Responding to a COVID-19 Outbreak at a Long-Term Care Facility

Abstract

This paper describes an outbreak of COVID-19 in a long-term care facility (LTCF) in West Virginia that was the epicenter of the state’s pandemic. Beginning with the index case, we describe the sequential order of procedures undertaken by the facility including testing, infection control, treatment, and communication with facility residents, staff, and family members. We also describe the lessons learned during the process and provide recommendations for handling an outbreak at other LTCFs.

Index Case Presentation

On March 22, 2020, a 72-year-old female at a LTCF was noted to have altered mental status and was transferred to the emergency room (ER). Her altered mental status was preceded by two days of cough and fever. In the ER a chest scan revealed bilateral ground glass opacities. Given the rapidly increasing prevalence of COVID-19 in surrounding states and concerning imaging findings, she was swabbed for COVID-19 and admitted to the hospital. Twelve hours later, the test returned as positive and the LTCF notified. Within 36 hours, 21 of 98 residents and 8 of the 56 staff initially tested were identified as positive for COVID-19.

As of August 20, 2020, the facility has had 52 residents and 19 staff test positive and 5 resident deaths secondary to COVID-19. With no new cases, the facility is considered COVID-19 recovered. The resident rate of infection (53%) and mortality (5%) are better than reported world averages for LTCFs, and we believe directly relate to the response from the facility, local health care system, and state. The purpose of this paper is to detail the initial testing, isolation, and system interactions that resulted in limited spread of infection within the facility and minimized burden on the local health system. We also highlight lessons learned throughout the response. This review was supported by facility leadership and residents and formal Institutional Review Board (IRB).

Testing

Early identification of infection is essential for limiting the spread of COVID-19 and limited test availability contributed to the rapid spread in at least one other LTCF (World Health Organization, 2020; McMichael, 2020). As such, immediately upon identification of the index case, all residents in the facility were evaluated. Five other residents were identified as having symptoms concerning for COVID-19. Conversations with the local hospital’s COVID-19 command center determined the ER, at the time, had capacity to isolate four individuals. Transfer of residents to the ER was staggered over 24 hours based on symptom severity and level of care needed as to not overwhelm ER capacity.

Immediately upon notification of a positive case, the facility medical director called the local county health officer who alerted the governor’s COVID cabinet. The day after the index case was identified, the National Guard was present onsite to facilitate sample collection for diagnostic testing for all residents and staff on the same unit as the index case. The National Guard returned the following day to assist with sample collection of all other residents in the facility. Although testing supplies and test processing were limited at the time of index case identification, both local hospitals and the state lab donated supplies. Test processing was divided between the local academic hospital and the state lab. All residents in the facility were tested, but due to limited testing resources approximately 56 out of 162 staff were chosen for rapid testing. Given their central role in day-to-day resident care, the initial wave of staff testing focused on certified nursing assistants (CNAs) and licensed practical nurses (LPNs). All other facility staff members were directed to local drive-up testing sites. The initial wave of testing resulted in 21 out of 98 residents and 8 of the 56 staff testing positive. Three residents (or their medical power of attorney) declined testing and they were treated as if positive. Weekly PCR testing was continued until all were negative.

At week four after the index case identification, all previously negative residents were retested for COVID-19. Thirteen were identified as new positives although viral load in these newly identified cases was similar to the viral load of those residents who initially tested positive. As with the initial wave, all positive cases were followed up with weekly PCR testing until all results were negative.

States have varied widely in their reporting requirements as well as privacy protections regarding test results. In West Virginia, daily reports of prevalence, incidence, and deaths related to COVID-19 were required by the state’s Department of Health and Human Resources (DHHR). The current and cumulative positive cases were listed by LTCF on the state’s DHHR website.

Infection Control Procedures

Creating an Isolation Unit

Once COVID-19 positive residents and employees were identified, the next step was creating an appropriate and safe setting at the LTCF. The facility is a free-standing structure with a 100-bed capacity providing long term care, skilled nursing, and hospice care. It has six separate units with four nursing stations. The designated isolation unit was chosen due to no shared common space with other units, private nursing station, and drive-up exterior access directly to unit.

All residents testing positive for COVID-19 were moved to the physical therapy center at the LTCF to allow their rooms to be sanitized by a commercial cleaning company. The cleaning company used a variety of cleaning procedures based on surface type, including alkalized spray, bleach, and alcohol. An activated ionized hydrogen peroxide solution, SteraMist™ which works similarly to commercial alkalized spray solutions, was used to sanitize soft surface items including clothes and fabric covered furniture. Cleaning procedures were chosen based on evidence of ability to kill on contact and to be rapidly safe of habitation. Only essential personal items were transferred with residents; all other belongings were stored. Residents testing negative for COVID-19 who had been in rooms in the now designated isolation unit were reassigned to other units. During all transfers, residents and staff wore gloves and masks. Beds and wheelchairs used for transport were sanitized before each use.

A decontamination area between the isolation unit and the main facility was set up using two sets of plastic drapes with overlapping pleated filters attached at drape openings. This decontamination area was used for staff to don and doff personal protective equipment (PPE) (gown, gloves, eye protection, and N-95 mask). A 93% alcohol solution was provided to spray off shoes. All shifts were either in the isolation unit or elsewhere in the facility to limit staff moving between areas of the facility.

Each resident room has its own ventilation, recirculating air through two-inch pleated air filters. Exhaust from each unit is independently vented to the outside, and roof ventilation units are all greater than 150 feet apart to decrease recirculation of air from another unit. Bathrooms are on a mixed ventilation system, so to prevent circulation of air between units all bathroom exhaust fans on the isolation unit were left on at all times. Laundry service went to all other units before going to the isolation unit. All meals for isolation unit were served on disposable trays with disposable silverware from a cart only used for isolation unit. Laundry and meal carts were sanitized before returning to main facility.

Daily Infection Control

As no medications are currently known to be safe and effective at preventing or treating COVID-19, the only measures to reduce transmission of the virus include social distancing, appropriate use of PPE, and consistent hygiene practices. Each day before entering the facility, all staff were asked about COVID-19 exposure or symptoms and had their temperature taken by thermal scan. Anyone with symptoms or temperature above 99.5 was not allowed in the building. Although temperature screening is known to have low sensitivity, it was felt the benefits of symptom self-awareness and subjective anxiety relief outweighed the imperfect screening (Nishiura and Kamiya, 2011). As discussed above, staff entering the isolation unit wore appropriate PPE and underwent thorough sanitization before exiting the decontamination area. Housekeeping used commercial grade cleaners with alcohol, bleach, and alkalized water for all cleaning. All surfaces in areas with the highest foot traffic were cleaned at least three times per day. Staff were instructed to increase cleaning of high-touched surfaces, including bed, handrails, remotes, computers, and nursing stations. Resident rooms were stocked with hand sanitizer and residents were encouraged to use it frequently. For those residents with advanced dementia, hand sanitizer was stored in a cabinet out of reach or outside their room. Rooms at a local hotel were arranged for any staff concerned about risk to their family. Visitors were not permitted in the facility unless a loved-one was actively dying.

Treatment Choices

Individuals over the age of 65 represent 80% of COVID-19 fatalities (Shahid, Kalavanamitra, McClafferty, et al., 2020; CDC COVID Response Team, 2020). Considering poor outcomes in this population, the few articles discussing recommendations for treatment focus on supportive care and early discussion of advanced directives with residents and their families (Shahid, Kalavanamitra, McClafferty, et al., 2020; Ouslander, 2020). Following these guidelines, family discussions were held with all residents testing positive. Discussions included the resident’s current status and symptoms as well as available knowledge of COVID-19 progression and outcomes. Wishes of the residents and goals of the family were documented with the understanding they would be readdressed as needed. These conversations, especially with health care providers known to residents and their families, not only helped set expectations but identified those who would want to be transferred to higher level of care. Clear patient and family wishes help decrease unwanted transfers and therefore the strain on and exposure risk to the local healthcare system. All residents were provided general supportive care for symptoms as needed, including supplemental oxygen and intravenous or subcutaneous fluids. With support from infectious disease specialists at the local academic hospital, all residents testing positive were offered treatment with both azithromycin 250 mg daily and Plaquenil 200 mg two times a day for five days.

Communication

The most difficult aspect of dealing with the outbreak at this LTCF was communication—both with staff and families of residents. Because of the critical need to keep residents in a familiar, caring environment, the LTCF leadership prioritized allocation of limited swabs and testing capacity. Staff who had the most contact with COVID-19 positive residents were tested first. Division directors were asked to make a list of staff most critical to patient care, which were primarily CNAs and LPNs. This led to concern and some resentment among staff who were not included. LTCF leadership scheduled a meeting with all staff to clarify why certain individuals had been prioritized. At the time of the initial round of testing, the LTCF leadership team was focused on emergently needed care and controlling infection spread. In hindsight, more proactive communication about testing decisions would have helped identify concerns earlier, allowing staff to focus on the teamwork necessary to care for those living and working at the facility.

Communication with families was also challenging to navigate. Family members of residents were alarmed by the outbreak and wanted to speak directly to the medical director, regardless of their loved one’s test result. During the first days of the outbreak individual calls to each family were made. With each call lasting 30–40 minutes, this was not a sustainable solution. Communication with families improved significantly once staff began implementing Zoom calls. The LTCF purchased the HIPAA-compliant version of Zoom, and the leadership team, including division directors (social work, nursing, dietary, activities), medical director, facility administrator, and chief executive officer, held weekly group calls by unit with families of residents. HIPAA compliance allowed families and staff to feel more secure about hacking concerns. Zoom calls addressed general facility updates including aggregated facility testing results and visiting policies. During this time, participation on the Zoom calls ranged from 10–23 family members per call. Families with private patient questions could telephone or use a private Zoom. All residents and family members provided consent before call initiation. Staff also facilitated video calls between residents and their families as well as between residents residing on different units within the facility. All communication equipment was sanitized between uses. Remote visits were reassuring to families and increasingly sought after. Despite measures to connect residents with their families and friends, many residents struggled with isolation, loneliness, and depression. Regardless of testing status many residents had declining food and water intake, leading to weight loss and difficulty maintaining hydration.

Implications for Practice

As is true for many facilities, our disaster plan addressed only natural disasters and our infection plans were targeted to influenza and respiratory syncytial virus (RSV). As such, our team wants to share insights and recommendations based on our experiences. We hope to help others revise inadequate disaster plans and respond more effectively in the future. Our biggest challenges were:

• communication on all levels (residents, staff, and families)

• management of fear and expectations

• effects of isolation on residents regardless of a positive or negative test for COVID-19

To deal with these pitfalls, we recommend implementing proactive communication with staff and families and taking advantage of available video call technology when possible. Staff at other LTCFs should be prepared to offer extra encouragement with meals and intravenous hydration due to significantly decreased oral intake resulting from the psychosocial impacts of isolation regardless of the resident’s COVID status.

The strategies most helpful in managing the outbreak included:

• early testing

• early isolation

• daily physician availability onsite

• communication with the local health system about equipment, testing needs, and capacity

• community-centric approach rather than a hospital-centric approach to managing the outbreak.

To limit transmission risk to our residents, emergency medical services staff, and hospital/ER staff, residents’ medical needs were handled at the LTCF to the extent possible. We only transferred residents to a higher level of care when absolutely critical. Based on our findings from testing, we also recommend the repeat testing of LTCF residents at one and two weeks after their initial negative test to ensure all cases are identified and isolated.

Overall, there has been a global paucity of data and research on the appropriate response measures to such an unprecedented event. We hope our lived experience of wins and failures can aid others in making more informed and evidence-supported decisions in dealing with outbreaks now and in the future.