I first heard about this from people connected to the nursing home industry, but on looking around I see it’s been discussed a bit in the media as well, e.g. here. This seems to me to be one of the stupidest government decisions I can remember. All the nursing home people I know think it’s insane, and the experts quoted in these articles are also leery of it. I would think when all is said and done there will have been thousands of extra deaths from this policy.
ISTM to be an example of tunnel vision, where senior officials were so focused on the task of freeing up hospital space that they lost sight of the fact that they were putting what’s probably the single most vulnerable group of people in the entire country at tremendous risk.
the logical plan would have been to shuffle the deck and put the coronavirus infected people in one nursing home and the non-infected in another. there’s just no practical way to keep the airborne virus from spreading within a building without negative pressure rooms and continuous cleaning.
Just looking at the NY numbers it looks like 25% of the deaths were in nursing homes and that’s probably a low percentage.
True, but that requires a heck of a lot of cooperation from the nursing homes themselves (which have disparate and scattered ownership), and from whoever is paying for the nursing homes (Medicaid, private insurers, family, etc.). Does a governor or state have the power to tell a privately-owned for-profit nursing home that the home must discharge patients A, C, D and F, to make room for B, E, G and H? Can the state compel whoever is paying for A’s care to pay the bill at what might be an out-of-network facility, and cut through the red tape of preauthorizations and such?
there was no cooperation when the state(s) compelled nursing homes to accept someone with the virus. It was mandated. So I would say it was an extension of the same mandate.
Pick any serious disease that is known to kill people. Can you see a mandate that an institution not equipped to handle it be forced to do so? I don’t see the logic this and that is backed up with the knowledge we can go into any building and set up a military hospital. Which is what happened.
Additionally, many nursing homes have a number of residents in varying stages of dementia. Such people are often seriously upset by a change to unfamiliar quarters.
It may be necessary in some cases to move large numbers of people around anyway; but it sure isn’t going to be easy.
From what I’ve seen, the mandate was “you cannot refuse to accept a patient based solely on their COVID-19 test results.” Have you seen anything more specific than that? What you are talking about is more like “you, Nursing Home X, will discharge Annie A., Brad B, and Charlie C. to Nursing Home Y and accept David D., Ethel E., and Fannie F.,” which is rather more than a mere extension.
A governor can set up a military hospital only if s/he has a National Guard unit in his or her control capable of establishing, equipping, and running one. I don’t think every state does, but perhaps you know differently?
Beyond that, any nursing home or skilled nursing facility should have a basic understanding of and supplies for infection control. It’s not at all unusual to have individual patients with infections, and influenza is an annual event for which any long-term-care facility needs to be prepared. This particular disease is more deadly, so the stakes are higher, but these really should not be nursing homes “not equipped to handle” an infectious respiratory disease. Remember, 90% of flu-related deaths and 50-70% of flu-related hospitalizations occur in adults over 65 (cite), so managing and containing an outbreak is not some never-before-encountered situation for these facilities.
Here, the governor has explicitly said many times, that if a nursing home can’t properly care for a particular patient, the nursing home can contact the Board of Health which will find an appropriate placement. But they can’t turn the patient down just because they test positive - and BTW, I have dealt enough with nursing homes to know there are some patients they just don’t want and certain homes will use any excuse they can to reject them or discharge them.
In my state, (and I assume the others) the issue is not so much admitting patients who test positive from the community , but admitting or re-admitting patients coming from the hospital who no longer need hospitalization but can't be cared for at home (including prior nursing home residents).
I very much doubt that there are orders to discharge patients. As beds open up (basically as residents die) new patents will be admitted. As doreen says, there are patients that nursing homes will do anything to avoid taking. The two that come to mind as those that have been residents of mental institutions, and those that have a golden staph infection. The former can be very difficult to manage. The latter leads to infecting the entire hospital, which is a long term disaster. Homes may simply be worried about perceptions. Most are commercial institutions and reputation counts.
But I have also seen at first hand what seems to be a serious hole in the health care system. Elderly patients who have recovered from an acute problem, but who are not well enough, or otherwise able, to be looked after at home. They fall between the cracks. A hospital is not the right place for them. They don’t get the care they need to recover. The usual answer is to ship them off to a far flung ward of the hospital and try to find them a place in a nursing home. Some go to a nursing home to recuperate with a view to eventually going home. The majority sadly find it is a one way journey, and the home they enter they will only ever leave in a box. But until a place is found they languish in a hospital bed in what amounts to the waiting room. They can wait months. It is a truly dismal and awful experience.
So, I interpret these orders to be - if you have an open bed, you can’t refuse a recovering covid-19 patient. As we know, many patients, although they have survived, are seriously beaten up, and in need of a lot of care.
There shouldn’t be any suggestion that these patient are infectious. Such a patient must be cared for in a setting rated for care of any infectious patient, and that is not a nursing home.
Having one specialized nursing home taking care of patients with Covid-19 is the logical thing to do. None of the nursing homes in my area want to accept any patients that have Covid-19. There isn’t going to be a scenario where patients need to be exchanged or shuffled around, since so far at least none of them are in the nursing homes yet. At least not in my area. This thing spreads like wildfire, and if there are any nursing homes out there with one or two patients with Covid-19, they won’t stay that way very long due to the nature of the beast. Such an order from government officials is tantamount to a death sentence for multiple patients. Whoever came up with the idea(s) to force nursing homes to take these individuals has no idea what they are doing.
Sources. I am a nursing home doctor. Every single one of my colleagues who I’ve spoken with feel the same way.
I believe that’s true. But the problem is that even if you have a perfect setup, with all the protocols and PPE etc. they are not a complete panacea, and the infection will still spread, even if less than without those protocols and equipment.
[In addition, all the nursing homes are required to have proper protocols in place anyway for dealing with Covid, so making an exception for not being able to care doesn’t mean much.]
This is correct. The driver of this was freeing up hospital space.
I think the politicians were looking at the shortage of hospital space - which had attracted a lot of publicity at the time - as “their problem” and people dying in nursing homes as “someone else’s problem”. And since they had government power and someone else didn’t, they got priority.
How long do you think it will take to create and staff a specialized nursing home in each area for those who are being discharged having resolved from COVID-19 (low albeit non-zero transmission risk COVID-19 patients with likely little to no viral shedding at that point, likely having peaked shedding in the day or two before symptoms and the first few days of illness)?
Soon enough to deal with a specific region that does not have adequate hospital beds and staff beds to take care of acutely ill patients, inclusive of those from nursing homes? Are you prepared to take care of those acutely ill nursing home patients in your sites on site because there are no hospital beds to accept them?
You know that the answer is no.
There is no question that we are failing to adequately protect the very vulnerable nursing home population. The source of infections into the facilities appear not to be resolved patients discharged from hospitals, but to be from asymptomatic and presymptomatic (or even mildly symptomatic) healthcare workers. These vectors likely are inclusive even of physicians who round at multiple facilities, but mostly the low paid staff with inadequate supplies of PPE (possibly with inadequate training on proper use) and inadequate testing (inclusive of screening of those asymptomatic with fast turn around tests). It spreads by way of that staff and by asymptomatic, presymptomatic, and mild to atypically symptomatic residents.
I don’t know what, in comparison to current standards, best practices should be to reduce that from happening but what is being done is clearly not the right approach. And keeping resolved patients in hospitals beds that they no longer need but that others do, because they are perceived as having a Scarlet C upon them, is not going to reduce that problem.
The problem I have with this line of thinking is the assumption that we’re talking about patients with resolved cases. Whether it’s Covid-19 or any other condition, the hospitals in this area are not in the business of discharging patients with resolved / asymptotic illnesses. Maybe it’s different in other areas of the country, but here hospitals are in the business of discharging patients who are just barely well enough to no longer need acute inpatient hospital care but are still very much ill and symptomatic.
On the other hand, I do agree with you on what the vector has been so far. 5 of the local nursing homes are in the process of testing everyone, staff and patients, due to having an employee who works at multiple facilities who tested positive. I myself am one of the individuals tested just yesterday due to this incident.* The conclusion I’ve drawn, however, is that this is one more instance demonstrating that nursing homes are not up to the task of taking care of patients with active cases. Someone who is no longer ill, sure, not a problem. But hospitals want to discharge patients way before they’ve reached that point in the recovery process.
*. I’ll be working via telemedicine until my test results are in.
So let’s play some different hypothetical circumstances.
Hospital capacity not near capacity. For sure keep until considered as no significant risk of contagion. Open debate if one asks for negative PCRs or 10 days from onset 3 days no fever and consistent improvement of symptoms. When back still good PPE use etc.
No room at the inn to accept patients getting sick in nursing homes. Patient from nursing home who was admitted sick now afebrile and improving to no longer needing hospital care but not completely resolved. No place to send if nursing home won’t take back. No room for new sicker patients if they don’t leave. Much less likely contagious than the newly sick person in the nursing home. What to do?
BTW, best hopes for your being negative!
Not having a hospital bed for the person in the nursing home is basically doing that.
Best is to figure out (and provide for) better best practices that keeping them from getting exposed by HCWs and others so fewer get sick. I’m not a big fan of the idea of mass testing everyone every week in general, but these HCWS and residents? Might be a reasonable part of a plan. Residents wearing N95s when in groups or getting visitors or a worker in the room? I don’t know but something better than we do now.
I think the nursing homes can get backed into a corner on this. If a COVID-19 patient is no longer infectious, I don’t see how he or she could be refused a bed in a nursing home.
Because of the highly infectious nature of this disease, it would be a great public health catastrophe for someone who is still shedding virus particles to be discharged from the hospital. This wouldn’t be +an insurance issue or a hospital ruling, it would be a public health matter.
So, if the patient is non-infectious, a nursing home may not be crazy about accepting him or her. Public, private, for-profit or non-profit, if the institution accepts any government funds, then the government has a huge say-so.
~VOW