welcome to covid clinical echo week 6
TRANSCRIPT
WELCOME TO COVID CLINICAL ECHO Week 6
Overview
•Covid-19 update
•Your Questions
•Medications in Community
•Verification
•AGP
•PPE
•Oxford Evidence
•Visiting Issues
•Resources
•Chat Box Feedback
Chat Box• Questions• Potential Answers• Resources• Information /innovations• Email [email protected]
Please share resources, powerpoint, links etc. to those who would benefit
Over 6,000 hospital deaths in past weekThese COVID numbers are us… mothers,
brothers, lovers, friends, grandparents, children…
Week 6 COVID ECHO Update
Delivering care in uncertain times
Community and Care Home Data
Care Home Surge?• Number nor included in “Ventilator Narrative”.
• Yet 400,000 beds vs 100.000 in NHS
• Slower to get PPE
• Mixed practice
• Physical distancing difficult
• Lack of training
• Staff fear
• Staff sick but too financially dependent not to got to work
• Are staff or patients the vector for transmission?
AcknowledgeHuge amount of work completed.
Easter break gave some a chance to catch a breath
Challenges of managing patients and families in midst of changing uncertainties
COVID UPDATE
Weekly review of literature video from Perth
Death Data
Varied COVID Responses
Silently infective
• Serial Interval = time til you infect somebody else
• Incubation period = time between infection and onset of symptoms
Multi System Disease expect significant rehabilitation burden
What you are doing
• Funeral at home info please share
• Face mask on the deceased. Body bags…
• Verification
• Comfort pebbles facebook page
• DNACPR Issues
• Antibiotics in secondary infection - Nice Guideines
• Please share single checker policies
• Ventilator tubing lack
• Care Home support through ECHO, education
• Hospitals using CSCI but not needed for long
• Birmingham st. Marys videos for informal carers
• Furlough stuff
• MND and tracheostomies…
Your Questions
• There follows responses to some of the questions raised at last week’s ECHO, and emailed to us over the week
• Please use Chatbox if you have any responses to the questions raised – we are much wiser together
www.hospiceuk.org
Your questions, our thoughts….
• “Does anyone have any guidance re non-destruction of meds / re-issue of meds?”
•YES!
2011
• People dying with no medicines for horrible symptoms
• Care homes have medicines …but for the wrong people
• Nurses visiting ….but then chasing round county for the right medicines
• Supply chain drying up….
• Not enough nurses to support stat doses or syringe pumps
Suffering in Covid times…..
• Availability - the creation of community supply hubs
• Rapid access to end of life packs for visiting nurses/doctors
• Care homes to hold stocks
• Stop destroying unused sealed packs of medicines
• Repurpose and re-use sealed packs
• Administration of subcutaneous medication by lay carers
• Non injectable routes of end of life medicines
What do we need…
Provide dying patients with as much comfort as possible
Permissive re: unlicenced use
NICE – sedation and opioids should not be witheldthrough fear of respiratory depression
What ‘s changing ?…
Local pharmacy planning measures should be considered to support recovery of unused drugs rather than destroying them…..
It may also be helpful to work with your local pharmacy teams to enable health care professionals to carry a locked supply drugs for recorded, emergency use in the community.
What ‘s changing ?…
10th April 2020
Local hubs to ensure rapid access to symptom medicines
Pharmacies, GP surgeries, community hospitals…
Anywhere where CDs can be safely stored & rapidly released
CCGs should work with providers to provide rapid access
What ‘s changing ?…
The RPS backs you to use your professional judgement, skills and expertise to help people.
There will be circumstances in the coming weeks where you’ll need to do things differently and prioritise putting people first and professional ethics over legislation, regulation and processes.https://www.rpharms.com/about-us/news/details/Make-professional-decisions-with-our-backing
What ‘s changing ?…
What next…
11th April
What next…
What next…
NHSE ….maybe TODAY Guidance on re-purposing medicines
Work with local CCG leads re local hubs for urgent access to medicine packs – oral and injections
Care home stocks…
www.hospiceuk.org
Your questions, our thoughts….
• “Any recent info on how long COVID-19 stays on surfaces?”
DOI: 10.1056/NEJMc2004973
On surfaces:
SARS-CoV-2 viable virus was detected up to 72 hours after application to plastic and stainless steel, although greatly reduced on both after 48 hours
Differs for different surfaces - on copper, no viable virus after 4 hours and on cardboard none after 24 hours
In aerosols:
SARS-CoV-2 remained viable in aerosols for at least 3 hours
van Doremalen et al (2020)
www.hospiceuk.org
Your questions, our thoughts…
“Is there any specific advice about cleaning the room/area at home after a positive patient has died?”
https://www.gov.uk/government/publications/covid-19-decontamination-in-non-healthcare-settings/covid-19-decontamination-in-non-healthcare-settings
www.hospiceuk.org
Your questions, our thoughts
“Is a small handheld fan in a well-ventilated room with not many people a big risk?”
https://www.kcl.ac.uk/cicelysaunders/resources/khp-gp-breathlessness-resource.pdf
www.hospiceuk.org
Your questions, our thoughts…
Can you advise on the latest updates on verification of death?
Update on verification
www.hospiceuk.org
Special Edition in response to COVID-19
Care After Death: Registered Nurse Verification of Expected Adult
Death (RNVoEAD)
Anita Hayes & Dawn Hart
www.hospiceuk.org
Special Edition RNVoEAD Guidance linkFeedback welcome, please get in touch: [email protected]
www.hospiceuk.org
Inclusion CriteriaDeath is expected and not accompanied by any suspicious circumstances. This includes when the person has died expectedly from or with COVID-19
An individualised conversation between the patient and a healthcare professional agreeing to the DNACPR decision has previously been undertaken, and recorded in the patient’s clinical notes
Where the person is found deceased without a DNACPR conversation documented and there are signs of irreversible death, verification of death by the RN can be carried out
Death occurs in a private residence, hospice, residential home, nursing home, prison or hospital
It includes where the patient dies under the Mental Health Act including Deprivation of Liberty Safeguards (DoLS)
Special Edition RNVoEAD Guidance linkFeedback welcome, please get in touch: [email protected]
www.hospiceuk.org
RN Competency and AssessmentA Competency Assessment Tool accompanies the Guidance, in Appendices on page 10
Already competent, then must familiarise yourself with the updated changes and revised procedure
Areas may choose to adopt RN self-assessment of competencies (during this emergency only) to expedite up-skilling staff
Remote support could be given by experienced colleagues for RNs lacking experience and/or confidence in verifying a death
Special Edition RNVoEAD Guidance linkFeedback welcome, please get in touch: [email protected]
www.hospiceuk.org
• “What is everyone classing as AGP - anything above the PHE guidance?”
Aerosol Generating Procedures.• Supplemental Oxygen
• “High flow oxygen via face mask up to 30L (i.e. high flow double flow humidified system) is not considered as an AGP by our respiratory and infection control teams.”
• The oxygen that can be delivered in people’s homes via mask or nasal prongs will not generate aerosols
• CPAP, BIPAP, Airvo or equivalent HFNO would all be considered AGPs.
www.hospiceuk.org
• “Re PPE [supplies] we are… really struggling with long-sleeved gowns - looking for scope to get reusable ones made -any thoughts?”
• “Are people able to access suitable facemasks? Are units able to follow PHE guidance of face masks when on a ward with COVID-19?”
Govt PPE Plan April 14
Update on PPE & Hospice Staff Testing
Masks for all to protect others from you
WHAT DO YOU THINK?
www.hospiceuk.org
Sharing community wisdom (3)“Are/should hospices be shielding in-patients who do not meet the official shielding criteria specified by the government but are still considered to be vulnerable?We know GPs are contacting patients not on the official shielding list who they consider to still be significantly vulnerable to COVID-19 and they are asking them to shield. Should we be doing the same for hospice in-patients? How should we decide who should be shielded?”
“We have heard from colleagues that paramedics are refusing to take patients to hospital if they can’t be ventilated - anyone else heard this?”
www.hospiceuk.org
Sharing community wisdom (4)
• “Is there any way of hearing about impact on activity for all hospices across UK – we are a community hospice and are not seeing a vast majority of increase in acute discharges for EOLC but we are beginning to see more increases from community sources for our Hospice at Home care input – currently double our usual caseload.”
www.hospiceuk.org
Hospice responses: a selection
A quick look at some of the ways in which hospices are responding to COVID-19
https://www.chas.org.uk/news-articles/chas-launches-the-uks-first-virtual-childrens-hospice
www.hospiceuk.org
Hospice responses: a selection (2)
Offering families
• Nursing, medical and pharmacy advice by phone and video• Bereavement support• Money and benefits advice• Practical advice around coronavirus.
• Storytelling service for children at home• Letter writing for children and parents• Activity packs and art clubs• Virtual Clown doctor visits
• And more in the pipeline!
www.hospiceuk.org
Hospice responses: a selection (3)
• John Taylor Hospice, Birmingham St Mary’s Hospice and the Marie Curie Hospice, West Midlands have joined forces to launch the new service which aims to provide rapid and expert support for local people and their families at end of life.
https://www.birminghamandsolihullccg.nhs.uk/news/1515-hospices-launch-hobs-a-new-service-for-specialist-care-at-end-of-life-during-covid-19
www.hospiceuk.org
Hospice responses: a selection (4)
The HoBS team comprises specialist nurses, supported by palliative care consultants, HCAs, social workers, OTs, physiotherapists and administrators, who will be running a telephone hotline service.
Working with other healthcare providers across Birmingham and Solihull, the team will assess whether patients need advice, community support or admittance to one of the three hospices’ IPUs.
Find out more about HoBS at:https://www.birminghamandsolihullccg.nhs.uk/news/1515-hospices-launch-hobs-a-new-service-
for-specialist-care-at-end-of-life-during-covid-19
Link Lancet Palliative Care Covid editorial
Practical steps:• Ensure access to drugs (such
as opioids) and protective equipment
• Consider a greater use of telemedicine and video,
• Discuss advance care plans, • Provide better training and
preparation across the health workforce,
• Embrace the role of lay carers and the wider community.
Rapid and flexible response
Protocols for symptom management; training non-specialists
Triage
Shifting resources into the community
Use volunteers to provide psychosocial and bereavement careAdopt measures to facilitate camaraderie and support staff stress
Use of technology to communicate with patients and carers
Use standardised data collection systems to inform operational changes and improve care
Oxford University Hospitals• End of life symptom management guidelines avoiding sc route:
• Oxford MMTC have just produced guidance (attached) which includes a lot about alternative routes for administration of medication (picking up on the question about buccal meds from ECHO 2-3 weeks back). This is partly based on our experience with buccal use in paediatric palliative care. (Incidentally, there is recognition that transmucosal absorption of concentrated oral morphine doesn’t have a good evidence base. The decision was made not to include parenteral opioids transmucosally in this guidance due to potential shortages with greatly increased ITU use at present, and potential increased risks with carer administration). There is also an A to Z guide to transmucosal use of medication at an advanced stage of preparation.
Alternative routes of medication
• “We've started a review on the role of oxygen in reducing symptoms for people dying with COVID.
• The other review that is now underway is looking at how we might adapt non-pharmacological treatment of delirium in the context of current safety concerns. ”
• Let me summarise the evidence we have found on PPE for healthcare workers to date. First, there is almost no direct evidence on the efficacy of PPE from research studies on COVID-19. Second, there is a lot of indirect evidence on prevention of other diseases which is of different kinds (randomised controlled trials, natural experiments, artificial laboratory studies and more). This evidence varies in quality, and its relevance to the current outbreak is contested. Third, healthcare workers at the front line are dying. Fourth, PPE provided to healthcare workers is in short supply and it does not always meet the minimum standards recommended by national and international bodies
Is this evidence
really applicable?
Big UNCERTAINTIES• Last Offices.
• Bag, double bag, no bag, mask on the body. Closed Coffin, open Coffin. What the Funderal Directors say and what the PHRE say. Risk to families with different approaches being taken.
• How to use PPE when supply lines are limited and is it safe to reuse, and should we be wearing all the time to protect other staff and patients from us? How do we preserve what we have and not compromise on the health of patients and staff.
• How do we provide end of life care at home.. Where do staff change into PPE? Special vehicles? Single double travelling??? How do we get informal carers PPE? How do we relate to informal volunteers??
Resources
Visiting in Covid
Effective communication for healthcare
Wales Ethical Guidance
Conventional Care Contingency Care Crisis Care
Usual resourcesUsual level of care
Functionally equivalent Adapted from usual practices
Inadequate resourcesIncreased M&M
Primary care triage COVID centre triage COVID centre triage
Admit if necessary Admit if necessary Admit if necessary and able
Community EoLc for patients who refuse admission or are discharged home for EoLc• PANG• RPMG EoL• Regional conversion tables• Community pharmacy palliative care
network
Community EoLc for patients who refuse admission/ too unwell for admission or are discharged home for EoLc• Telephone advice lines. • Return of retired colleagues.• RPMG COVID symptom management in last days of life.• Interim guidelines for funeral directors.• Rapid discharge home to die. • Guidance on the new arrangements for the completion and issuing of MCCD and
stillbirth certificates. • Just in case boxes.• Education and training.• Communication prompts and tools. • ACP.• Guidance for discharge/ keeping COVID patient in community.
Community EoLc for patients who cannot get into hospital- Lack of care, drugs, O2, CSCIs.• RPMG COVID symptom mangement at EoL 3rd line options.• Caring for your dying relative at home with COVID.• Guidance for CSCI without a McKinley in COVID.• Informal carer’s administration of PRNs during COVID.• Medicine reuse.
Symptom control for patients who cannot get into hospital• BHSCT symptom guidance in COVID.
Facilitate discharge from hospital Facilitate discharge from hospital• Use hotels to provide care
Facilitate discharge from hospital• Use hotels to provide care
Regional Palliative Medicine Response to COVID-19• Goal= stay out of crisis!
Comfort Pebbles• https://www.facebook.com/groups/642833409625446/announcements/
• twitter page @CPebbles2020
I am delighted to say that our rapid innovation project ComfortPebbles2020 is rolling out to hospitals and hospices.As you know the idea behind ComfortPebbles2020 is that patients, separated from friends and families, receive a hand decorated pebble with a brief message from their family or friend on the back. This pebble can stay with them and be held in their hand as a comfort and treasured message. When hand holding is so difficult. We hope that if the patient should die that the pebble will be passed back to the family to offer comfort during their bereavement.Pebbles are currently being decorated by the pebble painting community (Rockers), completely varnished and can be wiped and washed. Messages from the family can be written on the back with a paint pen. In the short time we have had we have experimented with this approach. Here is the community of painters. I am pleased to tell you that Milton Keynes University Hospital are currently waiting for delivery of their first batch of pebbles, alongside 2 hospices. Today we had a request from Northampton and Portsmouth hospitals.Claire Marshall National Lead for Patient Experience has sent it out to her network in hospitals. Thank you for your ideas, support and encouragement, I thought you would like an update.
Liz Searle Keech Hospice
Full Contact Details Contact Pebbles
Update from Nightingale London
Dr. Caroline Sterling
CHATBOX
Uncertainty
WORKING TOGETHERWe shape our selfto fit this worldand by the worldare shaped again.
The visibleand the invisible
working togetherin common cause,
to producethe miraculous.
I am thinking of the waythe intangible airpassed at speed
round a shaped wingeasily
holds our weight.So may we, in this life
trustto those elementswe have yet to see
or imagine,and look for the trueshape of our own self,
by forming it wellto the great
intangibles about us.-- David Whyte
from The House of Belonging©1996 Many Rivers Press