Mitigating the Impact of SARS-CoV-2 in the Skilled Nursing Facility Setting: Experience From the Frontline

The skilled nursing facility (SNF) setting is particularly vulnerable to the rapid spread of SARS-CoV-2, the virus that causes COVID-19, because of the congregate living environment, the generally frail population, residents’ need for assistance with many activities of daily living, and the potential for virus transmission among asymptomatic individuals. Additionally, older adults infected with SARS-CoV-2 may not present with typical symptoms,^1-3 and residents in the SNF setting may have more difficulty communicating changes in health status because of underlying dementia or other cognitive or functional impairment.

Initial guidance for managing SARS-CoV-2 in the SNF setting focused on limiting visitation, determining staffing protocols, implementing infection control procedures, and promoting resident-centered care in the setting of increased isolation from social networks.⁴ Here we describe the experience at one large, racially diverse, academic-affiliated SNF in Atlanta, Georgia. Containment strategies likely prevented widespread infection among residents and health care providers (HCPs), and clinical care protocols show preliminary promise in mitigating the severity of COVID-19 in this vulnerable population.

The SNF has 70 to 90 postacute care beds and 140 to 145 long-term care beds. During the reporting period, the SNF was staffed by three full-time physicians, including the facility medical director, and 153 nurses, including full-time, part-time, and contract staff (18 registered nurses, 56 licensed practical nurses [LPNs], and 79 certified nursing assistants [CNAs]).

We describe the evolution of care protocols to prevent, contain, and mitigate SARS-CoV-2 in a vulnerable population of primarily older adults with functional impairment. Protocols targeted facility-, resident-, and HCP-level needs. Analyses of resident outcomes include descriptive statistics with an exploratory evaluation of demographic and clinical characteristics between residents who were and were not hospitalized. As a report based upon quality improvement activities related to SARS-CoV-2 at one facility, this work did not constitute human subjects research requiring institutional review board review.

Facility-Focused

Several measures were deployed early to minimize the introduction of SARS-CoV-2 (Figure 1). On February 29, 2020, leadership recommended avoiding visitation by those who had traveled in the previous 14 days, had a temperature 38 °C, or had respiratory symptoms; by March 12, 2020, all visitation was restricted.⁵

Additionally, facility leadership worked to secure testing kits and at least a 3-month supply of personal protective equipment (PPE) through the facility’s affiliation with an academic health center and the medical director’s existing collaboration with infectious disease researchers engaged in antibiotic stewardship activities at the SNF. Initial infection control education focused on improving hand hygiene, appropriate use (including donning and doffing) of PPE, and compliance with universal masking. The team identified a closed unit to serve as a COVID-management unit, and the medical director negotiated for direct hospital admission of clinically stable SARS-CoV-2–positive patients, to reduce the potential burden of an emergency department transfer.

Leadership utilized updates provided by national postacute long-term care association groups, which proved helpful in establishing initial protocols as recommended by the Centers for Medicare and Medicaid Services.⁷ In advance of Centers for Disease Control and Prevention (CDC) and Georgia Department of Public Health guidance regarding the duration of transmission-based precautions, the medical director conducted chart review of all potential admissions to avoid imported SARS-CoV-2 cases.

Resident-Focused

To reduce the potential for resident-to-resident, HCP-to-resident, or HCP-to-HCP transmission, large group activities were eliminated, the facility gym was closed, and equipment was moved to resident floors to allow for individual or small-group activity. Tablet mobile devices were purchased by the facility and donated by community members to facilitate resident communication with families and medical providers. Clinical consultation visits were transitioned to telemedicine.

HCPs reviewed medication lists of patients receiving regular oropharyngeal suction or nebulizer treatments and attempted to reduce aerosolizing procedures, if indicated. Residents requiring outpatient hemodialysis were moved to private rooms in a dedicated wing due to their inherent immunocompromised status and possible exposures encountered during transport to and from a dialysis center. As of the end of data collection for this report, no residents who contracted SARS-CoV-2 were receiving hemodialysis or had frequent appointments outside of the facility.

HCP-Focused

Three town hall meetings were held and recorded in collaboration with the infectious disease consultant physician to educate HCPs about SARS-CoV-2 and about updated procedures for PPE use, and to avoid reporting to work if respiratory symptoms or fever 38°C occurred. Daily huddles were organized by nursing leadership to address staff questions, and universal screening of staff, including temperature checks, was initiated.

Although it was a challenge, staff were assigned to specific floors to minimize exposure and transmission. Therapy, nutrition, and pharmacy services were also encouraged to assign staff to individual floors. To alleviate burden, an increased staff-to-resident ratio (1:5 to 1:6 residents compared with 1:8 previously) was implemented on the dedicated COVID unit, including a dedicated LPN and CNA. The COVID isolation units were part of the postacute-care units in the facility. All staff who worked in the postacute-care units were limited to those floors and did not rotate to the long-term care floors of the building.

Facility-Focused

Testing using nasopharyngeal swabs was available on March 16, 2020, and syndrome-based testing was initiated. Active monitoring of all residents included documentation of absence or presence of possible symptoms of infection (ie, sore throat, diarrhea, chills, neurologic changes, and loss of appetite). All persons under investigation (PUIs) were tested using a modified CDC definition to include residents with symptoms (defined above) or a roommate of a symptomatic resident. The first SARS-CoV-2–positive resident was identified on March 17, 2020, and testing was expanded to include the affected unit and HCPs who had worked with residents in the 7 days prior to the positive test. In conjunction with infection control, these individuals were called to assess for symptoms and schedule testing through occupational health. The first 5 SARS-CoV-2–positive resident cases (initial 1 symptomatic resident and 4 asymptomatic) were linked to one HCP on one unit (1 of 13 tested staff). The facility was subsequently closed to new admissions for 2 weeks. Following identification of 3 SARS-CoV-2–positive symptomatic residents on two different floors, a facility-wide prevalence screen of all residents was conducted.  The facility-wide screen identified 12 of 41 asymptomatic residents were positive on a new floor and thus testing of all HCPs was conducted on the affected unit (7 of 21 staff tested positive). One of these asymptomatic cases was imported as a new admission from a long-term acute-care hospital. Additional scheduled cleanings of high-touch surface areas and common nursing areas were implemented and the Georgia National Guard provided decontamination of the facility. An additional facility-wide screen revealed 7 additional asymptomatic residents were positive for SARS-CoV-2 on April 30.

Resident-Focused

Any residents identified as PUIs were placed under DICE precautions (droplet-contact precautions with eye coverage) in the isolation unit. Additional measures are outlined in Figure 2. Respiratory panel testing was stopped when the co-infection rate was zero. Positive residents were evaluated by nursing staff at least 3 times daily for evidence of respiratory decompensation.

HCP-Focused

During the initial containment period, education continued with the infection-prevention nurse to reinforce the importance of correct technique for hand hygiene, social distancing, and appropriate use of PPE. Universal masking included the addition of face shields. Facility-wide SARS-CoV-2 screening was conducted on April 10, 2020. 

Facility-Focused

The facility began accepting new admissions on March 30, 2020. Newly admitted residents with no history of SARS-CoV-2 were placed on DICE precautions for 7 days and actively screened per facility protocol. Subsequently, as updated public health guidelines were published, persons newly admitted with no history of SARS-CoV-2 were placed on DICE precautions for 10 days.

Based on initial results from an active screening approach, two units on two floors were established as isolation units with containment doors and hanging shelves on each door for PPE. Facility-wide screenings of residents and staff occurred once and now occur monthly.

Initially, whether or not to transfer residents to the hospital was a collective decision made by the medical team and the infectious disease consultant to contain viral spread. Within a week, however, the capacity for quarantine within the facility increased with the launch of the SARS-CoV-2 isolation units staffed by nurses trained on isolation protocols and specific care needs of patients with SARS-CoV-2. With increased capacity to manage residents in-facility, HCPs shifted to a symptom-based approach to determine need for hospitalization. Additionally, the facility was able to readmit SARS-CoV-2–positive residents and newly admit SARS-CoV-2–recovering patients from the hospital. For residents recovering from SARS-CoV-2, CDC guidance using a symptom-based strategy was implemented to determine the timing of DICE precaution discontinuation.

Resident-Focused

Residents with a positive nasopharyngeal swab test result remained in the isolation wing for a minimum of 14 days from the positive test. Upon positive testing and regardless of symptoms, the resident and family were notified of the results. Each HCP engaged the family and/or resident in a goals-of-care discussion at the time of notification to maintain person-centered care.

A clinical care pathway was developed for all SARS-CoV-2–positive residents (Figure 2). The medical team conducted daily huddles to discuss PUIs and SARS-CoV-2–positive residents. Physicians maintained continuity of care as the resident transitioned to the isolation wing. Acute changes in clinical status, most often in the form of oxygen desaturation, altered mental status, and/or vital sign instability, were considerations for hospitalization in addition to family or resident preference.

HCP-Focused

Multiple activities (eg, gifts of food, cards from children, a motivation wall to share inspirational thoughts, etc) to promote HCP morale were conducted in collaboration with the nursing leadership team. CDC criteria were applied for HCP return to work including a “symptom-based strategy” for those with symptoms and the “time-based strategy” for those without symptoms.⁷

On March 1, 2020, there were 197 residents and 156 HCPs and, as of April 30, 2020, a total of 27 residents and 9 HCPs had tested positive for SARS-CoV-2; in all, 254 residents and 39 HCPs were tested by May 1, 2020. Of the 27 residents, 10 were hospitalized (24.0 admissions/1000 person-days at risk (95% CI, 12.9-44.6) and 2 individuals died (3.7 deaths/1000 person-days at risk (95% CI, 0.9-14.18) in this period. Table 1 demonstrates characteristics of the initial 27 confirmed positive cases. Hospitalized residents were younger and more likely to be male and Black. Symptoms associated with hospitalization included fever, increased need for respiratory support, and altered mental status. Laboratory testing suggests that higher C-reactive protein (CRP) levels may be associated with hospitalization.

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We describe the evolution of processes at one SNF in response to the SARS-CoV-2 outbreak that potentially reduced the spread and severity of the virus among residents and HCPs. Due to the unique vulnerabilities of SNFs to the rapid spread of SARS-CoV-2 and the unprecedented speed at which facilities were forced to adapt, our facility aimed to develop and implement protocols, initially in the absence of existing guidance.

One hypothesis for the finding that hospitalized SARS-CoV-2–positive residents were younger than their nonhospitalized counterparts is that younger residents may be more able to identify and voice symptoms or desire more aggressive measures than older residents. This finding may also be related to male gender and Black race, which were characteristics more common among hospitalized SARS-CoV-2–positive residents. These results mirror other SARS-CoV-2 studies suggesting that Black men have a disproportionate risk of poor outcomes.^3,8-11 Protocols implemented also directly targeted dyspnea, increased oxygen requirements, and elevated CRP levels as indicators for hospitalization based on published data indicating worse prognosis with these markers.^2,9,12 Our findings show a generally low hospitalization admission rate and mortality rate in comparison with facilities in other parts of Georgia and the United States over this same period.^11,13 These findings underscore the importance of early identification and isolation of infected individuals and aggressive clinical monitoring for better outcomes in older adults, particularly in a SNF.²

A strength of our process was the ability to rapidly develop protocols in close collaboration with an infectious disease consultant and the hospital infection preventionist. With an academic health care affiliation, the facility was able to order the SARS-CoV-2 polymerase chain reaction test with 24-hour turnaround, whereas most SNFs have limited laboratory capacity or longer turnaround time. We also rapidly escalated the testing process from syndrome-based to screening-based before national guidelines advocated for such a switch, allowing us to identify asymptomatic residents earlier in the pandemic.

However, our findings are not without limitations. This report follows a single facility with unique strengths, which limits generalizability. The lessons learned from these partnerships, however, may inform other practices. We also report outcomes from a small sample, which limits our ability distinguish the characteristics of hospitalized and nonhospitalized residents. Finally, the rapid evolution of procedures contributed to missing data for certain laboratory measures and a relatively short duration for data capture.

Despite these limitations, the approach described here coupled with our preliminary analyses suggest that early testing and isolation may contribute to prevention of SARS-CoV-2 transmission and mitigate COVID-19 disease in this vulnerable population. We propose that relying on efforts at the facility, resident, and HCP levels during prevention, containment, and mitigation efforts might promote favorable outcomes for SNF residents during the SARS-CoV-2 pandemic. Ultimately, ensuring access to timely, reliable information sources for infection control and management to prevent widespread infection among residents and staff, along with collaboration with the local health system partner, were likely critical factors in mitigating the impact of SARS-CoV-2 in our SNF. 

Authors: Sahebi Saiyed, MD, MPH, CMD¹• Laura C Plantinga, PhD^1,2• Elena Cabb, DO, MPH¹• Monica Gavaller, MD¹ Hyungseok Oh, MD, MBA¹• Alexis A. Bender, PhD¹• Scott K Fridkin, MD^2,3• William C Dube, MPH³• Camille P Vaughan, MD, MS¹

Affiliations: ¹Division of Geriatrics and Gerontology, Department of Medicine, School of Medicine, Emory University, Atlanta, Georgia; ²Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia; ³Division of Infectious Diseases, Department of Medicine, School of Medicine, Emory University, Atlanta, Georgia

Disclosures: The authors report no relevant financial disclosures.

Correspondence:

Camille P. Vaughan, MD, MS
1841 Clifton Rd NE, Rm 533,
Atlanta, GA 30329
Email: camille.vaughan@emory.edu