Coronavirus Disease 2019 (COVID-19) and Safety of Older Adults

Published: April 21, 2020

Background

According to experts, older adults with or without pre-existing chronic conditions are at higher risk of COVID-19 infection and are also more likely to have severe cases requiring intubation, ventilator support, and intensive care.1,2 In fact, the CDC reports that about 8 of 10 COVID-19 deaths in the U.S. have been adults over the age of 65 years, with the majority over 85 years of age.1 The risk of contracting and dying from COVID-19 is an even greater problem in the almost 16,000 U.S. nursing homes, where there are concentrated numbers of older adults with chronic disease and frailty. Nursing homes in general have been challenged with infection prevention and control management in the past; outbreaks of Norovirus, Clostridium difficile, and other infectious diseases have been widely reported over the years despite greater regulatory attention.2-5 As of April 18, 2020, the New York Times has reported more than 7,000 residents in U.S. nursing homes having died.6 Nursing homes are particularly challenged because of the age and health status of their residents, a physical environment that includes multi-resident rooms, close physical proximity, and shared bathrooms, and relatively low levels of registered nurse staffing.7 In addition, most nursing homes have relatively little information technology,8 few infection control supplies, and typically only one part-time infection preventionist who may not be a registered nurse.5,9 Assisted living communities and residential care facilities for the elderly are also at high risk because they have older adult populations that typically have multiple chronic diseases and these facilities have fewer clinical resources than nursing homes. Most of these facilities provide assistance with meals, activities, and some with medications; however, they typically do not employ licensed nurses to provide direct care.10

The Patient Safety Problems

Infection Control and Prevention:

COVID-19 has spread quickly through hundreds of nursing homes across the U.S., partially due to the challenges of providing adequate infection control and prevention measures in these congregate living facilities. The Washington Post has reported that 40% of the 650 nursing homes that have reported having residents with COVID-19 have been cited at one point in time for infection-control infractions.11,12 There are a variety of contributors to this problem, some of which are not modifiable such as older age, more chronic diseases, and close living quarters. Additional factors include lower and sometimes inadequate staffing,13-15 frequent hospitalizations, co-morbid conditions, and higher levels of functional impairment requiring close physical contact between staff and patients.16 Infection control and prevention problems are the most commonly found deficiencies in nursing homes, even in the highest CMS rated nursing homes.17 Multiple vulnerabilities in nursing homes have been reported widely during the COVID-19 pandemic including:6,12-18

Inadequate staffing
Lack of adequate personal protective equipment (PPE)
Lack of knowledge and adherence to appropriate use of PPE
Inconsistent hand hygiene
Improper isolation techniques
Inconsistent sanitization of equipment
Poor tracking of infections
Staff working in multiple facilities
High staff turnover
Staff working while ill

In particular, inadequate staffing and lack of a stable workforce has been identified as a weak point in nursing homes.18,19 In recent years, CMS has required that nursing homes employ a trained infection preventionist at least part time; however, that requirement is relatively new and little is known about how they are impacting infection rates.

Transitions of Care:

Previous Medicare and Medicaid regulations required that residents who left a nursing home for family visits and medical appointments or were transferred out of a nursing home to the hospital must be allowed to return to that nursing home. Nursing home leaders have expressed concern that residents who were exposed to COVID-19 in the emergency department or the hospital or from visiting family members should not be readmitted to the nursing home because of the potential risk of exposure to existing residents.20

In some states, nursing homes have been mandated to accept new COVID-19 patients.13Transferring COVID-19 positive patients who no longer need acute care but require nursing home care from the hospital to a COVID-19 naive nursing home is a significant patient safety concern as existing residents at that home would be at risk. Recent federal guidance advised nursing homes to designate separate staff or units for COVID-19 positive patients;21 however, this guidance has not been well received by many nursing home leaders due to concerns about their ability to prevent viral transmission.22

Telehealth and Telemedicine:

Historically, Medicare payment for telehealth visits in nursing homes was restricted to rural areas. Regulations have been loosened to allow Medicare telehealth visits in nursing homes so that practitioners can conduct routine, urgent and non-urgent video visits, which will help minimize spread of the virus and improve patient safety.23 This relaxed regulation can significantly improve access to care during this time of social distancing and the need to limit visitors, and reduce the number of clinicians (including physicians, nurse practitioners, physician assistants, dentists, and some therapists) who need to be physically present in the nursing home. Telehealth also allows a more immediate response to urgent patient safety issues as practitioners can initiate a video visit at any time using a cell phone, notebook, or computer, allowing them to address medication errors, adverse events, falls, pressure injuries, or health care associated infections. The Centers for Medicare & Medicaid Services (CMS) has published a telemedicine/telehealth toolkit for providers, available in the Tools and Resources section below.

Federal Guidance to Nursing Homes:

CMS published guidance on March 13th advising nursing homes to screen all staff and residents for fever and respiratory symptoms and restrict nonessential healthcare personnel and visitors, including family, except for compassionate care such as end of life situations.24 The April update has additional guidance on infection control and CMS announced enhanced inspections to focus on infection control.25 CMS also strengthened prior recommendations that staff wear appropriate PPE with patients if PPE is available and that facilities either use separate staff for COVID-19 positive patients or designate separate facilities for these patients.26

COVID-19 Tools and Resources for Nursing Homes

Several additional resources have been made available to nursing home leaders.

The Centers for Disease Control and Prevention (CDC) published a guideline entitled Preparing for COVID-19: Long-term Care Facilities, Nursing Homes.27 The CDC also included a self-assessment guide (CMS Self-Assessment Guide: Nursing Home Preparedness Checklist).28 This checklist is designed to ensure that nursing homes and other long-term-care settings can assess their ability to care for patients who may have or be at risk for COVID-19 and how to prevent other residents from exposure. From this checklist, long-term care facilities should devise a comprehensive COVID-19 preparedness plan. Another recently published resource from CMS is a toolkit that provides new guidance on telemedicine/telehealth visits in nursing homes.29

COVID-19 Guidance for Assisted Living and Residential Care and Retirement Communities

The CDC published interim guidance for owners, operators, and administrators of Assisted Living Communities, Residential Care Facilities for the Elderly, and other retirement communities including:

Cancel all non-essential group activities and events
Clean and disinfect all common or shared facilities such as dining rooms, libraries, and living rooms
Clean all high touch areas such as doorknobs, handrails, shared exercise equipment
Inform visitors, volunteers, staff, and residents about COVID-19, screen staff when possible
Encourage personal protection measures such as social distancing
Create buddy systems so that residents stay connected socially
Limiting non-essential visitors

Further CDC guidance for retirement communities and independent living advising them to post the signs and symptoms of COVID-19 and directions on what to do during an outbreak is also available on the CDC website.30

Professional Organization Resources

The Society for Post-Acute and Long-Term Care Medicine has published guidance for nursing homes, providers, and medical directors that is freely available on its website that provides extensive guidance for COVID-19 related issues.31 The website has a series of practical resources available including a COVID-19 frequently asked questions for nursing home staff, guidance on transfer of hospital patients to post-acute and long-term care settings, a COVID-19 Update that prioritizes care, keeping residents safe from transmission.32 Included are practical lessons learned from a nursing home that had a COVID-19 Outbreak: Lessons Learned from the COVID-19 Outbreak at Canterbury Rehab with timely information about reducing harm to NH residents.33

The American Geriatric Society published an article in the Annals of Long-Term Care emphasizing the ABCDs (awareness, behaviors, containment, and decisions) of the pandemic for older adults to improve patient safety, particularly cognitive bias in diagnosing older adults, behaviors to clinically manage patients, and efforts to contain the virus to prevent harm to other older adults, particularly in nursing homes and other long-term care environments.34

Author

Deb Bakerjian PhD, APRN, FAAN on behalf of the AHRQ PSNet team
Clinical Professor, University of California Davis School of Nursing
Co-Editor-in-Chief, AHRQ PSNet
dbakerjian@ucdavis.edu

References

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