Latest / The SHEA Podcast / COVID-19: Long-term Care Settings, 6/18

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COVID-19: Long-term Care Settings, 6/18 · The SHEA Podcast

• 0:08
  SPEAKER_01: Welcome to the Rapid Response Podcast brought to you by the Society for Healthcare Epidemiology of America, today, promoting the prevention of healthcare associated infections and antibiotic resistance and seeking to advance the field of healthcare epidemiology and antibiotic stewardship.
• 0:22
  SPEAKER_01: I am Dr.
• 0:23
  SPEAKER_01: David Bannock from the University of Connecticut and I will serve as today's podcast moderator.
• 0:28
  SPEAKER_01: Discussion on the podcast does not reflect today's perspective, but facilitates communication of multiple perspectives and experiences as we go through this challenging time together.
• 0:37
  SPEAKER_01: Today is excited to launch the 18th episode of this podcast COVID-19 updates of what we know now.
• 0:43
  SPEAKER_01: Today's episode will focus on COVID-19 in long-term care settings.
• 0:46
  SPEAKER_01: Our speakers today are Dr.
• 0:48
  SPEAKER_01: Jennifer Hamrahan, infectious disease specialist from the University of Toledo, and Dr.
• 0:52
  SPEAKER_01: Inwat Demiati, infectious disease specialist and professor of medicine at the University of Rochester Medical Center.
• 0:59
  SPEAKER_01: Thank you both for joining us today.
• 1:00
  SPEAKER_01: I would like to turn it over to Dr.
• 1:02
  SPEAKER_01: Hamrahan to get us started with a brief news and guidance update from this past week.
• 1:07
  SPEAKER_00: Thank you, David.
• 1:08
  SPEAKER_00: In updates on CDC guidance, the CDC has released consolidated recommendations for COVID-19 testing, including interim testing guidelines for nursing home residents and healthcare personnel, as well as testing strategy options for high-density critical infrastructure workplaces after a COVID-19 case is identified.
• 1:28
  SPEAKER_00: These recommendations compile and update previous testing guidance.
• 1:32
  SPEAKER_00: The consolidated recommendations for testing, overview of testing for SARS-CoV-2 were developed based on what is currently known about COVID-19 and are subject to change.
• 1:42
  SPEAKER_00: The document includes a summary of current CDC recommendations for testing people who have signs and symptoms of COVID-19, who have no signs and symptoms but recently had contact with someone known or suspected to have COVID-19, have no symptoms and no known contact with someone known or suspected to have COVID-19, but still may be tested for early identification in special settings, have had confirmed COVID-19, but no longer have symptoms, and may be tested by public health officials to track spread of the virus that causes COVID-19.
• 2:13
  SPEAKER_00: Testing guidelines for nursing homes is an important addition to other infection prevention and control recommendations aimed at keeping COVID-19 out of nursing homes and other long-term care facilities.
• 2:24
  SPEAKER_00: Updated recommendations include recommendation against testing the same individual more than once in a 24-hour period, consideration for testing residents with symptoms for other causes of respiratory illness, such as influenza, and coordination of repeat testing in response to outbreaks with local, territorial, and state health departments.
• 2:44
  SPEAKER_00: Outbreaks of illness among workers in food production facilities and surrounding communities have raised unique questions about testing for COVID-19.
• 2:52
  SPEAKER_00: CDC's testing strategy for COVID-19 and high-density critical infrastructure workplaces after a COVID-19 case is identified, presents different testing strategy options for exposed coworkers when public health organizations and employers determine testing is needed to help support existing disease control measures.
• 3:11
  SPEAKER_00: The CDC reminds us that there are entry restrictions into the United States.
• 3:16
  SPEAKER_00: Several presidential proclamations establish restrictions on the entry of certain travelers into the United States in an effort to help slow the spread of COVID-19.
• 3:25
  SPEAKER_00: With specific exceptions, foreign nationals who have been in any of the fallen countries during the past 14 days may not enter the United States.
• 3:33
  SPEAKER_00: These countries include China, Iran, the European Schengen area, which includes most of mainland Europe, and also included in travel restrictions are the United Kingdom, Ireland, and Brazil.
• 3:46
  SPEAKER_00: Moving on to infection prevention issues, a study published in JAML looks at the effects of sterilization with hydrogen peroxide and chlorine dioxide on the filtration efficiency of N95, KN95, and surgical face masks.
• 4:00
  SPEAKER_00: The authors note that CDC has suggested the potential reuse of disposable respirators to conserve available supplies.
• 4:07
  SPEAKER_00: Researchers compared sterilization by plasma vapor, hydrogen peroxide, and chlorine dioxide on the filtration efficiencies of three types of masks: N95s, KN95s, and surgical phase mass.
• 4:21
  SPEAKER_00: The hydrogen peroxide treatment showed a small effect on the overall filtration efficiency of the tested masks, but the chlorine dioxide treatment showed marked reduction in the overall filtration efficiency of the KN95 and surgical face mass.
• 4:35
  SPEAKER_00: This study found that the sterilization processes had different effects on the filtration efficiencies of different masks.
• 4:42
  SPEAKER_00: Sterilization with hydrogen peroxide had fewer negative effects than chlorine dioxide.
• 4:47
  SPEAKER_00: Last week we mentioned a study about patient self-collected swabs published in New England Journal of Medicine.
• 4:53
  SPEAKER_00: Another study looking at patient self-collected swabs was published in JAMA June 15th.
• 4:58
  SPEAKER_00: The target population was Stanford healthcare outpatients with a reverse transcriptase chlorose chain reaction test that was positive for SARS-CoV-2 in March 2020.
• 5:08
  SPEAKER_00: 30 patients consented to participate in the study.
• 5:12
  SPEAKER_00: Healthcare workers were excluded because of their familiarity with specimen collection.
• 5:16
  SPEAKER_00: Participants were scheduled to return to Stanford Healthcare for drive-thru collection of three specimens using a patient-collected lower nasal swab, a physician-collected lower nasal swab, and a physician-collected oropharyngeal swab.
• 5:30
  SPEAKER_00: They observed diagnostic equivalence across the three methods of specimen collection.
• 5:35
  SPEAKER_00: 11 participants had test results that were positive for SARS-CoV-2 across patient and physician collected specimens, and 18 participants had results that were negative for SARS-CoV-2 across patient and physician collected specimens.
• 5:50
  SPEAKER_00: The only discordant result was a participant whose self-collected nasal specimen tested positive, whereas both of their physician-collected specimens tested negative.
• 5:59
  SPEAKER_00: The sensitivity of the patient collected specimens was 100% and the specificity was 95%.
• 6:06
  SPEAKER_00: These findings show that patient-collected lower nasal slobs may be an acceptable alternative for specimen collection.
• 6:13
  SPEAKER_01: Thank you, Dr.
• 6:14
  SPEAKER_01: Henry.
• 6:15
  SPEAKER_01: You did talk a little bit about long-term care settings, which is going to bring us to our discussion with Dr.
• 6:19
  SPEAKER_01: Dumyti.
• 6:20
  SPEAKER_01: So, Dr.
• 6:20
  SPEAKER_01: Dumiati, thank you so much for joining the CHAPTER.
• 6:24
  SPEAKER_01: You have a really unique perspective as a practicing infectious disease physician who works both in academia but also in a role where you collaborate closely with long-term care.
• 6:34
  SPEAKER_01: And I think in what we're seeing with the COVID-19 pandemic, there's such a huge focus on long-term care.
• 6:39
  SPEAKER_01: And I'm really grateful that you're able to join us and provide your perspective as we talk through some of the challenges and what may lay ahead in long-term care facilities.
• 6:47
  SPEAKER_01: So thank you again for joining us.
• 6:48
  SPEAKER_02: Thanks, David, for inviting me.
• 6:51
  SPEAKER_01: So I want to start the discussion with kind of a broader approach to thinking about infection control in long-term care facilities.
• 6:58
  SPEAKER_01: A lot of our podcast listeners work in acute care hospitals, maybe a little less familiar in terms of what long-term care looks like with infection control programs.
• 7:07
  SPEAKER_01: So maybe if you can just provide some perspective on how, from your experience working with long-term care facilities, their approach may be similar, but in some ways different than what we see in acute care hospitals.
• 7:18
  SPEAKER_01: And then we can talk a little more specifically about COVID-19.
• 7:21
  SPEAKER_02: Yeah, so the difference, you know, for people who have not been into the non-term care is the fact that staffing are very different.
• 7:29
  SPEAKER_02: There is not the amount of staff that are available in the hospital.
• 7:33
  SPEAKER_02: So in the infrastructure of any program is limited.
• 7:37
  SPEAKER_02: For infection control, there's usually a recommendation that they have one, infection preventionist.
• 7:43
  SPEAKER_02: Many times it ended up being an added task to a nurse, either the nurse administrator or some other person, and without a lot of training, and it's part of their workload.
• 7:57
  SPEAKER_02: More recently, there was guidance that all the infection preventionists have to be trained in infection control.
• 8:04
  SPEAKER_02: However, there was no recommendation of how many FTE need to be in a facility.
• 8:10
  SPEAKER_02: And so in some facilities, you could see, like especially in smaller nursing homes with 20 bed, the infection preventionist is probably located outside the facility and does some consultation remotely or intermittently, but they're not on site, which is really very different from the hospital where you have a team of people.
• 8:31
  SPEAKER_02: And if someone is not there, there's other people that can take over what's required.
• 8:36
  SPEAKER_02: And if there is an outbreak or an emergency, someone is there.
• 8:39
  SPEAKER_02: In a nursing home, there's usually one person part-time, sometimes not on site.
• 8:45
  SPEAKER_02: So if there is an outbreak and that person becomes ill, that's a very big challenge for the nursing home.
• 8:52
  SPEAKER_02: The other thing that's different in the nursing home is it's a communal setting.
• 8:56
  SPEAKER_02: There's a lot of vulnerable patients.
• 8:59
  SPEAKER_02: They also require a lot of help with their daily living, help with feeding, help with ambulation, help with bathing, and so forth.
• 9:08
  SPEAKER_02: So there is a lot more contact between the healthcare workers and the residents that is a little bit different from the hospital where you have the intensive care unit, but you also have people who are ambulatory and there is less close contact with healthcare workers.
• 9:22
  SPEAKER_02: So that makes it challenging as well.
• 9:25
  SPEAKER_01: So it sounds like there's a lot of variability from what you're describing from facility to facility, and that some facilities often to be limited with the infrastructure that they have in terms of infection control.
• 9:36
  SPEAKER_01: I think that's an important backdrop as we start to talk more specifically about COVID-19.
• 9:41
  SPEAKER_01: So maybe you could take us back to the early phases of COVID-19 in the US.
• 9:45
  SPEAKER_01: I know you work closely with facilities throughout the New York region, and you were on sort of the earlier end of COVID-19 in the United States.
• 9:52
  SPEAKER_01: But maybe take us back to those early days when you started to see COVID-19 in these facilities and what were some of the early challenges that came up, and maybe you can talk through how you were able to begin to address some of these challenges.
• 10:04
  SPEAKER_02: Yeah, so locally, you know, based on my experience, when we started, it was the beginning of March, there was not a lot of testing available.
• 10:14
  SPEAKER_02: So the first nursing home that was affected, you really have to be very careful, you know, who could you test, how many tests are available.
• 10:22
  SPEAKER_02: So that kind of limited our understanding of the burden of disease once it was discovered in that first nursing home.
• 10:29
  SPEAKER_02: The other thing that was challenging is at that point we did not know at the beginning of March or mid-March that there was asymptomatic transmission.
• 10:39
  SPEAKER_02: So we had to deal with who to test, who could be prioritized, and then what do we do with the test result that is available.
• 10:46
  SPEAKER_02: So testing was a challenge.
• 10:48
  SPEAKER_02: And then the second thing that we did not realize is the amount of personal protective equipment that is needed.
• 10:56
  SPEAKER_02: You know, I have one of the nursing home infection preventionists that had her first COVID outbreak where she had to put a unit on isolation or in transmission-based precaution, where she said, it was frightening to realize how much we use PPE when you have everyone on transmission-based precaution.
• 11:15
  SPEAKER_02: It's frightening to know that our company where we get the PPE no longer have that available.
• 11:22
  SPEAKER_02: It's frightening to know that the emergency management office doesn't even have PPE.
• 11:27
  SPEAKER_02: So that availability of PPE was a big challenge at the beginning of the outbreak as well.
• 11:33
  SPEAKER_02: The other challenge was cohorting residents once they become positive.
• 11:38
  SPEAKER_02: If you have a full facility at the beginning of the outbreak, you know, many of the nursing homes were full.
• 11:45
  SPEAKER_02: And you had to try to figure out how you can move people from one unit or one bed, can you cohort them in an area of a unit or can you make a unit COVID-positive unit?
• 11:56
  SPEAKER_02: It was very challenging.
• 11:57
  SPEAKER_02: You never realize that those residents have been in a facility sometimes for two or three years.
• 12:03
  SPEAKER_02: And so if you decide to move them from one room to another, it's not just moving a bed in a hospital.
• 12:08
  SPEAKER_02: You have to move them, you have to move their couch, you have to move everything that's in their room that they have been living in for years and years.
• 12:15
  SPEAKER_02: And then once you start having a lot of cases, it becomes really very hard to figure out who moves where.
• 12:21
  SPEAKER_02: So that was also challenging.
• 12:24
  SPEAKER_02: The other challenge, and maybe we can talk some more about it, is the staffing.
• 12:29
  SPEAKER_02: You know, once you start having patients that are infected, you also see a significant amount of staff, especially at the beginning, before we understand and educated the staff on the best use of PPE.
• 12:41
  SPEAKER_02: Many in the in the first nursing home that was affected, we had a large number of staff that were ill, some were hospitalized, and probably there was more transmission because we were not also aware of asymptomatic transmission.
• 12:55
  SPEAKER_02: At that point, all we had were the use of masks to prevent transmission.
• 13:00
  SPEAKER_02: We we did not push for eye cover at the beginning of the outbreak.
• 13:04
  SPEAKER_02: So staff shortages was another challenge.
• 13:07
  SPEAKER_02: And when you know we have less staff, the staff that remains is really very hard to be able to be very compliant with PPEUs.
• 13:16
  SPEAKER_02: And another issue that became also very apparent during the outbreak is communication.
• 13:20
  SPEAKER_02: Communication, like some staff were not aware how many residents were ill, how many staff were ill, because the families were restricting from visitation, how do you communicate with the family?
• 13:32
  SPEAKER_02: So that was another challenge that we had to deal with.
• 13:35
  SPEAKER_01: So I think the issue with the cohorting, it's something that we're always thinking about.
• 13:40
  SPEAKER_01: You know, in the hospital, patients are here very temporarily and we can move them from room to room and on and off different units pretty easily.
• 13:47
  SPEAKER_01: But you know, like you mentioned, cohorting patients in all-term care facilities very different because they have all of their possessions and everything they need with them, and that can be really difficult.
• 13:56
  SPEAKER_01: So, what did you find from working with different facilities?
• 13:59
  SPEAKER_01: Were there certain types of strategies that you thought seemed to work pretty well, or anything with regard to the cohorting that you saw being effective and manageable that reduced the amount of patient movement within a facility?
• 14:11
  SPEAKER_02: Some of the larger facilities, because of the decrease in the post-acute patient, were able to dedicate a unit, which made it easier to kind of move the positive to the COVID unit.
• 14:25
  SPEAKER_02: And I want to mention the value of moving a resident that are COVID positive to another unit, is you're able to extend the use of your PPE.
• 14:33
  SPEAKER_02: So, for example, you can use the same gown if you're going from one room to another.
• 14:37
  SPEAKER_02: So that's very valuable.
• 14:39
  SPEAKER_02: The other thing that's very valuable in cohorting is to cohort staff, which is a challenge on its own because you have to, when you have shortage of staff, it's very hard to dedicate staff to the unit.
• 14:50
  SPEAKER_02: But I learned from some of the outbreak that that was really key to prevent the spread from one unit to another.
• 14:57
  SPEAKER_02: Because after you know, the beginning of March, visitation was restricted.
• 15:02
  SPEAKER_02: So the only way COVID infected patient or resident or staff would come in are the way it comes into the facility, it's not the visitor or the families.
• 15:12
  SPEAKER_02: So when you have a COVID unit, it's much easier to control who goes in and who's affected, and you have dedicated staff and you have a better way of monitoring sick people because some of the COVID infected residents in nursing home really deteriorated.
• 15:28
  SPEAKER_02: Some of them, I was told, were fine, you know, at 8 a.m.
• 15:32
  SPEAKER_02: by 10 p.m.
• 15:33
  SPEAKER_02: they were dead.
• 15:34
  SPEAKER_02: So monitoring was also important in the COVID unit.
• 15:38
  SPEAKER_02: The difficulty becomes when you have more than one unit infected, and the way it happens is it trickles down.
• 15:45
  SPEAKER_02: You know, you have, for example, you identify a healthcare worker, you identify two or three patients on day one.
• 15:52
  SPEAKER_02: And then our approach now is to test everyone on the unit and possibly everyone in the facility.
• 15:57
  SPEAKER_02: And then what happens, you start testing, and you two or three days later you get two more patients.
• 16:03
  SPEAKER_02: Two or three days that you've had five more patients.
• 16:05
  SPEAKER_02: So it becomes really kind of a struggle to try to move all the positive to another unit.
• 16:10
  SPEAKER_02: And what somehow the facility did is to move them to a part of the unit instead of you moving them to a completely different unit because of, you know, they didn't have the capacity.
• 16:21
  SPEAKER_02: You know, you open a unit and then very quickly it becomes full.
• 16:24
  SPEAKER_02: So they started moving patients to an area of a unit, or instead of just moving them to a COVID-positive unit.
• 16:33
  SPEAKER_02: And each nursing home did it differently.
• 16:35
  SPEAKER_02: Some nursing homes where they didn't have the capacity on a specific unit had like a day program that was open, so they moved patients there.
• 16:44
  SPEAKER_02: The difficulty, I think, is very hard to know at this point why some nursing homes were able to control their spread and why some had one patient or one healthcare worker and it did not spread.
• 16:59
  SPEAKER_02: It sometimes had to do with how quickly they identified the outbreak and how quickly they act.
• 17:07
  SPEAKER_02: So at the beginning, when we had the first few outbreaks of COVID in our area, I think the the identification of the first patient was delayed and there was a lot of exposure.
• 17:17
  SPEAKER_02: The first patient was someone who arrested and multiple people got exposed, and then then a week later it had spread in the entire unit.
• 17:26
  SPEAKER_02: This is not the case anymore.
• 17:28
  SPEAKER_02: But even despite the fact that we're identified cases more early, you were able to test more, you still see spread, you know, from one unit to another unit.
• 17:37
  SPEAKER_02: Some of it is more when you have a unit with dementia patients where you're not able to restrict them to their room.
• 17:45
  SPEAKER_02: Some of it might be you're not able to dedicate staff.
• 17:49
  SPEAKER_02: But at this point, really, I we don't have a hundred percent understanding why some nursing homes are able to even prevent it from coming in.
• 17:58
  SPEAKER_02: And some of them were they able to limit it to one unit, and some of them why it spread to multiple units.
• 18:03
  SPEAKER_02: And I'm hoping that with time we'll understand more so we can prevent, you know, when we get the next phase, we can prevent the transmission and the spread of this disease.
• 18:13
  SPEAKER_02: What I have learned though, the more prepared you're at the beginning, the better.
• 18:17
  SPEAKER_02: So some of the early nursing home, you know, when it happens, we really didn't understand what needed to be done, and we kind of did it as we went.
• 18:26
  SPEAKER_02: So right now we have a more structured approach to once you have COVID in the unit, we can say, okay, this is what you do.
• 18:34
  SPEAKER_02: You test everyone, you do contact tracing of your healthcare worker, you try to make sure that your healthcare workers are separated because there have been multiple episodes where there was transmission between healthcare workers and not just patient healthcare workers and vice versa.
• 18:49
  SPEAKER_02: So we're better at it at this point, but we still don't have 100% of the answer that we need.
• 18:54
  SPEAKER_01: That's really helpful.
• 18:56
  SPEAKER_01: So earlier you had talked about some of the staffing challenges, and I think those really need to be brought to the forefront.
• 19:01
  SPEAKER_01: You know, I know the facilities in our area in Connecticut have found the same challenges.
• 19:06
  SPEAKER_01: And one of the bigger picture challenges with staffing in nursing homes is that a lot of staff work in multiple nursing homes.
• 19:11
  SPEAKER_01: So I was hoping you could maybe talk a little bit about that.
• 19:13
  SPEAKER_01: And then the other piece that goes along with that is testing of staff and residents.
• 19:18
  SPEAKER_01: I know New York State has been at the forefront of really encouraging even mandating testing.
• 19:23
  SPEAKER_01: So maybe you could reflect a little bit on some of the experiences with testing of staff as that's begun to move into the mainstream.
• 19:29
  SPEAKER_02: Right.
• 19:29
  SPEAKER_02: So staffing is one of the main challenges in dealing with an outbreak in the nursing home.
• 19:35
  SPEAKER_02: And it is important to know that since they are lean with their staffing, if you have, for example, the nurse administrator is sick or your infection preventionist is sick, it becomes very hard to deal with an outbreak when there is no one on site.
• 19:50
  SPEAKER_02: That's the first thing when your leadership is ill and out.
• 19:54
  SPEAKER_02: And then for the frontline staff, there were a lot of staff that either got sick or refused to come in, which was another challenge.
• 20:02
  SPEAKER_02: And trying to find staffing to be able to cope with the workload in the nursing home was a very challenging.
• 20:09
  SPEAKER_02: So some of the staff had to do double shift, some of them had to work seven days a week.
• 20:15
  SPEAKER_02: That includes even medical providers had to work non-stop, which was very hard.
• 20:20
  SPEAKER_02: And some of the larger nursing homes that had time to prepare, their administrative staff, for example, the person that collects data for, you know, to put into various reporting databases, they were trained to do some work with nursing homes, passing trays, passing, you know, something that is not clinical.
• 20:40
  SPEAKER_02: So once the shortest of staff happened, they were kind of deployed to help with the nurses that are on the forefront.
• 20:48
  SPEAKER_02: There is also many nursing homes who had to use agency staff, had to use more pay to get those agency staff, but that creates another challenge because agency staff goes from one nursing home to another and spread.
• 21:01
  SPEAKER_02: So what they have tried to do in many nursing homes is try to get a way to pay them more and get them to work only for them so they don't transmit COVID between healthcare facilities, which has been a big challenge.
• 21:15
  SPEAKER_02: The other thing that we worked on locally is to try to recruit more staffing.
• 21:21
  SPEAKER_02: There was a waiver for training requirement, so you can get a certified nurse assistant in and train them quickly so they can help.
• 21:30
  SPEAKER_02: And so there's a lot of things that had to be done to be able to make sure that the residents that are in facilities are well taken care of.
• 21:40
  SPEAKER_02: So discussing your other question about what happened with the shortage of staffing is the staff has to also deal with a lot of issues, including the fact that they knew those residents for one or two years or longer.
• 21:55
  SPEAKER_02: So they had to deal with the grief of losing those residents.
• 21:58
  SPEAKER_02: There was a lot of Guilt as well is like what could we have done?
• 22:03
  SPEAKER_02: Am I the one that really led to this outbreak?
• 22:07
  SPEAKER_02: Was kind of became apparent.
• 22:09
  SPEAKER_02: They were very afraid that they were the one that brought it in.
• 22:13
  SPEAKER_02: And then the other thing they had to deal with is anger.
• 22:16
  SPEAKER_02: Anger because in the news media, the hospital, healthcare workers were heroes, the nursing home were not.
• 22:24
  SPEAKER_02: They're the ones that bring it in to the nursing home and result in death.
• 22:27
  SPEAKER_02: And so they were seen more as a problem, and it despite the fact that they're working hard and they really did care.
• 22:35
  SPEAKER_02: So there is a lot of support that needs to happen, not just residents and family, but also healthcare workers that are dealing with these outbreaks.
• 22:43
  SPEAKER_01: I think that is a piece that goes underlooked, sort of the uh psychological impact.
• 22:47
  SPEAKER_01: I think, you know, one of the other challenges in nursing homes is the relationships that the staff have with the residents is different than the relationship that healthcare providers have in the acute care hospital with the patients because of the length of time that they spend together.
• 23:01
  SPEAKER_01: So, what have you seen in terms of how the nursing home facility staff have managed the trauma that they're seeing when uh a large proportion of their residents become sick?
• 23:11
  SPEAKER_02: It is very difficult.
• 23:12
  SPEAKER_02: And I think they haven't recovered yet.
• 23:14
  SPEAKER_02: For the some of the nursing home, they have gone through this for like six weeks.
• 23:19
  SPEAKER_02: I think some of the staff is still grieving.
• 23:22
  SPEAKER_02: Some of them are even decide to quit.
• 23:25
  SPEAKER_02: And then there have been a lot of support, though, that I have seen from medical director and other staff, you know, supporting each other after they have gone through this outbreak.
• 23:36
  SPEAKER_02: You know, maybe initially support should have started earlier, but everyone was kind of doing it as we were going.
• 23:43
  SPEAKER_02: We didn't know what was required.
• 23:44
  SPEAKER_02: We didn't know that the impact was going to be so hard on the staff.
• 23:48
  SPEAKER_02: So it has really changed a lot of staff.
• 23:51
  SPEAKER_02: And I have heard that some of the older staff just don't want to do it anymore, which really leads to more shortages.
• 23:58
  SPEAKER_02: And if we have a second peak or second phase, we will have to deal with staffing issues.
• 24:03
  SPEAKER_02: So we really have to build our staff capacity.
• 24:06
  SPEAKER_02: What we also realize is that we also need more in the nursing home.
• 24:11
  SPEAKER_02: Most of the staffing is 35 nurse assistants.
• 24:14
  SPEAKER_02: But when you have a lot of sick people, you probably need more LPNs and RN.
• 24:18
  SPEAKER_02: So building that capacity is also important, building infection prevention is, and I'm glad to see that the CDC is recommending a specific FTE for facilities that have 100 beds or have an event unit or dialysis.
• 24:32
  SPEAKER_02: So I'm happy to see that.
• 24:34
  SPEAKER_02: We need to build that capacity, uh, staffing, infection control, so we can take better care of the resident in a case of the second wave of a COVID outbreak.
• 24:44
  SPEAKER_01: Thanks.
• 24:45
  SPEAKER_01: I think that's really critical.
• 24:46
  SPEAKER_01: And I think when we think about the future, providing that support to long-term care facilities needs to be, you know, kind of front and center.
• 24:55
  SPEAKER_01: And that support is, you know, both the sort of resources, but also the you know, psychological support for the staff there.
• 25:02
  SPEAKER_01: It's got to be really difficult to see such an impact on the residents who you've built relationships with.
• 25:07
  SPEAKER_01: And I mean, I think we can underlook the value of supporting in all facets and you know, building that relationship between acute care hospitals, long-term care facilities, and public health, I think is going to be the key in being able to navigate uh future waves of COVID-19 and future pandemics as well.
• 25:25
  SPEAKER_01: So thinking about what the future might look like, it sounds like there's a lot of need for collaborations with long-term care facilities more generally and other groups in the COVID-19 response.
• 25:34
  SPEAKER_01: Can you kind of share your thoughts on where you see those collaborations have been successful and what you think the future is going to look like and how we can all work together?
• 25:42
  SPEAKER_02: I fully agree with you that collaboration at different levels is very important for preparedness.
• 25:48
  SPEAKER_02: Collaboration between the hospital has been key, you know, because there is a lot of patient movement between the hospital and the nursing home as well.
• 25:58
  SPEAKER_02: There is also collaboration with lab.
• 26:00
  SPEAKER_02: For example, when you need to test the entire facility, the lab has to be ready.
• 26:04
  SPEAKER_02: Many times I had to call the lab and say, can you send me 10 swabs?
• 26:08
  SPEAKER_02: You know, can you get a courier?
• 26:09
  SPEAKER_02: I need to test the number of patients.
• 26:12
  SPEAKER_02: And do you have the capacity to test them quickly and so forth?
• 26:15
  SPEAKER_02: So collaboration is so important.
• 26:18
  SPEAKER_02: We also locally have collaboration between nursing homes with each other, and they shared information on how to approach COVID and support each other.
• 26:28
  SPEAKER_02: The relationship is important also to address shortages of staffing, shortages of PPE, and what the hospital can also do is education.
• 26:39
  SPEAKER_02: I did not mention, you know, the nursing home never had to do extended use or a reuse of any equipment.
• 26:46
  SPEAKER_02: So trying to train the staff, especially with this agency staff that are coming in on the proper use of PPE and the proper use of extended use, considering the shortage of PPE was also very important.
• 26:59
  SPEAKER_01: Great.
• 26:59
  SPEAKER_01: So it sounds like a lot of opportunities to work collaboratively in the future, which I think is going to be the key to success.
• 27:05
  SPEAKER_01: So thank you, Dr.
• 27:07
  SPEAKER_01: Damiati, for joining the SHAY podcast.
• 27:10
  SPEAKER_01: We really appreciate your insight in such an important aspect of the COVID-19 response.
• 27:15
  SPEAKER_02: Thanks, David.
• 27:15
  SPEAKER_02: Thank you, everyone.
• 27:16
  SPEAKER_01: A sincere thank you from Shay to all healthcare personnel for all that you are doing to respond to COVID-19.
• 27:24
  SPEAKER_01: This podcast can be accessed on SHAY's online education center, Learning CE, under the Rapid Response Program.
• 27:30
  SPEAKER_01: You'll also find additional resources such as the recorded webinars, healthcare facilitated outbreak preparedness, and the SHA COVID-19 town halls.
• 27:38
  SPEAKER_01: Additional resources available on Learning CE pertinent to this pandemic include the SHA CDC Outbreak Response Training Program, ORTP, and the Prevention Course in HAI Knowledge and Control, Prevention Check.
• 27:51
  SPEAKER_01: This concludes this episode of the Rapid Response Podcast.
• 27:54
  SPEAKER_01: Thank you for tuning in.