As concerns about the spread of COVID-19 continue to escalate throughout the country, healthcare providers such as long-term care (LTC) facilities and skilled nursing facilities (SNF) have seen the viral illness push the limits of preparedness. Now, providers are faced with the task of preparing for the virus.
Emergencies for nursing homes are nothing new. As a nursing home or LTC facility, coping with emergencies is made more difficult by the nature of the residents. Typically elderly and sick, these residents require extra care and precaution, particularly with COVID-19, which poses a greater risk to the elderly.
In recent days, the Centers for Disease Control (CDC) and Centers for Medicare & Medicaid Services (CMS) have released multiple forms of guidance to nursing homes in an attempt to help administrators and clinicians prepare for the virus. Below is a bullet-point summary of that guidance, along with links to the original source.
On Tuesday, March 17, the CDC held a Clinical Outreach and Communication Activity (COCA) call via live webinar, in which it provided clinicians with updated information on implementing prevention and control measures, assessing risks for exposure, and optimizing the use of personal protective equipment (PPE) supplies. Highlights of the webinar include the following guidance:
- The incubation period for the virus is 4-5 days, but it could be as few as 2, or as many as 14 days.
- Most cases are transmitted from people with symptoms, but it can be transmitted by people without signs or symptoms.
- Chest x-rays of infected patients may be normal initially.
- Symptoms are flu-like, including fever, cough but can also include fatigue and gastrointestinal symptoms (diarrhea).
- Older adults do not always get a fever. As a result, providers should evaluate for other indicators, such as confusion or malaise.
- The overwhelming majority of patients with COVID-19 (80%) have mild symptoms.
- The symptoms typically run their course and the patient improves.
- The average patient is sick for seven days before going into respiratory failure.
- Risk of Death by age (decade):
- 30s: 1/500
- 60s: 1/12
- 80s: 1/7
- Patients with heart or lung disease, kidney disease, or extreme obesity (BMI > 40) are at a higher risk.
The CDC also made multiple clinical recommendations:
- Assume COVID-19 is in your community, and check residents more frequently.
- If have a resident in your facility is infected with COVID-19, check vital signs on all residents twice per day.
- Treatment is supportive. There are no anti-viral medications for COVID-19. Be cautious with increasing IV fluids in elderly residents, as they are more susceptible to pulmonary edema and fluid overload. Because steroids have the potential to prolong viral replication, avoid them unless indicated for other reasons.
- The highest risk to LTC residents is sick visitors and sick personnel. The CDC and CMS recommend to immediately restrict all visitors with few exceptions.
- Practical social distancing: restrict resident activities, no communal dining, stay six feet away from others.
- Check everyone entering the building for fever or signs of respiratory illness. Staff should check temperature before starting work each day and at home.
- Have a plan for PPE shortages, e.g. re-use face masks and protective eye gear all shift, prioritize when using gown.
- Notify your health department if you suspect a resident or any personnel are infected with COVID-19.
- Isolation Rooms: Most skilled nursing facilities do not have an airborne infection isolation rooms, but this type of room is not required for COVID-19. Put a resident in a single room with a private bathroom, if available.
- If an infected resident is clinically stable, there is no need to transfer the resident to a hospital unless he or she requires a higher level of care.
- To get COVID-19 testing, contact state and public health departments. To take a sample, use NP swab deep in the nose.
- Resident may be positive for another virus such as influenza but may also have COVID-19.
In addition to yesterday’s webinar guidance, the CDC has issued a COVID-19 Preparedness Checklist, which it recommends LTC facilities consider when planning for COVID-19. The checklist covers three topics:
- Structure for planning a decision making
- Development of a written COVID-19 plan
- The elements of your COVID-19 plan, which should include:
- Facility communications
- Identification and management of ill residents
- Visitor considerations
- Occupational health
- Education and training
- Surge capacity
The CDC also released strategies for nursing homes and other LTC facilities to prevent the spread of the virus. The CDC recommends implementation of several policies:
- Restrict all visitation except for certain compassionate care situations, such as end of life situations.
- Educate residents, personnel, and visitors on the virus and the facility’s efforts to avoid its spread.
- Provide adequate infection prevention supplies, such as hand sanitizer, soap, paper towels, and PPE.
- Screen all personnel at the beginning of their shift for fever and respiratory symptoms.
- Evaluate, monitor, and manage residents with symptoms of respiratory infection.
- Place known or suspected residents with COVID-19 in a private room with their own bathroom.
- Transfer residents with higher level-of-care needs to another facility that is capable of implementation.
- Create a plan for cohorting residents with symptoms of respiratory infection, including dedicating HCP to work only on affected units.
The CDC noted that these strategies to prevent the spread of COVID-19 are the same as those every day to detect and prevent the spread of other respiratory viruses like influenza.
Finally, CMS is waiving the requirement of a three-day prior hospitalization for coverage of a SNF stay. This allows for temporary emergency coverage for patients in need of an emergency transfer, which may be useful in the event hospital beds become scarce.
Other helpful sources of information:
- CMS nursing home visitor guidance
- CMS’s infection control toolkit for bedside licensed nurses and nurses aids
- LTC facility infection control self-assessment worksheet
- Infection control and prevention regulations and guidance
The uncertainty caused by COVID-19 to health care organizations and medical professionals is unprecedented. Steptoe & Johnson’s Long Term Care team and Professional Liability attorneys are actively helping clients sensibly and proactively navigate the unprecedented regulatory and litigation issues facing health care facilities due to the COVID-19 pandemic. Please reach out if we can help.