At the LifeCare Center in Kirkland, Washington, we saw a vivid example of how uniquely vulnerable nursing homes are to COVID-19. In one month, over half of its 120 residents contracted COVID-19. Over 20 percent died, and one third of its staff show symptoms of COVID-19.
As more people in the community contract COVID-19, we are approaching a certainty that the disease will enter the state’s nursing homes, resulting in thousands of deaths and infections of healthcare workers. For this reason, the federal government restricted visitors from entering facilities, and the CDC released guidelines for infection control. These are good steps, but are not nearly adequate. In addition to visitors, staff themselves are very likely to bring the disease in, and although the CDC guidelines are sensible, we have no evidence that they are adequate to contain the disease in this setting.
Reducing transmission in nursing homes is an essential part of slowing the spread of the virus and flattening the epidemiological curve. Here are three steps that the State of Connecticut can take right now to advance this time-critical goal:
Send some patients back to families or friends. Many patients in nursing homes do not have a home to return to or are too sick to be cared for at home. However, a minority of patients could go home to friends or family, and those that can transfer to a private home should be encouraged to do so. If even 10% of residents return to private homes, this would save lives. Transferring patients to private homes would also free up bed space as the hospitals overflow.
The process could begin with a frank discussion of the risk with families. Financial support would certainly help. Connecticut Medicaid could quickly liberalize the “Money Follows the Person” program as part of the state’s emergency response, and shift funds to families or friends that accept residents into their homes for isolation. In addition to providing a safer option for residents, this may also provide a financial cushion for families whose incomes are affected by COVID-19 and would be budget-neutral for Connecticut.
Segregate nursing homes based on COVID-19 status. We must ensure that nursing homes that are not yet exposed to COVID-19 are kept free of the disease for as long as possible. Patients coming from the hospital with COVID-19 should be sent to a designated COVID-19 facility with properly trained staff and supplies. It is not fair to expose residents to a virus that could kill them when we cannot know with certainty that our infection prevention guidelines are adequate to contain the virus within the nursing homes.
Protect the staff and the patients. Nursing home staff are at high risk. While most authorities agree that SARS-CoV-2 is spread through respiratory droplets and by touching droplet-contaminated surfaces, fecal transmission also seems likely. The virus also becomes airborne in certain conditions that have not been exhaustively defined.
SARS and MERS, the close sisters of COVID-19, are acquired by airborne transmission in some circumstances. We cannot ask our frontline staff to take care of these patients without the same personal protective equipment that the rest of the world is getting. This includes N95 masks for staff that care for coughing patients, patients getting aerosolizing procedures, and patients being swabbed. We also need better body protection for Certified Nursing Assistants (CNAs) that clean diapers and interact with potentially infectious material.
If our staff is not protected, they will not work. If we need to release masks from the strategic reserves for the military, now is the time to do so. Nurses, nursing assistants, and other providers who are older or have chronic health conditions must be excused from hands-on care of possibly infected residents, to minimize the morbidity and mortality of healthcare workers. Furthermore, staff should start using surgical masks in the building to prevent them from accidentally shedding the virus onto patients. This has been called for by the American Medical Director’s Association, but not yet accepted by the CDC, or Connecticut Department of Health.
If we run out of surgical masks, they can be fashioned out of paper towels and rubber bands if need be. If we run out of N95s, we will re-use the existing supply as safely as possible. We need authorities to make the medical recommendations for protective equipment separately from practical considerations of supply, so that we maintain honesty and do not sacrifice our healthcare workers through miscommunication.
State Departments of Health, the CDC, and local governments play an essential role in establishing the rules of engagement in an environment that is emerging as ground-zero for the infection. Let’s encourage the best protocols to prevent unnecessary morbidity and mortality. What we do now will deeply impact the future.
Jesse Cohen, MD, MPH is the American Medical Director’s Association’s Chair of the Northeast COVID-19 Response Task Force. He is also Medical Director of the Newtown Rehabilitation and Health Care Center and Sharon Health Care Center.