By ANISH KOKA, MD
Our strategy with nursing homes in the midst of the current pandemic is bad. 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 in Philadelphia. He loves his nursing home residents. He can be found on twitter @anish_koka.