As the month of May opened, the Navy’s hospital ship “Comfort” departed Manhattan, having housed fewer than 200 patients over 3 ½ weeks, and the state of New York announced plans to close temporary field hospitals after little usage. The temporary hospitals had been constructed to ease pressure on hospitals and help absorb projected surges of patients with COVID-19, the illness caused by the new coronavirus.
The state wasn’t alone. In my state of Illinois, Gov. J.B. Pritzker (D) and Chicago Mayor Lori Lightfoot announced plans for deconstruction of a 3,000-bed alternate hospital in McCormick Place, an enormous convention center in Chicago — a city that has had hospital occupancy rates of less than 50% over the past couple years.
Meanwhile, nursing homes that provide both long-term and post-acute, rehabilitation care — also known as skilled nursing care — have reported devastating outbreaks. Some facilities in Chicago have seen 10%-20% of their residents die in the span of a week. As May began, COVID-19 had been reported in 1 of every 5 or 6 nursing homes nationwide, according to major national newspapers, and an estimated 1 of every 5 deaths from the virus were being linked to nursing homes and long-term care facilities.
I’d venture to estimate that to up to half of nursing home outbreaks in the U.S. have been seeded in whole or in part by still-contagious patients sent from hospitals to nursing homes for post-acute, rehabilitative care. By not prohibiting these transfers, some states implicitly allowed them. New York and at least several other states even issued blanket guidance telling nursing homes that they must accept coronavirus-positive patients discharged from the hospital.
States got it all wrong. Public health departments and state leaders have been so worried about unclogging hospitals — or preventing hospital from becoming overfilled — that they overlooked the biggest threat from COVID-19: mortality in nursing homes.
What if at least some of the hundreds of millions of dollars spent across the country on temporary hospitals had been spent on temporary post-acute care facilities?
What if, moving forward, we shift priorities and develop COVID-19 post-acute care centers to care exclusively for patients who have stabilized from the infection but still need skilled nursing care and are still potentially contagious?
In a blog post in Health Affairs in mid-April, Vishal S. Arora and Jonathan E. Fried estimated that at least 700,000 patients who survive COVID-19-related hospitalization during this pandemic will require short-stay post-acute care. This number, the authors wrote, would not only overwhelm our country’s capacity of approximately 345,000 available skilled nursing beds, but it would expose medically frail nursing home residents to a high risk of COVID-19-related complications and death.
Media reports about nursing home outbreaks have not dug into nursing home infrastructure and must leave readers believing that nursing homes are ill-prepared and therefore to blame. The reality is that most nursing homes are not equipped to deal with a pandemic of this magnitude and severity.
Most nursing homes lack the infection control expertise and staffing levels of hospitals, and few have the capacity and capability to effectively isolate and safely treat patients who are known or suspected to be infected. Even with increased personal protective equipment and stepped up infection control — and, in some areas, the help of staff who have been redeployed to nursing homes from temporary hospitals — nursing homes will still struggle to contain the spread of such an infectious virus among their vulnerable residents.
Some policy experts and geriatricians have begun calling for better preparedness for post-acute care and stressing the benefits of specialized settings dedicated to COVID-19. A white paper written last month by the California Association of Long Term Care Medicine, for instance, details how temporary COVID-19 post-acute care centers could operate with virtual daily management guidance provided to each department by an incident command team.
The option of moving uninfected residents out of skilled nursing facilities and temporarily relocating them so that these facilities can be repurposed as COVID-19-only sites is one that is being carried out today in Massachusetts — and perhaps other states as well.
However, as a geriatrician who has worked with nursing home patients, I see downsides to such an approach. Moving residents out their homes can be traumatic, especially since many of them are frail and have dementia. And as the California association points, transfers may evoke civil right issues and a risk of infection during the process itself.
Whenever possible, states and locales should use alternate sites for COVID-19 post-acute care facilities just as they did in creating temporary hospitals. Had we had about 250 alternate nursing home beds in the greater Chicago area, we could have prevented COVID-19 patients from going to our existing nursing homes, one by one, and seeding massive outbreaks.
The limited use of temporary hospitals is being cited as a sign of progress — of having prevented illness with social distancing rules — and the result of many canceled “elective” surgeries and procedures. This is true, to some extent. Resources were squandered in building field hospitals, however, and we need to do better as we work our way through this pandemic.
The hospital ship in Manhattan has sailed away after helping relatively few patients. Meanwhile, hundreds of nursing home patients are dying every day. It’s time we give serious thought to allocating resources for temporary post-acute care centers. All is not lost.
Dheeraj Mahajan, M.D., MBA, MPH, FACP, is clinical assistant professor of medicine at the University of Illinois at Chicago and section chief, Geriatrics, at Illinois Masonic Medical Center.