Should Your Facility Develop a COVID Unit?

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. 

For nursing home residents, this is generally not an option since they have complex care plans that are best carried out by the professionals who know them.  

In the SNF workgroup, I have a sense that many facilities are focused on keeping COVID out of their facilities by implementing all of the known CDC and PHD guidance.  This plan appears to include a reluctance to accept referrals from the acute hospital even with illnesses that don’t appear to be COVID, but where it has not yet been totally excluded.  In defense of this reluctance, COVID 19 can initially be asymptomatic in our patient population and may coexist with other illnesses with subtle manifestations. From the hospital perspective, they are having trouble placing patients in SNFs that previously weren’t a placement problem, and this is a time when many expect a surge of COVID in their communities.  From the SNF perspective, they know it will be a disaster for their facility if they admit someone with COVID disease and don’t effectively identify and quarantine the patient.  

Are there alternative options for hospitals and SNFs in your community? Our SNF members would love to see the hospitals reopen their TCUs (Transitional Care Units), that they closed about 15 years ago.  These could become centers of excellence and would reduce the risk of COVID spread within SNFs. However, this is an expensive endeavor and diverts hospital resources away from preparing for the expected surge.  Apart from unusual funding becoming available in our community, it likely won’t happen prior to a surge and at that time, there may be little other option but to send still-contagious COVID 19 patients to SNFs.

Developing a COVID unit is another option that some facilities have selected. In the facility I’m associated with, we have walled off one of our three units with a construction-grade plastic wall with tent-like doors on either entrance to this unit.  We have designated staffing exclusively for this unit and are directing these employees not to mingle with other staff during the pandemic. We have focused our limited PPE resources on this unit and have enhanced training of this staff. We have identified employees who may be excluded from that unit for health reasons (Asthma, COPD, Diabetes, Heart disease, Immunosuppression, & > 65 y/o).  We are adopting AMDA’s detailed CPR guidance on that unit and have enhanced our advance care planning skills. 

In addition, we, like other facilities in our area, are considering ways to incentivize our staff to work on this unit.  We remain COVID-free (PHD surveillance starting soon), but in the interim, we have the ability to accept hospital referrals of patients who are COVID unlikely, but not excluded (our perspective).  For these patients, they are initially quarantined on our COVID unit where we get experience with full PPE and then transfer them to a non-quarantine bed, once COVID presence is excluded or no longer transmissible.  This approach has the added advantage of calming staff fears that they too will become COVID victims. In this state, we have already seen a SNF in Riverside that couldn’t manage their COVID outbreak because of 80% of their staff not reporting to work.   

As of April 7, our PHD reported that over 62 facilities in the state were known to have COVID outbreaks. This number is sure to rapidly rise.  I am no longer confident that we can keep COVID out of our SNFs. I’m glad my facility has become better prepared by developing their COVID unit. This model will work for low level COVID activity, but will need support of PHD for enhanced staffing, PPE, and testing in a true surge.

Should your facility be implementing this option?

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