Renee Kinder

What a difference a year makes.

This time, just a year ago, we were all preparing for the Phase III implementation of the Requirements of Participation for skilled nursing facilities, which went into effect Nov. 28, 2019. 

Phase III implementation included key regulatory change and associated F-tag updates for areas including comprehensive care plans; trauma-informed care; behavioral health; and clinical competencies.

The timing of this implementation could not have proven more perfect. If the past 12 months have been anything for those serving in long-term care, it has been traumatic. With that said, we have risen to the occasion, we have learned to appreciate the need for greater focus on mental health, and we have all strived to demonstrate a greater level of clinical competency during care. 

Let us review the key points that Phase III implemented. 

First, we must have comprehensive care plans.

Per the Code of the Federal Register (CFR), §483.21(b)(3) Comprehensive Care Plans (F659)

The services provided or arranged by the facility, as outlined by the comprehensive care plan, must — 

(ii) Be provided by qualified persons in accordance with each resident’s written plan of care. 

(iii) Be culturally-competent and trauma–informed. 

Second, we must be informed and demonstrate knowledge of trauma-informed care.

The Substance Abuse and Mental Health Services Administration (SAMHSA), a division of the U.S. Department of Health and Human Services, has developed a concept of trauma based on the three “E’s”: event(s), experiences of event(s), and effect.

Individual trauma results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life-threatening and that has lasting adverse effects on the individual’s functioning and mental, physical, social, emotional, or spiritual well-being.

As such, communities need to consider the immediate and long-term impacts of recovery for those diagnosed with COVID-19 in addition to residents who may be experiencing trauma secondary to isolation and limited in person time with loved ones.

The trauma conversation you see is two-fold. 

§483.25(m) Trauma-informed care (F699)

  • The facility must ensure that residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents’ experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident. 

And finally, all the knowledge and care planning in the world will not change practice if we do not have staff competencies.

Current staff competency requirements are as follows:

§483.40(a) The facility must have sufficient staff who provide direct services to residents with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility’s resident population in accordance with §483.70(e). These competencies and skills sets include, but are not limited to, knowledge of and appropriate training and supervision for: 

§483.40(a)(1) Caring for residents with mental and psychosocial disorders, as well as residents with a history of trauma and/or post-traumatic stress disorder, that have been identified in the facility assessment conducted pursuant to §483.70.

Now that we have an understanding of what is required from a regulatory perspective, let us consider how we should define trauma.

Remember: Trauma impacts everyone differently and trauma is multifactorial.

According to the National Council for Community Behavioral Health Care, trauma occurs when a person is overwhelmed by events or circumstances and responds with intense fear, horror and helplessness. 

Furthermore, extreme stress overwhelms the person’s capacity to cope. 

There is a direct correlation between trauma and conditions such as diabetes, COPD, heart disease, cancer, and high blood pressure. 

Sound familiar? All these conditions also impact COVID-19 risks and recovery.

Additionally, trauma may be experienced and expressed in numerous ways and dimensions. Often trauma, like grief, is misunderstood or misdiagnosed and not attributed to the effects of trauma. People deal with trauma differently.

Communities should consider biological symptoms that include brain function, headaches, stomach aches, sleep changes; psychological symptoms include fear, anxiety, outbursts, flashbacks, nightmares; social symptoms include apathy, isolation, difficulty trusting, detachment.

Now that we understand how trauma is defined, we need to understand what it means to be truly trauma informed. 

SAMHSA defines trauma-informed are as a program, organization or system that is trauma-informed realizes the widespread impact of trauma and understands potential paths to recovery; recognizes the signs and symptoms of trauma in clients, families, staff and others involved with the system; and responds by fully integrating knowledge about trauma into policies, procedures and practices to actively resist re-traumatization. 

Trauma informed care is a process, not a destination.

When we consider how we will holistically address the following key elements trauma informed care in the COVID-19 environment, we must effectively integrate all of the following: Comprehensive Care Planning; Trauma Informed Care; and Clinical Competencies 

No silos allowed. 

Furthermore, we must understand that COVID-19 and the trauma created as part of diagnosis and recovery impacts the following systems: Pulmonary; Neurologic; Hematologic; Renal; Skin; Liver; Mobility; and Chronic Care considerations

A recent publication from the American Congress of Rehab Medicine titled “What Now for Rehabilitation Specialists? Coronavirus Disease 2019 Questions and Answers” outlines these systems for us in a comprehensive manner. 

Highlights below.

  • Pulmonary: The lung damage of COVID-19 leads to an impairment of gas exchange, with potential for impaired pulmonary function. As a result, many patients report prolonged dyspnea and chest tightness, although the dyspnea may not be commensurate with the degree of hypoxia. Pulmonary fibrosis is another factor that may affect long-term lung function
  • Cardiac: Complications can include hypotension, arrhythmia, reduced ejection fraction, and myocarditis. Left ventricular dysfunction in the acute phase may be attributed to markedly increased cytokine levels. Activation or enhanced release of inflammatory cytokines can lead to necrosis of myocardial cells and exacerbations of coronary atherosclerotic plaques, making them prone to rupture. An intense inflammatory response superimposed on preexisting cardiovascular disease may precipitate cardiac injury. 

Myocardial damage might result in long-term dysfunction and must be taken into consideration for patients entering rehabilitation. Although most patients develop persistent tachycardia, it has been found to be relatively benign and self-limiting.

  • Neurologic: Acutely, 36% of patients with COVID-19 develop neurologic symptoms, including headaches, altered consciousness, seizures, absence of smell and taste, paresthesias, and stroke. Posterior reversible encephalopathy syndrome, which causes headache, confusion, seizures and visual loss can be a complication. COVID-19 has been associated with viral encephalitis and has also been rarely reported. 
  • Hematologic: Patients severely affected by COVID-19 are at high risk for a hypercoagulable state, characterized by very high D-dimer levels, thrombo-embolism, and stroke. In one review, thromboembolism was documented in as many as 1 in 5 patients and strokes occurred in 3%. 
  • Renal: Patients severely affected by COVID-19 are more likely to have acute kidney injury. Studies have shown that among those with normal creatinine levels on admission, most will recover from an acute kidney injury. However, proteinuria and hematuria can be prolonged.It is recommended that patients with acute kidney injury be regularly assessed for three to six months after discharge.
  • Skin: COVID-19 has been associated skin lesions include (from most common to least common) maculopapular eruptions, urticarial, acral erythema with vesicles or pustules (pseudo-chilblains), vesicular eruptions, and livedo reticularis. Frank necrosis, secondary to vasculopathy, can also occur and may result in limb loss. Because of prone positioning, facial wounds may occur among survivors and could be problematic because of secondary infections and necrosis.
  • Liver: COVID-19 related liver dysfunction with abnormal liver enzymes (mainly elevated serum prominences in those patients who spend significant amounts of time in prone position.
  • Mobility: Interdisciplinary collaboration between the rehabilitation team, nursing, and respiratory therapy is crucial to provide frequent pressure relief. Prone teams that include physical or occupational therapists and are available 24 hours per day, seven days per week may be helpful in reinforcing proper technique to minimize injuries.
  • Chronic Condition and Ventilation: Survivors of acute respiratory distress syndrome with mechanical ventilation are reported to have complications such as laryngeal injury, tracheal stenosis, heterotopic ossification, contractures, adhesive capsulitis, decubitus ulcers, dysphonia, dysphagia, sensorineural hearing loss, brachial plexus injuries, and peripheral neuropathies (peroneal and ulnar)
  • Chronic Condition and ICU Weakness: Weakness and decreased exercise capacity are the most common symptoms after prolonged ICU stay and immobility. 
  • Chronic Condition and Cognition: COVID-19 can produce prolonged hypoxia that may lead to both acute and long-term neuropsychological dysfunction. The further elements of prolonged ventilation, use of sedatives, prone positioning, human isolation, and extended time away from social contacts may contribute to severe delirium. All components of cognition can be affected, including attention, visual-spatial abilities, memory, and higher order executive functions. Common adverse psychological effects include posttraumatic stress disorder, insomnia, depression, and general anxiety, and they can be exacerbated by fear, stigma, and isolation.

In closing, while managing the trauma associated with COVID-19 recovery requires an extensive knowledge base, ACRM provides us with guidance on the 6 “M’s” of Managing COVID Long Term, including mind (cognition), mobility (function), medications, multicomplexity (managing the complex medical/social issues of a given patient), matters most (what patients value most for their care), and motivation (factors affecting behavior change and/or health) as being critical factors in our rehabilitative care.

Renee Kinder, MS, CCC-SLP, RAC-CT, is Executive Vice President of Clinical Services for Broad River Rehab and a 2019 APEX Award of Excellence winner in the Writing–Regular Departments & Columns category. Additionally, she serves as Gerontology Professional Development Manager for the American Speech Language Hearing Association’s (ASHA) gerontology special interest group, is a member of the University of Kentucky College of Medicine community faculty, and is an advisor to the American Medical Association’s Relative Value Update Committee (RUC) Health Care Professionals Advisory Committee (HCPAC).