'How to Improve and Protect Nursing Homes From Outbreaks' diff viewer (10/11)

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How to Improve and Protect Nursing Homes From Outbreaks	How to Improve and Protect Nursing Homes From Outbreaks
2020-06-23 11:18:23 UTC	2020-06-23 21:56:39 UTC (about 11 hours later)
The doctors, researchers and advocates who have been paying close attention for years are appalled at the way the coronavirus has devastated the nation’s nursing homes — but they’re not shocked.	The doctors, researchers and advocates who have been paying close attention for years are appalled at the way the coronavirus has devastated the nation’s nursing homes — but they’re not shocked.
“Every geriatrician knew what was coming,” said Dr. Mike Wasserman, a geriatrician and president of the California Association of Long Term Care Medicine.	“Every geriatrician knew what was coming,” said Dr. Mike Wasserman, a geriatrician and president of the California Association of Long Term Care Medicine.
Robyn Grant, the director of public policy and advocacy for the National Consumer Voice for Quality Long-Term Care: “The sheer numbers are horrifying. The underlying factors that have contributed are no surprise; they’ve been issues of concern for a long time.”	Robyn Grant, the director of public policy and advocacy for the National Consumer Voice for Quality Long-Term Care: “The sheer numbers are horrifying. The underlying factors that have contributed are no surprise; they’ve been issues of concern for a long time.”
A New York Times analysis as of May 21 showed that more than 34,000 deaths — 37 percent of the nation’s fatalities from Covid-19 — occurred among residents and staff in long-term care facilities. In 15 states, long-term care accounted for more than half of all Covid-19 deaths.	A New York Times analysis as of May 21 showed that more than 34,000 deaths — 37 percent of the nation’s fatalities from Covid-19 — occurred among residents and staff in long-term care facilities. In 15 states, long-term care accounted for more than half of all Covid-19 deaths.
Because states report cases in varying ways, and some report few numbers at all, “all of this could be undercounted,” said David Grabowski, a health care policy researcher at Harvard Medical School, noting that testing remains inadequate.	Because states report cases in varying ways, and some report few numbers at all, “all of this could be undercounted,” said David Grabowski, a health care policy researcher at Harvard Medical School, noting that testing remains inadequate.
Not until mid-April did the federal Center for Medicare and Medicaid Services announce a reporting system to track Covid-19 in nursing homes and funnel the data to the Centers for Disease Control and Prevention.	Not until mid-April did the federal Center for Medicare and Medicaid Services announce a reporting system to track Covid-19 in nursing homes and funnel the data to the Centers for Disease Control and Prevention.
But because nursing home care receives scant public attention even in better times, advocates like Ms. Grant see an opportunity, however grimly won. “People have been horrified by what’s happening, and that’s shining a light on the changes we need to see,” she said.	But because nursing home care receives scant public attention even in better times, advocates like Ms. Grant see an opportunity, however grimly won. “People have been horrified by what’s happening, and that’s shining a light on the changes we need to see,” she said.
It’s not hard to understand why the virus has streaked through nursing homes like “fire through dry grass,” as Gov. Andrew Cuomo of New York put it. Dr. Philip Sloane, in a recent editorial in The Journal of the American Medical Directors Association, compared them to cruise ships and prisons as incubators for disease.	It’s not hard to understand why the virus has streaked through nursing homes like “fire through dry grass,” as Gov. Andrew Cuomo of New York put it. Dr. Philip Sloane, in a recent editorial in The Journal of the American Medical Directors Association, compared them to cruise ships and prisons as incubators for disease.
“All three have large numbers of people in relatively small spaces, so it’s hard to do isolation,” said Dr. Sloane, a geriatrician who co-directs the Program on Aging, Disability and Long-Term Care at the University of North Carolina. “They have congregant meals prepared in central kitchens, staff that have a lot of personal contacts with residents. They have activities that bring a lot of people together.”	“All three have large numbers of people in relatively small spaces, so it’s hard to do isolation,” said Dr. Sloane, a geriatrician who co-directs the Program on Aging, Disability and Long-Term Care at the University of North Carolina. “They have congregant meals prepared in central kitchens, staff that have a lot of personal contacts with residents. They have activities that bring a lot of people together.”
Nursing home residents, of course, are frailer and sicker than cruisers and inmates. “These nursing homes are yesterday’s hospitals,” minus the on-site medical staff, Dr. Wasserman said.	Nursing home residents, of course, are frailer and sicker than cruisers and inmates. “These nursing homes are yesterday’s hospitals,” minus the on-site medical staff, Dr. Wasserman said.
What needs to change?	What needs to change?
Over the coming weeks, experts on nursing homes say, the top priority should be to greatly expand rapid testing and tracing for residents and staff, as some states have begun to require, and to acquire sufficient protective equipment.	Over the coming weeks, experts on nursing homes say, the top priority should be to greatly expand rapid testing and tracing for residents and staff, as some states have begun to require, and to acquire sufficient protective equipment.
“We’ve basically locked nursing homes down, yet Covid is still spreading because we don’t know who has it and we don’t have the P.P.E. to protect the staff,” Dr. Grabowski said.	“We’ve basically locked nursing homes down, yet Covid is still spreading because we don’t know who has it and we don’t have the P.P.E. to protect the staff,” Dr. Grabowski said.
For this pandemic and beyond, researchers and advocates suggest several broad ideas for improvement.	For this pandemic and beyond, researchers and advocates suggest several broad ideas for improvement.
Even before the coronavirus arrived in nursing homes, they had a poor record of preventing contagion.	Even before the coronavirus arrived in nursing homes, they had a poor record of preventing contagion.
“Facilities know it’s a problem, yet it’s remained one of the top violations in the country” in federally mandated inspections, Ms. Grant said. “These problems are cited year after year.”	“Facilities know it’s a problem, yet it’s remained one of the top violations in the country” in federally mandated inspections, Ms. Grant said. “These problems are cited year after year.”
In 2016, Medicare began requiring each facility to employ an “infection preventionist” to oversee policies and train workers. But that is often a part-time position. “The person in charge of infection control always has another job,” Dr. Sloane said. “That person also doesn’t have much clout.”	In 2016, Medicare began requiring each facility to employ an “infection preventionist” to oversee policies and train workers. But that is often a part-time position. “The person in charge of infection control always has another job,” Dr. Sloane said. “That person also doesn’t have much clout.”
Last year, Medicare proposed relaxing that rule, so that the preventionist no longer needed to be an employee, but must log “sufficient hours,” which Ms. Grant called “part of the deregulatory policy of this administration.” She thinks the pandemic has instead spotlighted the need for mandatory, full-time infection preventionists.	Last year, Medicare proposed relaxing that rule, so that the preventionist no longer needed to be an employee, but must log “sufficient hours,” which Ms. Grant called “part of the deregulatory policy of this administration.” She thinks the pandemic has instead spotlighted the need for mandatory, full-time infection preventionists.
American nursing homes have, on average, about 100 beds, in rooms flanking long corridors, with staff moving from one to another. Residents typically share a small room and bathroom — an arrangement that many dislike, and one that provides excellent conditions for viral transmission. Assisted living complexes appear to have fared somewhat better during the pandemic, partly because individual apartments make isolation easier.	American nursing homes have, on average, about 100 beds, in rooms flanking long corridors, with staff moving from one to another. Residents typically share a small room and bathroom — an arrangement that many dislike, and one that provides excellent conditions for viral transmission. Assisted living complexes appear to have fared somewhat better during the pandemic, partly because individual apartments make isolation easier.
“It’s time to really focus on private rooms in nursing homes,” said Karl Pillemer, a gerontologist and researcher at Cornell University. In the Green House model, for example, a dozen residents live in private rooms with homelike common spaces and assigned staff who know them well. This approach has gained ground very slowly, with 268 homes, of more than 15,000 nursing homes nationwide.	“It’s time to really focus on private rooms in nursing homes,” said Karl Pillemer, a gerontologist and researcher at Cornell University. In the Green House model, for example, a dozen residents live in private rooms with homelike common spaces and assigned staff who know them well. This approach has gained ground very slowly, with 268 homes, of more than 15,000 nursing homes nationwide.
But the Green House Project reports that as of May 21, in 245 homes with 2,653 residents, only nine have had Covid-19 cases, resulting in six deaths. With several small buildings on a campus instead of one large one, administrators could also more easily quarantine infected residents, Dr. Sloane pointed out.	But the Green House Project reports that as of May 21, in 245 homes with 2,653 residents, only nine have had Covid-19 cases, resulting in six deaths. With several small buildings on a campus instead of one large one, administrators could also more easily quarantine infected residents, Dr. Sloane pointed out.
Although new nursing homes offer private rooms, very few are being built. But renovation can create similar small households within older nursing homes, said Martin Siefering, a principal architect who co-directs the senior living practice at Perkins Eastman.
Updated June 22, 2020	Updated June 22, 2020
A commentary published this month on the website of the British Journal of Sports Medicine points out that covering your face during exercise “comes with issues of potential breathing restriction and discomfort” and requires “balancing benefits versus possible adverse events.” Masks do alter exercise, says Cedric X. Bryant, the president and chief science officer of the American Council on Exercise, a nonprofit organization that funds exercise research and certifies fitness professionals. “In my personal experience,” he says, “heart rates are higher at the same relative intensity when you wear a mask.” Some people also could experience lightheadedness during familiar workouts while masked, says Len Kravitz, a professor of exercise science at the University of New Mexico.	A commentary published this month on the website of the British Journal of Sports Medicine points out that covering your face during exercise “comes with issues of potential breathing restriction and discomfort” and requires “balancing benefits versus possible adverse events.” Masks do alter exercise, says Cedric X. Bryant, the president and chief science officer of the American Council on Exercise, a nonprofit organization that funds exercise research and certifies fitness professionals. “In my personal experience,” he says, “heart rates are higher at the same relative intensity when you wear a mask.” Some people also could experience lightheadedness during familiar workouts while masked, says Len Kravitz, a professor of exercise science at the University of New Mexico.
The steroid, dexamethasone, is the first treatment shown to reduce mortality in severely ill patients, according to scientists in Britain. The drug appears to reduce inflammation caused by the immune system, protecting the tissues. In the study, dexamethasone reduced deaths of patients on ventilators by one-third, and deaths of patients on oxygen by one-fifth.	The steroid, dexamethasone, is the first treatment shown to reduce mortality in severely ill patients, according to scientists in Britain. The drug appears to reduce inflammation caused by the immune system, protecting the tissues. In the study, dexamethasone reduced deaths of patients on ventilators by one-third, and deaths of patients on oxygen by one-fifth.
The coronavirus emergency relief package gives many American workers paid leave if they need to take time off because of the virus. It gives qualified workers two weeks of paid sick leave if they are ill, quarantined or seeking diagnosis or preventive care for coronavirus, or if they are caring for sick family members. It gives 12 weeks of paid leave to people caring for children whose schools are closed or whose child care provider is unavailable because of the coronavirus. It is the first time the United States has had widespread federally mandated paid leave, and includes people who don’t typically get such benefits, like part-time and gig economy workers. But the measure excludes at least half of private-sector workers, including those at the country’s largest employers, and gives small employers significant leeway to deny leave.	The coronavirus emergency relief package gives many American workers paid leave if they need to take time off because of the virus. It gives qualified workers two weeks of paid sick leave if they are ill, quarantined or seeking diagnosis or preventive care for coronavirus, or if they are caring for sick family members. It gives 12 weeks of paid leave to people caring for children whose schools are closed or whose child care provider is unavailable because of the coronavirus. It is the first time the United States has had widespread federally mandated paid leave, and includes people who don’t typically get such benefits, like part-time and gig economy workers. But the measure excludes at least half of private-sector workers, including those at the country’s largest employers, and gives small employers significant leeway to deny leave.
So far, the evidence seems to show it does. A widely cited paper published in April suggests that people are most infectious about two days before the onset of coronavirus symptoms and estimated that 44 percent of new infections were a result of transmission from people who were not yet showing symptoms. Recently, a top expert at the World Health Organization stated that transmission of the coronavirus by people who did not have symptoms was “very rare,” but she later walked back that statement.	So far, the evidence seems to show it does. A widely cited paper published in April suggests that people are most infectious about two days before the onset of coronavirus symptoms and estimated that 44 percent of new infections were a result of transmission from people who were not yet showing symptoms. Recently, a top expert at the World Health Organization stated that transmission of the coronavirus by people who did not have symptoms was “very rare,” but she later walked back that statement.
Touching contaminated objects and then infecting ourselves with the germs is not typically how the virus spreads. But it can happen. A number of studies of flu, rhinovirus, coronavirus and other microbes have shown that respiratory illnesses, including the new coronavirus, can spread by touching contaminated surfaces, particularly in places like day care centers, offices and hospitals. But a long chain of events has to happen for the disease to spread that way. The best way to protect yourself from coronavirus — whether it’s surface transmission or close human contact — is still social distancing, washing your hands, not touching your face and wearing masks.	Touching contaminated objects and then infecting ourselves with the germs is not typically how the virus spreads. But it can happen. A number of studies of flu, rhinovirus, coronavirus and other microbes have shown that respiratory illnesses, including the new coronavirus, can spread by touching contaminated surfaces, particularly in places like day care centers, offices and hospitals. But a long chain of events has to happen for the disease to spread that way. The best way to protect yourself from coronavirus — whether it’s surface transmission or close human contact — is still social distancing, washing your hands, not touching your face and wearing masks.
A study by European scientists is the first to document a strong statistical link between genetic variations and Covid-19, the illness caused by the coronavirus. Having Type A blood was linked to a 50 percent increase in the likelihood that a patient would need to get oxygen or to go on a ventilator, according to the new study.	A study by European scientists is the first to document a strong statistical link between genetic variations and Covid-19, the illness caused by the coronavirus. Having Type A blood was linked to a 50 percent increase in the likelihood that a patient would need to get oxygen or to go on a ventilator, according to the new study.
The unemployment rate fell to 13.3 percent in May, the Labor Department said on June 5, an unexpected improvement in the nation’s job market as hiring rebounded faster than economists expected. Economists had forecast the unemployment rate to increase to as much as 20 percent, after it hit 14.7 percent in April, which was the highest since the government began keeping official statistics after World War II. But the unemployment rate dipped instead, with employers adding 2.5 million jobs, after more than 20 million jobs were lost in April.	The unemployment rate fell to 13.3 percent in May, the Labor Department said on June 5, an unexpected improvement in the nation’s job market as hiring rebounded faster than economists expected. Economists had forecast the unemployment rate to increase to as much as 20 percent, after it hit 14.7 percent in April, which was the highest since the government began keeping official statistics after World War II. But the unemployment rate dipped instead, with employers adding 2.5 million jobs, after more than 20 million jobs were lost in April.
States are reopening bit by bit. This means that more public spaces are available for use and more and more businesses are being allowed to open again. The federal government is largely leaving the decision up to states, and some state leaders are leaving the decision up to local authorities. Even if you aren’t being told to stay at home, it’s still a good idea to limit trips outside and your interaction with other people.	States are reopening bit by bit. This means that more public spaces are available for use and more and more businesses are being allowed to open again. The federal government is largely leaving the decision up to states, and some state leaders are leaving the decision up to local authorities. Even if you aren’t being told to stay at home, it’s still a good idea to limit trips outside and your interaction with other people.
Common symptoms include fever, a dry cough, fatigue and difficulty breathing or shortness of breath. Some of these symptoms overlap with those of the flu, making detection difficult, but runny noses and stuffy sinuses are less common. The C.D.C. has also added chills, muscle pain, sore throat, headache and a new loss of the sense of taste or smell as symptoms to look out for. Most people fall ill five to seven days after exposure, but symptoms may appear in as few as two days or as many as 14 days.	Common symptoms include fever, a dry cough, fatigue and difficulty breathing or shortness of breath. Some of these symptoms overlap with those of the flu, making detection difficult, but runny noses and stuffy sinuses are less common. The C.D.C. has also added chills, muscle pain, sore throat, headache and a new loss of the sense of taste or smell as symptoms to look out for. Most people fall ill five to seven days after exposure, but symptoms may appear in as few as two days or as many as 14 days.
If air travel is unavoidable, there are some steps you can take to protect yourself. Most important: Wash your hands often, and stop touching your face. If possible, choose a window seat. A study from Emory University found that during flu season, the safest place to sit on a plane is by a window, as people sitting in window seats had less contact with potentially sick people. Disinfect hard surfaces. When you get to your seat and your hands are clean, use disinfecting wipes to clean the hard surfaces at your seat like the head and arm rest, the seatbelt buckle, the remote, screen, seat back pocket and the tray table. If the seat is hard and nonporous or leather or pleather, you can wipe that down, too. (Using wipes on upholstered seats could lead to a wet seat and spreading of germs rather than killing them.)	If air travel is unavoidable, there are some steps you can take to protect yourself. Most important: Wash your hands often, and stop touching your face. If possible, choose a window seat. A study from Emory University found that during flu season, the safest place to sit on a plane is by a window, as people sitting in window seats had less contact with potentially sick people. Disinfect hard surfaces. When you get to your seat and your hands are clean, use disinfecting wipes to clean the hard surfaces at your seat like the head and arm rest, the seatbelt buckle, the remote, screen, seat back pocket and the tray table. If the seat is hard and nonporous or leather or pleather, you can wipe that down, too. (Using wipes on upholstered seats could lead to a wet seat and spreading of germs rather than killing them.)
If you’ve been exposed to the coronavirus or think you have, and have a fever or symptoms like a cough or difficulty breathing, call a doctor. They should give you advice on whether you should be tested, how to get tested, and how to seek medical treatment without potentially infecting or exposing others.	If you’ve been exposed to the coronavirus or think you have, and have a fever or symptoms like a cough or difficulty breathing, call a doctor. They should give you advice on whether you should be tested, how to get tested, and how to seek medical treatment without potentially infecting or exposing others.
If you’re sick and you think you’ve been exposed to the new coronavirus, the C.D.C. recommends that you call your healthcare provider and explain your symptoms and fears. They will decide if you need to be tested. Keep in mind that there’s a chance — because of a lack of testing kits or because you’re asymptomatic, for instance — you won’t be able to get tested.	If you’re sick and you think you’ve been exposed to the new coronavirus, the C.D.C. recommends that you call your healthcare provider and explain your symptoms and fears. They will decide if you need to be tested. Keep in mind that there’s a chance — because of a lack of testing kits or because you’re asymptomatic, for instance — you won’t be able to get tested.
	Although new nursing homes offer private rooms, very few are being built. But renovation can create similar small households within older nursing homes, said Martin Siefering, a principal architect who co-directs the senior living practice at Perkins Eastman.
At the New Jewish Home’s campus in Mamaroneck, N.Y., for instance, the firm converted 59 of 300 beds into five small house communities. It also retrofitted nonprofit nursing homes in Tulsa, Okla., and Ocean City, N.J., to create smaller households.	At the New Jewish Home’s campus in Mamaroneck, N.Y., for instance, the firm converted 59 of 300 beds into five small house communities. It also retrofitted nonprofit nursing homes in Tulsa, Okla., and Ocean City, N.J., to create smaller households.
A common way that the coronavirus enters nursing homes is through the employees, inadvertently. “It’s staff bringing this in and spreading the virus to residents,” Dr. Grabowski said.	A common way that the coronavirus enters nursing homes is through the employees, inadvertently. “It’s staff bringing this in and spreading the virus to residents,” Dr. Grabowski said.