Geriatricians have proposed a new standard for clinical management of COVID-19 outbreaks in nursing home settings. The approach may lead to improved mortality in facilities where the resident population is predominantly Black and therefore at high risk of severe disease, they say.
The doctors, from the University of Chicago and the MGH Institute of Health Professions in Boston, highlight their methods in a study of clinical outcomes in a 200-bed skilled nursing facility in Chicago.
Investigators used a retrospective chart review to determine demographics, comorbidities, symptoms, lab results, and clinical outcomes in all sub-acute and long-term care residents over 12 weeks. These data were compared between residents with and without COVID-19.
Fully 84% of the 204 residents tested positive for SARS-CoV-2 during the three-month study period, half were symptomatic, and a fourth were asymptomatic.
The doctors described a pattern of factors among these infected residents that they categorized as a syndrome. Along with low-grade fever greater than 99°F, weight loss, delirium and fatigue, infected residents experienced:
- hypernatremia, or high blood sodium (25% of infected residents),
- acute kidney injury (30%), and/or
- leukopenia, or low white blood cell count (39%).
To address this syndrome, facility administrators instituted an “escalated” program of care. This program included scheduled and frequent clinical assessments, goals of care discussions, serial laboratory evaluations, and intravenous fluids, antibiotics, and oxygen as needed.
The facility’s 30-day mortality rate of 16% was significantly lower than the 24% to 38% published rate range during the study period. Although the results do not prove causation, the better outcome may be due to this stepped-up management process, theorized corresponding author Kimberly J. Beiting M.D., and colleagues.
The enhanced clinical management program was possible due to several advantages, the investigators said. There were enough clinicians to expand staffing hours and consolidate care to one clinical team; facility administrators were receptive to proactive communication; and the facility has a partnership with an affiliated academic medical center.
What’s more, as part of the facility’s administrative response, nursing and certified nursing assistant ratios on the COVID-19 ward were increased, and hazard pay was provided to raise the level of care.
The new management approach, detailed in the Journal of the American Geriatrics Society, is meant to be adopted and adapted by other facilities, wrote lead author Lauren J. Gleason, M.D., MPH. The literature to date refers to COVID-19 management solutions for hospital settings, and not long-term care facilities, she added.
“[Long-term care] facilities with different access and care models may have to modify these proposed COVID‐19 management strategies to fit their specific clinical and administrative care structures,” wrote Gleason. She and her colleagues suggest that facilities with limited clinical resources may benefit from partnering with an associated acute care hospital or a health system when developing an outbreak management strategy.
The findings are particularly relevant to nursing home providers who care for high‐risk, medically complex, older populations composed of predominantly black residents, the authors added. Facilities with majority non-white residents have had three times the number of deaths compared with those with more white residents, they said.
“Given this, it is crucial to design COVID‐19 management strategies to improve outcomes in facilities that care for these vulnerable populations,” they concluded.
