COVID strategy in nursing homes doesn’t stop with screening and testing. It has to be capped with medical care designed to give the positive residents a chance at surviving, while being ready to provide comfort to residents both emotionally and medically when the time comes.
Vitamin D deficiency can make it hard for the body to fend off COVID-19, and dehydration can make it difficult to recover from an infection, so measures such as administering Vitamin D and making sure everyone gets enough water should be at the core of nursing home COVID care. Photo courtesy of Jabbar Fazeli, M.D.
More than a month into our nursing home’s COVID outbreak, 48 residents were treated, and about 80 percent recovered, the oldest being 103 years old. Most residents already had poor life expectancy, but we did our best to stop COVID from cheating them out of what they have left.
More than 20 frontline staff, including me, developed COVID and took it home to our families. Somehow the staff managed to keep up and no one quit or called out, despite the imminent danger. The staff had to contend with the fact that nursing homes don’t have negative-pressure rooms and PPE alone was failing to provide full protection.
As we worked on limiting the spread, we also initiated treatment for each patient who needed it. All along, the outside world was mostly unaware of the work needed to get the job done when so many staff members have to be sent home because of contracting COVID themselves. In an effort to free up nurses to do the frontline work and still meet family expectations, we had social services provide updates, and the director of nurses and I called the families of residents who were most ill.
While the vast majority of COVID cases had advance “do not resuscitate” directives, a couple of cases were what we call a “full code.” We had to plan around the fact that CPR on a COVID patient at a nursing home without negative air pressure or proper equipment to cover the patient is guaranteed to infect the nurses and providers who run the code.
As we do the work of geriatric COVID care, it is not always straightforward to explain. We are basically trying to communicate that being old with poor life expectancy is no reason to not treat a potentially reversible condition like COVID. We say that COVID should not be considered a terminal illness, and it should not cause any team to throw in the towel without a fight.
We improved our knowledge of COVID and ways to treat over time, and we now have practical treatment options. We know, for example, that dexamethasone reduces death rates by a statistically significant percentage among patients hospitalized with moderate to severe COVID, and we extrapolate that data to nursing home patients we treat on site.
We know that patients with Vitamin D deficiency do worse, so we started giving residents Vitamin D to ensure that if they get COVID, they don’t have vitamin D deficiency working against them.
We also know that certain labs can tell us who is doing poorly even if their symptoms haven’t caught up with them yet, so we check labs in nursing home COVID cases.
With geriatric patients, oftentimes a drop in food and water intake can mean the difference between life and death. Holding water pills, sleeping pills, antipsychotics, etc., before a person becomes dehydrated can be a life-saving measure and should be at the core of COVID care in nursing homes. All this needs to happens at hospital speed to anticipate the rapid decline, and work to prevent it by initiating early treatment.
No one deserves to die of COVID just because they are old or they are in a nursing home or eligible for hospice. We have some tools and methods that we should offer to everyone with COVID in nursing homes, unless they tell us not to. Many who survive will continue to have a poor prognosis, but that’s part of life in a nursing home. At the very least, post-COVID recovery, if death does come, maybe families can be at bedsides with lesser risk.
It can be mentally exhausting to lose patients after doing everything we can think of to save them, but we draw comfort from knowing that 80 percent of our residents made it. This survival ratio could easily have been the death rate if we had done nothing.
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