Residential Care Training Slides - Nursing Homes Ireland

Practical Advice for HealthcareProfessionals Working in ResidentialCare Settings for Older PeopleWebinar - 26th March 2020www.hse.ie/coronaviruswww.hpsc.ie

Instructions on using thispowerpoint Click on the links as you go through thepresentation to bring you to supportingdocuments and sites. The links will only work when you playthe presentation. All links are safe toopen To play the presentation go to the 4thicon on the bottom right of your screen

Residential Services forOlder PeoplePurpose:Provide practical guidance to healthcare staff providing continuing careRe: the management of COVID-19In general, residents in residential care who are COVID-19 Positiveshould be managed in their facilities.Please refer to www.hse.ie/coronaviruswww.hpsc.ie regularly for updates

COVID identificationand Referral PathwaysManaging residentclinical care with COVIDCOVID 19 inLTCFsAdvance Care PlanningIssuesPalliative Managementin last hours or daysManaging outbreaksincluding IPC Guidanceand HCW guidance

COVID Identification andReferral for Testing

Novel Coronavirus(COVID-19, SARS-Cov2) Incubation period: Current information suggests that it may range from 2-11days. Can be up to 14 days Clinical information about the disease is evolving.

Novel Coronavirus(COVID-19, SARS-CoV-2) Transmission:The virus can spread from person to person, usually afterclose contact with a person infected with the virus. directly, through contact with an infected person’sbody fluids (e.g. droplets from coughing orsneezing) indirectly, through contact with surfacesthat an infected person has coughed orsneezed on Similar to how Flu is spread How to prevent spread? One of the best ways to prevent person to personspread of respiratory viruses, including COVID-19,is to use proper hand hygiene and respiratoryetiquette.

Co-morbidities associatedwith increased risk Age 60 years, highest in 75 Cardiovascular disease Hypertension Diabetes Chronic respiratory disease Cancer Immunocompromised

Suspect COVID-19 Fever/Chills Cough Respiratory tract infection

CLINICAL PRESENTATION - note possibleatypical presentations in older peopleBased on an early analysis of case series, the most commonsymptoms are:MOST COMMON SYMPTOMSARE : Cough Dyspnoea Myalgia Fatigue Fever(BMJ Best Practice) LESS COMMON SYMPTOMSINCLUDE: Anorexia Sputum production Sore throat Confusion Dizziness Headache Rhinorrhoea Chest pain Haemoptysis Diarrhoea Nausea/vomiting Abdominal pain Conjunctival congestion.

Acute confusion/deliriumAtypical presentations mayinclude acute onsetconfusion/delirium suspectCOVID-19. However in the caseof delirium other possiblecauses must also be out ruled(see video for more information on delirium).Click here for video

PROTOCOL forsuspected COVID-19 Criteria: Patient meets clinical criteria Assess deviation from baseline condition Clinical Judgement Consider Senior Clinician (GP/MO/DON/PIC) re ? Need for testing While awaiting review isolate patient

COVID 19 in RCFClinical Management

Key MessageResidents with suspected or confirmed COVID 19 should bemanaged in the Long Term Care Facility in all but veryexceptional circumstancesPlan of care for most will be supportive treatment. Transferto acute hospital will confer little if any additional benefitand may increase riskAll staff need to understand this and early engagement withresidents and families to make them aware of this needs tobe happening around all discussions pertaining to COVID 19

Initial Management - ? COVIDAltered respiratory status New or worsened cough New or worsening shortness of breath New or increased sputumAltered Mental Status New signs or symptoms of increasedconfusion/delirium Decreased level of consciousness Inability to perform usual activities (due tomental status change) New or worsening agitation New or worsening delusions orhallucinationsAltered body temperatureClick on links below Review COVID guidelines PPE as per current HPSC recommendationsManage in Residential Care FacilityMonitor vital signsUse escalation protocol AND clinicaljudgementMonitor Intake & Output as appropriate/perlocal policyReview medicationConsider antibiotic therapyEvaluate Vital Signs and interventions asappropriateEvaluate signs and symptoms as appropriatefor improvement/deteriorationCheck Advance Care PlanCommunicate using ISBARRECORD VITAL SIGNSEscalation Protocol Flow chartsee next slidesCONSIDER POSSIBILITY OF NONCOVID RELATED DETERIORATION !

Vital signs shouldbe recorded on agraph to ensureearly alert todeterioratingresident

Key early signs of deterioration inall residents are:RecognisingdeteriorationA change in respiratory rate; RRshould be counted for a full 60secondsA new requirement forsupplemental oxygen or anincreasing requirement to sustainSpO2 levelsNew confusion/altered mentalstatus

In Deteriorating Patient with suspect / COVID 19consider following parameters of response1. Be aware that deterioration can occur quite rapidly2. Set an observation protocol in place that can be managedrelative to your available staff and skillset and needs of thedeteriorating resident3. Be prepared!4. Ensure first principles supportive Care for Hypoxia, Pain,Fever and / or other symptoms5. Refer to Advance Care Plan and anticipatory guidance6. Consider need for additional senior nursing and / ormedical review especially if considering transfer out of unit7. Stay in regular contact with the resident’s family

Investigations to be considered- use clinicaldiscretionIf indicated byGP/MO/OOH/Senior ClinicianMonitor andrecord VitalsignsPulse oximetry Throat/ NasalSwab FBC U&E, LFT CXR Investigationsto out ruleunderlyingnon COVID19 relatedconditionsmay beappropriatePLEASE NOTEClinicaldiscretion andjudgementshould be usedregardingfurtherinvestigationand risks posedby transfer toand fromhospitalfacilities

Supportive therapies Monitoring of vital signs by pulse oximetry, BP, RR, Temp onminimum twice daily basis / as determined in conjunctionwith GP/ MO or other medical advice Monitor for common symptoms identified above and treataccordingly with supportive measures including paracetamoland oxygen Optimise and encourage good oral fluid and nutritionalintake Use clinical judgement regarding appropriateness ofmonitoring where there is an expected change in thepatient’s clinical condition Oxygen: supplemental oxygen maybe appropriate in certainsituations to alleviate symptoms and distress

Use of Oxygen in LTCFs during COVID Patients who are hypoxic may benefit from oxygen Absence of oxygen in care facility should not determine decisionto transfer a resident this should be determined by the agreedceiling of care Has a limited role in supportive care in this setting May help with symptom of breathlessness Where primary objective of care is supportive then titrateoxygen levels to provide comfort Generally appropriate O2 flow levels of 2 /3 L /min or to keepsaturations at 90% If oxygen not adding to comfort then prioritise other palliativemeasures over oxygenation

Oxygen at End of Life Patients who are hypoxic at EOL may benefit fromsupplemental O2 for comfort, if available. However, patients who are agitated/distressed by oxygenmasks or tubing can have O2 discontinued and havepharmacological management of breathlessness instead. Monitoring of oxygen saturations is not required in the EOLperiod

Communication using ISBARClick on link below to bring you tofurther information on using ISBAR

AdvanceCarePlanning

Should be part of normal good practice in this settingReflect on current ACPs and residents baseline statusAdvance CarePlanningBe aware that survival and outcomes with COVID 19 arepoor in this patient group.For very frail (e.g. CFS 7,8,9) intubation / ventilation withCOVID 19 won’t work for them. If the resident survivesICU they are likely to have significant functional decline.Most of the supportive care they need in LTC can beprovided for them thereBe aware that CPR in residents with COVID 19 posessignificant risk of infection transmission to healthcareworkers

A resident has a life‐limiting advancedprogressive illness including dementiaA resident is very frailAdvance CarePlanningparticularlyimportant if:When the answer is ‘No’ to the followingquestion ‐ “Would you be at all surprised ifthis resident were to die in the next year?”If there has been a recent significantdeterioration in the resident’s conditionIf referral to specialist palliative careservices is plannedThe outcomes of advance healthcare planning,including any decisions about ceilings of care,should be carefully documented andcommunicated to all staff.

Summaryresponse Management of all known orsuspect COVID 19 residents willtake place in the LTCF itself Need to ensure that the facilityis prepared for same Ensure anticipatory care plan isavailable Avoid offering treatment thatwill not confer benefit in thissetting If non-COVID related followusual pathways ofmanagement and referral

Managing Care in LastHours or Days of Life;COVID 19 Specific Issues

Nursing Considerationsat end of life duringCovid 19Frances NevilleNurse Lead Clinical ProgrammePalliative CareMarch 26th 2020

Covid-19 The COVID-19 outbreak currently beingexperienced around the world is unprecedentedWe all need to work together to ensure ourresidents receive the care that they requireImportant that the resident is supported at theend of their life or those who are very unwell asthe result of both Covid-19 or other life- limitingillnesses.

Diagnosing dying Not easy to do, reassess, involve the teamClinicians must accurately diagnose dying inorder to ensure that a high standard of end of lifecare is provided to al who need itSome physical signs: profound weakness, withdrawalfrom the world, reduced cognition, reduced levels ofconsciousness, reduced intake, difficulty with swallowingmedications, bronchial secretions, reduced urinaryoutput.

Nursing considerations Nurses and midwives have a vital role to play in treating patients and containing the virus, whilstalso maintaining ongoing healthcareservices.(NMBI, 2020)Dyspnoea or breathlessness is a distressingsymptom which frightens both patients andcaregiversBreathlessness common in the advanced stagesof many chronic diseases and for Covid-19positive patients

Nursing management ofbreathlessnessIn the last hours of life, breathlessness canbe a distressing symptom, but nurses canreduce suffering and distress for thepatient and the family Have a comprehensive plan of care whichfocuses on the patient and symptomcontrol considering psychological, socialand spiritual issues.

Aim to diminish the sensation ofbreathlessness Pharmacological management is key butoverarching nursing care is important Reassure, comfort and reduce anxietywhich will reduce suffering

Refer to Anticipatory Prescribing in theLast Hours or days of life Opioid (Morphine sulphate) combined withan anxiolytic (Midazolam) are veryeffective for breathlessness Very distressed patients will requiresubcutaneous injections PRN, hourlyadministration and dose titration may benecessary

Clinical decision making is an essentialcomponent to end of life care Nurses at the frontline of care caninfluence the experience of care Using their skills of assessment, being withthe patient and relatives Effective communication

Non-pharmacologicalmanagement Positioning: forward lean, adapt with pillows/bedtableFelling of ‘fresh air’, open windowUse of hand held fan, assisted by family/carerMouth care: ensure mucous membranes andlips are kept moistAcknowledge the feeling and fear, reassure themthat the unpleasant feeling will pass

Palliative Care- Anticipatory /Anticipatory-prescribing-v1-20-3-20.pdf

Managing COVID 19Outbreaks in RCFs- IPCand HCW Guidance