Policy Recommendations Regarding Skilled Nursing Facility Management of Coronavirus 19 (COVID-19): Lessons from New York State

Abstract

To provide policy recommendations for managing Coronavirus 19 (COVID-19) in skilled nursing facilities, a group of certified medical directors from several facilities in New York state with experience managing the disease used e-mail, phone, and video conferencing to develop consensus recommendations. The resulting document provides recommendations on screening, protection of staff, screening of residents, management of Coronavirus 19 positive and presumed positive cases, communication during an outbreak, management of admissions and readmissions, and providing emotional support for staff. These consensus guidelines have been endorsed by the Executive Board of the New York Medical Directors Association and the Board of the Metropolitan Area Geriatrics Society.

Coronavirus 19 (COVID-19) has rapidly affected the healthcare systems in New York. The impact of this pandemic has been widely recognized in hospital systems, but guidelines for care for this disease in the skilled nursing facility (SNF) are sorely lacking.

One of the biggest challenges we have faced in SNFs is the transmission by asymptomatic carriers and patients. As a result, COVID-19 can insidiously spread prior to awareness of the first case, which leads to rapid spread within the facility.¹ Many older adults manifest COVID-19 with low grade temperatures, diarrhea, or fatigue, and may not have overt respiratory symptoms, causing rapid spread without detection.

We describe expert consensus policies for SNFs to prepare for and manage COVID-19.

Methods

The consensus statements presented here have been formulated by the authors who had experience with outbreaks of COVID-19 as the SNF community needed to rapidly adapt to the dynamic changes that occurred in these healthcare facilities during this unprecedented pandemic. The authors are actively working Certified Medical Directors, are Board Members of the New York Medical Directors Association, and serve as Medical Directors in Long Island, New Rochelle, and Rochester. The guidelines included in this report are based on current knowledge at the time of manuscript transmission (May 22, 2020) and may change over time—especially regarding medication management and laboratory testing. Literature review through PubMed was conducted and review of studies at ClinicalTrials.gov.

Our suggestions should not take precedence over local Department of Health or Centers for Disease Control (CDC) recommendations. It is imperative to recognize that recommendations regarding COVID-19 are frequently evolving and providers and facilities should adapt accordingly.

Recommendations

Measures Regarding Staff

• •Screen all employees when reporting for duty for fever, symptoms of respiratory illness, and other COVID-19 symptoms. Do not let anyone enter if they have fever or symptoms of COVID-19. Screener should be wearing a surgical mask.
• •If your community might participate in contact tracing, then a written sign-in log should be maintained for anyone who enters the facility.
• •Provide a face mask daily to each staff member to be worn at all times while in the facility. This mask should be available at the front entrance, prior to contact with the screener. The screener should be stationed at least 6 feet away from the area of those entering the facility.
• •
  Periodic point-prevalence COVID-19 testing of staff should be conducted based on regional prevalence only if:

  • °
    Utilized on staff not previously diagnosed with COVID by polymerase chain reaction (PCR) or antibody testing,
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    Conducted on a serial basis with a series of at least 3 rounds of testing 1 week apart to allow for newly infected staff to convert,
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    Point of care technology is used so to avoid the trauma of repeated nasopharyngeal swabbing and to ensure quicker results, and
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    There is a plan in place to manage potential staffing shortfall.
• •Staff should have a place to eat meals that allows them to practice appropriate social distancing while eating without masks.
• •Usage of locker rooms should follow social distancing guidelines while protecting employees' rights.
• •
  The following are mandatory once COVID-19 is known to be in the facility, are strongly recommended if COVID-19 is becoming prevalent in your community, and should be strongly considered if equipment is available regardless of local COVID-19 prevalence.

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    Provide N95 (or similar mask) to clinical staff to be worn during direct patient care and to cleaning crew and others when in patient areas.
  • °
    Provide eye-shields to all clinical staff to be worn during direct patient care and to cleaning crew and others in patient areas. This practice is becoming more common in both COVID positive and COVID negative areas as it is becoming clear that the main way to prevent spread is with aggressive personal protective equipment (PPE) use.
  • °
    Assign staff (including physical therapists/occupational therapists) to particular units when possible. This will lead to easier contact tracing in the event of positive COVID cases in the facility. It also limits spread to other units if a staff member is positive but asymptomatic.

Screening Measures for Residents/Patients

• •Screen all residents for COVID symptoms along with measurements of temperature and pulse oximetry at least twice daily. The facility medical director should set criteria for a positive screen.
• •The SNF should be prioritized for rapid, point of care testing as it is the best way to manage the epidemic in real time. Until this is available, facilities should be provided with a sufficient supply of test kits for PCR testing to meet diagnostic needs of the facility on an ongoing basis with access to a laboratory that can provide results of PCR testing within 24 hours.
• •
  Periodic point-prevalence COVID-19 testing should be conducted based on regional prevalence only if:

  • °
    Utilized on residents not previously diagnosed with COVID by PCR or antibody testing or clinical criteria,
  • °
    Conducted on a serial basis with a series of at least 3 rounds of testing 1 week apart to allow for newly infected residents to convert, and
  • °
    There is a plan to cohort residents who test positive.
• •Avoid group activities (such as recreational activities and physical and occupational therapy) that do not allow for the maintenance of 6 feet social distancing. Notably, it is often difficult for ambulatory residents with dementia to follow social distancing rules.
• •Because COVID-19 can spread prior to detection, to minimize risk of spread, convert nebulizer medications to metered dose inhalers (MDI) and stop nasal sprays which might spread virus.
• •
  The following are mandatory once COVID-19 is known to be in the facility, are strongly recommended if COVID-19 is becoming prevalent in your community, and should be strongly considered if equipment is available regardless of local COVID-19 prevalence.

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    Provide a clean face mask each day to all residents to wear throughout the day if tolerated. Efforts especially should be made for COVID positive residents to wear their masks when staff are in the room.
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    Review your Rapid Response/cardiopulmonary resuscitation team and strongly consider changing team to only 2 staff members who have an N95 and face shield. One member provides chest compressions and the other provides bagging for respirations. This limits exposure of health care team to COVID-19 while awaiting emergency medical service arrival.

Management of COVID-19 Positive/Presumed Positive Cases

• •Institute contact-droplet precautions and test for COVID-19 by PCR (if testing available) for any resident who is demonstrating symptoms. Maintain precautions while awaiting test results. If residents test positive, move as described below.
• •Create a dedicated COVID-19 Unit and assign staff who do not work elsewhere in the facility to this area. This COVID-19 Unit should receive transfers from within the facility as well as new admissions/re-admissions from hospitals who are COVID-19 positive; if possible, such a Unit should have a separate entrance/exit or try to install temporary walls or doorway at entryway.
• •If not able to segregate COVID-positive patients in a separate Unit, cohort such patients in 1 area of the affected unit and assign dedicated staff to care for them.
• •In addition to the use of face shields, gowns, and gloves, provide N95 masks (or similar) to staff providing direct care to COVID positive patients; use/re-use/store in accordance with CDC guidelines.²
• •Monitor all patients who are positive/suspected for COVID symptoms along with measurement of temperature and pulse oximetry 2 or 3 times a day. The facility medical director should set criteria for a positive screen.
• •The role for routine antibody testing in the SNF is currently unclear. In the future, it may be useful to assess for presence of immunity to guide room assignments. However, per the Infections Diseases Society of America, antibody tests are expected to be most useful as surveillance tools to estimate relative proportions of different populations that have been exposed to COVID-19.³
• •Review all resident's advance directives with resident and/or family–including do not resuscitate, do not intubate, and do not hospitalize. Physicians, nurse practitioners/physician assistants, social work, and nursing can contribute to the discussion. Conversations should include an explanation of the limited success of mechanical ventilation in older adults with COVID-19 as well as a description of the type of care which the SNF can provide while avoiding hospitalization.
• •Of note, COVID positive patients can have relatively minor symptoms but then quickly progress to fulminant shock and respiratory failure. This is likely due to the cytokine response related to COVID-19 infection.⁴ Educate residents/families regarding this possibility and that comfort-based medications can be titrated if this occurs.
• •More research is needed on symptom manifestation of COVID-19 in older adults, especially in the SNF, however, the authors have noted several patterns: significant decline in oral intake, white blood cell count is normal or low, fatigue as a primary symptom, and acute kidney injury with hypernatremia or hyponatremia.
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  Consistent with the resident's goals of care along with consideration of realistic goals of care, manage COVID-19 positive patients and, absent testing, those presumed to be COVID positive:

  • (1)
    Provide antipyretic therapy with acetaminophen–consider as needed (PRN) or standing doses.
  • (2)
    Provide supplemental oxygen by nasal cannula if pulse oxygen is <90% and titrate as needed. Advance to venti-mask if hypoxia not improved.
  • (3)
    Discontinue (or hold for 2‒3 weeks) any nonessential medications such as multivitamin, calcium, and vitamin D. Consider changing medications such as artificial tears and allergy medications to PRN. This reduces pill burden for the resident and reduces nursing administration time.
  • (4)
    Discontinue nebulizers (can change to MDI) and discontinue medications administered by nasal spray as these medications might spread virus.
  • (5)
    Published data show that COVID-19 is procoagulant.⁵ In addition, patients with COVID-19 in the SNF are generally spending more time in bed or chair and are at increased risk of deep vein thrombosis from decreased mobility. Consider prophylactic anticoagulation therapy with heparin SQ or enoxaparin SQ for 2 weeks or longer (depending on course of COVID-19 and level of mobility). Some practitioners are measuring d-dimer levels and determining anticoagulation based on current clinical guidelines and a patient's specific clinical condition. If patient is already on anticoagulation, additional deep vein thrombosis prophylaxis is not needed. Individual considerations including fall risk, bleeding risk, and concurrent use of antiplatelet medications must be factored into decisions about anticoagulation.
  • (6)
    Consider antibiotics if there is concern for bacterial pneumonia.
  • (7)
    Consider h2 blocker if resident is on an alternative treatment for gastroesophageal reflux disease, as there are studies underway for famotidine as treatment for COVID-19, and famotidine is a known treatment for gastric reflux, so this is not off-label or experimental.⁶
  • (8)
    Decisions regarding checking labs (complete blood count, erythrocyte sedimentation rate, comprehensive metabolic panel, C-reactive protein, ferritin and D-dimer levels) or chest radiographs should be made based on access to laboratory testing/imaging, consideration of risk exposure to residents and staff, and consideration of whether it will change management.
  • (9)
    Decisions regarding use of intravenous fluids should be made with consideration of realistic goals of care and other resident comorbidities. Intravenous fluids can worsen dyspnea and/or edema, especially in acute illness and at end-of-life.
  • (10)
    Manage end-of-life symptoms on-site with palliative approaches, tailored to each patient based on comorbidities, renal function, liver function, prior or current opioid use, age, weight, and symptom burden. Consider starting as PRN doses and transition standing doses with PRN in between, recognizing that symptoms of a patient with COVID-19 can quickly worsen.

    • a.
      Parenteral concentrated opioids for pain and/or dyspnea

      • i.
        morphine 20 mg/mL, consider start at 2.5 mg or 5 mg PO/SL q4-6 hours–avoid repeated morphine doses if CrCl <30
      • ii.
        oxycodone 20 mg/mL, consider start at 2.5 mg or 5 mg PO/SL q4-6 hours
      • iii.
        higher doses may be appropriate for higher symptom burden and non-opioid naïve patients
    • b.
      Parenteral concentrated benzodiazepine for dyspnea and/or restlessness

      • i.
        Lorazepam 2 mg/mL–consider 0.5 mg PO/SL q6-12 hours based on symptom burden
    • c.
      For excess secretions

      • i.
        Avoid suctioning because can lead to spread of virus and be uncomfortable for patients.
      • ii.
        Atropine eye drops can be used sublingually (usually 1 drop q2h prn excess secretions) to reduce secretions. Atropine can cross blood-brain barrier and cause delirium, so avoid in cognitively intact patients.
      • iii.
        Glyclopyrrolate can be used if patients can tolerate PO meds (usually 1‒2 mg PO bid-tid PRN). Glycopyrrolate does not cross the blood-brain barrier so is preferred if not delirious.
      • iv.
        Scopolamine patch is generally avoided in geriatrics because of anticholinergic side effects but can be considered for palliative approach.
• •
  Discontinue transmission-based precautions once the following conditions are met. There may be differences between your local health department and the CDC recommendations, so review those recommendations prior to initiating. The New York State Department of Health recommends the following strategies:

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    Nontest-based strategy:

    • i.
      At least 3 days (72 hours) have passed since recovery, defined as resolution of fever (greater than or equal to 100.0) without the use of fever-reducing medications, and
    • ii.
      Improvement in respiratory symptoms (eg, cough, shortness of breath), and
    • iii.
      At least 14 days have passed since symptoms attributed to COVID-19 first appeared (or first positive test if asymptomatic)
  • °
    Test-based strategy:

    • ▪
      Lack of fever (greater than and equal to 100.0), without fever reducing medications, and
    • ▪
      Improvement in respiratory symptoms (eg, cough, shortness of breath), and
    • ▪
      Negative results from at least 2 consecutive COVID-19 molecular assays at least 24 hours or greater apart, and
    • ▪
      For asymptomatic patients, testing may begin a minimum of 7 days from the first positive test

Based on observed failures of the nontest-based strategy (recurrent illness and/or positive molecular assays after discontinuation of transmission based precautions), the majority of the authors have adopted a combination approach in which the benchmarks of the nontest-based strategy are achieved and then the test-based strategy is used to confirm the discontinuation of transmission based precautions.

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  Specialty units (on-site hemodialysis and on-site ventilator units)

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    Fit test staff on ventilator/respiratory units for N95s pre-emptively given the patient population and higher possibility of aerosilization of the virus on these units
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    Encourage use of face shields on these units regardless of COVID status
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    On-site hemodialysis:

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      Consider creating a “late shift” for hemodialysis for patients with COVID-19 to allow for additional disinfecting prior to the next day dialysis sessions.
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    On-site ventilator units:

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      Attempt to change nebulizer medications to MDI to reduce risk of spread of COVID-19.
    • ▪
      Consider use of ambu-bags with hepa filters if possible to decrease spread of virus when bagging patients

Communication

• •Consider use of Telehealth visits for Medical consultant providers (dermatology, podiatry, etc) for use when necessary with proper cleaning of this equipment.
• •Arrange for video or window visits between residents and families.
• •Provide regular updates on the status of COVID-19 in the facility to staff. This can be though written, e-mail or video updates, and can improve morale.⁷
• •Develop ID cards with prominent photo of staff with name and title, to help residents identify caregivers who are wearing PPE obscuring the face.
• •Develop a color coding system for doors regarding COVID-19 status to remind staff to use appropriate PPE.
• •Provide in-service to staff regarding proper use of PPE and hand washing, and post signs as reminders.
• •Recognize that many older adults have hearing impairment. Many will have difficulty understanding healthcare providers wearing masks, which muffles sound as well as eliminates ability to lip read. Consider basic communication boards in each room to ask residents questions in writing.
• •The facility should develop a protocol to notify other patients and families residing in that facility regarding COVID status per local Department of Health regulations. Possible ways to achieve this include updating the facility website daily to inform families or utilizing a robo-call system.
• •Inform residents directly (if cognitively aware) and family members/designated representatives about diagnosis of COVID-19. Share your treatment plan and discuss advance directives.
• •Plan for a memorial/remembrance service following social distancing guidelines when acute management of the crisis has resolved sufficiently to allow for reflection and shared condolences.

Admissions/Re-admissions

• •The authors do not support the mandatory admission of patients with COVID-19 from hospitals to nursing homes as it may force unprepared facilities to provide care to patients with COVID without the necessary resources or precautions.
• •Hospitalized patients who are known COVID-19 positive should be admitted to a COVID positive unit.
• •If space allows, hospitalized patients who are COVID-19 negative, or were not tested, can be admitted to a “transition” unit for 14 days while they are monitored for symptoms of COVID-19 and tested if indicated (and available).

Additional supportive measures for staff and residents:

• •Unlike hospital staff who generally care for patients for short periods of time, the SNF staff care for SNF residents often for many years. This strong connection can make the death of SNF residents even more devastating. Emotional support should be provided to staff as they grieve loss of residents.
• •Cheerful drawings and messages from the community can be uplifting to SNF workers and patients. They can be posted in hallways and distributed to residents.
• •Many hospitals are touting their “success” stories as patients coming off a ventilator or being discharged. “Success” in the SNF, especially for long-term care residents, is different.
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  “Success stories” for the SNF which can be acknowledged:

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    Nurses and other staff who were sick with COVID and recovered
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    Staff, clinicians, and administrators who come to work despite personal risk
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    Residents who are recovering from COVID
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    Residents who went to the hospital with COVID and returned to the SNF
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    Residents who died from COVID in the facility after being treated with dignity and comfort measures
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    Families who are grateful for the care their loved ones are receiving and the updates provided by SNF.

Discussion

Managing COVID-19 in the SNF is uniquely challenging because the SNF serves both as a home and a medical facility. Additionally, the close quarters of SNFs and natural design of facilities for communal and group programs likely contribute to spread of the virus. Without periodic widespread testing of all employees and visitors entering the facility, it will be difficult to recognize when there is COVID-19 in the facility prior to its spread. Although our guidelines are limited because they represent experiences from only 1 state, authors represent both upstate and downstate, New York State has a high rate of COVID-19 in SNFs,⁸ and there is limited data on COVID in SNFs.⁹

Implications for Practice and Policy

Older adults have high mortality rates from COVID-19,¹⁰ and those in SNFs are at higher risk because of frailty, medical conditions, and the need for assistance with activities of daily living that made them need SNF care. Research is needed into transmission patterns and patient factors that impact individual outcomes. In our current situation, we must endeavor to reduce spread of infections, support the SNF staff, assist our residents, and consider public health policy impact in SNF.