Doctors try to safeguard nursing home patients from COVID-19

By | March 11, 2020

This is part of our Coronavirus Update series in which Harvard specialists in epidemiology, infectious disease, economics, politics, and other disciplines offer insights into what the latest developments in the COVID-19 outbreak may bring.

As the number of cases and deaths alike mount from COVID-19, the respiratory illness associated with the new coronavirus, the toll of fatalities at a skilled nursing center in Washington state reached 19, highlighting the deep danger the virus presents to the elderly.

Harvard-affiliated Hebrew SeniorLife offers a continuum of care for 3,000 elderly people daily, with a range of services including residential assisted living, short-term rehabilitation, outpatient services, and long-term care for those with chronic illness. In a Q&A interview aimed at understanding the challenges involved, Harvard Medical School Assistant Professor Helen Chen, Hebrew SeniorLife’s chief medical officer, discussed steps the facility has taken to combat the virus and the outlook going forward.

GAZETTE:  How concerned are you for your elderly residents and patients in the face of this epidemic?

CHEN:  We’re very worried, and I know they’re anxious because I’ve been getting a lot of emails from them. For the inpatients, many are here because they’re not cognitively able and, for them, we’re just trying not to make them anxious. But it is really the families of those patients and residents who have expressed the most concern.

GAZETTE: Are you taking any special steps in the face of this?

CHEN: We’ve enhanced staff training and are looking at revising protocols regarding personal protective equipment. But the main intervention is limiting visitation, and no visiting if you are ill. We recognize that many people who live here are reliant on their family members for emotional and social support, but we’re encouraging people to limit visits with an eye toward protecting the vulnerable people who live with us. Today I heard from security that we’ve had a significant decline in the number of visits, which is, I think, a good thing.

For those who do come, we have moved to screening all visitors who enter any of our health care campuses and most of our housing sites. The health care campuses are a particular focus because people who live in a long-term chronic hospital or in the rehab unit are at high risk. They are older and have comorbid conditions, so every visitor receives a health and travel assessment before they’re allowed on campus.

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GAZETTE: Does that screening happen when you walk in the door?

CHEN: Yes. There’s a symptom review, there’s a travel review, and there’s an exposure review. And if the answer to any of those questions is yes, then you’re asked to not come in. And so far people have been compliant and have left. So that is a good thing.

GAZETTE: How many folks have been asked not to come in?

CHEN: [The number is] very small — three or four — because we told our Family Advisory Council we were moving forward with this and sent written and email communication to our families and to frequent visitors. So most people were not surprised when they came to visit.

We are also no longer allowing volunteer programming, which is a sad thing. We have a huge number of volunteers, but I think it is a prudent measure. We also have a wonderful, multigenerational program on one of our campuses, which is co-located with a K-8 school. The kids would come over to do activities and visit. That has been temporarily suspended. We also hosted quite a number of events — parties and celebrations and things of that nature — which have all been suspended until further notice.

GAZETTE: How hard is it to make these decisions, given the importance of social connectivity and visits from family to the lives and emotional health of your older residents?

CHEN: It’s incredibly hard. At the end of the day, for the people who live with us, this is their home. And in our homes, we have visitors, guests, people coming in and out. Likewise, when someone is living here, we’d like them to have visitors and social support. But we’re trying to balance the psychological and emotional well-being of our residents against their heightened risk for complications and mortality from this virus. We continue to learn more, but the highest-risk group — if you’re talking about mortality — is people over the age of 80 who have comorbid conditions. That describes a lot of people who live here.

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GAZETTE: How closely have you followed the Life Care Center situation near Seattle? Are there lessons that you can draw from that? Or is what you’re doing drawn from standard public health practice?

CHEN: I only know what’s been published. What we have seen from that is it’s about avoiding exposure to an infected person as much as possible, and then being as aggressive as possible if exposure occurred.

I hope that when this all improves, everyone who’s been involved would openly share what we should be doing as a nation in terms of our public health infrastructure — in particular for our older patients and those in long-term care.

GAZETTE: What should family members know ahead of time about visiting an elderly family member, either in your facility or another? Should they put all visits off? Monitor their own health and then make a decision?

CHEN: It’s a very individualized decision regarding whether or not to visit with someone. Everybody should use common sense and judgment about symptoms. If you have a cough and a fever, if you’ve got respiratory symptoms and you’re short of breath, if you’ve traveled to a place of concern or if you may have been exposed to someone who did — especially if you’re symptomatic — then I would definitely ask, “Do I really need to visit my grandma today? Can I wait and can I Skype her? Can I do FaceTime?”

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I know that’s hard for some of our older adults who aren’t technologically savvy, but maybe now is the time to get them hooked up. It really would be heartbreaking if, in wanting to do something positive for someone’s emotional or mental health, you ended up infecting them.

GAZETTE: Any advice to people considering elective surgery like hip replacement that might land them in a rehabilitation facility? Should they consider delaying it?

CHEN: I haven’t seen any specific recommendations — and I’m not advising anyone — but my personal take, separate from the rehab issue, is to ask, do you want to be in the hospital during this time if something’s really completely elective and can absolutely be delayed? Why not wait until we either know more or we have more experience or we have more clarity about the true prevalence? If it could wait, I might consider having a conversation with my primary care doctor or surgeon.

GAZETTE: Anything else the public should know concerning this new virus and our elderly, whether at Hebrew SeniorLife or elsewhere?

CHEN: I’m saying this to everybody — everybody — and I can’t emphasize this enough: really, wash your hands, wash your hands, wash your hands. I know people are tired of hearing it, but it is really true. During the SARS epidemic, washing your hands, using good cough etiquette, using social distancing and not touching your face, they estimate dropped SARS spread by 30 to 50 percent.

And, because there’s no vaccine, because there’s no targeted treatment for this virus yet, we would implore the public to really think about protecting our most vulnerable population, namely the very old and those with chronic medical conditions. Think carefully about whether — even if you think you just have a cold — you want to expose this very vulnerable population to your viral pathogens. Our elders are vulnerable and we’re all very concerned about their health.

Health & Medicine – Harvard Gazette