By ANISH KOKA, MD (7)
Our strategy with nursing homes in the midst of the current pandemic is bad. No, make that terrible. Nursing homes and other long term care facilities house some of our sickest patients in and it is apparent we have no cogent strategy to protect them.
I attempted to reassure an anxious nursing home resident a few weeks ago. I told him that it appeared for now that the community level transmission in Philadelphia was low, and that I was optimistic we could keep residents safe with simple maneuvers like better hand hygiene, restricting visitors, as well as stricter policies with regards to keeping caregivers with symptoms home. I was worried too, but optimistic.
I figured the larger medical community would be on the same page if someone did get COVID. It made sense to me to be aggressive about testing staff and residents and quickly getting COVID-positive patients out of the nursing home. So when I heard of the first patient that was positive in the nursing home, my heart sank, but it fell even further when I found out the COVID-positive patient was sent back from the hospital because they weren’t “sick enough” to be admitted.
This is exactly what we do with the general public when they arrive in the ER. If you’re not sick enough, the best place for you to recover from COVID is at home, not the hospital. But treating nursing home patients like everyone else is really not smart. Long term care facilities are not designed with pandemics in mind. They are basically converted dormitories with care staff ratios of 1:10. Isolating patients in these facilities is close to impossible. There are usually no flexible spaces in which to isolate residents, and the staff at these facilities are relatively lower-paid, poorly trained and ill-equipped to suddenly handle a patient with COVID that requires a significantly higher level of care than usual.
This is a recipe for disaster. We were unable to even get the local Department of Health to cohort COVID positive patients in another part of the nursing home because it was a common area that would not have enough privacy. Keeping these patients where they are means the entire nursing home is likely to get infected. Even without the benefit of common sense or imagination, how this story plays out is relatively obvious from the very first outbreak of COVID in the US which took place at a skilled nursing facility in Washington state. In a 130 bed facility, 101 residents, 50 personnel, and 16 visitors were ultimately infected. As of March 26th, 35 residents and staff have died. Double-digit mortality rates. An expected outcome of a virus with a special predilection for the most infirm among us.
There are a number of considerations here, and they are not easy. If your city is in the midst of a massive outbreak, like the New York/NJ metro area was with a total of 11,000 new cases/day at last count, the hospital system simply does not have the capacity to keep patients until they are no longer shedding virus. If the nursing home residents are unwell enough to make attempts at resuscitation not worthwhile, it is certainly best to discuss goals of care with patients or their proxies. Severely ill coronavirus patients who end up on a mechanical ventilator have a poor prognosis even under the best of conditions. It certainly does not make sense to transfer every patient from a nursing home in the throes of an arrest or an impending arrest given the significant issues that relate to the transmissibility of this virus to first responders.
But none of these considerations mean the status quo is the best strategy if it leads to a much bigger problem down the road. The point here is to attempt to intensively isolate and manage initial cases in high resource settings like hospitals so the Health System doesn’t have to deal with the entire nursing home being infected later.
Philadelphia, which so far has seemed to escape the type of surge New York is facing, is now facing an uptick in hospitalizations from nursing homes precisely because of the stay in your home strategy applied to nursing home residents two weeks prior. As an epidemic spreads in the nursing home, staffing concerns become even more and more difficult as caregivers themselves get sick, or require quarantines. The ability of this virus to spread even with minimal symptoms or perhaps no symptoms also means that nursing homes become a significant mode for community transmission as healthcare workers return to their homes every night.
Remarkably, a very different approach in the city has been taken towards the homeless who contract COVID. Recognizing the problems with sending these patients back to homeless shelters, the city contracted with an empty hotel to house patients there. An operation to sort out how to sequester COVID positive nursing home patients in COVID-only facilities is clearly more complicated given the significant staffing needs for this population, but they certainly aren’t insurmountable.
It’s important we get this right because this virus is likely to be with us for some time before a vaccine or herd immunity develops. There is likely to be a second wave to deal with as the country eventually but inevitably starts to open. Clearly the best strategy is one that allows for aggressive surveillance testing of nursing home workers to keep these sites COVID-free. But even with all the testing in the world available, the virus just has to win once. Unless we can rapidly make consequential moves to effectively quarantine residents in nursing homes early on, I fear our most vulnerable will continue to pay a heavy price and we will continue to see larger outbreaks that result in larger, more costly mitigation efforts.
Anish Koka is a cardiologist based in Philadelphia. This post first appeared in The Health Care Blog.
Good post.
From what I know about nursing homes (a fair bit) in Oregon a POLST form is required for everyone wrt hospital transport.
I have as much concern for healthcare workers as for nursing home residents. Quarantine would change this dimensionally
See this group testing strategy.
We need to deploy it widely. It’s mean for confined groups like nursing homes:
To a certain degree, this is unavoidable. This virus kills more seniors than young people. It is what it is.
That said Ron DeSantis calmly, quietly & effectively averted a potential massacre in Florida, while NY Gov Cuomo panicked + turned the whole thing into a TV soap opera
It isn’t what it is.
It’s what you do with it
If I have an elderly relative in a nursing home where COVID is spreading I have the option of bringing them home
The state has the option of isolating COVID patients rather than allowing the virus to spread and kill unchecked
I did say “To a certain degree…” 🙂
To be fair to Cuomo, New York was the first place in the country to take a hard hit.
We didn’t understand what was coming and then it hit and then all hell broke lose.
I still don’t think we understand what we’re dealing with.
Did he save the day? Did he screw up? Quite frankly, I have no idea.
I’m going to reserve judgment.
Nonetheless, the criticism about nursing homes is a valid one. This is clearly a really bad decision.
My guess it that this a New York politics thing.
Unfortunately, like the epidemic itself, this thoughtful post shows this is a problem with no ready solution. The fact that many infected people are asymptomatic makes it virtually impossible to control the epidemic in a nursing home setting because you don’t know who is infected and who isn’t. Unless you’re testing everyone everyday, you can’t identify all the cases. Probably the best solution is the one that was apparently ruled out, i.e, a COVID ward within the facility with isolation precautions. Absent that I hope they are treating every patient as presumably infectious. Staff and patients should all be masked.
The road to herd immunity is almost unimaginably difficult. Assuming that exposure is protective, it’s estimated that about it would take about 60% prevalence of immunity to provide significant herd immunity. We probably have on the order of 6% of the population exposed so far. So, if current death rates hold it would take over half a million additional deaths to get to that point. That would make the U.S. death toll worse than World War II.
Similar problems are affecting three other populations: the homeless, prisoners and factory workers. The virus is teaching us that we really are “in this together” whether we like it or not.
Other posts show how politics gets easily involved, so I’ll make my own political observation. Over the two decades from 1961 to 1980 we had an evolution in this country from “ask not what your country can do for you, ask what you can do for your country” to “are you better off now than you were four years ago?” We might ask which approach works better in a COVID world. And, those that think that “government isn’t the solution, government is the problem” might take a look at the countries that have handled this crisis much better and recognize that they have national health systems and governments that can effectively institute national policies. As the deaths in the U.S. mount, the contrast may become even more apparent.
DS