We are in August and it’s time to plan “back to school” for parents and students. It seems the summer flew by although it had its own challenges of limiting vacations, avoiding COVID-19 hotspots and almost cutting out social interactions unless they are on zoom!  Schools, teachers and parents have been hopeful to return to in person teaching. They have been working on setting up hand wash stations, small group classes, outdoor education, and other methods to socially distance while being on campus. It’s not even a possibility for some jurisdictions and a challenge for most public schools. With California’s COVID 19 database potentially being inaccurate – now schools have lost hope for at least another month before a waiver can even be considered for on-campus education. There are other states where schools are opening in person.

Coronaviruses are a class of enveloped viruses with a single-stranded RNA genome that infects animals and humans. There are many types of coronaviruses that cause infections exemplified by the common cold, severe acute respiratory syndrome coronavirus (SARS), Middle East respiratory syndrome-related coronavirus (MERS), and the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the pathogen associated with COVID-19. ⁽¹⁾ The clinical development of remdesivir, with a confirmed capability to inhibit SARS-CoV-2 replication, supports the evaluation for COVID-19 treatment ⁽¹⁾.

My 10 grandchildren are all in “virtual” school for the coming year, but I do remember an advance in responsible parenting, which was applied to the care of the grandkids 10 and under.  It’s a technology that has now become standard for most parents, called “baby cams.”  This has allowed “never out-of-sight or sound” parenting on a 24/7 basis as long as this device is being used.  

Our community is experiencing a surge of COVID in our Senior Living Facilities with the vast majority of cases traced to asymptomatic HCWs, particularly those working in multiple facilities.  This problem is further compounded by delays in reporting the results of mandated HCW COVID testing as long as 10 days.  Our contact tracing suggests that much of the initial infection of HCWs is occurring in the home setting where there is intergenerational living and multiple relatives living in close proximity.  We have traditional sterile hygiene measures expected of HCWs going from one facility to another, but know that transmission risk during intimate care may occur through medical masks, which may be only 45-70% effective in containing the virus, versus 95+% with certified N95 masks that have been fit tested.  

What do the above scenarios have in common?  Under the new abuse regulations, each one must be reported and investigated as potential abuse, neglect, misappropriation of resident property or mistreatment.   And if YOU hear about them, then YOU are a mandated reporter.

The Covid-19 pandemic has radically changed how providers deliver health care.  Realizing that in-office and in-facility clinical care risks transmission of SARS-CoV2, CMS has removed all restrictions on the adoption of Telemedicine.  Multiple organizations including CALTCM, AMDA, and AGS (American Geriatric Society) have provided helpful webinars and resources that have helped providers implement Telemedicine in their work flow.  Understandably, seniors have had difficulty embracing this technology.  Medical offices have enhanced their MA’s (Medical Assistant’s) training so they can contact patients prior to the telemedicine visit, to help them with technical issues and to gather pertinent information for that appointment.  

The NEJM Online June 3 edition reported a study from the University of Washington and United Health Group comparing the efficacy of COVID-19 testing in 530 subjects by nasopharyngeal swab vs. patient-collected anterior nasal swab, or mid-turbinate swab, or tongue swab.  This well-done study found similar sensitivity and specificity to that of our gold standard for RT-PCR testing, the  uncomfortable and universally detested nasopharyngeal swab.  An audio interview with Editor-in-Chief, Dr. Eric Rubin, and Deputy Editor, Dr. Lindsey Baden, endorsed these alternative collection sites.  Since that study, the public health departments of San Diego and Contra Costa Counties have approved the anterior nasal site as a collection option for SNF patients and staff.  PPE isn’t required for patient-collected swabs, and adherence to our mandated and recommended testing protocols will likely be better.  

As President of CALTCM, I want to thank our Board of Directors and our members, many of whom have “stepped up” in the face of the COVID-19 pandemic.  I am so proud of our organization, the efforts we’ve made, and our accomplishments.  Our membership is composed of many interdisciplinary experts in geriatrics and long-term care medicine.  We have been making a difference during this crisis.  I want to share some of what’s happened over the past few months.

As of mid-June 2020, all skilled nursing facilities in California have submitted COVID-19 mitigation plans to the California Department of Public Health, pursuant to All-Facilities Letter (AFL) 20-52—and it is thought that a majority of skilled nursing facility residents and staff have been tested at least once for COVID-19.  CDPH guidelines are now calling for testing of all staff at least once monthly.  Unfortunately, the more widespread availability of testing was not present a month or two ago, and test results were taking a week or more to get back—placing many nursing home residents and staff at risk and almost certainly causing preventable deaths.  This pandemic has been a true scourge for nursing home residents, with over one-third of deaths nationwide in long-term care facilities.

One of the frustrating aspects of mitigating the impact of the COVID-19 pandemic on our post-acute and long-term care (PALTC) facilities has been the difficulty that each entity has had procuring adequate PPE to protect their health care workers (HCWs) and residents.  As I look at my community, the acute care hospitals have had sufficient PPE to meet their needs for about the last 7 weeks, but not enough PPE to share with our PALTC providers.  Our local health department (LHD) has created a real-time inventory of each facility’s PPE and has been working hard to procure sufficient PPE to direct to a facility when there is an outbreak.  

CALTCM has been advocating for a strategy involving State-led PPE procurement as part of our Quadruple Aim for combating the COVID-19 pandemic. 

The spread of COVID-19 in nursing homes, residential care and assisted living has gained incredible attention in the past few weeks for very good reasons.  Residents living in nursing homes or residential care use common dining and activity spaces and, in many cases, also share sleeping rooms.  Staff providing care in these organizations often work in multiple different facilities and overall staffing is significantly lower than available in hospitals, which increases the risk for transmission of COVID-19.  Staff in nursing homes and assisted living have a much more personal relationship with the residents, because they care for them for months or years versus the hours or days that patients are cared for in hospitals.

The decision to initiate CPR has become more difficult.  We know that CPR substantially increases the risk of aerosolized SARS-CoV-2 and its transmission to health care workers (HCW) in the area of CPR.  For this reason, AMDA and other societies have given guidance on ways to reduce the risk, but these added risk reducing measures may delay initiation of CPR.  

SNFs are now required to report patients under investigation for COVID-19 (PUIs) and actual COVID 19 cases among their residents and HCWs (Health Care Workers).  The report is updated every working day (https://www.cdph.ca.gov/Programs/CID/DCDC/Pages/COVID-19/SNFsCOVID_19.aspx ) and indicates that over 20% of our SNFs have one or more cases associated with their facility.  

The World Health Organization has recognized what experts in geriatrics and long term care medicine have known for over two months.  Unfettered COVID-19 infections are devastating to nursing homes and assisted living facilities.  Reports are finally coming out that more than half of the reported deaths have occurred in senior congregate living settings.  It is quite likely that the number of deaths is still far underreported.  Only when the epidemiologists review all of the deaths across the U.S. and the world during this pandemic will we have the true answer.  The sad truth is that the experts in our field already know the answer.  We’re just waiting for corroboration.

The Wall Street Journal reported on April 11 that over 2100 skilled nursing and assisted living facilities in 37 states had been infected with SARS-COV2 with over 2,000 deaths occurring. In Sonoma County, we have developed 2 workgroups for coordinating, disseminating, and implementing best possible practice ideas.  One workgroup consists of Leadership from Public Health (PHD), skilled nursing facilities (SNFs), Hospitals, and Foundations. The other has leaders from the assisted living (AL), residential care facilities for the elderly (RCFE), and Senior Living Communities.  In the latter group, we were relieved to learn that our county just developed a contract with Sonoma State University to house up to 580 seniors with stable COVID disease so they can be quarantined outside their home facility, reducing the risk of COVID transmission within this high risk population. 

On February 29th, the first case of COVID-19 was announced, occurring in Washington state in the Kirkland nursing home.  Geriatricians around the country immediately knew what this meant. CALTCM went into action and had our first webinar on March 9.  It’s six weeks later and we’d like to give everyone direction. For anyone who has not watched our webinars, we will redirect you to the most important, in the order that they should be watched.  Keep in mind, if you’re already far along the curve, some of this might seem remedial. We can assure you, it’s not.   

Note: This article was prepared by Mr. Horowitz and Dr. Ferrini with special thanks to Dr. Robert Gibson PhD JD, Psychologist, for his input. 

Our country now has the distinction of having the most COVID cases in the world.  Our response as a nation is a stress test that has exposed our lack of a coordinated system of health care in this country.  In my community, there remains a shortage of naso-pharyngeal swabs, a public expectation of easy access to testing (County Public Health Department can do 100-120 tests per day), and many facilities still don’t have real-time access to adequate PPE.  Because of the lack of PPE and nasopharyngeal swabs, testing in some facilities for influenza/RSV/Other viruses is not being done. There appears to be an over-reliance on quarantine of residents with respiratory illness as well as shelter-in-place strategy to keep their facilities COVID-naïve.