Latest / The SHEA Podcast / COVID-19 & Long-Term Care

Transcript

COVID-19 & Long-Term Care · The SHEA Podcast

• 0:08
  SPEAKER_00: Welcome to the Rapid Response Podcast brought to you by the Society for Healthcare Epidemiology of America, SHE, promoting the prevention of healthcare associated infections and antibiotic resistance and seeking to advance the field of healthcare epidemiology and antibiotic stewardship.
• 0:25
  SPEAKER_00: I am Dr.
• 0:26
  SPEAKER_00: Ishwal Kamal Ahmed, Healthcare Associated Infections and the Microbial Resistance Epidemiologist at the Nebraska Department of Health and Human Services, and I will serve as today's podcast moderator.
• 0:38
  SPEAKER_00: Discussion on the podcast does not reflect Shay's perspective but facilitates communication of multiple perspectives and experiences as we go through this challenging time together.
• 0:50
  SPEAKER_00: Shay is excited to launch this episode of the podcast, COVID-19 updates what we know now.
• 0:57
  SPEAKER_00: Today's discussion will focus on long-term care.
• 1:01
  SPEAKER_00: Our speaker today is Dr.
• 1:02
  SPEAKER_00: Morgan Katz, Director of Antimicrobial Stewardship at Johns Hopkins Bayview and assistant professor of infectious disease at Johns Hopkins University School of Medicine.
• 1:13
  SPEAKER_00: Thank you for joining us today.
• 1:15
  SPEAKER_00: Let's move right into the discussion.
• 1:17
  SPEAKER_00: Can you provide our listeners with your background around COVID-19 and long-term care?
• 1:23
  SPEAKER_01: Hi, thank you so much for having me.
• 1:26
  SPEAKER_01: So I am an ID physician at Hopkins, and my research really, even prior to the pandemic, focused on both infection prevention and antibiotic stewardship in the long-term care setting.
• 1:38
  SPEAKER_01: So a lot of that work required me to be on site in the facilities trying to better understand the system and how to make infection prevention practices feasible in a setting that really is so different from acute care, even though we often try to apply some of the same acute care policies there.
• 1:58
  SPEAKER_01: So, because of my previous research, I did have pretty strong relationships with the nursing homes in the Maryland area.
• 2:05
  SPEAKER_01: And when COVID hit, I was actually called down to the incident command of the Hopkins Health Center early one Sunday morning in late March after one nursing home in Maryland essentially folded because it had such a significant outbreak.
• 2:22
  SPEAKER_01: They didn't have enough staff to care for the residents, and the residents were transferred en masse out to acute care facilities surrounding the nursing home.
• 2:32
  SPEAKER_01: So I think that was when the acute care facilities started to realize that we needed to support nursing homes or we were going to be dealing with a significant surge.
• 2:42
  SPEAKER_01: So I was given the role as the long-term care incident commander for the Hopkins Health System and sort of given a job to prevent exactly that.
• 2:52
  SPEAKER_01: I was given one incredible med student and we just got to work.
• 2:56
  SPEAKER_01: Within about a week, we had organized testing teams to go out and start to provide universal testing to nursing homes.
• 3:04
  SPEAKER_01: This was before we were doing any asymptomatic testing at all during the pandemic.
• 3:09
  SPEAKER_01: So we were pretty shocked with what we found.
• 3:12
  SPEAKER_01: And that just these missions sort of led to a floodgate of other things, including the development of the Maryland State strike teams.
• 3:19
  SPEAKER_01: I was eventually asked to be on the White House commission to guide CMS on the care of nursing home residents during the pandemic.
• 3:27
  SPEAKER_01: And I've just been deep in it ever since.
• 3:30
  SPEAKER_01: That's sort of where we are.
• 3:32
  SPEAKER_00: Thank you.
• 3:34
  SPEAKER_00: So what does the COVID-19 landscape currently look like in long-term care facilities?
• 3:39
  SPEAKER_00: Do they continue to be hotspots for outbreaks?
• 3:42
  SPEAKER_00: And while predicting the future is nearly impossible, what do you think is in store for these facilities?
• 3:49
  SPEAKER_01: So I think the landscape is definitely different.
• 3:52
  SPEAKER_01: So many of the old challenges, including the fear, the limited resources, the lack of knowledge or understanding of transmission, lack of access to vaccines, isolation that the residents were going through, that has certainly improved.
• 4:06
  SPEAKER_01: And I think nursing homes are definitely in a better place in regards to that.
• 4:11
  SPEAKER_01: I will say now, anecdotally, and in some pre-print papers I reviewed, it does seem like while the outbreaks are still occurring in nursing homes, the mortality and hospitalization rates are definitely lower.
• 4:24
  SPEAKER_01: This is likely due to a combination of vaccination status of the residents.
• 4:28
  SPEAKER_01: We've seen pretty good uptake in resident vaccination and probably Omicron being more mild.
• 4:34
  SPEAKER_01: I think what facilities are really struggling with now is staff fatigue as well as reporting burdens.
• 4:42
  SPEAKER_01: That has been a huge challenge for the facilities.
• 4:45
  SPEAKER_01: In terms of the future, I think the one silver lining to all this is that there has been a new emphasis and understanding that we need to do better in terms of infection prevention and staff support in this setting.
• 4:58
  SPEAKER_01: This is a topic that, in my opinion, has been overlooked for far too long.
• 5:03
  SPEAKER_01: I do suspect that universal masking for staff will probably remain in place at least during the flu season for a long time.
• 5:13
  SPEAKER_01: This probably should have been a practice in nursing homes before all this because of how vulnerable they are to respiratory outbreaks.
• 5:20
  SPEAKER_01: I also think there's probably going to be more emphasis on private rooms.
• 5:23
  SPEAKER_01: It was really challenging to control outbreaks in quad and triple rooms.
• 5:28
  SPEAKER_01: So if facilities can make it work, I think they should really start moving that direction.
• 5:33
  SPEAKER_00: So you talked about staff fatigue.
• 5:36
  SPEAKER_00: What resources do long-term care facilities need to prioritize to ensure they are protecting both staff and residents?
• 5:45
  SPEAKER_00: How do these facilities advocate for them?
• 5:48
  SPEAKER_01: Yeah, this is a great question.
• 5:49
  SPEAKER_01: So staffing is far and away the biggest challenge right now.
• 5:54
  SPEAKER_01: We know that turnover rates in long-term care settings were high before the pandemic.
• 5:59
  SPEAKER_01: And you can imagine the combination between initially the fear of working in this setting and then the fatigue of all the restrictions and reporting requirements.
• 6:08
  SPEAKER_01: And now, even with vaccine mandates, the turnover has been through the roof in the nursing home setting.
• 6:16
  SPEAKER_01: So I've noticed that administrators really have had to be creative about finding ways to show staff that they value them.
• 6:24
  SPEAKER_01: I've seen and discuss a lot of strategies with administrators to this end.
• 6:29
  SPEAKER_01: Some are offering hazard pay or benefits such as on-site child care or paying education loans for staff who have been there for a certain amount of time.
• 6:38
  SPEAKER_01: I've also been working with a large chain of facilities with many sites in the Midwest who were really struggling with the vaccine mandates because so many of the staff were opposed to vaccination.
• 6:50
  SPEAKER_01: So just to give a number, sort of prior to the mandates, about 30 to 50% of their staff were vaccinated.
• 6:57
  SPEAKER_01: So they had to make big steps in a short period of time.
• 7:01
  SPEAKER_01: It really was a Herculean effort to offer education incentives for vaccination.
• 7:07
  SPEAKER_01: And so one of the strategies they use is in order to avoid some of the controversy around vaccination, they actually outsourced their review of religious and medical exemptions to either an infectious disease physician or a lawyer.
• 7:22
  SPEAKER_01: And that really helped to keep the process objective.
• 7:26
  SPEAKER_01: I think that's one strategy that can help to facilities to get through these challenging times.
• 7:33
  SPEAKER_00: Have you implemented or heard about any outside-the-box thinking that help give long-term care facilities what they need in order to better keep staff and patients safer from COVID?
• 7:45
  SPEAKER_01: Yeah, so I definitely have seen some outside-of-the-box thinking early in the pandemic when the resources were scarce.
• 7:52
  SPEAKER_01: One of the things that I noticed working in the acute care setting and then going into these facilities with active outbreaks is just how much support we have in the acute care setting.
• 8:03
  SPEAKER_01: So I think a lot of us don't have a great understanding of this, but I was in the incident command for the Hopkins Health System, which was is in just an incredible operation.
• 8:15
  SPEAKER_01: We looked, you know, there were at least 50 infection preventionists on site, sharing ideas, having discussions about difficult situations throughout the course of this pandemic as things change.
• 8:28
  SPEAKER_01: And if you think about what it's really like in the long-term care setting, they had one infection preventionist, maybe, that's carrying several hats that really has no support or no one to talk to.
• 8:41
  SPEAKER_01: So just that alone, I think, was something that we really needed to address.
• 8:47
  SPEAKER_01: Another example is at Hopkins, we had these safety assistants who would sit outside of a room, watch us don and doff our PPE before we walked into a COVID patient room and make sure that we had everything we needed.
• 9:01
  SPEAKER_01: So one of the things that we offered, based on our understanding of the various resources in acute care, Maryland state actually offered a$10 million grant through the Healthcare Cost Services Commission, which basically asked every acute care system to partner with several long-term care facilities to assist them through the pandemic.
• 9:24
  SPEAKER_01: So our program, I actually served as a director of infection prevention for the program.
• 9:28
  SPEAKER_01: We paired with 14 different facilities, with facilities that often sent transfers to the Hopkins system.
• 9:35
  SPEAKER_01: And the first thing that we did based on our understanding of the resources in acute care was to train up a team of safety assistants who would actually go on site in the facility and provide on-site assistance to do exactly that, translate some of the policy into practice.
• 9:52
  SPEAKER_01: They would help with PPE donning and DOFing, fill hand sanitizer, do silent observations.
• 9:58
  SPEAKER_01: They even served as secret vaccine champions to help tout the vaccine to staff that had reservations.
• 10:06
  SPEAKER_01: We also put out a weekly newsletter, which basically summarized all the changes in guidance, community prevalence, testing requirements, and new research into one place so that the infection preventionist wasn't overwhelmed trying to track the various changes with COVID going on.
• 10:24
  SPEAKER_01: And then as things calmed down a little bit with vaccination, we were able to provide more tangible resources like hand sanitizer machines, on-site fit testing, signage, really whatever else they needed.
• 10:37
  SPEAKER_01: So I think that that has been one sort of different intervention that was really successful.
• 10:44
  SPEAKER_00: Thank you.
• 10:45
  SPEAKER_00: Given your expertise in antibiotic stewardship in long-term care facilities, what influence do you think AMS programs or lack thereof have over treating patients in these facilities?
• 10:58
  SPEAKER_01: Well, unfortunately, I think we were just starting to make headway with establishing stewardship programs in nursing homes prior to the pandemic.
• 11:07
  SPEAKER_01: And a lot of this has now been overlooked for the past two years simply because staff had just been completely overwhelmed.
• 11:15
  SPEAKER_01: Obviously, I think stewardship is incredibly important in nursing homes.
• 11:20
  SPEAKER_01: The inappropriate antibiotic prescribing that we see here can have an impact on both the individual resident because they're more likely to suffer side effects from antibiotics, but also for public health reasons like the cultivation of multidrug resistant organisms.
• 11:35
  SPEAKER_01: I think having a dedicated full-time infection preventionist who moving forward can help to re-establish these programs will be really helpful for facilities to refocus their efforts.
• 11:47
  SPEAKER_01: But unfortunately, this has been really hard with current staffing shortages.
• 11:52
  SPEAKER_01: So we're going to have to get back on track in the near future, hopefully.
• 11:57
  SPEAKER_00: Visitations.
• 11:58
  SPEAKER_00: Let's move on to that topic.
• 11:59
  SPEAKER_00: It's been a hot topic in long-term care facilities.
• 12:03
  SPEAKER_00: Is there any data to suggest what strategies and precautions work best when allowing visitors?
• 12:10
  SPEAKER_00: What are your personal thoughts on this issue?
• 12:12
  SPEAKER_01: This is a great question.
• 12:13
  SPEAKER_01: I have to say, I've seen every side of this issue.
• 12:16
  SPEAKER_01: It has been so, so challenging for both the facilities trying to control transmission and for family members wanting to see their loved ones.
• 12:26
  SPEAKER_01: As you know, even one case of COVID entering the facility really can spread like wildfire.
• 12:33
  SPEAKER_01: So you do have to understand why the nursing homes, even now, are pretty nervous about visitation.
• 12:39
  SPEAKER_01: There's not a lot of great data on this, but I will say the most successful interventions I've seen is number one, having a highly vaccinated visiting population.
• 12:51
  SPEAKER_01: We do have good data that if COVID is in the community, it will enter the nursing home.
• 12:56
  SPEAKER_01: So if the community around is vaccinated, then you have a lower risk of introducing it into the facility.
• 13:05
  SPEAKER_01: Number two, ventilation, the good old outdoors.
• 13:08
  SPEAKER_01: Outdoor visits are super helpful, but even just opening all the windows in visitation rooms, putting in portable air filters can be a simple solution to make visits safer.
• 13:19
  SPEAKER_01: So whenever I go to a facility to help them with their practices, I will immediately open all the doors in the visiting rooms and make sure that they have ventilation on task.
• 13:31
  SPEAKER_01: A lot of the facilities are doing rapid testing of visitors, which can be pretty time consuming, but it's also a nice additional safety measure if you can make it happen.
• 13:40
  SPEAKER_01: Those are some of the strategies I've seen.
• 13:43
  SPEAKER_00: Thank you.
• 13:50
  SPEAKER_00: Unfortunately.
• 13:51
  SPEAKER_00: But yeah, thank you for that guidance.
• 13:53
  SPEAKER_00: Now, as CDC guidance around protective measures continue to change, what do you think long-term care facilities should be doing to maximize safety and minimize risk?
• 14:04
  SPEAKER_01: I think the most important thing is that they need to be prepared to pivot with their responses as community prevalence changes.
• 14:12
  SPEAKER_01: So, as we've seen throughout this pandemic, if COVID is prevalent in the community, it is virtually impossible to keep it out of the nursing homes.
• 14:22
  SPEAKER_01: So knowing that we need to be able to adapt our protection measures as things change, have a good incident command team in place.
• 14:31
  SPEAKER_01: And this doesn't mean it has to be, you know, a huge system, but having corporate leadership involved, having your infection preventionist and a medical director involved to touch base and really be able to adapt their policies based on community prevalence.
• 14:48
  SPEAKER_01: And also having a really solid way to communicate changes with not only staff, but also residents and their family members.
• 14:56
  SPEAKER_01: I think that really helps to establish trust and it also helps improve communities working with the nursing home and not causing so much distress.
• 15:07
  SPEAKER_00: Thank you.
• 15:07
  SPEAKER_00: Before we wrap up, do you have any final thoughts for our listeners?
• 15:13
  SPEAKER_01: So through all my work with these facilities, I have been so consistently amazed by the long-term care staff that continue to show up to work to care for these residents, despite how incredibly challenging this job is.
• 15:29
  SPEAKER_01: I really do think they genuinely care for the residents, and that is why they keep showing up.
• 15:35
  SPEAKER_01: But moving forward, I think we're going to have to figure out a way to put more value on these direct care staff, the CNAs, the nurses, they really are the backbone of the long-term care facilities.
• 15:47
  SPEAKER_01: And I think all of our infection prevention and stewardship efforts are going to be futile if we don't have their buy-in.
• 15:55
  SPEAKER_01: So for example, continued staff turnover makes any education challenging.
• 16:00
  SPEAKER_01: If they lack trust in the system, they don't feel the support from the system, it makes it hard to increase vaccination rates.
• 16:07
  SPEAKER_01: At the end of the day, they really are the people on site and it comes down to them.
• 16:14
  SPEAKER_01: So I guess as a final note, I'm going to continue to advocate to increase the benefits and sustain this incredibly important workforce because I think without them, it's going to make efforts moving forward really challenging.
• 16:28
  SPEAKER_00: Yeah, absolutely.
• 16:29
  SPEAKER_00: I mean, this had been a great workforce that had contributed so much into this pandemic.
• 16:35
  SPEAKER_00: Thank you for such a great conversation and for joining us today.
• 16:39
  SPEAKER_01: Thank you so much for having me.
• 16:40
  SPEAKER_01: It was great to talk with you.
• 16:42
  SPEAKER_00: Thank you again to our speaker for sharing their perspective and experience.
• 16:46
  SPEAKER_00: This podcast can be accessed on SHA's online education center, Learning CE, under the Rapid Response Program, where you'll also find resources such as SHA COVID19 Town Halls.
• 17:00
  SPEAKER_00: Interested in becoming a SHA member?
• 17:02
  SPEAKER_00: Take$1.20 off any membership type using the coupon code Learning CE2020 at checkout.
• 17:11
  SPEAKER_00: This concludes today's episode of the Rapid Response Podcast.
• 17:15
  SPEAKER_00: Thank you for tuning in.