Long‐Term Care Facilities and the COVID‐19 Pandemic: Lessons Learned in Madrid

To the Editor:

We have read with interest the excellent article by DʼAdamo et al on the ABCDs of managing the coronavirus disease 2019 (COVID‐19) pandemic in long‐term care, ¹ and we want to report our experience in Madrid, the hardest hit city by the pandemic in Spain. ¹

The Autonomous Community of Madrid is a Spanish region with a population of 6,662,000 people. It has one of the highest longevity rates in Europe, with 17.5% and 5.5% of its total population aged 65 years and older and 85 years and older, respectively. This region was first hit by the COVID‐19 pandemic at the beginning of March 2020, with a rapid dissemination and an exponential increase in the number of contagions and deaths, particularly in older adults living in long‐term care facilities (LTCFs). At the time the pandemic started, Madrid had approximately 480 LTCFs, housing approximately 44,000 older adults. Older patients living in LTCFs in Madrid were clearly the most vulnerable population during the pandemic. From March 8 to April 19, 2020, 19% of older patients (n ~ 8,300 cases) living in these facilities died, with a six‐fold increase compared with the same period in the last years.

To provide guidance for coping with the spread of COVID‐19 across LTCFs, here we will briefly discuss some important issues we have learned and should be kept in mind when providing care to patients living in these facilities (Figure 1).

1. Make sure to have a team prepared to take care of this vulnerable population. In all countries affected by the pandemic, initial efforts focused on treating patients in acute‐care hospitals and intensive care units. ² Yet, once the pressure on acute care decreases, the sad reality of LTCFs is likely to emerge.

2. Be aware of the geographical distribution of LTCFs. Hospital catchment area volumes are often based on the general population, and do not take into account the number of patients living in LTCFs in the area, which can overload some hospitals.

3. Minimize contacts within the LTCFs, avoiding visits of family and friends.

4. Implement all the recommended hygiene measures for everyone working in—or visiting––the facilities: handwashing, use of face masks, surface disinfection, and cloth washing. ³

5. Provide appropriate protective equipment to avoid high risk of contagion among staff members. In the case of LTCFs, it is also essential to protect caregivers who may visit the facilities.

6. Isolate suspect cases. In a pandemic situation, any individual with respiratory symptoms should be considered suspicious, and isolation should be performed.

7. Test everyone you can, the more the better. To implement successful isolation measures, it is essential to first identify those individuals who are infected, including the asymptomatic ones who are potent transmitters.

8. Because the patient will be much more isolated than normal, implementing communication tools, such as videoconferences, will anticipate this problem and will not add more despair to relatives.

9. Provide facilities with a minimum of supplies (oxygen, intravenous solutions and lines, antibiotics, morphine, and sedatives). ⁴ We have observed that in some areas of Madrid, requests for oxygen have increased by 400%. It is essential to define a series of minimum resources that each center must have, depending on the total number of residents and of affected people among them, and to establish effective circuits to replenish them.

10. If possible, adjust working hours and shifts to decrease the risk of infection among healthcare workers. We propose the creation of shifts of a shorter duration throughout the week.

11. Establish consultation circuits with hospitals to discuss cases and decide on the most appropriate treatment. In the case of Madrid, a geriatrician was the “coordinator physician,” who is available to guide workers at the facilities.

12. Make resources available for patients with dependency. Those transferred to a COVID‐19 area could lose their routine resources and make it more difficult to assist them properly.

Figure 1.

The 12 tips learned in Madrid, Spain, not to be missed for long‐term care facilities (LTCFs) amid the coronavirus disease 2019 pandemic.

In conclusion, the high fatality rate among older adults living in LTCFs in Madrid during the COVID‐19 pandemic showed us our strengths, such as being aware of the geographical distribution of all LTCFs and keeping in close contact between hospitals and LTCFs in a consolidated continuing healthcare program led by a hospital‐based geriatrician. What we failed to do was not to reallocate resources earlier, as we focused first in acute care in tertiary hospitals, and not to test as many patients as possible to implement better successful isolation measures. We learned the importance of minimizing contacts, applying stringent hygiene measures, and providing protective equipment to staff members.