Could all those COVID-19 nursing home deaths have been prevented? No.
Could some of them have been prevented? Certainly. And many more can be prevented in the future.
How? With more testing, with better testing that produces rapid results, with more personal protective equipment (PPE) and better staff training in how to use it, with far better management of staff and operations, and with timely data.
Ideal settings for spreading coronavirus
Before getting into the details, keep in mind that nursing homes are almost ideal settings for spreading novel coronavirus and for high levels of mortality.
Recent studies in the US and elsewhere (here and here for example) show that the virus is most aggressively transmitted with prolonged contact in enclosed spaces—the very definition of a nursing home. While visitors are barred, staff routinely come in and out. Many work multiple jobs, increasing their risk of spreading the disease from site to site. And the disease often is spread by people who show no symptoms.
At the same time, many of those nursing home residents who died from COVID-19 already were severely compromised. About one-third of residents will die in any given year. Nursing home residents are, almost by definition, very sick and susceptible to infectious disease. And, as we have learned, older adults with conditions such as diabetes, obesity, and heart and lung disease are especially at risk of dying from COVID-19.
That said, the Kaiser Family Foundation reports nearly 25,000 residents of long-term care facilities died of COVID-19as of May 7 (in only 33 reporting states). That’s 38 percent of all deaths in those states. And many of these deaths certainly could have been avoided.
How? We may be able to learn some lessons from experiences in Canada. One 85-bed senior care facility in Toronto, the Ivan Franko Home, has had no COVID-19 cases or deaths. That may be partly due to good fortune, but it may also have been because the community responded both quickly and aggressively to the pandemic. The 50 year old facility is especially challenged because many residents share rooms and bathrooms.
On March 16, management implemented a pre-existing pandemic control plan. It required staff to work in only one facility, and put part-time workers on full-time to make that feasible. It hired an additional housekeeper to help clean commonly touched surfaces, and provided two masks for each employee each day—more than many US hospitals are doing, even today. It increased infection control training, and testing for symptoms.
Based on those lessons and other evidence, here are five ways US nursing homes and assisted living facilities can slow the pandemic in their facilities. Most will cost money, a lot of it. And the government, as the primary payor of long-term care, needs to chip in. But even beyond the human toll, think about what we are spending to keep COVID-19 patients in hospitals, on ventilators, for weeks. It is shortsighted at best.
Improve staffing and staff support. Facilities may be able to reduce spread by staff by prohibiting aides from working second jobs. But to do that, they’ll need to make nursing aid positions full time, raise staff pay, and provide paid sick leave to encourage aides to stay home if they do not feel well. Says Michael Schwandt, Medical Health Officer at Vancouver Coastal Health in British Columbia, “When it comes to LTC staff, monitor symptoms closely, test early, and test broadly, and support workers [who] stay off of work for any compatible symptoms.”
Testing, testing, testing. Despite President Trump’s claims, many facilities still do not have the equipment to do viral routine viral tests for residents and staff. And even when they can test, they often must wait days—or longer—for results. Without rapid, accurate, ubiquitous testing, it will be impossible to control the spread of COVID-19 in long-term care facilities. Routinely taking staff temperatures is no substitute for viral testing.
More PPE. By now, we’ve all heard the stories. Masks, gloves, and gowns are hard to get, and very expensive. Providers report paying $10 or more for masks that cost 90 cents before the pandemic. Because of shortages, staff are forced to use paper surgical masks instead of the more effective N-95 versions, and they must reuse these masks for days at a time.
Not only is access to PPE limited, but staff still are not well trained in how to use it. High staff turnover, even before COVID-19, made training difficult. But it was common for aides to go in and out of resident rooms without taking the most basic precautions such as wearing gloves and washing their hands .
Reduce unnecessary ED visits. In many facilities, residents are routinely sent to hospital emergency departments for minor changes in health status, such as a fever. A hospital visit likely increases the chances that a resident will contract COVID-19 and spread it though a facility. Now, more than ever, nursing home staff should be better trained to handle minor medical issues internally and avoid hospital visits.
Collect data on senior living outbreaks. We are months into the pandemic and still have no good data on where cases and deaths are occurring. The Trump Administration promises publicly-reported nursing home data, but probably not until the end of May. There is no national system for collecting information on assisted living facilities and senior communities.
It is possible to slow these deadly outbreaks. It isn’t too late. But it won’t happen without commitment and resources.