On March 19th, the Society for Post-Acute and Long-Term Care Medicine released their “Resolution on COVID-19.” This well thought out and rapidly developed resolution basically states that because of several factors, including the fact that nursing homes are generally unprepared to manage COVID-19 illness, have vulnerable populations, and are experiencing COVID-19 outbreaks suggesting problems with infection control, they resolve the following:
BE IT FURTHER RESOLVED that AMDA advocate that COVID-19-naïve nursing homes should not be
forced by local hospitals or officials to accept new admissions who demonstrate clinical evidence
or a positive test for active COVID-19, unless they are considered non-infectious based on
current CDC guidelines; and
BE IT FURTHER RESOLVED that AMDA urge local/state/federal governments to develop and deploy
alternative care settings (e.g., hotels, cruise ships, conference centers, etc.) and to partner with
AMDA and with other stakeholder experts to provide the appropriate care for those who have
suffered from COVID-19 infection and ensure that post-acute and long-term care patients are
not placed at undue risk of the infection; and
BE IT FURTHER RESOLVED that AMDA urge all relevant representatives of the healthcare system to
identify and/or create specialized centers of excellence, to deliver care to patients who have been
treated for COVID-19 in the acute hospital setting, or, who require skilled nursing care instead of
acute hospital care.
Let’s take a moment to distill AMDA’s thoughts on the matter. As hospitalists (and many hospitalists obviously work in post-acute care), generally I have two concerns when I consider post-acute care.
- If post-acute care facilities do not accept patients expeditiously after hospitalists and their hospital-based infection control colleagues feel that they are ready to be discharged, we will fill up hospital beds. If our ability to discharge patients is significantly impeded, looking for hospital beds will become as difficult as finding a ventilator. That is a problem.
- If we let a patient slip through the cracks who is discharged to a facility, that would be problematic. Despite my strong desire to consider enhancing the expediency of discharge options, no hospitalist wants to discharge a patient who ultimately causes harm to other patients at a nursing home or other post-acute care facility.
To address this problem, we need to be clear – nothing is happening. The government is figuring out how to get and possibly ration ventilators and get enough hospital beds. They are converting convention centers into hospitals, and preparing for acute hospital volume. The anticipated benefits of all of the efforts to create hospital beds will be very limited if we don’t fix the discharge problem. Patients with COVID-10 who require hospitalization are older adults who will likely have a prolonged hospitalization. A long hospitalization will decondition thousands of patients, and this will require rehab beds. Patients from a facility will return to the facility. We will be unable to absorb large volumes of COVID-19 patients if we are unable to discharge anyone.
That said, I have never discharged a elderly patient to receive rehab and post-acute care in a room on a cruise ship, but we better start thinking creatively as AMDA suggests or we will be facing more difficult decision – open up beds in hospitals for acutely ill patients and put nursing home patients at risk or deny care to people that require hospitalization. We are already fearing the need to ration ventilators. Legislators need to heed AMDA’s concerns and create a feasible discharge plan for patients requiring post-acute care, or we will also be faced making decisions about rationing hospital beds.
What can hospitalists do now? Some key ideas that you should consider include the following:
- Recognize that this is a problem, and will impair your ability to discharge patients
- Post-acute care facilities will hesitate to take any patient with a viral respiratory illness.
- Even if a patient has established influenza, unless they also have one or more COVID-19 tests, SNFs may decline the patient
- Given the above reality you will be facing, immediately draft discharge criteria for patients who require post-acute care, in collaboration with your infection control and care coordination colleagues.
- Send the draft guidelines to the post-acute care facilities that you work with most frequently
- If possible, first speak with the Medical Director at each of these facilities so they are aware of the plan to develop a standardized set of guidelines
- Review with them that it will not be possible to manage multiple different facility infection control requirements for discharge
- Request a comment on your draft guidelines, and rationale for any changes (evidence)
- Things to include on the guidelines include patients with:
- Viral respiratory illnesses NOS, negative COVID-19 result(s)
- Viral respiratory illnesses, NOS, pending COVID-19 result(s)
- COVID-19 confirmed patient
- Exposure with sick contact (while at hospital or prior to hospitalization)
Note: Since the original post date of March 24th, a thoughtful publication appeared in JAMA regarding this issue.
Seems like some way in which risk is shared, or support (PPE sharing?) is increased, would engender greater trust and collaboration.
As you noted, everyone is scared, SNF have reason to be just as scared as most – how do convey and follow through on idea of “we’re in this together”?
Thanks for these comments Chris. Ideally, this would happen at the state level, where specific places are designated for discharged patients (such as a convention centers). Another option would be for the state to identify post-acute facilities in each county which will take COVID-19 patients (cohorted to one unit on the facility, etc) and the state in return would support these SNFs by providing appropriate PPE, supporting staffing, rolling out telehealth options, etc. At the local hospital level, we are bound to, at least short-term, working with SNFs to at least be consistent and establish some mutually agreed upon discharge criteria.