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by: Terry E. Hill, Taejoon Ahn, Rebecca Rozen, Joe Greaves

For some of us, the cruelest month was mid-March to mid-April, during which our warnings about COVID-19 infections in long-term care (LTC) seemed to get little response. Here in one Bay Area county, that changed when hospital nurses engaged LTC facilities and triggered county-wide public-private coordination. As a result, an opportunity for creativity rather than finger-pointing has emerged.

The wakeup call that everyone should have heard came from a March 18th report of the index nursing home in King County, Washington: 81 of 130 residents had been infected, of whom 46 were hospitalized and 22 died. According to the follow-up New England Journal of Medicine paper, those numbers quickly grew to 101 residents infected, of whom 55 were hospitalized and 34 died, in addition to 50 infections among health care workers and 16 among visitors. COVID-19 infections had spread to 30 other LTC facilities in the county.

Two days after the Washington State report, the California Department of Public Health released a letter telling nursing homes that they should “prepare to receive residents with suspected or confirmed COVID-19 infection.” The more detailed instructions included bullets such as the following:

  • Ensure the facility has an adequate supply of facemasks, N95 respirators, face shields or goggles for eye protection, gowns and gloves…. 

The New York State Department of Health advisory was more blunt:

  • No resident shall be denied re-admission or admission to the nursing home solely based on a confirmed or suspected diagnosis of COVID-19. 

Nursing home advocates, trade associations, physicians and academics protested in unison that without adequate resources, staffing, and infection control expertise, this guidance was ill-informed or delusional.

The challenges of community transmission and asymptomatic infectivity 

While this policy impasse continued, on-the-ground realities began emerging in photos of nurses donning garbage bags for gowns and in lurid headlines, e.g., “A California nursing home was evacuated after its staff didn’t show up.” It became increasingly obvious that community-based transmission was widespread and that LTC settings would not be spared.  Nursing homes were screening for symptomatic staff at the front door as per guidelines while infected asymptomatic staff were walking in with a viral load.

The loudest wakeup call about asymptomatic infection came in a March 27th report showing that over half of COVID-positive nursing home residents were asymptomatic. There was no difference in infectivity among asymptomatic, pre-symptomatic or symptomatic residents.

This information sat uncomfortably with one of the authors (TEH) who visited an outbreak nursing home in which staff had gone to enormous trouble to cohort COVID-positive residents and don full PPE in that wing. Their access to testing, however, had been only for symptomatic residents, making it likely that a nursing assistant in another wing with inadequate PPE was giving intimate care to an asymptomatic COVID-positive resident before moving to the next resident for a similarly close encounter. Prospects for COVID-19 containment did not look good.

A prompt for community collaboration 

A new model began to emerge when Contra Costa County public officials asked John Muir Health, a community hospital system, to provide emergency staffing and infection control training for a nursing home with a large outbreak. The Muir CEO asked all relevant departments to contribute immediately, foregoing concerns about competition, finances, or politics, all of which could be sorted out later. Beyond nursing, an array of departments pitched in, including medical staff, laboratory, purchasing, palliative care, and the family medicine residency program. John Muir Health and Kaiser Permanente began working together on another outbreak, this one in an assisted living facility, after which all hospitals in the county agreed to a division of responsibility for proactive outreach to all 32 nursing homes in the county, followed by a similar approach to the much larger number of assisted living facilities. A similar public-private partnership is shaping up next door in Alameda County.

The nurses are going on-site to nursing homes to do readiness assessments and infection control training, along with action plans to address gaps in resources and care. They are following up to assist the nursing homes with those action plans. Telephonic outreach cannot rival this on-the-ground assessment and assistance. Staff at one nursing home had checked all the right readiness boxes during a telephonic assessment and announced that they were ready to accept COVID-positive patients. The hospital nurses arrived shortly thereafter and quickly concluded, “No, not yet.”

What makes hospital nurses different? 

COVID-19 checklists are plentiful and useful, but a checklist doesn’t make things happen. To achieve the goal of preventing infectious disease transmission, experienced infection control nurses bring critical thinking, confidence, determination, and problem-solving savvy. They have absorbed the lessons of the patient safety movement. They can leverage huddles to make rapid workflow adjustments, and they are accustomed to functioning in a culture of accountability.

Professionals in nursing homes, on the other hand, must make do with limited resources in a culture of low expectations. Even under direct observation by regulatory authorities, the most basic of standards may not be met. An April 2nd CMS press release reported that “36 percent of facilities inspected in recent days did not follow proper hand washing guidelines and 25 percent failed to demonstrate proper use of PPE” while being actively observed by surveyors.

The power differentials between the nurses on these hospital teams and the nurses in nursing homes cannot be overstated. Hospital infection control managers pursue measurable objectives backed by hospital executives and supported by performance improvement systems with the active participation of physician leaders. The infection preventionist required by nursing home regulation can be a part-time licensed vocational nurse. The knowledge, power, and resources necessary for rapid workflow change is beyond the reach of most nursing home infection preventionists.

What makes on-site training so important now? 

The nursing home nurse leaders may be fully able and committed, but what the hospital nurses bring is a greater expectation that standards will be met, and while on-site they also see for themselves the barriers that must be overcome. Is enough PPE really available? Could donning and doffing be safely done in a cleared-out equipment closet? Should it be done on an outside patio, and does the patio need an awning or tent? Have emergency drills and simulations been mastered? A bottom-line question is whether the hospital nurses think they themselves could safely care for COVID-positive patients in this setting, shift after shift.

Equally important as the infection control knowledge and know-how is the positive effect on nursing home staff confidence that can result from these sessions. In addition to illness, fear is decimating staff levels in nursing homes, most of whom have minimal or no health insurance coverage. If staff have more confidence that they can protect themselves and their families, they are more likely to come to work. Preserving current staff with their tacit knowledge and patient relationships is of paramount importance. Many have become skilled in behavioral management of residents with dementia, for example. Volunteers or emergency personnel brought in as replacements may have never given much thought to preventing falls, dehydration, or pressure sores or comforting an older person at end of life.

Will these hospital teams fix all our problems? 

Two or three hospital nurses who spend a half-day several times in a week at a nursing home will not themselves overcome all the barriers to safe care in the COVID-19 era. They will, however, do better problem identification than could ever be done from a distance. Most hospitals already have an infrastructure for liaison with post-acute care, thanks to years of work on readmissions, bundled payments, and accountable care. In the usual model, hospital nurse leaders have invited staff from their preferred nursing homes to come to collaborative meetings at the hospital. In these meetings, now held virtually, the hospital nurses offer guidance and support similar to that offered by public health departments – but that’s where the typical liaison model tends to end.

Once the same nurses have done on-site assessments at the nursing home, they bring back compelling reports to their hospital leadership and public health officials, many of whom do not know, for example, that mask fit-testing is virtually unheard of in nursing homes. Stories potentiate change. While the nurses cannot miraculously increase testing capacity, their descriptions of staff working without appropriate PPE can motivate procurement scrambles that pay off. As boundary-spanners they can facilitate relational coordination in which hospital and nursing home teams improve their mutual trust, communication, and problem-solving, all of which can ease the inevitable difficult discussions about patient transfers. When these nurses say that the Riverbend facility is ready for COVID-19 care but Shady Grove isn’t even close, both public health officials and their own hospitals pay attention.

Our experience suggests that with a modest amount of coordination from local health departments, hospital-based teams can collaborate on who takes responsibility for outreach to which LTC facilities and can help resolve thorny issues of PPE, testing, staffing, and placement. Here in the East Bay, the Hospital Council Northern and Central California and Alameda-Contra Costa Medical Association participate in public health department deliberations, thus increasing the chances that appropriate settings with appropriate staffing can be found. LTC outbreaks will still continue, of course. In particular, nursing homes and their staffs will continue to be popular scapegoats. The current crisis should prompt reflection on the structural biases in the health economy that have led to this reality. These hospital nurses are not the entire solution, but their proactive outreach can prevent “mini-surges” from LTC that can strain a neighboring hospital, and their problem-solving savvy facilitates creativity within the local health care ecosystem.

An example of collaborative creativity can be seen in this Saturday morning message from one hospital team to another, shortly after getting a list of priority facilities from the public health department (names removed): “Our team can take the first 9 buildings at the top of the list as we have the bandwidth to complete all 9 on-sites by next Friday. That would give you the bottom 5. Does that sound reasonable?” The way we can save the lives of nursing home residents during the COVID-19 era is to get hospital nurses like these to look up a nursing home address, drive over, find the parking lot and the front door, take a deep breath, and begin making things happen.

Author Bios: 

  • Terry E. Hill, MD, FACP, is a geriatrician and COVID-19 Medical Director for the Alameda-Contra Costa Medical Association, supported in part by the Stupski Foundation.
  • Taejoon Ahn, MD, MPH, is President and CEO at John Muir Medical Group and Assistant Clinical Professor in the Department of Family and Community Medicine at the University of California, San Francisco.
  • Rebecca Rozen, MSc, is Regional Vice President, Hospital Council Northern and Central California.
  • Joe Greaves, MA, is Executive Director for the Alameda-Contra Costa Medical Association.
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