Taking Healthcare by Storm: Industry Insights with Benjamin Canter (Part 1)

In this captivating episode of Taking Healthcare by Storm, delve into the world of expert insights as Quality Insights Medical Director Dr. Jean Storm engages in a thought-provoking and informative discussion with Benjamin Canter, OTD and PhD student from the Center for Psychiatric Rehabilitation Department of Occupational Therapy at Boston University.

Benjamin discusses the ongoing impact of COVID-19 on nursing home care, focusing on prevention, mitigation, and rehabilitation strategies. His studies highlight the links between functional dependence, dehydration, and poor outcomes in COVID-19 patients and emphasize the importance of tailored monitoring and interventions in long-term care facilities.

If you have any topics or guests you'd like to see on future episodes, reach out to us on our website.

Publication number QI-042525-GK

Transcript

Welcome to "Taking Healthcare by Storm: Industry Insights," the podcast that delves into the captivating intersection of innovation, science, compassion, and care. 

In each episode, Quality Insights’ Medical Director Dr. Jean Storm will have the privilege of engaging with leading experts across diverse fields, including dieticians, pharmacists, and brave patients navigating their own healthcare journeys. 

Our mission is to bring you the best healthcare insights, drawing from the expertise of professionals across West Virginia, Pennsylvania and the nation.

Subscribe now, and together, we can take healthcare by storm.

Hello, everyone, and welcome to another episode of Taking Healthcare by Storm. I am Dr. Jean Storm, Medical Director of Quality Insights. And today I am so excited to be talking about this topic because it is So very relevant right now. I am joined by Benjamin Cantor. He is a doctor of occupational therapy and a PhD student.

And he is a researcher who has been instrumental in exploring the impact of COVID 19 on nursing home care, something that has not ended. with the pandemic. It continues to go on. We still have outbreaks happening in long term care facility. His work spans COVID 19 prevention and mitigation, treatment, and probably the most important thing that I am thinking about today is rehabilitation.

Ben has published several important studies on the effectiveness of prevention measures and skilled nursing facilities, rehabilitation strategies for COVID 19 patients and the role of functional decline during illness. Again, something that is so very important. We'll be just discussing Ben's recent findings on how skilled nursing facilities navigated the pandemic, the effectiveness of various preventive measures and the importance of rehabilitation during recovery.

We know that it's important. Physical therapy, occupational therapy, all types of rehabilitation and long term care facilities are exceedingly important. We know that facilities that have lower levels of these therapies actually have higher levels of emergency room visits, especially in their long term care population.

So we know that rehabilitation plays such a crucial role in long term care facilities. So we are going to explore how these insights can inform better practices for improved patient care in long term care facilities in the future. Ben, thank you so very much for being with us today. Yeah, I'm happy to be here, excited to have this discussion and talk about COVID 19 in post acute and long term care.

Great. So we are going to go through each of your research papers and  be talking about some of the issues and things that can be applied for each one. But first off, can you tell us how you came to do what you do, and can you explain to the audience what an occupational therapist does, especially in the nursing home setting?

Yeah, so. I got interested in post acute and long term care when I was in middle school. It's quite a funny story. So my, school had half days on Fridays and my mom said, you are certainly not coming home because Fridays are for me. And I was like, okay, so I had to find something to do. And I tried lacrosse, but I wasn't sporty enough.

And I tried comedy, but I wasn't funny enough. And so I ended up volunteering in this nursing home serving tea and I really liked it as a middle schooler. And then I stayed there in, during high school, I helped out with the recreation activities and I got to shadow in the rehab. At the facility, and then that was when I decided I wanted to become an occupational therapist.

And then when I was in college, COVID 19 hit and nursing homes entered a crisis, really. And I wanted to help this facility that I had spent 10 years volunteering at by that point. And so there was no in person volunteering, but I had some basic research skills from college. And so that's how I got.

I'm interested in COVID 19 and post acute and long term care and transitions of care and post acute and long term care and  I'm excited to talk a little bit about what I've been doing since then, some of the results of my work and share that with you all. Yeah, I'm going to say, I think a lot of people feel drawn to long term care for whatever reason.

I share a similar feeling, so I can relate. So what issues in long term care have you been focusing on  in your work? So obviously I'm an occupational therapist. I think I forgot to answer that part of your question. Occupational therapy is a type of rehabilitation that really specializes in the things that make individuals lives meaningful and  empowering and the activities that do that, fostering those activities.

So In geriatrics, that's often activities of daily living, things we take for granted. Toileting, eating, bathing, getting dressed, the things that you need to do in order to live your life. And so helping people recover and maintain independence in those activities. And so occupational therapy and other forms of rehabilitation is a focus of mine, as well as transitions of care.

When do we move people to and from different facilities?  When can they be discharged home? How do we make those discharge processes as seamless as possible? And what role does rehabilitation and occupational therapy play in that? And then COVID 19 is  like my third research interest obviously.

And  that's what we're here to discuss. So yeah. That's, I will say those intersect and just to like let everybody at home know when we talk about ADLs, we call them ADLs, activities of daily living, and Ben really explained it very well  things that we take for granted every day, being able to get up, go to the bathroom.

Get dressed, brush your teeth, all of those kinds of things. And when nursing home residents stop doing those things, and basically stop moving, they have a higher mortality. Their quality of life is worsens. Obviously, you can imagine if you're not able to kind of go to the bathroom yourself, then your quality of life  is not good.

So all of those things are really important, and we know that COVID affects them. And I'll just give a little shout out to the Barthel Index. I'm a big fan of the Barthel Index, which is a like a calculator, and you can find it online. It's, uh, B A R T H E L, and that kind of is a calculator that can  tell you where you are on that  on those activities of daily living, and it's really a great index for nursing home patients.

So. Great topic. I'm really excited about it. So how we're going to do this. Ben has sent me four of his research papers that are so instrumental and I think provide so much guidance in how nursing home residents should be approached in especially around COVID. And today we're going to be talking about two of them.

And in a part two, we're going to be talking about two more. So I'm very excited about the conversation. I don't want to cut any of these short because I think they're very important and I think they're going to provide really useful information for everyone out there who's working in a long term care facility.

So first one, the title is associations between eating mobility and toileting function dependence and COVID. Symptoms. So these are really important things for nursing home residents. So, Ben, your study explores the relationship between pre COVID functional dependence and the severity of COVID symptoms.

So can you explain how functional mobility, eating, and toileting dependence before illness might influence the experience of symptoms like dehydration or shortness of breath during the COVID 19 illness? Yeah, so the way that you can kind of think about this is that when you can't perform these functional tasks, toileting, eating, walking around, transfers, these kinds of things can pose a barrier to your ability to prevent different kinds of symptoms from coming up as much as possible.

So for dehydration and shortness of breath, those were the symptoms that this study found were the most impacted by. These functional deficits that individuals in post acute and long term care often face more specifically for dehydration. The way I kind of like to think about this is if you're struggling to eat independently.

and to move around independently, you're likely struggling to hydrate independently as well. We know that nursing facilities are often understaffed. We know that there's a lot of residents and the staff resident ratio can be a little bit skewed. And not in the direction that we like to see. And as a result, people might not have water in front of them all the time.

Right. Or they might not have the cognitive in like the, they might be cognitively impaired and not have the cognitive ability to say, Oh. the interoception to say, Oh, I'm thirsty now. All right. What does that mean? I have to get water. All right. Where am I going to get that? I got to walk over here. Like putting all of those things together or even being able to hit the button.

Okay. I am going to, I'm going to call for the nurse to bring me water. If you don't have the cognitive awareness to do those things, you're reliant on other people to say, huh, maybe this person needs water now. Right. And often that's kind of on an autopilot, like, okay. We're going to check every however many hours to see if this person needs water every, I don't know, 30 minutes, right?

And that timeline is going to be even more if the facility is understaffed. It's going to be every 45 minutes maybe, right? And so every hour. And that depends on staffing and the attentiveness of those staff. If you can't advocate for yourself it's just going to be based off of whatever that routine is.

And if that routine isn't adjusted. If you have a fever or other COVID 19 symptoms, you're more likely to get dehydrated. And so we, that's why we see this correlation between functional dependence and dehydration. It's so very interesting. And I think a lot of individuals out there don't realize how many times these things fall through the cracks because  in the facilities.

Maybe when somebody does have COVID, it's kind of like a blanket. Order set of what is going to happen, but it really doesn't, isn't tailored to each individual  especially these individuals who have, uh, deficits in their ADLs prior to illness. So, your findings highlights a significant functional decline associated with dehydration and shortness of breath during COVID.

Huge. So how can health care providers better monitor and intervene for patients, especially those with pre existing functional dependencies to mitigate these declines during illness? So, we can talk about shortness of breath in a second, but regarding the dehydration component, right, the intervention is to monitor more, right?

A lot of times people who have COVID 19 are on isolation precautions of some kind, right? And that means that people aren't, there's a big like hazard sign, like droplet precautions, isolation precautions, whatever kind of precautions that individual is on. And people aren't dying to go into their room.

So, oftentimes, Logically, they get the same, if not less, monitoring, right? Because people aren't going in there without a gown, and they're not going in there if they don't need to. And so, I think what this study kind of shows is you need to, right? And monitoring is a part of that care. And so, seeing, okay, it's 6 a.

m. How much water is in there? Oh, it's full. Okay, let's come back at X time. Alright, the cup is still full. Maybe we need to, like, try to encourage them more to drink the water. Right? Okay. it's like still three quarters full an hour later. Alright let's see if we can try to incentivize them somehow.

Spend time with them, get, talk with them a little bit more to get them to drink the water. What can we do to kind of encourage that? Maybe you have to help bring it to their mouth. Maybe their functional dependence has declined during COVID 19, right? Or maybe they just didn't have that in the first place.

So really being attentive to that individual's needs and how those needs might be heightened because of COVID 19. Shortness of breath is really interesting because it's not usually something that we associate with like functional dependence in the same way feeding or dehydration are easily associated with functional dependence, right?

We're kind of like, Oh, I'm short of breath. Like, that's a symptom I have, what am I going to do? And to demonstrate the relationship, I like to use this analogy of like a marathon runner, right in a healthy adult. So let's say that you're running like Marathons or half marathons every two or three days.

That's like your average, you're like a super athlete, right? And then you get COVID 19 the recommendation is that you don't do vigorous activity. when you're sick. And so for that individual, it might be going on like a mile run is like not vigorous activity. Whereas for me, who I have a day job sit at my desk all day.

And honestly, I go home and still probably not exercising enough, right? For me going on a mile run with COVID 19. I'm going to be short of breath after that, right? And so we can kind of equate that on the other end of the spectrum to older adults in a nursing home, right? Where they have tons and tons of functional dependence.

They're easily fatigued. And so if they got fatigued walking to the bathroom before, Now, or even sitting up in bed, now, sitting up in bed might increase their chance of short of breath, right? Because it is, that was their baseline. And so now they can't even do that. But because that's essential to swallow, to eat, to get dressed, it's really hard to do those things without.

The minimum, we see them getting short of breath performing those basic tasks. And so taking it easy is the solution to preventing shortness of breath. But that needs to be balanced with not doing all of those things, right? Like if you're not going to the bathroom and you're not being changed so that you don't get shortness of breath, you might get an infection.

And so there's, some clinical judgment involved in trying to manage shortness of breath versus too vigorous activity. Versus well, this person needs to do this in order to stay healthy. They need to get, they need to get sat up. They need to sit up so that way they can eat and get better.

Right? So there's like a cost benefit analysis that needs to take place. Yeah, I think you need to look at each individual independently  and I love that dehydration. It's so interesting because residents get far down the road with being dehydrated and then everybody wants to put an IV in them.

They can't put an IV in, like they can't find the line, all of this stuff. It's like, if we could just get people, we could just get them hydrated, get these residents hydrated orally with their mouth. prior to getting all far down the road where you need an IV, then we could avoid the IV. So, exactly. This approach is just so very important to think about.

Okay, so next topic, next study, which is co occurring dehydration and cognitive impairment during COVID 19 in long term care patients. Again, I will say I mean, residents who are cognitively impaired, I think are at risk of dehydration at all times, at risk of dehydration and malnutrition at all times because  they, they just don't have the same, they're not in the same kind of awareness that you and I are.

So they're not drinking, they're not eating like we are. So your study found that 59 percent of nursing home residents with symptomatic COVID 19. experience dehydration. That's a huge number. I was shocked. A much higher rate compared to those with other infections pre pandemic. Interestingly. So what do you think are the key factors contributing to this increased dehydration risk in COVID 19 patients and how can nursing home residents again better prepare to address this challenge?

Yeah. So the interesting thing about this is This study is that it was published in 2021. And so that's important context because at the time of this study, we were what I would consider to be like, quote unquote, early pandemic, right? Then you had like your mid pandemic, which is like 2022, maybe.

And now we're kind of in what I would call like late pandemic, almost like endemic at this point. And so when we think about it like that, at the time of the study, it was a real crisis in these facilities. There was so much happening and so little staff to address it, and nobody really knew anything yet.

And so when we really considered that, context, that is probably playing a role in this huge change. Percentage of patients with COVID 19 experiencing dehydration, right? They're not able to do that monitoring. They're not, everything is kind of on like crisis control. Like  they're triaging everything in the facility.

And that's important context. So I'm not sure if there was a COVID 19 outbreak today. Even in that same facility, if we would see 59%, it might be something more like 3035. I'm just speculating, right? But even that number is quite large. And so the reason this is happening is likely for all those reasons we mentioned, right is when there's any kind of outbreak, the needs of the entire population rise, not just for those with the illness, but also the preventive needs for everybody else.

And so cognitive impairment and dehydration, we talked a little bit about the relationship between those things. But just the fact that we saw a relationship between those things is notable, right? Because most individuals in long term care especially have some kind of cognitive impairment. And so it's important to, to consider that, I also think that The sheer amount of functional dependence that takes place combined with the fact that we didn't know what the real symptoms were in this population at the time of the study. No one knew that this was going to increase risk of dehydration, in theory. Perhaps we should because if you look, 79.

6 percent had a fever and so fever is also contributing to dehydration risk and played a role as well. You're sweating more. Your body's hotter. You need more water. So, so those are some of the primary factors. And, The only cure to dehydration is hydration at the end of the day. Yes.

Absolutely. You can't get around that. What I found was really interesting that your study highlights that dehydration is linked to increased falls and mortality among COVID 19, something that every nursing home company is really invested and focused on reducing falls, reducing mortality, obviously.

 But it also showed that managing these residents in the nursing home setting can lead to better outcomes than transferring them to the hospital. Interestingly there have been Many studies that demonstrated not just COVID 19, but managing nursing home residents in facility actually show better outcomes with quality of life and mortality than sending Residents to the hospital  so this kind of jives with all of that research.

So again, what are some of the best practices or protocols that nursing homes can implement to manage dehydration, reduce hospitalization, and maybe the million dollar question, reduce falls, especially in the context of COVID 19. Yeah, so it's a really great point about how those two literatures overlap here, intersect taking off my COVID 19 researcher hat and putting on my more general

occupational therapist, clinician hat. I would say that something that isn't necessarily a best practice or like protocol, but more just a rule of thumb that can help is like a team approach. you know, when I was working in nursing home, we had a whole team and everyone kinda ideally knew everything at every point in time through standup meetings or email, whatever kind of communications.

were going on, and everyone knew that this patient delirium. This patient had dehydration, right? And whatever the patient's symptoms were, everyone was on board, and a part of that plan to prevent it, and if they were at risk, and intervene if they weren't. So, for someone who's dehydrated, or has a fever and at risk of dehydration, getting that person water, is critical.

And so that might mean that during their rehab session, even if they have a goal of like home management for post acute patient, right, or a goal of toileting, if they're dehydrated, maybe something we do is we practice feeding that day, because we can practice having them drink water as a part of the session, or just making sure we're incorporating water.

into the routine. Okay, we're going to practice getting up and getting water for our functional mobility today and not just walking to the toilet, right? So changing the way that care is provided from rehab's perspective, from nursing's perspective, those team members making sure and checking in even when you're doing other things with them, right?

Even so you might have the goal of changing the bandage, but also asking are you thirsty? Right, I'll get you some water. And then for individuals who need treatment in the facility   this facility was unique in that they were able to provide IVs. in the facility. And like you alluded to, that prevents the need for an ER visit until someone's had a fall already, right?

And so if we can intervene preventively, and we can intervene secondarily, there's no need for like a hospitalization or an ER visit as much down the line. So those would be my recommendations, and to probably have a protocol too. If you notice that someone isn't drinking who should be drinking, or you would expect based on their functional level to drink, I might say something like, Huh.

All right, they spent X number of hours without drinking. So our protocol says that we are going to increase the frequency of monitoring them. Oh, this person has COVID 19. So we're going to increase the frequency that we're monitoring that. Having that protocol in writing. As something that the staff in the facility can follow some order from the medical director that individuals with COVID 19 get checked X number of hours, whenever possible X number of minutes, we want to make sure that they're drinking and we want to be monitoring that.

And then, that way, it's clear if they're not getting the the hydration that they need. And then okay, time to intervene with an IV. Okay, we should prepare to have to send them to the hospital if this doesn't get better. And everything is prepared ahead of time, right? And then, even if it does get to the point where, with an IV, someone were to need to go to the hospital, You would have all of that stuff ready, all those documents that would need to go with them to the hospital.

Cause there's lots of adverse events that come with care transitions as we could get into that another time, but everyone should kind of be aware Of all those adverse events, I imagine, and so having all that documentation prepared ahead of time, trying to anticipate if hospitalization may be needed.

So trying to take preventive, proactive steps at every phase in the process  is the best way to treat dehydration.  In the moment yeah, I mean, it just, yes, there's very common sense, but you know, we both know it doesn't often happen in practice. Ben, this is a really great conversation and I am so excited to cover the other two research papers that.

You have here and maybe we can just do wrap up next time with some occupational therapy tips, quick tips  around COVID and then just infections in general. But I look forward to part two. Thank you very much for joining us today. Great. Thanks so much for having me. 

Thank you for tuning in to Taking Healthcare by Storm: Industry Insights with Quality Insights Medical Director Dr. Jean Storm. We hope that you enjoyed this episode. If you found value in what you heard, please consider subscribing to our podcast on your favorite platform.

If you have any topics or guests you'd like to see on future episodes, you can reach out to us on our website. We would love to hear from you.

So, until next time, stay curious, stay compassionate, and keep taking healthcare by storm.