The COVID-19 pandemic has been a nightmare for everyone associated with nursing facilities, with the most severe devastation landing on their residents. Outbreaks have wiped out a large swath of these precious, vulnerable elders, and this virus is even more cruel in that most of them have not been able to have loved ones at their side on their deathbed.
It is estimated that over 40 percent of the COVID deaths in the United States have occurred in the long term care setting, which constitutes only about 0.6 percent of the U.S. population. In other words, a nursing center resident is about 70 times more likely to die of the coronavirus than a person who lives in the community at large. Unavailability of personal protective equipment (PPE) and testing have been problematic.
Effects on Staff
The pandemic has also been extremely difficult for the nursing center workforce. These frontline heroes are placing themselves, and potentially their families, in harm’s way because they care about the people who reside in nursing centers, and they are doing it with grace and compassion. Some of them have died. Some staff work in multiple facilities, increasing the risk of transmission, and there is no simple solution to this problem. Staffing shortages can also occur when there are outbreaks, which can compound the difficulties nursing centers are facing.
COVID-19 has been an insidious, diabolical foe—the asymptomatic transmission, the unreliability of testing, the unknowns about immunity after infection, and the severe respiratory manifestations requiring prolonged mechanical ventilation are just a few of the factors that make it very different from, say, influenza A.
Numerous online resources are available on COVID from organizations like the American Health Care Association/National Center for Assisted Living (AHCA/NCAL), the Centers for Disease Control and Prevention (CDC), and the Centers for Medicare & Medicaid Services. Amid the plethora of helpful sites, AMDA – The Society for Post-Acute and Long-Term Care Medicine has excellent clinical and nonclinical COVID information, suitable for all professionals working in skilled nursing centers, but perhaps best shared with medical directors and other attending practitioners (https://paltc.org/COVID-19).
How the Pandemic is Playing Out
Clinicians have learned much since the early days of the pandemic, and they continue to learn rapidly and improve their processes accordingly. Medical information is coming out on a daily basis, and there is a reasonable hope that an effective vaccine may be available within a year.
At the same time, there has been a wide variability in how the federal government and the various states and county health departments have provided guidance to nursing centers, creating mixed messages and often—unfortunately—bringing a continued punitive and critical attitude toward their efforts to prevent COVID cases and to use best practices in using PPE, cohorting, quarantining, and treating outbreaks.
Some states, seemingly in the interest of ensuring hospitals did not become overburdened, created mandates for nursing centers—even those with no known or suspected COVID cases—to accept COVID-positive patients from hospitals, with predictably unfortunate results. AMDA and AHCA released a joint statement on March 29 opposing such policies forcing COVID patients into nursing centers, which almost certainly saved lives as some states and counties walked back or never initiated similar mandates.
The public sentiment and media coverage often vilify nursing centers, dredging up years-old, resolved infection control deficiencies (for example, one nurse assistant failed to wash her hands after checking a resident’s vital signs three years ago during survey) to somehow suggest that this is why a COVID outbreak has now occurred in 2020 in this facility.
Media posts and broadcasts similarly tend to emphasize perceived failings in nursing centers’ efforts and not the conscientious, diligent, and demanding endeavors to provide safe and appropriate care to its residents under the most extreme circumstances.
The Washington Case
The nursing center in Washington that really appeared to have been ambushed by the first severe nursing center COVID outbreak in mid-February (weeks before COVID had even been deemed a pandemic) received over $600,000 in civil monetary penalties for perceived deficiencies, mostly related to infection control (the deficiencies and fines are being contested).
Among the deficiencies were an alleged failure to timely notify the public health department of a respiratory outbreak and an alleged failure to have a backup practitioner available if the attending physician or medical director were not available.
Even though this nursing center had the medical director or a nurse practitioner available by telephone, the statement of deficiencies suggests that another provider should have been available to make an in-person visit—although that does not appear to be an explicit requirement in the federal or state regulations.
There will no doubt be many more state agency and federal deficiencies written in nursing centers, and some may be deserved, but it is clear that most nursing centers are doing the very best they can under extremely difficult circumstances.
The COVID lawsuits have already begun and may represent a new boutique industry for plaintiff attorneys, although in some 20 states there have been executive orders granting immunity to nursing centers (except in cases of willful misconduct, gross negligence, or other extreme situations), acknowledging that the standard of care during a disaster is different from the usual standard.
Infection prevention and control programs (IPCP) were already a mandate before this pandemic began, and the importance of the nursing center’s infection preventionist (IP) has never been clearer. Local health departments can be a source of additional information, but probably the best resource for most centers is their medical director.
Leadership During the Crisis
Nursing center medical directors and other staff interested in infection prevention can access an excellent (and free) online IP certificate course via CDC at
www.train.org/cdctrain/training_plan/3814. It is hoped that during this pandemic, medical directors and IPs should step up their surveillance and ensure employees and essential visitors are doing consistent, appropriate hand hygiene and utilizing PPE, including donning and doffing, correctly.
The medical director should be a vital member of every center’s infection prevention and control program, and should be a leader in quality assurance/performance improvement (QAPI) in addition to merely attending the center’s mandatory Quality Assessment & Assurance committee meetings.
Nursing centers that do not have engaged medical directors are encouraged to support their medical director by recommending or requiring education through AMDA and its state affiliates, certification as a Certified Medical Director through the American Board of Post-Acute and Long-Term Care Medicine, and considering time spent on education in infection prevention and medical direction as hours toward medical direction for the center.
Alternatively, if a medical director is not supporting the center during this pandemic, it may be time to consider a new medical director or obtaining additional medical support and guidance from physicians who do have the requisite knowledge of clinical issues, geriatrics, bioethics, telemedicine, and the unique and arcane regulatory framework nursing centers work under.
Nursing center leaders, including an engaged, knowledgeable medical director, can be a godsend, as many of Provider’s readers already know. Nursing centers, and the people who live and work there, will face a difficult road ahead, even looking at things most optimistically. More precious residents and staff will be lost.
But centers will get through it. A unified, supportive, compassionate, and collective attitude will carry them beyond this catastrophe together, and may they pray that some good things actually come along with all of the tragedy.
Karl Steinberg, MD, CMD, HMDC, is president-elect of AMDA – The Society for Post-Acute and Long-Term Care Medicine, vice president of National POLST, chief medical officer for Mariner Health Care, and a long-time skilled nursing center and hospice medical director and attending physician from Oceanside, Calif. He is also a certified health care ethics consultant and takes his dogs to work on most days.