Supervisor nursing in the division of geriatrics Department of the Ministry of health for the southern district of Israel, a specialist in geriatrics and palliative care Claudia Conson told “Kommersant” about the problems identified in Israeli institutions of long-term care during a pandemic, and how to solve them to better prepare for a second wave.”We are very far away in tech, but had forgotten about such simple truths as care”— What is important to consider palliative care in the coronavirus?— There are people who have you will immediately see, the symptoms of viral infection: fever, septic disorders, unwillingness to eat. But we are faced with a large number of trophic ulcers of the lower limbs, which began to appear so rapidly that it was impossible to guess. In some patients, we saw that the saturation continues to fall even when one hundred percent oxygen and we had very quickly evacuated in large hospitals. The symptom of pain, fear, panic — all this, too, is our patients, and you need to remove these symptoms in the process while making the care and manipulations. Therefore, we must come to the patient.Usually we plan ahead the whole process of providing patient care. The patient is always the center of attention. We need to consult with a large number of colleagues, to draw conclusions and make a decision. We used to work in a multidisciplinary team. In ordinary life we know that certain symptoms should be treated, did not come to a deterioration — for example, a person has a slight fever, and we write a Protocol of action how to prevent the development of disease and high temperature. With the coronavirus we didn’t even have time to draw up reports, because in many patients the disease developed rapidly. In this new situation for us, we, the nurses and doctors left with the disease of the patient one-on-one. Our colleagues, physical therapists, social workers, nutritionists — could not enter into the red zone hospitals or geriatric hospitals. Of course, we communicated with them remotely, but often we had to act quickly and without support from their side to which we are accustomed. Of course, then we held online meetings to brief them and get their opinion.If the coronavirus fell ill elderly person in the institution, we must isolate the patient within the institution and to make epidemiological route of the staff who worked with him to prevent the spread of infection. If the patient started respiratory problems, need to move it closer to the nurses ‘ station. And that means you need to arrange him a meeting with a psychologist. After the patient is accustomed to his room��those, and you pulled it out of her — his anxiety and stress, a psychologist or a social coordinator in the Department, since the quarantine. This is a new environment in which we still need to help patients, not forgetting their honour and dignity.Sometimes you see the person in the ambulance, his last way: you can already see the symptoms that he likely will not come out of it. And you hope that if he leaves, then with oxygen, with dignity and without pain.
So we discussed with the ambulance staff that the patient must have the plaque with his name and they should check its availability before transferring him to hospital. We take pictures of our patient and send pictures to the hospital so that our colleagues took him there and made sure that it was him. First we have rides with the Windows open (as required by the Protocol to wind machines), and we ask our doctors to cover the patients with blankets, because they can freeze.— In some cases, in Israel hospitalitynet patients with COVID-19 from long-term care institutions and nursing homes?— If the patient’s saturation is below normal, if the saturation falls, then in the system of long-term care we cannot provide him the oxygen that it needs. We have no such opportunity, so we need to transport patients needing ventilation in the Central hospital. To do this we call an ambulance. We determine that this man needs an emergency supply of oxygen, without oxygen he could die, and soon connects it to oxygen. We have all the information computerized, so for a minute or two we can send his medical records to the hospital, where he was going.As I said, it is important that the patient, already dressed in PPE was worn and the special plate with his name, he rides in the ambulance without support, without family, and the paramedic will give information only about the symptoms that a person has now. The patient often can’t tell about some of their chronic diagnoses, on drug therapy, about the necessary care, prevention of bedsores, use of the probe. Our colleagues need to get all this information about the patient from us. But if the patient became ill COVID, but the Sats good?— If patients with COVID+ do not have serious symptoms, we must isolate them and provide them with the necessary care. But we must not forget that they can become carriers of infection that can be fatal for a large number of persons in institutional long-term care. So you need to competently organize epidemiological route of the staff to this patient.In any case, we pass the information on each patient with COVID+ in the Central headquarters of the Ministry of health. Here in Israel, doctors in uchr��rdeneh long-term care services do not operate 24 hours a day, and we need to know where to take the patient if he would be worse. At the headquarters of the military along with doctors decide which one to translate.I am in the region every day were sent to hospitals from institutions for long-term care for eight to ten people. Israel was designated for the Department for elderly patients with COVID. If you decide to transport the patient from the B. Baer-Sheva, Netanya, because there are places in the hospital is quite a long trip, it can be difficult for the patient, we must understand whether he will be able to move it, and discuss it with the family. Once the patient is transported to the hospital, it is important to call and clarify where he is, as he was if he was okay. Connect social workers begin to talk with the families about the conditions in which is their loved one, what his situation is.— Did I understand correctly: the hospital is transferred to only those who need intensive therapy, ventilatory support? The rest are treated in institutions for long-term care?— Yes, and this is an important ethical question. If I, a specialist palliative care, can’t care for my palliative patients, ill COVID, if I got scared and lucky their 20 grandparents in the hospital, I will put doctors in a very difficult position. Who them to quickly intubate — grandmother 98 years old or 49-year-old man, who has three children? Answer all know.And this is a huge ethical issue, which needs to think that we, the workers of palliative care, not our colleagues in his field of battle.In addition to General hospitals is the care that is needed by our palliative patients. Still, large hospitals used that patients do not lie long, and basically, there are patients in the intensive manipulation so that care part, of nursing there is given less importance. So often our patients returning in geriatric hospitals from hospitals, it is difficult to know. It is good that the State of Israel decided to translate our infected patients, who are more or less stable, specialized COVID-Department for the elderly. There is necessary care. This pandemic has posed many important problems. One of them is just lack of basic care in General hospitals. I think we will need to work very hard with colleagues in medicine, surgery, orthopedics, so we developed some General principles of basic care. I think our entire medical community needs to pay attention to problems of maintenance. We are very far away in technology, in laboratory studies, but had forgotten about such simple truths of like concern.Every grandmother that taken by ambulance to the hospital, should not only be in the perchthe atok and the mask — it should be covered, she should give her bag and blanket, and where she goes, people should practice the same philosophy as we do in geriatrics and palliative care.”This virus is teaching us personal responsibility”— What is the most difficult to work with palliative care patients during a pandemic?— We must not forget that there are palliative patients who take not from the coronavirus, but from their underlying disease. And we in geriatric hospitals were forced to determine where the most complex patients, in which there is no time, and where the patient can wait. One we must come immediately and be with him for 15 minutes, to talk, to shake hands. And to the other we come not now, but in 30 minutes. And here is the difficult choice. But the main thing — do not forget to approach him. Even if you have just lost a patient, we cannot forget the other who too will leave soon. When understaffed because someone called in sick, and someone is left for insulation to work in this mode very difficult.One of the most difficult moments in our work — to convince staff that the wearing of PPE saves lives. Today we have no cure for coronavirus infections, there is no vaccine, we have only hygiene, discipline and the rules of wearing PPE. When my colleagues said they were at the front, fought with COVID and got sick, it meant that the person did not follow all the rules and thus got infected.And it’s very important to our responsibility as professionals, as citizens. Coronavirus proved once again that every citizen has a zone of personal responsibility. You should try to stay home during the quarantine, to wear a mask in public places, not to get sick or infect other people. Every physician in addition to personal and civic responsibility is still a professional. Prevention of introduction of infection into the institution or home — it is our responsibility to our families, our patients and their families.— In Israel, too, there are problems with poor tests?— We just insane tests, we do a lot of them, we test all of our patients in geriatrics. After receiving the negative results, people think that they can do anything. And we need every person to work hard to explain that a negative result says nothing and after three or four days it may lose the sense of smell, or sacarlal, or he will have dyspepsia. Yes, the correctness of the analyses is sometimes questionable. We often get edge analyses and do not understand the patient infected or not. At this stage we cannot come to a common denominator, can’t agree on what still say these or those figures, and I would really like a more thorough analysis and better quality of work of laboratories. Because it depends on MSZn is not one person but of many people: those who were with him, who was taking care of him. And if laboratory staff do their work not very efficiently, we get substandard results — and this is the agony of waiting is the wrong decision.But it is necessary for their understanding to other people’s mistakes and not to swear. When we start someone from the staff to blame: here, ilina not wearing a mask, she is to blame, it is bad — it doesn’t work! Ilyin, maybe wear a mask, but she had no desire to do it right. A lot depends on the mood of the person. We don’t have anyone to blame, no talk, no rush. These are the principles that are very important in our work. Yes, everyone can make a mistake. Especially in a situation full of suspense. But each of us needs to understand the extent of their personal responsibility. This virus is teaching us personal responsibility. We must understand that the coronavirus has not gone anywhere.Once in my country the population was allowed a little more than usual, in a week the number of cases began to rise, and closed offices have been reopened. No, this is not the second wave, it’s still the first, and in this situation, our mission is to continuously conduct interviews with the population about how to properly exit the isolation. We, as physicians, should tell people why hand washing remains the main measure against the virus and why the treatment of hands with an antiseptic does not negate the hand washing. Today, many are skeptical about the masks but it is a barrier to infection, and each such barrier important. First of all, it is important for us as physicians, because if we Slagel, no one will give painkillers to our patients, there will be no one to wash them, to feed, to hold his hand.We must prepare for future infectious epidemics. And much depends on us, on our behavior. If you will be wearing a mask and gloves if you will be epidemiological your route, you protect yourself and other people. Yes, hard, hot, impossible to breathe. At this stage, patience is necessary. You know how I dream to open the sky? I for six years every week flew somewhere. And I understand that soon will be able anywhere. But I know that now my country needs me. I need to do here is max just that I know how to prevent the growth of infection.I keep thinking about our old people, the immigrants from Europe, how much they had to worry about: war, blockade, fascism, the Soviet Union, various modes, moving to Israel, in some other country… They had to go through it all, then to die from coronavirus is such injustice… And I think this is the personal responsibility of each of us — in front of these old men, in front of each palliative patient in front of their families. And if we know that somewhere did something is wrong, we must be honest to admit it and to begin to correct their mistakes.”We must not fight with people” In Israel to palliative care patients during a pandemic relatives allowed?— Initially, we had a ban, but then it changed. If I am a specialist in palliative medicine, I must not forget that my patient is dying. And I can’t always deny him the right to see his family. I know that many of the palliative hospitals are afraid to let relatives because there is a risk of introduction of infection. But it is wrong. We found a solution: they began to create ethical advice in the institutions. What is it? The ethical review boards are a nurse, doctor, social coordinator, social worker. If the patient remains a matter of days and hours in this life, the ethical Council can talk with the family to advise them to purchase PPE and provide them with epidemiological route, so they came and said goodbye with a loved one. Because people then all life to live with it. Yes, very easy with a single command to say that we will never let anybody, because the pandemic. But people would be outraged, devastated. If you on the ethical Council will discuss it, I’m sure you can come up with a way in which the care of a person in a different world happens the least traumatic for his family and allow his family to cope with it and not blame you. We need to think about our patients, but we must think about our fellow citizens whom we deprived of the opportunity to bid farewell to mom or dad. And it happens that you are not allowed the relatives to a patient who does not die, but they scandals? What to do in this situation?— It is very important to avoid conflicts. With some people you need to communicate for a long time — sometimes an hour and a half. This is very important! To say “We do our best, trust us”, “We, your dad and the next, we will not leave it” — a simple, short phrases, relieve tension and increase trust.You see, we suddenly at the same time closed all the doors and people were left outside the gates without knowledge, without information. They don’t know what’s going on with their loved ones. Information is very important! For a long time I could not see my mother, we only talked on the phone and she complained: “why me? What have I done that even you, my only daughter, I can not come to me?”And I knew that my mother was in a bad emotional state and I have to explain to her what is happening and why I can’t join her. We have to say with every elderly person. As with his mother.If doctors have no time, need to find those people who can communicate with their relatives. Any professional in the green zone can take the phone and call. It would be good to create a team of social workers, psychologists, volunteers, who couldut to come to the aid of physicians to inform relatives, to inform people, to tell more people about what’s going on. Or you can create a group of relatives and friends and tell them at least once a day everything that happens with their families.There were cases when we had to call the police and even soldiers: people went in a mad state of panic, screaming why we don’t allow them to see my mother, just rushed into the breach. But it was at the beginning of the pandemic. Then was coined a lot of schemes, through which people could see their relatives. We have geriatric hospitals did schedules of visits, and brought many patients to the street, allowed family members to come to them and sit on the street at a distance of 1.5 m from each other. Of course, not everyone adhered to those rules. You imagine — the Jewish mother Jewish daughter at a distance of five feet from each other! Social coordinator-psychologist, who was observing the people, says: “Now I see that mother daughter kissed, hugged — well, I like them separate? No, but I’ll let the nurse in the institution that was tactile contact and so she watched the symptoms in this elderly lady.” We don’t have to fight with people and tear them apart by force. Imagine that this happens not with them but with you. But still, it is important to explain to them that the desired distance is that it is a safety issue.I’m not just talking about the ethical Council the ethical Council helps to make the right decision not to go on the battlefield with this unfortunate family, and to seek consensus with them.”The isolation of the elderly, frail, palliative citizens will continue throughout the year 2020″— You said that after the end of the pandemic will raise the issue of the need to develop General principles of basic care in General hospitals. What other conclusions have you made, what still needs to change in medicine?— I’ll tell you about the main findings, which I have done for myself. Not all employees in our field have the same knowledge that I have or some other specialist. Not all nurses, doctors, care helpers possess such knowledge. And they are very afraid. Ignorance often encourages them to wrong action. And so we should include them in our work in a multidisciplinary team in our institution long-term care. It is very necessary trainings for employees, especially for agencies long-term care, palliative care, and of these trainings is not to exclude anyone, neither the level of education or position.Another important aspect is the construction. I do not only training, but also to the design of various institutions, geriatric centers. Now I see how important�� to the institution of the quarantine Department, which fully decapsulate with patients and staff. Also it is very important that the chamber was large — it is impossible to isolate people in a small space. Impossible isolation, if between the beds there is two meters. You must have such conditions, coming out of the sickroom, from the so-called red zone, you can change the neutral zone, and then to leave the green zone. For this purpose, good bathroom, but it needs to be in each room. If the building is properly planned, you will be able to organize the isolation of patients within the office.It is important to consider where you will place the patient, when his condition worsens, what will be the route of the personnel during epidemics, some people will have to participate in bathing, dressing, feeding the patient.Next, what did I learn from this quarantine. If an older person was in contact with a sick person or yourself has received a positive test, we isolate for 14 days — at home, in a nursing home or in the office long-term care. For many of our patients this isolation — with or without palliative — can result in death. They die from loneliness. They don’t understand what’s going on.We, like the astronauts, we go to their room, and they don’t understand who came to them, they begin to get lost in space and time, they ask: “Why I quit?” In this period they will have to work a clinical psychologist. This specialist should also advise nurses: how to behave with older people, how to speak with those who are hard of hearing, poor vision, bad recollection, and also with those who have had cancer in the terminal stage, dying.This quarantine has shown us that it is impossible to take the same linear measure for all. We close the elderly at home or in geriatric hospitals, and many of the insulation stops working muscle tissue. Once this occurs, people begin to breathe worse, they develop congestive pneumonia. All this for our palliative and geriatric patients is very bad. Therefore, it is impossible to abuse with bans, but at the same time, all you need to do to preserve the life and health of people. It is impossible to completely isolate the elderly?— Yes, they have to come care helpers — man must get the same care as before the plague. And yet he must necessarily be communication. Here in Israel, this began to involve the army: soldiers call at the door to the elderly and asking them to look out the window. So they communicate with each other.— Israel lost COVID-19? Or are you waiting for the second wave?— We are waiting for the second wave. While ended only the first phase of the war against coronavirus infection, and we are trying together �� him to live. The state of Israel decided that the isolation of the elderly, frail, palliative citizens will continue throughout 2020. We fear that the usual seasonal virus will mate with the coronavirus and then the second wave can be even more intense. But I would not want to escalate. This coronavirus taught us a lot. No need to intimidate people. We need certain restrictions and the gradual withdrawal of these measures. It is important that people continue to adhere to epidemiological measures, being on the street and in public places. All of us are now very difficult, but I realized that this coronavirus — check for all of us. We must try to be strong, positive thinking and caring about other people, then we’ll deal with this infection.We all prepare for the second wave train to work in capsules. We have no watches for two weeks, when the whole shift of personnel out in the visual observation in any institution, as, for example, you have in Russia. This is incompatible with the ideology of Jewish mothers to leave their children and family for 14 days, this does not happen, it seems to me, ever. But the work in capsules with patients is an interesting experience. With me are a great epidemiological sisters, and together we drew attention to the fact that, observing all safety precautions when working with COVID-positive patients, we do not become infected. If the staff is trained properly to work in PPE, in full gear, then when the disease of a patient in a geriatric or palliative care Department, we no longer have to send in isolation and patient and all in contact with it staff. The heads of the agencies made the decision that workers are in full PPE in capsules.What is a capsule? We have divided the personnel in our institutions long-term care as would be in two streams. These two streams do not intersect. The patient lives in his room, to him in the morning, nurse comes and assistant, and in the evening come the other nurse and the assistant on care — and they spend their allotted time in this capsule, which includes the patient room, bathroom and part of the corridor. The most important thing that these people do not overlap. If you have to feed the patient, you do in your capsule is your only area of responsibility for your patients. You are working in full ammunition, and, passing from the capsule into the capsule, this ammunition change. Of course, glaucous leaves an incredible amount, but it’s the only “cure” for such institutions. It is the encapsulation helps us to provide services at the same level as before the pandemic. The heads of the agencies decided that employees work in capsule in full PPE.— Can you tell us more about the capsule and the encapsulation?— For example, in each Department of the geriatric center at the lives of 36 people. During the construction of the centers plansmiling so that in each compartment there are two parts — right and left, and thus it can be divided into two zones. How is encapsulation? If the Department someone has been infected, it is closed in the capsule. If the infected employee, he immediately leaves for insulation, and with it removed from the Department contact the staff. Intrudes new staff, which is divided into two groups. Patients are also divided into two groups of 18 people. With each group powered by its own staff, which is not mixed with another group, because we can not know which patients are infected. The second aspect of encapsulation — create capsules inside each chamber. This happens when we suspect that patients got in the epidemiological route of infected employees or other residents of the center and could be infected. In this case, the capsule includes the patient room, bathroom and part of the corridor. The patient lives in his room, to him in the morning, nurse comes and assistant, and in the evening come to the other nurse and assistant. The most important thing that these people do not overlap. If it happens at night when the unit has only one nurse and one assistant, they first work on one side of the compartment and then pass sanitation and work in the second half.Of course, Sizov out an incredible amount, but it’s the only “cure” for such institutions. It is the encapsulation helps us to provide services at the same level as before the pandemic.Interviewed By Olga Allenova
