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Practice Innovations: Rapid Deployment of Palliative Care

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Palliative Care DJ2021

By James Downar, MDCM, MHSc;Amit Arya;Genevieve Lalumiere, BScN RN MN;Ghislain Bercier, Advanced Care Paramedic;Shannon Leduc;Valerie Charbonneau, MD, MSc, FRCPC

Introduction

 The greatest impact of the COVID-19 pandemic has been felt in long-term care (LTC) facilities. In Canada, approximately 80% of COVID-19 deaths have been linked to LTC facilities[1] and the strain of caring for so many acutely ill residents has been challenging. Even prior to COVID-19, some LTC facilities were struggling to care for a population that is increasingly elderly and comorbid[2], without commensurately increasing resources. As a result, some LTCs have had to use acute care facilities and emergency rooms to fill gaps in care, particularly for palliative and end-of-life care[3].

This environment has created the opportunity for leaders to emerge from the community and to be innovative. Recognizing the need for immediate intervention, care coordination and support, a multidisciplinary team which included community paramedics was created out of necessity. Communication channels between physicians, nurses and paramedics existed prior to COVID-19[4] and were a key factor in bringing the team together.  

In an effort to improve and better support LTC facilities facing outbreaks of COVID-19, we present a model for providing acute clinical support, including practical advice informed by experience supporting a dozen facilities. Our purpose is to demonstrate the advantages of using a multidisciplinary team approach in managing the current crisis. This is a guide to helping clinicians form a “response team” to support the medical care provided to a facility in acute crisis due to a large number of COVID-19 cases.

What is it?

Our clinical response team is a multidisciplinary team of clinicians with acute care experience as well as training in palliative and end-of-life care (e.g. physicians, nurses (including nurse practitioners), and community paramedics). The inclusion of community paramedics into a strike team is groundbreaking[5], adding hands-on experience of short-term medical management in LTC’s, while also providing the capacity to initiate treatment on a full range of clinical severity from mild symptoms to the actively dying. Equipped with cardiac monitoring, intravenous, fluid therapy, oxygen and symptom relief medication capabilities, the clinical teams are one arm of the response teams deployed. Others include staffing, Infection Prevention and Control (IPAC) supports, communication and administration support where needed. The clinical teams can complement these efforts by directly assessing staffing levels and expertise at the facilities, highlighting concerns with medical supplies and organizations, as well as observing IPAC practices. Team members are familiar with IPAC practices[6] and equipped with sufficient personal protective equipment (PPE). Each team member has a transcutaneous oxygen saturation probe and a simplified assessment form is used to efficiently document findings.

How is it delivered?

Given the scale of the outbreaks in some facilities, our response teams adopt a “mass casualty” approach; triaging a large number of individuals to identify those who require further assessment and treatment. All team members are autonomously able to conduct a focused assessment of each COVID-19+ve resident and other residents on a ward with many COVID-19+ve residents. Given the possibility of false negatives and residents presenting with symptoms, the response team is able to assess and provide clinical guidance to the COVID-19-ve, or pending, as well. The approach has been to introduce ourselves, take a focused history for symptoms of COVID-19 (respiratory, gastrointestinal, or constitutional symptoms), assess for signs of respiratory distress, lethargy or mental status different than baseline and measure transcutaneous oxygen saturation. Anyone with dyspnea, respiratory distress, lethargy or low oxygen saturation is “flagged” as requiring a follow-up. To improve efficiency and minimize PPE use, one team member documents while the others assess residents individually. Using different staff for COVID-19+ve and COVID-19-ve residents reduces the risk of transmission. Gloves are changed and saturation probes cleaned with anti-infective wipes between each assessment and gowns are changed after every encounter.

Each “flagged” patient is reviewed with the clinical staff on the ward, particularly to know their baseline and the time course of any symptom. Community paramedics played an active role in the clinical review process. We also obtain a focused medical history to determine whether symptoms/signs could be related to a cause other than COVID-19. Finally, we discuss goals of care with each “flagged” patient (or their substitute decision maker). For residents who are “flagged” by our team, we note whether the bedside staff were aware of the patient’s clinical status and whether the response to address the care needs has already been initiated. If the patient’s preference is to be treated for comfort on-site, we suggest the addition of symptom management medications[7]. In order to do so we determine; if the clinical staff is able to obtain appropriate and timely orders from the attending physician, if the staff is able to obtain the medications required and if they are able to administer. For those who have already received ‘prn’ medications more than once, we often suggest low-dose scheduled medications[8] (e.g. every four hours) to ensure appropriate symptom control if residents cannot be routinely assessed due to low staffing levels. By assessing staffing levels and staff appreciation of symptoms and familiarity with provision of comfort care, we can determine whether deteriorating residents can be safely palliated on-site or whether additional resources are required. Some patients may need to be transferred out.

Our management of residents depends on their clinical stability, goals of care and our assessment of the ability and availability of the facilities clinical staff to provide care to people who may deteriorate quickly. Some residents need to be transferred to acute care for either medical or symptom management reasons. While others may be kept on site with a clear follow-up plan. Depending on the size of the outbreak, the number of symptomatic residents and staffing levels in the facility, it may be necessary for team members to follow-up every day or every other day to ensure that care needs are being met. This would ideally be the role of the most responsible physician at the LTC, but in some cases it may be necessary to recruit additional clinicians with experience in LTC or palliative care to provide bedside support. To that effect, nurses (including NPs) and community paramedics have been able to fill an important gap. Communication with family members of any resident that we are concerned about to ensure that the family members are aware and involved in the decision-making process is the most important.

Who is eligible?

Our response team is aimed at addressing the acute needs of LTC residents in facilities experiencing a COVID-19 outbreak, whether palliative or otherwise. There is often a preference in this population to receive comfort care and avoid transfer to the hospital. We usually initiate or escalate symptom management medications for several residents on a single visit, depending on the size of the outbreak. The composition of the team allows us to provide a broad spectrum of care, while having the flexibility for personalized care on-site.  We also recommend transferring residents to acute care facilities when appropriate.

What are the harms?

We have not identified any harms associated with our team. On the rare occasion, LTC staff or management have initially been reluctant to our clinical advice. However, we have always been able to demonstrate our abilities to support and improve what is currently in place which has appeased their initial concerns. We are also clear that our teams are focused on acute medical and symptom management needs, rather than traditional holistic palliative care that addresses physical, psychological, social and spiritual needs. In outbreaks that can feature >100 COVID-19+ve residents, with as many as a dozen acutely deteriorating residents at one time, full palliative care consultations are not feasible. Anecdotely, many moments of therapeutic communication, personalized care and human connection have still occurred. Our clinical response team is not well-suited to the management of chronic medical issues and is intended to be a part of a broader response strategy that also includes IPAC, staffing and management supports. 

Evidence?

Like several other aspects of COVID-19, we do not have evidence that our team offers benefits over another approach. Our teams have assessed more than 1400 residents, including over 400 COVID-19+ve residents at a dozen facilities. Consistent with published evidence, the majority of these residents were not symptomatic or unstable, and most have survived the outbreak. However, we have identified dozens of residents that have required acute changes in management, symptom management medication or transfers to an acute-care facility for ongoing care. Furthermore, residents, staff and family members routinely expressed their gratitude for our assistance.

What can be expected in the future?

Like most practice innovations, our team-based approach which included community paramedics for the first time, was born out of necessity and we are describing it in the hope that it might help others.

Having a multidisciplinary team was an integral part of our success in achieving great care. It allowed different specialists to bring their skills, knowledge and experience forward in an effort to address the crisis that is unfolding. Community paramedics brought great value with equipment and experience of out of the hospital environment. Palliative care remains a gap[9] in LTCs and RHs. With often no means to deliver most appropriate palliative care, having a multidisciplinary team can signicantly enhance the current model that is in place.

Acknowledgments.

The authors wish to acknowledge the courage, dedication and sacrifices of those most affected by the crisis in long-term care facilities, including the residents and their family members, staff and managers. 

References:

  1. MacCharles T. 82% of Canada’s COVID-19 deaths have been in long-term care, new data reveals. The Star. 2020;.
  1. Ng R, Lane N, Tanuseputro P, Mojaverian N, Talarico R, Wodchis W et al. Increasing Complexity of New Nursing Home Residents in Ontario, Canada: A Serial Cross‐Sectional Study. Journal of the American Geriatrics Society. 2020;68(6):1293-1300.
  2. CIHI Annual Report, 2018-2019 [Internet]. Cihi.ca. 2019. P. 40 Available from: https://www.cihi.ca/sites/default/files/document/cihi-annual-report-2018-2019-en-web.pdf
  1. Hospital T. Ottawa Hospital Research Institute [Internet]. Ohri.ca. 2020.  Available from: http://www.ohri.ca/newsroom/story/view/1207?l=en
  1. Brown P. A day in the life of a paramedic advanced clinical practitioner in primary care. Journal of paramedic practice. 2017;9(9):378, 386.
  2. [Internet]. Publichealthontario.ca. 2020 [cited 30 November 2020]. Available from: https://www.publichealthontario.ca/-/media/documents/ncov/ipac/covid-19-ipack-checklist-ltcrh.pdf?la=en
  3. Arya A, Buchman S, Gagnon B, Downar J. Pandemic palliative care: beyond ventilators and saving lives. Canadian Medical Association Journal. 2020;192(15):E400-E404. PMID: 32234725
  4. Arya A, Buchman S, Gagnon B, Downar J. Pandemic palliative care: beyond ventilators and saving lives. Canadian Medical Association Journal. 2020;192(15):E400-E404. PMID: 32234725
  5. Right to care: palliative care for all Canadians [Internet]. Cancer.ca. 2016. Available from: https://www.cancer.ca/~/media/cancer.ca/CW/get%20involved/take%20action/Palliative-care-report-2016-EN.pdf?la=enhttps://www.canada.ca/en/health-canada/services/health-care-system/reports-publications/palliative-care/framework-palliative-care-canada.html#p1.2
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