key: cord-0696892-o15ldm5d
authors: Verdoorn, Brandon P.; Bartley, Mairead M.; Baumbach, Lori J.; Chandra, Anupam; McKenzie, Kyle M.; De la Garza, Maria Mendoza; Sanchez Pellecer, Daniel E.; Small, Tina C.; Hanson, Gregory J.
title: Design and Implementation of a Skilled Nursing Facility COVID-19 Unit
date: 2021-02-06
journal: J Am Med Dir Assoc
DOI: 10.1016/j.jamda.2021.02.001
sha: 23e852e7818c91c05a9b86b841122bdd66504a68
doc_id: 696892
cord_uid: o15ldm5d

Coronavirus disease 2019 (COVID-19) has challenged the healthcare system’s capacity to care for acutely ill patients. In a collaborative partnership between a health system and a skilled nursing facility (SNF), we developed and implemented a SNF COVID-19 unit to allow expedited hospital discharge of COVID-positive older adults who are clinically improving, and to provide an alternative to hospitalization for those who require SNF care but do not require or necessarily desire aggressive disease-modifying interventions.

A longstanding relationship between the health system and SNF, including a health system 24 physician serving as facility medical director and regular joint leadership meetings, was key in creating 25 the SNF COVID-19 unit (Table 1) . Safe nurse staffing ratios, a long-term challenge for SNFs, were 26 achieved via a professional services agreement where volunteer health system nurses supplement SNF 27 nurse staffing by filling shift needs reported by the SNF. The SNF pays the health system an hourly rate 28 for nurse time, invoiced monthly. Health system nursing and facility administrators meet regularly to 29 address operational issues. Unit closure is determined by health system leadership based on hospital 30 capacity status. 31 32 Implementation 33

The 56-bed SNF, part of a continuous care retirement community owned by a national nonprofit 34 chain, consists of three wings in a clover leaf pattern. The 18-bed COVID-19 unit occupies the distal 35 portion of the middle wing and has a separate entrance with anteroom for donning/doffing PPE. Other 36 infection control measures include: infection control training for all staff, negative pressure private 37 rooms, universal droplet precautions (N95 mask, eye protection, gown and gloves), no nursing station to 38 avoid congregation (charting completed using mobile workstations), dedicated Emergency Kit, and 39 separate laundry, meal delivery carts, and break/conference rooms. The dedicated nature of the unit 40 including physical space, personnel, and equipment facilitates conservation of PPE. 41

Six geriatricians and three advance practice providers (APP) with experience in SNF practice staff 42 the unit (one physician and one APP each week). Physicians complete new admissions in the afternoon 43 and APP are present either in the morning or all day (depending on unit census) to complete follow-up 44 contact information, vital signs, COVID-19 signs/symptoms, date/type of positive test, oxygen needs, 48 baseline functional and cognitive status, and comorbidities. 49

Nurses work 12-hour shifts, with numbers varying based on unit census. Vital signs are 50 monitored every 8 hours with abnormalities or changes in condition promptly reported via a 51 standardized notification process. Portable x-ray and phlebotomy are available weekdays. Virtual 52 interdisciplinary team rounds are held each morning (7 days/week), and formal virtual handoff between 53 off-going and oncoming APP/physician precedes this on Mondays. 54

To minimize provider COVID-19 exposure and ensure 24-hour-a-day availability, the unit is 55 equipped with two tablets for telemedicine visits (real-time audio-video communication with 3-way 56 conferencing capability), meeting SNF requirements under COVID-19 Centers for Medicare and Medicaid 57 Services waiver. 6 Physical exams are performed by a nurse with provider guidance, assisted by 58 peripheral devices including a wireless stethoscope. Orders and notes are e-faxed directly to the unit. 59

Medical capabilities specific to COVID-19 management (Table 1) The unit partially opened (on-campus ALF residents only, no shared staffing from health system 72 nurses) on November 12, 2020. Six patients were admitted during the initial 2.5 weeks, 4 directly from 73 ALF and 2 ALF residents after ED evaluation. Full opening (including shared staffing) occurred on 74

November 30, 2020. In the two weeks since, there have been 7 admissions, 6 from the hospital and 1 75 from a transitional care unit. Since initial opening, there have been 2 ED visits, 1 hospital readmission, 76 and 1 death (patient on hospice) among unit patients. Four patients discharged from the unit, all to ALF. 77 during an outbreak to assist with infection control, testing, triage, and facilitating hospital transfers. 9-11 92 At least one of these interventions involved a health system provider completing daily telemedicine 93 rounds on infected SNF residents, though this was consultative in nature and seemingly aimed mainly at 94 monitoring and triage, including anticipating potential upcoming hospital transfers. 11 While our model 95 falls under the same philosophical umbrella of health system-SNF collaboration, our approach is 96 fundamentally different in that the SNF is utilized as a means to offload acute hospitals when capacity 97 becomes strained. This leads to a more bidirectional collaboration than the above models, wherein the 98 SNF helps the health system by absorbing patients that would otherwise be hospitalized, and the health 99 system helps the SNF by augmenting staffing. 100

At least two other SNF COVID-19 units, perhaps the most similar reported models to our own, 101 have been described, one in a Veterans Affairs hospital/post-acute facility in southern California and 102 another in a post-acute facility in Barcelona, Spain. 12, 13 The Veterans Affairs unit was physically attached 103 to an acute hospital, took only post-acute patients referred from that hospital who were in the recovery 104 phase of COVID-19 with clinically mild signs/symptoms, and relied entirely on in-person provider visits. 105

The Barcelona unit had a similar target population (both post-acute and direct access) and referral 106 sources (hospital, ED, community) to our own, but also relied completely on in-person visits and 107 benefited from being housed in a facility with much greater baseline provider support (dedicated 108 physicians already present on a daily basis and on-call 24 hours per day prior to the pandemic). Both 109 other units provided a similar comprehensive model of clinical care to our own, including management 110 telemedicine emphasis that allows the unit to run smoothly without physical provider presence (likely 115 enhancing feasibility of such a model for SNFs that may otherwise have difficulty with implementation, 116 such as those located in rural areas). We provide another in a series of important examples highlighting 117 how health systems and SNFs can collaborate to optimize COVID-19 care for older adults, which can 118 hopefully serve as a blueprint for others as the pandemic continues to unfold. 119

Recent Food and Drug Administration approval of the first COVID-19 vaccine heralds a future 120 when pandemic control will improve. However, COVID-19 will remain a major concern in SNF for at 121 least several months. Vaccine distribution will take time, and even once residents and employees have 122 access, compliance may be limited. 14 Duration of protection remains unknown. COVID-19 may become 123 endemic and cause periodic outbreaks (similar to influenza). SNF COVID-19 units are an important tool 124 that can help health systems and SNFs address the current pandemic and future outbreaks. 

Shared administrative structure between SNF and academic health system, with weekly joint meetings Shared nurse staffing model utilizing combination of SNF and health system nurses Team-based provider staffing model utilizing a weekly rotation of advance practice providers and physicians with experience in SNF medicine Strong interdisciplinary team focus, including daily virtual team rounds and weekly provider handoffs Rigorous infection control practices including: negative pressure air exchanger, physically separate unit with dedicated entrance/exit and anteroom for personal protective equipment donning/doffing, reliable personal protective equipment supply and universal use (N95, eye protection, gown, gloves by all providers/staff when on unit), dedicated nursing staff, dedicated facilities (break room, conference room, laundry facility), private rooms, and infection control training for all staff Heavily protocol-driven including defined admission/transfer/discharge criteria, standardized triage assessment for admissions from assisted living facilities, and end-of-life respiratory distress protocol Telemedicine emphasis with visits conducted via real-time audio-visual connection (with 3-way conferencing capability) and 24/7 physician availability Ready availability of COVID-specific clinical expertise via phone or e-consultation from Infectious Disease and Infection Prevention specialists Access to COVID-specific medical therapies: Bamlanivimab (after approval from Infectious Diseases specialists given limited supply), tailored Emergency Kit including dexamethasone and low-molecular weight heparin (Remdesivir availability (after use in hospital for at least 48 hours) is under discussion) Targeted respiratory care including ability to provide moderate-high flow nasal oxygen support and use of breath-actuated nebulizers to minimize aerosolization On-site basic diagnostic services including lab/phlebotomy and portable x-ray (Monday-Friday) Prioritization of care that matters most -temporary discontinuation of nonessential medications (including vitamins and supplements) and self-administration of topical agents when feasible Universal admission advance care planning and rapid access to hospice services for end-of-life patients *Skilled nursing facility 2

Beyond chronological age: Frailty and 135 multimorbidity predict in-hospital mortality in patients with coronavirus disease 2019

Provisional Death Counts for Coronavirus Disease 2019 (COVID-19). Centers for Disease Control 140 and Prevention (CDC) National Center for Health Statistics

Mortality Among Residents With Coronavirus Disease 2019 (COVID-19) in Long-term Care Facilities in 144

COVID-19 in Nursing Homes: Calming the Perfect Storm

COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers

Airborne transmission of severe acute respiratory 151 syndrome coronavirus-2 to healthcare workers: a narrative review

Time to Leverage Health System Collaborations: Supporting Nursing Facilities 153 Through the COVID-19 Pandemic

A Health System Response to COVID-19 in Long-Term Care and 155 Post-Acute Care: A Three-Phase Approach

Implementation and Evaluation of an IPAC SWAT Team 157 Mobilized to Long-Term Care and Retirement Homes During the COVID-19 Pandemic: A Pragmatic 158 Health System Innovation

Collaborative Model for an Academic Hospital and Long-Term Care Facilities

Establishment of a 163 COVID-19 Recovery Unit in a Veterans Affairs Post-Acute Facility

How a Barcelona Post-Acute Facility became a Referral Center 165 for Comprehensive Management of Subacute Patients With COVID-19

Attitudes Toward a 168 Potential SARS-CoV-2 Vaccine: A Survey of