Care of the COVID-19 Patient

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.

Overview

The goal of outbreak management is to promptly detect the occurrence of infections that are linked by exposure to a common source and control their spread. Rapid investigation and implementation of control measures are required to prevent further transmission of infection.

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Overview

Hand hygiene has been proven to be effective in preventing health care-associated infections¹. Implementing a hand hygiene program will:

• Help health care facilities address the barriers to hand hygiene.
• Provide supports and products to enable appropriate and effective hand hygiene at all times.

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Posters

Overview

Cleaning and disinfection of the physical environment and where care is provided reduce the number of microorganisms that may potentially be transmitted to other people. Environmental cleaning in health care settings is typically performed by cleaning or housekeeping services.

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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:

• Staying in one position for too long (pressure)
• Skin rubbing against something (e.g., bed sheets) too much (friction)
• Sliding or shifting in bed or chair (shearing)
• Skin exposed to sweat, urine, or stool for a long time (maceration)

Pressure injuries can cause:

• Pain
• Infections
• Open sore and reduce heal ability
• Lead to further complications

Preventing pressure injuries can be integrated into the resident's daily routine. Strategies include:

• Moving (repositioning at least every two hours) and shifting positions
• Drinking and eating a nutritious and well-balanced diet to maintain healthy skin;
• Keep skin clean (changing incontinence products regularly, as needed);
• Observing and reporting changes in skin condition.

Be concerned about:

• Reddened areas;
• Blisters, red or darkened areas anywhere on the skin;
• Opened or blackened area(s) on the skin.

Additional Resources

Pressure Injury Prevention - Patient Educational Resources

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:

1. Identify potential causes of delirium:
   • Are there any modifiable causes? This may include things like:
     • Unmet needs (i.e., hunger, thirst, pain, toileting, temperature, access to hearing aids, mobility)
     • Acute medical problems (i.e., infection, agitation, hypoxia)
     • Level of Stimulation (i.e., too much or not enough, lack of daily routine & structure, sleep pattern)
     • Consistent approach to care from staff
     • Pharmacological review of current medications and indications
   • Are there unmodifiable factors?
     • Existing medical conditions (i.e dementia stage & type)
2. Be meticulous in describing and documenting what is happening with the resident / patient (i.e., when does it occur? What was the resident doing? Who was involved? What was the response? What are the residents emotions (crying / anger)?
3. Analyze – are there trends that are readily identified? Are staff using a consistent approach to providing care? Are there triggers that can be identified as a direct cause or solution to delirium behaviour?

(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.

Additional Resources

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:

• Increase in falls
• Increased length of stay
• Difficulty recovering from acute illness
• Increased mortality

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.

Atypical COVID-19 Presentations in Frail Older Adults

(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.

• Very low percents (20-30%) of older residents with COVID-19 present with fever
• Atypical COVID-19 symptoms include delirium, falls, generalized weakness, general malaise, functional decline, and conjunctivitis, anorexia, increased sputum production, dizziness, headache, rhinorrhea, chest pain, hemoptysis, diarrhea, nausea/vomiting, abdominal pain, nasal congestion, and anosmia
• Tachypnea, unexplained tachycardia, or decrease in blood pressure may be the presenting clinical presentation in older adults
• Older age, frailty, and increasing number of comorbidities increase the probability of an atypical presentation
• Older adults may present with mild symptoms that are disproportionate to the severity of their illness
• Delirium may be a common sign in atypical COVID presentation
• Frailty screening must be completed on all residents living in LTC.

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.

Additional Resources

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.

Additional Resources

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:

• Implement toileting schedule
• Reduce exposure to irritants: avoid briefs, if pads used check them every 2 hours
• Cleanse skin gently with either a no rinse pH balanced cleanser/moisturizer and protector (Baza Cleanse and Protect) product can be used
• Apply a skin protectant (Critic-Aid Clear, Baza Protect II) following cleansing after each incontinent episode
• Consider use of low-air-loss therapeutic surface

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

Social interaction can stimulate appetite in older adults in LTC. During COVID-19, consider:

• Have family or friends call the resident before a meal—talk about their day and what they are having for their next meal
• Create fun events for residents that are food focused. For example, recreation team members can have themed snack options e.g. ice cream delivery, make your own sundae (resident sits at their door and instructs the team); bingo or other competitive events can have a food prize
• Team members spend a few minutes discussing the meal choices with residents to stimulate interest in upcoming meals.

Increasing Appetite

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:

• When staff are setting up the meal, speak with the resident about how good the food smells, compliment how it looks, and that they anticipate it tastes good too.
• Arrange daily opportunities for residents to leave their room, be outside in the nice weather etc.
• Every interaction with staff should include a verbal interaction that can support the resident’s mood. Smile, ask how they are doing, share something you know they like to hear about.
• Consider providing high energy and protein foods as the ‘standard’ for most residents when they are eating in their room.

Importance of Fluids

Inadequate fluid intake is a common concern when residents are eating alone in their rooms. Some considerations for increasing fluid intake:

• Provide medications one at a time, encouraging a sip of fluid with each pill.
• Offer the residents their preferred fluid several times a day.

Eating

Residents may lose capacity for self-feeding when isolated. Some considerations to support eating:

• Resident may require modifications to their current diet during the course of illness. Consider dietician consult.
• Have someone support opening packages, encouraging the resident and ensuring they have everything they need. Help with tray set up and positioning.

Additional Resources

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 Nova Scotia Health Library Services' guide on Palliative Care for additional tools and resources: