Since the first report of the coronavirus impacting a nursing home in Kirkland, Wa., geriatricians around the country have been concerned. For good reason, as the mortality rate at Kirkland and other subsequent outbreaks has often exceeded 30%.
Fortunately, the experts in geriatrics and long term care medicine working on the front lines of this crisis have been doing what we do best. We make the complex simple. Over the course of the last six weeks, a few things have become clear.
First. We don’t know what we don’t know. There are stories of nursing homes and assisted living facility owners and executives resisting efforts to test. What will we do if we find out that staff or residents are positive? The incomprehensible nature of this type of thinking should be clear to any rational human being. Readily available testing is the key to identifying outbreaks before they get out of hand. Does it make a difference? We believe it does.
Second. Sufficient personal protective equipment (PPE) is critical to combating this disease. Surgical masks might help asymptomatic people (we still don’t know for sure), but N95 masks certainly are useful in stemming the spread of the virus in staff and patients who are infectious. Without sufficient PPE, the fight will be lost.
Finally, without stellar infection control, the coronavirus can become overwhelming. Strict attention to hand hygiene, avoiding coming to work if there are any signs or symptoms of infection and proper use of PPE is of the utmost importance.
On March 27, two residents at Brier Oak skilled nursing facility on Sunset Boulevard had coughs and fever. COVID-19 testing was performed on four residents including two that were in the same room as one of the symptomatic residents. On April 1, all four residents tested positive for COVID-19.
As soon as the facility determined it had COVID-19 patients, they immediately went to full PPE for all staff and initiated isolation protocols. They also immediately began testing every staff member. While the County of Los Angeles continued to vacillate on providing testing to every nursing home, and while many nursing homes did not initiate complete testing of all staff, Brier Oak tested everyone. They subsequently tested all of the residents. To date, 70 staff and 77 residents have tested positive. Three residents have died, and all three were either nearing the end of life or on hospice subsequent to COVID-19. Eleven residents have been hospitalized.
On April 1, the Los Angeles Jewish Home (LAJH) began testing its asymptomatic staff that had possible contact with its first two COVID-19 residents. We were given 500 kits by the city of Los Angeles. The mayor’s office asked us to share kits with other organizations. Two hundred and fifty of those kits were given to Brier Oak. To date, together with Brier Oak, we have conducted nearly 500 tests. The LAJH has contacted dozens of other organizations that would like to join us in this program and test their asymptomatic staff. We have offered to facilitate this program for the county, but continue to wait for further test kits to implement our plan.
Without readily available testing, Brier Oak would not have known that most of its staff and residents were positive. They would have been on a path towards replicating the Kirkland experience, and other facilities that have been in the news. In fact, they have received kudos from the Los Angeles County Department of Public Health (LACDPH) for their efforts to contain and mitigate the impact of COVID-19.
Every nursing home should have all staff tested immediately. They must also test all symptomatic residents and any of their roommates. Not to make this testing readily available puts the lives of more residents and staff at risk.
What is frustrating to us is that the LACDPH appears to have had the means and wherewithal to provide testing for every nursing home in the county for over two weeks. Every nursing home should have all staff tested immediately. They must also test all symptomatic residents and any of their roommates. Not to make this testing readily available puts the lives of more residents and staff at risk. We have been urging the LACDPH to do this for over two weeks, but have not received a response.
Symptomatic staff knows that they should stay home. Asymptomatic staff comes to work and becomes the vector of infection to the most vulnerable members of our community. The mission of the LACDPH is “to protect health, prevent disease and promote health and well-being across the life span through targeted population-based interventions and service operations that improve health and quality of life, and reduce health disparities.” We look forward to Dr. Ferrer, director of LACDPH, immediately announcing a specific program to assure that testing is done in every nursing home in the county. This is an opportunity for the LACDPH to fulfill its mission when it comes to housed older adults.
Dr. Noah Marco is the chief medical officer for the Los Angeles Jewish Home. Dr. Michael Wasserman is president of the California Association of Long Term Care Medicine.