Nursing Homes: the COVID-19 Pandemic’s “Perfect Storm”

On March 13, 2020, the CMS1 (Centers for Medicare & Medicaid Services) released guidelines,2 regarding COVID-19, for use by nursing homes. As has been the case, SARS-CoV-2 (the virus that causes COVID-19 disease) has found fertile ground in nursing homes due to

· the institutional living arrangement of such facilities,

· the nosocomial propensity for illness, and the fact that

· all residents are compromised by age and/or comorbidities, both of which increase the risk of COVID-19-related mortality.

Added to these three leading conditions for transmission and severity of illness is the traffic of visitors from outside who may either bring COVID-19 to their loved ones or, alternatively, leave the facility having been exposed to it. In short, the fertile ground that nursing homes offer to SARS-CoV requires additional guidance to, and prevention practices for, these facilities to both help them improve their infection control and prevent the transmission of COVID-19 disease. Most significantly, these include revised guidance for visitation.

Basic guidelines for facility staff

· Regularly monitor the CDC website3,4,5 for updates, information, and resources.

· Frequently remind residents of the need for social distancing and hand hygiene.

· Implement triage for prompt detection of COVID-19 disease.

· Frequently monitor for signs (fever) and symptoms (cough, sore throat) of respiratory illness in residents.

· If you suspect a resident of having COVID-19, you should contact the local health department.

· Maintain a person-centered approach to care—emphasis on direct communication with patients and/or their families, e.g., needs, goals, etc.

· Actively screen all staff for fever and respiratory symptoms at the beginning of every shift. Special emphasis should be placed on those working at more than one facility. If any staff are suspected of illness, have them wear a face mask and self-isolate at home.

· Promptly isolate suspect patients.

· Cancel communal dining, internal and external group activities.

· Allow no sharing of medical equipment.

· Increase cleaning and disinfecting.

· Increase availability of alcohol-based hand rubs, reinforce hand hygiene, and emphasize recommended barriers (facemasks, etc.).

· If you have COVID-19 questions, they should contact the local health department.

Visitation: no longer business as usual

A major reason for reissue of these guidelines is to include new restrictions regarding visitation and traffic in and out of the facilities:

· No visitation except for compassion crises, such as end-of-life situations.

Exceptions to the above, i.e., compassion crisis visitors, will be required to use hand hygiene and PPE (personal protective equipment), i.e., mandatory facemasks. If they were to have signs or symptoms of COVID-19, as above, visitation will be denied, regardless of the situation.

With such visitation, continue policies of social distancing, avoiding hand contact of others and surfaces, etc.

· Surveyors (state agency inspectors) may enter for their inspection duties and can be allowed entrance even if they had been to a COVID-19-clustered facility within 14 days (it is assumed they had sufficient barriers to pose minimal risk).

· Vendors should drop off supplies, not transport them within the facility.

· In lieu of in-person visits, offer virtual visitation. Create listserv communication for updating family and friends. Conduct regular outbound calls to apprise family of a resident and on-going policies. Assign one staff as a patient’s liaison for inbound calls.

· Offer a recorded message number for family and friends to call to get the latest up-to-date information on when visitation might resume.

· Advise anyone entering the facility to self-quarantine for 14 days after leaving.

Transferring patients

Residents with COVID-19 disease vary in severity from the asymptomatic to severe disease to fatality.

· Asymptomatic or those with mild disease may not require transfer to a hospital (unless additive comorbidity warrants), if CDC infection prevention and control practices5 can be followed.

· If there is an airborne infection isolation room, transfer is unnecessary if the resident does not require a high level of care (e.g., ICU/ventilator) and if CDC infection prevention and control practices5 can be followed.

· When transfer FROM the facility is indicated, such as with the need for a higher level of care, EMS and the receiving facility should be informed of the diagnosis and precautions needed during transfer, including PPE for transfer personnel and facemask for the resident transferred.

· Transfer TO the facility (e.g., of a COVID-19 patient from the hospital) is allowed as long as CDC infection prevention and control practices5 can be followed. The CDC has issued interim guidelines6 for discontinuing precautions or home isolation for COVID-19 patients.

· Select a unit/wing designated for COVID-19 patients coming into the facility or returning from the hospital.

Conclusion

COVID-19 has changed every aspect of medical care, which has required additional safeguards for nursing home facilities to implement.7 This is especially important due to the fact that the typical nursing home resident is either elderly, has co-morbidities, or both, and that the living arrangements make for a nosocomial risk of infectiousness. Thus, the nursing home facility offers undue advantage for an infectious organism such as SARS-CoV-2 to thrive and spread exponentially. As such, these CMS guidelines are effective immediately.