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COVID-19
March 24, 2020

Nursing Homes Are Ground Zero for COVID-19 Pandemic

Author Affiliations
  • 1Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
  • 2Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
  • 3Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
JAMA Health Forum. 2020;1(3):e200369. doi:10.1001/jamahealthforum.2020.0369

At the start of 2020, the Life Care Center of Kirkland nursing home in Kirkland, Washington, cared for roughly 120 residents with 180 staff members. Although this facility has the highest rating of 5 stars on the federal government Nursing Home Compare website, it received a deficiency during its most recent inspection survey in April 2019 for failing to provide and implement an infection control program. The deficiency was considered less serious because it was associated with “minimal harm or potential for actual harm.”

This Seattle-based nursing home became, in the words of former US Centers for Disease Control and Prevention (CDC) director Tom Frieden, “ground zero” in the COVID-19 pandemic. Of the first 46 confirmed deaths attributable to COVID-19 in Washington by mid-March 2020, 30 deaths, more than 1 in 4 residents of the facility, were associated with Life Care Center. Dozens of residents at the facility have been transferred to the hospital, and those remaining have been isolated in their rooms. Because of a no-visitors policy, these residents have not been able to spend time with their families and loved ones. Testing of residents and staff for COVID-19 was slow, and communication with families has reportedly been poor. To make matters worse, dozens of staff members at the facility were reported to have COVID-19 symptoms and eventually quarantined at home. The lack of available staff led the US Department of Health and Human Services to send in a 28-person strike team to assist clinicians at the home.

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    2 Comments for this article
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    At Nursing Homes with a Few Common Drugs and COVID-19
    Paolo Mazzarello, MD | Alice Cervetti, MD; Giovanni Pietro Corsini, MD - Genoa, Italy
    People are worried about getting and managing COVID-19 and, when they live communally, problems particularly make themselves felt. From the early stage of COVID-19 it seems important to decrease the cytokine IL-6 level in patients (1). In Italy, at home as well as at nursing homes, hydroxychloroquine is not available at the moment. We noticed a few experimental tests of the effects on IL-6 level of four commonly used drugs: rupatadine inhibits IL-6 release from HMC-1 cells (2); melatonin enhances IL-6 production by PBMCs (3); serenoa Repens reduces the level of inflammatory factors, including IL-6 (4); and palmitoylethanolamide decreases the production of IL-6 in tissue homogenates in mice treated (5). For patients that are taking these four drugs, or that can need them for their recognized indications, at the moment we recommend their use.

    Alice Cervetti, MD, Psychiatrist, Ospedale San Martino, Genoa, Italy
    Giovanni Pietro Corsini, Psychiatrist, Ospedale San Martino, Genoa, Italy
    Giuseppe Paolo Mazzarello, General Practitioner, ASL 3 Genovese, Genoa, Italy

    REFERENCES

    1) Detectable serum SARS-Cov-2 viral load (RNAaemia) is closely associated with drastically elevated interleukin 6 (IL-6) level in critically ill COVID-19 patients.
    Chen X et al. MedRxiv (Preprint, March 2020)
    DOI: 10.1101/2020.02.29.20029520

    2) Rupatadine inhibits proinflammatory mediator secretion from human mast cells triggered by different stimuli.
    Vasiadi M et al. Int Arch Allergy Immunol 2010
    DOI: 10.1159/000232569

    3) Melatonin enhances IL-2, IL-6, and IFN-gamma production by human circulating CD4+ cells: a possible nuclear receptor-mediated mechanism involving T Helper type 1 Lymphocytes and Monocytes.
    Garcia-Mauriño S et al. The Journal of Immunology 159 (2): 574-81 – August 1997

    4) Effect of Serenoa Repens on oxidative stress, inflammatory and growth factors in obese wistar rats with benign prostatic hyperplasia.
    Colado-Velázquez J III et al. Phytotherapy Research 2015
    DOI: 10/1002/ptr.5406

    5) Palmitoylethanolamide stimulates phagocytosis of Escherichia Coli K1 by Macrophages and increases the resistance against infections.
    Redlich S et al. Journal of Neuroinflammation 11, Article number : 108, 2014
    CONFLICT OF INTEREST: None Reported
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    Nursing Home Preparedness for COVID-Infected Patients
    Claude Gerstle, MD | None
    Most nursing homes have no requirement to provide any kind of respiratory care. This is a major shortcoming in this epidemic and should be addressed immediately with nursing homes being supplied with and taught to use at least supplemental oxygen with nasal cannula and hopefully oxygen via CPAP mask and given supplies to be able to do this for at least 20% of the population as many of these patients will be deemed low priority for hospital transport or care.

    The following is the checklist from CDC requirements for nursing homes:

    A. Infection control by staff - Facilities
    should have supplies of facemasks and respirators (if available and the facility has a respiratory protection program with trained, medically cleared, and fit-tested HCP), gowns, gloves, and eye protection (i.e., face shield or goggles).

    B. Consumables and durable medical equipment and supplies - Estimates have been made of the quantities of essential resident care materials and equipment (e.g., intravenous pumps and ventilators, pharmaceuticals) and personal protective equipment (e.g., masks, respirators, gowns, gloves, and hand hygiene products), that would be needed during an eight-week outbreak.  Estimates have been shared with local, regional, and tribal planning groups to better plan stockpiling agreements.

    A plan has been developed to address likely supply shortages (e.g., personal protective equipment), including strategies for using normal and alternative channels for procuring needed resources.

    A strategy has been developed for how priorities would be made in the event there is a need to allocate limited resident care equipment, pharmaceuticals, and other resources. 

    A process is in place to track and report available quantities of consumable medical supplies including PPE.
    CONFLICT OF INTEREST: None Reported
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