Skilled Nursing Facilities Remain Vulnerable to COVID-19

Since the beginning of the SARS-CoV-2/COVID-19 pandemic in the United States, we have widely known the vulnerability of certain patient populations. Early on, skilled nursing facilities and other long-term care facilities began to show a propensity for transmission of the viral infection.

From limited infection prevention resources to vulnerable patient populations and often staff stretched thin, these environments showed promise for the disease to take hold. While we knew this would be a weak point, how many were truly infected? In the early days of the outbreak, testing was only done on those with symptoms, but as resources have increased, so has the testing availability. A new study from the Centers for Disease Control and Prevention’s Morbidity and Mortality Weekly Report (MMWR) evaluated the prevalence of COVID-19 in Detroit skilled nursing facilities (SNFs) from March until May of this year.

Utilizing a point prevalence survey in which all staff and residents were tested regardless of symptoms, they found deeply worrying statistics across twenty-six of Detroit’s SNFs. Testing occurred across multiple facilities based upon prioritization and was performed in conjunction with the city health department. Moreover, the researchers performed onsite infection prevention assessments and consultations—“Two follow-up IPC assessments were conducted for the 12 facilities participating in the second survey and included examination of cohorting practices using a facility floorplan, supply and use of personal protective equipment, hand hygiene practices, staffing mitigation planning, and other IPC activities.”

The local health department aided in collection of information on positive results, symptom status, hospitalizations, and fatalities. Ultimately, the researchers found that from March 7 to May 8, 44% of the 2,773 Detroit SNF residents were found to be positive for SARS-CoV-2/COVID-19. The median age for those positive residents was 72 years and 37% ended up requiring hospitalization. Unfortunately, 24% of those who tested positive, died. The authors noted that “Among 566 COVID-19 patients who reported symptoms, 227 (40%) died within 21 days of testing, compared with 25 (5%) among 461 patients who reported no symptoms; 35 (19%) deaths occurred among 180 patients for whom symptom status was unknown.”

Of the 12 facilities that participated in the second point prevalence survey, eight had enforced cohorting of positive patients in dedicated areas prior to the survey. Most facilities had a census of roughly 80 patients and of those tested during the second survey, 18% had positive results and were not known to be positive. As the authors note, this study points to the vulnerability of this patient population and the high attack rate. Across those 26 SNFs, there was an overall attack rate of 44% and a hospitalization rate related to COVID-19 of 37%. These numbers are startling and point to a continued need for early detection, infection prevention efforts, cohorting, and collaboration with local public health departments. There is a desperate need to infuse SNFs with more resources, not only in terms of personal protective equipment, but also the critical infection prevention resources and staffing. As these are vulnerable environments, continued support will be needed for not only the duration of the pandemic but well after.