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Building Vaccine Confidence

When COVID-19 exploded last March, my community went to work attempting to keep COVID out of our facilities.  We developed county-wide virtual learning collaboratives for Assisted Living (AL) communities and for SNFs, which met on a weekly basis.  By the end of June, we had done well with no outbreaks and only 4 deaths in the county.  Unfortunately, last summer’s surge in COVID prevalence shattered the myth that we had done enough to contain it.  Like the rest of our state, we pivoted to follow guidance focused more on infection control and early recognition of outbreaks.  By the end of October, we seemed to be back in the driver’s seat with much better facility COVID metrics.  However, with the winter surge, we are stretched thin on staff, resources, and again wondering when the bad news will end.  In my county, we have now have had 196 deaths, and 70% of them have occurred in senior congregate living facilities.  

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Using Monoclonal Antibodies in LTC

The FDA has given EUA (Emergency Use Authorization) for bamlanivimab (Lilly) or the “cocktail” of casirivimab and imdevimab IV infusions for mild to moderate COVID-19 patients.  These monoclonal antibodies block the binding of the spike protein to the ACE2 receptor on the human cell, which blocks viral attachment.  If given early (within 10 days of symptom onset), both medicines have been shown in high-risk adults to reduce the viral load and risk of progression to severe COVID-19, and reduce the necessity for ED visits and hospitalization.  However, they didn’t help those already hospitalized and outcomes were worse in those receiving high-flow oxygen or mechanical ventilation.  Experts suspect that infusions given within the first 3 days of symptoms will be more effective than when given later.  This is similar to what we have experienced with the use of oseltamivir (Tamiflu) in Influenza or antivirals with shingles.  

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COVID-19 Vaccines are Arriving!

Since the SARS CoV-2 virus arrived in the USA last winter, our lives have been disrupted in many ways.  We are currently in a Winter Surge that has locked down most of the state.  The latest statistics on COVID activity show a doubling or tripling of cases in most of California in the month of December, which greatly increases the risk of outbreaks in our post-acute and long-term care settings.  As of 12/10, the USA had 15.6 million confirmed cases and 294,000 deaths.  Though only 6% of the cases have been in post-acute and long-term care (PALTC), including skilled nursing facilities (SNFs) and assisted living communities (AL), our residents have had a hugely disproportionate 34% of the deaths.  As of Friday, December 11, over 100,000 persons with COVID in the USA were hospitalized and 21,000 were in ICU beds. In California, we had 33.500 new cases reported over the preceding day.  

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Local Interventions to Address Workforce Shortage

Prior to the pandemic, most of the SNFs in Sonoma County had applied for waivers, because they weren’t able to staff CNAs at the required 2.4 FTE state standard.  I heard one administrator comment that the website “Indeed.com” had become a main source for attracting CNAs from other SNFs.  In our area, we do have a training program for CNAs through partnerships of facilities with the Red Cross and the local community college, but the number of CNAs attracted to this track has been small.  Since the COVID pandemic, our CNA shortage has been aggravated by concern for personal safety, complicated sick leave policies, inconsistent work hours, and the realization that those working in multiple facilities had a much higher risk of transmitting COVID.  

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To Mask or Not to Mask: A Matter of Opinion

On October 19, 2020, an article in the Wall Street Journal was written observing that some governors in States with surges of COVID are still insisting that masking in public settings should be a personal decision.  This conflicts with the public health guidance of CDC, CDPH, and our Governor, but is still an issue in the public domain in our state where it’s common to observe people in public without a face mask, or wearing the mask under the nose or mouth.  This may not only increase the risk of our health care providers (HCP) acquiring COVID, but data are emerging to suggest that those who acquire COVID while not wearing a mask have a greater dose exposure to COVID, and are likely to become sicker.  

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Call for Non-Inferiority Test of Abbott Labs’ POC (Point of Care) Ag BinaxNOW

As a retired internist and gerontologist, I have closely followed our government’s efforts to help us identify HCP (Health Care Personnel) with SARS-CoV-2 with the goal of reducing the risk of its transmission to residents in our homes.   Early on, we had significant difficulties obtaining the materials for molecular (RT-PCR) testing and later had difficulties obtaining the results within the desired 48-hour TAT (Turn Around Time).  However, in the past several months many facilities in our state have been able to obtain at least this TAT on their mandatory weekly screening of their HCP.

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Advance Care Planning & Palliative Care Important During Pandemic: CDPH

On September 22, 2020, the California Department of Public Health posted this all-facilities letter (AFL 20-73), available at https://www.cdph.ca.gov/Programs/CHCQ/LCP/Pages/AFL-20-78.aspx.  This letter provides guidance to nursing homes about the importance of person-centered advance care planning, including ensuring that current treatment preferences in light of COVID-19 are reflected in up-to-date treatment orders.  

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Are California Nursing Homes “Death Traps”?

In Sonoma County since the surge of COVID-19 cases in late June, our senior congregate living homes have consistently had about 82% of the fatalities in our county.  This fact is consistently reported in our media on a weekly basis.  Early on in this outbreak, the term “die offs” was commonly used in facilities in recognition of how quickly some of our residents died after onset of COVID.  As in many other areas in our country, the initial bad outcomes were associated with the lack of PPE and timely testing, as well as staff shortages, and the need to learn and practice optimal IPC (Infection Prevention and Control).   However, with the in-facility assistance of specialists from CDPH HAI (Health Associated Infection) program, HSAG QIO (Health Services Advisory Group), and our public health department, most of our facilities have extinguished their initial outbreaks and have minimized the impact of new cases.  

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Influenza Immunization During the COVID Pandemic

This year, we must improve our vaccination program and IPC (Infection Prevention and Control) for influenza prevention.  In recognition of this necessity, CALTCM provided a free webinar on this subject on September 21, the slide handout and recording are available on CALTCM's COVID-19 Webinar Series webpage.  In that webinar, Dr. Lily Horng, CDPH Public Health Medical Officer, noted that the CDC recommends that persons with COVID should not receive the influenza vaccination until they are out of quarantine (10 days from diagnosis and 24 hrs afebrile), so as to reduce the transmission risk to HCP and other residents.  This statement can be found in the August 21 CDC Influenza Vaccination Guidance for Professionals.  If available, our seniors should receive the enhanced vaccines, which have been shown to be more effective and durable.  Immunization should start now so that our seniors and HCP are immunized prior to onset of influenza.  You should know that San Francisco has already had cases of influenza A.  The above CDC web site has a link to current influenza activity.  My county is considering an order for mandatory vaccination of all HCP unless there is an identified contraindication.  We now know that the masking rules at work do not prevent employees who have refused a flu shot from acquiring COVID outside of the facility and then spreading it within our facilities.  On a recent AMDA podcast, Dr. Barbara Resnick shared great ways to encourage your residents, families and HCP to receive flu shots.  She and AMDA were parts of work groups which created four helpful one-page fact sheets that will enhance your flu immunization program.  Please go to this free AMDA ON-THE-GO podcast where you can hear this superb educator and also download these helpful fact sheets.  

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Important CDPH AFL of Sept 12 that Updates COVID Testing/Response Guidelines

The 9 page (AFL-20-53 ) update should be studied by management in the SNF and hospital setting since it sets expectations for testing during care transitions, dialysis care, and outbreaks.  In addition, it creates a new expectation that all HCP will be tested weekly, even when in surveillance mode.  The guidance allows for routine use of Antigen testing rather than exclusive use of RT-PCR testing.  This should allow facilities to have immediate test results.  The tracking and reporting requirements for testing results in symptomatic and asymptomatic persons are also addressed.  

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#CALTCMProud: CALTCM President Report

On March 9, CALTCM produced our first webinar on COVID-19.  On August 31st we produced our 21stwebinar.  It truly has taken a village of volunteers.  Some of the webinars attracted a thousand-plus attendees.  Over 200 people participated in our most recent webinar, which is a remarkable achievement in view of the abundance of information that is available online.

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Two High School Sisters Put Feet to Compassion

Please click on the link to the ABC news video and report on the letter writing project that these sisters operationalized not only for their loved one, but also for those who need loving through pandemic spawned isolation.  Then click on their web site and take action.

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Hope for the COVID Pandemic From the SPRINT Study

July has been a discouraging time for the SNF community in Sonoma County.  Like the rest of California, we have experienced a surge of COVID-19 cases.  We now have had COVID resident cases in 10 or our 20 SNFs and have experienced a “die-off” with 30 deaths in July.  Our county experienced a 5-fold increase in deaths in July, and 67% of those deaths were in the SNF setting.  16% were in RCFE settings, including assisted living communities and dedicated dementia or “memory care” facilities, for a total of 83% of the deaths occurring in senior congregate living settings.

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Falling Back Into School

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.

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Is it Time for “Granny Cams” for your COVID Isolation Rooms?

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.  

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Review of the Literature of Remdesivir Use for COVID-19

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).

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The Problem of the Asymptomatic Health Care Worker (HCW)

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.  

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Have You Experienced the Benefits of a Robust Telemedicine Program?

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.  

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Nasal Swabs Are Approved for COVID-19 Testing

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.  

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CALTCM COVID Response

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.

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