In several states, nursing home staff and residents make up nearly half of residents who have died from COVID-19, including 55 percent of deaths caused by the coronavirus in Massachusetts. While hospitals’ personal protective equipment (PPE) shortages have been highlighted, less attention has been paid to the critical need for PPE and infection control expertise at nursing homes. In response, states are launching rapid-response initiatives to assess and stabilize patients and provide infection control recommendations and support.
Maryland and other states state are creating teams made up of National Guard members, local health department leaders, and providers reassigned from neighboring hospitals to bolster infection control and testing among nursing home residents and staff. During a recent webinar, Keeping Nursing Home Residents and Staff Safe in the Era of COVID-19, sponsored by the National Academies of Sciences, Engineering, and Medicine and other organizations, experts from Maryland’s Institute for Emergency Medical Services Systems and Johns Hopkins University School of Medicine highlighted their joint efforts to address COID-19 outbreaks in nursing homes.
Using a Strike Team Approach
Maryland Gov. Larry Hogan created a strike team initiative in early April that involves Johns Hopkins University School of Medicine experts and providers, the state Department of Health, emergency medicine professionals, hospital system leaders, and members of the National Guard. The private-public partnerships were already cemented by years of hurricane disaster planning work.
The rising number of nursing home COVID-19 cases that required hospitalizations, “made clear we needed in-place infection control practices in skilled nursing facilities as well as the ability to assess and treat these patients in the environment in which they were familiar,” Maryland State Emergency Medical Services Director Timothy Chizmar explained during the webinar.
How Maryland’s strike teams work:
- When confronted with a COVID-19 case, nursing homes make requests for assistance to their county health departments, each request is then routed to the state’s emergency operations center.
- The center dispatches a health assessment team made up of physicians, nurses, and behavioral health specialists from the Maryland National Guard, supplemented by personnel from the state’s Department of Health and Human Services to assess the needs of the facilities and stabilize patients.
- The team triages patients into three categories, those requiring: hospitalization, moderate care provided by the facility, and monitoring of mild symptoms also provided in the nursing home.
- A clinical teams from a local hospital assists the facility with treatment and proper infection control.
“We’ve engaged early on with our state and federal partners to form these teams,” Chizmar explained. “Out of these visits, we generate reports that are provided to the state and facility. These records don’t serve as a means to penalize the facility, they’re designed to help reassure the facility and patients and provide recommendations to help the facility continue to care for patients.”
To date, Maryland has averted two large-scale evacuations of nursing homes besieged by COVID-19, according to Chizmar, by stabilizing patients and providing temporary staffing until staffing agencies provide needed resources. “One of our successes has been to prevent patients transferred unnecessarily (to a new facility, which is traumatic for frail and elderly patients) for lack of staffing,” he added. Chizmar pointed out that it remains a challenge to recruit certified nursing assistants and geriatric nursing assistants, even after the state has loosened regulations over job certifications to boost this critical workforce.
The Importance of Universal Testing
Megan Katz, director of Antimicrobial Stewardship at Johns Hopkins Bayview and assistant infectious disease professor at Johns Hopkins University School of Medicine, addressed the toll that limited testing has taken on resource-poor nursing homes.
At the beginning of the pandemic, she noted, regulations set a low threshold for testing residents for COVID-19 – they had to be symptomatic with a temperature of at least 99 degrees F. “(Nursing homes) would wait for supplies from the state, and then waited another couple days to get the results,” she said. In that period, more residents usually develop symptoms. “They were left chasing their tails,” she added.
Working with the state, Hopkins put a team together to develop a new universal testing approach when a facility reported a COVID-19 case. The team would go in and test both symptomatic and asymptomatic residents and staff in a unit or often the entire facility.
The results were shocking, she reported. In cases where one or two positive coronavirus cases were initially reported at a facility, testing of all residents and staff in the entire facility revealed that three-quarters of the entire facility staff and patients were positive for COVID-19, with 60 to 70 percent of them asymptomatic.
“What we’re trying to do is to get many different private hospitals and academic institutions and state and federal partners to work together to expand the ability to test in these facilities, so they can capture asymptomatic residents and staff who are contributing to a lot of this transmission,” she said.
Once infected and uninfected residents and staff are identified, facilities are able to implement targeted infection control practices and identify infected, asymptomatic staff who may be working at several long-term care facilities and spreading the infection, she noted.
Massachusetts has also implemented targeted universal testing, using a mobile testing program that tests both symptomatic and asymptotic residents and staff at nursing homes, rest homes, assisted living facilities, and group homes, staffed in part by the National Guard.
In an effort to expand its nursing home testing reach, the state recently sent 14,000 COVID-19 testing kits to nursing homes, but only 4,000 were returned. State health officials have paused the program and acknowledged that many nursing home staff lack the medical expertise to conduct the tests properly, underscoring the importance of having trained National Guard or health care providers on loan from local hospital systems present in nursing homes to train staff about proper test taking and infection control practices.
Lingering PPE Shortages in Nursing Homes
Even after state “strike teams” work with nursing homes and improve infection control practices, the lingering shortage of PPE can contribute to the continued spread of infection among residents and staff, noted Chizmar. Having the capacity to immediately test residents – instead of waiting for the state strike team to arrive – would help nursing homes identify the infected and enable them to conserve PPEs, so they are used with only infected patients. Webinar participants noted that in addition to hospitals, nursing homes should also be the recipients of masks and other PPE by local community groups.
Webinar speaker and Massachusetts resident Alice Bonner, director of Strategic Partnerships for CAPABLE and adjunct faculty member at Johns Hopkins University School of Nursing, noted that in Massachusetts every nursing home with a COVID-19 case is assigned to a state health officials who calls the facility daily to ask about staffing, PPE, best practices for infection control, and other problems in order for the state to respond to quickly and get the facility the support it needs.
Massachusetts also has a website to recruit nursing home employees, a resource line for nursing home residents and their families to learn more about their facility’s situation, and a weekly call between public health officials and nursing homes to identify problems and solutions.
