key: cord-0763296-djlj6xyg authors: Stall, Nathan M.; Farquharson, Carolyn; Fan‐Lun, Chris; Wiesenfeld, Lesley; Loftus, Carla A.; Kain, Dylan; Johnstone, Jennie; McCreight, Liz; Goldman, Russell D.; Mahtani, Ramona title: A Hospital Partnership with a Nursing Home Experiencing a COVID‐19 Outbreak: Description of a Multi‐Phase Emergency Response in Toronto, Canada date: 2020-05-22 journal: J Am Geriatr Soc DOI: 10.1111/jgs.16625 sha: cf17cba2ed65efc5d3fc08ef6d15564216637355 doc_id: 763296 cord_uid: djlj6xyg Nursing homes have become “ground zero” for the coronavirus disease 2019 (COVID‐19) epidemic in North America, with homes experiencing widespread outbreaks resulting in severe morbidity and mortality among its residents. This manuscript describes a 371‐bed acute care hospital's emergency response to a 126‐bed nursing home experiencing a COVID‐19 outbreak in Toronto, Canada. Like other health care system responses to COVID‐19 outbreaks in nursing homes, this hospital‐nursing home partnership can be characterized in several phases: 1) engagement, relationship and trust‐building; 2) environmental scan, team‐building and immediate response; 3) early phase response; and 4) stabilization and transition period. This article is protected by copyright. All rights reserved. Nursing homes have become -ground zero‖ for the coronavirus disease 2019 (COVID- 19 ) epidemic in North America, with homes experiencing widespread outbreaks resulting in severe morbidity and mortality among its residents. This manuscript describes a 371bed acute care hospital's emergency response to a 126-bed nursing home experiencing a COVID-19 outbreak in Toronto, Canada. Like other health care system responses to COVID-19 outbreaks in nursing homes, this hospital-nursing home partnership can be characterized in several phases: 1) engagement, relationship and trust-building; 2) environmental scan, team-building and immediate response; 3) early phase response; and 4) stabilization and transition period. Nursing homes have become -ground zero‖ for the coronavirus disease 2019 (COVID-19) epidemic in North America. 1 In both the United States and Canada, the first recorded COVID-19 deaths and outbreaks occurred in nursing homes, with case fatality rates in these settings reported to be as high as 33.7%. 2 Since that time, more than 25,000 nursing home residents have died of COVID-19 in the United States, while more than 80% of all COVID-19 deaths in Canada are among nursing home residents. 3, 4 There are a number of reasons why nursing home residents are at disproportionately high risk of contracting severe acute respiratory syndrome coronavirus 2 virus (SARS-CoV-2)-the causative agent of COVID-19-and related morbidity and mortality. First, nursing homes house a large number of frail older adults-often within shared rooms or with shared bathrooms-which predisposes to rapid transmission of SARS-CoV-2. 2 Second, early infection prevention and control (IPAC) strategies focused on screening and testing symptomatic nursing home residents, yet many who swab positive for SARS-CoV-2 are pre-symptomatic at the time of testing. 5 Further, screening for COVID-19 tends to emphasize fever and respiratory symptoms, yet frail older adults are more likely to have -atypical presentations‖ of COVID-19 such as delirium, falls and function decline. [6] [7] [8] Third, severe COVID-19 infection occurs more commonly among older adults and those with underlying chronic conditions, features that define the majority of nursing home residents. 9, 10 In Canada, nursing home residents have an average age of 82 years, most suffer from multimorbidity with nearly 70 % having dementia, and they take an average of 10 medications a day. 11, 12 In Canada's most populous province of Ontario, nearly 80,000 individuals live in more than 625 nursing homes. 13 At the time of writing, there were 274 cumulative COVID-19 outbreaks in Ontario nursing homes resulting in the deaths of 1,389 nursing home residents and 5 staff. 14 Prior the pandemic, Ontario nursing homes and acute care hospitals had no prescribed relationships, and they continue to be regulated by independent ministries. In response to the evolving crisis, the Government of Ontario took the extraordinary step of asking hospitals to develop and deploy specialized -COVID-19 SWAT teams‖ from hospitals to provide additional staffing, IPAC, occupational health and operational support to nursing homes. 15 Absent a roadmap for the partnership, our 371-bed acute care hospital developed a multi-phase emergency response to a 126-bed nursing home experiencing a COVID-19 outbreak in Toronto, Canada. When a partnership was established between the hospital and the nursing home on Prior to the hospital's partnership, the nursing home had made several requests and advocated with a variety of organizations and governmental agencies seeking immediate assistance in managing the COVID-19 outbreak; unfortunately, none of these interactions translated into meaningful assistance and the home had developed a lack of trust towards outside help. Recognizing the well-established evidence highlighting trust as the -vital ingredient for effective emergency-response teams‖ across a variety of settings, relationship and trust building were the key principles in our emergency response. 17 The relationship and trust-building process involved thoughtful listening by the hospital about the urgency of the situation within the nursing home, and collaborative problem solving on tangible ways for the hospital to offer assistance within hours. Through this process, both the gravity of the situation in the home as well as the nature of the immediate response required became evident, setting the stage for a co-designed multiphase emergency response. Building on the relationships and trust we established, Phase 2 (detailed in Table 1 ) started with an environmental scan of the needs of the nursing home. Immediate needs identified included more direct access to palliative care, geriatric medicine, and IPAC clinicians to support the nursing home's long-term care physicians. There was also a need for staffing, and the hospital's human resources and occupational health leads worked with the home to understand the current and projected staffing shortages. The environmental scan also determined the nursing home's personal protective equipment (PPE) stockpile, supply chain and expected burn rate as well as shortages and expected needs for medical equipment (e.g., vital sign monitoring machines, pulse oximeters, and oxygen tanks) and medications. We also established an interdisciplinary clinical and operations team to oversee and execute the emergency response. Members of the hospital team included clinicians in geriatric medicine, palliative care geriatric psychiatry, IPAC, pharmacy and nursing as well as senior leadership and administrators from nursing, IPAC, occupational health and human resources, materials management, and environmental services. The full list of team members, roles and responsibilities is detailed in Appendix 1. Daily operations meetings occurred throughout the duration of the emergency response, and the team liaised closely with the local Public Health Unit (PHU). The immediate response involved widespread SARS-CoV-2 testing of the remaining nursing home residents and an urgent IPAC risk assessment. The hospital-This article is protected by copyright. All rights reserved. Accepted Article based IPAC team met with the local PHU to understand and review the scope of the nursing home outbreak, and worked with the home to identify any gaps in recommended IPAC measures and procedures. 18, 19 Finally, recognizing the severity of the COVID-19 crisis within the nursing home as well as critical staffing shortages, an agreement was made to immediately decant 15 residents (>15% of the remaining residents in the home) to the acute care hospital for inpatient admission. At that time, the nursing home was experiencing its peak of COVID-19 resident deaths, so Phase 3 of the emergency response (detailed in Table 2 ) focused on establishing the infrastructure for virtual care, clinical triage of the remaining residents, and the emergency provision of palliative and medical care. Virtual care is a recognized means of improving health care delivery in public health emergencies and was an ideal tool for this response to minimize staff exposure, the PPE burn rate, and SARS-CoV-2 transmission between the hospital and the nursing home. 20 The virtual care infrastructure included remote access to the nursing home's electronic medical records, tablet computers donated by the hospital (with plastic cases and screen covers which could be cleaned between resident interactions), and secure video communications software. 20 Once this infrastructure was established, the clinical team urgently triaged the nursing remaining residents to identify those who were medically unwell and end-oflife. 21 This involved a rapid and systematic review of residents' medical records, screening by the nursing home staff using a tool we developed (see Appendix 2), and virtual rounding-prioritizing those residents flagged by chart review and the screening tool-with an on-site registered practice nurse (RPN). 22, 23 When a resident was identified as being medically unwell or end-of-life, the team immediately pursued a goals of care conversation to understand the resident and/or substitute decision maker's illness understanding, values, wishes, treatment goals (i.e., active medical management or comfort-based care) and preferred place of care (i.e., transfer to hospital or remain in the nursing home); almost all residents chose to remain in the home. 22 Active medical management included access to STAT in-home blood work and xray imaging, hypodermoclysis for dehydration, and low-flow supplemental oxygen for This article is protected by copyright. All rights reserved. Accepted Article hypoxia emphasizing that this posed no risk of SARS-CoV-2 aerosolization or transmission. 24 The provision of palliative care involved assessment and management of commonly experienced COVID-19 end-of-life symptoms including dyspnea, respiratory congestion, pain, nausea and delirium, and regular contact with families to provide emotional support during the dying process, including suggestions about how to be present with their dying loved one using technology. 21, 22 The early phase response also involved intensive IPAC interventions, including By the onset of phase 4 (detailed in Table 3 ), there were no further unanticipated resident deaths or transfers to hospital, and the outbreak was stabilizing. This phase focused on alleviating staffing shortages, optimizing the medical and psychiatric care of residents, psychosocial support for the nursing home's staff, and preparing the home for a transition back to more autonomous clinical care and management. Given the extreme staffing shortages, the hospital redeployed 12 of its nurses for a 4-week assignment at the nursing home. Prior to redeployment, these nurses were provided with an intensive orientation and -shadowing‖ experience to prepare them for work in the nursing home environment. A geriatric hospital pharmacist also started participating in clinical team rounds. Recommendations were made to consolidate and limit medication administration times to decrease the risk of SARS-CoV-2 exposure to staff and the PPE burn rate. This included switching medications to less frequently dosed formulations or reducing dosing frequency, aligning administration times to bundle with timing of other resident care tasks, and deprescribing non-essential medications. 25 The pharmacist also performed comprehensive medication reviews to optimize medication safety and resident care. Like others, we observed that the nursing home outbreak triggered incident mental health problems and worsened existing psychiatric symptoms among residents. 26 In particular, residents with cognitive impairment experienced challenges and distress with the isolation and frequent room changes required for outbreak management. 27 The team's geriatric psychiatrist provided virtual consultations to residents with new mental health concerns while also liaising with nursing-home based mental health clinicians to reassess and optimize treatment plans for residents with pre-existing mental illness and cognitive impairment. This included strategies for the effective and compassionate isolation of residents with COVID-19 and dementia who were prone to wandering. 27 Another major effort involved providing psychosocial supports for the nursing home staff. Recognizing the staff's psychological stress as a result of caring for vulnerable and dying residents, navigating rapidly changing IPAC guidance, and worrying about their own health and safety, the hospital's psychiatry group offered individual and group-based counselling to the home' staff. 28 A psychiatrist and clinical nurse specialist also joined daily rounds to offer point-of-care support and to continue fostering relationship building and trust between the nursing home and hospital teams. Finally, there were a number of stabilizing interventions to facilitate the nursing home's transition back to more autonomous clinical care and management. This included the IPAC team and PHU overseeing the testing of all asymptomatic nursing home staff and clearing residents who had recovered from COVID-19. The clinical team also coached and empowered the nursing home staff to monitor and manage geriatric and palliative syndromes and pursue goals of care conversations. In this phase, the nursing home's family physicians started joining virtual rounds, and eventually began rounding independently using the newly established virtual care infrastructure. Even in the midst of the COVID-19 pandemic, many nursing homes are still under-prepared and under-equipped to manage outbreaks within their homes. 29 Recognizing this, there is an urgent need for real-time data and experiences of nursing This article is protected by copyright. All rights reserved. Accepted Article home interventions during the pandemic to help inform effective responses worldwide. This hospital and nursing home partnership demonstrates that it is not too late for health systems to regroup and restructure to help homes survive the surge of COVID-19 outbreaks. 30 Indeed, other countries like Singapore radically retooled the organization and provision of care within their long-term care sector, and did not experience a single case of SARS-CoV-2 transmission within their nursing homes. 31 This multi-phase emergency response highlights how hospital and nursing home administrators and clinicians can effectively collaborate to manage a large COVID-19 outbreak and ideally prevent the risk of future outbreaks. The key principles of this intervention included a phased response that emphasized relationship and trust-building; a robust clinical and operations team with central input from geriatric medicine, palliative care, IPAC, psychiatry, nursing as well as senior hospital leadership and administration; and a non-hierarchical and collaborative approach to working with the nursing home staff and most responsible family physicians. While COVID-19 has devastated nursing homes across the world, we do hope that responses like ours can be a model for other homes in crisis. It is also critical that governments and policymakers recognize that their support is not only needed now, but well beyond the pandemic to fundamentally redesign and modernize the long-term care sector. 30 This article is protected by copyright. All rights reserved. Nursing Homes Are Ground Zero for COVID-19 Epidemiology of Covid-19 in a Long-Term Care Facility in King County One-Third of All U.S. Coronavirus Deaths Are Nursing Home Residents or Workers. The New York Times Web site Impact of COVID-19 on residents of Canada's long-term care homes -ongoing challenges and policy responses Presymptomatic SARS-CoV-2 Infections and Transmission in a Skilled Nursing Facility Typically Atypical: COVID-19 Presenting as a Fall in an Older Adult Coronavirus Disease19 in Geriatrics and Long-Term Care: An Update Delirium: a missing piece in the COVID-19 pandemic puzzle Coronavirus Disease 2019 in Geriatrics and Long-Term Care: The ABCDs of COVID-19 AGS) Policy Brief: COVID-19 and Assisted Living Facilities When a Nursing Home Is Home: How Do Canadian Nursing Homes Measure Up on Quality? Canadian Institute for Health Information About long-term care in Ontario: Facts and figures Government of Ontario. Ontario Takes Immediate Steps to Further Protect Long-Term Care Residents and Staff During COVID-19 Outbreak A Health System Response to COVID-19 in Long Term Care and Post-Acute Care: A Three-Phase Approach Oxfam GB for the Emergency Capacity Building Project. Building Trust in Diverse Teams: the Toolkit for Emergency Response Infection Prevention and Control for COVID-19: Interim Guidance for Long Term Care Homes COVID-19: Infection Prevention and Control Checklist for Long-Term Care and Retirement Homes Virtually Perfect? Telemedicine for Covid-19 Conservative Management of COVID-19 Patients-Emergency Palliative Care in Action Pandemic palliative care: beyond ventilators and saving lives Pandemic Influenza Triage Tools. Oak Ridge Institute for Science and Education Aerosol generating procedures and risk of transmission of acute respiratory infections to healthcare workers: a systematic review Ontario Ministry of Health. COVID-19 Outbreak Guidance for Long-Term Care Homes (LTCH) Addressing the COVID-19 Pandemic in Populations With Serious Mental Illness Achieving Safe, Effective and Compassionate Quarantine or Isolation of Older Adults with Dementia in Nursing Homes Addressing Skilled Nursing Facilities' COVID-19 Psychosocial Needs via Staff Training and a Process Group Intervention COVID-19 Preparedness in Nursing Homes in the Midst of the Pandemic Post-Acute Care Preparedness in a COVID-19 World Preventing the Spread of COVID-19 to Nursing Homes: Experience from a Singapore Geriatric Centre The authors of this paper would like to acknowledge the heroic dedication, indescribable efforts, and persistent advocacy of the health care workers and administrators in the extraordinary nursing home described in this manuscript-it was a true privilege for the hospital to be partnered with this nursing home.