A pandemic in long-term care: Growing stronger in unprecedented times

Talk Tuesday - May 26, 2020



With COVID-19 quickly becoming part of reality in long-term care, there have been many challenges that shine a light on our weaknesses and test us like never before.
 
Instead of focusing on the gaps, we see the many opportunities that we can capitalize on to create a culture of growth, advocacy and change. The reality is not depressing, but hopeful and inspiring. Tough times bring out the best in many – those that become the champions, the heroes and the strength that gives us the energy to push forward and make positive change.

Featured presenter 

Victoria Marek RN GNC (C), Clinical Services Coordinator

Victoria began her career as a health care aide in 1991 at Seven Oaks Hospital.  In 2003 after her youngest child went off to school, she followed suit and began attending the University of Manitoba Nursing program fulltime.  She then graduated in 2007 as the valedictorian and senior stick for student council. She has held several postions throughout her career such as Emergency Room Nurse,  Clinical Education Facilitator at the University of Manitoba, Nursing Specialist at Great West Life, Long Term Care Educator at Misericordia Health Centre, and Resident Care Manager at Misericordia Health Centre. Currently Victoria is the Clinical Nurse Specialist at River Park Gardens PCH and the President of the Manitoba Gerontological Nurses Association.

Summary

Victoria Marek, a clinical nurse specialist and president of the Manitoba Gerontological Nurses Association, spoke about the challenges, innovations, silver linings and future plans in long-term care in context of COVID-19.

Though staff and visitor screening started in early March it was on March 17 that visits were suspended, the same day as the first presumptive case of COVID-19 in Manitoba. Around the same time they had to make changes to residents dining routines to ensure they were physically distant from one another and suspend and then modify recreation programs all while they tried to maintain routines and connection with families and loved ones outside the facility as much as possible. 

While the routines and circumstances of the residents in long-term care changed so did those of the staff. Not only were they responsible for implementing and supporting these changes they had to keep track of them. Change management is hard work in normal times but it was particularly difficult given the rapid pace, massive scope and the background changes COVID-19 was prompting at the same time for everyone in their non work lives. 

The team of staff in long-term care had to change the ways they supported residents in maintaining relationships with family and loved ones outside the facility. This includes:

  • Providing PPE and teaching safe donning and doffing for individuals allowed visits at end of life
  • Acting as mediators/facilitators during window or tech assisted visits for those residents with visual, hearing or cognitive impairment
  • Helping with technology to allow residents to “visit” with their loved ones and most recently
  • Setting up outside visit stations, screening the visitors and maintaining the visit schedule

One silver lining that has come out of these COVID-19 prompted changes is a daily conference call for LTC facilities. These calls are an opportunity to share ideas, answer calls for help from each other and an avenue to connect with senior leadership on a regular basis. 

Victoria emphasized that the future of long-term care is positive. There are lessons to learn and advocacy to do for funding, staffing and to promote LTC as the nursing specialty that it is. Long-term care is not broken - it is full of amazing people who do amazing things every day. 

Question and answer

What has the impact of visitor restrictions been on residents?

It’s been hard on them mentally and physically to have their loved ones not sitting with them, helping feed them, speaking with them… Staff have really stepped up to fill these gaps. The recreation staff are doing a lot more with smaller groups and one on one’s tailored to individual needs.

Do the people working in LTC have enough PPE?

Yes. It is normal for LTC facilities to have an IP&C connection so preparing for COVID-19 had some similarities to regular seasonal flu planning in terms of PPE refresher training and screening.

When will families be allowed to visit?

They’re allowed to visit now. The visits have to be outside, the visitors are screened and have to remain physically distant from the residents.

Do you expect an increase in staffing for LTC?

Expect or advocate for? I expect advocacy for sure but it must be done thoughtfully with clear data to back it up if it’s to be effective.

There has been some controversy in other provinces re: private vs public LTC facilities - can you comment on that related to Manitoba?

LTC facilities in Manitoba all have to meet the provincial standards. Inspections are every two years but there could be a surprise inspection at any time. In my experience, when the facility is clear that the standards are to be met at all times, not just at inspection time, it’s not unrealistic to do so.

Why do you think LTC facilities in Manitoba did so much better than in other provinces?

In large part because we had the opportunity to learn from centres that were impacted sooner than us. Manitoba gathered experts and made decisions quickly based on data from outside the province.

How do mealtimes work now?

Depends on the facility. Those with larger dining rooms were able to space people out well enough, some facilities with smaller dining rooms are having their residents eat in shifts.

If we have a second wave, what policies and procedures are in place to administer oxygen to residents instead of sending them to hospital?

Again, depends on the facility. Some facilities have supplemental oxygen and some don’t - those that do have longstanding guidelines around its use. There are some new COVID-19 specific policies around aerosol generating medical procedures and general care for COVID-19 suspect and positive patients and those are provincial.

Do you think the restriction of employees working at only one facility made a difference? Should that have been done as soon as visitor restrictions were established?

Workplace restriction definitely helps reduce transmission. It would have been nice to restrict employee mobility at the same time as visitors were restricted but the logistics involved were enormous so it just wasn’t possible.

What kind of data is collected by long-term care that is being shared with the province? Has the federal government requested any data?

Some LTC care data goes to the Canadian Institute for Health Information as usual. COVID-19 is a reportable illness so that information is shared with Manitoba Health.

How many frail, older adults will be able to see or hear their family from 6 feet away? Why are dying people being denied a hug?

For residents with decreased vision or hearing or with dementia, physically distanced visits it can be more difficult than close ones. In these cases staff often help out with gestures, facilitating verbal communication and keeping the resident focused on the visit. In my facility, when someone is at end of life their visitors are screened using the same questions asked of staff when they come to work, staff facilitate the visitor wearing full droplet contact precautions PPE (eye shield, mask, gown & gloves), and if they want spiritual care may come and do prayers or other rituals. She acknowledged that COVID precautions add another layer of difficulty to an already sad time.

Do you think there is a need for new infrastructure, larger hallways, separate rooms etc to prevent the spread of respiratory infections?

Yes. There is already a huge body of research that supports these specific recommendations, offers many more recommendations and includes a lot of additional detail. It will be interesting to see what changes come as a result of COVID-19 transmissibility research.

How have residents responded to staff in full PPE?

Initially with confusion, now most have gotten used to it though it remains difficult for those who lip read or who are very aware of facial expressions.

Are you aware of inequities between rural or remote LTC facilities and those in more urban areas?

No. Though my experience is limited in terms of other facilities. The standards that LTC facilities have to meet are provincial so that should ensure a standard baseline across the province.

Are there protocols in place to avoid spreading illnesses from newly admitted residents?

Yes and much more stringent in light of COVID. All new admissions are tested for COVID-19 even if they aren’t symptomatic. Physical distancing is maintained even between residents who aren’t new. If new admissions or existing residents display respiratory symptoms they are isolated and the Shared Health algorithm is followed.

How are LTC facilities managing residents who smoke when the facility is locked down?

I work at a non-smoking facility but another attendee shared that her facility has a small smoking area outdoor with physically distant spaces marked on the pavement and they have a staff member who monitors to make sure the residents stay apart, that no visitors approach the residents while they smoke and there is a schedule so there isn’t a lineup.

When will students be allowed back in facility?

They are allowed in facility now. They’re asked the same screening questions staff are and also aren’t allowed to work at another LTC facility.

Are there any additional changes to come to the isolation requirements, PPE and disinfection protocols?

We’re not likely to see dramatic change at this point though some fine tuning of the recommendations is expected.

What has the greatest challenge been?

PPE. Arranging to get it and to keep staff up to date on the current guidelines. This is a bit easier now that the pace of change has slowed a bit.

Why doesn’t the one facility restriction also apply to those who work in acute centres or home care?

I expect that is likely as a result of the even larger logistical challenge.

LTC facilities usually have Family & Resident Councils, have these been continued?

Absolutely, it’s even more important for people and families to be able to advocate when other forms of being together and communicating have been changed. The meetings tend to be a bit smaller now with some participating by video or telephone conference, those that do attend physically must follow distancing guidelines and the family info nights have been suspended in favour of a newsletter. These meetings still result in action items that change how the facility is run so it’s different but definitely still working.