This article details an Ontario acute care hospital’s response to COVID-19 outbreaks in nearby nursing homes. The hospital explained the partnership in four 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”

Introduction

COVID-19 disproportionally affects older populations. In the United States, over 25,000 nursing home (NH) residents have died from COVID-19, and 80% of deaths in Canada are in NH residents. NH residents often have multiple comorbidities, and share rooms and bathrooms, contributing to the rapid spread of COVID-19. Older adults may also have atypical presentations of COVID-19, such as delirium, falls, and functional decline, making early diagnosis more challenging. Additionally, individuals with chronic conditions are more susceptible to severe COVID-19 infection.

“COVID-19 SWAT Teams”

In response to the unfolding crisis, the Government of Ontario asked hospitals to create and deploy “COVID-19 SWAT Teams” from hospitals to provide additional staffing, infection prevention and control (IPAC), occupational health and operational support to NHs. The government did not provide a roadmap for this partnership.

This hospital/NH partnership began on day 16 of an outbreak. At that point in time, the NH had 89 infected residents (in a 126-bed NH), 12 deaths, and 47 infected staff members.

Phase 1: Engagement, relationship and trust-building

• Before partnering with the hospital, the NH requested assistance from multiple organizations and did not receive sustained help. The NH developed some mistrust toward outside organizations.
• The hospital carefully listened to the NH, and together they drafted potential solutions. During this time, the severity of the outbreak and need for immediate action became apparent.

Phase 2: Environmental scan, team-building and immediate response (first 72 hours)

• The hospital and NH identified:
• Immediate needs: palliative care, geriatric medicine, and IPAC physicians to support the NH physicians
• Additionally, they needed staffing.
• The environmental scan estimated the NH’s PPE supplies, supply chain, and predicted burn rate. They also looked at medical equipment needs, such as vital sign monitoring machines, pulse oximeters, O₂ tanks, and medications.
• Phase 2 outcome:
• They established a team to oversee the response. The team consisted of individuals from: geriatrics, palliative care, geriatric psychiatry, IPAC, pharmacy, nursing, HR, occupational health, materials management, and environmental services. Members of this team met frequently and worked with the Public Health Unit.
• The NH moved 15 residents to the acute care hospital for inpatient care, alleviating some staffing burden.

Phase 3: Early phase response (next 7 days)

• This phase was at the peak of COVID-19 deaths.
• Phase focuses: establishing virtual care, clinical triage, and emergency palliative and medical care.
  • Virtual care involved remote access to the electronic medical records, tablets, and a secure video conferencing software.
  • The team created a tool to rapidly triage residents to identify those who were unwell and at the end-of-life. Using this tool, NH staff reviewed medical records and flagged the chart for review. Flagged charts were prioritized for a goals of care conversation, with the resident and/or their decision maker.
  • Palliative care provided expertise on the assessment and management of COVID-19 end-of-life symptoms. They regularly contacted families to provide support and help them be present, via technology, for their loved one’s end-of-life.
• The team also implemented intensive IPAC interventions including:
  • Providing onsite training for NH staff on: transmission, risk assessment, PPE choice, PPE donning and doffing.
  • The IPAC team advised the NH to complete additional testing, move residents, clean terminals, increase cleaning of high touch areas, optimize cleaning products and schedules, set up PPE donning/doffing stations, and increase access to PPE and hand hygiene.

Phase 4: Stabilization and transition (day 10 to present)

• By the beginning of this phase, the outbreak had stabilized. There were no additional unanticipated resident deaths or hospital transfers.
• Phase focuses: improving staffing shortages, optimizing the medical and psychiatric care of residents, psychosocial support for NH staff, and preparing the NH for autonomous clinical care and management
• The hospital deployed 12 of its nurses to the NH, following a shadowing experience to prepare them.
• A geriatric hospital pharmacist rounded with the clinical team and made recommendations to condense and reduce medication administration times to limit staff exposure and PPE use. The pharmacist also reviewed medications to optimize medication safety and resident care.
• Across many nursing homes, COVID-19 outbreaks and subsequent isolation exacerbated mental health and psychiatric conditions. The team’s geriatric psychiatrist offered virtual consultations and worked with NH mental health clinicians to reassess and treat residents with pre-existing mental health conditions and cognitive impairment. They also utilized strategies to compassionately isolate COVID-19 positive dementia residents who were prone to wandering.
• The hospital’s psychiatry group offered group and individual counselling to NH staff, and joined daily rounds to offer support and build relationships between hospital and NH staff.
• To facilitate the return to a more autonomous NH, hospital staff coached NH staff through monitoring and managing the residents’ conditions, and initiating goals of care conversations. The IPAC and Public Health Unit staff oversaw testing of all NH staff, and cleared recovered COVID-19 residents. The NH’s usual practitioners joined virtual rounds and continued their practice independently using the virtual care previously established.

Stall NM, Farquharson C, Fan-Lun C, et al. A Hospital Partnership with a Nursing Home Experiencing a COVID-19 Outbreak: Description of a Multi-Phase Emergency Response in Toronto, Canada. J Am Geriatr Soc. Published online May 22, 2020. doi:10.1111/jgs.16625