Long-term Care Communication Bulletin | Fall 2020

TO:

LTC Physicians and Nurse Practitioners

FROM:

Dr. Margaret Manville, Medical Director Long-term Care

RE:

LTC update #11 

Date:  Fall 2020

I want to update you on the LTC program’s COVID-19 response since my last memo sent May 2020.  Island Health facilities have had no outbreaks to date. There continue to be outbreaks on the lower mainland and we are learning valuable lessons from their experience. As COVID-19 prevalence increases on the Island, we must remain highly vigilant.  We need to maintain our prevention practices to protect our vulnerable LTC residents.

Here are some learnings from the lower mainland, nationally and internationally regarding LTC and COVID-19:

 Two main risk factors for an outbreak occurring in LTC:

  1. Community prevalence
  2. Nursing home size

The greater number of LTC residents in the facility, the larger number of staff needed to provide care.  The vast majority of the initial infections occur from care staff to the resident.

 Once a LTC facility has an outbreak, the factors associated with spread within the facility are:

  1. Inability to effectively isolate infected residents (2-4 bed wards, wandering residents, full nursing homes, infected residents remaining  at the LTC site)
  2. Late identification, isolation and testing of infected residents (residents with vague symptoms)
  3. Pre-symptomatic transmission (both staff and residents)
  4. High frequency/long duration tasks which expose staff and residents to each other (eg. personal care for bowel incontinence)
  5. Breaches in PPE and hand hygiene in patient care and in staff areas
  6. Lower staff ratios of RN/LPN to care aides

Atypical presentations of COVID-19 are very typical in the LTC elderly patient. Many residents do not exhibit SOB, cough and fever, but demonstrate anorexia, fatigue and delirium as their presenting features. In Vancouver Coastal Health Authority, some symptomatic patients who were in an outbreak LTC site tested positive for COVID-19 on serology testing, despite two negative NP swabs. This emphasizes the importance of identifying and isolating ill residents early, using appropriate PPE consistently, and swabbing symptomatic residents, no matter how mild.  

Island Health Outbreak Response:

If there is an outbreak in any LTC facility on the Island, MRPs/NPs of infected residents will be supported by the local medical health officer, the site administration and staff, and the LTC Island Health Emergency Operations Committee to best care for affected residents. Our Outbreak Response Team will assist each site, as needed, to isolate or transfer residents (depending on medical condition, and characteristics of the outbreak site), supply PPE as necessary, provide staffing as necessary, and facilitate communication with families and the community.  Once a COVID + resident is identified,  the MRP/NP will be invited to join the COVID Emergency Outbreak Management teleconference to learn the details of their resident’s condition, outbreak characteristics, and to help make decisions about disposition, communication to families, and the care of the resident.  

The most up to date versions of our COVID SBAR to MRP/NPs, our LTC containment plan, and our COVID response protocol are available here:

COVID-19 Response Protocol

Daytime SBAR COVID-19 Screening

LTC Containment Plan

If a LTC outbreak initially seems small, a decision may be made to transfer one or more residents to a COVID+ cohort site in South, Central or North Island.  If an outbreak looks more widespread at onset, it will likely be managed within the facility, with the supports provided by the outbreak response team until the outbreak is declared over.  This approach has been used and refined by Fraser Health and Vancouver Coastal to manage their outbreaks to date. We are practicing our responses with simulations every 4 weeks to ensure we have the correct teams with the proper skill sets engaged to help manage outbreaks.

Medical care of COVID-19 + LTC residents:

The care of infected residents is largely supportive, managing symptoms of shortness of breath, delirium and pain.  I have appended the most recent BCCDC guideline which recommends considering dexamethasone or prednisone for LTC residents requiring supplemental oxygen therapy.  The benefits and risks of steroid treatment should be weighed before prescribing. Our colleagues across Canada are using dexamethasone for treatment of LTC residents who require oxygen therapy.  Practitioners are to use their own clinical judgement for each infected resident.

Antimicrobial and Immunomodulatory Therapy in Adult Patients with COVID-19

Caring for LTC residents in their home:

There was a dramatic reduction in transfers to ER from LTC during the first few months of the pandemic, from 7 per day Island-wide to 2 per day. There was no increase in mortality in LTC residents from the reduction in ER transfers from March-October 2020. Please continue to provide as much care in the LTC facility as is safe, and as guided by the resident’s MOST designation. 

LTC residents, their families and staff continue to have high praise for the support that physicians and NPs provide to our LTC homes. Please do not hesitate to reach out to me or your geography LTC medical leads if you have any concerns or questions.

Dr. Margaret Manville, FCFP, Care of the Elderly

Medical Director Long Term Care, Island Health