ACEP COVID-19 Field Guide

Author: Aisha T. Terry, MD, MPH, FACEP, Associate Professor of Emergency Medicine and Health Policy, George Washington University School of Medicine and Hospital, American College of Emergency Physicians, Board of Directors Member

Older adults and the elderly are particularly vulnerable populations relative to COVID-19. During the beginning of this pandemic in parts of China, Italy, and South Korea, the elderly who tested positive for COVID-19 presented with more severe symptoms and a greater mortality rate. A recent WHO report found that the case fatality rate for COVID-19 patients older than 80 years in China was 21.9%, while patients of all ages with no underlying chronic conditions had a fatality rate of only 1.4%. It should be considered that issues such as inadequate emergency department or ICU care, or a lack of resources, could also adversely affect mortality, and that age is one of many such factors. Mortality data from Italy reveal the staggeringly high risk of this virus in older adults. In Italy, where 23% of the population is over 65 years, 89% of COVID-19 deaths are those over 70 years (31% between 70 and 79 years; 58% over 80 years).

In the US, the first state to be hit the hardest by the COVID-19 pandemic was Washington, where many of the initial cases were among elderly nursing-home patients. In fact, a cluster of 23 older adult deaths was reported from a single nursing facility in Washington State in the early days of the pandemic in the US. Due to the physiologic changes of aging, decreased immune function, and multiple comorbidities, the elderly are at a significantly increased risk of contracting the infection and suffering from the more severe forms of complications from it. Moreover, making accurate and timely diagnoses in the elderly is often compromised because they tend to present with atypical symptoms, such as differing time courses of illness and lower-than-expected fevers. For example, older adults with respiratory viruses often present with a median duration from symptom onset to death of 11.5 days in persons greater than 70 years, while the median duration of symptoms to death in younger persons is 14 days. While fever is a common presenting complaint for viral illnesses, the definition of fever may need to be altered to account for the fact that fever is often blunted or absent in the elderly, even in the setting of serious infection. One study showed that among patients with a known diagnosis of influenza, only 32% of patients over 60 years had triage temperatures of over 37.8°C (100°F). This finding contradicts data from China that asserts that 83% of 99 inpatients with a mean age of 55 years (15% were over 70 years) exhibited fever. As such, the Infectious Diseases Society of America recommends modifying the definition of fever in adults to a single oral temperature over 37.8°C (100°F); two oral, repeated temperatures over 37.2°C (99°F); or an increase in temperature of 1.1°C (2°F) over the baseline temperature. 

Given the increased morbidity and mortality rates among the elderly with COVID-19 and other viral illnesses, prioritizing their testing and timely quarantining, as appropriate, should be considered. Older adults needing only COVID-19 and influenza testing, or those with less acute medical needs, should be referred to testing locations or medical settings outside of the emergency department. Those experiencing only subtle symptoms may be observed and monitored by caregivers where they live, with follow-up by telephone to support any changes in their condition. However, all patients at risk of COVID-19 should be appropriately isolated from other vulnerable populations, including older adults. 

Interfacility transfers

Older adults are a unique population given that they are more likely to live in group and nursing-facility residences. The decision to transfer from senior living (ie, nursing homes, assisted-living facilities, independent-living communities) to the emergency department for evaluation is often dependent on local emergency medical services (EMS). Triage is vital in that it influences emergency and inpatient capacity and resources while seeking to minimize risk of patient harm. The protocols used to determine transport vary and should be cooperatively adjusted to account for comorbid-illness burden, frailty, and the local prevalence and activity of disease. A community’s access to resources such as telehealth, community paramedicine, home-based primary care, home-health nursing, and facility-based complex care management will determine the most efficient and effective triage and transport protocol implemented. For older adults with less acute and milder symptoms who live in groups and need COVID-19 and influenza testing, the preferred testing location is outside of the emergency department, whenever possible. Individuals with only subtle and extremely mild symptoms may be observed and monitored for changes by caregivers where they live, with close follow-up with a medical professional as needed. All persons under investigation (PUIs) or at risk for COVID-19 should be appropriately isolated from others, particularly other vulnerable older adults, until a definitive conclusion can be made. 

Transfer of older patients to and from assisted care is critical in terms of optimal management of emergency department bed capacity. Emergency department crowding and boarding can be influenced by a nursing facility’s ability to receive transfers of their own patients back. Given the COVID-19 pandemic, on March 12, 2020, the Centers for Medicare and Medicaid Services (CMS) waived an important restriction to nursing home and skilled nursing facility (SNF) access called the “3-day rule.” This regulation required a minimum of 3 days of inpatient hospitalization for a patient to qualify for CMS payment of admission into SNF rehabilitation. Relaxation of this rule now allows direct transfer of appropriate, stable older adults to SNFs from the emergency department. The implications of this new transfer ability to free both emergency department and inpatient resources are significant and could greatly reduce capacity burdens related to stable patients who require only skilled care. SNFs may have limited ability to isolate patients with suspected COVID-19 infection due to a limited number of private rooms; therefore, advanced communication and planning between emergency departments, hospitals, and local SNFs must be prioritized to control infection and properly allocate space. Guidance has been provided by the CDC, CMS, and trade associations to reduce risk of transmission. It is paramount to provide advanced training to SNF and nursing facility workers in appropriate techniques. Opportunities for emergency department personnel to educate nursing facility and home-health workers, such as physical therapists, about infection control may be available. Instructions for implementation of isolation and contact precautions include the CDC’s “Implementation of Personal Protective Equipment (PPE) in Nursing Homes to Prevent Spread of Novel or Targeted Multidrug-Resistant Organisms (MDROs).” 

Medication management

In managing COVID-19, it is important to ensure that older patients have timely and adequate access to their prescribed and over-the-counter medications. Efforts should be made to avoid unnecessary exposure to infection by limiting the need for patients and their loved ones to visit pharmacies to retrieve medications. Dispensing medications directly to patients at discharge and encouraging home delivery of medications are potential solutions. Caregivers should be instructed to review the patient’s medications to ensure access to an adequate supply. Having an extra supply of medications on hand during times of quarantine is recommended. In some cases, providing patients with a 30- to 90-day supply of medication may be warranted. A “quantity limit exception insurance form” may allow patients to obtain early refills. Such Medicare forms can be found at www.Express-Scripts.com. Many plans already allow these exceptions, given that COVID-19 has been declared a National State of Emergency.

Mental health and social-isolation implications

Frequent news and social media reports about COVID-19 can provoke anxiety in all populations. Given that up to 30% of older adults have some degree of age-related cognitive impairment, they are at an increased risk of having difficulty with navigating rapidly evolving situations. Sleep and maintenance of circadian rhythms are vital to immune function, as sleep deprivation affects various components of the immune system, such as the percentage of CD4+ and CD8+ cells, subpopulations, and cytokine levels. Therefore, a simple, yet effective, recommendation for mitigating anxiety and preventing transmission of infection during crises, such as COVID-19, is to sleep well. Regular, clear communication with patients who are at particular risk of anxiety is recommended. Checking in with patients’ family and caregivers is also essential to providing proper mental health management of patients at risk of cognitive limitations, while also providing reassurance to their loved ones.

Many older patients experience isolation at baseline, due to institutionalization, as well as impaired function and cognition. For these patients, visitation by family and friends brings tremendous meaning to their lives. Thus, isolation due to social distancing and quarantine can exacerbate baseline issues around isolation and create grief relative to the lost sense of connection. Furthermore, a lack of regular interaction with older patients during times of social distancing and quarantine can decrease the caregiver’s ability to recognize changes in cognition, function, and general health status. Caregivers, family, friends, and community should regularly reach out to older adults by phone or video conference, especially during times of isolation. 

Some helpful resources for patients:

• Guide providing information on virtual and in-person activities for seniors facing loneliness: Virtual and In-Person Activities for Seniors
• AARP List of FREE interactive online events and classes designed for learning, self-improvement, and fun. Available at: Virtual Community Center

Older adults in health care

Many physicians, nurses, and other health care workers are themselves older adults; hence, they are at high risk during this pandemic. Those with health concerns should be invited to take breaks from clinical practice to allow their younger counterparts to provide direct patient care or should consider using telehealth strategies to provide patient care. Physician and nursing administration may need to consider flexible staffing hours to fill openings and strengthen the back-up system to supply workers in the likely event workers are unable to work due to illness or quarantine. Health care workers who have COVID-19 symptoms (fever, cough, shortness of breath) should remain at home. Health professionals should be directed to the latest and reliable resources for COVID-19 testing and information. 

References

1. Malone ML, Hogan TM, Perry A, et al. COVID-19 in older adults: key points for emergency department providers. The Geriatric Emergency Department Collaborative website. 2020 Mar 21.
2. Hwang U, Malsch AJ, Biese KJ, Inouye SK. Preventing and managing delirium in older emergency department patients during the COVID-19 pandemic. The Geriatric Emergency Department Collaborative website. 2020 Mar 21.
3. Addiction Connections Resource; ADvancing States; African American Health Alliance; et al. Recommendations to protect the health of America’s older adults during COVID-19. Trust for America’s Health website. 2020 Mar 27.
4. Khoujah D, Martin P, Malsch A. Emergency department discharge of older adults with viral syndrome during the COVID-19 pandemic. 2020 Apr 9;1(4 suppl 2):1-2.