Hope for the COVID Pandemic From the SPRINT Study

by: Timothy L. Gieseke, MD, CMD
Category: The CALTCM WAVE 2020
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Aug
17

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.

Even though we had time to improve our IPC (Infection Prevention and Control) practices, our ideas of adequate practices were based on our prior ability to mitigate the effects of multi-drug-resistant organisms (MDROs), norovirus, C. difficile, and influenza/RSV infections.  This SARS Co-V-2 virus has proven that only consistent IPC practices will “tame this lion.”  On our countywide SNF work group call last week, one of our SNF Infection Preventionists, Jodi Arnheiter, shared that a team approach was essential and that a strategy of teaching and subsequent verifying was essential.  She was very encouraged that a CNA recently confronted a visiting nurse who was exiting a room without doffing her PPE.  This is an example of a well-trained and confident CNA.   Jodi has expanded her education program to include helping her staff set up safe activities outside of the work setting to reduce their risk of COVID exposures.  Her facility remains COVID-free for their residents.

For facilities in our community that have had outbreaks, our local public health department has requested in-house technical assistance from our CDPH HAI (Healthcare Associated Infection) Program and our state’s federal QIO (Quality Improvement Organization), HSAG (Health Services Advisory Group), which is now providing technical assistance for our 4 facilities with the most resident COVID cases.  

We know from the experiences in New York State SNFs, San Francisco’s Laguna Honda distinct-part SNF, and countries such as New Zealand (no community spread of COVID for 100 days), China, South Korea, Hong Kong, Singapore, and Germany, to name a few locations, that good public health measures work.  These include universal masking, social distancing, good droplet hygiene measures, prompt testing of exposed persons with short test turnaround times, and contact tracing. 

However, our country has taken a fragmented approach to implementing these public health measures, which has been a disaster.  This has resulted in an unacceptably high prevalence of community COVID-19, with complicating asymptomatic COVID in our HCP (Health Care Personnel), and then COVID entering our facilities creating widespread and tragic “die-offs”.  

We should have learned from the experience of the SPRINT (Systolic BP Intervention Trial) Study.  This was a trial initiated in 2010 to determine if it was safe and beneficial to lower systolic BP into the 120-130 range for seniors being treated for hypertension with medication.  The study was unique in that it had a large number of subjects and was conducted in the real-world outpatient setting.  For the first time in this setting, all BPs were taken correctly so that clinicians could adjust meds to treat to goal with confidence that the BPs were accurate.  

Most of our readers have probably never had their BP taken correctly.  In brief, not only do you need to have the correct-sized cuff placed in the correct position in the arm with the higher BP, but you need to be in a quiet room for 5 minutes sitting in an upright chair with feet flat on the floor and be in a stimuli-free environment with no talking, device use, reading, etc.  The BP measurement is repeated 1 minute later and the average is recorded as your BP.  This has been shown to be highly reliable and generally produces a systolic BP about 10 mm lower than that recorded in a traditional office setting. 

You might say, so what’s the big deal?  The study was stopped before completion in 2015 because of findings of significantly less strokes and no significant increase in the traditional feared complications of falls, syncope, or injuries.  Subsequent studies have shown reduced CKD and vascular dementia.

It’s been 5 years since these results became available, but I have not yet seen medical care in my community allow the time it takes for BPs to be measured correctly.  In 2017, the US Preventive Services Task Force recommended that electronic office BP measurements be viewed as screening only, and that hypertension diagnosis and follow-up occur by electronic ambulatory devices or properly taught home electronic BP recordings.  Again, if you or your loved ones have hypertension, are you receiving this optimal diagnostic monitoring?

Similarly, the SARS Co-V-2 virus can be controlled by good adherence to CDC/CDPH/Local public health guidance. The piecemeal approach that we continue to see with Systolic High Blood Pressure management and have seen with SARS Co-V-2 prevention is a traditional and much less resource-intensive approach, but will not get us to goal.

There is hope.  The SPRINT Study and worldwide experience with SARS Co-V-2 teach us that simple and consistent public health measures work.  As Jodi said, it takes a village to provide 24/7 optimal IPC.   Let this be our message in our communities, and let us take advantage of the technical support that is becoming more available in California.  

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