4 Steps to Preventing COVID-19 Outbreaks in Nursing Homes

Dr. Wasserman:
On February 29, I heard for the first time about the outbreak of COVID-19 in a nursing home in Washington State, and literally at that moment, I, as well as most of my colleagues in the field of geriatrics and long-term care medicine, knew what was coming.  We knew from what we had been hearing about the impact that this virus could and would have on vulnerable older adults living in congregate housing.  And actually, within the next couple of weeks, the word came out from Europe, from Spain and Italy, about the devastation in nursing homes, and so it was obvious in March that this virus was at its most lethal in nursing facilities.  In fact, one of the terms I’ve often been using is nursing homes are accelerators for the COVID-19 infection, and this has been borne out with the greatest percentage of deaths occurring in nursing homes throughout the country. 

The key things that our association, CALTCM, the California Association of Long Term Care Medicine—we put out what we call the Long-Term Care Quadruple Aim for COVID-19 Response, and that quadruple aim is 4 things:  the first, abundant PPE; the second, readily available testing; the third, stellar infection prevention and control; and the fourth, emergency preparedness mode, which is actually a proxy for excellent leadership and management at the nursing home facility level. 

Now, in terms of the first element of our quadruple aim—abundant personal protective equipment—that has been borne out to be the single most important factor.  If a nursing home doesn’t have PPE, the virus will win, and another Kirkland will occur.  And it’s very simple.  If we’re not wearing masks and we’re not using PPE properly, this virus, once it gets into a nursing home, will spread like wildfire, so it’s really important that PPE never, ever become an issue in nursing homes or assisted livings or group homes or other congregate senior housing settings. 

The second that was difficult to achieve in March but became readily available in April was testing.  It’s actually unfortunate that we didn’t begin to do widespread testing of nursing home staff as early as April because we knew from the CDC’s own experience investigating Kirkland that this virus can be spread by healthcare workers who are asymptomatic.  One of the real important factors in testing is to make sure we know who’s got the virus, who’s bringing the virus in and out of facilities, and this is important on multiple levels—because we’re all human beings, we’ve got human beings working in nursing homes, and those human beings make mistakes, and so, if you’ve got nursing home staff who have the virus but they’re not using their PPE properly or they’re not doing good infection prevention, then you’re going to have a greater chance of spreading the virus, so testing is a very important adjunct to having abundant PPE. 

And then the third item is actually the old-fashioned infection prevention and control.  People have to wash their hands.  People have to do all the right things from an infection prevention perspective, and this is really very important and critical.  And we actually know from the hospital literature that hospital staff historically don’t even come close to achieving even 85% or 90% effective handwashing, and we need 100% handwashing in nursing homes and hospitals with COVID-19. 

The fourth item, which is really underlooked often times but absolutely critical, nursing homes throughout the country must be functioning in their emergency preparedness mode.  They must be functioning in their pandemic operational mode.  And functioning in an emergency preparedness mode is really a proxy for excellent leadership and management.  And I think if we look back we’re going to ultimately find that COVID-19 unmasked the poor leadership and management preparation in most nursing homes around the country.  

But that said, you need abundant PPE, you need readily available testing, and you need stellar infection prevention, and you tie it all together with great leadership and management, and that’s the quadruple aim that CALTCM put forth back in April.