It is only Saturday afternoon and our emergency department has already seen the fourth patient with Covid-19 from one of the local nursing homes this weekend. She was fine just a few days ago; now she is disoriented and can’t catch her breath. At age 75 and with other chronic conditions, should we put her on an experimental therapy?
A few hours later, an ambulance brings a patient from a different nursing home, one that already has 21 residents with Covid-19 cases, three of whom died in the past week. He is 87 years old, has severe heart disease, is unresponsive, and no family member is reachable. He needs to be placed on a ventilator in order to survive, but once on the machine, his chance of getting off it alive is not great.
Although much of the nation’s focus has been on the surge of Covid-19 cases and deaths in New York and other large cities, the overlooked epicenter of the pandemic is our nation’s nursing homes, veterans’ homes, and other long-term care facilities. At the end of April, with data available from 30 states, in one-third of them more than 40% of the statewide Covid-19 deaths were in long-term care facilities.
The plight of the elderly in this pandemic should come as no surprise. This was expected from reports as the pandemic spread across the globe and from what unfolded in the King County, Washington, nursing home tragedy that began in late February.
Since then, we’ve heard similar stories from around the country. In Massachusetts, 103 veterans so far have died in two residential and long-term care facilities. In Illinois, hundreds of deaths due to Covid-19 have been reported by long-term care facilities. Nearly all nursing homes in New Jersey have reported at least one case. Should staff in these facilities be worried about whether they will have enough personal protective equipment to protect themselves each day?
It is past time to focus the full weight of our testing, supply chain for personal protective equipment, and workforce strengthening efforts to nursing homes, veterans’ homes, and other long-term care facilities. Recent reports in the New England Journal of Medicine and Morbidity and Mortality Weekly Report detail just how rapidly and widely older Americans are being affected. In the former report, more than half of the 48 infected residents had no symptoms at the time they tested positive of SARS-CoV-2. In the latter, 16 days after SARS-CoV-2 was first detected in the facility, 30% of residents tested positive.
The current widespread strategy of testing only individuals who are symptomatic for Covid-19 won’t curb this pandemic, especially in these settings. Rapidly increasing the capacity for testing of all residents and prioritizing long-term care facilities for delivery of personal protective equipment is a moral imperative.
As a physician who specializes in infectious diseases and as an epidemiologist, I have seen the terrible effects of Covid-19 among hospitalized patients and in my state’s long-term care facilities. While local and state public health departments have been doing herculean work to combat the pandemic, I am dismayed at the long-standing absence of a national strategic focus on nursing homes. It was not until April 30 that the Centers for Medicare and Medicaid Service announced an independent commission to focus on long-term care facilities, and the task force is not expected to meet until late May.
Each week I take part in calls that Connecticut’s Department of Public Health has set up to discuss updates and issues with long-term care facilities. During these calls, distraught leaders of long-term care facilities have asked state officials where they can obtain tests for their staff or residents. They want to know whether residents should be moved to designated Covid-19 facilities or if their own facilities should designate special Covid-19 units, not knowing if they will have the workforce to undertake such tasks and the infection control training to do it properly. We have been asked if certain health care workers can wear less personal protective equipment than others and how to manage staff shortages. The plight of long-term facilities as the pandemic continues its march across states is heart wrenching.
Since the beginning of the surge, the nation’s attention has been on ventilators, personal protective equipment, and testing. That’s appropriate, and there is still more work to be done on these fronts. But we’ve missed another important mark by not focusing on residents in long-term care facilities, as they make up the largest proportion of Covid-19 cases that are hitting our hospitals, requiring ventilation, and succumbing to the virus. To save lives, conserve limited medical supplies, and prevent hospitals from hitting their breaking points, we should be preventing elderly folks from needing to come to the hospital in the first place.
Clinicians aggressively treat blood pressure and other risk factors to help prevent people from needing to be hospitalized for strokes and heart attacks, which is often too late to truly help them. We should think of preventing Covid-19 in nursing homes the same way.
All nursing home workers must be provided with the protective equipment they need. Enough Covid-19 tests should be made available to test all residents and staff, especially if a single case is present in the facility. The leadership and staff should be supported with training on how to reconfigure their facilities so that infected individuals are separated from residents who have not tested positive. Facilities not yet affected must be provided with infection-control training, sufficient work-force support to make sure this remains the case, and strict policies for staff screening should be mandated. Workers should be financially supported so they do not have to work in multiple facilities to make ends meet, which would limit the spread of Covid-19 from one facility to another.
Preventing new infections will limit the needless deaths of thousands of Americans, reduce the demand for personal protective equipment, and lower the risks of infection borne by frontline health care workers.
An aggressive policy effort at the national level can help curb this epidemic where it is hitting hardest. Let’s give state and local health care workforces the resources they need to save our most vulnerable.
Sunil Parikh is an infectious disease physician at the Yale School of Medicine and an associate professor of epidemiology at the Yale School of Public Health.