Nursing home residents are among the most vulnerable to COVID-19. Fatality rates from the virus are highest in individuals over the age of 85, and long-term care residents and providers now comprise more than one-third of all COVID-19 related deaths.
In light of the increased rate of hospitalizations, an Indiana University School of Medicine Associate Professor Kathleen T. Unroe, MD, MHA, and her colleagues have developed a “top 10” list of points for safe care transitions of nursing home residents to emergency departments.
In an email interview with Florence Health, Unroe said one of the most important factors to keep in mind when considering a transfer from nursing home to hospital is communication.
“Communication balls keep getting dropped,” she says. “Key information needs to be transferred written/electronically but a direct phone call – a warm hand-off – is important as well.”
Points of Safety
Among the 10 points of safety the authors say to consider during a patient transfer are:
- Medically stable patients, who are appropriately isolated should not be transferred to the emergency department. Close, proactive communication between the emergency department and the nursing home physician can support the nursing home in providing care in place.
- Nursing home providers must address advance care planning with every patient and family in the context of COVID-19.
- Nursing home providers should consider the risks and benefits of transferring residents with a febrile respiratory illness to an emergency department. This should include an evaluation of the patient’s current state of health, patient-centered goals, and an assessment of prognosis in the context of COVID-19.
- Nursing home providers should consider “forward triage” when considering residents for a transition to the emergency department. An assessment of the resident’s level of acuity and where their care needs could most appropriately be met should involve a conversation with the emergency department physician.
Exposure in Long-Term Care Facilities
Nursing home residents have a high risk of COVID-19 infection due to advanced age, frailty, the close quarters they share with others and a necessarily high level of interaction with multiple caregivers. While nursing home staff often treat infections in-house, COVID-19 presents unique challenges in facilities with limited private rooms and high patient-to-staff ratios.
The researchers say that while nursing homes provide medical treatment and diagnostic testing, the turnaround time for “stat” labs or chest x-rays, and the intensity of care, differs from hospital settings. Additionally, delays in getting COVID-19 testing poses additional stress.
According to Unroe, one of the unique challenges that nursing home staff encounter when treating COVID-19 is the patient’s level of cognitive impairment.
“They may not be able to wear a mask when they have symptoms and have difficulty keeping oxygen tubing in place,” Unroe tells Florence Health. “The way nursing homes are set up make ideal infection control difficult.”
Unroe also emphasizes that most nursing homes do not have private rooms and that it’s common for a nursing home resident to have a roommate or to share a bathroom.
“We need appropriate PPE supplies to care for residents,” Unroe says. “If a resident requires a higher level of clinical care and their goals of care include hospitalization, then he or she should be transferred out.” In this case, she said, suspicion for COVID-19 needs to be shared with EMS and during a warm hand-off with the Emergency Department provider.
- COVID-19 in Older Adults: Transfers Between Nursing Homes and Hospitals. Journal of Geriatric Emergency Medicine.
- Making transition from nursing home to hospital safer during COVID-19 outbreak, Regenstrief Institute.