Nursing homes are cruise ships on land; they have conditions that create the Perfect Storm. Physically, even with communal dining and group activities cancelled, often residents are in shared bedrooms with limited space making social distancing difficult. And, everyone has an underlying condition and age going against them as two more risk factors for complications for COVID-19. Cognitively, per the Alzheimer’s association, over half of all nursing home residents have some level of dementia or memory impairment, making compliance with self-masking and social distancing a challenge.
Socially, many of the employees, which make up the backbone of nursing home care, have multiple jobs to put food on the table. They go directly from one job to the next, often without going home to shower/change, and many use public transportation and frequently live in close quarters that do not allow for social distancing at home even when someone tests positive. These conditions enable COVID-19, wearing its invisible cloak, to take a free ride on unsuspecting healthcare workers as they rush from place to place all along the way to and within senior living communities.
Current Centers for Disease Control & Prevention guidelines suggest diagnostic testing for the presence of COVID-19 only for symptomatic residents or employees. (Our mayor announced this week expanding the CDC criteria to allow some asymptomatic individuals who have high exposure and are in high-risk groups to be prioritized for testing; guidance will be forthcoming.) We knew early on that we needed more than symptomatic testing access to protect our residents. Instead, we aggressively began testing all of our residents and our workforce that serve them. We chose to pursue universal testing through private resources with LabCorp to assess the asymptomatic presence of COVID-19.
In a world of limited resources, knowing the answer to “What would you do differently with the data from universal testing than you already are with universal masking and appropriate PPE usage?” is important. At Knollwood Military Life Plan Community, in Washington, DC, we charted a path out of our Perfect Storm.
The big picture
- To give the current CDC guidelines for universal masking time to work, we needed to help bend the curve internally to prevent further, potentially widespread outbreak. Now that we know that COVID-19 is transmitted mostly asymptomatically, we are using universal masking. This is the reverse of what we knew a month ago; then it was thought that the most active transmission period was during active symptoms, so universal masking guidelines had not been in place.
- We tested all SNF residents and all employees in two days to proactively manage an outbreak in our secured, skilled area for residents needing memory care. At that time, utilizing Department of Health testing reserved for symptomatic persons, we had one COVID-19-positive resident, and a few days later, potentially five more positive residents pending. With a dementia unit, the challenges included residents in shared rooms with limited space for consistent social distancing, residents with wandering behaviors, residents with very limited abilities to self-mask due to memory impairments, and residents unable to self-communicate if they were feeling symptoms of COVID-19. This is a unique environment.
Our process to universally test residents and employees of our skilled nursing unit once medical orders for testing and consent were granted utilized an interdisciplinary team which:
- Formed an agreement for diagnostic testing with a vetted and Food and Drug Administration-approved local commercial lab.
- Brought aboard temporary help of a physician and two nurse practitioners to help swab for samples. The CDC also sent three people to help on testing day. Three of our RNs and one LPN worked alongside the experienced professionals we brought in to quickly learn the testing protocols for future testing.
- Prepared the test kits the day before testing to include completed lab test request forms, labeling stickers to pair test request forms with swab test tubes containing transport medium, storing kits alphabetically by resident or employee list. This was key to efficiently collecting samples on test day.
- Formed teams of two to collect samples. One “helper” person from our team provided positive visual verification of the person being tested, name, and date of birth, against the pre-assembled, pre-labeled test kits. The “helper” person received the sample from the person conducting the swabbing, and placed the sample in the sample bag, and then into a portable cooler. Note the full PPE burn rate was two outfits of gowns and gloves per test kit. Testing teams wore goggles, N-95s and face shields, which were not touched throughout the testing process with residents and did not need to be changed until all testing was done.
- Prepared rolling carts were set up for each unit to travel form room to room with the teams. They held PPE supplies, hand sanitizer, coolers for sample storage and discarded PPE.
- Planned to minimize resident resistance, given our dementia unit. Residents were tested starting at 8 a.m. since most would still be in bed or their rooms rather than up and about. A social worker was placed in each of our two units that were tested to be able to work with residents that were confused, or didn’t recognize the person swabbing; we found this very effective. There were a total of five teams of two people to swab approximately 50 residents. It took about 2 hours to complete the collection of samples. The CDC team noted it was the most efficient team effort they had seen particularly given the residents being tested.
- Created a separate, walk-up testing site on our patio for asymptomatic employees with 4 stations over a few days. The optimal time to catch staff was after their shift or before their shift, when they were not in PPE. If staff had to change out of their PPE during the shift we also sent them over for testing. All staff were tested. Employees were reminded via text by HR to report for testing.
- Created a drive-up station in our parking lot for symptomatic employees at home on self-isolation for a small window of time. This limited potential exposure to those conducting the tests, as well as eliminated the need to sanitize any testing area between tests.
- Samples were stored in smaller coolers with ice packs until the lab did a special pickup of all the samples each day during testing. We stayed in close communication with our lab account manager throughout testing and specimen pickups to ensure proper collection, handling and storage of the specimens.
- We identified 13 asymptomatic residents we would not have known about without universal testing.
- We moved three residents temporarily using the CMS blanket wavier to 42 CFR 483.10 related to transfer/discharge and resident roommates and groupings to move residents in order to cohort for COVID-19, placing positive residents with positive residents and negative residents with negatives.
- We found 11 asymptomatic, positive employees which we sent home for to self-isolate 10 days per CDC guidelines.
- We discovered three asymptomatic residents in a different skilled unit and moved that unit to full PPE usage to include gowns, goggles, bonnets and shoe covers in addition to the masks and gloves already in place. We would not have done this without the testing since there were no symptoms on the unit. Current convention by CDC says to conserve PPE for when symptoms appear in a time with national and regional mask and gown shortages. Yet, to start a full burn on PPE for residents with asymptomatic residents makes full sense, given the vulnerability of our population.
- We created a day room space for positive residents and another space for negative residents, knowing that residents with dementia and other memory care needs will not self-isolate. Many need supervision during the day for wandering and other behaviors.
Testing is a huge part of being able to chart your way out of the COVID-19 storm. An out-of-the-box vision, private labs and a strong commitment to testing was super-important to our efforts. Finally, leadership was the crucial ingredient in navigating our waters. Our entire C-Suite and all of our Directors rolled up their sleeves to get it done and stem the spread. Key lessons learned on testing in our nursing home have informed our subsequent COVID-19 strategy across our assisted living and independent communities.
Each community has to answer the starting question of “What would you do differently than you are doing now if you knew the data from universal testing than you already are with universal masking and appropriate PPE usage?” If you have a case to make, then engaging your team, your community resources, and your passions to care for people make sense as an option to bend the curve in nursing homes. It takes a village.
Tina Sandri, MHSA, LNHA, is administrator of Knollwood Retirement Community in Washington, D.C.