Long-Term Care Rapid Response Teams: A Palliative Care Focused Approach - Thursday February 11, 2021 Presented by: Dr Amit Arya, MD, CCFP (PC) ...
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Long-Term Care Rapid Response Teams: A Palliative Care Focused Approach Thursday February 11, 2021 Presented by: Dr Amit Arya, MD, CCFP (PC), FCFP, BSc Dr Naheed Dosani, MSC, MD, CCFP(PC), BSc
Learning objectives • To introduce a COVID-19 LTC Rapid Response Team model with acute clinical supports to optimize the delivery of quality care • To develop capacity to build LTC Rapid Response Teams in your own environment
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From the Field…
A 93 year old gentleman with dementia, COVID +ve
• O2 sat=97% on 5 L, respiratory rate of 40, using accessory muscles
• Goals of care= full code
• Adequate staffing present in the home
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Outline
• What is the impact of COVID-19 in LTC in Ontario?
• What are some assumptions we will need to make for today’s
presentation?
• How can we approach this challenge quickly and effectively?
• How does the Rapid Response Team model work?
• What we have observed and learned from the implementation of this
model?
• How can you implement the model (e.g., tools/resources)?
• Q&A
Background Source: https://files.ontario.ca/moh-covid-19-report-en-2021-02-10.pdf Public Health Case and Contact Management Solution (CCM) for all PHUs by PHO as of February 9th, 2021
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Background
63% of COVID-19 deaths are linked to LTC
homes in Ontario. At one point of time in
wave 2, one person per
hour was dying of
COVID-19 in a LTC
Approximately 68% of COVID-19 deaths are home in Ontario. [2]
linked to LTC homes in Canada.
[1] https://ltc-covid19-tracker.ca/
[2] Wilson, K. (January 26, 2021). Hundreds of doctors, advocates ask Ontario government to better support long-term care homes
battling COVID-19. CTV News.7
Background
Hospital rapid response Quality of care
teams have been including symptom Access to high-quality
called upon to assist management has been palliative care is a
several LTC homes in variable due to a basic human right
crisis. variety of factors
Source: Canadian Medical Association Journal (CMAJ): Pandemic Palliative Care: Beyond Ventilators and Saving Lives8 Using a Mass Casualty Framework
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Framework Elements
STUFF SPACE
e.g., equipment, Optimize use of beds,
comfort meds, identify spaces to
PPE create palliative
care areas
SYSTEMS
STAFF Triage systems,
Identify, mobilize, telemedicine, order
educate, engage & sets, provider groups
support trained & ready to
provide palliative care
Source: Canadian Medical Association Journal (CMAJ): Pandemic Palliative Care: Beyond Ventilators and Saving Lives10
Additional Elements to Support Palliative Care
SEDATION COMMUNICATION
Preparation Update advance
for use care planning,
goals of care
discussions
EQUITY
SEPARATION Ensure access &
provision of
Ensuring family has
service for all
safe access
Source: Canadian Medical Association Journal (CMAJ): Pandemic Palliative Care: Beyond Ventilators and Saving Lives11 A Mass Casualty Framework that Supports Palliative Care Source: Canadian Medical Association Journal (CMAJ): Pandemic Palliative Care: Beyond Ventilators and Saving Lives
Interprofessional Teams and Roles
• A multidisciplinary team enables capacity to provide a broad spectrum of
care and flexibility for personalized care
• Focused education on end-of-life care for COVID-19+ve patients should be
provided to frontline health care providers (i.e., primary care physicians,
nurse practitioners, paramedics, ED staff and nurses in LTC facilities)
• Roles:
• Support identification and management of symptoms (including pain)
• Management of family caregiver grief
• Engage in discussions about prognosis, goals of treatment, suffering
and resuscitation status
Source: Canadian Medical Association Journal (CMAJ): Pandemic Palliative Care: Beyond Ventilators and Saving Lives13
The Solution: A Rapid Response Team Model
• Leverages an interprofessional team to perform mass
triage & provide quality care for LTC residents
• Focuses on acute medical and symptom
management
• Enables care planning by considering:
– Clinical stability of the resident;
– Goals of care; and
– The ability and availability of LTC clinical staff to provide
care to residents who may deteriorate quickly
Source: Canadian Paramedicine: Practice innovations: rapid deployment of palliative care in clinical response teams to support long-
term care facilities: the community paramedic perspective14
The Model at a High-level
Communicate
with family
(based upon
resident consent)
Source: Canadian Paramedicine: Practice innovations: rapid deployment of palliative care in clinical response teams to support long-
term care facilities: the community paramedic perspective15
Requirements to Set up the Team
Rapid Response team is equipped with:
1. Oxygen & symptom relief medication
capabilities
2. Personal Protective Equipment (PPE)
3. Transcutaneous oxygen saturation
probes (each team member)
4. Simplified assessment form
Source: Canadian Paramedicine: Practice innovations: rapid deployment of palliative care in clinical response teams to support long-
term care facilities: the community paramedic perspectiveSupplies in LTC for RRT
• Medications
• Medication delivery supplies (e.g. subcut cannulae & CADD PCA
pumps)
• Ipads/tablets with reliable wifi connection
• 24 hour physician on-call support
• O2 concentrators/tanks
Sourcehttps://physicians.northernhealth.ca/sites/physicians/files/physician-resources/covid-19/guiding-principles-for-palliation-of-COVID-19-
patients-in-LTC-homes.pdf17
Building IPAC Support for the RRT
Key Considerations:
• Different staff for COVID-19+ve & COVID-19-ve residents
to reduce transmission
• One team member documents while others assess residents individually
to improve efficiency & minimize PPE use.
• Gloves and gowns changed & saturation probes cleaned with anti-
infective wipes between each resident assessment.
• Each team member has a transcutaneous oxygen saturation probe
Source: Canadian Paramedicine: Practice innovations: rapid deployment of palliative care in clinical response teams to support long-
term care facilities: the community paramedic perspectiveSymptom Management
• Opioids for dyspnea
• Lorazepam/Midazolam for severe dyspnea/
anxiety
• Methotrimeprazine for agitation/restlessness
• Glycopyrrolate/Scopolamine for respiratory
secretions/congestion near end-of-life
Source: https://med-fom-fpit.sites.olt.ubc.ca/files/2020/05/End-of-Life-Symptom-Management-COVID-19-1.pdf19
From the Field…
A 93 year old gentleman with dementia, COVID +ve
• Hydromorphone 0.5 mg subcut given X 1, little effect noted after 30 minutes
• Hydromorphone 0.8 mg subcut given X 1, little effect noted after 60 minutes
• Started on Hydromorphone 1 mg subcut q4hourly scheduled + breakthrough,
noted to have minimal relief of dyspnea and respiratory distress
• Midazolam given X 1, 1 mg, palliative care specialist called on call who
recommended initiation of midazolam infusionBest Practices for Caregiver Communication
• Use plain language
• Share information in ‘bite size’ chunks
• Repeat information, if necessary
• Be empathetic
• Minimize distraction & noise
• Support individuality
• Be open to receiving information from
caregivers
• Enable dignity
• Avoid short forms
• Avoid medical jargon
• Avoid escalation of emotions
Source: Caregivers as Partners eLearning for healthcare providers (2019): Module 2 - communication21
Important questions to guide decision-making about transfer to acute care
in case of decline
• What do you feel
• Is the standard of care in this situation?
• Is clinically indicated?
• The hospital will provide that cannot be provided in LTC?
• What are the patient’s wishes, values and beliefs in case of decline in health,
and for end-of-life?
• Do they appreciate the risk of death in this situation?
• Is there a substitute decision maker (SDM)?
• Is the LTC home staffed well enough to implement the treatment plan (if you
decide not to transfer to hospital)?
Source: Canadian Paramedicine: Practice innovations: rapid deployment of palliative care in clinical response teams to support long-
term care facilities: the community paramedic perspective22
Scripts for Communication with Families
• Based on our review of your loved one’s clinical status, we are worried that COVID-19,
along with their previous medical conditions is leading to an end-of-life process.
• We are sorry to share that we believe your loved one is sick enough to die.
• Under these circumstances we do not provide CPR or ventilation. We want to make
sure you understand this decision and have the opportunity to ask any questions that
you have.
• We will make sure that your loved one will have the best care under the circumstances
with the resources that are available.Criteria for palliative care specialist involvement
• Complex/refractory symptoms
• consider consultation if need for palliative sedation (needed more often with
COVID-19)
•Complex goals of care discussions
• assistance with conflict resolution re: goals of care or methods of treatment
within families, between staff and families, treatment teams24
From the Field…
A 93 year old gentleman with dementia, COVID +ve
• conversation with daughter and POA re: treatment options, recommendation
made for comfort in LTC facility
• palliative sedation provided with assistance of palliative care specialist team
• assisted daughter to come in for visit at EOL, help provided for zoom visit for
other relativesIn summary Rapid response teams with acute palliative care supports are required for LTC homes with large scale COVID-19 outbreaks A multidisciplinary team can quickly be formed to assist with acute medical and palliative care needs of residents All residents deserve high quality symptom management, goals of care discussions and family communication
Thank You
Articles / Toolkits
• Canadian Medical Association Journal (CMAJ): Pandemic Palliative Care:
Beyond Ventilators and Saving Lives
• Canadian Paramedic: Rapid Deployment of Palliative Care in Clinical
Response Teams to Support LTC Facilities: The Community Paramedic
Perspective
• Ontario Caregiver Organization/The Change Foundation: Caregivers as
Partners eLearning for Healthcare Providers
• Ontario Palliative Care Network: Toolkit for Providing Palliative and End of
Life Care for LTCYou can also read
