The vulnerability of nursing home residents to the Covid-19 pandemic

Crises expose a society’s failings. The Covid 19 pandemic has revealed weaknesses in national and local governance, public health systems, and health care systems around the world. An alarming feature of this pandemic has been the tragic vulnerability of older individuals, especially those residing in nursing homes (NH) or other long-term care facilities. Residents of long-term care facilities have accounted for nearly one-half of Covid 19 deaths in Europe, ¹ over 40% of deaths in the U.S, and over 80% of deaths in Canada. Given the significant frailty and co-morbidity in nursing home patients and the close quarters in which they live, was it unavoidable that a virus with high transmissibility and lethality would so ravage this population? Several U.S. states report Covid 19 cases and deaths for individual nursing homes in the state. Perusal of these data suggests considerable variation in the percentage of residents affected by and dying from the virus, even among nursing homes located in the same communities. NHs with large numbers of cases and deaths are common and dominate the news. But the New York Times recently reported that 39% of NHs where greater than 25% of residents were black or Latino (demographic groups with the highest mortality rates) had no reported Covid 19 cases. ² What accounts for the variation?

The first known cluster of Covid 19 cases and deaths in the United States arose among the residents, staff and visitors of a single Seattle-area NH—Facility A in the references. ³ Facility A is part of a large (200+ facilities) for-profit chain of NHs. On February 27, 2020, the local Health Department was notified that a 73-year-old female resident of Facility A had been hospitalized with signs and symptoms consistent with Covid-19, which was later confirmed by testing. This prompted more intensive study that found that several residents had developed fever and respiratory symptoms as early as mid-February but went undiagnosed because testing for the virus was not available until later. As of March 18, 167 COVID-19 cases and 35 deaths were linked to Facility A. The cases included 101 residents (about 75% of all residents), 50 health care staff, and 16 visitors.

National and local public health specialists studied the Seattle area cluster and concluded that five factors “likely contributed to the vulnerability of these facilities”. ⁴ Three factors pointed to staff characteristics: staff members working while sick; staff members who worked in more than one nursing home; and inadequate staff familiarity with and adherence to infection control practices. Staff appeared to act as disease spreaders, by bringing the virus into the facility from the community and/or spreading it from patient to patient. When asked why staff work in more than one long-term care setting and work while sick, Dr. Jeff Duchin, public health officer for Seattle and King County, said: “They need the money. They don’t have sick leave. They don’t recognize their symptoms. They deny their symptoms”. ⁵ The remaining two factors focused on the institution’s dearth of equipment to deal with the epidemic: insufficient supplies of personal protective equipment, and limited availability of Covid-19 testing.

The quality of NH care has long been a concern. In 1986, a U.S. Institute of Medicine report on nursing home care stated: “In the past 15 years many studies of nursing home care have identified both grossly inadequate care and abuse of residents … leading to premature death, permanent injury, increased disability, and unnecessary fear and suffering on the part of residents. ⁶ ” The major quality problems noted in NHs included both errors of commission (e.g., inappropriate use of physical restraints or psychoactive drugs) and errors of omission (e.g., failure to prevent pressure sores or dehydration and malnutrition). Follow-up IOM reports in 1996 ⁷ and 2001 ⁸ indicated that inappropriate use of physical and chemical restraints had been reduced by federal regulations and quality reporting, but frequent preventable medical problems related to inadequate or insufficient care persisted. Pertinent to the Covid-19 pandemic, the U.S. Government Accountability Office recently reported that state surveyors found deficiencies in infection prevention and control in 82% of the 16,266 NHs surveyed between 2013 and 2017. ⁹

The IOM reports attribute these persistent deficiencies in U.S. NH care to the chronic underfunding and resultant understaffing of long-term care. More recently, Konetzka, lamenting the persistence of poor quality NH care, said:

“Nursing homes in the United States and Canada rely largely on constrained public funding…. To the extent that adequate staffing and meaningful quality improvement require resources, high-quality care may be out of reach for some nursing homes. ¹⁰ ”

The staffing model—minimum wage, lightly trained workers supported by bare bones professional staff—limits costs but may also endanger residents in an epidemic. While NH staff may have acted as spreaders of Covid 19, as well as its victims, they are also “the unsung heroes of this pandemic” ¹ providing compassionate care to sick and frightened older people cut off from visits by family and friends.

Essentially all NH’s rely heavily on health workers with only 1–3 months of job-related training who earn wages at or just above the minimum wage. ¹¹ Generally called nursing assistants (NAs) in the U.S., they have a variety of other titles around the globe—health care aide, personal care aide, etc. Although NA training includes nursing functions such as taking vital signs, monitoring input and output, and evaluating mental status, most of a NA’s working day is spent delivering personal care—bathing, dressing, toileting, feeding, etc. ¹²

For NH residents, NAs are the staff that know them best; they comprise 70 to 90% of the staff in most NHs and provide an estimated 80% of the personal care. The typical NA is a woman in her 40’s with a high school education, who is often the sole family breadwinner and frequently provides unpaid care for children and sick relatives. In the U.S., her current median wage is $14.25 an hour, and she may not have paid sick leave. If she does have paid sick leave, its use may be punished by demerits or requirements for a physician excuse. To make ends meet, many NA’s work second jobs, generally in long-term care, that increase their exposure to infectious agents. ¹³ Unscheduled absences from work are also relatively common and negatively influence quality of care. ¹⁴ Unsurprisingly, turnover is high; 1 in 2 will be working elsewhere at one year, and 2 in 3 will be gone at year 3. ¹⁵ Because of chronic understaffing, most NAs report on surveys feeling rushed, and frequently missing important tasks such as talking with residents.^16,17

Supervising and supporting the NAs are licensed nurses–registered nurses (RNs) and licensed practical nurses (LPNs). To receive Medicare and Medicaid funds, American NHs are required to have an RN on site only 8 hours a day and a licensed nurse 24 hours each day. In 1985, the IOM recommended increasing the required RN presence on site from 8 to 24 hours a day, ⁶ and repeated this recommendation in subsequent reports. Yet, the 8-hour-a-day RN minimum requirement continues to this day. RNs in NHs are paid less than their counterparts in hospitals, yet because of understaffing report higher levels of burnout than nurses in other settings. ¹⁸

Many organizations, including the World Health Organization ¹⁹ and the U.S. Centers for Disease Control, ²⁰ have provided recommendations to help NHs better prepare for, prevent, and manage Covid-19 infections among their residents, staff and visitors. The recommendations include: adequate staffing and plans to mitigate acute shortages; paid, non-punitive sick leave for staff; frequent testing of residents and relevant staff; the capacity to isolate exposed or infected residents; and adequate supplies of personal protective equipment. An apparently successful innovative intervention in four NHs in Spain included several of these recommendations. ²¹

The variation among NHs in Covid 19 infection and case fatality rates mentioned above presents opportunities for comparative research to identify NH staffing, quality of care, and other characteristics associated with fewer infections and deaths. Three recent publications^22–24 linked routinely collected U.S. data ²⁵ on nurse staffing, quality of care, and other facility characteristics with facility-specific data on Covid-19 cases and deaths. All three studies found that larger facility size, location in an area with a high rate of infection, and a greater percentage of African-American residents were related to having COVID-19 cases. Nurse staffing and quality of care measures did not distinguish between facilities with and without cases. However, among institutions with at least one case in Connecticut, Li and colleagues found that facilities with higher RN staffing and better quality measures had fewer Covid-19 cases and deaths. ²⁴ NH residents likely will remain at high risk from infectious diseases and deficiencies in care as long as the prevailing staffing model remains in place. Chronic understaffing must be addressed. In addition to possible reductions in Covid-19 cases and deaths, evidence indicates that increased nurse staffing reduces hospitalizations for influenza and pneumonia ²⁶ and improves overall quality of care.^27–29

Finally, the NA role needs to be rethought. The hard-working, dedicated folks caring for our vulnerable parents and grandparents need better training and deserve a living wage and full benefits. Better trained NAs with more fitting wages and benefits should provide a more stable workforce that is less likely to work while ill or in multiple long-term care settings, and able to play a more effective role in preventing and controlling infectious diseases.