DETROIT ― A spike in the number of coronavirus cases in Detroit’s nursing homes is straining the region’s hospitals and is partially responsible for an uptick in the state’s already-high mortality rate. Now public health officials are working to head off the kind of facility-based outbreak that has killed hundreds of elderly nursing home residents in Seattle, New York and elsewhere.
Over the last week, Detroit Medical Center’s Sinai-Grace hospital saw a “huge increase” in nursing home resident admissions, the hospital’s chief geriatrician, Pragnesh Patel, told HuffPost.
DMC epidemiologist Teena Chopra called the growing mortality rate among the region’s nursing home population “astonishing.” She estimated that about 60% of coronavirus-infected residents who are admitted to metro Detroit hospitals die, and that the population accounts for at least 25% of the region’s overall coronavirus deaths. Those figures will likely continue climbing and “fuel the fire” during the next several weeks, Chopra said.
“The virus has infiltrated nursing homes in Detroit, and that’s why these patients who are the weakest part of society are being fed to DMC and neighboring hospitals,” she added. “These are the ones with much higher mortality rates, who push the overall rate higher.”
At his daily press conference on Tuesday, Detroit Mayor Mike Duggan said 14 nursing homes “have reported some rate of infection” as well as 12 deaths, although it’s unclear how extensive testing is within the facilities. Duggan also noted that there is about a week’s lag in reporting deaths. DMC doctors said they’ve seen the number of deaths jump during the last week, even if it’s not yet reflected in the official count.
Why Nursing Homes Are Uniquely Susceptible
The high caseloads in nursing homes are not at all surprising. The first big COVID-19 outbreak in the U.S. was at a nursing home in the Seattle area, and public health officials eventually tied it to 40 deaths including both residents and workers. In New York, officials estimate that 700 nursing home residents have died so far.
Meanwhile, near Pittsburgh, administrators at a large nursing home say they now presume all 450 residents and more than 300 staff “may be positive” after efforts to contain an outbreak failed.
Nursing homes are an almost perfect environment for the disease to spread. Residents are either old, infirm, or both, which means they have the physical conditions that make them most likely to develop severe, life-threatening complications from the coronavirus.
In addition, they need assistance with at least some daily functions, including eating, washing and toileting. That requires lots of close contact with caregivers, with lots of exposure to germs in both directions.
Long-term care facilities ― a category that includes not only nursing homes, but also assisted living facilities that cater to residents with less intense needs ― are famously understaffed. Employees are typically rushing from resident to resident, which makes it harder to observe basic hygiene and safety protocols like thorough hand-washing.
Once a resident gets sick, stopping the infection’s spread is a challenge even under the best of circumstances. And many nursing home staffers have part-time positions at several facilities, which means a worker can pick up an illness at one and then infect people at another.
“You might be working for two or three different employers,” said Salli Pung, Michigan’s long-term care ombudsman. “Full time positions are harder to come by … so employees have to work for multiple employers in order to get enough hours in to be able to make a living wage.”
This is an especially big danger with COVID-19, the disease caused by coronavirus, because workers can be carrying and spreading the virus for as long as two weeks before showing symptoms. And in Detroit, as in so many other parts of the country, workers don’t have enough personal protective gear.
Trece Andrews, an union steward at the Regency at St. Clair Shores nursing home, said that is the situation staffers there face, which has lead to unease.
“The workers should come first, they’re working with the [residents], and if they don’t have the proper safety equipment then they’re panicking and feeling like their employers don’t care and the government doesn’t care,” she said.
When supplies do come in, first responders and workers in the acute settings are frequently the first priority. “I think nursing homes that are a little bit further down the list for receiving the supplies that they need,” Pung said.
‘By The Time They Come To The Hospital, It’s Very Late’
The geriatric unit at Detroit Medical Center is already at capacity, but its staff has so far managed the situation, Patel said. Assessing and treating elderly nursing home patients is challenging because it’s difficult for many to communicate and their bodies may exhibit fewer signs of an infection.
Some suffer from immunosenescence, or the deterioration of the immune system, and don’t have the same antibody response as those with healthy immune systems. That means they won’t develop a fever, a common sign of infection, even if they’re fighting COVID-19.
Many patients are also mentally declining, have dementia, are recovering from a stroke, or have some other condition that makes communicating symptoms difficult. That creates a situation in which the disease can advance without caretakers knowing, which ultimately makes it more difficult for doctors to save the patients.
“By the time they come to the hospital, it’s very late and some of them are dying after a few days,” Chopra said.
Many elderly patients also suffer from multiple health issues, which makes treating them even more complex and challenging.
“They already have a system that is compromised,” Patel said. “Their heart is not pumping properly, maybe they have lung problems, their kidney isn’t functioning right, so when one gets infected there’s a domino effect on their systems, therefore they are more at risk and it’s more difficult for them to rebound.”
That sort of complexity demands a team of doctors to care for and make decisions for the patient, Chopra added.
“It’s not just about testing. We need a team of workers who know what to do with the results,” she said. “To effectively intervene, we need more physicians who can make decisions.”
Why Testing Every Resident Is So Important
Nursing homes have made changes in response to COVID-19, in some cases because of federal and state guidance and emergency regulations.
Like hospitals, they have mostly gone on lockdown, prohibiting nearly all visitors. (Exceptions include allowances for residents who are dying; some advocates are pushing to loosen those rules further, in order to help with emotional support, care and monitoring of residents.)
In addition, nursing homes are eliminating communal dining, entertainment and therapy. But this is tough on residents, who tend to benefit from these activities, and it places a greater strain on personnel, since staff have to spend more time going in and out of rooms and attending to residents individually.
“You’ve had a real fundamental change in the operations of the facility, and it’s incredibly labor intensive,” said Melissa Samuel, president of the Health Care Association of Michigan, the trade group that represents long-term care facilities.
Chopra said the only way to fully stop the disease’s spread through the facilities is to test every nursing home resident and separate those with positive results from those with negative results.
The Detroit Health Department and Wayne State University are heading up a new citywide testing effort, with a goal of testing the entire resident population at one nursing home per day. The initial focus is on the homes that have already reported the most cases and results are supposed to be available the next day.
Nursing homes are also looking at ways to divide the infected and non-infected populations, whether that is within individual facilities — by putting COVID-positive residents in special isolation areas — or among them, by designating some for residents with COVID and some for residents who don’t have the infection.
The latter seems more likely to stop the spread of the disease, but it creates many more complications, because it would require moving residents who, by definition, are not so easy to move. “Anytime you’re transferring, you’re concerned with that,” Samuel said.
It would also require more coordination, which is one of the many ways the state may have to get more involved. Pung said that officials in Lansing have been responsive and proactive, especially given their limited staff resources and the multiple challenges they are facing. “I’ve been really impressed with the state response, from the governor on down.”
Even so, she added, the situation is grave. Chopra agreed. She warned that the explosion in nursing home cases could push the curve back four to six weeks, and she isn’t confident that the region is equipped to handle the spike in cases among the elderly.
“The basic structure of public health is broken,” she said. “What is now happening is like we are removing a scab from the wound and revealing a broken infrastructure.”
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