Judith Graham
A wrenching battle is rising because the COVID-19 virus storms by means of U.S. communities: Some sufferers are falling right into a no man’s land between hospitals and nursing properties.
Hospitals must filter sufferers who now not want acute care. But nursing properties don’t wish to take sufferers discharged from hospitals for concern they’ll convey the coronavirus with them.
“It’s a huge and very difficult issue,” stated Cassie Sauer, president of the Washington State Hospital Association, whose members have been hit early by the coronavirus.
Each facet has reputable issues. Hospitals in coronavirus scorching spots must liberate beds for the subsequent wave of critically in poor health sufferers. They are canceling elective and nonessential procedures. They are additionally making an attempt to maneuver coronavirus sufferers out of the hospital as shortly as potential.
The aim is to “allow hospitals to reserve beds for the most severely ill patients by discharging those who are less severely ill to skilled nursing facilities,” Seema Verma, administrator of the Centers for Medicare & Medicaid Services, stated a number of weeks in the past because the federal company relaxed guidelines limiting which Medicare sufferers can obtain nursing dwelling care.
Nursing properties are alarmed on the prospect of taking sufferers who might have coronavirus infections. The penalties might be dire. The first nursing dwelling identified to have COVID-19, the Life Care Center in Kirkland, Washington, noticed the virus unfold like wildfire. It killed 37 individuals.
“We’re looking at case fatality rates of 30, 40, 50% in nursing homes when coronavirus gets introduced,” stated Christopher Laxton, government director of AMDA — the Society for Post-Acute and Long-Term Care Medicine, which represents nursing dwelling medical administrators.
Fears prolong to sufferers with different situations, comparable to strokes or coronary heart assaults, who’ve been within the hospital and shouldn’t have COVID-19 signs however might harbor the virus.
In its most recent guidance, the American Health Care Association, an trade commerce group, stated nursing properties can settle for sufferers “who are COVID negative or do not have symptoms.” If somebody has signs comparable to a dry cough or fever, they “should be tested for COVID-19 before being admitted to the facility.” If somebody is COVID optimistic, they need to be stored solely “with other COVID positive residents.”
But nursing dwelling docs fear this doesn’t go far sufficient. According to a resolution by the California Association of Long Term Care Medicine, nursing properties shouldn’t must take sufferers identified to have the coronavirus except “they have two negative tests that are 24 hours apart, OR 10 days after admission AND no fever for 72 hours.” A brand new AMDA resolution echoes this warning.
“We have an obligation to our patients to draw the line,” stated Dr. Michael Wasserman, president of the California affiliation. “Increasing the number of COVID-19 positive residents in facilities — whether these facilities have patients with the virus or not — raises the risk of infecting the uninfected and dramatically increasing the number of deaths.”
For their half, hospital leaders say an emphasis on testing earlier than discharging sufferers is impractical, given the scarcity of exams and delays in receiving outcomes.
“Many nursing homes are requiring a negative COVID-19 test even for patients who were in the hospital for nothing to do with COVID,” stated Sauer in Washington state. “We don’t agree with this. It’s using up very limited testing resources.”
Nowhere are tensions increased than in New York, the place Gov. Andrew Cuomo has stated 73,000 further hospital beds shall be wanted inside weeks to deal with a surge of COVID-19 sufferers. Hospitals within the state have 53,000 beds.
On Wednesday, the New York State Department of Health issued an advisory noting: “No resident shall be denied re-admission or admission to the NH [nursing home] solely based on a confirmed or suspected diagnosis of COVID-19.”
Speaking on behalf of nursing dwelling physicians, AMDA voiced sturdy opposition, calling the coverage “over-reaching, not consistent with science, unenforceable, and beyond all, not in the least consistent with patient safety principles” in a statement.
Some nursing properties are sending residents with suspected coronavirus to hospitals for analysis after which refusing to take them again till exams affirm their unfavourable standing.
“Essentially, they’re dumping patients on hospitals and saying, ‘Too bad — you’re stuck with them now,’” stated a guide who works intently with hospitals and spoke on the situation of anonymity.
Others wish to do their half to serve COVID-19 sufferers. “It is our obligation to keep the health care system flowing,” stated Scott LaRue, president of ArchCare, the well being care system of the Archdiocese of New York.
LaRue has no illusions about conserving the coronavirus out of ArchCare’s 5 nursing properties, which, mixed, have 1,700 beds.
“In New York City the virus is everywhere,” he stated. That means it must be managed, not prevented. “Our intention is to take COVID-19 stable patients” and transfer them to a single ground at every nursing dwelling, he stated.
That will occur below two situations, LaRue stated. First, ArchCare will want adequate private protecting gear — robes, masks and face shields — for its workers. Currently, the system can’t get face shields. It was as a consequence of run out of robes by Wednesday.
Second, ArchCare might want to check whether or not its protocols for managing COVID-positive sufferers are working. Those embrace placing sufferers in isolation, monitoring them extra intently, limiting the quantity of people that can go in, and making certain that workers use private protecting gear and are skilled correctly.
So far, solely considered one of its nursing dwelling sufferers is thought to have COVID-19.
“We won’t know for 14 days if the steps we’re taking are working,” LaRue stated.
But it’s unrealistic to count on different nursing properties to observe go well with.
“I would be surprised if 10% to 15% of skilled nursing facilities in the U.S. could take a COVID-positive patient and treat that patient safely while ensuring that other residents in the home are safe,” stated David Grabowski, a professor of Health Care Policy at Harvard Medical School.
In a new commentary within the Journal of the American Medical Association, Grabowski requires establishing “centers of excellence” to look after sufferers recovering from COVID-19 and constructing “temporary capacity” in scorching spots the place the necessity for post-hospital providers is more likely to surge.
That’s starting to occur. On Tuesday, Cuomo introduced that a area hospital being constructed by the U.S. Army Corps of Engineers to deal with overflow coronavirus sufferers on the Jacob Ok. Javits Convention Center in New York City would come with 1,000 beds for sufferers who don’t want acute care providers.
On Wednesday, a unit of Partners HealthCare, a big Massachusetts well being care system, introduced a brand new heart for sufferers recovering from COVID-19 on the fourth ground of Spaulding Hospital for Continuing Care, a long-term care hospital in Cambridge. The heart, set to open quickly, can have 60 beds and settle for sufferers from Massachusetts General Hospital and Brigham and Women’s Hospital.
In the Twin Cities space of Minnesota, Allina Health, which operates 11 hospitals, is partnering with Presbyterian Homes & Services to transform a 50-bed expert nursing dwelling to a “step-down site,” stated Dr. Emily Downing, a vp of Allina Health. The aim is to assist COVID-19 sufferers recuperate to allow them to return to nursing properties or senior dwelling communities.
Katie Smith Sloan, president of LeadingAge, which represents not-for-profit nursing properties, dwelling care businesses and assisted dwelling facilities, stated she was listening to about nascent plans to reopen closed nursing properties for COVID-19 sufferers. Government businesses must make financing obtainable to construct further capability to look after these sufferers, she stated.
As for sufferers who want much less intensive care or who must be quarantined after the hospital to make sure they aren’t infectious, different choices exist.
“King County has bought a hotel and is leasing another and is looking at what are now empty ambulatory surgery centers or a Christian summer camp in the area,” stated Sauer of the Washington State Hospital Association.
Kaiser Health News (KHN) is a nationwide well being coverage information service. It is an editorially unbiased program of the Henry J. Kaiser Family Foundation which isn’t affiliated with Kaiser Permanente.