Transcription:
Proactivity and Partnership: How The Geriatrics Team Mitigated COVID-19's Impact On The Nursing Home

Melanie: Welcome to Better Edge, a Northwestern Medicine podcast for physicians. I'm Melanie Cole and joining me today is Dr. June McKoy. She's an academic geriatrician and an Associate Professor of Medicine, Preventive Medicine and Medical Education at Northwestern Medicine. Dr. McKoy joins us today to discuss experiences during the coronavirus pandemic and steps taken to mitigate the impact on nursing homes.

So Dr. McKoy, I'm so glad to have you with us today. And you and I were talking briefly off the air about the impact on nursing homes, which was severe, but could have been a lot worse. So has This pandemic has been so challenging for healthcare providers, but especially so for nursing homes. Can you tell us a little bit more about some of the challenges for nursing staff and residents as you've seen it?

Dr June McKoy: Thank you for having me. The pandemic has really uh, decimated nursing homes to a great extent, and the challenges have been varied. And I think one of the major problems is that nursing homes already had what I would call a kind of fragile infrastructure. And so when the pandemic hit, it actually just threw nursing homes off kilter.

And one of the major challenges was in the area of staffing. The workforce shortage has always been a problem in nursing homes. And when the pandemic hit, we lost a lot of our nursing assistants and our nurses. Some stopped working because of fear of the pandemic. Some stopped because they got ill. And others just started to stay away and take less and less shifts.

In addition, what we saw was the impact also on our residents. Now, the residents were told they could not come out to eat. They could not visit with families. They could not go out for activities, which are such a big part of nursing home world. And they had to stay in their room. And so we had at one side, the nursing shortage, the overall workforce shortage. And on the other side, we had residents who were increasingly being isolated.

And I literally saw patients on skilled nursing units and residents in long-term care just fade away emotionally. People got more sad. You saw this wasting away of the energies of these residents and patients. There's not much that we could do. And so I think those were the two big things that we saw and we did our best to try to mitigate the impact that the pandemic had in those areas.

Melanie: Well, I saw that myself and from personal experience, the mental health situation for residents of assisted living and nursing homes was really harsh. I mean, they were in their own prisons, as it were. As you said, they couldn't leave. If they did have to go into the hallway, for some some therapy. Even many therapy services were cut off, which was especially hard for things like speech therapy, occupational therapy, physical therapy that were making inroads, right? So speak just a little bit about how you were able to help mitigate some of the impact with nursing home staff. And include for me, Dr. McKoy, if you would the come and go caregivers, because that was another issue that I saw where the people that were not on staff at these nursing homes and assisted living, but caregivers for the individuals and that created its own set of problems.

Dr June McKoy: Oh, my goodness. That did create its own set of problems. If I start with the come and go caregivers, we were under Illinois Department of Public Health and Chicago Department of Public Health directives. And in the beginning of the pandemic and through a good portion of the remainder of the pandemic, we could not have outside caregivers come in. They were not allowed certainly at our facilities because we could not really verify that they would not bring the virus with them. We had control over our staff members, but we didn't have that control over the ones who were come and go.

And so we did Institute, I mean, literally weekly testing. But again, we had to stop many of the come and go, if not all caregivers, from coming in. They were allowed later on in the pandemic, but in the initials basis, no. And what did that do? It put more burden on our already fragile workforce, if you describe it that way. And it actually was detriment to a lot of our residents because now, many of them were getting this almost one-on-one support, someone getting their meals, helping them to feed and all that. And with the shortened work staff force, we could not get people into the rooms to feed everyone. And I remember at some of the facilities where CNAs were trying their best to go in quickly and feed one person, get off their gown, get on gown again and feed the next person in the next room.

And that was hard because some of our residents needed more time and they wanted the socialization, they wanted to talk. And so that brought, I think, a lot of stress on not only the residents, but on the actual staff members who had built bonds with many of these residents and who were suffering because of what was happening to them.

So yes, the loss of that workforce was especially hard, because they were taking off some of the pressure from the regular nurses and CNAs who are in the facilities. And understand that we have in our nursing homes patients who are not or residents who are not only physically deconditioned or disabled, but also cognitively disabled. And so many of them are not able to follow instructions really well. They don't do very well with social distancing and then they're in a room. Literally, what we saw happening was that the cure or so-called isolation or social distancing was at times worse than the disease itself, the actual virus coming in.

Melanie: I certainly think you're making such great points because that is what we saw, the impact on mental health and, as you said, some of those physical things. Now, tell us about some technologies and strategies that are in use in other areas of healthcare. I find this so interesting how things are bridging over. I mean, we've learned about telehealth, Dr. McKoy, and how that really impacted the ability of healthcare providers to reach out to people that might not otherwise have had healthcare during this pandemic. Tell us about some of the strategies that you found that worked really well to improve care and outcomes at these nursing facilities.

Dr June McKoy: many nursing homes, uh, uh, All nursing homes have a computer system and electronic health record. They were mandated to have that under some provisions of Obamacare. And so we see those, but they tend to be centrally located. You'll see them at the nurses station, but you don't really see them outside individual patient's rooms.

Now, I understand that logistically having computer permanently outside a patient's room might not be feasible, but what about mobile technologies? In our hospital at Northwestern, we use mobile electronic medical record. And so when I'm on the teaching service with my medicine residents, we are literally moving the mobile technology from one room to the other. We're looking up labs, inputting vitals, looking at vital signs, inputting information, putting orders in in pretty much real time as we are talking about a patient or coming out of a patient's room. We can do that right away.

I think what nursing homes need to do is to adapt some of those mobile charting platforms and make it easier for the nursing assistants who are at the forefront of care or the ones taking the vital signs, checking the skin for any kind of pressure injuries, checking the patient's overall status, and then reporting to the nurses to be able to do that much more quickly. That's not what you're seeing on a general basis, but during the pandemic, I saw a difference.

I saw where nursing homes were actually using other kinds of so-called mobile technologies like iPads and laptops. And these were especially important because they were allowing our staff to set up visits virtually with family members. And we're allowing our staff to not have to constantly be donning and doffing their personal protective equipment, their gowns and masks and all that. They had the ability to actually, by leaving these devices in patient's room or residents room of people who were cognitively intact, able to actually communicate with them. For those who could not do that, of course, we had to dress appropriately and go in and assist them. But we saw that that really worked and that really helped.

And so we think that it's important that nursing facilities start looking at these kinds of technologies and adopting them as approaches to more immediate care and fluid care and constant care. We also have many residents who needed to see their doctors outside. Telehealth technologies actually were helpful in keeping those residents in touch with their primary care physicians and other specialty physicians that took care of them.

What we did a lot of in our nursing home and what should be done and continued to be done even when the pandemic is over, is video technologies. Remember I talked about the fact that nursing homes are not just for people with physical challenges, but it's a place where people with cognitive challenges also reside. And they depend on a lot of the cues that can only be passed along through seeing, through visualizing. And so having video technologies where they can see the caregiver, where they can see their nurse and CNA and administrator in addition to seeing families when families schedule these video visits is critically important.

A lot of people are using within long-term care some new technologies that actually came out of the intensive care unit arena. And there is a technology called Support Staff Education and Training Relaxed Guidelines. And this is a technology that is not only focused really on the patient per se, but focused on staff. Because during the pandemic, we needed to learn a lot. This was a pandemic that we knew nothing about, a virus we knew nothing about. And the CDC, the local health departments were all learning and we were learning with them. We're all in this learning phase together.

And we found it important to get information to our CNAs and to our nurses and yet we wanted to socially distance. And so having technologies like the one I mentioned, that can be an education portal to provide education to staff during the time of crisis when things are changing, regulations are coming down literally every day that are different, updated, is important because an educated staff will be a powerful staff in really suppressing or decreasing the risk of transmission of the virus to the residents of the nursing facility.

Melanie: Such an important topic we're discussing here today. So as you're talking about things we don't know and what we could be doing and how this has all evolved, boy, we sure learned a lot about this pandemic, what about the Delta variant in vaccinated individuals and specifically our elderly loved ones, Dr. McKoy? Should assisted living and nursing homes now be concerned with this new variant? What would you like them to know about that and trying to mitigate it? I mean, nobody wants to go back into that quarantine situation. What do you see happening? What do you think should happen?

Dr June McKoy: One good thing about nursing homes and the residents or the population residing in nursing homes is that residents have been very open to getting the vaccine. When you look at all the news media and you saw the clips on television, you saw that a lot of the people who were in line overnight were elderly persons. And elderly persons are in our nursing homes. And what we have seen is that the vaccination rate has been extremely high. In our nursing home, almost all our residents are vaccinated. And even initial few, whose daughters or sons because of their cognitive impairment refused, have now come on board. So we have in our facility, our primary nursing facility, we have almost a 98% vaccination rate.

And so what I want people to know is that if you're fully vaccinated, if you've gotten your two Moderna, your two Pfizer, you've got your one Johnson & Johnson, if you've gotten your vaccinations and you're two weeks out and you're exposed to the Delta variant, if you even become ill, you're going to have mild disease and, in most cases, not going to be hospitalized.

The majority of persons being hospitalized, not only the United States, but also in the UK are people who are unvaccinated and they get really quite ill. So that's the first thing. I don't want people to fear it, that they're, "Oh my gosh, I'm going to die from this," no. The second thing is in our nursing homes, we continue to do masking. So if someone is coming from the outside, mainly the staff members seeing residents, they're wearing masks. So we're wearing masks at all times still. Our residents don't have to, but we do. Doctors, nurses, physician assistants, nurse practitioners, our dieticians and our social workers are all masked.

So the takeaway point is, yes, u nderstand that our nursing homes, vaccination rates are in excess of 85% across the board, across the country. And as such, we don't anticipate severe illness even from this strain that's coming down the pike. We know that if we've got the vaccine on board, we're going to do well or our symptoms will be mild. And we recommend that providers listening to this podcast make sure that when they're going into these facilities, they're masking and following whatever the protocol is for that particular nursing home. Please give our nursing home family and colleagues an opportunity to continue to keep our relatives and our patients safe.

Melanie: So well said. Dr. McKoy. As we wrap up, tell us a little bit more about how the geriatricians at Northwestern Medicine have been collaborating and how you really think the learnings, what we've learned during this just unprecedented time. And certainly and especially for nursing homes and assisted living, kind of wrap this all up for us and tell us what you've learned and really give us a last bit of parting information, a best piece of advice, about what you want to happen in the future for our elderly loved ones.

Dr June McKoy: What we have learned during this pandemic is that we are resilient, certainly as a country. Us, in the nursing home arena are resilient people despite our deficiencies, despite our challenges, workforce, and otherwise; despite the fact that we're taking care of a wonderful population, but a population with comorbid illnesses on the physical and the cognitive side. Despite all these challenges, when we have the will, we can rise to the occasion.

I want to point out in our primary nursing home, that when COVID struck, we actually took four rooms on one particular floor and we converted those rooms in to COVID units. We had the right ventilation system put in to place. We made sure that we had designated nurses and CNEs going in and we gave them all the personal protective equipment that we could.

I mentioned this to say that when crisis occurs, if we can continue to mobilize like nursing homes have done and there've been some challenges in different nursing homes and some people have died and we mourn the deaths. However, it shows up we still have the will if we are resilient, if we rise to the occasion of following public health directives and if we have good communication system.

So my takeaway is that despite the unprecedented challenge of this pandemic, organizational skills were seen as critically important. Communication skills were seen as critically important. Our group mobilized itself. Our division and section chief met with us. What she did was she actually organized it whereby we were scheduled to go to our nursing homes at different times. So for one week, one doctor would go. The next week, a different doctor would go. We did not expose everyone to the nursing home nor the nursing home to all of us at the same time.

We also made sure that we were checking to make sure that everyone was doing well. And we met regularly through either Zoom media or we met through encrypted emails, and I'm putting met in quotes. And we were always communicating almost every single day. We were given the directive. We were updated on what was going on. The nursing home updated us. We updated the nursing home. Our section chief, Dr. Lee Lindquist updated our faculty. And we worked as a team. Everything we did was through consensus. Of course, making sure that we kept the guidelines, the CDC guidelines and the local health department guidelines in place.

We all increased support to our vulnerable population, but I also want to ask providers to really consider the challenges that nursing homes face and that we support our nursing homes staff, that we make sure that we provide them with not only physical support, but make sure that if we're sending patients, that we're following the guidelines and we're making sure that we're following the guidelines of the nursing home and sending patients over who will follow those kinds of directives and who will be appropriately vaccinated or appropriately tested to make sure that they're coming in and not bringing any more virus into our environment.

I just ask that we also encourage and support or facilities in their use of electronic medical records and emerging telehealth and video health technologies. That's going to be what the future holds for nursing homes. So going forward, we just ask you to support our nursing home and our nursing home vulnerable staff members who often are from the groups in our community that are most apt to become exposed or to die from the virus. They're doing a terrific job. And I think often nursing homes are not rewarded or really, you know, kind of lauded for the really challenging work that they do to support our loved ones.

Melanie: One-hundred percent agree. So well said, I can hear the passion in your voice, Dr. McKoy. It nearly chokes me up because I, like you, have elderly loved ones and I know what they went through during that pandemic and those unprecedented times. So thank you also for all of your great work.

And to refer your patient to the geriatrics team at Northwestern Medicine, please visit our website at nm.org to get connected with one of our providers. That concludes this episode of Better Edge, a Northwestern Medicine podcast for physicians. For updates on the latest medical advancements and breakthroughs, please follow us on your social channels. I'm Melanie Cole. Thanks so much for tuning in today.