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Difficulties in communicating with the elderly necessitate close speaking. These circumstances are a ripe atmosphere for spreading respiratory diseases. While residents were largely isolated from the broader population, their caretakers were not.
Coronavirus disease 2019 (COVID-19) found many long-term care facilities (LTCFs) splashed across the front page of national newspapers, but not in the manner that they desired. The well-cultivated images associated with beautifully groomed gardens and formal dining settings were replaced by exhausted care workers wheeling hospital beds to waiting ambulances. These gloomy images captured a severe health care crisis unfolding as quarantining Americans watched and wondered about their elderly loved ones. The LTCF industry watched expectantly as well. As these events unfolded, each organization wondered how they might sidestep a similar crisis, maintain care standards, and avoid an ensuing public relations storm. The efforts of each organization would rely on the ability to manage infection control within buildings, routines, and staffing structures all foundationally not inclined to prevent disease transmission. In retrospect, which organizational response model produced the best outcomes for infection control?
President Joe Biden’s pick for United States assistant secretary of health, then Pennsylvania’s Health Secretary Rachel Levine, MD, confirmed on May 11, 2020, that the state of affairs in Pennsylvania was so compelling that it warranted the removal of her mother from a personal care home.1 As the Pennsylvania’s governor’s choice in leading the pandemic response, Levine had a bird’s eye view of the unfolding crisis. The view from above showed that although only a minority of elderly individuals receive care at LTCFs, the pandemic had disproportionate effects in these facilities. By May 2020, of the COVID-19 deaths in Pennsylvania, 70% had occurred in LTCFs, and these locations accounted for 21% of the reported cases. These staggering statistics were enough for some family members to remove loved ones from facilities.
For those in the industry, removing residents was not an option. They would have to face down the systemic risks rooted in an industry lacking any significant innovation since its inception. These risks included buildings designed for efficient congregant living, communal dining, and shared overextended staffing. In defense of the nursing home industry, these risks are largely a byproduct of decreased assistance in the form of reimbursement. Thus, LTCF providers must continue to consolidate costs to manage historic and continued underfunding. According to a 2016 American Health Care Association report, the cost to nursing homes to care for Medicaid patients exceeded their actual Medicaid reimbursement by $25.43 per day in 2015. This means the average Medicaid resident would cost in excess of $27,000 over their expected 3-year care period.2
Systemic risks associated with the intersection of long-term care and infectious diseases required a successful response in the form of a combination of robust measures. Facilities placated with business as usual, the checking-off of survey boxes, and hopes that daily Centers for Disease Control and Prevention (CDC), Centers for Medicare & Medicaid Services (CMS), and state health department guidelines would provide the organization protection, soon reported facility wide outbreaks of COVID-19 and accompanying deaths.
A robust response required an organizational structure with components previously in place and an ability to modify existing structures. The organization needed the ability to sustain and achieve new goals within short time frames. These included new regimes in sanitation, dining, laundry, cleaning, and supplies, among others. At the forefront was a culture of trust associated between employees and the organizations’ directors. Managers would need an established trust and support from those working within departments to maintain morale during difficult times. This trust would hopefully avoid extensive turnover and short staffing during a time when the organization needed to maintain high levels of care. Sadly, this has been a significant issue in long-term care, where a recent study in Health Affairs found that the mean annual turnover nationally for total nursing staff was roughly 128%.3
The best prepared organizations had previous investments in disease prevention personnel. Outside the traditional medical team, 2 important roles include an infection preventionist nurse and a respiratory therapist. These roles, with the associated training and professional development, were required to provide competences in personal protective equipment (PPE) fitting and infection control practices. Respiratory therapists with hospital training and previous treatment experience in infectious diseases were a strong asset able to provide nursing facilities novel respiratory insight and treatment.
COVID-19 spread quickly in high-density congregant living spaces. Most residents live in shared rooms and have between 3 and 6 caretakers a day. The average resident has about 100 sq ft of living space with limited associated air supply. The entire air in this space is shared with others for 15-minute increments. Difficulties in communicating with the elderly necessitate close speaking. These circumstances present a ripe atmosphere for spreading respiratory diseases. Although residents were largely isolated from the broader population, their caretakers were not. Those organizations that could afford to decrease the interactions of infected individuals within stood the best chance of keeping the virus from spreading. Many measures attempted by organizations focused on this area of containment: screening staff and vendors, suspending or modifying visitations, freezing admissions, isolating residents in their rooms, dedicated isolation floors, masking, decreasing or prohibiting shared staffing between organizations. All of these measures had unintended consequences of isolating and depressing social interaction and thus the quality of life for residents, but they worked. They worked like a porous block of Swiss cheese (ie, James Reason’s Swiss cheese model [SCM]). Reason’s SCM model proposes multiple layers of protection like slices of Swiss cheese to manage risk. The more layers of protection (slices), the greater the likelihood of preventing the transmission of infections.
The timing of precautionary measures was an important contributing factor. Instituted too late, even the strictest of measures are bypassed by a spike in community spread. Records I collected in Lancaster County, Pennsylvania, revealed that facilities that instituted early isolation measures with extensive prohibitions faired the best at keeping the virus out of the facility. Had the pandemic been shortened, these measures might have provided significant returns. However, these early prohibitions were akin to a city under siege. They lasted for some time, but the virus ultimately seems to have “acquired” each facility.
The purpose and mission of long-term care is to provide life-affirming health care services to populations that have no other means or access to skilled care. However, hospital emergency departments and case managers relate stories of elderly individuals for whom they could find no accommodations during the pandemic. Some states had limited programs involving COVID-19–only facilities. This was an attempt to avert the commingling of hospital and nursing home populations. The low quality of the care and poor performance within these facilities has been a topic within CMS advocacy groups.4 Otherwise, skilled nursing facilities mostly closed their doors to protect internal populations. This was arguably a logical component to a broader infection control program. However, defying purpose by closing off resources to a community in urgent need of assistance and causing hospitals the additional burden of providing extended care during a health crisis is hardly a model approach. So, what could have been done?
Here’s How It’s Done
One facility attempted a novel approach, which I hold up as a model in maintaining the essential purpose and mission of long-term care providers. The facility proactively established a negative pressure zone in its therapeutic center modeled alongside university research engineers. Nursing staff obtained training and expertise from a respiratory therapist with hospital experience in infectious diseases involving PPE and proper isolation techniques. Additionally, they consulted nursing staff at research hospitals operating COVID-19 centers. They then promptly began providing COVID-19 assistance to the elderly within their community, strictly within their designated unit.
The measure was proactive, and the facility experienced no COVID-19 cases outside of the designated unit for several months. During this time, the facility garnered experience in managing COVID-19 while keeping the virus isolated to a uniquely engineered zone. This experience in managing COVID-19 became a resource when the virus successfully “acquired” the facility after months of working through layers of isolation protections (SCM). The virus entered the facility not from the COVID-19 unit as some feared would happen, but a separate location most likely associated with staffing and community spread. The ensuing results were similar yet somewhat better than what other facilities experienced. The facility, sufficient in size with 114 beds, was one of the last in the associated area and broader state to acquire the virus outside its designated COVID-19 zone.
This novel approach is the only one I know of where a nursing facility was able to record assisting more COVID-19-positive residents within the community than it would have had original exposure to. This approach benefited community hospitals, prepared facility staff, and provided economic resources to the organization. The intent to provide this care and the labor and risk that this organization expended deserves recognition. It is to this that I commend Jerry Lile and the employees past and present at Fairmount Homes in Lancaster, Pennsylvania.
CEDRIC STEINER is a licensed nursing home administrator in Lancaster County, Pennsylvania. Contact him at firstname.lastname@example.org to learn more about the use of negative pressure for immediate or future COVID-19 relief.