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COVID-19 Resources and FAQs for Clinicians in Post-Acute & Long-Term Care

March 22, 2020 COVID-19, Infectious Disease, Public Health, Treatment Protocols 0

 COVID-19 Resources and FAQs for Clinicians in Post-Acute & Long-Term Care

A crowd-sourced collaboration of volunteer physicians in SDCMS. These resources were put together at the request of our members looking for support for physicians practicing in post-acute and  long term care. We have done our best to include links that are updating frequently from reliable sources like the CDC, CDPH, and San Diego County. These are NOT meant to be guidelines or standards of practice. Use all of this at your own risk and discretion. We hope that you use this as an open-source resource and tailor the documents to your particular practice. 

 

Please let us know if there are things that we can improve, or something that you don’t see on here that you or other practices may need. If you have something helpful that is new or different enough that it would change practice/outcome, please send it our way. If what we have is close enough, please refrain from minor tweaks so we can triage our busy inbox. We’ll do our best to try to incorporate your feedback after reviewing it with our volunteers. Our volunteer physicians are also seeing patients and are doing this in their spare time, so we may not be able to get to every request or suggestion during this challenging time.   

(post-acute and long-term care [PALTC] encompasses skilled nursing facilities [SNFs] and residential care facilities for the elderly [RCFEs], including assisted living [AL] communities and smaller board-and-care facilities and group homes)

Key Resources:

A good central resource for updates from AMDA, CMS, CDC, CALTCM and others; numerous links available on this AMDA website:  https://paltc.org/COVID-19

Considerations for clinicians in PALTC Settings:

  • Do not do direct patient care if feeling ill. Stay home and follow CDC guidelines about returning to work.  
  • Routine Rounding:
  • Medically Necessary (for ill or unstable residents) Visits
    • For clinicians who have multiple residents in a single facility who require visits, proceed with on-site face-to-face visits, using all appropriate PPE.  
    • If there is an alternate physician who is already seeing residents in the facility that day (e.g., facility medical director or other post-acute clinician), it may be reasonable to ask that physician to do the direct, face-to-face visit.  
    • As always, it is reasonable in many cases to rely on on-site nursing staff for basic assessment, vital signs, description of resident symptoms, etc., and give appropriate orders remotely.  Whenever possible, transporting residents to the hospital during this pandemic should be avoided.  
  • Advance Care Planning/POLST
    • Given the high probability that we will see COVID-19 in our LTC facilities, and given the high probability of critical illness and death in the LTC population, it is recommended that—as time permits—advance care planning conversations occur with each resident and/or family at the soonest available time.  These should include reviewing and revisiting code status, creating or modifying POLST orders as medically appropriate, and ensuring that the facility has the updated orders.  The extremely poor survival rate for CPR in this population, and the burdens of intubation and mechanical ventilation, in conjunction with existing medical conditions, should be reviewed.  For those who do want CPR and intubation, those orders can be written—with the understanding that if the supply of ventilators is limited, those who are least likely to survive are least likely to receive ventilator support.  Honest discussions in advance can be very helpful.  
    • Make sure to write “Comfort Care” or “Do Not Transfer to Hospital” orders in appropriate residents’ charts to help ensure they receive the type of care they wish in their familiar environment.
  • Should I send a resident with symptoms consistent with COVID-19 to the hospital?
    • First, isolate the patient and protect staff per CDC guidelines.
    • Do initial workup including flu swab (if resident not seriously ill/unstable) and COVID-19 swab if available, ensuring appropriate PPE is utilized.
    • Residents who are not seriously ill/unstable should be isolated and treated in place, in accordance with their goals of care.  As of now, testing for COVID-19 via nasopharyngeal swab is recommended in such residents where available. If testing is not available, treat them as it they do have COVID-19. 
    • Do not forget about other common causes of respiratory symptoms in this population, like aspiration pneumonia, which should also be considered and treated as appropriate.
    • If the resident is ill enough to warrant treatment that can only be given at a higher level of care (e.g., ventilator, pressors)—AND if the resident’s goals of care include hospitalization and full treatment—send the resident to the hospital.  You must call the emergency department and EMS transport to alert them about a potential COVID-19 patient beforehand, if possible.
    • NOTE:  There is a nationwide shortage of bronchodilator inhalers, such as albuterol, that is expected to worsen.  If your resident is using an inhaler and you are transferring them to the hospital, please specify orders to SEND THE MDI to the hospital with the resident.
    • If the resident is significantly ill or unstable and has “comfort care” or “do not hospitalize” orders, provide treatment in place and ensure isolation and appropriate PPE are being utilized.  
      • Provide oxygen, morphine, benzodiazepines and other comfort-oriented medications as appropriate.  
      • For those who desire selective treatment, consider periodic lab work as medically indicated, judicious intravenous fluid resuscitation, and other routine, non-burdensome interventions.  If concurrent bacterial infections or other comorbid conditions are present, treat them as appropriate.  
      • Consider hospice care, if appropriate.
  • Other Orders 
    • It is recommended to discontinue nebulizer treatments, especially in patients with COVID or suspected to have COVID because of the risk of aerosolized virus transmission.  If nebulizers are truly medically necessary, reduce the frequency if possible and ensure full airborne precautions are observed by staff. Consider MDI with a spacer with a higher dose (e.g., 4-8 puffs), if feasible, for these patients. 
      • Follow strict airborne precautions for suspected or positive patients with BiPAP, CPAP, high-flow oxygen, tracheostomy suctioning, sputum induction, and CPR.
      • For more information on airborne precautions, see https://www.cdc.gov/infectioncontrol/basics/transmission-based-precautions.html.  These include N-95 mask and an airborne infection isolation room (AIIR) in facilities where these are available.  
    • Routine orders for antihypertensive and cardiac rate-related medications that have “hold” parameters often require daily or multiple-times-daily vital signs.  Unless residents have unstable vital signs, consider reducing the frequency of routine vitals to weekly or less—especially blood pressure, which requires cleaning of the cuff between uses.  Obviously, continuing to check temperature and respiratory rate routinely, especially in facilities with known or suspected COVID-19, is important.  Checking pulse oximetry may also be appropriate. Clean equipment between each use.
  • Minimizing isolation
    • Encourage staff to assist patients in using technology like FaceTime or Skype to allow patients to “see” their loved ones who are not allowed into the facility. 
    • Make sure that devices are thoroughly cleaned in between each use.


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