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How to Reduce COVID-19 Spread in Long-Term Care Facilities: Challenges and Recommendations

Diane Meyer, RN, MPH, and Elena Martin, MPH | March 23, 2020

Long-term care facilities (LTCFs), including nursing homes, skilled nursing facilities, and assisted living facilities, take care of some of the most vulnerable populations, including elderly people and those with chronic medical conditions. This, coupled with the proximity in which the residents live, staffing shortages, and often poor infection control measures, makes them highly susceptible to infectious disease spread, including the current outbreak of coronavirus disease 2019 (COVID-19). This was exemplified earlier this month when some of the first US cases of COVID-19 were reported in an LTCF in Washington State. Sadly, 35 deaths in King County have been associated with this facility alone,1 and additional COVID-19–related deaths have been reported in other LTCFs in Washington.2 In the past week, other LTCFs across the United States have begun to report suspected or confirmed cases and deaths, including facilities in Kansas,3 Oregon,4 Florida,5 Louisiana,6 and Illinois, and 1 facility in the Chicago suburbs that alone has 46 cases.7 According to the Centers for Disease Control and Prevention (CDC), more than 1.3 million individuals reside in 15,600 nursing home facilities across the United States (8), and in the days and weeks to come, we will likely continue to see reports of COVID-19 outbreaks in LTCFs.

We know from our own experiences the challenges of working in LTCFs, which include staffing shortages and frequent staff turnover, high resident-to-staff ratios, supply shortages, and insufficient training around and lack of infection prevention and control measures. The work is physically and emotionally demanding but also incredibly rewarding and fulfilling.

When we reference those most at risk for COVID-19, we are often speaking specifically of those who reside in these facilities. However, these are not just “elderly and sick people,” but grandparents and parents, aunts and uncles, brothers and sisters—people with families who love them and want them to be safe, comfortable, and cared for. LTCFs and local, state, and federal health officials must continue to act to prevent further spread within these facilities.

The CDC has released interim guidance for the prevention and control of COVID-19 in LTCFs.9 Below we provide some additional thoughts on how to maintain the quality of care provided in these facilities while also following CDC guidance. We would like to note the heterogeneity among LTCFs: The resident populations in some are healthier and more mobile than in others. Therefore, each facility will need to take a nuanced approach in how they implement CDC and other guidance in the context of their own resident population.

Restrict Visitors per Federal Guidelines. On March 13, 2020, the Centers for Medicare and Medicaid Services (CMS) released a memorandum directing all nursing homes to restrict visitors except those medically necessary.10 This is important to prevent disease introduction and further spread within these facilities, but it will undoubtedly be extremely difficult for both residents and their families. Thus, facilities should work to identify alternative means of communication to facilitate “e-visits.” This might include telephone calls, Facetime, or other applications that allow face-to-face communication. Families might also be encouraged to record video messages for their loved ones. Families should be updated regularly on the status of the facility and their loved one, and residents should also be apprised of the new rules and regulations. Establishing set times when families can call their loved ones can help ensure continued communication.

Special consideration should be given to those residents with cognitive impairment, such as Alzheimer’s disease, who will likely experience additional anxiety and stress because of changes in their routine and lack of contact with family. Simple and clear talking points, setting up alternatives to visits with family, keeping as normal a schedule as possible, and monitoring for changes in behavior should be done to help reduce mental health impacts.11

Integrate Medical Reserve Corps or Other Trained Volunteers. As staff shortages become more pronounced due to staff illness and absenteeism, additional help will be needed to maintain the quality of care residents receive. The Medical Reserve Corps (MRC) includes medical and public health professionals and other trained personnel without medical backgrounds who could assist with a variety of different tasks in LTCFs, including activities of daily living (eg, bathing, toileting, eating) and medication administration. Other volunteers, such as nursing or medical students, might also be used to assist staff. Additionally, these volunteers could help provide emotional support to residents, as they will likely suffer mental health effects as a result of separation from family and interruptions to their regular activities and schedules.

Reduce Internal Activities. Facilities should cancel large group activities (eg, exercise classes) and communal dining. Facilities should identify alternative ways to entertain residents, which might include smaller group activities that do not involve close contact—for example, taking a few residents out to a facility garden where they can be kept more than 6 feet apart or conducting hallway fitness classes where residents can remain in the entryway to their rooms. Identifying games or arts and crafts that residents can work on independently might also be useful. MRC (or other volunteers) could also engage with the residents.

Cleaning and Disinfection. LTCFs should be cleaned and disinfected according to CDC guidance using hospital-grade disinfectants. The Environmental Protection Agency has provided a list of products to use against SARS-CoV-2.12 LTCFs should ensure that the proper supplies are available to staff. Additionally, facilities should consistently engage with environmental services staff to ensure they understand the importance of following proper disinfection procedures. However, implementation of these guidelines requires staff and resources which are not always available, thus additional support will likely be needed to ensure facilities have the capacity to clean and disinfect effectively.

Personal Protective Equipment. LTCF staff must be provided with the personal protective equipment (PPE) needed to keep themselves and the residents safe, including gloves, gowns, facemasks, respirators (if available and fit-tested), and eye protection. According to the CDC, for known or suspected COVID-19 cases, respirators (eg, N95 masks) should be “prioritized for procedures that are likely to generate respiratory aerosols” (such as collecting respiratory specimens) and “facemasks are an acceptable alternative when the supply chain of respirators cannot meet the demand."13 If respirators are available, facilities should immediately conduct fit testing of healthcare provider staff.

For all residents with undiagnosed respiratory infections, standard, contact, and droplet precautions (including eye protection) should be utilized (9). It is important to note that the presence of PPE may frighten residents, particularly those who are cognitively impaired. Staff should introduce themselves at the resident’s doorway prior to donning PPE and notify the resident that they will be entering the room with their face covered.

Staff should receive training on how to select, don, and doff PPE, and they should demonstrate competence before being allowed to return to work. This should include all staff who provide direct resident care (eg, nurses or nurses aides) and others who might come in contact with residents or their environment (eg, environmental services, food services, maintenance workers).

Implement a LTCF Help Line. State health officials should provide LTCFs with a dedicated call line to answer questions or concerns about COVID-19 in LTCFs. These facilities are at great risk for outbreaks and should have direct and immediate access to assistance from state health officials.

Encourage Family to Take Residents Home, if Possible. Family or friends who can temporarily take care of a resident at home should consider doing so. This should only be done if they are confident that they can safely take care of the resident for an extended period. If the resident requires infrequent medical interventions that the family is unable to provide but that could be provided in home, such as wound care, they might consider setting up visits by a home health nurse so that they are able to bring the resident home.

References

  1. Public health-Seattle & King County COVID-19 update for March 18, 2020. Last updated March 18, 2020. https://www.kingcounty.gov/depts/health/news/2020/March/18-covid.aspx. Accessed March 23, 2020.
  2. Washington death toll from coronavirus rises to 25. Komonews March 10, 2020. https://komonews.com/news/coronavirus/inslee-up-to-64000-coronavirus-cases-in-wash-by-may-if-we-dont-take-action. Accessed March 19, 2020.
  3. After first COVID-19 death in Kansas, KCK facility says no one else showing signs or symptoms of coronavirus. Ksnt.com March 16, 2020. https://www.ksnt.com/health/coronavirus/after-first-covid-19-death-in-kansas-kck-facility-says-no-one-else-showing-signs-or-symptoms-of-coronavirus/. Accessed March 19, 2020.
  4. COVID-19 testing completed for 151 residents at Oregon Veterans’ Home in Lebanon. KVAL March 18, 2020. https://kval.com/news/local/covid-19-testing-completed-for-151-residents-at-oregon-veterans-home-in-lebanon. Accessed March 19, 2020.
  5. Glorioso A. Coronavirus surfaces in 19 elder care facilities in Florida. Politico March 18, 2020. https://www.politico.com/states/florida/story/2020/03/18/coronavirus-surfaces-in-19-elder-care-facilities-in-florida-1267712. Accessed March 19, 2020.
  6. Simerman J, Vargas RA. ‘Indescribable” sadness at Lambeth House: fears of coronavirus spreading and killing are now reality. Times Picayune March 18, 2020. https://www.nola.com/news/coronavirus/article_aaa731ae-6969-11ea-bb01-57709c10f84c.html. Accessed March 19, 2020.
  7. Pathieu D. Coronavirus Illinois update: Willowbrook nursing home outbreak leaves 46 sick with COVID-19; 3 other facilities report cases. abc News (Chicago) March 19, 2020. https://abc7chicago.com/health/46-sick-in-willowbrook-nursing-home-covid-19-outbreak/6027262/. Accessed March 19, 2020.
  8. Centers for Disease Control and Prevention. Nursing home care. Last reviewed March 11, 2016. https://www.cdc.gov/nchs/fastats/nursing-home-care.htm. Accessed March 19, 2020.
  9. Centers for Disease Control and Prevention. Preparing for COVID-19:long-term care facilities, nursing homes. Last reviewed March 21, 2020. https://www.cdc.gov/coronavirus/2019-ncov/healthcare-facilities/prevent-spread-in-long-term-care-facilities.html. Accessed March 23, 2020.
  10. Centers for Medicare & Medicaid Services. Center for Clinical Standards and Quality/Quality, Safety & Oversight Group. March 13, 2020. https://www.cms.gov/files/document/qso-20-14-nh-revised.pdf. Accessed March 19, 2020.
  11. Society for Post-Acute and Long-Term Care Medicine. Strategies for mitigating the emotional impact of COVID-19. March 15, 2020. https://paltc.org/sites/default/files/Strategies%20for%20Mitigating%20the%20Emotional%20Impact%20of%20COVID-19.pdf. Accessed March 19, 2020.
  12. US Environmental Protection Agency. Pesticie registration. List N: disinfectants for use against SARRS-CoV-2. Updated March 19, 2020. https://www.epa.gov/pesticide-registration/list-n-disinfectants-use-against-sars-cov-2.
  13. Centers for Disease Control and Prevention. Interim infection prevention and control recommendations for patients with suspected or confirmed coronavirus disease 2019 (COVID-19) in healthcare settings. Last reviewed March 19, 2020. https://www.cdc.gov/coronavirus/2019-ncov/infection-control/control-recommendations.html. Accessed March 23, 2020.