August 2020
Palliative Care and COVID-19
Schyuler Barbour-Johnson, MSN, CRNO, ANP-BC
The COVID-19 pandemic has caused health care facilities to revise their operational and financial procedures. Older adults and people with multiple chronic conditions are at higher risk of morbidity and mortality related to COVID-19. Their conditions decline rapidly and change frequently. This places an importance on constant communication, advance care planning and symptoms management. Staffing may be limited to provide care for the patients and communications and support to families /responsible parties. This is where the unique skills of Palliative Care can be a part of providing the quality of care for patients.

Palliative Care is specialized care that focuses on improving quality of life and relieving symptoms or stress for patients and families/responsible parties. Palliative Care has been shown to improve quality, satisfaction, and cost appropriateness such as:

  • Reduces symptom distress by 66% with improvements lasting months after initial consult
  • 93% of people who receive Palliative Care are likely to recommend it to others
  • Decreased Emergency Room (ER) and hospital transfers in skilled nursing setting by 43%
  • Decreased ER and hospital transfers in an outpatient setting by 50% hospitalizations and 35% ER

Palliative Care can be delivered via telephone, video conference, or in person with personal protective equipment. Palliative Care ensures all medical staff involved in the patient’s care are updated.

Some benefits of Palliative Care are: 

  • Medical staff may be caring for multiple patients with acute illness and the staffing is limited due to illness or call outs. Palliative Care can provide detailed assessment of patients and their goals of care including families/ responsible parties while including families/responsible parties in the conversation.
  • Palliative Care has been helpful in cases where the patient is hospice eligible and the families/responsible party is not acceptable to hospice. Palliative Care will manage pain and symptoms of conditions along with goals of care conversations.
  • Families/responsible parties are restricted from visiting patients during the COVID-19 pandemic. This can be incredibly challenging knowing their loved ones has an acute or life-threatening illness. Palliative Care can be the communication bridge between the patient’s status to families and responsible parties. This will also alleviate the multiple calls facility staff receives from families/responsible parties concerning the patient.  

While we are facing the most critical time with the COVID-19 pandemic, healthcare professionals have realized that we cannot be content with the ordinary process. We must be innovative and strategic. This is a great opportunity to unite with Palliative Care to provide strong collaboration and quality of care for patients and families/responsible parties. 

References
Center of Advance Palliative Care. (2018). Palliative Care Ensure Value. Retrieved from Center to Advance Palliative Care: https://www.capc.org/covid-19/

Any views or opinions presented in this article are solely those of the author and do not necessarily represent any policy or position of PAMED, PMDA, AMDA, its affiliates and members.
All Pain with Little Gain
Is Pennsylvania Universal Nursing Home COVID-19 Testing Plan Sound?
Dillard Elmore, DO, CMD, MBA
I am ushered into a large ballroom filled with military gear-clad figures covered by full personal protective equipment (PPE). I am given my COVID-19 test kit and directed to a soldier who administers the test. A curette is inserted into nostril until it touches my pharynx (the back of my nose). It feels like it is lodged in my brain. The swab is then rotated five times. Just thinking about it makes my nose twitch involuntarily. My colleagues have endured being tested several times weekly by different long term-care facilities (LTCF). Some clinicians openly wonder if this can continue so frequently.

As states go through the reopening process, skilled nursing facilities will be dealing with extreme pressures to do so also. Particularly from family members who have not seen their loved ones, since most long-term care facilities (LTCF) closed to visitors March. Point prevalence surveys (PPS) of residents and healthcare providers mandated by the state of Pennsylvania are to be completed by 7/24/20. If the PPS reveals positive cases the facility must retest until there are no new positives. Once a LTCF reopens to visitors, they will be faced with more complex challenges.

LTCF’s are a fertile ground for COVID-19. Even if the prevalence of COVID-19 in a specific community is low it can cause havoc if it gets into the LTCF. Testifying before Congress on June 23, 2020, Dr. Robert Redfield suggested that for every one symptomatic individual with COVID-19, there are 10 infectious asymptomatic individuals. An asymptomatic person can introduce COVID-19 into a LTCF. Data from AMDA shows that COVID-19 has a 30% mortality rate in a LTCF. So, a COVID-19 outbreak in a LTCF with 100 residents can kill 30 residents four weeks later. These are alarming numbers!

Even one confirmed case of COVID-19 in a LTCF leads to increased absenteeism, utilization of agency help, anxiety, and spend rate on PPE (to name just a few). All of this while concurrently trying to implement the most stringent infection prevention and control processes (IPC) possible. Even the highest performing LTCF risk some degree of failure performing the mandated PPS.

The Commonwealth of Pennsylvania has 700 skilled nursing facilities numbering approximately 80,000 residents and 120,000 healthcare professionals (HCP). The state set a goal to perform 8,500 tests per day. If this goal were met and only LTCF residents and staff were being tested, all the testing could be completed in approximately 24 days. However, there are many other organizations lobbying for the limited number of COVID-19 tests including hospitals, universities, professional sports leagues, and other municipalities. I am informed by other medical directors that test kits are in short supply.

There are other costs to universal testing. My organization noted a $120 average cost for each test. One PPS in a facility with 1350 HCP’s and residents adds up to $162,000. This does not count the cost of repeated testing if necessary. The CARES Act carves out financial support for baseline and surveillance testing, but this is not the only hurdle. Repeating this uncomfortable test on a weekly basis may not be tolerated by residents and HCP’s. What about the demented resident who cannot understand why this is even being done? PCR testing can also create panic when a COVID-19 case is discovered. PCR tests can remain positive long after the virus is cleared and person is no longer infectious. Staff would then be needlessly excluded from work for approximately 10 days. This lack of staff will be magnified by others quitting or going on a leave of absence.

If the goal of mandated testing is to get a clearer picture of the prevalence of COVID-19 in LTCF’s, I believe an initial antibody test is appropriate. This can be ordered rapidly for staff and residents. It would give retrospective understanding of the prevalence of COVID-19 in the facility. Individuals with a positive IgG should be excluded from PCR testing. Individuals who do not show IgG production should be tested with a PCR. The PCR test is just a snapshot of what is happening but when combined with IgG serology we get a clearer picture of what has been occurring. The IgG positive staff will not need to be excluded from work and will likely feel less anxiety about working on a COVID-19 unit. This would be extremely valuable since their lack of contagiousness and susceptibility allow them to work with COVID positive and negative residents alike.

I am a proponent of universal testing however PCR testing alone only provides limited data. Repeated testing of staff and residence is impractically secondary to limited supplies and the discomfort of testing. There is also a slow turn around in test results which make them less valuable. I strongly encourage the states to consider making IgG titers part of their COVID-19 testing strategy.


Dillard Elmore, DO, CMD, MBA is Chair of PMDA’s Public Policy Committee. Any views or opinions presented in this article are solely those of the author and do not necessarily represent any policy or position of PAMED, PMDA, AMDA, its affiliates and members.

References

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