Managing COVID-Positive Patients
For nursing home residents who have tested positive or have COVID-19-like symptoms, guidance on resident management continues to evolve during this pandemic. Jane Pederson, MD, MS, chief medical quality officer of Stratis Health, a member of the Superior Health Quality Alliance Quality Innovation Network-Quality Improvement Organization (QIN-QIO), summarized the most current practices and recommendations during her June 18, 2020 presentation for the Centers for Medicare & Medicaid Services (CMS) National Nursing Home Training Series.
Caution: COVID-19 Has No Typical Path
One of the mysteries of COVID-19 has been the variable course of the illness. Residents may test positive with no symptoms at all. Sign and symptoms may be as subtle as a loss of alertness or greater fatigue. A speedy recovery may follow minor symptoms, while in other residents, initially minor symptoms may descend into rapid respiratory or organ failure. Others are severely ill from the onset. Sadly, the latter two situations have proven fatal for many nursing home residents.
It’s that variable presentation, Pederson says, that makes communication among all staff members so crucial. Any significant change from baseline can signal the onset of COVID-19. Accordingly, the Centers for Disease Control and Prevention (CDC) recommends increasing resident monitoring to at least three times daily.
How to Prepare for All Scenarios
Nursing home care teams can also prepare standing orders for COVID-19 symptom management and comfort care, which may include:
- Supplemental oxygen
- Transitions from nebulizers to metered dose inhalers
- Discontinuation of non-critical medicines
- Proning to ease breathing (check out the presentation for details); alternately, access to concentrated opioids to ease discomfort from shortness of breath
Administration of anticoagulants or famotidine (an antihistamine and antacid) may also be considered, Pederson says, though no clear guidance exists yet on their use. Likewise, there is no clear evidence so far on the efficacy of vitamin D treatment.
It may make sense to use symptom-based charting during cohorting to track the condition of COVID-19-positive residents.
Help Residents and Families Plan
Advance care planning discussions with residents and families should be happening now, if they haven’t already. A key point to cover is the resident’s and family’s decision on hospitalization should symptoms worsen. This decision will inform any do-not-resuscitate (DNR) or do-not-intubate (DNI) orders. Electronic Health Record (EHR) documentation should be paired with a hard copy of the advance care plan in the event of a swift decline.
Create CPR Protocols
Guidance has not been consistent, so create a protocol for cardiopulmonary resuscitation (CPR) based on your facility’s access to personal protective equipment (PPE), and communicate this protocol to your residents and their families. Staff safety is central to any protocol. Some recommendations specify CPR initiation with two staff members equipped with fit-tested N95 face masks, face shields and an Ambu-bag with HEPA filter.
Short-term, there are various definitions for recovery (check out the Week 3 presentation, Cohorting: Effective Management of Residents and Staff, for details). But unfortunately, the long-term effects of COVID-19 and the criteria for complete recovery will remain unclear for some time, Pederson says.
Download the Superior Health Quality Alliance QIN-QIO slides and resources from the National Nursing Home Training Series page, visit www.QIOProgram.org to connect with the QIN-QIO serving your state or territory and sign up for updates about the CMS National Nursing Home Training Series.