Integrating home and community, long-term care facilities are supposed to be a haven for patients and their families. But during the COVID-19 pandemic, keeping the patients and the staff safe was a constant battle. An infection preventionist who lived through it discusses the challenges at her facility.
With the winter months fast approaching, I am reminded of being a child and wanting to play in the snow. Before I could go outside, I had to put on all the necessary gear to protect myself. I donned snow pants first, ensuring the inner liner was perfectly tucked into my boots. I zipped up a large heavy jacket to my chin, put on my scarf and hat, and wore gloves under my coat sleeves. As a parent today, I find myself going through the same motions but also putting all that gear on a toddler who doesn’t understand why. I can’t have an educated conversation with them about protecting their skin from frostbite or their body from hypothermia. They wiggle around, sometimes cry, and have zero patience for what I am trying to do to protect them. Both scenarios parallel the long-term care (LTC) environment, with the use of personal protective equipment (PPE) and the isolation and quarantine of residents, many of whom have dementia.
The COVID-19 pandemic has amplified existing challenges faced by LTC facilities. Trying to implement infection control measures, both person-centered and broad-based, is influenced by many factors that have led to a continuous uphill battle. To understand the complexity of these challenges, we should recognize where LTC was prior to the beginning of the pandemic and how things have changed since.
LTC facilities were created to integrate home and community. They allow those who have unmet personal and health care needs to have a safe place to live and remain close to their family and friends. LTC often involves the most intimate aspects of a person’s life, such as meal preparation and assistance with eating, bathing, dressing, and toileting. According to LongTermCare.gov, a website managed by the US Department of Health & Human Services, individuals 65 years or older have an almost 70% chance of needing long-term care in their remaining years, with 20% of those individuals needing it for more than 5 years.3 Because of these close interactions, sometimes extending over a long period of time, strong connections form between staff and residents. This relationship was of utmost importance during the COVID-19 pandemic, especially when visitors were denied access to their loved ones. At many times, staff not only functioned as direct care workers but also as surrogate family members during a resident’s last days.
Before COVID-19, the majority of LTC staff had never dealt with a novel infectious disease outbreak. The 2009 H1N1 influenza pandemic primarily affected children and young adults, and by August 10, 2010, the World Health Organization declared an end to the pandemic.1 Prior to COVID-19, antiviral chemoprophylaxis, adaptable vaccines, and quick implementation of infection control measures such as isolation and PPE use effectively halted outbreaks. The 2009 H1N1 was the last time N95 masks were needed in most nursing homes. When the SARS-CoV-2 virus entered our country in 2020, the entire nursing home industry was jolted into the unknown. It could either adapt and overcome or succumb.
Staff in LTC facilities faced many unique and difficult challenges during the COVID-19 pandemic. Infection preventionists were tasked with balancing strict infection control guidelines with the hardship those measures imposed on residents and staff. Because of the multitude of regulatory changes over the past 32 months, pandemic fatigue relating to PPE use, testing, and isolation has led to high levels of staff turnover and notable decline in residents’ overall health. According to one investigation,2 during the first year of the pandemic, nursing homes with active COVID-19 cases experienced significant increases in weight loss and depressive symptoms among residents. Even facilities that did not have known COVID-19 cases experienced adverse changes in some health and quality of life measures. (See Table.2)
Many LTC staff felt they were struggling with and left searching for ethical guidance when enforcing specific infection control measures, notably isolation and quarantine of the residents and repeated nasal swabs for testing. Not only was it physically exhausting to don a respirator, gown, goggles, and gloves every time they needed to go into a resident’s room, but it was mentally taxing to see residents confined to their rooms for an indefinite amount of time. Although we know that isolation and quarantine are effective infection control measures, enforcing them effectively in a population where an average 70% of residents have dementia3 was extremely challenging. These residents did not have the cognitive ability to understand why they could not come out of their rooms, and it was very difficult to keep them in there, especially those who had a need to wander. They also did not understand why staff kept trying to put a swab up their nose and would frequently turn their head away or physically refuse the testing.
What do you do when a wandering resident, who attained a positive result for COVID-19, continuously leaves their room, wiping their nose on their hand and using the handrails in the hallway? How do you handle a resident with COVID-19 who is asymptomatic, cannot understand they have a contagious illness, and asks staff every 5 minutes why they can’t leave their room, becoming emotionally distressed? How do you care for a resident with
COVID-19 who has frequent falls, but because of a safety risk, you cannot shut the door and may not have time to put on the required PPE to get into the room quick enough? How do you group residents or create an isolation unit when the physical layout of your facility doesn’t allow for it, and you don’t have the staff support you need? These are the tough questions an infection preventionist must answer on a daily basis in a nursing home. Sometimes there are no good answers, and you must do the best you can with what you have.
This is a defining moment for LTC facilities as the effects of the pandemic reach an inflection point. The COVID-19 virus will continue to be a defining part of nursing home culture, and infection preventionists remain front and center, charged with making person-centered decisions that also support the safety of the broader community. There are many barriers when it comes to implementing infection control measures, and staff will continue to need support and training for managing these unique situations.