COVID-19 infections at several long-term care facilities in the Seattle area have killed at least 32 elderly residents and infected two healthcare workers, the King County Health Department reported. As of March 15, 2020, 29 of the deaths were associated with a large outbreak at Life Care Center in Kirkland, WA. Three other residents have died of COVID-19 in other area nursing homes.

One healthcare worker employed at the Kirkland nursing home is a woman in her 40s who was hospitalized in satisfactory condition. She had no known travel history outside of the United States, as health officials now think that COVID-19 may have been circulating in the Seattle community for weeks. The other healthcare worker at Kirkland also was in her 40s and is being cared for at home.

The expectation is that more cases will be identified in the area as testing becomes more available and capacity expands. Efforts were underway to expand intensive care unit capacity at area hospitals and convert a hotel to house those who test positive. Broader social mitigation strategies, such as school closures, were in effect for several districts in Seattle.

At least 15 of the COVID-19 patients died at EvergreenHealth in Seattle after being admitted with life-threatening respiratory conditions, such as severe pneumonia. Approximately 50 additional patients with the coronavirus were being treated at EvergreenHealth as of March 11, 2020. The hospital has added more rooms with negative pressure air flow, and healthcare personnel are wearing the full regalia of personnel protective equipment, said Ettore Palazzo, MD, chief medical and quality officer at EvergreenHealth.

“We have made adjustments at the organization to allow for airborne precautions,” he said. “We are in a situation where we are able to convert our entire critical care unit over to a negative pressure scenario, so we keep those patients and staff safe. And we have those capabilities in other areas of the hospital.”

One of the hardest hit states, Washington was reporting 769 cases and 42 deaths as of March 15, 2020. The Seattle and King County area is the epicenter of the outbreak, with 420 cases and 37 deaths.

“There are likely many mild cases in the community that we are not aware of,” said Jeff Duchin, MD, public health officer for Seattle-King County. “These cases at facilities like EvergreenHealth are those at the tip of the iceberg cases with severe illness.”

As the state increased its testing capacity, more cases were found, he said. “This virus has been in our community, and we are now recognizing that because we are looking for it,” he said. “And the more we look for it, the more we are going to find it.”

CMS Advice for Nursing Homes

In light of nursing home outbreaks, the Centers for Medicare and Medicaid Services (CMS) issued a March 4, 2020, memorandum detailing compliance issues for long-term care facilities.1 The CMS memo provided the following answers to frequently asked questions about preventing COVID-19 in nursing homes, which are paraphrased as follows.

Q: How should facilities monitor or limit visitors?

CMS: Facilities should screen visitors for the following:

  • international travel within the last 14 days to restricted countries (for updated information on restricted countries visit: (https://wwwnc.cdc.gov/travel/notices/);
  • signs or symptoms of a respiratory infection, such as a fever, cough, and sore throat;
  • has had contact with someone with or under investigation for COVID-19.

If visitors meet the above criteria, facilities may restrict their entry to the facility.

Specifically, a facility may need to restrict or limit visitation rights for reasonable clinical and safety reasons. This includes restrictions placed to prevent community-associated infection or communicable disease transmission to the resident.

Q: How should facilities monitor or restrict healthcare facility staff?

CMS: The same screening performed for visitors should be performed for facility staff. Healthcare providers who have signs and symptoms of a respiratory infection should not report to work. Any staff that develop signs and symptoms of a respiratory infection while on-the-job, should:

  • immediately stop work,
  • put on a facemask,
  • self-isolate at home;
  • inform the facility’s infection preventionist, and include information on individuals, equipment, and locations the person came in contact with;
  • contact and follow the local health department recommendations for next steps (e.g., testing, locations for treatment).

Q: When should nursing homes consider transferring a resident with suspected or confirmed infection with COVID-19 to a hospital?

CMS: Nursing homes with residents suspected of having COVID-19 infection should contact their local health department. Residents infected with COVID-19 may vary in severity from lack of symptoms to mild or severe symptoms or fatality. Initially, symptoms may be mild and not require transfer to a hospital as long as the facility can follow the infection prevention and control practices recommended by the Centers for Disease Control and Prevention (CDC). Facilities without an airborne infection isolation room are not required to transfer the patient, assuming the patient does not require a higher level of care and the facility can adhere to the rest of the infection prevention and control practices recommended for caring for a resident with COVID-19.

Q: What if the resident develops more severe symptoms and requires transfer to a hospital for a higher level of care?

CMS: Prior to transfer, emergency medical services and the receiving facility should be alerted to the resident’s diagnosis and precautions to be taken, including placing a face mask on the resident during transfer. If the patient does not require hospitalization, he or she can be discharged to home (in consultation with state or local public health authorities) if deemed medically and socially appropriate. Pending transfer or discharge, place a face mask on the patient and isolate him or her in a room with the door closed.

Q. When should a nursing home accept a resident who was diagnosed with COVID-19 from a hospital?

CMS: A nursing home can accept a patient diagnosed with COVID-19 as long as it can follow CDC guidance for transmission-based precautions. If a nursing home cannot, it must wait until these precautions are discontinued. The CDC states that decisions to discontinue transmission-based precautions in hospitals will be made on a case-by-case basis in consultation with clinicians, infection prevention and control specialists, and public health officials. Nursing homes should admit any individuals that they would normally admit to their facility, including individuals from hospitals where a case of COVID-19 was/is present.

REFERENCE

  1. CMS. Guidance for infection control and prevention of coronavirus disease 2019 (COVID-19) in nursing homes. March 4, 2020. https://www.cms.gov/medicareprovider-enrollment-and-certificationsurveycertificationgeninfopolicy-and/guidance-infection-control-and-prevention-coronavirus-disease-2019-covid-19-nursing-homes