In nursing homes maximize communication with staff early on – like, before your first infection: guidance around PPE, and infection control. Medical or nursing leadership hosting a daily brief huddle or phone-in session will build openness and information-sharing. Connect with your local ED (how many EDs does your site transfer to?) to request a strategy for communication (e.g. one-number-to-call to speak with a physician about transfers.)

Make sure you know what the capabilities of the facility your older patient is coming from. The term “nursing home” includes a myriad of variations from highly-resourced and -staffed to independent living with no medical oversight.
In preparing disposition plans, you need to communicate directly with the receiving facility to collaborate on the discharge plan.

Our ED is hosting daily huddles at 07:30 with the approx. 30 facilities who use us as their 911 care provider.

• We start the huddle with the update on our numbers of COVID-19 positive.
• We let them know the number of patients needing placement.
• We ask them to report out if their PPE is adequate; challenges in staffing; their ability to take COVID-19 patients; any problems they are experiencing.
• We distribute supplies and/or we discuss with others who may help.

We have one-hour weekly calls with our ED Leadership and CMO, Infection Control Officers to help field questions, alleviate concerns, connect them with resources – powerful sharing.
We have set up COVID-19 swab test kits for them to use.
We are working with a facility setting up a COVID-19 wing.
We hosted our first Medical Director meeting: “Sharing Care Strategies for the most vulnerable during the COVID-19 pandemic”.
We encourage the medical director of the facility to notify the ED physician prior to transfer as a form of “forward triage”
Work also with your EMS to help you identify concerns they have when they go into a facility eg. lack of PPE; incorrectly using PPE. Not punitive but helpful so you can all work together to improve education and strategies to reduce the spread.

This is the time to consider reproducing their virtual consult program between EDs and nursing homes in San Diego County.

Guidance on creating a COVID-19 only nursing home or section of a nursing home that covers infrastructure, clinical, operations. and staffing.

Add a palliative care physician to the ED team – or develop a mechanism where palliative care is readily accessible by phone or in person to the ED.
Practice scripts for emergency clinicians to inform goals of care conversations. Avoid medical jargon; be clear; make a recommendation. Use the format:

• Warning “I wish I had better news”;
• Headline: “it is very serious”;
• Meaning: “you may die from this”.

Expect an emotional response and let it guide you.
If you’re practicing mock codes, add a “goals of care” conversation to the Code.

• VitalTalk.org
• CAPC.org
• Speak Up Ontario
• Goals of Care Module
• BC Centre for Palliative Care
• EM Ottawa End-Of-Life Care in the ED Related to COVID-19
• The Importance of Addressing Advance Care Planning and Decisions About Do-Not-Resuscitate Orders During the Novel Coronavirus 2019 (COVID-19)

https://jamanetwork.com/journals/jama/fullarticle/2763952

• West Health COVID-19 Resource Center
• West Health Post-Acute and Long Term Care Guide
• IHI COVID-19 Resources: Care of Older Adults

Adam Perry, MD
Emergency Physician/Geriatrician, Pensylvania
Don Melady, MD
Emergency Physician, Univeristy of Toronto
Stacie Levine, MD
Chair of Geriatrics, University of Chicago
Kathleen Unroe, MD
Geriatrician, Indiana University
Mike Wasserman, MD
Geriatrician, President CALTCM
Leah Steinberg, MD
Palliative Care Physician, University of Toronto
Zia Agha, MD
CMO, West Health Institute

1. To hear from specialists in both nursing home care and ED care about the challenges of NH/ED transfers particularly during the COVID pandemic.
2. To understand what level of care your local NH can provide and ensure you are sending your patient to the right level of NH care.
3. To address issues around discharge or return of COVID- positive or -suspected to nursing homes.
4. To consider some guidance about improving transfers and communication between the two sites.
5. To highlight 2-3 promising models of care that are already succeeding in various settings.