Palliative Care Program Response to COVID-19: Union Hospital, ChristianaCare

The palliative care program at Union Hospital in Elkton, MD covers Cecil County, MD and is led by two palliative nurse practitioners. Inpatient palliative care is delivered within a 96-bed hospital. A palliative care clinic provides care for patients in a large rural service area.

This is a snapshot of the palliative care program's involvement in Union Hospital's COVID-19 response, based on an interview with Brenda K. McKenzie, MSN, NP-C, CRNP, Christiana Care/Union Palliative care, on May 13, 2020. At the time of the interview, many geriatric patients in the region had tested positive for COVID-19, but critical care unit capacity had not been exceeded.

• A merger between Union and another hospital is in process
• At the time of interview, hospice and home health agencies in the region were taking all patients – including those with COVID-19
• There is a serious outbreak of COVID-19 in area nursing homes; the State of Maryland is coordinating clinical teams to provide support in nursing homes

• Participating in a state-wide palliative care collaborative (supports rapid information-sharing during COVID-19)
• Palliative care had not been part of crisis planning at Union Hospital, but this changed after a difficult patient death
• Team is seeing both COVID-positive and COVID-negative patients; COVID-19 is an automatic palliative care consult trigger
• Because the palliative care team is small with limited access to PPE, they must consider how they staff themselves. The two NPs rotate 1 week in the hospital and 1 week in the clinic. They may do a very rare home visit, if it will prevent a hospitalization.
• Supporting hospital in various ways:
  • Palliative care helped transform outpatient and infusion area to a non-COVID-19 ICU
  • Union's Progressive Care unit is now a COVID unit
  • Palliative care social worker performs advance care planning
• Team presents 'lunch and learns' on palliative care topics such as pain and symptom management to the hospital and community
• Most care provided by the palliative care team is done via teleheatlh:
  • Team secured a new iPad to support palliative care delivery for patients in both the hospital and the clinic
  • Some in-person care is delivered for inpatients and clinic patients as dictated by the clinical situation
• Palliative care census has decreased overall

Collaboration:

• Be willing to collaborate no matter how difficult
• Consider the needs of the community (e.g. meals, emotional support)

Clinical Care:

• Support the organization as new needs arise
• Check in with staff after a patient’s death to offer support, particularly since there are many newly graduated nursing students

Personnel:

• Think flexibly about scheduling during COVID-19, and be strategic about where and how to use scarce staff resources

Information Dissemination:

• A challenge for teams during COVID-19 is rapidly changing information, which makes it difficult to focus on clinical care. Ensure that palliative care is included in the organization's regular chain of communication updates.