One of the primary factors in the spread of COVID-19 in skilled nursing facilities is the workforce — specifically staff members in a facility who are infected with the virus while not showing any symptoms of illness.
Regardless of whether or not those infected do begin to show symptoms, they can still pass on the virus, rendering symptom screenings — such as testing for fever and checking for cough or shortness of breath — ineffective in keeping it from getting inside a SNF. That makes widespread testing of staffers and residents paramount.
But in a time of scarce testing resources, operators have had to make hard decisions about who receives a test for COVID-19, or scramble to arrange their own partnerships to make sure they had the capacity to test in the event of an outbreak.
And while guidance on reopening nursing homes from the Centers for Medicare & Medicaid Services (CMS) issued on May 18 recommends that SNFs have the capacity to test staff once a week, among other benchmarks, the language of the guidelines emphasizes flexibility for states and does not appear to be a mandate, despite how forceful the recommendations are.
Vice President Mike Pence and President Donald Trump recommended ramping up testing in nursing homes at the federal level, but states have been left largely in charge of securing testing for COVID-19, and their strategies for testing among nursing homes varies widely.
West Virginia, for instance, was quick to call for testing at nursing homes, and over the past few weeks, other states have issued either mandates or goals to test all residents and workers in long-term care at least once.
In Colorado and Utah, testing has gradually come to focus on the staffers at long-term care and congregate living settings, but with different nuances.
Colorado’s testing initiative in nursing homes will focus on staffers over the next eight weeks, according to a May 22 Colorado Public Radio News report, based on work done at Colorado State University (CSU) that zeroed on the testing of nursing home workers due to the risk they pose for bringing in infection. The testing performed by CSU showed significant numbers of presymptomatic or asymptomatic workers – and allowed the SNFs where they worked to send them home to isolate and recover.
Utah also is focusing its testing efforts on workers in long-term care and congregate settings, according to a May 11 report in the Salt Lake Tribune.
The efforts of both states highlight how the call to “test, test, test,” which has become a mantra of sorts since the pandemic began gathering steam in the U.S., can be implemented — and how the reality of supplies and risk and time affect those strategies.
‘I’ve got nursing homes if you’ve got tests. How do we make this work?’
As COVID-19 began to spread across the country, the shortage of testing was a major concern for Dr. Nicole Ehrhart, director of the Columbine Health Systems Center for Healthy Aging at Colorado State University (CSU).
It was a point she and her colleague, CSU virologist Greg Ebel, discussed on a conference call held with multiple health care stakeholders in Colorado in the middle of March.
The concern both she and Ebel raised was that in addition to scarcity of tests, the testing was limited to people with symptoms; both Ehrhart and Ebel believed that there was some level of pre-symptomatic infection by those infected, or that in some cases, those infected might never develop symptoms at all.
Ebel’s work involves surveillance as a means of understanding disease, and given the concerns about COVID-19’s risk to people of older age in congregate settings such as SNFs, both wanted to focus their efforts on this population.
“I said: I think we should think about doing surveillance in these SNFs,” Ehrhart told Skilled Nursing News in a May 18 interview. “But the actual people we’re most interested in are the workers, because at that time, they had shut down visitors … and then they were screening workers for just symptoms, so fever, cough, history of coughing, etc., or history of exposure.”
That mid-March conference call had so many participants on it that Ehrhart’s pitch to focus on workers almost got lost in the number of voices.
But Dr. Gregory Gahm, the general medical director at Vivage Senior Living, which operates almost 30 facilities in Colorado, was able to hear her argument for screening workers. He just didn’t know who was making it at the time. But with some help from an employee of the state, he was able to connect with Dr. Ehrhart.
“I got in touch with Nicole and I said: Hey, I’ve got nursing homes, if you’ve got tests. How do we make this work?” Gahm told SNN.
For Gahm, testing residents for COVID-19 has never struck him as the best use of the resources available, since tests are hard to get and — in the first few months of the pandemic — results were slow to come back.
While the impulse to test every resident is a typical part of the medical mentality of testing — diagnosing and treating — the fact remains that testing is hard to obtain and there is no treatment for COVID-19, he told SNN. Vivage had already stopped communal dining for residents, and was testing resident temperature and oxygen three times a day; if symptoms emerged, they would be addressed, but that didn’t require a positive or negative test.
Asymptomatic workers were another matter entirely.
“What we really are learning is that you’ve got to get the asymptomatic carriers out of the facility,” Ebel told SNN on May 19. “And the only way you can do that is by testing them and asking them to self-quarantine for 14 days.”
To launch the testing partnership, Vivage chose a couple of SNFs to start, roughly in mid-March, and Gahm trained the staffers on how to perform the test correctly. The results were such that two more facilities were added to the pilot, and then a fifth and a sixth.
The tests led to some surprising findings. One facility with 120 patients and 100 staff saw no positive staff members, while in one facility with 75 patients and 70 staff who chose to participate, 14 nurses tested positive in the first week, while “14 or 15 other staff members” were positive, Gahm told SNN.
“That was devastating to them; it took out more than half of their nursing staff and a whole bunch of other people, and they really had to scramble to make things work and keep people there,” he said.
But two weeks later, those workers could return. And one other key part of catching the workers early is that the impact on cases was tangible.
“What we’ve learned is that, as we told people to go home if they’re positive, the number of new cases has gone down, down, down — down to zero in most of the facilities,” Ehrhart told SNN. “There’s still some facilities that have a very low, kind of smoldering amount of it still in this worker population. But we’re seeing that number of new cases in workers decrease.”
That suggests that early identification of COVID-19-positives before they show symptoms can reduce the number of new positive cases, she said.
The state of Utah has also zeroed on workers as a testing priority, because nursing homes and other long-term care facilities have been in lockdown since the middle of March, Utah Department of Health public information officer Charla Haley told SNN on May 19.
“The way [facilities] get a case is through exposure to an asymptomatic staff person who got it somewhere in the community,” she said. “So we are starting with just doing baseline testing in staff. We are starting with facilities at highest risk for larger outbreaks, i.e., those with memory care units, those with behavioral or intellectually disabled patients, and those with ventilated patients.”
Once that baseline test is complete, the state wants to implement infection control improvements on these specific units, including the limiting of staff movement and repeated testing of staff on the unit on a weekly basis, as well as improving use of and access to personal protective equipment (PPE), she said.
Research to reality in Colorado
After the success of the five-facility pilot in Colorado, the project was expanded, and now Colorado is planning to test all nursing home staff in Colorado every day for eight weeks.
However, there are some crucial factors that might make it hard to replicate elsewhere. The CSU lab had been studying the West Nile virus and was able to repurpose to study COVID-19 and add “enormous capacity,” Gahm said, but this entailed changing equipment and pivoting to make use of emergency authorizations on the state and federal level.
While the reverse transcription polymerase chain reaction (RT-PCR) testing done for COVID-19 is done “all the time in research labs,” these labs are not clinical labs, and the work is being done as a research effort — even though it’s the same testing as those done at ClIA-certified (Clinical Laboratory Improvement Amendments) labs, Ehrhart explained.
As a result, any positives that CSU finds need to be verified by a CLIA-certified diagnostic lab. And because the data is anonymized, CSU only has a case number for each positive.
When it comes to transmitting the results to workers in a timely manner, however, this isn’t as major an issue as it might sound. At the same time that CSU sends the COVID-19 positives to the CLIA lab, it sends the results to Gahm as well; Gahm can take the case number and find the associated name to contact the administrator, who can then notify the positive worker. Even though it might take a few days to get the person’s data to the state health department, the positive person knows “usually within hours of the time the test is run,” Gahm said.
But there were other hurdles that other testing initiatives in the country should keep in mind. At the beginning of the pilot, Ebel and Ehrhart were self-funding the project with startup funds Ehrhart had on hand because of her August 2019 assumption of the directorship at CSU’s Center for Healthy Aging. The state, at that point in March, was not ready to finance the study, given the chaos of the times and the fact that things were starting to escalate, Ehrhart said.
“We just said: This is so important, this is going to save lives,” she told SNN. “If we delay even by a week, it’s a matter of cost of lives. So we’ll just self-fund this.”
The other challenge is that CSU has some unique qualities that make it able to do this type of work. The university has a large number of labs that are Biosafety Level 3, the level needed for this research on various infectious diseases. But not every local research lab has that level of clearance.
Then there’s the personnel needed who can do the research on de-identified samples and work with local health officials on reporting and compliance.
“So it’s not quite as simple as reaching out to a research lab,” she said.
CMS administrator Seema Verma has said that states have either untapped or sufficient testing capacity, but Gahm believes the picture is more nuanced than that: He believes this is excess “potential” lab capacity, citing the pivot by CSU from West Nile to COVID-19. If labs cross the country repurposed for COVID, that would lead to plenty of capacity, he said. But it’s hard for them to do so overnight.
“You could do that at lots of universities and other labs,” he said. “You could do that, but I don’t know that people have done it.”
It’s also important to remember that the CSU initiative is a not a public health directive but a research project, albeit a crucial one. The surveillance testing over eight weeks will provide valuable information on the virus and how it behaves, particularly in terms of how it shifts as communities open up, Ehrhart said. That will have ramifications for visitation rules and how to adjust to changes outside the SNF walls, she said.
But because it’s a research project, there’s no requirement that employees participate, and as Ehrhart observed, “it isn’t exactly convenient for everybody to have their nose invaded weekly.”
Staff at Vivage felt the same way, Gahm said.
“We found anywhere to 20% to 50% of staff don’t really cherish the idea of having a swab poked back into your nose so it comes down to your throat and then you do it on the other side — every week for eight, 10, 12 weeks,” he told SNN.
And there’s one other crucial factor: the supplies of the tests themselves. As more and more states set mandates for nursing home resident and staff tests, that will mean exponentially increasing the tests provided.
There are roughly 210 nursing homes in the state of Colorado, with the average nursing home having 120 staff members, plus roughly 10 extra other essential workers, Gahm explained. That means each week, 210 nursing homes would need 130 test each. And that doesn’t include assisted living facilities.
“From what I can tell, they don’t have enough tests,” Gahm said when asked about the expanded push to test in Colorado. “They’re kidding themselves. We can do a lot more facilities, but I just can’t see that there are enough tests unless somebody is willing to step up and say … we’re only going to test hospitals and nursing homes and critical personnel. If they were willing to do that, there might be enough tests to do that.”