@theGEDC

New York, NY

Finland, ED

Indianapolis, IN

Grand Island NE VA Medical Center

Louisvillle KY VA medical center outpatient clinic

Hi from Thunder Bay, LTC there are 5 of us. We would like to know how best to transfer residents in

VA Northern California

Nursing home, Manitoba Canada - general information

Brandon MB, ER chief and COVID lead

Joplin, MO VA CBOC

Poonam Jain - Saint Louis VA Medical Center

port Colborne Ontario LTC

Winnipeg, MB; long term care-hybrid health centre

Home and Community with VA Medical Center in New Orleans,La.

Barrie Ontario Nursing Home

Kathleen, Have there been challenges in getting a sufficient supply of PPE for all your staff? How did you navigate that?

atypical presentations for older adults with COVID

PPE considerations for use by NH staff, plans for testing of patients (entire wings and staff (don't forget housekeeping), for isolation and cohorting of covid+ NH patients

Best practice tip: Whenever having a LTC patient test positive, have a line open for NH staff to answer questions and answers to improve communication and allay anxieties

https://www.cdc.gov/mmwr/volumes/69/wr/mm6913e1.htm

Innovative patient monitoring ideas include using video monitors in NH patient rooms if they need to be placed in room requiring doors closed.

Are you seeing nursing facilities asking for a negative COVID test prior to admission from a hospital, regardless of respiratory problems/COVID symptoms in their immediate health history?

MMWR APRIL 3RD 2020 - 57% of + NH residents were presymptomatic at time of + test

If you’re posting in the Chat Box please ensure you have selected “All panelists AND attendees”

one negative test has a 30% False negative rate, two negatives, 10%, abundance of caution needed

https://www.optimistic-care.org/probari/covid-19-resources for key information for NH facility staff about advanced care planning discussions during a crisis

Long Term Care Quadruple Aim for COVID-19 Response, www.caltcm.org/covid-19

when is a negative test not truly neg?

Question: How should ED providers balance recommendations for Advanced Directives (and efforts to find/interpret them) with series of TRIAD studies demonstrating inability for multiple levels of emergency medicine providers to accurately and reliably interpret them (see http://pmid.us/17214023 + http://pmid.us/17976563 + http://pmid.us/19157750 + http://pmid.us/22100496 + http://pmid.us/25692502)?

From Post-acute hospital & LTC - Guelph & Hamilton, Ontario.

Question: What can ED’s within hospitals without any Palliative Care programs or interest do during COVID-19 to ease patient suffering? In other words, what feasible Palliative Care approaches for non-Palliative Care trained individuals exist?

Long Term Care Quadruple Aim for COVID-19 Response, www.caltcm.org/covid-19

does testing negative change management?

Gene Ginchereau, Pittsburgh VA Health System

Our nursing home requires a negative COVID-19 result prior to transfer from any setting to our nursing home, due to pre-symptomatic conditions, no matter what their diagnoses. In our state a resident was transferred to the NH from a hospital for a fracture hip repair, and that nursing home now has 30+ positive cases, as well as staff, and many deaths. We will not take that chance.

Question: The Journal of Geriatric Emergency Medicine review describing “Nursing Home Transfers” emphasizes the importance of shared decision making with LTCF patients and families prior to ED transfer. What prognostic models/instruments exist to guide shared decision-making discussions with family - preferably adjusted for health literacy levels and cognitive impairment. In other words, which patients are more likely to survive? Early reports from northern California indicate a 50% extubation rate for those (of all ages) who were intubated, whereas Italy (cited in the JGEM review) reported 80% never able to extubatne. Why the large difference?

Cathy, you are correct. That’s why I’ll be speaking about COVID19 positive facilities

Nobody picks up phones

Bravo for emphasizing the importance of knowing the type of facility and their capabilities. Create a directory of the facilities that use your ED as their 911 care provider and hyperlink their capabilities. Consider color code example: green "independent"; yellow "assisted living" and red "skilled" etc.

Awesome tip Michelle!

Lisa — please change your setting to ATTENDEES. That message came only to me!

one thing we lack in our emergency room is the skilled nursing home facility or assisted living's staff calling the ER to give us report

Hi Lisa, add panelist and attendees to your chat

Michelle great ideas, shared from Sioux Falls, South Dakota VA

Ideal best practices pre-COVID and during COVID is good two-way communication between NH and ED

https://www.vitaltalk.org

Consider reaching out to the skilled and assisted living and discuss why the "warm handoff" is beneficial for their resident. Give them examples of a great and poor handoff. When they do call, make sure you acknowledge this win.

https://www.capc.org for good examples of communication dialogues around goals of care with COVID

Vital talk tips is an app. Free! Check out the OOPS conversation tips. I think we have all had an OOPS

Webinar Resources: Here is the URL for the Geriatric Emergency Department’s website https://gedcollaborative.com/ Check out COVID Resources on the GEDC website later today. https://gedcollaborative.com/resources/ where you will be able to find the presentation slides upon conclusion of today’s webinar.

Dr. Perryhttps://emottawablog.com/2020/03/end-of-life-care-in-the-ed-related-to-covid-19/End-of-life care in the Emergency Department for the patient imminently dying of a highly transmissible acute respiratory infection (such as COVID-19). The EMOTTAWA link describes an excellent protocol.CAPChttps://www.capc.org/Dr. Unroehttps://www.optimistic-care.org/probari/covid-19-resources/Advance Care Planning During a Crisis – Key information for nursing facility staff

Thank you for this discussion!

Thank you, great information!

Dear Colleagues, Thank you for participating in the Geriatric Emergency Department Collaborative’s webinar GEDC Webinar "Transitions Between Nursing Homes and EDs in the Age of COVID-19"Webinar Resources: Here is the URL for the Geriatric Emergency Department’s website https://gedcollaborative.com/ Check out COVID Resources on the GEDC website later today. https://gedcollaborative.com/resources/ where you will be able to find the presentation slides upon conclusion of today’s webinar.Dr. Aghahttps://www.westhealth.org/covid-19-resource-center/Outstanding resources at West Health’s Covid resource page with full implementation manual and toolkits for EDs and PALTCs.

Shoutout to Michelle Moccia at St. Mary's in Michigan for daily huddles on how to improve communication between ED and NH care. Scroll up for some innovative tips she has given

Question: For large urban areas with 50 (or more) LTCF’s each with their own leadership and none of which coordinate or communicate with one another, which LTCF should Geriatric ED leaders target for communication recommended by Dr. Malady? We certainly cannot have dozens of conversations with different leaders generating different protocols, priorities, transfer forms, and procedures?

Good question Chris. In most cases, the SNFs have referral practice patterns - which means that a relatively limited number of SNFs send the ED the majority of patients that ED receives from SNFs. Ie - reach out to the ones that send you the most patients first.

I would strongly urge connecting with your state’s AMDA (Society for Post Acute and Long Term Care Medicine) chapter

Also, connect with your state’s QIN-QIO

Also trade organizations for nursing homes (AHCA and LeadingAge chapters) can be excellent vehicles to disseminate best practices/information across facilities.

What is QIN-QIO?

Quality Improvement Organization

Have the national, regional or state AHCA and LeadingAge chapters disseminated the JGEM article and webinar?

in addition to protocols, etc, warm hand off/phone calls are still needed for each patient, particularly now

We are hosting daily huddles at 07:30 with the facilities who use us as their 911 care provider. 34+. We start the huddle with the update on our numbers of COVID-19 positive. We let them know the number of patients needing placement. We ask them to report out if their PPE is adequate, are they have challenges in staffing, their ability to take COVID-19 patients and any problem they are experiencing. We distribute supplies and/or we discuss with others who may help. We have one hour weekly calls with our ED Leadership and CMO, Infection Control Officers to help field questions, alleviate concerns, connect them with resoureces - powerful sharing. We have set up COVID-19 swab test kits too for them to use. We are working with a facility setting up a COVID-19 wing. We hosted our first Medical Director meeting :Sharing Care Strategies for the most vulnerable during the COVID-19 pandemic". Encourage the Med Dir. of facility to notify the ED physician prior to transfer "forward triage"

THANK YOU Michelle for providing real support to nursing facilities in your region - willingness to communicate and facilitate access to PPE, etc!

Michelle! wow. great info Also, in my health system days... looked at the discharge data ... started communicating with those facilities with highest numbers of the health system's patients

http://www.ihi.org/Topics/COVID-19/Pages/COVID-19-Care-of-Older-Adults.aspx This IHI webpage on COVID-19 and Older Adults is updated every 1-2 weeks. Age Friendly Health System work now includes a focus on COVID-19.

https://www.voanews.com/silicon-valley-technology/us-military-government-workers-still-use-zoom-despite-fbi-warning

Never too late!

Most facilities want to work with their local ED and hospital. They are waiting for an invitation.

thank you!

West Health tele health guide: www.westhealth.org/resource/telehealth-paltc-guide

please check the JAHF website for our NH plans

Thank you for the all the websites

West Health Covid resources link

West Health SNF ED tele health implementation toolkits www.westhealth.org/covid-19-resource-center

Great point about maintaining the health of the staff — both for keeping them healthy AND for protecting the residents.

JAHF is the John A Hartford Foundation

https://www.westhealth.org/covid-19-resource-center/

NHs are required by CMS to have an "infection preventionist" on staff however the person with this responsibility may wear multiple hats; Dr. Wasserman advocating for these to be full time positions.

can you please share direct link to slides in this chat box. Thank you

Terry — could you copy and paste the JAHF URL into the chat — the best way for people to access it.

Watching from a hot spot; nursing home staff and residents definitely starting to feel the stress.

WE are just going through the curve now, Sioux Falls, South Dakota... this is very helpful.

Slides and a recording of this presentation will be available after the session is complete. Please check back on the GEDC website for these.

Thank you Ula!

Marcus — please send that post to ALL ATTENDEES

GEDC website is https://gedcollaborative.com/

Thanks Catherine. And here are two links for JAHF/The John A. Hartford Foundation on nursing homes that Dr. Fulmer referencedResources: https://www.johnahartford.org/dissemination-center/view/nursing-home-long-term-care-resources and Blog post: https://www.johnahartford.org/blog/view/nursing-homes-in-the-time-of-covid-19-we-need-urgent-action-now-and-a-long-term-strategy

Check out https://gedcollaborative.com for the slides and many other tools for ED clinicians caring for older adults during COVID

NHs are required by CMS to have an "infection preventionist" on staff however the person with this responsibility may wear multiple hats; Dr. Wasserman advocating for these to be full time positions. Great way for health systems to share their resources and expertise, infection preventionists

thank you

Dr. Steinberghttps://www.speakupontario.ca/http://www.goalsofcaremodule.com/Vital Talkhttps://www.vitaltalk.org/guides/covid-19-communication-skills/?referringSource=articleShareSerious Illness Conversation (SIC)https://bc-cpc.ca/cpc/category/sic/

For Mike Wasserman's NH Covid units, staffing includes:StaffingVolunteers<Age 65No diabetes/heart disease/or lung diseaseNo immunocompromising conditionsAntibody evidence of previous COVID-19 immunity (eventually)Willingness to stay in hotel (and willingness not work anywhere else for the duration of duties)

Work also with your EMS to help you identify concerns they have when they go into a facility eg. lack of PPE; incorrectly using PPE. Not punitive but helpful so you can all work together to improve education and strategies to reduce the spread.

Speak Up Ontario website

https://www.speakupontario.ca

Helpful guide for NHs to simplify medication regimens to reduce staff exposure to COVID and time administering medicines from Lamy center and US Deprescribing Research Network: https://www.pharmacy.umaryland.edu/PALTC-COVID19-MedOpt

An initial step in collaboration is to let referring facilities know that the ED prioritizes communication with NH providers by assigning a single point of contact, such as a phone line to an ED provider or transition coordinator.

SDM - Shared Decision Maker

Surrogate Decision Maker

Great tip Adam!

Dr. Steinberghttps://www.speakupontario.ca/http://www.goalsofcaremodule.com/

Thank you everyone!

What a great webinar - thank you all!!

Excellent job by all of the speakers! Thank you - thank you - thank you!

Dear Colleagues, Thank you for participating in the Geriatric Emergency Department Collaborative’s Webinar, "Transitions Between Nursing Homes and EDs in the Age of COVID-19"Some Post-webinar Resources: Here is the URL for the Geriatric Emergency Department’s website https://gedcollaborative.com/ Check out COVID Resources on the GEDC website later today. https://gedcollaborative.com/resources/ where you will be able to find the presentation and slides upon conclusion of today’s webinar.Dr. Agha - West Healthhttps://www.westhealth.org/covid-19-resource-center/Outstanding resources at West Health’s COVID resource page with full implementation manual and toolkits for EDs and PALTCs.Dr. Perryhttps://emottawablog.com/2020/03/end-of-life-care-in-the-ed-related-to-covid-19/End-of-life care in the Emergency Department for the patient imminently dying of a highly transmissible acute respiratory infection (such as COVID-19).CAPChttps://www.capc.org/Dr. Unroehttps://www.optimistic-care.org/probari/covi

How do we get the CEU?

Thank you!

Dr. Steinberghttps://www.speakupontario.ca/http://www.goalsofcaremodule.com/Vital Talkhttps://www.vitaltalk.org/guides/covid-19-communication-skills/?referringSource=articleShareSerious Illness Conversation (SIC)https://bc-cpc.ca/cpc/category/sic/

May 11 3p EST next webinar

Great presentation! Thanks!

Thanks. Great information

Thanks!

Thank you speakers!!

Thank you all, great information!

From Sethany Johnson RN at VA Medical Center in New Orleans, La. Very informative!!!

More COVID/GED related resources:SCCM Surviving Sepsis Campaign COVID-19 Guidelines.https://www.sccm.org/disasterBMJ Best Practice.https://bestpractice.bmj.com/topics/en-us/3000168#important-updateCOVID at LTACHhttps://www.nejm.org/doi/full/10.1056/NEJMoa2005412?query=featured_coronavirusAMA Journal of Ethics“March 2020 - Ethics Talk Podcast: COVID-19 Pandemic Response”https://journalofethics.ama-assn.org/covid-19-ethics-resource-centerMarch 27 - The Importance of Addressing Advance Care Planning and Decisions About Do-Not-Resuscitate Orders During Novel Coronavirus 2019 (COVID-19) https://jamanetwork.com/journals/jama/fullarticle/2763952March 27 - Epidemiology of Covid-19 in a Long-Term Care Facility in King County, Washington https://www.nejm.org/doi/full/10.1056/NEJMoa2005412?query=featured_coronavirusMarch 20 – Surviving Sepsis Campaign: Guidelines on the Management of Critically Ill Adults with Coronavirus Disease 2019 (COVID-19)https://sccm.org/getattachment/Disaster/SSC-COVID19