Post-acute and long-term care (PA-LTC) facilities provide care to frail and vulnerable older adults. Approximately 1.5 million individuals (<0.5% of the total United States population) reside in nursing homes, yet these individuals have accounted for approximately 25% of the documented deaths attributed to coronavirus disease 2019 (COVID-19) (Grabowski & Mor, 2020). As of May 28, 2020, the State Reports of Long-Term Care Facility Cases and Deaths Related to COVID-19 have reached 39,039 (Chidambaram, 2020). Unfortunately, variability remains in nursing home cases due to testing capabilities and reporting despite action taken on April 19, 2020 (Centers for Medicare & Medicaid Services, 2020).
Nursing is at the helm of providing care within the PA-LTC setting. A major duty of nurses is medication administration, a complex and highly time-consuming process. Numerous medications are commonly ordered multiple times per day at specific times. In addition, these medications may need to be administered via enteral tubes, or to residents whose cognitive or swallowing impairments create additional challenges. For this reason, preparing and “passing” (i.e., administering) medications often consumes a tremendous proportion of nursing and other staff time, can be perceived as problematic and inefficient, and is a common source of error (Kaasalainen et al., 2010; Scott-Cawiezell et al., 2007). In addition, many medication orders have hold parameters or criteria for additional doses, which further increase the burden on nursing staff.
During the current pandemic, these challenges may be stretched to the breaking point. Inconsistent and insufficient staffing can slow down an already laborious process, as shown in a time-and-motion study, which found that nursing staff who are not familiar with residents and/or the facility took 32% longer to complete a medications pass (Thomson et al., 2009). Donning and doffing personal protective equipment and other infection control measures further add time, complexity, and potential for error. Frequent, close contacts between nursing staff and residents during medication passes may increase risk of disease transmission in either direction. Finally, all of the aforementioned challenges faced by nursing staff further strains staff members and decreases the time they have to perform other essential activities for residents.
To address this challenge, a multi-disciplinary team took action to provide practical guidance on strategies to improve medication management and support the efforts of frontline staff within these care settings. The goal of the implementation guide is to improve resident-centered health and well-being by reducing use of unnecessary medications and the potential for related adverse events, simplifying medication management, and reducing opportunities for transmission of COVID-19 between residents and staff (Peter Lamy Center on Drug Therapy and Aging, 2020). The current article reviews principles of this guide adapted from a previous publication (Brandt & Steinman, 2020), as well as provides resources to help the entire team (“village”) navigate the challenges of managing medications during this pandemic.
Optimizing Medication Management Rationale and Approach
Streamlining medication administration may increase the time that staff have available for other direct care activities (Liebel & Watson, 2005). There is precedent for this type of effort from a recently published trial—the Simplification of Medication Prescribed in Long-Term Care Residents (SIMPLER)—which, using fairly simple changes to medication orders, led to a sustained reduction in number of medication administration times (Sluggett et al., 2020). The guide offers a series of recommendations (Table 1). Its goal is to address some “low-hanging fruit” that can often be changed fairly quickly (Ouslander, 2020). For instance, some recommendations focus on reducing use of medications that are often unnecessary or inappropriate, including certain vitamins and herbal medications, which are commonly used but rarely have a compelling indication, as well as medications inappropriate for a person's circumstances, such as long-term preventive medications for a person with limited life expectancy. Because of the imperative to reduce resident–staff contact in high-risk situations of potential infection transmission, it may also be advisable to temporarily discontinue bisphosphonates and vitamin B12. These medications/vitamins often have appropriate therapeutic uses but may be able to be held for a period of weeks to a few months without compromising goals of care.
Recommendations to Reduce Medication Burden
Very frequent monitoring related to medications is often unnecessary, burdensome to residents and staff, and associated with more harm than good. For instance, use of short-acting insulins in vulnerable older adults with type 2 diabetes is a paradigmatic example (Lipska et al., 2016). The guide thus suggests re-evaluating whether short-acting insulins can be eliminated in favor of using only long-acting insulins or oral medications. Even among residents with diabetes who are not on insulin, monitoring can be tapered to a minimum number of finger sticks depending on the stability of glucose levels.
Major gains may also be achieved by reducing the number of medication passes required per resident. This reduction in passes can involve converting medications and medication regimens to alternatives that require less frequent dosing and consolidating and aligning the administration of medications to a limited number of times. For instance, twice-daily metoprolol tartrate can often be safely converted to once-daily metoprolol succinate. Long half-life statins, such as atorvastatin, have similar effects on lipids regardless of time of dosing, and thus can be safely administered during the day with other medications rather than making a separate visit to dose at bedtime (Awad et al., 2017).
Finally, certain infection and prevention control issues merit close attention. For instance, in attempts to reduce potential aerosolization of virus, conversion from nebulizers to handheld inhalers (e.g., metered-dose inhalers with a spacer) should be considered where possible (Lavorini et al., 2016). Reducing opportunities for contact-based transmission of virus by observing hand hygiene for residents prior to passing medications and avoiding direct hand-to-hand contact where feasible may reduce risks of disease transmission (Cao et al., 2016).
COVID-19 Treatment Resources and Guidance
During times of uncertainty, it is critical to look to the support of the interprofessional team. Interprofessional collaboration has not only been critical in the development of the implementation guide, but also with the rapidly evolving treatment approaches for this virus. When treating primarily frail older adults in the PA-LTC setting, it is important to look at the risks and benefits of all treatment approaches (Table 2).
Summary of COVID-19 Treatment Approaches
The use and efficacy of hydroxychloroquine remain an ongoing debate. To date, leading medical organizations, such as the National Institutes of Health (NIH; 2020) and the Infectious Diseases Society of America (IDSA; 2020), have concluded that there is not enough evidence to support the use of hydroxychloroquine for the treatment of COVID-19. Randomized controlled trials are still needed to guide treatment with hydroxychloroquine and clinical trials are currently enrolling to fill in the knowledge gap regarding hydroxychloroquine.
Chen et al. (2020) enrolled a total of 62 patients in a randomized clinical trial (RCT) demonstrating that patients with COVID-19 treated with hydroxychloroquine had a shorter time to clinical recovery by approximately 1 day. On the other hand, treatment with hydroxychloroquine has been associated with cardiovascular side effects, such as myocarditis and QTc prolongation (Keshtkar-Jahromi & Bavari, 2020). In fact, because COVID-19 has also appeared to induce myocarditis and other cardiovascular events, treatment with hydroxychloroquine could potentially precipitate cardiovascular events (Keshtkar-Jahromi & Bavari, 2020). As such, hydroxychloroquine use is cautioned, particularly in patients with a history of QT prolongation or heart disease (American College of Cardiology, 2020; Guastalegname & Vallone, 2020; Gupta & Misra, 2020). In addition, the risk of hydroxychloroquine toxicity is increased in patients with acute renal or hepatic failure; thus, use of hydroxychloroquine is recommended against in those patient populations.
Remdesivir is another treatment option, which has been investigated in two RCTs for its use in COVID-19. The Adaptive COVID-19 Treatment Trial (ACTT) is a multinational trial that presented preliminary data suggesting that compared to placebo, remdesivir shortened the time to recovery in patients hospitalized with COVID-19 and had evidence of lower respiratory tract infection (Beigel et al., 2020). Similar to the ACTT, a Chinese-based RCT also supported the results of a shortened time to recovery in patients hospitalized with COVID-19 (Wang et al., 2020). However, this reduction in time to recovery was not statistically significant. In comparing the trials, the Chinese-based RCT permitted co-administration of lopinavirritonavir, which has also started to be investigated for the treatment of COVID-19. Moreover, although the patient population of the ACTT was younger (mean age = 58.9 years) than the Chinese-based RCT (median age = 65 years), the patient populations for both trials were notable for having more severe or progressive COVID-19 (Beigel et al., 2020; Wang et al., 2020).
In contrast with hydroxychloroquine, the most common side effects associated with remdesivir include gastrointestinal symptoms (e.g., constipation, nausea, vomiting), elevated aminotransferase levels, anemia, and prothrombin time elevation (Beigel et al., 2020; NIH, 2020; Wang et al., 2020). In addition, because remdesivir is formulated in an excipient that is renally cleared, patients with severe renal impairment (i.e., estimated flomerular filtration rate <30 mL/min) were not included in either of the aforementioned RCTs. As such, caution should be exercised in patients with severe renal impairment.
At this time, according to NIH guidance, remdesivir is recommended for treatment of COVID-19 only in hospitalized patients with severe disease, which is defined as having an oxygen saturation (SpO2) level <94% on ambient air, requiring supplemental oxygen, extracorporeal membrane oxygenation, or mechanical ventilation. IDSA guidance is not available on remdesivir, as the guidelines were published before data on remdesivir were available. Similar to hydroxychloroquine, more evidence, particularly in older adults, is needed to guide safe and efficacious use of remdesivir for the treatment of COVID-19.
Communication Tactics to Avoid Unintended Consequences
Throughout this process, attention to communication among all members of the health care team is essential, including prescribing clinicians and frontline staff who have a ringside view of challenges and can provide critical insights about workflow. Communication with residents and their family, friends, or other care partners is also essential. Medication discontinuation and other changes can engender fear of the unknown, perceptions of abandonment, and cognitive dissonance (e.g., “My previous doctor told me it was essential to take this medicine and now you are saying I should stop/change it?”) (Reeve et al., 2016). Addressing such concerns and attending to the emotion behind them is critical to successful changes, and unless changes are urgently necessary due to health or safety considerations, it is best to achieve buy-in before changes are made. It is imperative to be attentive to potential unintended consequences of these changes and take proactive steps to prevent and mitigate their impacts.
Implications for Nurses as Leaders of The Interdisciplinary Team
Nurses within the PA-LTC setting are in critical roles to provide education to residents and their families to reduce the risk of disease transmission (Munanga, 2020). During this pandemic, nurses have been leading the delivery of care and they need to be supported. Tools to optimize medication regimens, such as the Medication Management Guide (Peter Lamy Center on Drug Therapy and Aging, 2020), provide a resource for nurses to feel empowered to tackle challenges presented by COVID-19 and provide resident-centered care ideally in collaboration with the interprofessional team (Table 3).
Education and Communication Resources for COVID-19
The value of the medication guide and the implications will hopefully continue well beyond COVID-19. It takes a “village” to optimize medications, as well as critically evaluate treatment approaches that are the safest and most effective for frail older adults with multiple comorbidities receiving care in PA-LTC settings. Oftentimes, we do not have all of the answers but it is critical to use evidence-based tactics well supported with literature to help in decision making. Rapid and easy access to necessary tools, including evidence-based standards, algorithms, and care plans embedded within the workflow, is critical. That is why, now more than ever, collaboration and communication are critical to optimize not only the medication regimen, but also the delivery of care for older adults.
- American College of Cardiology. (2020, March29). Ventricular arrhythmia risk due to hydroxychloroquine-azithromycin treatment for COVID-19. https://www.acc.org/latest-in-cardiology/articles/2020/03/27/14/00/ventricular-arrhythmia-risk-due-tohydroxychloroquine-azithromycin-treatment-for-covid-19
- Awad, K., Serban, M. C., Penson, P., Mikhailidis, D. P., Toth, P. P., Jones, S. R., Rizzo, M., Howard, G., Lip, G. Y. H. & Banach, M. (2017). Effects of morning vs evening statin administration on lipid profile: A systematic review and meta-analysis. Journal of Clinical Lipidology, 11(4), 972–985.e9. doi:10.1016/j.jacl.2017.06.001 [CrossRef] PMID:28826569
- Beigel, J. H., Tomashek, K. M., Dodd, L. E., Mehta, A. K., Zingman, B. S., Kalil, A. C., Hohmann, E., Chu, H. Y., Luetkemeyer, A., Kline, S., Lopez de Castilla, D., Finberg, R. W, Dierberg, K., Tapson, V., Hsieh, L., Patterson, T. F., Paredes, R., Sweeney, D. A., Short, W. R. & Lane, H. C.the ACTT-1 Study Group Members. (2020). Remdesivir for the treatment of Covid-19—Preliminary report. The New England Journal of Medicine. Advance online publication. doi:10.1056/NEJMoa2007764 [CrossRef] PMID:32445440
- Brandt, N. & Steinman, M. A. (2020). Optimizing medication management during the COVID-19 pandemic: An implementation guide for post-acute and long-term care. Journal of the American Geriatrics Association. Advance online publication. doi:10.1111/jgs.16573 [CrossRef] PMID:32424906
- Cao, J., Min, L., Lansing, B., Foxman, B. & Mody, L. (2016). Multidrug-resistant organisms on patients' hands: A missed opportunity. JAMA Internal Medicine, 176(5), 705–706 doi:10.1001/jamainternmed.2016.0142 [CrossRef] PMID:26974592
- Centers for Medicare & Medicaid Services. (2020, April19). Upcoming requirements for notification of confirmed COVID-19 (or COVID-19 persons under investigation) among residents and staff in nursing homes. https://www.cms.gov/files/document/qso-20-26-nh.pdf
- Chen, Z., Hu, J., Zhang, Z., Jiang, S., Han, S., Yan, D., Zhuang, R., Hu, B. & Zhang, Z. (2020). Efficacy of hydroxychloroquine in patients with COVID-19: Results of a randomized clinical trial. medRxiv. Advance online publication. doi:10.1101/2020.03.22.20040758 [CrossRef]
- Chidambaram, P. (2020, April23). State reporting of cases and deaths due to COVID-19 in long-term care facilities. https://www.kff.org/medicaid/issue-brief/state-reporting-of-cases-and-deaths-due-to-covid-19-in-long-term-care-facilities
- Grabowski, D. C. & Mor, V. (2020). Nursing home care in crisis in the wake of COVID-19. Journal of the American Medical Association. Advance online publication. doi:10.1001/jama.2020.8524 [CrossRef] PMID:32442303
- Guastalegname, M. & Vallone, A. (2020, March24). Could chloroquine/hydroxychloroquine be harmful in coronavirus disease 2019 (COVID-19) treatment?Clinical Infectious Diseases. Advance online publication. doi:10.1093/cid/ciaa321 [CrossRef] PMID:32211771
- Gupta, R. & Misra, A. (2020). Contentious issues and evolving concepts in the clinical presentation and management of patients with COVID-19 infection with reference to use of therapeutic and other drugs used in comorbid diseases (hypertension, diabetes etc). Diabetes & Metabolic Syndrome, 14(3), 251–254 doi:10.1016/j.dsx.2020.03.012 [CrossRef] PMID:32247213
- Infectious Diseases Society of America. (2020). Infectious Diseases Society of America guidelines on the treatment and management of patients with COVID-19. https://www.idsociety.org/practice-guideline/covid-19-guideline-treatment-and-management
- Kaasalainen, S., Agarwal, G., Dolovich, L., Papaioannou, A., Brazil, K. & Akhtar-Danesh, N. (2010). Nurses' perceptions of and satisfaction with the medication administration system in long-term-care homes. Canadian Journal of Nursing Research Archive, 42(4), 58–79 PMID:21319638
- Keshtkar-Jahromi, M. & Bavari, S. (2020). A call for randomized controlled trials to test the efficacy of chloroquine and hydroxychloroquine as therapeutics against novel coronavirus disease (COVID-19). The American Journal of Tropical Medicine and Hygiene, 102, 932–933 doi:10.4269/ajtmh.20-0230 [CrossRef] PMID:32247318
- Lavorini, F., Mannini, C., Chellini, E. & Fontana, G. A. (2016). Optimising inhaled pharmacotherapy for elderly patients with chronic obstructive pulmonary disease: The importance of delivery devices. Drugs & Aging, 33(7), 461–473 doi:10.1007/s40266-016-0377-y [CrossRef] PMID:27216613
- Liebel, D. V. & Watson, N. (2005). Consolidating medication passes: It can lead to more time with patients. The American Journal of Nursing, 105(12), 63–64 doi:10.1097/00000446-200512000-00034 [CrossRef] PMID:16327394
- Lipska, K. J., Krumholz, H., Soones, T. & Lee, S. J. (2016). Polypharmacy in the aging patient: A review of glycemic control in older adults with type 2 diabetes. Journal of the American Medical Association, 315(10), 1034–1045 doi:10.1001/jama.2016.0299 [CrossRef] PMID:26954412
- Munanga, A. (2020). Critical infection control adaptations to survive COVID-19 in retirement communities. Journal of Gerontological Nursing, 46(6), 3–5 doi:10.3928/00989134-20200511-03 [CrossRef]
- National Institutes of Health. (2020). Coronavirus disease 2019 (COVID-19) treatment guidelines. https://www.covid19treatmentguidelines.nih.gov
- Ouslander, J. G. (2020). Improving drug therapy for patients with life-limiting illnesses: Let's take care of some low hanging fruit. Journal of the American Geriatrics Society, 68(4), 682–685 doi:10.1111/jgs.16395 [CrossRef] PMID:32129903
- Peter Lamy Center on Drug Therapy and Aging. (2020). Optimizing medication management during the COVID-19 pandemic: Implementation guide for post-acute and long-term care. https://www.pharmacy.umaryland.edu/centers/lamy/optimizing-medication-management-during-covid19-pandemic
- Reeve, E., Low, L. F. & Hilmer, S. N. (2016). Beliefs and attitudes of older adults and carers about deprescribing of medications: A qualitative focus group study. The British Journal of General Practice, 66(649), e552–e560 doi:10.3399/bjgp16X685669 [CrossRef] PMID:27266865
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- Sluggett, J. K., Hopkins, R. E., Chen, E. Y., Ilomäki, J., Corlis, M., Van Emden, J., Hogan, M., Caporale, T., Ooi, C. E., Hilmer, S. N. & Bell, J. S. (2020). Impact of medication regimen simplification on medication administration times and health outcomes in residential aged care: 12 month follow up of the SIMPLER randomized controlled trial. Journal of Clinical Medicine, 9(4), 1053 doi:10.3390/jcm9041053 [CrossRef] PMID:32276360
- Thomson, M. S., Gruneir, A., Lee, M., Baril, J., Field, T. S., Gurwitz, J. H. & Rochon, P. A. (2009). Nursing time devoted to medication administration in long-term care: Clinical, safety, and resource implications. Journal of the American Geriatrics Society, 57(2), 266–272 doi:10.1111/j.1532-5415.2008.02101.x [CrossRef] PMID:19170782
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Recommendations to Reduce Medication Burdena
|Medication Recommendation||Examples or Comment|
|Discontinuation (temporary or permanent)||Vitamins, herbal medications, appetite stimulants, bisphosphonates (temporarily), long-term preventive medications (e.g., statins, aspirin) in people with comfort-oriented goals or limited life expectancy|
|Less frequent dosing||Convert metoprolol tartrate to metoprolol succinate; consolidate laxatives to be administered at a single time; discontinue short-acting insulins|
|Change in monitoring||Consider reduced frequency of monitoring of pulse, blood pressure, fingerstick glucose in residents who are stable; if a medication requires frequent checks but may not be needed (e.g., short-acting insulins), consider discontinuation|
|Administer at different times to reduce number of medication passes||Administer statins, alpha blockers with other medications during the day (i.e., not a separate pass at bedtime)|
|Align medication administration times||Eliminate outlier medication administration times if not necessary; change “every 12 hours” medications to “twice daily” unless medication requires precise dosing interval|
|Enhance hygiene during medication passes||Observe resident hand hygiene prior to handing medications; if appropriate, place medications on bedside table rather than handing directly to resident|
Summary of COVID-19 Treatment Approaches
|Hydroxychloroquine||Has had some in vitro activity against SARS-CoV-2
Demonstrated shortened time to recovery in patients with COVID-19||Cardiotoxicity is the most concerning side effect (i.e., QRS/QTc prolongation, arrhythmias)
Not recommended with acute renal and hepatic failure||Baseline ECG, renal/hepatic function, serum potassium, serum magnesium should be obtained
Follow-up ECG monitoring is recommended in patients at moderate risk or higher of QTc prolongation|
|Remdesivir||Demonstrated in vitro activity against SARS-CoV-2
Demonstrated shortened time to recovery in patients with severe COVID-19||Common side effects include GI symptoms, elevated aminotransferase levels, elevated prothrombin levels, and anemia
Not recommended in patients with severe renal impairment (eGFR <30 mL/min)||Renal and hepatic function should be monitored at base-line and throughout therapy
Serum chemistries and hematologic studies should also be monitored at baseline and throughout therapy|
Education and Communication Resources for COVID-19
|American Society of Consultant Pharmacists (ASCP)
Help with My Meds
|Handouts, videos, and information on COVID-19||www.HelpWithMyMeds.org|
|American Geriatrics Society (AGS)
|Basic facts on COVID-19, including causes of the virus, symptoms, and care and treatment of COVID-19
Hyperlinks to reputable agencies that provide information on COVID-19||https://www.healthinaging.org/a-z-topic/covid19|
|US Deprescribing Research Network (USDeN) & University of Maryland Peter Lamy Center on Drug Therapy and Aging
Optimizing Medication Management During the COVID-19 Pandemic: Implementation Guide for Post-Acute and Long-Term Care (PA-LTC)
|Recommendations on optimizing medication management in PA-LTC settings
Regulatory considerations regarding evaluating medication administration, management, and monitoring
Additional resources to supplement guide, including dose conversion tables and sample letters to prescribers or residents||https://deprescribingresearch.org/covid-19-response-in-post-acute-and-long-term-care-task-force-develops-new-guide-to-optimize-medications|
|Society for Post-Acute and Long-Term Care Medicine
Heat map (1)
Guidance and tools for LTC facilities (2)
Podcasts and webinars (3)
In conjunction with the ASCP, displays prevalence of COVID-19 in nursing homes and assisted living facilities throughout the United States
Guidance documents, tools, and resources for patients and health care professionals regarding COVID-19
Updates in the form of emails, podcasts, and webinars on COVID-19