COVID-19 Testing in Nursing Homes: Better Late than Never

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.

As tens of thousands of nursing home residents took their last breaths as a result of COVID-19, the Centers for Medicare and Medicaid Services (CMS) has been busy patting themselves on the back for doing such a good job.  Those of us who work on the frontlines know that the initial response from CMS and the federal government was anemic, inconsistent, and sometimes counterproductive.  Many mixed messages were received.  Perhaps most troubling was the lack of assistance in procuring PPE, which went preferentially to hospitals. 

Now in early June, CMS has added fuel to the fire, promising the public over Memorial Day weekend that there will be greater accountability and more enforcement with enhanced penalties for nursing homes with respect to COVID outbreaks.  CMS even made a statement erroneously conflating “quality” as measured by the five-star system with incidence of COVID—even though the actual data completely refute that claim.  It is disappointing that during a time when facilities are working as hard as they can to protect their residents and staff from the pandemic, they are getting slammed even harder.  While there are some facilities where deficient practices may have contributed to outbreaks, there are also outstanding facilities who have done everything possible to prevent outbreaks, and still experienced high numbers of cases and deaths.

For those who would like to read more, a couple of recent brief blog posts in McKnight’s may be instructive.  This piece by Sondra Norder called out the CMS attitude of blaming nursing homes for COVID outbreaks:   A few days later, none other than CMS Administrator Seema Verma felt obligated to reply with this self-congratulatory column: 

While all this was going on, CALTCM leaders, AMDA experts, and other geriatricians and long-term care professionals were working on guidelines for testing in nursing homes.  Our own Dr. Mike Wasserman, CALTCM President, convened a modified Delphi panel of experts to deliver consensus guidelines, which are hot off the press, published online in the Journal of Nutrition, Health & Aging and available here:  The article was co-authored by Dr. Wasserman and CALTCM colleagues Drs. Albert Lam and Flora Bessey; along with geriatrics heavyweights Drs. Joe Ouslander and John Morley; AMDA leaders Drs. Sabine von Preyss-Friedman, Dan Haimowitz and Arif Nazir; and Drs. Adam Wolk and Noah Marco, also from California. 

Among the consensus items reported in this article were:

  • Asymptomatic spread of COVID-19 from nursing facility staff and residents is a major accelerator of infection. Facility-wide point-prevalence testing is an emerging strategy in disease mitigation.
  • The panel endorsed facility-wide testing of staff and residents without dissent when diagnostic RT-PCR was available. While the panel recognized the limitations of RT-PCR testing, it strongly recommended this testing for both staff and residents in NFs that were either COVID-19 naive or had limited outbreaks.
  • There was also consensus on testing residents with atypical symptoms in a scenario of limited testing capability. The panel favored testing every 1 to 2 weeks if testing was readily available, reducing the frequency to every month as community prevalence declined or as the collection of additional data further informed clinical critical thinking and decision-making.
  • The panel recognized that frequent testing would have consequences in terms of potential staff shortages due to quarantine after positive tests and increased PPE use. However, the panel felt that not testing would allow new clusters of infection to form. The resulting high mortality rate would outweigh the potential negative consequences of testing.
  • The panel also recognized the pandemic as a rapidly evolving crisis, and that new science and increasing experience might require an updating of its recommendations.

Dr. Wasserman and his colleagues are hopeful that these guidelines will help inform local, state and federal agencies and other stakeholders, and include the caveat that COVID-19 is a moving target.  One thing is for sure, adequate testing strategies and a reliable supply of appropriate PPE are going to be necessary to slow the hemorrhage of vulnerable elder lives that this disease has wrought.

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