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.
I am beginning my 36th year as nursing home administrator. Two big mistakes were made by the CDC. First was not including long term care residents in Level One testing for COVID as the First Responders and inpatients hospital patients were. The second was telling nursing homes to put those with symptoms together (Cohort) at the same time telling us it takes up to two weeks to develop symptoms. This left many roommates without symptoms that were moved around too. I was very hesitant to do this as this is not how we respond to the flu virus in our facility. Once we get 2 or more in a wing with it, we quarantine the wing so as to reduce the chances of it spreading. We had been successful two years in a row keeping the flu from spreading to the entire building doing this. Now we were being told to move people around not knowing who really had it and who didn’t. The real problem is that CMS has so bludgeoned nursing homes to do what they are told by government agencies, most follow like Pavlov’s Dogs. The CDC and CMS need to step back and understand they are not the experts when it comes to running a nursing home. I have done it very successfully for over 35 years, 28 of them as an owner. I doubt anyone at CDC has done it for 35 seconds. Tell me what you know about the disease but, more importantly, tell me what you don’t know about it. Let me decide how best to protect those I care for and have for years. I’ll reach out if I have questions.
After our first resident tested positive at the hospital after being admitted, i began my quest to get all of my residents tested. It took me ten days and having a long time political friend for me to pull it off. The hospital that wa doing the testing finally sent us 100 test kits. They told us to send only 20 back at first as the lab was busy. We sent test from 20 residents that had symptoms. 19 came back positive and had already began treatment prior to the testing. We received the results on a Thursday. On Friday I instructed my staff to test the rest and send them to the lab. Saturday evening we found out that 24 non symptomatic residents tested positive, more than we had with symptoms. We discussed on Friday making massive room changes as we thought one wing was totally negative. We were going to move other symptom free residents into that wing as it had the most open beds and no one with COVID symptoms. I finally said to wait until Monday after we get the results back. Thank God we did. The wing we thought was our best wasn’t, it was another wing. Myself and many others came in Sunday and made the massive room changes this time armed with knowledge and doing it correctly. Since all those moves were made things have calmed down. We have had only two more go positive since and are graduating 44 off COVID Monday. We did lose 8 residents early on and it has been tough on the residents and staff. Very few that were tested positive without symptoms ever developed any as they were treated with Vitamins, Zinc and Hydroxychloroquine, if they had no heart issues precluding it.
I was asked on that Sunday when we were moving residents around if I felt bad about having 43 residents with COVID out of about 82. I said no, this is the first time I felt like we were doing something knowingly since it all began and I felt much better about things. Testing is the key without a doubt. CMS and CDC told out industry to look at what happened in that Washington nursing home, Kirkland, and learn from it. I wish they had learned from it and allowed nursing home residents into first level testing when the first symptom hit the facility.
While Trump gets tested EVERY DAY (yes – every day) the whole country is short of tests. Clearly aware of the merit of testing, he should be the prime promotor of higher testing rates, certainly for his age group, and particularly in hot spots like nursing / long term care / veterans homes, etc. But alas, as these do not contribute to the economy (read : no profits) this idea will likely unfortunately fall on his deaf ears.
If you had been paying attention you would know. THE test is not like a ph test. it takes skilled techs and equipment. Then the government bureaucrats wouldn’t pay enough to the labs to process the test. Hospitals had equipment that could process the test but didn’t know it. They probably had the chemicals but the right ones weren’t FDA or gov certified. typical government bullshit.
Epicenter implies they are the source. They are just a derivative of larger scale infection in the younger, relatively invulnerable population. Proponents who suggest we need to isolate the vulnerable population fail to understand this is the scenario of what happens when you isolate a vulnerable, together, and you let the virus run unchecked.
“Let the virus run unchecked” is an odd statement – you likely are not aware of the hard work that’s being done in those “homes of the vulnerable”.
Hot off the research press : men are also more vulnerable, Covid-19 appears to have an androgen link ………….
People who commit themselves to nursing homes go on to live another three or so on average. In other words, death-by-nursing-home has the appearance of a mortality rate of something like 33% a year. Who, then, in their right minds would go to a nursing home if they’re such death traps?
I jest, of course. Nursing homes are not necessarily death traps. They are, however, places at which people situate themselves when they no longer have the capacity to take of themselves. Harsh, but true.
This sets up my question: May we expect that the the Covid experience will have induced sharply higher rates of mortality in nursing homes in 2020 than we will have observed over the last several years?
A blessing is that Covid-19 has not ravaged the population of younger people — not like the Spanish Flu of 1918 which disproportionately affected the young. Societies lost some of their futures in that pandemic, and, many of the survivors suffered effects that lasted decades.
It is true that CV-19 has hardly affected the young – so far. However, in 1918, the influenza virus mutated, and new versions, presumably selected for by the conditions of WW I trench warfare, were more deadly.
Coronaviruses and influenza viruses have fundamental differences in how they mutate and evolve. While coronaviruses have proofreading mechanisms that slow down mutation, they also can engage in recombination when a host is infected with 2 viruses at once. And cats and humans are essentially equivalent hosts for CV-19. As the pandemic grows, there is an increasing likelihood that CV-19 will recombinate with a different coronavirus and produce a totally new virus. That recombination need not be with a human virus, as there are coronaviruses known that only infect cats, and there are lots of cats in the USA. The selection pressures on the virus today are the ones of social distancing and other mitigation measures. Therefore, one would expect a newly evolved virus that is more contagious, or otherwise has the ability to modify host behavior to overcome social distancing, to have an advantage. A virus that becomes more stealthy would also have an advantage. There is no way to predict in advance if such an evolved virus would be more deadly, less deadly, or if its relative effect on the young would change or not.
Dr. Parikh, your article points out key factors surrounding the most vulnerable community—those in long term care, residents and staff—and the need for attention to address them in this pandemic. You speak to conscience of this country, and many of us share your concern. Thank you for being a voice.
I have no traditional medical training, but was forced to learn much about traditional and non traditional medicine caring my 18 year old whose treatment started with infectious disease specialists in 1999. She fell prey to multiple staph infections over 15 years, including MRSA. But survived them all with traditional and alternative medicine.
Given the great limitations of our medical system to adequately attend the needs of the public, patients, and workers, I hope non traditional strategies will get the consideration they deserve. There is a strategy that could provide protection against the spread of covid-19 and support for those suffering with it. Non traditional modalities (such as I used to help combat MRSA and other infections) could significantly mitigate damages while a vaccine is being developed. In fact, people could safely return to work within a short period of time.
Yale class of 80
It’s called enjoy your life. You can’t stay scared with for the rest of your time on the earth my Lord
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