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Front Line Perspectives from a Nursing Home Director with AMDA · The SHEA Podcast

• 0:10
  SPEAKER_01: Welcome to the podcast series.
• 0:12
  SPEAKER_01: We are all in this together: COVID-19 Allies and Infection Prevention, as part of the Society for Healthcare Epidemiology of America, SHAY Rapid Response Program.
• 0:22
  SPEAKER_01: I'm Robin Jump, an associate professor of medicine at the Case Question Reserve University, and also a staff physician at Lewis Stokes Cleveland Veterans Affairs Medical Center.
• 0:33
  SPEAKER_01: I'm going to serve as the SHA moderator and speaker today.
• 0:36
  SPEAKER_01: I'm also delighted to welcome Dr.
• 0:37
  SPEAKER_01: Swati Gar, who is the Medical Director at the Northeast Georgia Health System, and who is also the Chair of the Infection Advisory Committee for AMDA, which is a Society for Post-Acute and Long-Term Care Medicine, and she is our speaker for today's podcast.
• 0:52
  SPEAKER_01: Discussion on the podcast does not reflect SHAY or Amda's perspectives but facilitates communication on multiple perspectives and experiences as we go through this challenging time together.
• 1:02
  SPEAKER_01: Today's episode will focus on collaborations and how we as a team can work together to address the most important questions during the COVID-19 outbreak.
• 1:11
  SPEAKER_01: Let's get started with our first question.
• 1:13
  SPEAKER_01: Dr.
• 1:14
  SPEAKER_01: Garr, thank you for being part of this.
• 1:15
  SPEAKER_01: And let's start by having you please describe what AMDA is doing to address COVID-19.
• 1:22
  SPEAKER_00: Thank you for having me.
• 1:24
  SPEAKER_00: We started an AMDA Infection Advisory Committee.
• 1:28
  SPEAKER_00: We had four of the experts who started writing guidance end of February.
• 1:33
  SPEAKER_00: And Robin, thank you for being one of those experts.
• 1:36
  SPEAKER_00: We have been since writing guidance as we find out more since this is a rapidly evolving situation.
• 1:44
  SPEAKER_00: At AMDA, we are also responding to different stage requirements and also CMS requirements that have come since then and trying to help our physicians and medical directors and nursing homes, APPs, with the guidance on best practices.
• 2:02
  SPEAKER_01: That sounds like it's been a heroic effort.
• 2:05
  SPEAKER_01: And just for the purposes of some of our folks listening on the podcast, what are APPs?
• 2:10
  SPEAKER_00: Advanced practice practitioners.
• 2:12
  SPEAKER_01: Okay, thank you.
• 2:14
  SPEAKER_01: So tell me what some of the guidance has been stating.
• 2:18
  SPEAKER_01: I imagine that there's been a lot of interpretation that has to happen to help move some of the broad guidance about COVID-19 and make it more specific to the long-term care setting.
• 2:28
  SPEAKER_00: Yeah, so the long-term care setting is a very unique setting, and we have to quickly write guidance.
• 2:35
  SPEAKER_00: And as you can imagine, a lot of it is around infection control practices and what is the best way of dealing with a disease that is a respiratory illness, which has a very high attack rate and very high case fatality rates that we were finding initially.
• 2:51
  SPEAKER_00: And to take all that and put that into a very unique nursing home care model, which is a contained space, was was a big challenge.
• 3:01
  SPEAKER_00: And that that's basically what our guidance talks about.
• 3:05
  SPEAKER_00: Initially, we started with a lot of facilities that were COVID naive and the prevalence of disease was low in the community.
• 3:14
  SPEAKER_00: And as we evolved with the disease process throughout the nation, it kind of all came together to, you know, there is COVID in pretty much every community, all states in the United States, and that evolved.
• 3:30
  SPEAKER_00: Essentially providing checklists and helping our facilities to navigate some of those challenges has been our work in the last several months.
• 3:47
  SPEAKER_01: So tell me what it is that you're doing at your own nursing homes to address the challenges around COVID-19.
• 3:55
  SPEAKER_00: Yeah, I think we have been incredibly fortunate.
• 3:59
  SPEAKER_00: We have a great team at the nursing home, and it was, I believe, very helpful being in the role that I was in AMDA, and I am in AMDA, and basically taking the same guidance that we were thinking of and coming up with, and doing facility preparedness based on that really helped us out.
• 4:21
  SPEAKER_00: One example is, Robin, you know, because you have been so critical in coming up with the screening tool for common and uncommon symptoms of COVID.
• 4:33
  SPEAKER_00: We implemented that very, very early on and have been having preparedness meetings very early.
• 4:40
  SPEAKER_00: And I think that has helped our nursing home really keep the caseload down, have best practices instituted, and really also have a good communication with our referral hospital and plan for this disease.
• 4:55
  SPEAKER_01: And I recall from some of our previous conversations that you actually implemented some changes within your building, like to the physical structure, to make it easier to address some of the COVID challenges.
• 5:08
  SPEAKER_01: Can you tell us a little bit more about that?
• 5:11
  SPEAKER_00: Sure.
• 5:12
  SPEAKER_00: In our preparedness, we looked at the map of our buildings, and I think this is important in any illness, but primarily restory illness, this even is relevant to illnesses like flu.
• 5:26
  SPEAKER_00: There are some areas in our buildings, as it is an older building, that you know, a lot of through traffic happens.
• 5:34
  SPEAKER_00: And we quickly realized early on when we had PUIs and we had tried to cohort our PUIs that there are some areas that are just absolutely not going to work.
• 5:46
  SPEAKER_00: So we looked at our facility map and in during our preparedness, we said, what is a good area if we did get COVID in our building?
• 5:55
  SPEAKER_00: What is a good area where we can separate completely cohorts, not just the patients, but staff and equipment and to be able to operationalize it.
• 6:06
  SPEAKER_00: So we were able to do that by really looking at our building maps and strategizing.
• 6:13
  SPEAKER_01: And so you actually wound up quadring off one area of your building, right?
• 6:20
  SPEAKER_00: Absolutely.
• 6:21
  SPEAKER_00: So we had an area that we identified, which is, you know, we call it a transitional care unit, where we typically get our short-term rehab patients come into that area.
• 6:34
  SPEAKER_00: That is separated from the rest of the building by administrative offices.
• 6:39
  SPEAKER_00: That was the area that we realized could be operationalized into a COVID unit because it is possible for us to feel off the rest of the building and have that area as a standalone building because of external exits and the whole setup being there.
• 7:00
  SPEAKER_00: And that was the best way we found.
• 7:02
  SPEAKER_00: We would not share equipment, we would not share staff, and we essentially closed that area off and converted that into our COVID unit.
• 7:13
  SPEAKER_00: We also looked at an area with, again, external exits to bring in new patients from the hospital because we had to cohort our new patients also and identified those areas.
• 7:27
  SPEAKER_00: We also found out we have two buildings in our system, two nursing home buildings, and we quickly found out that one of the buildings would have been a nightmare to cohort COVID patients because of the way it is set up and doesn't allow for that physical barrier.
• 7:47
  SPEAKER_00: So we made a decision that all of our COVID patients would be going to that building that I just described, which was physically separated from all other parts of the building.
• 8:00
  SPEAKER_00: So we assigned one COVID unit.
• 8:03
  SPEAKER_01: So your team made some very deliberate decisions to leverage your system-wide resources to improve the care of residents both with and without COVID.
• 8:15
  SPEAKER_00: Absolutely.
• 8:16
  SPEAKER_00: So that allowed us to decrease the burden of disease in the main units and continue to provide care of the patients in the main unit.
• 8:26
  SPEAKER_00: But we also created a specialized unit because our COVID patients do need that special care.
• 8:34
  SPEAKER_00: And we ordered extra PPE for the staff, for staff protection, but also extra equipment for patients, including pulse oximeters, thermometers, vital science machines, extra medication carts because we just didn't want to share equipment.
• 8:53
  SPEAKER_00: And that allowed us to give specialized care to our COVID patients because then we started new protocols and put them in place to address their special needs.
• 9:06
  SPEAKER_00: For example, checking their vital signs, checking their pulsoxymeters frequently.
• 9:12
  SPEAKER_00: We also ordered oxygen concentrators anticipating our patients' needs.
• 9:17
  SPEAKER_00: We also talked to the families about goals of care immediately and addressed them because we had made a decision to be able to try to provide care of our patients within the setting if they did so wish.
• 9:35
  SPEAKER_00: And really most of our patients did, and their families did wish to be really in the nursing home.
• 9:42
  SPEAKER_00: And essentially, we just had to send one patient who was in dialysis to the hospital because the dialysis center would not accept him because he was COVID.
• 9:54
  SPEAKER_00: And uh and we he needed he needed dialysis.
• 9:57
  SPEAKER_00: So that for that one day we had to transfer him to the hospital, but for the most part, we were able to care for our patients in our own setting with the extra preparation that we did.
• 10:08
  SPEAKER_01: That sounds remarkable to me, and I admire your dedication to your residents and keeping their comfort, including staying in their homes, as part of the priorities of care.
• 10:20
  SPEAKER_01: You mentioned staff during all this.
• 10:23
  SPEAKER_01: If you have separate staff going into your COVID unit and ordering them PPE to work in that area, tell me what else you are doing to support your staff as they go about doing their daily activities and also how you're supporting the morale of your staff as we all struggle with COVID-19.
• 10:44
  SPEAKER_00: Absolutely.
• 10:45
  SPEAKER_00: So we realized that COVID obviously is a rest or illness, and we realized that the attack rates were high.
• 10:55
  SPEAKER_00: And as we were preparing for COVID in our buildings very early, end of February, we quickly realized that the situation was critical enough where that top-down communication, we didn't want to depend upon that.
• 11:13
  SPEAKER_00: We wanted very clear, transparent communication between the staff and the leadership team, which is administrators, DON, and medical director.
• 11:24
  SPEAKER_00: So what we did is, since the message was so important as to how do we protect our staff and our residents, we decided to do a town hall format to relay that critical information during all shifts.
• 11:40
  SPEAKER_00: And in that town hall format, our focus was on infection prevention and donning and doffing of PPE, hand washing, how the staff can protect themselves and their families, what is critical for them to do, not just inside the building, but when they get home, how do they clean their own personal equipment, et cetera?
• 12:06
  SPEAKER_00: And how can the staff help each other in keeping themselves safe?
• 12:12
  SPEAKER_00: So, you know, institution of buddy system, et cetera.
• 12:16
  SPEAKER_00: So we started that early on, and I think that has helped and that culture that got started then.
• 12:23
  SPEAKER_00: We are able to see that, you know, what we are four months into this, and we still see the staff calling on each other, of course, in a very respectful way, but we have made that a positive event rather than you know, somebody is trying to call you on something.
• 12:42
  SPEAKER_00: So it's been very productive.
• 12:44
  SPEAKER_01: So it's a way for all of us to remind each other and care for each other about how to stay safe.
• 12:50
  SPEAKER_00: Yes.
• 12:51
  SPEAKER_00: And the town hall we established that you when you remind people of properly donning and doffing your PPE or not putting your elbows or your hands on surfaces, that is just you have my back.
• 13:09
  SPEAKER_00: And and I think that that was a message that resonated with staff, and I think that is a good culture to have in the facility.
• 13:17
  SPEAKER_01: That sounds fantastic.
• 13:19
  SPEAKER_01: And one of the the stories that I hear in the media is about nursing home staff that work at more than one facility almost entirely so they can make ends meet for their own lives.
• 13:32
  SPEAKER_01: How did you address that with your staff?
• 13:36
  SPEAKER_00: You bring up a good point.
• 13:38
  SPEAKER_00: That is a huge challenge, and I think that is something we need to keep in mind, even after we are over this crisis, and I'm hoping that you know the agencies and the powers to be would focus upon that because that is a challenge this crisis has brought forth.
• 13:57
  SPEAKER_00: That being said, we recognize a lot of our staff was working in multiple facilities, like you said, to make ends meet.
• 14:07
  SPEAKER_00: So what we did is we started out with creating spreadsheets.
• 14:12
  SPEAKER_00: Our DOMs created spreadsheets of staff members who were working in multiple facilities so that we can keep track of where the disease was and you know be more careful.
• 14:24
  SPEAKER_00: And then we quickly realized even if we had that information early on, we didn't really have facility information as to how many cases were happening in other facilities.
• 14:37
  SPEAKER_00: This is early on before it all became reportable and transparent.
• 14:42
  SPEAKER_00: And then, you know, we really could not find a good way to be able to say to the staff, well, now you cannot come here.
• 14:50
  SPEAKER_00: This doesn't seem to be a very humane way of doing it.
• 14:53
  SPEAKER_00: So after a lot of thought, what we did is, and facilities have done this different, but what we decided to do is we went back and kind of said, why do we have the policies?
• 15:06
  SPEAKER_00: Why does the staff really need to work in multiple facilities?
• 15:09
  SPEAKER_00: And what we realized is facilities generally don't want to get to that threshold where they have to pay over time.
• 15:18
  SPEAKER_00: And essentially our leadership team said, in this time of crisis, we are going to have to keep that aside.
• 15:26
  SPEAKER_00: And we sat down with the staff who were working in several facilities and said, You have the choice of working here, putting in the hours that you need to, and we will not put a ceiling on your time.
• 15:41
  SPEAKER_00: So essentially, we kind of started that overtime pay, and then we went to that crisis pay for the staff.
• 15:50
  SPEAKER_00: So we decided to increase the pay and just not worry about the overtime during this crisis time.
• 15:58
  SPEAKER_00: That way, we have had a lot of staff members who have decided that they are going to only work in our facility.
• 16:04
  SPEAKER_00: And I think that has worked in our favor.
• 16:07
  SPEAKER_01: That sounds like a really great solution, and that shows a degree of caring for the individuals that work for you as well as maximizing the safety and well-being of our other residents as well.
• 16:21
  SPEAKER_01: I wanted to ask you next about how your nursing home is preparing to open up and to allow visitors in.
• 16:31
  SPEAKER_01: There's a lot of regulations and guidance that CMS has offered in terms of a window of negative testing and how often we're supposed to retest our individuals, both our staff and a nursing home resident.
• 16:44
  SPEAKER_01: And it's created, as many things have for COVID, a lot of confusion as we all figure out how to operationalize these recommendations or these requirements in some cases.
• 16:54
  SPEAKER_01: Tell me what you're what you're doing at your nursing homes.
• 16:59
  SPEAKER_00: Right.
• 17:00
  SPEAKER_00: So testing has been a hot topic right now.
• 17:04
  SPEAKER_00: And I know that testing is really now dependent upon state mandates.
• 17:10
  SPEAKER_00: CMS has suggested universal testing, and um CDC has suggested universal testing, but really the mandate is coming from the state.
• 17:22
  SPEAKER_00: And Georgia currently does not have a mandate, and I'm from Georgia.
• 17:26
  SPEAKER_00: So what we decided is we actually did universal testing very early on before people were talking about universal testing.
• 17:35
  SPEAKER_00: That was when we discovered our first case end of March.
• 17:39
  SPEAKER_00: We did universal testing of staff and residents at that time.
• 17:44
  SPEAKER_00: And essentially what we found then was we had several asymptomatic positive residents.
• 17:50
  SPEAKER_00: So we had about eight total residents that we found in our universal testing after our first case was positive.
• 17:58
  SPEAKER_00: We moved them to the COVID unit.
• 18:01
  SPEAKER_00: So that was helpful.
• 18:02
  SPEAKER_00: And then we tested staff and we found 15 staff members that were positive.
• 18:07
  SPEAKER_00: And they were primarily uh nursing staff.
• 18:10
  SPEAKER_00: What we realized is the few days after having the nursing staff tested and having shortage of nursing staff were very tough for us because we were not prepared to have that many staff short.
• 18:26
  SPEAKER_00: That is a situation that arose and caught us unprepared, and our DON was on a cart, and our infection preventionist was on a cart, and the daily clinical meetings that we were having to assess COVID situation in our buildings was basically we didn't have it for two days, and that was not a good time.
• 18:50
  SPEAKER_00: So the lesson from that is you've got to be having a checklist of people and prepare ahead of testing if you want to embark upon universal testing.
• 19:02
  SPEAKER_00: So we tried that again about three weeks back, and we did it in a very staged format, basically testing staff members over several weeks, a couple of weeks.
• 19:17
  SPEAKER_00: And that was because we assessed our facility and we realized that a couple of things.
• 19:24
  SPEAKER_00: Even when our staff was positive, uh, and that is really a function of the prevalence of disease in the community, our patients were not turning positive.
• 19:34
  SPEAKER_00: So, what it proved to us is that the staff was doing a good job in their infection control practices and their PPE use and their hand washing use.
• 19:43
  SPEAKER_00: So then we felt comfortable in doing staff testing in stages.
• 19:47
  SPEAKER_00: But before that, we really talked about what happens if you know 0 to 50% of our staff is out, test positive, and is out.
• 19:58
  SPEAKER_00: So we made uh contingency plans and put things in place ahead of time so that if we did have 75% of the staff, which has happened in some other buildings in the state of Georgia, what would we do?
• 20:12
  SPEAKER_00: That is one thing that I would really want the listeners to focus upon before uh embark upon this widespread testing.
• 20:21
  SPEAKER_00: The other thing that I would say is when you test, it's not the result of the test that is your final step.
• 20:29
  SPEAKER_00: It is what we learn from that result is the most important thing.
• 20:34
  SPEAKER_00: So, really, if the residents are testing positive, the staff is testing positive, then it really needs to be almost like a root cause analysis of what happened, what was the reason why this happened, and what would we put in place so that this doesn't happen.
• 20:49
  SPEAKER_00: So, for example, the first time when we did testing and found extensive staff members positive, we put in place face shields in addition to masks.
• 20:58
  SPEAKER_00: We didn't have face shields at that time, but we put in place the face shields.
• 21:02
  SPEAKER_00: And for staff, what we put in place is that the staff could not have communal dining, they could not sit together and take breaks and universal masking.
• 21:11
  SPEAKER_00: So they couldn't talk to each other without the mask present.
• 21:15
  SPEAKER_00: So those are the measures that we put in place.
• 21:18
  SPEAKER_00: And the second time when we did three weeks back, the universal testing, I think we have lower numbers of residents and staff that are testing positive.
• 21:27
  SPEAKER_00: It may be because of the things that we put in place.
• 21:29
  SPEAKER_00: So I think the second important lesson from this testing, universal testing, is the job doesn't get over with results.
• 21:39
  SPEAKER_00: It is what you do with the results that is important.
• 21:42
  SPEAKER_01: So testing is the first step, it sounds like.
• 21:45
  SPEAKER_01: And it also sounds as if you're almost thinking about this maybe in two different levels that you're, of course, testing individuals that develop symptoms and responding appropriately to get them into transmission based precautions based.
• 22:00
  SPEAKER_01: Some symptoms.
• 22:01
  SPEAKER_01: And then you have a maybe a separate program for doing screening and surveillance for asymptomatic individuals.
• 22:08
  SPEAKER_00: Correct.
• 22:09
  SPEAKER_00: That is a good point for Robin, because doing one doesn't eliminate the need for the other.
• 22:15
  SPEAKER_00: We are aggressively clinically screening our residents and staff.
• 22:21
  SPEAKER_00: And essentially we were at a point where we were testing almost 25% of our residents almost on a weekly basis.
• 22:30
  SPEAKER_00: So if in that setting, and plus the staff with extensive contact tracing, you know, with a good look back, a long look back.
• 22:40
  SPEAKER_00: And essentially what that did is we were testing a lot of staff and a lot of patients in a very focused way.
• 22:48
  SPEAKER_00: So when we did extensive testing or universal testing of our patients, we found in all of those buildings, in both the buildings, in all the patients, we found two asymptomatic positive.
• 23:01
  SPEAKER_00: And that was the only thing that we found.
• 23:04
  SPEAKER_00: So your yield, if you're aggressively doing this clinical screening, finding patients, and doing good contact tracing and testing aggressively on a regular basis, your yield from universal testing is going to be limited.
• 23:20
  SPEAKER_00: But you make a good point that one doesn't eliminate the need of others.
• 23:25
  SPEAKER_00: I think it's more important to really aggressively look for disease and have good measures in place.
• 23:32
  SPEAKER_01: That's a fantastic answer.
• 23:34
  SPEAKER_01: And I want to thank you and commend you for the heroic efforts that you and your nursing homes and administration and staff have put forth to fight this pandemic.
• 23:44
  SPEAKER_01: Before we finish up, I wanted to bring us back to the level of AMDA and what the society is doing and how AMDA and Shay and people within our organizations can work together to help improve what we're doing with the pandemic now.
• 24:01
  SPEAKER_01: And also how does this help us create opportunities for working together in the long term?
• 24:07
  SPEAKER_00: Absolutely.
• 24:08
  SPEAKER_00: That's a very good point to end the talk on.
• 24:13
  SPEAKER_00: We at AMDA have talked about how unique nursing home settings are.
• 24:19
  SPEAKER_00: And I think COVID pandemic and especially its effect on the nursing homes and the mortality in the nursing homes has really brought into focus the unique environment that nursing homes are.
• 24:32
  SPEAKER_00: And it has really made uh different agencies like CDC and CMS and HHS and multiple other agencies really focus upon that and understand that that is very true and create special models of care within that nursing home setting.
• 24:52
  SPEAKER_00: So that is one of the great things that has happened, and I hope that these big agencies would continue to understand the nursing home world a little better and bring about a more supportive work, especially CMS can be more supportive with resources and their regulations that work for long-term care facilities.
• 25:13
  SPEAKER_00: The other great opportunity that has come about is I see the extra research opportunities that are going on with enrollment in the nursing home environment that has always been important and still continues to be very important.
• 25:28
  SPEAKER_00: And I hope to see that continue, especially the vaccines as we look for vaccines for COVID.
• 25:35
  SPEAKER_00: And on a state level, also close coordination between nursing homes and health departments and other state agencies, you know, is a great area of opportunity.
• 25:46
  SPEAKER_00: And I hope that continues going forward, even if we are out of this COVID crisis.
• 25:51
  SPEAKER_01: That's a great note to end on.
• 25:53
  SPEAKER_01: So, Dr.
• 25:54
  SPEAKER_01: Garr, thank you very much for joining us today and for sharing your perspectives and experiences.
• 25:59
  SPEAKER_01: And I also want to offer a sincere thank you personally and also on behalf of Shay to all healthcare personnel for all that you're doing to respond to COVID-19.
• 26:10
  SPEAKER_01: This podcast can be accessed on Shay's online education center, Learning CE, under the Rapid Response Program.
• 26:17
  SPEAKER_01: You will also find additional resources such as recorded webinars, healthcare facility outbreak preparedness, and the SHAY COVID-19 town hall, as well as additional podcast series, COVID-19 updates, what we know now, which is released every Thursday.
• 26:31
  SPEAKER_01: This concludes this episode of the COVID-19 Allies and Infection Prevention Podcast Series.
• 26:36
  SPEAKER_01: Thank you for tuning in.