By Gary Evans, Medical Writer
The combination of a highly infectious virus and a frail resident population in a closed environment — where infection control has been historically difficult to implement — has resulted in devastating outbreaks of COVID-19 in U.S. nursing homes.
Infection preventionists with oversight or consulting arrangements with nursing homes know that introduction of the pandemic coronavirus into these facilities may be the first wave of a perfect storm.
As of April 23, 2020, a report by the Kaiser Family Foundation (KFF) found that in the 23 states that publicly report mortality data, more than 10,000 reported nursing home residents and staff have died of COVID-19.1
“Our data also finds that there have been over 50,000 reported cases, accounting for 11% of coronavirus cases in 29 states,” the report states. “In six states reporting data, deaths in long-term care facilities account for over 50% of all COVID-19 deaths — Delaware, Massachusetts, Oregon, Pennsylvania, Colorado, and Utah.”
Although incomplete reporting undermines full accuracy, it is clear that nursing homes are bearing the brunt of the pandemic.
There are more than 1 million residents in about 15,000 nursing homes nationally, Terry Fulmer, PhD, RN, FAAN, president of the John A. Hartford Foundation, said during a recent webinar.
“Our healthcare system has failed our nursing homes and all those who live and work there,” she said. “It is heart-wrenching to see the devastating toll this is having on our residents and staff in long-term care facilities. We have to act now to prevent further death and suffering.”
CMS Requires Reporting Respiratory Conditions
In one of the first reported nursing home outbreaks of COVID-19 in the United States, the Centers for Disease Control and Prevention (CDC) recently described a transmission in a Washington state facility that resulted in 23 deaths in February and March of this year. 2 The novel coronavirus infected 81 residents, 34 staff members, and 14 visitors. Overall, 57% of residents, 36% of visitors, and 6% of staff members were hospitalized. All staff members survived, but the mortality rate was 27% in infected residents and 7% in visitors, the CDC reported.
“Limitations in effective infection control and prevention, and staff members working in multiple facilities, contributed to intra- and interfacility spread,” the CDC concluded. “Long-term care facilities should take proactive steps to protect the health of residents and preserve the healthcare workforce by identifying and excluding potentially infected staff members, restricting visitation except in compassionate care situations, ensuring early recognition of potentially infected patients, and implementing appropriate infection control measures.” (See “Clock Starts Ticking When COVID-19 Enters Nursing Home.”)
According to the KFF report, about 40% of U.S. nursing homes were cited for infection control deficiencies in 2017. The Centers for Medicare & Medicaid Services (CMS) recently announced it will be enforcing existing standards for infectious disease reporting and develop specific regulations for COVID-19.3 (See “CMS Moves to Enforce Infection Control in Nursing Homes.”)
While calling for “transparency,” CMS made it clear that nursing homes that do not comply could be subject to regulatory enforcement. This has raised concerns in nur-sing homes that CMS may take punitive actions even as the facilities are struggling to deal with the pandemic, says Lori Popejoy, PhD, RN, FAAN, associate dean for innovation and partnerships at the Sinclair School of Nursing at the University of Missouri in Columbia.
“Historically, ‘transparency’ has not necessarily been a friend of nursing homes,” she says. “Being transparent at this really vulnerable time is a challenge. Yes, we need them to be transparent and know what they are doing, but they are concerned that they are going to be receiving financial penalties.”
In addition to vigilant hand hygiene and environmental disinfection, communication is a bedrock prevention measure, emphasizes Connie Steed, RN, president of the Association for Professionals in Infection Control and Epidemiology (APIC).
“They need to keep the residents and the employees informed,” she says. “Don’t ignore COVID-19 — there really needs to be some communications [and planning]. How would they take action in a certain situation?”
Because some residents may have dementia, you cannot simply set out hand sanitizer at the bedside and expect it to be used properly, she says. This is but one example of how the intensity of care increases when you are dealing with an outbreak in a setting where people are normally encouraged to socialize.
As the staff work harder to keep residents safe, their own health becomes a key part of the outbreak response. “The nursing homes need to ensure that they have sick leave policies for employees, so they will stay home if they have respiratory symptoms,” Steed says.
Although they care for one of most vulnerable patient populations, nursing home staff may be paid minimum wage and have few options for sick leave or personal healthcare coverage.
“The tragedy has spread across the country to every state. All of us have lessons to learn about actions to take,” Fulmer said. “Existing inequalities in our system are being exacerbated and highlighted. Unfortunately, this crisis has everything to do with how we as a country treat our nursing home communities.”
One problem in stopping these outbreaks is that investigators are finding long-term care residents with asymptomatic coronavirus infections. This is somewhat counterintuitive given their age and underlying health conditions.
Morgan Katz, MD, a physician at Johns Hopkins Hospital investigating COVID-19 outbreaks in long-term care, says the more you test, the more asymptomatic cases you find.
“The results we got from universal testing were really stunning,” she says. “If we had one or two symptomatic cases in the facility, we find that about three-fourths [of residents] were positive. About 60% to 70% of those were completely asymptomatic. There really hasn’t been enough attention given to infection prevention in this setting.”
As with other aspects of the pandemic — such as the heightened risk to people of color or those who bear longstanding socioeconomic burdens — the plight of nursing homes raises ethical questions about the pandemic response, says Nancy Berlinger, PhD, a research scholar at the Hastings Center, a bioethics institute in Garrison, NY.
Partially as the result of social stigmas about death and aging, nursing homes were something of an afterthought as the pandemic hit.
“I look at it like they just were not ‘dealt in,’” she tells Hospital Infection Control & Prevention. “We sometimes talk about a population being ‘invisible’ — if not invisible, neglected.
“I think part of that is we can imagine ourselves using hospitals — because they have emergency rooms and people have babies — more readily than we can imagine using a nursing home. We don’t associate nursing homes with positive experiences, and that [is related] to how we think about aging and disability. It’s almost a foregone conclusion that when we think of nursing homes, we say, ‘I don’t want to go there.’”
One of the lessons that will come out of the pandemic is that early interventions in long-term care could have prevented some hospitalizations, relieving some pressure from a healthcare delivery system threatened with being overwhelmed.
“Long-term care facilities have to be on our mental map, or as we sometimes call it in ethics, our moral imagination,” she says. “I think some of the hospital-based doctors really felt this very keenly. Some said maybe the best way to protect an older person was to have gone way upstream and made sure these facilities had adequate gear [and resources]. Then we would not have these patients in hospitals in a condition where we could not do anything for them.”
The idea of avoiding hospitalizations by detecting and treating illness in nursing homes has been the goal of a project begun by Popejoy and colleagues at the University of Missouri in 2012. The intent is to head off more invasive and intensive care that could include multidrug-resistant bacteria — and now COVID-19.
“We are seeing nursing homes really try to minimize hospital transfers now, keeping the residents and not sending them to where they could be potentially exposed to COVID-19,” she says. “This has really made the facilities rethink when they might transfer them otherwise. That’s really been an emphasis all along, keeping people in facilities and treating them as much as they can.”
On the other hand, when residents show symptoms of the coronavirus, such as respiratory illness and onset of fevers, they are being sent to hospitals for needed acute care, she adds.
“At the beginning, part one of the complications was the profound lack of testing,” Popejoy says. “The only way to get a test was to go to a hospital and once they come back to the hospital, they have to be cohorted in an infection control/COVID-19 unit, and it creates a lot of complications.
“Now that testing has become readily available, they can be tested within the facilities, so that impetus to actually transfer has been tamped down a little bit unless they are heavily symptomatic.”
Mental Toll on Residents?
The potential for asymptomatic patients and healthcare workers complicates control measures considerably, but at least nursing homes now know what pathogen they are dealing with.
“If you go back to the first facility in Washington, they probably thought they had a flu outbreak,” Popejoy said. “They were managing it as the flu and they were probably confused about why things were evolving so quickly — and at that point, you will recall there was very little COVID-19 in the United States.”
The chronic shortages of personal protective equipment hit nursing homes hard, as they were not initially viewed as a priority to receive masks, face shields, and the like.
“I reached out to the emergency management system in the county and asked them if they were talking to nursing homes, saying ‘If you don’t involve them now, there are going to be huge problems later,’” she says.
As the pandemic set in, traditional transfers between hospitals and nursing homes became more difficult, as the movement of patients and residents between facilities was slowed by coronavirus concerns.
Another part of the new normal is that a resident may be isolated in their room to contain transmission, able to see relatives and visitors only through smart phones and other devices. This threatens physical and mental health, since nursing homes emphasize mobility and socialization.
“The normal nursing home environment is to socialize,” Popejoy says. “You bring residents out of their rooms and they dine together and do activities together. All of that lets them be more mobile, they eat better, and they are less likely to become depressed or anxious and have behavior issues.
“Now that we have them isolated, we will start seeing more of these types of things.”
- Chidambaram P. State reporting of cases and deaths due to COVID-19 in long-term care facilities. Kaiser Family Foundation. April 23, 2020. https://www.kff.org/medicaid/issue-brief/state-reporting-of-cases-and-deaths-due-to-covid-19-in-long-term-care-facilities/
- McMichael TM, Clark S, Pogosjans S, et al. COVID-19 in a long-term care facility – King County, Washington, February 27-March 9, 2020. MMWR Morb Mortal Wkly Rep 2020;69:339-342.
- Centers for Medicare & Medicaid Services. Upcoming requirements for notification of confirmed COVID-19 (or COVID-19 persons under investigation) among residents and staff in nursing homes. April 19, 2020. https://www.cms.gov/files/document/qso-20-26-nh.pdf