Dear Colleagues,Welcome to the Geriatric Emergency Department Collaborative’s Webinar, COVID-19 in Older Adult: Key Points for ED Providers

Here is the URL for the Geriatric Emergency Department’s website (https://gedcollaborative.com/)

San Antonio Texas

maaret from Finland

Boston

Dallas, Texas

Alberta, Canada

chicago

Illinois, US

Tasmania

Fayetteville, AR

Iowa City

New York

from nortthport, ny long island

yes will cover pal care

San Diego , california

Tasmania

Decatur, IL

Tasmania is wonderful!

joining from Little Rock, Arkansas

Check out the GEMCAST on critically ill COVID-19 patients with an intensivist from Mt Sinai. It is here:https://gempodcast.com/2020/03/23/covid-icu/

Pat from Albany NY

Jackson, Mississippi

Today’s webinar is being recorded. Webinar RECORDING & SLIDES will be available in a link you’ll receive via email after the webinar.

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.

you can use #GeriED #COVID-19

From Eddy Lang: Should all transers to ED from assisted living or LTC facilities be considered as R/O COVID even if no outbreaks or COVID +ve cases reported in the facility?

I don’t think all transfers should be considered rule out COVID. Given limited testing supplies, and long turn around times of tests, without symptoms suggesting COVID probably not feasible at this time.

Having said that a low threshold of COVID concern is important for SNF and ALF residents given risk of transferring COVID back to SNF especially if COVID not identified.

Should we have a different fever threshold in older adults? If so what should constitute a fever in older adults?

A good tool for guiding COVID discussions with patients and families can be found at vitaltalk.org

Our long-term care ED transfer key points — reminded everyone — EDs and LTCHs/SNFs — about the importance of addressing and re-addresxing advanced care plans for EVERYONE (not just LTCHS residents) at this time when everything has changed

Vital talk is a great resource with scripts talking points and standardize comforting statements providers can make to comfort patients and familieshttps://www.vitaltalk.org/guides/covid-19-communication-skills/?referringSource=articleShare---

Tests are NOT less sensitive by age

Dr. Shenvi and Dr. Mathews - GemcastCheck out the GEMCAST on critically ill COVID-19 patients with an intensivist from Mt Sinai. It is here:https://gempodcast.com/2020/03/23/covid-icu/

I know that what Adam is suggesting at the moment — taking the time to interact with your nursing home colleague — both about the decision and value of transferring to the ED — and about who is suitable for return. This seems like a lot of time and work that we don’t usually do but may be best for the patient AND for your hospital.

COVID-19 tests are new, and assessing their accuracy is challenging.PCR tests may produce false negatives, failing to identify evidence of SARS-CoV-2.Sometimes false negatives result from human error or problems with the procedure. Giving the test too early or late, for example, can lead to a false negative.The accuracy of similar tests for influenza is generally 50–70%.

Dr. Mathews — our hospital has essentially forbidden use of BiPAP for ALL patients at this point. Comments?

Great question Eddy - our next panelist will be addressing exactly that!

Eddy — Dr. Sanon will focus her talk on some resources to support ED folks in critical conversations.

is their any benefit to covering the patient’s face and head with clear plastic during intubation? and woking with your hands under the plastic?

Re isolation - very important to triage before coming inside the ED - tent triage out in front of ED, augmented with teleproviders is key

Dr. Mathews — are there enough patients at your sites to make a separate part of the ED feasible that other patients cannot be cared for in —

Another good question: Eddy Lang 03:30 PMPatients may want to know what their likelihood of surviving mechanical ventilation is - do we know what that looks like in non-frail elderly? Please ignore if it will be addressed.

(Slide 23) Surviving Sepsis Campaign COVID19 Guidelines: https://www.sccm.org/getattachment/Disaster/SCCM-COVID-19-Infographics2.pdf?lang=en-US

To respond to Don: Yes -- we have more than enough patients to have a COVID ED. This was built into the ED model of care about a week ago. There is also a tent outside and use of Express Care to help care for lower acuity patients. The tent in Central Park will open on Tuesday, per report.

To help physicians and other health care providers discuss and convey a patient's wishes regarding cardiopulmonary resuscitation (CPR) and other life-sustaining treatment, the Department of Health has approved a physician and nurse practitioner order form (DOH-5003), Medical Orders for Life-Sustaining Treatment (MOLST) , which can be used statewide by health care practitioners and facilities. https://www.health.ny.gov/forms/doh-5003.pdf

Re: procal -- we use it primarily to rule OUT concurrent bact infection (if low, we stop the abx). But when they get sicker in a few days, we will recheck to see if now they have developed a superinfection.

Re: CRP -- this is part of the testing for the classic inflammatory cascade that we are seeing with COVID. The higher these inflammatory markers are -- the worse off patients are. I don't know how these markers change with age.

Another important message - Ferdinando Mirarchi 03:42 PMPlease take caution not to misintepret the LW, MOLST or POLST. Many of these forms reflect a providers thoughts and not the patients. Many are highly discordant with what the patient believes they have agreed to.

For all audience members using the chat box, please be sure to address to "panelists and attendees" so everyone can see your questions and responses

I think the comment about not misinterpreting LW, MOLST, POLST reminds us all of the importance of discussing what these forms say with the patient and/ or family so you can ensure the forms are understood correctly

Consider the medications recommended by Dr. Sanon for symptom management. Many hospitals are running low on fentanyl and versed as these are being used up for RSI

Goals of Care should be carefully addressed if there is a Living will or POLST present so as not to to misinterpret what is documented on paper. What his documented if often discordant with the patients wishes. The initial aspect of care they often agree to. Its the long term life support they do not.

Does the use of an electric fan cause problems with droplet precautions?

Wu C et al. Risk factors associated with acute respiratory distress syndrome and death in patients with coronavirus disease 2019 pneumonia in Wuhan, China. JAMA Intern Med 2020 Mar 13; [e-pub]. (https://doi.org/10.1001/jamainternmed.2020.0994)

And the importance of re-addressing the previously expressed wishes when the person had multiple slowly declining chronic conditions — but now has highly mortal condition which may require extended ventilation. Many person may have re-adjusted their wishes — and need to be asked. That was one of the main messages of our SNF/LTCH paper — that it is essential to have these conversations anew.

Re: Chris's question: When intubating (old or young) patients in ED, what is role of an isolation box around the patient’s head? https://vimeo.com/401701163

If you can get one, yes!

Helps to minimize aerosolizaiton in theory

About a dozen questions posted but only sent to panelists. I’ll re-type as many as I can so that attendees can see them too. Question 1: Does a 1-page health literacy appropriate decision aid exist depicting risk of COVID-19 progression stratified by decile of life >age 60? Question 2: Does a 1-page health literacy appropriate decision aid exist depicting benefits (leave hospital to home) for intubating patients by decile >age 60 from the pre-COVID era? Question 3: How does an ED physician or nurse have a conversation with anxious families when inundated with patients (limited time to spend with any individual patient)? Can furloughed physicians come to the ED (or teleconference into the ED) to assist? Question 4: What are some of the atypical COVID-19 presentations from China, Korea, and Europe when the symptoms are non-respiratory? Falls? Confusion? Anorexia? What are the sensitivity/specificity of those symptoms for COVID-19?

Er doc here- worked last week and lot

If you have a specific question that you want to ask — now is your time!

Question 5: Does the diagnostic accuracy of available COVID-19 vary by age-group? Is it less sensitive in older adults?

How should fever be defined in the older adult population (e.g. temperature parameters)?

thank you for sharing info!

On an anesthesiology call I was on yesterday, recommended against airway boxes. Focus on the basics of great airway skills. Boxes likely to make laryngoscopy more difficult and therefore decrease first pass success rate

Question 7: Fred Mirarchi is listening and published series of TRIAD studies over last decade. How can ED misinterpretation of advanced directives that occur in the best of times (pre-COVID era) be avoided in the scary and chaotic era of COVID-19?

There is a resuscitation Pause checklist published in TRIAD VI and VII in the journal of patient safety.

Question 8 (for Kusum): Why PCT rather than CRP? Recent (March 2020) Academic Emergency Medicine diagnostic SR of viral URI vs. pneumonia demonstrated that CRP has superior accuracy. Furthermore, most hospitals lack PCT. If using PCT, what protocols do you use to rule-out pneumonia? When do you retest?

British Geriatric Society recently issued new statement about delirium in the setting of COVID: because of the ease of transmission of COVID-19, "the risk of harm to others may exceed risk of harm to the individual and this may necessitate earlier use of pharmacological treatments for potentially risk behaviour" - thoughts? https://www.bgs.org.uk/resources/coronavirus-managing-delirium-in-confirmed-and-suspected-cases

for the procalcitonin vs. CRP question: procalcitonin often normal in covid patients. CRP if high, then good indicator. elevated IL6 even more indicative of likely cytokine storm.

molecular tests by PCR depend on the organisms genome and therefore age of the patient does not matter. Serologic tests look for antibodies and therefore could clearly be affected by the patient’s immune function and age.

Journal of American Geriatrics Society just published a wonderful paper from Joseph Ouslanader describing the COVID-19 in long- term care. You can access it on the AGS website.

Review the CDC website as well for best practice guide.

Dear Colleagues,Thank you for participating in the Geriatric Emergency Department Collaborative’s Webinar, COVID-19 in Older Adult: Key Points for ED ProvidersSome Links from Today’s webinar:Vitaltalkhttps://www.vitaltalk.org/guides/covid-19-communication-skills/?referringSource=articleShareSCCM 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_coronavirusCheck out the GEMCAST on critically ill COVID-19 patients with an intensivist from Mt Sinai. It is here:https://gempodcast.com/2020/03/23/covid-icu/(DOH-5003), Medical Orders for Life-Sustaining Treatment (MOLST) , which can be used statewide by health care practitioners and facilities.https://www.health.ny.gov/forms/doh-5003.pdfHere is the URL for the Geriatric Emergency Department’s website (https://gedcollaborative.com/)Check out COVID

Thank you for a wonderful presentation. Great speakers and panelists!

Scary thought about delirium and infecting others

Stay safe everyone!!!

Thank you all, be blessed and be safe!

Thanks to everyone for joining! Will try to disseminate new data via @GeriatricEDNews

For Chris: The PCT is suggested by our ID colleagues and in the SCCM guidelines. If it's not available at your shop or without quick turnaround, it ends up being a more clinical decision.

should essential staff still work around potentially ill patients prior to or without being tested...???

Congratulations panelists! and Thank you!!!