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Lessons learned – Outbreaks of COVID-19 in nursing homes

      To the Editor:
      Nursing home (NH) residents comprise a disproportionately high percentage of the deaths from COVID-19 in the United States
      • Abrams HR
      • Loomer L
      • Gandhi A
      • Grabowski DC
      Characteristics of U.S. nursing homes with COVID-19 cases.
      because close quarters exacerbate asymptomatic and presymptomatic spread among vulnerable populations. As infectious disease doctors and healthcare epidemiologists, our collective practice has been dedicated to preventing the spread of resistant bacteria in NHs, with a focus on implementing and assessing the use of personal protective equipment (PPE).
      • Roghmann M-C
      • Johnson JK
      • Sorkin JD
      • et al.
      Transmission of Methicillin-Resistant Staphylococcus aureus (MRSA) to healthcare worker gowns and gloves during care of nursing home residents.
      • Pineles L
      • Morgan DJ
      • Lydecker A
      • et al.
      Transmission of MRSA to healthcare worker gowns and gloves during care of nursing home residents in VA community living centers.
      • Blanco N
      • Pineles L
      • Lydecker AD
      • et al.
      Transmission of resistant gram-negative bacteria to health care worker gowns and gloves during care of nursing home residents in veterans affairs community living centers.

      Morgan DJ, Zhan M, Goto M, et al. The effectiveness of contact precautions on methicillin-resistant Staphylococcus aureus (MRSA) in long-term care across the United States [e-pub ahead of print]. Clin Infect Dis. https://doi.org/10.1093/cid/ciz1045. Accessed August 13, 2020.

      Thus, we were well-positioned to provide guidance for preventing the introduction of COVID-19 into the local NHs, and subsequently preventing its spread within these facilities when we had cases. Here are some lessons learned.
      Lesson 1: After restricting visitors and volunteers, and screening admissions, staff will be the main source of COVID-19 in NHs. COVID-19 symptoms can be delayed, initially mild, and widely varied.
      Coronavirus Disease 2019 (COVID-19) – Symptoms.
      When calling out sick, staff must be supported with adequate sick leave and coverage to prevent presenteeism. Occupational and Employee Health play a critical role in preventing COVID-19 in NHs. Rapid testing of staff is mandatory so that a contact investigation can be initiated quickly.
      Lesson 2: NH residents generally present with nonspecific symptoms prior to developing typical COVID-19 symptoms. Decreased appetite and energy, confusion, and low-grade fever often precede respiratory complaints. Any patient with these vague symptoms should be moved to a private room and tested. Time is your enemy; a single infected resident likely represents multiple asymptomatic or presymptomatic infections.
      Lesson 3: Be able to test residents and staff quickly. While the CDC has advocated for weekly universal testing, we have focused on broad contact investigations.
      Coronavirus Disease 2019 (COVID-19) - Testing Guidelines for Nursing Homes.
      As soon as you identify a resident with COVID-19, test all residents and staff regardless of the PPE being used. This is analogous to cancer staging; you need to assess the extent of your outbreak. If you find subsequent cases, continue testing with broad contact investigations until you stop finding positives. Be particularly focused on break room contact among staff where PPE adherence is low. Then hold your breath for 14 days and hope no more symptomatic residents or staff test positive.
      Lesson 4: Assume everyone has COVID-19 in an outbreak until they test negative. Residents exposed to infected staff should be in private rooms until their tests return negative. Exposed staff should not return to work until they test negative and remain asymptomatic.
      Lesson 5: After controlling your outbreak, focus on measures to prevent spread in the event that an asymptomatic carrier of COVID-19 comes to work, such as:
      • Daily surveillance of both staff and residents for COVID-19 symptoms and exposures, followed by rapid isolation and testing. For residents, temperature trends seem more important than absolute values.
        • High KP
        • Bradley SF
        • Gravenstein S
        • et al.
        Clinical practice guideline for the evaluation of fever and infection in older adult residents of long-term care facilities: 2008 update by the Infectious Diseases Society of America.
        As testing becomes more available, expand testing to include at-risk asymptomatic staff or residents (eg, those who live in high-prevalence zip codes or work at other institutions with an active outbreak).
      • Universal PPE, focused on protecting the faces of staff and residents in the moments when they are closest together. In addition to universal masking, eye protection (ie, face shield or googles) is required while providing direct resident care or when in a resident's room, and gowns and gloves are required for high-contact care (eg, bathing, wound care).
        Implementation of Personal Protective Equipment (PPE) in Nursing Homes to Prevent Spread of Novel or Targeted Multidrug-resistant Organisms (MDROs).
        Residents wear masks while receiving care, and when leaving the unit.
      • Limiting traffic through NHs. We have restricted visitors and prohibited volunteers and geographically assigned clinical staff and housekeeping to specific units. Most outpatient visits have been converted to telemedicine. For specialty care, we have asked a single provider to come to the NH rather than sending the residents to outpatient clinics. NHs should invest in treatment rooms which can accommodate in-facility procedures. Private rooms may be needed for family communication (eg, videoconferencing) and isolation to prevent resident-to-resident transmission.
      • Physical distancing for NH staff. NHs need to re-envision their work and break areas. Computers on wheels allow staff to spread out. Plexiglas shields could be used for change of shift reporting. Outdoor and large dining rooms should be used as break areas.
      We need to re-imagine how care is delivered in NHs and invest in infrastructure that keeps residents and staff healthy. It is difficult to control the introduction and spread of COVID-19 in NHs and requires resources that most NHs do not currently have. NHs need to invest in Infection Preventionists and Occupational and Employee Health. Testing needs to be readily available and free of charge. COVID-19 will not be the last respiratory infection to threaten NH residents; it is time to invest in prevention for the future.

      References

        • Abrams HR
        • Loomer L
        • Gandhi A
        • Grabowski DC
        Characteristics of U.S. nursing homes with COVID-19 cases.
        J Am Geriatr Soc. 2020; 68: 1653-1656
        • Roghmann M-C
        • Johnson JK
        • Sorkin JD
        • et al.
        Transmission of Methicillin-Resistant Staphylococcus aureus (MRSA) to healthcare worker gowns and gloves during care of nursing home residents.
        Infect Control Hosp Epidemiol. 2015; 36: 1050-1057
        • Pineles L
        • Morgan DJ
        • Lydecker A
        • et al.
        Transmission of MRSA to healthcare worker gowns and gloves during care of nursing home residents in VA community living centers.
        Am J Infect Control. 2017; 45: 947-953
        • Blanco N
        • Pineles L
        • Lydecker AD
        • et al.
        Transmission of resistant gram-negative bacteria to health care worker gowns and gloves during care of nursing home residents in veterans affairs community living centers.
        Antimicrob Agents Chemother. 2017; 61 (e00790–17)
      1. Morgan DJ, Zhan M, Goto M, et al. The effectiveness of contact precautions on methicillin-resistant Staphylococcus aureus (MRSA) in long-term care across the United States [e-pub ahead of print]. Clin Infect Dis. https://doi.org/10.1093/cid/ciz1045. Accessed August 13, 2020.

      2. Coronavirus Disease 2019 (COVID-19) – Symptoms.
        Centers for Disease Control and Prevention, 2020 (Available at:) (Accessed July 1, 2020)
      3. Coronavirus Disease 2019 (COVID-19) - Testing Guidelines for Nursing Homes.
        Centers for Disease Control and Prevention, 2020 (Available at:) (Accessed July 6, 2020)
        • High KP
        • Bradley SF
        • Gravenstein S
        • et al.
        Clinical practice guideline for the evaluation of fever and infection in older adult residents of long-term care facilities: 2008 update by the Infectious Diseases Society of America.
        Clin Infect Dis. 2009; 48: 149-171
      4. Implementation of Personal Protective Equipment (PPE) in Nursing Homes to Prevent Spread of Novel or Targeted Multidrug-resistant Organisms (MDROs).
        Centers for Disease Control and Prevention, 2019 (Available at:) (Accessed June 22, 2020)