Saturday, April 4, 2020

Nursing homes need greater focus in COVID-19 battle

It is clear that age is a major factor in COVID-19 morbidity.  It is clear that underlying health status is a major factor in COVID-19 morbidity.  It appears the place one resides (SETTING) is also a major factor.  Specifically, reporting indicates nursing homes and other elder care facilities are the major setting source for COVID-19 outbreaks leading to death.  Data collection and reporting must increase immediately to identify and report the setting in which COVID-19 is contracted and immediate policy implemented to prevent and mitigate vulnerability in the short term.  In the long term, the nation must dramatically change and improve residential elder care or rethink the current model.

There are about fifteen thousand nursing homes with nearly 2 million licensed beds in the United States.   These facilities "appear" a hotbed for COVID-19 deaths.  “Appear” because there is no available repository of data to validate this hypothesis.  The Centers for Disease Control (CDC) does not release the names of nursing homes or the number of residents who have contracted COVID-19 when outbreaks occur - but it should.  There is some media and state reporting from which one can extrapolate the extent and severity of the problem.

The first such case occurred at the Life Care Center of Kirkland in King County, Washington where 81 residents, 34 staff members, and 14 visitors contracted COVID-19.  Of these cases, 23 patients and visitors died.  A more recent example is unfurling at the Commonwealth of Massachusetts’ state run Soldier’s Home in Holyoke, MA where 21 have thus far died.

At least 400 nursing homes across the country have COVID-19 outbreaks.  The number is increasing daily.  No doubt, there will be a correlation between this growth and a climbing number of deaths reported from COVID-19.

Elders over the age of 65 with underlying disease or immune suppression are disproportionately vulnerable to COVID-19.  But those in long term care settings are far more vulnerable because of the lack of effective infection prevention, mitigation, and control at these facilities.   Their presence in these facilities is the proximate cause in many of their deaths, not their age or underlying health.

There is an abundance of research that proves long-term care facilities are contaminated with Methicillin-resistant Staphylococcus aureus (MRSA), Methicillin-sensitive Staphylococcus aureus (MSSA), Clostridium difficile (C-Dif) and other communicable disease sources.  Regulations to control communicable disease in these facilities are inadequate and the federal government, which pays for at least 65% of long term care patients through Medicaid, is conflicted between providing care and the cost of paying for it.

These problems of communicable disease extend outside the long-term care facilities.  Many of these facilities, in the name of efficiency, have hospice, long term care, and rehabilitation patients commingled in the facility sharing rooms, equipment and staff.  There is frequent cycling back and forth to hospitals in ambulances that go out into the community.   These problems are known.  Unfortunately, because the problem is difficult and costly to address those directly involved in providing or managing care shrug their shoulders in reluctant acceptance.

COVID-19 is not the last pandemic.  In a world where travel is abundant and dense urbanization inevitable there will be more and worse such pandemics.

Now is the time for rigorous examination of the lack of resilience in much of our medical treatment system, but particularly in long term care facilities.   In the name of “efficiency” we have accepted patient placement in high risk facilities where communicable diseases are tolerated as a part of doing business.  Treatment of underlying diseases, general health, and comfort are impaired by these communicable diseases.  Often they hasten death, just as COVID-19 is hastening, if not causing death now.    Adding insult to injury many patients are dying alone - their families unable to be with them.

It is largely in the name of efficiency that this situation exists.  Rooms are shared.  Staffing is minimized.  Hospitals must discharge as quickly as possible to rehab.  We prize efficiency in business and government.  But resilience is just as important.  We have ignored that too long.   We can do a lot better and we must.

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