Tamara Konetzka, a health economics and aging services expert at the University of Chicago, had reason to hope that a new surge of coronavirus would be kinder to nursing home residents than the first was.
After all, testing, a key tool for curtailing transmission of the highly contagious disease, is much more available now. And long-term care providers know more about how to prevent spread, from what kind of protective gear staff should wear to how to group residents who do and don’t have the disease.
But when Konetzka crunched the numbers recently for six Midwestern and Western states with especially high levels of coronavirus, she saw a disturbing trend: As cases in the community rose, there was a corresponding surge of cases and deaths in nursing homes. From Sept. 1 through Oct. 25, weekly staff cases more than tripled to 930 and weekly resident cases more than quadrupled to 716. Weekly resident deaths for those states hit new highs.
Ten months into the pandemic, the virus was still seeping into the long-term care facilities where our most vulnerable citizens live, despite intense efforts to keep it out.
“We were surprised at how much things hadn’t changed,” said Konetza, who got similar results when she analyzed data from 20 states for the Associated Press over a longer period.
She and fellow researcher Rebecca Gorges concluded that either best practices “are not being fully implemented or are inadequate to control the virus.”
Nursing home residents are still at risk, other experts say, for a complex set of reasons, including regional politics that may devalue mask-wearing, uneven access to test kits and protective gear, testing limitations, staffing shortages and turnover, the close nature of nursing home life, facility design problems, and human error.
Previous research has found that the level of coronavirus spread in a community is the best predictor of outbreaks in long-term care facilities. Staff members, who may become infected at home, are the most common source of outbreaks. Large facilities, which have larger staffs, tend to have more outbreaks. Those in minority communities, which have been disproportionately affected by the virus, are also at higher risk.
» Here are Philly’s current COVID-19 guidelines: inquirer.com/phillyguidelines
“We need to expect that, if there’s community spread, there will be nursing home outbreaks, and that doesn’t necessarily represent a failure of practice,” said Nina O’Connor, chief of Penn Medicine’s palliative care program. She heads a Regional Response Health Cooperative Program (RRHCP) in the Philadelphia area, an unusual state initiative that pairs academic medical centers with area nursing homes for help with infection control.
“This year we just gotta cool it,” said Morgan Katz, an infectious diseases specialist at Johns Hopkins University who helps Maryland nursing homes fight the virus. “The virus is just absolutely out of control right now.”
What happens in nursing homes is important because the frail, chronically ill people who live in them are at high risk for serious illness and death if infected. While nursing homes house just 1% of Americans, they have accounted for 40% of deaths nationally, according to the COVID Tracking Project. Sixty-five percent of COVID-19 deaths in Pennsylvania and 48% in New Jersey have been tied to long-term care facilities.
Nationally, coronavirus cases are at an all-time high and hospitalizations and deaths are rising.
The American Health Care Association, which represents long-term care providers, last week released national data showing that weekly nursing home cases increased by 73%, from 5,939 to 10,279 between the weeks of Sept. 13 and Nov. 1. Weekly deaths rose from 1,053 to 1,431 — a 36% increase — during that time period. That is well short of the peak in weekly deaths of 2,847 the week of May 31.
In Pennsylvania, average daily cases and deaths in long-term care are still short of spring peaks, but cases are up from around 40 per day during the summer to about 300 this month. Daily deaths have hovered between seven and 14 since July. New Jersey does not report daily statewide long-term care cases or deaths over time and has not yet responded to an Inquirer request that it do so. However, officials have said that outbreaks in nursing homes are increasing.
Death is a lagging indicator, so fatalities may rise more slowly than cases. Wider testing is now identifying more mild or symptomless cases than in the spring.
Experts say one encouraging sign is that survival rates seem better in nursing homes now. Janet Tomcavage, executive vice president and chief nursing executive at Geisinger, heads an RRHCP in north-central Pennsylvania. She said nursing home death rates were 30% to 40% in the spring surge and are now more like 10% to 15%. Wider testing could be a factor, but experts say testing has allowed earlier identification of infected residents. They are now more closely monitored for breathing problems and dehydration. David Nace, clinical chief of geriatric medicine at the University of Pittsburgh and head of the western RRHCP, suspects that widespread use of masks means residents are getting smaller initial doses of the virus. Theoretically, that could lead to milder illness.
Outbreaks have tended to be smaller in recent weeks than they were when the virus first invaded the state, although there have still been facilities with widespread infection, especially in rural areas. While the pandemic once centered on the Philadelphia and Pittsburgh regions, much of Pennsylvania now has high levels of infection.
An Inquirer analysis of federal data for four weeks ending Nov. 1 found only five facilities in this region with cases in 15 or more residents: Shady Lane Nursing Home in Clarksboro, 31; CareOne at Evesham in Marlton, 29; Pennypack Nursing and Rehabilitation Center in Philadelphia, 25; Riverfront Rehabilitation and Healthcare Center in Pennsauken, 21; and Fair Acres Geriatric Center in Lima, 15.
Of those five, only Shabsi Ganswieg, administrator of Riverfront, responded in detail to Inquirer questions. In the first wave, he said, the center had 73 cases. Thirteen residents died. The recent wave began Oct. 7. Thirty residents tested positive and one died. The most recent round of tests found no new cases. Ganswieg said some newly admitted residents tested positive for the virus. But testing and protective equipment, he said, slowed the spread this time, and patients have done better.
Konetzka was dismayed to see that, in the six states she studied, nursing homes were still reporting supply and staff shortages. Most had tested residents for the virus in the previous week, but 12% had not tested staff, a number she found “alarming.”
RRHCP leaders said their program makes sure Pennsylvania nursing homes have adequate supplies and staff.
This raises the question: How is the virus still getting to residents?
The answer is that the best protection is not perfect. Katz and Ashley Ritter, an expert on nursing home care at Penn Nursing, pointed out that nursing homes are an especially challenging environment. Some residents, especially those with dementia, can’t or won’t wear masks. Staffers may spend an hour or more with a resident in close quarters bathing, feeding, and brushing teeth. Distancing is impossible. Many nursing homes lack negative-pressure rooms and might not have great ventilation.
“It is possible to have breaches in PPE [personal protective equipment], even more than you would see in a hospital,” Katz said.
Tomcavage takes a harder line. “I think in the hospital we have demonstrated that we cannot infect other patients,” she said. “I think that, with the right equipment, with the right processes followed 100% of the time, we can stop the spread of COVID.”
Still, everyone agrees that people are tired, and they make mistakes. Workers let down their guard in break rooms. Maybe they don’t notice when the mask slides off their nose. Or they’re in such a hurry that they take their gown or gloves off wrong.
Joshua Uy, a Penn Medicine geriatrician and medical director of Renaissance Healthcare and Rehabilitation Center in West Philadelphia, said having the knowledge and supplies doesn’t necessarily equate with being able to execute proper infection control. “Just because you have the ingredients doesn’t mean you can bake the cake,” he said.
And then there’s the inescapable matter of politics. Pitt’s Nace said he is working with a half dozen nursing homes in his RRHCP role that have owners or administrators who question the value of masks for containing coronavirus.
“This is a frustrating time for us, because we see cases rising,” he said. “The infection control measures do work. Unfortunately, what we have seen is that many people are not masking well. It’s directly because the current occupant of the White House … has made this a political issue.” Some of these facilities have not yet had outbreaks, he said, because “they’ve been lucky.”
While nursing homes have a long list of shortcomings that should eventually be addressed, several experts said now is the time to help them get through this. They see blame as counterproductive. For now, Konetzka said, nursing homes need financial assistance, help with supplies and surge teams.
“We need to continue to treat this as a crisis as long as the pandemic lasts,” she said. We should think of nursing homes more like we think of hospitals, “part of the health system that is really overwhelmed by this crisis.”