Guidelines for Preventing the Spread of COVID-19 in Nursing Home "Hotbeds"

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Novel coronavirus, or COVID-19, which began in December in Wuhan City, Hubei Province, China has quickly spread to virtually all parts of the globe, with more than 6,703,686 confirmed cases reported as of June 5, 2020. Older populations appear to suffer poorer outcomes from the disease than younger populations. The vulnerable elderly who also have underlying conditions, such as heart disease, diabetes, lung disease, or a weakened immune system due to cancer or other conditions are considered higher risk for severe illness. Thus far, one-third of all deaths related to COVID-19 in America have been nursing home residents and staff. 

Life Care Center Nursing Home, Kirkland, Washington

This virus spreads very quickly, placing residents of nursing homes and long-term care facilities at particularly high risk. A COVID-19 outbreak was first reported in February at Life Care Center, a Seattle area nursing home, and the first U.S. death from COVID-19 was in one of its male residents who was in his 50s and had underlying comorbidities. At least 30 COVID-19 related deaths have now been attributed to this facility.

The U.S. Centers for Disease Control and Prevention (CDC) provided a detailed report on March 18th about how the outbreak proliferated through Life Care Center in Kirkland, Washington. Public health authorities in the Seattle area conducted surveillance of local nursing homes and long-term care facilities and found that staff came to work with symptoms of illness, often worked in multiple facilities, and did not follow protocols for protecting themselves when caring for an ill resident. Facility inspections revealed a shortage of personal protective equipment (PPE) and alcohol-based hand sanitizer. Administrators did not initially believe the illness outbreak was coronavirus, and once it was suspected, there was limited ability to confirm through tests.

Burlington, Vermont

Burlington Health and Rehab Center on Pearl Street currently has the largest cluster of COVID-19 cases in Vermont. As of March 23rd, 14 residents and one staffer have been confirmed to have the virus. Four residents who tested positive for COVID-19 died the previous week.

According to the commissioner of the Vermont health department, proper infection control practices and procedures were being followed when the outbreak occurred. The facility is now separating high-risk patients from those who are low-risk, and are considering relocating short-term residents who are there for rehabilitation purposes. 

Reporting Cases

Nearly 40,000 nursing home residents and staff have died from COVID-19 in the U.S., which represents more than one-third of the total number of deaths from the virus. Experts expect this number to grow as states begin to report their data publicly. At this time, states have only been required to report nursing home cases to the CDC, fellow nursing home residents, and resident family members. The American Association for Retired Persons (AARP) is advocating that all states be required to report nursing home deaths each day and name the affected facilities, so healthcare resources can be appropriately distributed in an effort to save lives. 

Prevent Introduction of COVID-19 into Nursing Homes

In mid-March new visitation restrictions were placed on long-term care facilities across the U.S. in an effort to prevent this highly vulnerable population from becoming infected with COVID-19. All non-essential healthcare workers and outside visitors are banned from entering nursing home facilities until further notice. Exceptions may be made for compassionate care visits during end-of-life situations. Screening of compassionate care visitors should be conducted to ensure they are free of fever and/ or respiratory symptoms and they will be required to wash hands and wear PPE, including face masks. Compassionate care visitors, including clergy and bereavement counselors with fever and/or respiratory symptoms will not be allowed to enter the nursing home, even during end-of-life situations.

Healthcare workers must be screened for fever and respiratory symptoms at the beginning of each shift. If any staff member is noted to have fever, dyspnea, sore throat, or cough, they will be required to wear a face mask and return home to self-quarantine. Screenings should be implemented for all residents who display respiratory symptoms or fever. All resident group activities, including communal meals, games, crafts, parties, worship services, and music gatherings should be cancelled until further notice. Residents have been instructed to implement social distancing and increase hand hygiene. Routine inspections to ensure compliance with all recommendations have begun in Washington state, California, and New York, and will be extending to other states in the coming days and weeks. A COVID-19 Preparedness Checklist for Nursing Homes has been created by the CDC to help those who care for this population follow proper safety measures.

Centers for Medicare and Medicaid Issues New Guidelines for Nursing Homes

In response to large outbreaks of COVID-19 across U.S. long-term care facilities which have resulted in a significant loss of life, the Centers for Medicare and Medicaid Services (CMS) issued new guidance for nursing homes on April 2nd. Key takeaways include:

  • All facilities must ensure they are following CMS and CDC guidelines for infection control
  • State and local leaders are urged to consider nursing home needs for PPE and COVID-19 tests when distributing these resources
  • All who enter or reside in a nursing home should be screened through a series of symptom-related questions and have their temperature taken daily; new residents should be tested for COVID-19, if available
  • All staff should use appropriate PPE when caring for patients, if available
  • COVID-19 positive residents should be isolated from other residents, when possible; One group of staff should be assigned to care only for COVID-19 positive residents, while a separate staffing group should provide care to non-infected residents

Guidance from the CDC for Testing in Nursing Home Facilities

Implementing formal testing with nursing home residents and healthcare workers using the reverse transcription polymerase chain reaction (RT-PCR) test for SARS-CoV-2 infection is paramount to preventing the rapid, deadly spread of COVID-19 that has occurred in many long-term care facilities. The CDC wants all nursing homes to use the following four guiding principles when testing residents and healthcare worker employees:

  • Infection Prevention Interventions: Do not stop practicing infection prevention interventions. Strict infection prevention and control practices should be done in conjunction with testing. 
  • Test to take Action: Perform testing with the goal of implementing infection prevention and control actions, such as identification of healthcare workers who are positive and will need to remain at home until deemed recovered and no longer contagious, separating positive residents from negative residents, and allocating healthcare resources to COVID-19 burdened units or facilities.
  • Suspected or Known Cases: If test inventory allows, perform a test of all healthcare workers and residents within facilities with suspected or known cases. If test inventory is not plentiful, test entire units with symptomatic personnel and residents. If there are not enough tests for this approach, test only symptomatic and high-risk residents.
  • When to Repeat Testing: Repeat testing of any resident or healthcare worker who later develops COVID-19 symptoms. Retest residents a few days after an initial negative test result, and then weekly until no new cases are reported. If there are not enough tests for this method, test only those residents who frequently visit other facilities to receive healthcare services, and those who have had known exposure to an infected person. Retest healthcare workers who were previously positive to determine when they may return to work. If there are not enough tests to retest all healthcare workers, prioritize testing those who work at other facilities with COVID-19 cases. Plan to retest healthcare workers at repeated intervals as they engage with the community outside the nursing home.

 

References

Centers for Disease Control and Prevention: Preparing for COVID-19: Long-term Care Facilities, Nursing Homes

Centers for Disease Control and Prevention: Testing for Coronavirus (COVID-19) in Nursing Homes

Centers for Medicare and Medicaid Services: CMS Announces New Measures to Protect Nursing Home Residents from COVID-19

Centers for Medicare and Medicaid Services: COVID-19 Long-Term Care Facility Guidance

Centers for Medicare and Medicaid Services: Guidance for Limiting the Transmission of COVID-19 for Nursing Homes

 

 

Melanie Allison, DNP, MSN, RN, ACNP-BC

Executive Editorial Specialist, McGraw-Hill Education

Melanie Allison is the Executive Manager of Education & Learning with McGraw Hill. She earned her Doctor of Nursing Practice (DNP) degree and Post-Master’s Certificate in Nursing Education from The Johns Hopkins University. She earned her Master of Science in Nursing (MSN) degree, specializing as an acute care nurse practitioner (ACNP), from Vanderbilt University. Melanie has more than 20 years of experience as a registered nurse and nurse practitioner in adult cardiology and advanced lipid management. She is a part-time faculty member at a top school of nursing where she has taught for more than 15 years.

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