Barnett ML, Grabowski DC. Nursing Homes Are Ground Zero for COVID-19 Pandemic. JAMA Health Forum. Published online March 24, 2020. doi:10.1001/jamahealthforum.2020.0369
At the start of 2020, the Life Care Center of Kirkland nursing home in Kirkland, Washington, cared for roughly 120 residents with 180 staff members. Although this facility has the highest rating of 5 stars on the federal government Nursing Home Compare website, it received a deficiency during its most recent inspection survey in April 2019 for failing to provide and implement an infection control program. The deficiency was considered less serious because it was associated with “minimal harm or potential for actual harm.”
This Seattle-based nursing home became, in the words of former US Centers for Disease Control and Prevention (CDC) director Tom Frieden, “ground zero” in the COVID-19 pandemic. Of the first 46 confirmed deaths attributable to COVID-19 in Washington by mid-March 2020, 30 deaths, more than 1 in 4 residents of the facility, were associated with Life Care Center. Dozens of residents at the facility have been transferred to the hospital, and those remaining have been isolated in their rooms. Because of a no-visitors policy, these residents have not been able to spend time with their families and loved ones. Testing of residents and staff for COVID-19 was slow, and communication with families has reportedly been poor. To make matters worse, dozens of staff members at the facility were reported to have COVID-19 symptoms and eventually quarantined at home. The lack of available staff led the US Department of Health and Human Services to send in a 28-person strike team to assist clinicians at the home.
Although Life Care Center was the first nursing home in the US to experience a COVID-19 outbreak, it is not alone. More reports are emerging of outbreaks in nursing homes across the US. It is likely that other nursing homes around the country will also become hubs in their communities for the worst clinical manifestations of COVID-19.
This evolving pandemic presents an important case study of infection control for some of the frailest, most vulnerable individuals in the US health care system. Nursing homes are no strangers to outbreaks, including seasonal influenza and norovirus. A 2014 report from the CDC found that of 2590 nonfoodborne outbreaks of norovirus in the US from 2009 to 2012, 80% happened at long-term care facilities. The COVID-19 pandemic will be like these other outbreaks, only more devastating.
Why are nursing homes so vulnerable to COVID-19? Nursing home residents are typically older adults with high levels of chronic illness and impairment. As such, they are particularly susceptible to severe complications and mortality from COVID-19. Unlike a hospital, a nursing home is someone’s home. Often, residents live in close quarters with one another, so it can be quite challenging to move or quarantine residents once they are sick. Moreover, caregivers move from room to room assisting residents, thus providing a further challenge in limiting the spread of infections. Compounding the risk, many staff do not have paid sick leave, so they may continue to work even while experiencing symptoms. Many staff and residents also do not consistently wash their hands, a perennial problem in health care facilities, and thereby spread the virus.
Outbreaks will also place a huge burden on direct care staff. This could be a great source of vulnerability for facilities because infection and quarantine of nursing home staff has the potential to create overwhelming workforce shortages. Nursing homes already face notoriously high staff turnover rates and have difficulties attracting staff because of low salaries and a demanding work environment. When caregivers get sick, which will be difficult to avoid in a nursing home outbreak, they will have to stay home for a full quarantine period even in the best-case scenario. How will facilities fill these vacancies as communities cope with the collective impact of COVID-19? Nursing homes can hire temporary contract staff from an agency, but this is expensive and may prove impossible to sustain. It could be extremely difficult to attract workers to a nursing home with an ongoing outbreak.
A vitally important question is how to prevent COVID-19 outbreaks at nursing homes. Nursing homes can take several steps, many of which are familiar infection control practices put in place during other outbreaks. The CDC recommends proactive education of caregivers in facilities regarding hand washing, personal protective equipment (PPE), and nonpunitive sick leave policies to help keep potentially contagious staff away from facilities. In additional to hospitals, nursing homes will need to be priority locations for PPE distribution in the setting of national shortages. Telemedicine will likely become a default to prevent nosocomial spread and extend the clinician workforce, especially now that Centers for Medicare & Medicaid Services has relaxed many restrictions associated with Medicare reimbursement for telemedicine services. Physical location of residents is also important, such as moving those with suspected infection to private rooms or “cohorting” suspected cases into single units.
Another tragic, but necessary, change is the decision by Centers for Medicare & Medicaid Services to restrict nearly all visitors to facilities. Although this is just as important as the aforementioned infection control steps, unlike standard hygiene, it imposes a significant social and emotional cost on already isolated residents. Technologies like video chat could mitigate the effects of social distancing but also require additional investment for equipment and training and may not be a good fit for all residents.
The plight of nursing homes demands policy attention to mitigate the potential consequences of COVID-19. Lawmakers are debating the terms of stimulus packages to bolster the economy as the US and the world engage in social distancing. Nursing homes will require some of these funds to get through staff shortages, provide additional training, purchase communications equipment, and maintain supplies of PPE, to name a few priorities.
Although many prefer not to think about nursing homes, they are a critical safety net for frail older adults and part of the fabric of our society. According to a 2014 report from the Center for Retirement Research, 44% of men and 58% of women 65 years and older will use nursing home care at some point in their lives. Therefore, the grave threat that COVID-19 poses for nursing homes involves all of us. As the story of the Seattle-based Life Care Center shows, a lack of attention to the availability of testing and poor infection control led to ramifications with statewide and national effects. There is no reason to believe that the situation will be much different in other settings with institutionalized populations, including jails, prisons, and other types of group homes. In an epidemic like the COVID-19 outbreak, our response will only be as strong as the weakest, most vulnerable link.
Corresponding Author: Michael L. Barnett, MD, MS, Harvard T.H. Chan School of Public Health, Department of Health Policy and Management, 677 Huntington Ave, Kresge 411, Boston, MA 02115 (email@example.com).
Conflict of Interest Disclosures: Dr Grabowski reported receiving grants from the National Institute on Aging, Agency for Healthcare Research and Quality, Warren Alpert Foundation, Arnold Foundation, and Donaghue Foundation and personal fees from NaviHealth, RTI International, Abt Associates, Medicare Payment Advisory Commission, Vivacitas, Compass Lexecon, Analysis Group, CareLinx, and Precision Health Economics. No other disclosures were reported.
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