April is the cruelest month, breeding Lilacs out of the dead land, mixing Memory and desire, stirring Dull roots with spring rain....
T. S. Eliot (The Waste Land, I. The Burial of The Dead)
MY world as a family physician simultaneously imploded and exploded midmorning on April 8, 2020. I work in rural Maine, where April is still mud season, where early lilac buds are often interrupted by a late spring snowfall, and where the resilience of the people making a life on the coast allows us to understand the power of geological, biological, and seasonal cycles. Little did I suspect what was about to disrupt my clinical world, while sitting in an office examination room at Seaport Community Health Center (SCHC),* conducting a newly familiar remote telehealth visit with a patient whose multiple chronic primary care issues and needed prescription refills were the pretext for our talk about herself, her family, and community coronavirus disease 2019 (COVID-19) concerns. As I dialed into to the next telehealth visit, the director of nursing (DON) at Tall Pines Nursing Home (where I am medical director) sent me a text reporting the overnight death of our second patient due to COVID-19 in 24 hours. Two other patients with mild symptoms also tested COVID-19 positive. This would be the last of my “usual primary care” visits for the next 35 days, as my nursing home work exploded to take over all available time and care.
Two days before, our first Tall Pines patient died shortly after transfer to the local hospital, Waldo County General Hospital (WCGH) in Belfast, Maine. This death was not only of COVID-19 but also of other illnesses; this was a complicated case and might have alerted us to the challenges to come. This patient tested COVID-19 negative 3 weeks earlier at an emergency department (ED) visit for exacerbation of chronic conditions. After that ED visit, the family and patient preferences for intensity of care related to chronic cardiac and respiratory comorbidities changed from DNR/DNI (Do Not Resuscitate/Do Not Intubate) to Full Code. In the ensuing weeks, this patient's conditions seemed to stabilize, but the weekend before the patient was transferred to the ED, the patient needed immediate intubation and was admitted to the intensive care unit (ICU). Promptly, the family requested that Code Status be changed to Comfort Care/DNR/DNI. This patient died within 24 hours, testing COVID-19 positive during the admission. The ED medical director contacted me and told me that many of his ED colleagues asked whether all Tall Pines patients had clear Code Status documented. I replied tactfully that after each WCGH (or tertiary care center) discharge to Tall Pines, I always reviewed the Code Status, which often had changed from DNR to Full Code during the hospital admission. I discussed the Advance Care Planning (ACP) again with the patient or family and often changed Code Status back to DNR/DNI. This communication process was soon to become the foundation of our days.
The next telehealth visit with one of my 30 recovery patients on MAT (medication-assisted treatment, in this case oral buprenorphine/naloxone) for outpatient treatment of substance use disorder/opioid dependence continued longer than expected. She explained that her urine drug screen (UDS) was positive for illicit substances and negative for buprenorphine because she was “helping” another SCHC recovery patient and ran out of her own Suboxone (buprenorphine/naloxone) Rx before the renewal date. The partner of the SCHC recovery patient she was “helping” was admitted to a tertiary care center (110 miles away) after injecting prescribed buprenorphine/naloxone and cocaine and was on a ventilator in the ICU. We made plans for a follow-up telehealth visit within 1 week. I logged onto the next visit, knowing the elderly woman I was trying to reach faced significant challenges in managing massive chronic, unilateral lower extremity lymphedema and pain she developed after surviving uterine cancer. She lives 40 miles away and, until last month, swam daily at a local hotel pool to alleviate her pain. My colleagues are hesitant to refill her monthly controlled prescription (despite reassuring UDS/pill counts), and we cannot find other outlets for her to mobilize. I stared at my image in the telehealth room and redialed her son's mobile number but was unable to connect and no voicemail was set up. I ended the attempted telehealth visit feeling somewhat relieved, and very apprehensive, and decided to respond to the nursing home text.
Being a primary care provider (PCP) in rural Maine is complex/multilayered in the best of times. I was not sure how I might navigate the reality of being a part-time medical director at Tall Pines in a COVD-19 outbreak, while juggling a busy outpatient rural health center practice of 20 years. I wandered out into our unusually empty hallways (all providers were in closed door offices conducting telehealth visits rather than bustling in and out of the shared spaces) and reported to our clinical coordinator medical assistant. I told her I was so distracted by the news of our second death at Tall Pines Nursing Health Care Facility and fearful for the additional 2 patients who tested positive for COVID-19. She immediately relieved me of the remaining office telehealth visits and fitted me for an N95 mask before I headed over to Tall Pines Nursing Health Care Facility.
Returning to Tall Pines twice in 1 week was not the usual medical supervision strategy. The day before was my usual 6 hours per week allotted time at Tall Pines where I am the PCP for all but 4 patients at the facility. The census is usually 65 patients but was low at 55 patients at the time of the COVID-19 outbreak. When I learned of our first patient who died of COVID-19 on April 6, 2020, I recommended that one other patient with known pulmonary symptoms (thought to be an exacerbation of known underlying conditions and being cared for with compassion and comfort measures) be tested for COVID-19 in addition to 3 other mildly symptomatic patients. The symptomatic patient's death was anticipated, but the patient's positive test and 2 other patients' positive tests for COVID-19 propelled us into outbreak response with 4 COVID-19–positive facility cases.†
Once I entered Tall Pines on that Wednesday afternoon, it would be 35 days before I worked in any other site,‡ and I was grateful to have the colleague and friend, Alana Rose, FNP-C, to help me with the incredible efforts necessary to respond to this outbreak. Alana's expertise in working in long-term care was recently honed after 2 years as a member of the Maine Medical Center (MaineHealth, Portland, Maine) Palliative Care Team. That afternoon we began a process that became a virtual journey, together talking with patients and calling all families to discuss the very real implications of this pandemic on our community.
Over the next 2 and a half days, we held 50 conversations to clarify Goals of Care (GOC), to review and verify Code Status, to discuss and determined preferences about possible transfer to hospital, and to define and commit to the care we could provide at Tall Pines (regardless of their choices). We needed to know whether the patient would be Do Not Hospitalize (DNH) or whether they wanted to discuss/consider transfer later if the patient became ill. These were long, thoughtful conversations with families discussing end of life/comfort treatment we would be able to provide including use of oxygen, morphine concentrate (after explaining mechanism of action for dyspnea/air hunger), lorazepam intensol, and intravenous fluids (rarely used and minimally effective). We learned that these up-front family conversations discussing ACP were essential before patients were diagnosed with COVID-19 or acutely symptomatic. Families referenced these conversations over the next few weeks and expressed gratitude that we had brought this up to discuss treatment options before family members became ill. Part of the implosion of our world included the abandonment of Alana Rose, FNP-C, and my other primary care practice. The explosion included the expansion of work in the nursing home where I spent 13 consecutive days and was relieved for a few days off when we established a rotating schedule with 2 more family physicians assisting Alana Rose, FNP-C, and myself for 2 weeks.
When we finally had a chance to step away 28 days after the onset of the Tall Pines outbreak, we realized that there were many “lessons learned” from the management experience of COVID-19 at our facility, that we hoped others could learn from, or maybe use to prevent other facilities from going it alone, or facing some of the predictable challenges. Our outbreak resulted in 32 patient cases, 11 staff cases, 19 recovered patient cases, and, sadly, 13 deaths due to COVID-19 infection.
We learned the following lessons from Tall Pines Healthcare Inc:
- Embrace what is your own reality. Tall Pines is a moderate-size, privately owned facility (65 patients) with primarily 1 family physician/PCP also acting as medical director covering facility 6 hours per week and 1 FNP-C providing 4 hours per week coverage as area physicians withdrew from following their patients over the past 10 years. Both medical director/PCP and FNP-C have busy primary care practices at a local FQHC. Usually, the nursing home DON and the nursing staff function autonomously, calling when they have specific questions and requesting appropriate telephone orders. This functional “symbiotic” relationship changed within 24 hours of our outbreak. At the onset of the outbreak, we transitioned from 10 hours per week coverage to approximately 90 hours per week, providing 7 days per week coverage by 2 providers. After 13 days, our presence increased to 120 hours per week, divided by 3 family physicians and 1 FNP-C working in 2 providers per day teams 7 days per week for 2 more weeks. The 2 family physicians who joined Alana Rose, FNP-C, and myself provided needed relief and a fresh perspective looking forward to a post–outbreak reality at the facility.
- GOC conversations must be initiated early and reviewed as often as needed with residents and families. Assess potential transfers to hospital (eg, DNR/DNI, but not DNH)—plan daily sign-out with the ED staff and make sure transfer travels with POLST or ACP documentation. Plan daily sign-out with the on-call provider (eg, SCHC/FQHC provider during outbreak re: active patients; potential transfers).
- For DNH patients, make sure there are as-needed supplemental oxygen, morphine concentrate, and lorazepam intensol (and possibly atropine ophthalmic solution for excessive oral secretions) orders on hand and in Emergency Kit as patients may suddenly (and even simultaneously) deteriorate.
- Your team will only be as resilient as you have led them to be. It is important to bolster your teams in communication skills and unaddressed needs/distress levels before a pandemic strikes.
- Consider the unexpected. Be prepared for the competent nursing staff to be quickly overwhelmed by the stress of multiple very ill patients, staff becoming ill or declining to work, and loss of so many beloved patients in a brief period of time. Your management team may be the first to be affected by the pandemic virus or the first to be intermittently overwhelmed. Tall Pines social worker/admissions officer tested COVID-19 positive soon after the first 2 cases and returned to work 1 month later. Her assistance in communicating with families and fielding questions by the press may have afforded a more calm/tempered response to the outbreak. The assistant DON RN and her RN husband tested COVID-19 positive at the onset of the outbreak and were in isolation for more than 2 weeks, leaving only 1 ward RN for 4 wards. Thus, the DON, usually a strong/resilient leader, was easily/repeatedly overwhelmed and worked as a ward RN, which often meant also taking on a certified nursing assistant [CNA] role). The lead facility maintenance person tested COVID-19 positive within the first week of the outbreak and has not returned to work yet. Fortunately, the assistant maintenance person was employed 1 month before the COVID-19 facility outbreak, outages due to 2 April snowstorms, unusually high winds persisting for many days, generator failures, and ultimate demise after a weekly generator auto-check. (Consider the unexpected.) His unflappable, calm, competent manner helped mitigate the apocalyptic sense many of us shared as we grieved patient losses, struggled to support leadership, and were personally bereft and depleted.
- Clarify roles and responsibilities as soon as possible or in advance. Make sure others are oriented to essential aspects of these roles/responsibilities when other staff member needs to be out. It is essential that team members can admit if there is a task that is “too much” for them to manage (considering new demands). Tasks re-delegated are preferable to another staff member taking on too much and becoming overwhelmed and neglecting tasks/commitments. For example, a physical therapist unable to continue physical therapy sessions, stepped forward, assuming many roles: housekeeping, delivering meals, helping patients with bathing, dressing, and eating. She also developed a fluent system for tracking personal protective equipment (PPE) supplies. The activities director also relegated herself to ward duties and basic patient care. This pivoting into new roles early on in the outbreak mitigated the remaining staff members' sense of being overwhelmed, encouraged them to continue to work with more dignity, and provided much needed comradery in the midst of unrelenting loss and fatigue. Despite PPE including head cover, mask, face shield, gown, gloves, and shoe covers, our most vulnerable patients recognized the voice and laughter of “repurposed” staff members and were consoled.
- Consider that your “team” may also extend beyond your actual facility/organization. It might include local paramedics who were helpful in starting intravenous fluids for our residents. Your local hospital might be your best collaborator as was ours: WCGH/MaineHealth, which quickly pivoted their hospital preparations for a local surge to our facility. Family physician, Heather Ward, MD, WCGH primary care medical director, provided essential collaboration and connection to the outside medical staff, clinical services, and testing capacities, critical for our efforts in confronting this outbreak.Frequent ZOOM meetings with WCGH and Tall Pines leadership teams and Maine CDC representatives guided and informed us, especially at the height of the outbreak. We also had incredible support of the area behavioral health resources: director of Waldo County Hospice Volunteers (Flic Shooter) and WCGH chaplain (Jean Ashland) were essential in offering much needed support: connecting with families affected by loss and estrangement during this time with outdoor visits and approved phone calls. They supported residents through outdoor/window visits and provided outdoor staff visits 3 days per week. They offered ZOOM support huddles for staff, organized numerous gifts of support and encouragement for staff, posted signs of encouragement at multiple sites on the facility grounds, and organized area churches, whose congregations donated 40 meals per day for staff to take home at the end of long shifts when many, who are also solo family providers, were returning home to help with home schooling.
Community members set up bird feeders on poles; buckets of potted tulips and daffodils appeared outside patients' windows; musicians (fiddlers and accordion player) appeared randomly to offer music and dance. Staff appreciation and ongoing support were essential as committed staff members were saddened by loss, fatigued by working in understaffed wards, and angered by some negative press and social media posts. The Tall Pines activities director assumed being the contact person for the many community organizations that offered varied forms of support. This proved essential as leadership was initially hesitant to have attention brought to the facility and unsure of how to accept/organize an almost constant flow of community generosity.
- Too much communication with families is not possible. This should be a priority for daily updates, and some staff members may be able to manage this if a written log is available for providers to reference. We learned it was more important for providers to call families regularly and update them concerning patients' status, and we prioritized clinical changes: plan for COVID-19 testing and next-day results, the initiation and management of as-needed morphine, lorazepam, oxygen, and intravenous fluids. We initiated bereavement calls and asked permission for Hospice Volunteers director and WCGH chaplain to call in future for bereavement calls/letters.
- PPE management can be very challenging in the midst of a crisis. Multiple daily donations coincided with multiple staff shifts requests. It is important to designate staff person(s) and system (flow sheet) capable of managing supplies and accurate “burn rate.” This is essential in order to ensure continued supply. The role can include repurposing carts/coat hooks in entryway of wards when creating PPE stations on COVID wards. Tall Pines recruited Maine National Guard to perform 2 days of outdoors testing of staff for N95 masks before any more masks would be donated because of National Institute for Occupational Safety and Health (NIOSH) requirements.
- Huddles! Despite constant pressing needs/emergencies to address, it is imperative that regular (physically distanced) huddles occur at nursing stations. These provide clinical/operational updates and an opportunity to assess how staff members are coping on the ward. Providers need to supply this leadership/support if nursing staff leadership is overwhelmed. Additional “support huddles” by ZOOM 1 to 2 times per week to offer gratitude, support, and inspiration, with “outside” support (eg, medical director of hospice, formally a frequent/well-known PCP at Tall Pines) were appreciated by the staff during the height of the outbreak.
- A spreadsheet or COVID board of positive patients (with or without symptoms) helped guide us and convey information at beginning and end of day concerning code/transfer status, vital signs, and clinical status interventions: supplemental oxygen, intravenous fluids, and morphine. This was essential for orienting us and for daily sign-out with the local ED during the most active time of the outbreak.
- Cohort patients as able, which will depend upon stage you are in during a surge and availability of housecleaning and other staff members to clean and transition rooms. Because of attrition of the house cleaning staff and inability to recruit area cleaning services during the outbreak, the Maine National Guard provided 4 guard members who assisted with cleaning the facility, patient rooms, sorting, loading, labeling deceased patients' belongings, and transporting them to a large tent provided as a storage until families were able to pick up belongings.
- Prepare for management of multiple and even simultaneous clinical deteriorations and deaths. Consider having a nursing “non–code team” that can pivot responsibilities for the day (or recruit a per diem) if the tenor of the morning or evening suggests a potentially distressing shift. Consider replacing team members within one or two shifts if needed in order to avoid any charge nurse (licensed practical nurse [LPN]/RN) consecutively bearing the weight of these stressful scenarios. Find a way and the time to debrief with the affected staff. Unfortunately, we were unable to implement this formally in the midst of the outbreak and better coping and collaboration among staff members may have resulted from well-timed debriefing sessions.
- Your “help” will come in a form as clear as you make it. Early in the outbreak, WCGH, SCHC (PCHC), and Maine CDC Workforce Development asked for nursing staff and housekeeping needs either in our 3 per week ZOOM meetings or in e-mails or phone calls. Tall Pines leadership and Human Resources, historically accustomed to understaffed conditions, underestimated staffing needs. It is essential to not allow cross coverage and to assure staff to stay on the same ward regardless of working multiple shifts or roles. Prior to the COVID-19 outbreak, Tall Pines leadership and staff accepted 1 LPN or RN as night nurse covering the entire facility with 4 wards (usually 65 residents) and possibly 2 CNAs on each ward during the day and 1 at night. During the height of the outbreak, patients were simultaneously very ill and requiring much more care throughout the day and night. CNAs were more crucial than ever, providing all the usual care of their patients but now also offering social contact and stimulus as all patients were isolated in their rooms. Continuing to underestimate staffing needs frustrated outside agencies and complicated logistics of the quick-hire process.
On May, 10, 2020, the outbreak that started at Tall Pines Healthcare on April 8, 2020, was officially closed, 16 days after the last patient tested COVID-19 positive. Our Tall Pines community was changed beyond the toll imparted by 32 patient cases, 11 staff cases, 19 recovered cases, and 13 deaths due to COVID-19. The wards, the remaining patients and staff, and Alana and I looked different. We are different; we weathered April (“the cruelest month”) and emerged at the end of the outbreak with mixed feelings: relief tempered by apprehension; self-doubt laced with a modicum of pride for a “job well done” (or at least for being of use); grief not ready to be comforted by fond memories of our patients and their families. The Tall Pines community shared a COVID-19 outbreak experience that is uniquely our own; we will need time and the will and courage to heal ourselves by facing each other and acknowledging the “different.”
On May 12, 2020, Tall Pines executive director, DON, assistant DON, and I sat at separate tables in the dining room of the empty Birch Boulevard wing. (We had cohorted negative and recovered patients onto Alder Avenue and Cedar Court the week before.) We were waiting for the 2 pm Daily Maine CDC Update conducted by Dr Nirav Shah, Head of Maine's CDC. The wind was howling and the sky was gray, typical for the weather of the past 5 weeks in Maine, where many said spring was “cancelled” along with everything else. I noticed a pile of large, labeled plastic bags against the wall where patients should have been sitting in recliners watching the big screen or waiting for BINGO. I inquired and the executive director said, “The National Guard tent collapsed on Mother's Day when the snow was flying horizontally. I hauled the bags back inside.” Dr Shah announced the daily statistics starting with genuine, compassionate condolences to the families and friends of all those who had died of COVID-19; fortunately, no new deaths in the past day. In his calm, reassuring, measured manner, he announced the closure of the Tall Pines Nursing Health Care Facility outbreak and explained the epidemiologic relevance as the state's first facility outbreak to be closed. I looked around me at my 3 colleagues; I clapped softly and wept—again.