge, and we don’t have enough tests in our facilities. We do have an extensive screening process that we use.” She added, “Things have changed for us now. We don’t take any admissions until we have all the tests on each patient.”
Dr. Nace said, “One thing I’m worried about is the issue of false-negative test results for people who are asymptomatic.” He observed that about 20% to 30% of tests in these patients are false negatives, and he stressed, “Remember that tests aren’t always 100% sensitive or specific.” Dr. Nace recommended closely following the patients who can be asymptomatic or early cases. “Know their baseline and monitor them closely.”
Monitoring staff can be challenging as well. For instance, Dr. Gaur said, “Fever is not a common symptom in the staff. The Centers for Medicare & Medicaid Services wants us to actively monitor for fever, and we have temperature checks before they come into the facility, but we also ask questions about other symptoms.” Dr. Nace added, “We rely heavily on identifying symptoms such as gastrointestinal issues and headache.” To be on the safe side, Dr. Gaur observed, “We have requested that all staff wear masks caring for all patients at all times” and avoid touching the front of their mask. Some states now require that all staff wear masks and those with direct patient contact wear full personal protective equipment (PPE).
The Precious: Making the Most of Masks
Speaking of masks, Dr. Gravenstein noted, “N95 masks are a precious commodity. We use masks for all things, but we save the N95s for aerosol-producing procedures like intubations. We’ve also started using face shields to prolong the life of the mask.”
Dr. Gaur added, “We’re reusing our N95 masks, storing them in brown paper bags to extend their lives. We’re also using cloth masks and face shields over the N95.” For other PPE, Dr. Gaur said, “We have started risk stratification. We use cloth gowns that can be washed and reused to extend their life.”
Duke University, Dr. Gaur noted, has developed a cleaning protocol for N95 masks. This involves using existing vaporized hydrogen peroxide methods to decontaminate the masks so they can be reused. The process uses specialized equipment to aerosolize hydrogen peroxide, which permeates the layers of the mask to kills germs, including viruses, without degrading the mask material. However, Dr. Gaur observed, most facilities don’t have the capability for this currently. Decontamination methods have been summarized by the Centers for Disease Control and Prevention (“Decontamination and Reuse of Filtering Facepiece Respirators,” https://bit.ly/2UP2h4P).
In her general session presentation on Saturday, American Medical Association (AMA) President Patrice Harris, MD, MA, observed, “The pandemic has dramatically changed how we live, work, and care for those we love.” She told her virtual audience that the public is relying on them for “timely, accurate, and evidence-based information in the face of fear and misinformation.” She added, “There is a lot of disinformation out there. It is up to us as leaders to make sure the public and those in our profession know about and communicate trusted information. We start and end with the science.” The AMA is constantly updating its materials, Dr. Harris said. “The science and research are coming out quickly. As we learn more, there will be new information, and we want the public to expect new guidance and updates.”
Dr. Harris stressed that she uses the term “physical distancing” instead of “social distancing.” She explained that even as we must stay physically remote from others, “We have to stay socially connected.” She acknowledged that this can be challenging as business and employees suffer. However, the best step for economic recovery, she said, is to stop the spread of the illness. This requires patience, and she urged her audience to model and lead on this.
Turning to the concerns about PPE shortages, Dr. Harris said, “We have been actively, vigorously pressing for action on PPE and the need for test kits.” She has discussed this with President Donald Trump, she said, and has urged a coordinated strategy to address this.
Nursing homes and other post-acute and long-term care facilities have been hard hit by COVID-19. Dr. Harris said, “It is critically important for your teams to have what they need to care for patients.” CMS has expanded telehealth service coverage and payment for skilled nursing facility patients, waived the 3-day hospitalization requirement for skilled care coverage, and loosened regulatory restrictions and red tape to help physicians and facilities address the pandemic. “We are working to get you the resources that you need,” she said.
In their heroic efforts to care for their patients and support their teams, Dr. Harris reminded the Society’s members, “We need to make sure we take care of ourselves.” She offered, “In this time of crisis, we should always remind ourselves that there is hope and that smart people are working on these issues.”
Update resident contact information so that legally authorized representatives can be reached if and when needed.
Educate staff on the use of personal protective equipment. Enforce proper hand washing and use of masks.
Fit N95 masks to each user.
To reduce the risk of lateral transmission, implement cleaning protocols for equipment (forehead scanners, tablets, smart phones for use with resident and family communication, EKG machines, portable X-rays).
No matter how difficult, cohort COVID-positive patients.
Prepare for staffing shortages.
Reduce inbound traffic as much as possible.
Work with nursing staff and the consultant pharmacist to minimize the use of potentially unnecessary medications and simplify medication administration schedule.
Consider referring to the guide for optimizing medication management during the COVID-19 pandemic developed specifically for PALTC by the University of Maryland School of Pharmacy, https://bit.ly/39ZEfbG.
Monitor resident temperatures and pulse oximetry twice daily or every shift to identify symptoms early.
Avoid nebulizers given the increased risk of viral exposure. Instead, use bronchodilators with spacers.
In collaboration with the infection control team, develop a system for tracking residents should an outbreak occur. Information can include name, room number, age, COVID test date, date of family notification, onset of symptoms, and date of advanced care planning discussion and decision.
Ghinwa Dumyati, MD, cautioned, “We need to make sure people don’t do crazy things like putting masks in the dishwasher or microwave.” If masks are cleaned at home, the N95 filter will change properties and stop being protective. Dr. Gravenstein mentioned a possibility of making masks using available materials like H600 sterilization fabric (University of Florida, “Mask Alternative,” https://bit.ly/2V9MvR5). “You can sew these pretty cheaply and use them immediately,” he said. However, Dr. Nace noted that these homemade masks may not be adequate, especially depending on the kinds of material used to make them, and even effective ones will have a limited life span.
Dr. Nace stressed the importance of making sure that people know how to put on and remove their masks. “Have a buddy system where staff watch each other. This can help identify weaknesses in technique,” he said. “Create a blame-free environment for this.” He emphasized, “It is important to wash your hands before you touch the mask and immediately after to avoid contamination.” Never store masks in a plastic bag, he said; always use paper, and always use a new bag every time. “Cloth masks are good to prevent splatter,” said Dr. Gravenstein. They can be worn over the N95 mask to prolong its life, but washing them after each use is essential.
Technology and Regulatory Efforts Launched to Help
Telemedicine has come front and center in the COVID-19 response. Dr. Gaur said, “We got telemedicine in a hurry. We decided that all medical director, clinical care, and meeting activities provided by me will be handled via telemedicine.” She added, “As leaders, we want to be present physically, but we do a great service if we don’t transfer the virus from one facility to another.”
Waivers now allow practitioners to do initial as well as 30- and 60-day visits via telemedicine. “We are now authorized to use Zoom and other platforms,” Dr. Nace said. “You can use this technology to maintain a presence in the facility, conduct meetings, and interact with care teams, as well as patients and families.”
Communication Is Key
Keeping staff in the loop is essential, Dr. Gaur noted, stressing that regular meetings are important. These don’t have to be long — even 15 minutes can help address issues and keep staff invested. Dr. Gravenstein added, “The recommendations on addressing COVID-19 change day to day, so we have to constantly stay in touch with staff. We need to make sure they’re not doing things we don’t know they’re doing. We need to communicate frequently and stay up to date on the knowledge and how it impacts what we do.”
Despite the challenges of dealing with this pandemic, Dr. Nace stressed, “One of the most important things, especially in those individuals who are cognitively impaired, is to make sure that we talk to patients or families about what the goals of care should be.” He added, “If you’ve already had this discussion, it makes it much easier to reopen the conversation now.” It also is essential, he said, to have enough supplies on hand for end-of-life management, such as morphine.
The panelists, as well as several audience members, offered expert advice and useful, practical guidance, and Dr. Nace noted, “We know this care setting better than anyone, and this allows us to adapt, learn, and change moving forward as new information comes out.” He also advised, “Don’t be hard on yourself as you make tough choices, as long as you make them in the best interest of staff and patients.”