As we continue to confront the COVID-19 pandemic, we are witnessing a potential decimation of our nation’s most fragile population — elderly Americans who reside in nursing home facilities. Nursing home residents represent a disproportionately high percentage of victims for a few reasons.
First, they are at high risk for acquiring this infection because of their physical proximity to one another and the staff who care for them. Most residents are also well over age 65 with lower immune function and numerous health conditions that put them at a far higher risk of hospitalization and death from COVID-19.
These residents can hardly socially isolate. While the average American household has two to three people, the average nursing home houses 109 people with dozens of staff and nurses on rotating shifts. Thus, it is not surprising that massive outbreaks have occurred in these facilities as we saw tragically in New Jersey and Washington state.
As an infectious disease doctor and health care epidemiologist, I have focused my research over the past three decades on preventing infections in nursing homes. Specifically, this has involved testing and implementing new practices that involve increasing the targeted use of gowns and gloves, two types of personal protective equipment (PPE), to prevent the spread of antibiotic-resistant bacteria. Based on my research findings, the Centers for Disease Control and Prevention developed new guidance that recommends nursing home staff be required to don a gown and gloves during high-contact activities like caring for wounds, bathing, or changing dirty bed linens.
The current COVID-19 crisis underscores just how important PPE protocols really are. New York Gov. Cuomo has declared that nursing home infections are the “single biggest fear” during the pandemic. Clearly, more needs to be done to protect the most vulnerable of our population. In Maryland, at least 80 nursing homes have reported COVID-19 clusters or outbreaks. In response, Gov. Hogan and the Maryland Department of Health have issued a directive and order that requires staff to wear additional personal protective equipment, including appropriate eye protection, gloves and gowns.
The CDC’s recommendation for protecting staff and residents from COVID-19 in nursing homes, however, differs significantly from their recommendations for hospitals which have more high-risk procedures. Nursing home staff have been told to use medical face masks instead of more protective N95 masks. Like hospitals, nursing homes have always assumed that they can get PPE if needed, so they are currently experiencing a severe shortage from their failure to adequately stockpile supplies. Nursing homes also tend to be small- to medium-size entities that do not have the depth or breadth of workforce like larger hospitals. Residents are largely cared for by geriatric nursing assistants who are paid low wages that barely cover their costs of commuting and child care. Paid sick leave is often incorporated into annual leave, so staff may feel discouraged from taking off when they have mild respiratory infections. As a result, infected workers have been the source of most COVID-19 clusters in nursing homes.
The COVID-19 pandemic should change health care in nursing homes in many positive ways. Telemedicine should continue to be used more extensively for provider visits that do not require an in-person exam. Nursing homes like hospitals should have new guidance on how much PPE they need to keep stockpiled, so they are better prepared for future epidemics. Public health officials need to consider what nursing homes need to help isolate sick patients and prevent infection spread. Having two levels of recommendations, one for hospitals and one for nursing homes, is suboptimal as nursing homes often become de facto extensions of hospitals, taking care of sicker patients with complex health issues.
Last, but not least, we in health care need to change our culture on working while not feeling well. As a group, we hate asking others to cover for us. As part of this, nursing homes (and other businesses) must evaluate their policies on paid sick leave to encourage sick workers to stay home and prevent the spread of future infections. A new federal law now requires essential employees (including nursing home staff) to have 10 days of paid sick leave during the pandemic. While this is an important step forward, adequate paid sick leave needs to be incorporated as a permanent annual work benefit for these employees. As we continue to move through and past the peak of this crisis, we need to pay attention to the lessons learned so we can be better prepared for the next pandemic.
Dr. Mary-Claire Roghmann (firstname.lastname@example.org) holds various roles at the University of Maryland School of Medicine, including professor of epidemiology and public health and medicine, and associate dean for physician scientist training.