Nursing homes prepared for pandemics, but COVID-19 reveals gaps

But it might have been worse.

New data suggests that at least in Michigan, nursing homes that responded to a survey were far better prepared for this pandemic than they were for the last one. The study includes responses from 130 nursing homes to a survey performed during the week the state announced its first documented case of COVID-19.

It shows that nearly all had a pandemic plan in place. That's compared with just over half of the 280 nursing homes that answered the same survey in 2007. Nearly all said they now have at least one staff member in charge of pandemic preparedness.

The findings are reported in the Journal of the American Geriatrics Society by a team from the University of Michigan that has studied and worked to improve nursing home infection prevention for years.

Members of the team have several other recent publications with direct or indirect relevance to the COVID-19 pandemic, including putting forth recommendations for nursing homes and other housing facilities for older adults to use in planning how they will respond to pandemics such as COVID-19.

Lona Mody, M.D., M.Sc., a geriatrician at Michigan Medicine, U-M's academic medical center, and the VA Ann Arbor Healthcare System, is senior author of both of the new publications. She's a professor of internal medicine, the associate director for clinical and translational research at the U-M Geriatrics Center, and director of the Infection Prevention in Aging research group.

"Our nursing homes house some of the most vulnerable in our society," says Mody. "This virus unfortunately is very contagious, the disease it causes has incredibly poor outcomes in older adults with comorbidities, and nursing homes are communal settings with shared spaces and resource limitations. This creates a perfect storm of sorts. Being novel, we learn as go and have to learn really quickly."

Mody heads the PRIISM, or Preventing Resistance and Infection by Integrating Systems in Michigan, project, which partners with skilled nursing facilities, hospitals and public health agencies across the state to perform research and create and test education and training materials for nursing home staff. The program's website has many free materials for use by nursing homes everywhere.

Pandemic planning

The new survey data show Michigan's nursing homes have done a lot to prepare for pandemics since the last time the U-M team performed the survey. That previous survey was taken before the H1N1 influenza pandemic of 2009, but after the H5N1 "bird flu" pandemic of 2005 raised national awareness of the importance of pandemic preparedness. Mody and colleagues published pandemic preparedness guidance for nursing homes at that time.

In mid-March of this year, 85% of nursing homes said they had stockpiled supplies before COVID-19 hit, compared with 57% after the H5N1 pandemic. Most of those that had stockpiled supplies had focused on surgical masks, gloves and hand sanitizer. Less than half had stockpiled N95 respirator masks, which are recommended by national and global health authorities for health care workers performing certain types of care on a COVID-19 patient.

Still, 42% of the nursing homes that answered a question about COVID-19-specific concerns said they were worried about running short of personal protective gear.

"Although the size and severity of COVID-19 outbreaks in some nursing homes have taken everyone by surprise, just as so much about this pandemic has, in general nursing homes knew exactly what their challenges were going to be in a pandemic -- PPE shortages, staff shortages and worries that they did not have the capacity to care for COVID patients after their hospital stay."

Nearly all now said they had trained staff on how their facility would respond in a pandemic, up from 42% in 2007. But only one-third had conducted a pandemic drill. And Mody notes that nursing homes have a much higher rate of staff turnover than hospitals -- meaning that training on infection prevention and pandemic response has to be offered whenever a new person joins the organization.

Michigan's nursing homes appear to have gotten better connected to the broader health care system in the past decade, with significantly more saying they now have communication lines established with local hospitals and public health departments.

Many also said they were drawing COVID-19 guidance not just from the Centers for Disease Control and Prevention, but also from state and local health departments. Half also received guidance from their home's corporate parent.

And while half of the nursing homes surveyed this year said they expected significant staff shortages due to COVID-19, most of them said they had a plan to deal with that. Most planned to ask existing clinical staff to work more hours, and to redeploy non-clinical staff. Two-thirds expected they'd need to require staff to work overtime.

The survey also explored the potential for nursing homes to relieve the burden on hospitals. In all, 82% said they'd be willing to take non-pandemic patients from overburdened hospitals now, compared with 53% in 2007. But the percent that said they'd be able to accept patients with the pandemic disease stayed the same, at one-third of responding homes.

Additional guidance

Mody and her colleagues John P. Mills, M.D. and Keith Kaye, M.D. from the U-M Division of Infectious Diseases recently published some recommendations regarding COVID-19 and older adults in the journal JCI Insight. Mody and Kaye are members of the U-M Institute for Healthcare Policy and Innovation.

They note that it's not just nursing homes with long-term residents that need to be ready to care for vulnerable older adults during pandemics.

In fact, the trend over the past decade to use nursing homes more often for short-term stays by patients who have been discharged from a hospital, and to create state and local programs that allow older adults to 'age in place' instead of moving to nursing homes for the long-term, have led to potential gaps for pandemic responses to help older adults.

They call for policymakers to address those gaps, by creating pandemic-specific plans for community-dwelling older adults, especially those with health needs.

As for nursing homes, they recommend that in areas where COVID-19 is spreading widely in the community, facilities should take these steps, and others:

• place patients with known or suspected disease in the same area of the facility, away from others
• perform rapid COVID-19 tests on all patients, both short-stay and long-stay
• screen healthcare workers and other staff for symptoms including checking temperatures
• limit visitors and group activities
• require everyone wear a surgical mask
• require additional protective gear for clinical staff

The limits on group activities tie in to other research by Mody and her colleagues, published in JAGS in December.

That study sampled surfaces, and the hands of patients and staff, in the common areas and rehabilitation gyms with in nursing homes, and looked for drug-resistant bacteria that can cause dangerous infections. Though the team didn't look for the presence of viruses in these areas, they did find that half of the samples taken in rehab gyms contained at least one type of bacteria that was resistant to several types of antibiotics.

In addition to stockpiling PPE and cleaning supplies, the team recommends that nursing homes should use "burn calculators" to predict how quickly they'll use those supplies based on their patient population.

If nursing homes and other residential facilities for older adults haven't already done so, they should establish lines of communication with local health departments in advance of any outbreak of COVID-19 in their facility. They should also focus on staff retention, including providing for generous sick leave policies so that staff can stay home when ill, and hazard pay for those who can come to work.

And, the team says, nursing homes should make sure they have an infection prevention plan in place for staff when a patient has died of COVID-19.

Another gap in preparedness that the COVID-19 pandemic is revealing, Mody says, is a gap in communication with patients and their families. Keeping families informed, and enabling them to connect virtually with their loved ones when they can't visit in person, is crucial, she says.