Across the province, Long Term Care Facilities (LTCF) are home to thousands of Nova Scotians who are more susceptible to acquiring COVID-19 and suffering related complications due to increased frailty, high prevalence of underlying chronic health conditions, and living in a congregate facility.
Long-term care facilities licensed and funded by the Department of Health and Wellness provide services for people who need ongoing care; either on a long-term basis (permanent placement) or short-term basis (respite care). There are two types of long-term care facilities available, nursing homes and residential care facilities.
Nursing homes provide nursing and personal care on a 24-hour basis including care given under the supervision of a nurse, administration of medication and assistance with daily living.
Residential care facilities provide assistance with personal care such as, bathing and dressing, and reminders about daily routines..
A Care in Place model is used for nursing home residents with active COVID-19, including residents who reside and receive care in Residential Care Facilities (RCF). Ideally, a COVID-19 unit in an entirely separate unit or area of the facility is established. At a minimum, the COVID-19 unit may be a grouping of rooms at the end of a hall that is separated from the other rooms and common spaces by a barrier (temporary as needed), and treated as a separate care space.
LTC facilities must follow the most recent direction outlined by the Department of Health and Wellness (DHW):
The following recommendations and supply checklist provide guidance for LTC facilities planning to house a COVID-19 unit:
Outbreaks of respiratory tract infections occur in long-term care (LTC) facilities (LTCF) throughout the year, but are more common during the winter months. Residents in LTC settings are likely to be older, frailer, and have chronic conditions that weaken their immune systems or impair their ability to clear secretions from their lungs and airways.
The goal of Covid-19 Outbreak Management in Long term care is to, as much as possible prevent the introduction of the Sars Co-V2 Virus into the facility and or prevent transmission between residents and staff.
As outbreaks occur at Long Term Care (LTC) facilities, the initial first days will be stressful. Outbreak response needs will vary dependent on the number of residents in the LTC facility, the number of staff and the amount of support and resources available at the LTC facility. Each response will require its own specific set of objectives based on the needs.
It is very important to note that residents in LTC facilities may be symptomatic or asymptomatic for COVID-19. Residents must be monitored TWICE per day (AM and PM) for new onset of symptoms and fever.
If the resident develops fever (greater than 37.8 C) or any of the following symptoms contact the MRHP (most responsible healthcare provider) to determine if resident requires test for COVID−19. Place resident on Droplet and Contact Precautions and notify local Infection Prevention and Control.
The following is a list of resources that can be utilized once an outbreak is determined:
A Medical Support Team has been established to provide support services to long-term care medical directors and physicians including formal consultation services and immediate advice from internists. NSHA Medical Support Service for LTC Medical Directors/Physicians can provide necessary support with goals of care, acute medical management advice and coordination of care and disposition planning.
Approved care in place LTC facilities may utilize the following Order Set - Long Term Care Facility Resident with Known or Suspected COVID-19
to guide treatments that are in line with the resident's Goals of Care.
The goal of designating a specific care area of a facility for the care of residents with COVID-19 is to prevent the transmission of infection to other residents and to health care workers and to maximize health care personnel and non-personnel resources (Nova Scotia Health, 2021). All LTC facilities in Nova Scotia follow the COVID-19 Management in Long Term Care Facilities - Directive from OCMOH.
There are many IPAC guidance documents on the COVID HUB to guide practice. Please be sure to check them frequently in case IPAC guidance has changed. The following are a list of a few key features essential for caring for residents within LTC.
This resource index is a cheat sheet which lists and provides links for key IPAC resources for long term care.
Families are essential to care within LTC facilities and can often be a wealth of information for health care providers. Depending on the current IPAC guidance, it is important to keep the following in mind:
Appropriate PPE for droplet and contact precautions should be available for all individuals entering the unit. This includes:
N95 respirators are only necessary when conducting an AGMP. Staff must be fit tested for appropriate mask prior to use.
Whenever a mask is removed, it should be safely stored in a clean, dry paper bag (such as a brown paper lunch bag) clearly marked with the wearer's name.
Hand hygiene should be performed whenever indicated, paying particular attention to during and after removal of PPE, and after leaving the resident care environment.
Consider using single-use, disposable equipment and supplies as much as possible.
All reusable equipment and supplies, along with personal belongings, will be dedicated to the the use of the resident with COVID-19.
Ensure that any materials (e.g., electronic tablets or other devices, craft supplies, bingo cards, magazines, books, cooking utensils, linens, tools) are not shared among residents unless they are cleaned and disinfected between uses for each resident.
At discharge, room transfer, or death of a resident, any resident-owned items should be removed, any items with hard surfaces cleaned, and items placed in a bag for family or representative.
An AGMP is any procedure conducted on a resident that can induce production of aerosols of various sizes, including droplet nuclei. AGMPs are rarely performed on Long Term Care Facility (LTCF) residents, though potential examples in this setting may include:
Avoid use of nebulizer and use alternatives such as metered-dose inhaler with spacer.
An AGMP on a resident with COVID-19 requires airborne precautions, including use of a fit-tested, seal-checked N95 respirator.
AGMP is only to be performed if:
Refer to the following document, which provides recommendations and a list of activities considered to be AGMPs:
NOTE Microsoft Edge is the optimal browser for LMS. For more information: https://intra.nshealth.ca/UCS/BPS/SitePages/LMS.aspx
Care of the resident within designated units requires care planning that is centred on:
Here's an example of a care plan that can be used:
The following acronym, A SAFE MIND, can be used as a guide to support care for residents within Care in place Long Term care facilities.
Assess goals of care
Skin breakdown (pressure injury prevention)
Agitation (delirium)
Frailty
Environment
Mobility
Incontinence (bowel and bladder care)
Nutrition (feeding / fluids)
De-escalation in care
Let’s break down some important considerations in caring for the LTC resident:
At Nova Scotia Health, the Medical Support Service for Long Term Care (MED-LTC) has outlined the following indicators for framing resident goals of care:
Residents within LTC who are COVID-19 positive are to have goals of care completed ideally before transfer to hospital. The following can help health care providers guide those discussions:
Refer to the following documents for Residents who have an identified need for acute oxygen therapy:
For Residents that require oxygen support and can tolerate laying on their side or stomach, refer to page 3 of the following document:
The following guidelines will support staff working in Nova Scotia Health Long Term Care (LTC) in their response to a witnessed cardiac arrest in the LTC setting during the COVID-19 pandemic.
Preventing skin breakdown is crucial in providing good care to residents. Skin breakdown that leads to a pressure injury can result in longer length of stay, poor patient outcomes, and if not well controlled or able to be healed, can result in an increased risk of death.
A pressure injury is defined as localized damage to the skin and/or underlying tissue, usually over a bony prominence or related to a medical or other device (NPAUP, 2016). Pressure injuries are most prone to develop on head, ears, shoulder blades, elbows, tail bone and buttocks. A pressure injury can go unnoticed and result in something very serious. Prevention and ongoing monitoring are very important (RNAO, 2013).
Pressure injuries can result from:
Pressure injuries can cause:
Preventing pressure injuries can be integrated into the resident's daily routine. Strategies include:
Be concerned about:
Bruyère, 2019.
According to Canadian Coalition for seniors' Mental Health, delirium:
- is a sudden and severe disturbance in thinking
- can cause changes in a person’s ability to stay alert, remember, be oriented to time or place, speak or reason clearly
- is a common and serious condition often experienced by older people
- can be caused by many things including having an infection, recent surgery, various medical conditions, untreated pain, starting, increasing or stopping some medicines, or not eating or sleeping well
- is sometimes not recognized or is misdiagnosed as another condition such as dementia or depression
- can often be prevented
Research is showing COVID-19 patients have increased amounts of delirium. One theory is that delirium is related to acute hypoxic changes that COVID-19 patients often have, but the direct cause of delirium is often difficult to discern, as these patients may have infection, sedation, or even neurological impacts of COVID-19 (Cleveland Clinic, 2020).
Delirium can often be seen in asymptomatic patients as well, and can potentially exacerbate the acute illness projection. There are a variety of delirium assessment tools that can be utilized in the management or prevention. Confusion Assessment Tool (CAM) is often one that is used in acute care to show a baseline and trend changes in patient’s cognition.
Managing delirium involves astute assessment and identification of triggers. Creating a care plan includes assessing for delirium in the older frail adult, including assessing for:
(Adapted from Alberta Health Services, 2021)
COVID-19 provides an added complexity to caring for residents with delirium and or dementia. Staff need to be creative in communication strategies when the resident isn’t able to see their mouth or expressions. The following are a list of strategies that can be considered for providing care during COVID-19 to residents with delirium. As always, it is a continual balance of mitigating risk of contamination with the virus and holding IPAC principles of appropriate PPE.
Frailty is commonly defined as physiological decline with increased vulnerability leading to poorer health outcomes (Canadian Frailty Network, 2021).
Identifying Frailty Contributors and the Frailty Level Descriptions gives key indicators of the implications of a resident’s frailty scale and how to incorporate into their care plan.
As a health care provider, one of your key functions is to Identify frailty through screening. Frailty screening will be utilized to inform clinical decisions and care pathways.
Frailty has been linked to:
There are 10 key aspects of frailty that are important to understanding and planning a resident's / patient's plan of care. In particular, dementia and social function are key predictors and drivers of frailty. Think of those as you plan for care of COVID-19 residents / patients.
(University of Toronto, 2020)
Typical symptoms of COVID-19 such as fever, cough, and dyspnea may be absent in the elderly with COVID-19. The following outlines key considerations to monitor your patient with COVID-19 for an atypical presentation. Find the full resource at Regional Geriatric Program of Toronto.
Be sure to complete Using Frailty to Inform Care available on the Nova Scotia Health Learning Management System (LMS) and Frailty Case Studies to increase your knowledge and comfort with frailty in resident care.
NOTE Microsoft Edge is the optimal browser for LMS. For more information: https://intra.nshealth.ca/UCS/BPS/SitePages/LMS.aspx
Moving a resident from their home within long term care in order to prevent a further outbreak of COVID-19 has the potential to cause distress to the resident, the resident's roommate, and family. It is important to recognize that if the resident is coming with any type of dementia or delirium, this change can potentially exacerbate their behaviours.
Use this document for guidance on safe transfer of residents within an LTC facility:
Inform resident's family of the move to another location/room within the LTC facility. Consider having extra staff that are familiar to the resident on hand to facilitate smooth transition.
Mobility is a key to prevent de-conditioning as well as prevention of nosocomial infections. Mobility can be a release for residents with delirium and dementia as well as provide a sense of connection to people in the COVID-19 pandemic.
When building your plan of care for COVID-19 residents, be sure to identify the level of activity the resident normally has. Determining a patient’s baseline mobility is critical to maintain throughout their diagnosis with COVID-19 infection.
Mobility is important for prevention of pressure injuries, prevention of nosocomial infections and maintenance and prevention of delirium. Utilizing IPAC principles for appropriate PPE for health care providers and COVID positive residents is very important and will maintain the health and safety of both resident and provider.
As noted above, prevention of skin breakdown is critical in pressure injury prevention. Attention to bowel and bladder care for maintenance of continence is equally important in providing fundamentals of care.
A resident's delirium can be triggered by the primary need to use the bathroom, so frequent toileting and maintenance of continence would be necessary for any resident's plan.
Some considerations to manage skin damaged from incontinence would be:
Be sure to read the following resources:
Often, residents within long term care require assistance with feeding. Many are at risk for choking and require supervision. The long-term care atmosphere provides an opportunity for residents to have socialization as well. COVID-19 presents a challenge to all those fundamental aspects of nutrition.
Assessing adequate nutrition on a resident is essential for ensuring they have the appropriate caloric needs for their bodies’ requirements. The Research Institute for Aging (2020) has produced the following guidelines for consideration with elderly and nutrition with COVID-19.
Social interaction can stimulate appetite in older adults in LTC. During COVID-19, consider:
Being alone in resident rooms can affect mood as well as result in less physical movement; both can reduce appetite. Some considerations to stimulate appetite:
Inadequate fluid intake is a common concern when residents are eating alone in their rooms. Some considerations for increasing fluid intake:
Residents may lose capacity for self-feeding when isolated. Some considerations to support eating:
Despite all the best efforts in providing care to residents with COVID-19, there may come a time when care needs increase and acuity changes. At that point in may be appropriate to reconsider the original care goals and consider de-escalation in acute interventions and a shift towards comfort measures.
Follow the link below to review several free COVID-19 palliative care modules that provide further information on palliative care:
Be sure to read NS Health Library Guide on Palliative Care for additional tools and resources.
