Long-Term Care Facilities Particularly Vulnerable to COVID-19 (and Criticism)

March 16, 2020

It’s a matter of demographics, say the authors of an article in press in the Journal of Post-Acute and Long-Term Care Medicine. COVID-19 will disproportionately hit nursing homes and other long-term care facilities because the disease is particularly lethal to the elderly. 

With that in mind, investigators with Brown University and the Veterans Administration are putting out an early call against the blame game. 

Under a subtitle in the article that is, in fact, labeled, “The Blame Game,” they write: “In recent years, negative outcomes in nursing homes during disaster situations have led the media, public health officials, and politicians to find fault with nursing home providers.”

Investigators cite the case in which 4 nursing home workers were charged with criminal homicide in Florida during Hurricane Irma. Without commenting on the particulars of that case, the “historical reality is chilling” given that the epicenter of COVID-19 in the United States is the Life Care Center in Kirkland, Washington where 19 residents have died and at least 50 more are under observation. In addition, 47 of the center’s employees have tested positive for the novel coronavirus. 

“Quite clearly, mortality within long-term care environments related to COVID-19 will be significantly higher than among the general population as a function of resident advanced age and comorbidity rather than substandard care,” the article states. “Some understanding of this fact will certainly be welcomed by the long-term care industry, who are often responsible for delivering difficult care under suboptimal circumstances.”

The fatality rate in China for those 70 to 79 is estimated at 8%, and for patients over 80, that shoots up to 14%. “Even as the overall case fatality rate drops, the risk of death among older adults may be 10-fold higher than for younger individuals,” the article states. 

Mortality rates also increase with the presence of heart or chronic respiratory disease, which are common in long-term care facilities. Rates of heart disease exceed 30% and, for chronic obstructive pulmonary disease, it exceeds 20% in long-term care facilities, say investigators. 

“Further, extreme functional impairment within long-term care facilities makes close contact between health care workers and residents inevitable,” the article states. “Additionally, cognitive impairment among residents may make contact precautions and isolation a practical impossibility.”

Workers should wear gowns, gloves, facemask, and eye protection, but…. 

“This may be challenging in the nursing home environment, where supplies of these items may be limited and are prioritized for acute care hospitals,” the article states. “In long-term care settings, few of which have negative pressure (airborne isolation) rooms, simple measures like pulling room-dividing curtains and closing doors are helpful.” 

Even the admonishment that workers with symptoms need to stay home can be problematic, as most of the workers live paycheck to paycheck and long-term care facilities are often understaffed. Workers are used to being pressured to work even when sick. 

“Providing a work environment that allows healthcare workers to call out without repercussion will be critically important,” the study states. 

 

Whether to admit someone who has been diagnosed with COVID-19 will be another concern. “Long-term care facilities are a key component of our healthcare system, and we can anticipate significant pressure to receive discharged hospitalized patients for convalescence or to accommodate sicker patients arriving from the community,” the article states. “We do not yet know how long individuals shed transmissible levels of virus, whether older individuals shed virus longer, nor whether cohorting confirmed cases can reduce risk of spread within a facility or contributes to disease severity among those cohorted.”