Jan 25, 2021
By Monakshi Sawhney , Michael J. Lamb , Anthony La Delfa

Mobilizing an interprofessional IPAC-SWAT team to long-term care during COVID-19

istockphoto.com/frazaostudioMany long-term care facilities in Ontario did not have the education, staff, or resources to manage COVID-19 outbreaks independently. However, the IPAC-SWAT team was effective in assisting care homes in managing their respective outbreaks. The team’s strategy, engagement plan, construction, and mandate were created ad hoc and modified based on observations and feedback.

Takeaway messages

  • A team specializing in infection, prevention, and control (IPAC) and focusing on strengths, weaknesses, and threats (SWAT) was created to help three long-term care facilities in Toronto.
  • The expertise and clinical experience of the IPAC-SWAT team members played an important role in modifying IPAC practices at the facilities to maximize safety for residents and staff.
  • While there was no significant difference regarding the number of beds or the number of residents and staff diagnosed with COVID-19, the mean length of outbreak was 10.7 days shorter in facilities that received support from the IPAC-SWAT team. This finding was clinically significant.

Nurses and physicians are on the front line of the COVID-19 pandemic in Canada. This includes providing direct care for patients with a COVID-19 diagnosis, COVID-19 testing, and education on COVID-19 outbreak prevention and management.

Outbreaks of COVID-19 have negatively affected older adults and specifically residents of long-term care facilities. In Canada, 89.6% of all COVID-19-related deaths have occurred in individuals who are 70 years of age or older (Government of Canada, 2020a). In Ontario, by the summer of 2020, there were 454 long-term care outbreaks, with 64.5% (1,831/2,837) of all deaths occurring in residents of these facilities and 8 deaths reported among health-care workers employed by them (Government of Canada, 2020b; Public Health Ontario, 2020).

In April 2020, the government of Ontario requested that hospitals provide infection, prevention, and control (IPAC) support to long-term care facilities (Government of Ontario, 2020a, 2020b; Stall et al., 2020). Following this request, North York General Hospital, a community teaching hospital in Toronto, mobilized support in the form of a COVID-19 IPAC-SWAT team. (SWAT stands for strengths, weaknesses, and threats.)

Highlights

The interprofessional IPAC-SWAT team consisted of the following:

  • One geriatric emergency management clinical nurse specialist
  • Five emergency department registered nurses (RNs)
  • One nurse coordinator
  • One resource team RN
  • One nurse practitioner (NP) (surgery)
  • Two physicians (one internal medicine, one infectious diseases)

The team was led by the NP and physicians with support of the hospital’s director of IPAC and medical director of IPAC, two project managers, and two vice-presidents (VP strategy and integration, and VP planning and development).

The IPAC-SWAT team was deployed to three long-term care facilities that had both residents and staff diagnosed with COVID-19 in order to assist with their outbreak management between April and July 2020. Prior to deployment all members of the team were trained on appropriate hand hygiene practices, donning/doffing of personal protective equipment (PPE), and fundamentals of COVID-19. The team’s PPE was provided by the hospital and consisted of ear-loop procedure masks, face shields, and alcohol-based hand rub. Gowns and gloves were used only if direct care was provided. N95 respirators were not used by any team member.

Implementation

The expertise and clinical experience of the IPAC-SWAT team members played an important role in modifying IPAC practices as these applied to providing care to residents.

The provincial government funded IPAC-SWAT teams in Ontario. At North York General Hospital, vice-presidents and directors provided ongoing direct support for the team members. Project managers made the initial contact with the long-term care facilities to offer support in obtaining PPE and to arrange for the team to provide assessment using the Public Health Ontario IPAC checklist (Public Health Ontario, 2020b). Three of the long-term care facilities were provided assistance with their outbreak management.

All three facilities were given formal education and relevant training on COVID-19 disease transmission, active screening of residents and staff, donning and doffing of PPE, appropriate and safe mask and visor use and storage, hand hygiene, principles of droplet and contact precautions, cohorting, communal dining, group activities, and visits with family members. In addition, our team provided post-education audits, trained local IPAC champions, and created written guidelines for outbreak management.

The expertise and clinical experience of the IPAC-SWAT team members played an important role in modifying IPAC practices as these applied to providing care to residents.

IPAC-SWAT team nurses were able to assist nurses and personal support workers (PSWs) in modifying their daily activities to maximize safety for residents and staff. An example of this was strategizing how medications such as eye drops and insulin pens could be disinfected after resident use and before they are returned to a medication cart.

Environmental cleaning was another intervention that was deemed imperative for decreasing the viral load and subsequent transmission. Training regarding cleaning practices was provided to nurses, PSWs, and environmental services staff. Focus was placed on increased frequency of high-touch surface cleaning, proper application and contact time of disinfecting chemicals, and terminal cleaning of resident rooms. Appropriate cleaning of shared equipment, such as vital signs machines and thermometers, was also discussed. Deployment of environmental services staff occurred in two of the long-term care facilities to supplement staff and expertise.

Courtesy of Monakshi SawhneyThe North York General IPAC-SWAT team members from left to right: Anthony La Delfa, MD; Monakshi Sawhney, NP(Adult); Judith Minsky, RN; Diana Adams, RN; Karoleen Abdel-Shahied, RN; Desiree Crawford, RN; Kaitlin Vandenbroek, RN; Shakhnoz Niezova, RN; Kaitlin Gurr, RN; Michael J. Lamb, MD.

Results

To better understand whether our interventions were effective, we compared the length of outbreaks in the three facilities with six long-term care facilities in Toronto with similar outbreaks. Ethics review was obtained from the research ethics board at North York General Hospital. We also examined the length of outbreaks after the IPAC-SWAT team intervention, the number of on-site visits by the SWAT team, and the facilities’ satisfaction with our interventions.

The three hospital IPAC-SWAT-assisted facilities were matched with six other facilities in Toronto based on the number of beds in each facility and the number of residents and staff who were diagnosed with COVID-19 (according to the data obtained by Toronto Public Health on August 6, 2020).

To avoid bias, we conducted a statistical analysis to ensure there were no differences among the long-term care facilities. Owing to the small sample size, we used an independent-samples Mann-Whitney U test to compare the number of beds in the facilities, the number of residents and staff diagnosed with COVID-19, and length of outbreaks for hospital-assisted facilities versus the matched facilities (Pallant, 2016).

There was no significant difference regarding the number of beds or the number of residents and staff diagnosed with COVID-19 in the facilities among the three that our IPAC-SWAT team assisted compared to the six matched facilities (see Table 1). Two of the facilities that our IPAC-SWAT team assisted had outbreaks for more than 30 days prior to the team’s intervention. There was no statistical difference in the mean length of outbreaks in those facilities that were assisted by our team and the matched facilities. However, the mean length of outbreak was 10.7 days shorter in the facilities our team assisted, a finding that was clinically significant (see Table 2).

Personnel were satisfied with the on-site COVID-19 outbreak management provided by our team and felt that we positively affected their ability to manage current and future outbreaks

The number of visits to the facilities by our team was 15 (SD=5.6), and the length of each visit varied between one and eight hours, with longer hours being spent at the beginning of the outbreak management interventions (see Table 3).

To facilitate regular communication between the facilities, the hospital, and the associate medical officer of Toronto Public Health, regular telephone “huddles” were conducted. Hospital personnel involved with the huddles included the medical director or director of IPAC, the project manager, the NP and physician co-leads of the IPAC-SWAT team, and the director of environmental services. RN team members were included in the huddles for the facilities they were directly supporting. From the long-term care facilities, administrative managers, directors of care, corporate administrators, and medical directors were invited to participate in these calls. Huddles focused on discussing outbreak management and prevention. Twenty-nine huddles were completed across the three facilities, with a mean of 9.7 (SD = 2.5) huddles per facility.

Anonymous electronic surveys were distributed to directors of care at all three facilities. These personnel were satisfied with the on-site COVID-19 outbreak management provided by our team and felt that we positively affected their ability to manage current and future outbreaks. All three facilities remained free of further outbreaks at 90 days post-outbreak.

Lessons learned

Many long-term care facilities in Ontario did not have the education, staff, or resources to manage COVID-19 outbreaks independently. However, our IPAC-SWAT team was effective in assisting care homes in managing their respective outbreaks. The team’s strategy, engagement plan, construction, and mandate were created ad hoc and modified based on observations and feedback.

Long-term care facilities were not required to have an IPAC-SWAT assessment and respective education. This meant that North York General Hospital had to actively engage with each facility directly to build a partnership that would allow our team to enter them. It is unclear whether the duration of the outbreaks could have been shortened or prevented if the IPAC-SWAT team had been accessed earlier.

A unique feature of the hospital’s response was the interprofessional make-up of our team. The combination of RNs, an NP, and physicians facilitated stronger connections with staff in the care facilities, with identification of realistic IPAC strategies that could be applied while providing care to residents. Collaboration was further fostered by the amount of time spent on site at each of these facilities combined with the multiple telephone huddles.

Next steps

During the time period of April to July 2020, our IPAC-SWAT team provided assessments and education to more than 25 long-term care facilities, retirement homes, and other congregate care settings in North York General Hospital’s catchment area. Our team also assisted homes with fall 2020 preparedness. The goal of fall 2020 preparedness sessions was to facilitate the institutions’ ability to prevent future COVID-19 outbreaks. No one has been afforded foresight during this global crisis, but the hope is that by sharing our experience, these strategies can be replicated if needed.

Acknowledgments

Members of the North York General Hospital IPAC-SWAT initiative include Dr. K. Katz, M. McGuire, S. Daub, R. Dahdal, K. Abdul-Shahied, D. Adams, J. Schembri, T. Belfer, J. Minsky, D. Crawford, K. Gurr, S. Neizova, and K. Vandenbroek.

Tables

(Tables are best viewed on a desktop computer.)

istockphoto.com/byryo

Table 1
Resident and staff cases, length of outbreak, and number of beds in long-term care facilities

Setting ID number IPAC-SWAT visit Residents COVID-19 diagnosis, no. Staff COVID-19 diagnosis, no. Length of outbreak (days) Number of beds in facility
1 Y 83 21 82 195
2 Y 44 5 61 194
3 Y 2 2 20 378
4 N 86 41 90 128
5 N 79 40 97 215
6 N 35 6 63 55
7 N 45 10 63 131
8 N 2 3 37 204
9 N 3 1 40 200

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Table 2
Differences between long-term care facilities assisted by the IPAC-SWAT team and matched facilities

  Mean Standard deviation Standard error mean p value (Mann-Whitney U, z)
Resident cases of COVID-19
North York General Hospital SWAT 43.0 40.5 23.4  
Matched facilities 41.7 36.0 14.7 1.0 (9.5, 0.1)
Staff cases of COVID-19
North York General Hospital SWAT 9.33 10.214 5.897  
Matched facilities 16.83 18.584 7.587 0.7 (11.0, 0.5)
Length of outbreak
North York General Hospital SWAT 54.33 31.533 18.206  
Matched facilities 65.00 24.763 10.109 0.5 (12.0, 0.8)
Number of beds
North York General Hospital SWAT 255.67 105.945 61.167  
Matched facilities 155.50 62.176 25.383 0.5 (6.0, –0.8)

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Table 3
Number of visits, huddles, and strategies implemented

Setting ID number North York General Hospital IPAC-SWAT visits n Telephone huddles n Environmental services (Y/N) IPAC champions educated (Y/N) Outbreak days pre IPAC-SWAT n Outbreak days post IPAC-SWAT n
1 20 12 Y N 33 28
2 16 10 Y Y 56 26
3 9 7 N N 2 18
Total (mean, SD) 45 (15, 5.6) 29 (9.7, 2.5) 2 1 91 (30.3, 27.1) 72 (24.0, 5.3)

References

Government of Canada. (2020a). Coronavirus disease (COVID-19): Outbreak update. Retrieved from https://www.canada.ca/en/public-health/services/diseases/2019-novel-coronavirus-infection.html

Government of Canada. (2020b). Coronavirus disease 2019 (COVID-19): Epidemiology update. Retrieved from https://healthinfobase.canada.ca/covid-19/epidemiological-summary-covid-19-cases.html

Government of Ontario. (2020a). How Ontario is responding to COVID-19. Retrieved from https://www.ontario.ca/page/how-ontario-is-responding-covid-19

Government of Ontario. (2020b). Ontario takes immediate steps to further protect long-term care residents and staff during COVID-19. Retrieved from https://news.ontario.ca/en/release/56737/ontario-takes-immediate-steps-to-further-protect-long-term-care-residents-and-staff-during-covid-19

Pallant, J. (2016). SPSS survival manual (6th ed.). Berkshire, England: McGraw Hill Education.

Public Health Ontario. (2020a). Daily epidemiologic summary: COVID-19 in Ontario. Retrieved fromhttps://www.canada.ca/en/public-health/services/diseases/coronavirus-disease-covid-19/epidemiological-economic-research-data.html

Public Health Ontario. (2020b). COVID-19: Infection prevention and control checklist for long-term care and retirement homes. Retrieved from https://www.publichealthontario.ca/-/media/documents/ncov/ipac/covid-19-ipack-checklist-ltcrh.pdf?la=en

Stall, N. M., Farquharson, C., Fan-Lun, C., Wiesenfeld, L., Loftus, C. A., Kain, D., … Mahtani, R. (2020). A hospital partnership with a nursing home experiencing a COVID-19 outbreak: Description of a multiphase emergency response in Toronto, Canada. Journal of the American Geriatrics Society, 68(7), 1376–1381. https://doi.org/10.1111/jgs.16625

Monakshi Sawhney, NP(Adult), PhD, is associate professor, School of Nursing, Queen’s University, Kingston, Ont., and nurse practitioner, department of surgery, North York General Hospital, Toronto, Ont.

Michael J. Lamb, MD, MBBS, is director, department of internal medicine, North York General Hospital, Toronto, Ont.

Anthony La Delfa, MD, MBBS, is a doctor of general internal medicine, infectious diseases, North York General Hospital, Toronto, Ont.

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