WELCOME TO COVID CLINICAL ECHO Week 26

Overview•Covid-19 update

•Your Questions

•Developing better together Day Services Overgate Hospices and Dorothy House

•Ambulance Service perspective Karina Catley.

•Hospice Perspective St. Luke’s Sheffield (Unconfirmed)

•Chat Box Feedback &New Resources

•Care After Death Dawn Hart

Chat Box• Questions• Potential Answers• Resources• Information /innovations• Email clinical@hospiceuk.org

Please share resources, powerpoint, links etc. to those who would benefit

Day Care and Ambulances

Services in COVID

Facing the Autumn Together

Over 248 deaths across the UK since we met last. These COVID numbers are us… mothers, brothers, our colleagues and co-workers , friends, grandparents, children…

Daily death total up from 15 to 155

Week 26 COVID ECHO Update

In past Month daily death total varied from 5 to 123

X3

Daily up 1

7 million more infected130,000 more deaths

12th September, 2020

Key things to remember from the

Spring Surge of COVID-19

Uncertainties Abound

www.hospiceuk.org

PositivesPPE saves lives, - distribution much better

Collaboration works, improves morale, quality of care, the management of uncertainty, and the speed of innovation

The majority of people want to do the “right thing”

People are capable of amazing self-sacrifice for the benefit of others

Care Home Awareness raised to unprecedented level

Community support initiatives reconnected people.

Leadership hugely difficult balancing risks of health & economic destruction

Ignoring care homes, ethnic minorities, people with chronic illness, isolated populations, doesn’t work

Scapegoating doesn’t help outcomes even if it feels good, - GPs, Young people, Pubs, Beaches,Politicians, Dominic Cummings, Donald Trump. Individual agency remains.

Managing uncertainty is very stressfulVisiting or stopping visitingKeeping service going or stopping servicePatient need or staff need

Mixed messages create distrust

Negatives

Serious Disease

Asymptomatic transmission

RememberLong Covid

Maybe even much more

mild cases (like seasonal flu)?

Changing Regard For NHSMay September

Charity challenges relative visiting rulesThe UK charity John’s Campaign instructed lawyers to ask for a judicial review of government guidance that restricts family visits to loved ones in care homes, saying it believed that family members were not visitors but were integral to care home residents’ wellbeing and happiness. ..the guidance had fundamental flaws that were “rooted in the government’s failure to take account of human rights . . . There is no emphasis on the importance of meeting the individual needs and choices of care home residents, many of whom are living with dementia—a disability as well as a terminal illness.”

www.hospiceuk.org

Revisit visiting policy on a regular basis

Testing & home working plans

Set safe limits in consultation before crisis

Business Continuity ECHO Network

Autumn Challenges

• Managing visiting for patients, families and staff• Managing workforce which is going to be irregular with

sudden infection spikes taking people off the rota• Managing services and balancing the need to keep

services going with the risks of running a service with inadequate staff

• Managing finances as recession, and slump in income hits• Dealing with personal and professional loss of colleagues,

family members and friends• Managing the loss of esteem and support from general

public• Brexit uncertainties ramping up

Network and staff support priorities

Update on SARS-CoV-2August 31st 2020

Grant Waterer

Professor of Medicine, University of Western Australia

BMJ seven days in Medicine.• Risks to younger children in COVID are minimal Publich Health Englan’s COVID-19

Surveillance in SCHOOL KIDS (sKIDS found that of 12,026 childen and adults in primary schools tested in 136 schools just one child and two adults tested positive.

• Russian Sputnik V vaccine 76 people aged 18-60 followed for 7 weeks mild side effects common antibody responses seen in all within 21 days

• USA. CDC ready to distribute Vaccine by November 1. Two days before American Election.

• Visits to A&E departments in England by children and teenagers fell by 62% from mid March to Mid May and visits for injuries fell by 67%

• A simplified Doctors appraisal scheme due to restart in October, with “focus on support and wellbeing rather than paperwork”

EPIDEMIOLOGY

TestingStill not clear when, how where

Concern we do not confuse screening and testing

Boris Johnson was warned over Covid 'moonshot' testing plan

Pharmacology

WHO on Steroids• Hydrocortisone can be used as an alternative to dexamethasone to treat patients severely ill

with covid-19

• The WHO Rapid Evidence Appraisal for Covid-19 Therapies (REACT) Working Group conducted a meta-analysis of seven trials that evaluated corticosteroids (mainly hydrocortisone or dexamethasone) in 1703 critically ill patients in 12 countries from 26 February to 9 June 2020, with final follow-up on 6 July.

• They reported in JAMA that, when compared with usual care or placebo, dexamethasone and hydrocortisone reduced the risk of death by about a third (fixed effect summary odd ratio for association with mortality 0.64 (95% confidence interval 0.50 to 0.82) with dexamethasone and 0.69 (0.43 to 1.12; P=0.13) with hydrocortisone), while methylprednisolone showed a smaller effect (0.91 (0.29 to 2.87)).

So steroids?• Probably anyone needing MV

• None of the trials have shown harm

• Although we don’t have >28-day outcomes

• Probably anyone under 70 who has rapidly deteriorating oxygenation

• Need more data in women, diabetics, older adults

• Need longer term follow up data

Recovery trial

• Covid-19: RECOVERY trial will evaluate “antiviral antibody cocktail”

• BMJ 2020; 370 doi: https://doi.org/10.1136/bmj.m3584 (Published 15 September 2020)Cite this as: BMJ 2020;370:m3584

• REGN-COV2 comprises two monoclonal antibodies that bind to the critical receptor binding domain of the virus’s spike protein

Conclusions• No magic bullet

• Steroids probably justified in severe disease pending more data

• No other effective therapy

• Outcome actually pretty good in those who don’t present needing oxygen

• Outcome not as bad in high quality healthcare settings as is being reported in some series – unless you are over 70

Vaccines• Induce a humoral (antibody

response)

• Induce a cell-mediated immune response

• Multiple current vaccines in development have shown they can do this

Amazing Work being Done• Over 300 vaccines under development across world

• Oxford made vaccine in February monkey adeno virus vector and Covid spike protein genetics

• Astrazeneca producing millions of doses, in the hope…

• Trials 18-59 now over 60s

Why might a vaccine not work?

• Large exposure

• Infection outcome is a race between the immune system and the pathogen

• Vaccines give the immune system a head start

• Too much bug – even an immune system with warning can’t cope

Why might a vaccine not work?

• The immune response isn’t where it needs to be

• Immunoglobulins in the blood don’t help you in the upper respiratory tract

• Need IgA response or CMI in the respiratory tract

• Variable and challenging

• Inhaled antigen?

Why might a vaccine not work?• Just because you make antibodies doesn’t mean they work very well

• Amount of antibody varies

• Genetic

• Age

• Comorbidity

• ‘stickiness’ or affinity of the antibodies varies

• Age

• Properties of the vaccine antigen

Why might a vaccine not work?

• A vaccine could make the disease worse

• RSV in the 1970’s

• Dengue

• Mass produce, distribute

• Antigenic shift just like influenza

1 patient, 2 episodes of SARS-CoV-2 4.5 months apart

So where are we at with vaccines?

• We know the spike protein can produce an antibody and cell-mediated immune response

• We don’t know if this response is protective

• We don’t know how protective

• We don’t know how long the response will last for

• We don’t know if it will have adverse effects

• Best guess – partially effective vaccine widely available mid 2021

Isn’t there any good news?

Saliva samples seems to be just as good as nasopharyngeal

Whylie et al New Engl J Med 2020 Aug 28

CLINICAL ISSUES

According to research from the COVID Symptom Study app (52%) of children school aged children (those under the age of 18) who tested positive for COVID don’t log any ‘adult’ classic symptoms (cough, fever, anosmia) in the week before and after the test.In addition, a third (33%) of children who

tested positive for COVID never logged any of the 20 symptoms listed in the App suggesting many children are asymptomatic.

The top five symptoms in school aged children who test positive for COVID fatigue (55%) headache (53%), fever (49%), sore throat (38%) loss of appetite (35%)(15%) children who test positive for COVID present with an unusual skin rash.adults; fatigue (87%), headache (72%), loss of smell (60%), persistent cough (54%) sore throat (49%).

Covid-19: UK studies find gastrointestinal symptoms are common in children

BMJ 2020; 370 doi: https://doi.org/10.1136/bmj.m3484 (Published 07 September 2020)Cite this as: BMJ 2020;370:m3484

Gastrointestinal symptoms are common in children infected with SARS-CoV-2 and should trigger tests for the virusA prospective study of 992 healthy children (median age 10.1 years) of healthcare workers from across the UK found that 68 (6.9%) tested positive for SARS-CoV-2 antibodies.1Half of the children testing positive reported no symptoms, but for those that did the commonest were fever (21 of 68, 31%); gastrointestinal symptoms, including diarrhoea, vomiting, and abdominal cramps (13 of 68, 19%); and headache (12 of 68, 18%).

SARS-CoV-2 (COVID-19) infection in pregnant women: characterization of symptoms and syndromes predictive of disease and severity through real-time,

remote participatory epidemiology.

Objective: To test the hypothesis that pregnant women in community differ in their COVID-19 symptoms profile and disease severity compared to non-pregnant women. Study design: This observational study used prospectively collected longitudinal (smartphone application interface) and cross-sectional (web-based survey) data. Participants in the discovery cohort were drawn from 400,750 UK, Sweden and US women (79 pregnant who tested positive) who self-reported symptoms and events longitudinally via their smartphone, and a replication cohort drawn from 1,344,966 USA women (162 pregnant who tested positive) self- reports samples from the social media active user base.

Pre Print Link to Article Abstract

Results: Pregnant and non-pregnant women positive for SARS-CoV-2 infection drawn from these community cohorts were not different with respect to COVID-19-related severity. Pregnant women were more likely to have received SARS-CoV-2 testing than non-pregnant, despite reporting fewer clinical symptoms. Pre-existing lung disease was most closely associated with the severity of symptoms in pregnant hospitalized women. Heart and kidney diseases and diabetes were additional factors of increased risk. The most frequent symptoms among all non-hospitalized women were anosmia [63% in pregnant, 92% in non-pregnant] and headache [72%, 62%]. Cardiopulmonary symptoms, including persistent cough [80%] and chest pain [73%], were more frequent among pregnant women who were hospitalized. Gastrointestinal symptoms, including nausea and vomiting, were different among pregnant and non-pregnant women who developed severe outcomes.

No difference in severity of COVID in community pregnancy unless pre

existing disease

Pregnant women with pre-existing conditions require careful monitoring for the evolution of their symptoms during SARS-CoV-2 infection.

www.hospiceuk.org

Your questions…

• Here we take a look at some of the questions raised at the ECHO on 19 August and others emailed to us between these sessions

• Please use the Chatbox if you have any responses to the questions raised –we are wiser together.

www.hospiceuk.org

Community wisdom

• “Are hospices continuing to shield patients given the change in the government advice?”

• “Has everyone come across the NHS Risk assessment tool that looks at environment and then 'Covid-age’?”

• https://www.gov.scot/publications/coronavirus-covid-19-guidance-on-individual-risk-assessment-for-the-workplace/

www.hospiceuk.org

Community wisdom

• “Children under 18 are sometimes still barred from visiting dying relatives. Do any hospices have examples of good/flexible practices to share to facilitate this please?”

• “What are other Hospices planning to do about re-opening their services in light of the new Government rule of 6 especially in regard to day services?”

www.hospiceuk.org

• Normal disease progression can cause increased chest excretions and sometimes spiking temperatures. We are re-swabbing over and over despite negative tests. Do any hospices have a protocol for symptoms that can be applied or is a blanket approach used?

www.hospiceuk.org

Hetherington et al• Dyspnoea and agitation most prevalent

symptoms• Short dying phase• Symptoms can be controlled effectively

in most cases with standard doses of opioids and benzodiazepines

• Short time spent under Palliative Care (median 2 days - usual 5 days)

(n=186 none from ICU/few from high dependency)

Pall Med (2020) https://journals.sagepub.com/doi/pdf/10.1177/0269216320949786

Alderman et al

• Shortness of breath (57.5%)

• Agitation/delirium (55.5%)

• Cough and audible respiratory secretions relatively uncommon

• Increase in number of patients with shortness of breath, agitation and audible respiratory secretions in last 72h of life

(n=61)

Pall Med (2020) https://journals.sagepub.com/doi/pdf/10.1177/0269216320947312

People with Covid receiving EOL in hospital –two retrospective analyses

www.hospiceuk.org

Hospice responses

A brief look at some of the ways in which hospices are responding to COVID-19 and supporting local communities.

www.hospiceuk.org

Blythe House Hospice Builds Back Better

This Autumn will see Blythe House Hospice launch new community hub

Wide range of services to be delivered in ‘a more modern, post-COVID-19 way’

Find out more: https://blythehousehospice.org.uk/blythe-house-hospicecare-is-building-back-better-with-launch-of-new-community-hub/

Health Care Worker Safety in COVID

Infection rates in Health staff vary across the world

In UK Patient facing 1.58% vs non Patient facing 0.27% June 27 2020

Mortality also increased especially in males but caveats..

DAY SERVICES

Development of Virtual Day Hospice

Why?

Trials

Who? How?

What?

Successes Moving Forwards

Everyday, Everyone.Day Services – Revive and Thrive

Our community700 Square mile

BaNES

NE SOMERSET

NORTH WILTS

WEST WILTS

Where are we today?

586 Palliative patients being cared for320 Clients being supported32 New referrals a week on average451 DHNS contacts per week on average134 Day patient contacts per week on average

Day services

Building for the future

What services sit within Day Services• Day patient Unit• Time out for you• COPE• Hydrotherapy• Physiotherapy• Occupational Therapy• Lymphoedema• Creative Arts• Complementary Therapies• Nutrition & Dietitics Service• Community Outreach

Service

5 priorities of care

1. To continue to support the patient and clients at a time where access to health and social care is compromised.

2. To continue to provide a safe and quality based service that meets all the requirements of our contracts and CQC

3. To support our community and primary care partners in delivering healthcare and palliative care.

4. To support and review capacity of team and consider how to meet the challenge of supporting patients and families with a reduced workforce

5. To work within government guidelines in managing Infection Control and social distancing.

So that we continue to be at the heart of ourcommunity, when it matters most, not justnow but in the future.

What are we doing now?

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Wellbeing HubBrought together services that had to be stopped due to COVIDTelephone ContactVideo ConsultationCommunity VisitsVirtual GroupsExercise GroupsLymphoedema Support SessionsFatigue and SleepRelaxation and Anxiety ManagementBreathlessness managementCoffee Clubs Teens GroupYoung Persons Group

Add content by clicking on of the icons above or inserting text in

the placeholders

Revive and Thrive

• Continue with virtual support• Develop community outreach

model • Watch and wait about

restarting of Day Hospice Model providing targeted support and advice

• Community based groups and support available in the PCN’s to have care, groups and clinics closer to home

• Winter planning!!

Supporting our people to Meet the challengeMaintain what’s working well

Good ethos, good supervision and

culture of support

Multi-Disciplinary Team (MDT) model

Support the team to engage with, review and

plan for what needs to be changed

Ambulance and Palliative Services

Karina CatleyMacmillan Evaluation Lead | Paramedic London Ambulance Service NHS TrustKarina.Catley@londonambulance.nhs.uk

Delivering Pre-hospital Palliative & End of Life Care during a Pandemic

London Ambulance Service NHS Trust

• Over 2 million 999 calls & attended 1.1 million in 2019/20• 4,957 Ambulance Operational

staff

ØPalliative and End of Life Care on Paramedic curriculum 2017

ØAt least 18,500 palliative/EoLC patients per year

Background

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London Ambulance Service NHS Trust

• Demand increasing by approx. 25%• A rise in advance care planning- 10,235 new ‘Coordinate My Care’ records

April

Key areas highlighted:• High call rate from Health Care Professionals• Importance of clear advance care planning• Shared Decision Making • Anticipatory Medications

COVID-19

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London Ambulance Service NHS Trust

Paramedic Role

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* Temporary COVID-19 guidance

Paramedics can… Paramedics cannot…

Administer anticipatory medications including via subcutaneous route

Administer if no MAARs chart available on sceneChange/stop/start a syringe pump

Administer Trust issued Morphine for pain and breathlessness* and anti-emetic

Routinely prescribe medications

Review advance care planning if made available (CMC in London)

Always access this information electronically

Perform advanced patient assessment Change/adjust blocked catheters, take bloods routinely, limited wound management

Leave patients in the community Leave deteriorating patients in the community without an onward referral

Identify acute presentations/crisis Make the BEST for the decision for the patient without your specialist input

London Ambulance Service NHS Trust

• Advance Care Planning- clear & easily accessible• Shared decision making- the ‘unknown’ patient• Limited out of hours support- the ‘3am’ scenario•Mutual understanding of each others practice and processes

ØLink in with your local ambulance trust Palliative and End of Life Care Lead/Champions

Working effectively with Ambulance Clinicians

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London Ambulance Service NHS Trust

Thank you

Questions…

75

EOLC@LondonAmbulance.nhs.uk

Resources

www.hospiceuk.org

3rd Edition Care after Death Guidance

• Fully revised and updated resource

• Significant to all staff who are responsible for care after death

• Relevant to all four nations, respecting both individual law and evolution of clinical practice

• Supports the care of the deceased adult during the time of COVID-19

• Includes a practical guide to the Personal Care After Death

https://www.hospiceuk.org/what-we-offer/publications

www.hospiceuk.org

Updates in the 3rd Edition

Legal Aspects

Care after Death

Personal Care after Death

Education and Training

https://www.hospiceuk.org/what-we-offer/publications

www.hospiceuk.org

Appendix 1

https://www.hospiceuk.org/what-we-offer/publications

Conventional Care

Contingency Care Crisis Care Sustainable Care New Conventional care

Usual resourcesUsual level of care

Functionally equivalent Adapted from usual practices

Inadequate resourcesIncreased morbidity and mortality

Re-opening and changing servicesLearning lessons

Innovative, efficient and effective careReduced morbidity and mortality

Primary care triage COVID centre triage COVID centre triage

Admit if necessary Admit if necessary Admit if necessary and able Admit if necessary Admit if necessary

• PANG• RPMG EoL• Regional

conversion tables

• Community pharmacy palliative care network

• RPMG diabetes EoL.

• Telephone advice lines. • Return of retired colleagues.• RPMG COVID symptom

management in last days of life.• Symptom guidance in COVID. • O2• 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.

• Urgent pandemic pack for PNH (Just in case boxes)

• Education and training.• Communication prompts and tools. • ACP.• Information for HCPs re potential

options for care during COVID • Verification of life extinct for COVID-

19• Bereavement

Lack of care, drugs, O2, CSCIs.• RPMG COVID symptom

management 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.

• Reuse of prescribed medicines in PNHs and hospices.

• Visiting rules• Telemedicine• OOHs advice • Caring for your dying relative at

home with COVID

• Regional approach to improve standards for End of Life Care across settings.

- Regional education programme

- Regional documentation• Increased community

presence- coordinated and seamless with other services.

• SPC OOHs advice service• 7-day specialist palliative care

face-to-face support.• Advance care planning

- Regional education programme

- Regional ACP documentation- Anticipatory care plan- Regional DNACPR

• Regional interventional cancer pain service

• Development of psychological services for palliative patients.

Facilitate discharge from hospital

Use of hotels to provide care following discharge from hospital

Regional Palliative Medicine Response to COVID-19• Goal= stay out of crisis!

Link to BMA Call

CHATBOX

www.hospiceuk.org

Upcoming COVID-19 (Clinical) ECHO sessions* Every session will be 15:30 – 17:00 on a Wednesday

2020 Sessions

August 19th Rehabilitation & Day Care

September 16th Ambulance Service Connections

October 14th Clinical & economic evaluations of new services

November 11th New partnerships

December 9th Community services

Covid updateExamples of the “good new” retainedExamples of past let goResponses to questions raised

Sessions also to include

www.hospiceuk.org

THANK YOU

www.hospiceuk.org

Revisit visiting policy on a regular basis

Testing & home working plans

Set safe limits in consultation before crisis

Business Continuity ECHO Network

Autumn Challenges

• Managing visiting for patients, families and staff• Managing workforce which is going to be irregular with

sudden infection spikes taking people off the rota• Managing services and balancing the need to keep

services going with the risks of running a service with inadequate staff

• Managing finances as recession, and slump in income hits• Dealing with personal and professional loss of colleagues,

family members and friends• Managing the loss of esteem and support from general

public• Brexit uncertainties ramping up

Network and staff support priorities

www.hospiceuk.org

Evidence for 6?

www.hospiceuk.org

Poem?? Ideas??

September 2020