As Governor Mike DeWine and Ohio Director of Public Health Dr. Amy Acton regularly remind us at their daily 2 p.m. briefings, the data about COVID-19 cases both in the community and in long-term care facilities is emerging and far from complete. As Dr. Acton is fond of saying, it’s really just the tip of the iceberg. Even so, Ohio began reporting COVID-19 cases originating in long-term care facilities on April 16 in an effort to help residents and their family members gain access to information about the number of infections within their facilities. Data was then removed due to inaccuracies and was reposted on April 22. Families and residents have been seeking this information for weeks, as long-term care facilities with high rates of infection have received the attention of both media and public health departments across the country. In fact, one of the first COVID-19 outbreak clusters in the U.S. occurred in a long-term care facility in the State of Washington.
One of the first COVID-19 outbreak clusters in the U.S. occurred in a long-term care facility in the State of Washington.
Data recently released by the Ohio Department of Health (ODH) includes the number of COVID-19 cases identified in both staff and residents as of April 21, the date of the report. Not included in the count are residents and staff who have either recovered or passed away prior to this date. Data is categorized by county, facility name and the type of facility. The dashboard reports 781 active cases, with 558 residents and 228 staff currently infected with COVID-19. Because this dataset does not include all cases originating in long-term care facilities, the total number of Ohio cases of COVID-19 originating in residents and staff of long-term care facilities is still unknown. The COVID-19 Dashboard will continue to report the number of cases originating in long-term care facilities, including nursing homes, assisted living and intermediate care facilities. The dashboard will not provide data for cases that originate in independent senior housing, or subsidized senior buildings. (Definitions of the various types of living situations in Ohio for older adults can be found here). ODH has indicated individuals with symptoms “in long-term care/congregate facilities” are considered the second priority in the state’s tiered testing approach, behind individuals with symptoms who are hospitalized or those who are health care workers. There are a number of other types of congregate living within the state besides long-term care facilities that will likely see clusters of cases, as has been described here.
Even with incomplete data, we can start to consider what the numbers may tell us.
Looking at the data available for cases originating in long-term care facilities, it is clear that distinct clusters of infection have emerged in some Ohio counties. What is less clear is whether the clusters truly represent the full penetration of the virus in a community or are a result of where testing has become available.
One thing we do know is that clusters exist because of how quickly the virus spreads when people spend time together in close proximity.
While there are many questions that remain unanswered about this virus, one thing we do know is that clusters exist because of how quickly the virus spreads when people spend time together in close proximity. The newly-released data shows some clear indications of clustered infections, with eight facilities having more than 25 identified cases among staff and residents. Of the 91 facilities with identified cases, 68 percent have more than one case. Long-term care facilities are by design places where people are in close proximity as they receive medical care and therapies during their residency. Until guidelines were released mandating they stop, many facilities offered congregate dining and social activities to bring residents together as way to reduce isolation, which may have unknowingly spread the virus. As Dr. Acton mentioned in the April 16 briefing, clusters of COVID-19 do not mean that long-term care facilities are doing something wrong. These are high-risk places, with many people often exposed before the first case is known to exist. She explained that we should not be surprised, it is in fact, the nature of the virus to spread this way.
As it became increasingly clear, older adults and those with underlying medical conditions are vulnerable populations to this virus and it spreads quickly in institutional settings, the Centers for Disease Control and Prevention (CDC), Center for Medicaid and Medicare Services (CMS) and Ohio Department Aging (ODA) issued guidance for long-term care facilities to protect their residents and staff.
Long-term care facilities received guidance and checklists from the CDC as early as March 13, providing them with strategies to keep unrecognized COVID-19 cases from entering the facility; identify infections early and take actions to prevent spread; assess the current supply of personal protective equipment (PPE) and initiate measures to optimize supply; and quickly recognize and manage severe illness reduce the spread of infection. The CDC also provided facilities with a letter template to be sent to residents, friends and families to outline steps being taken to protect residents from infection including restriction of visitation, monitoring of staff for symptoms and limiting all activities within the facility.
In addition to recommending facilities follow CDC guidelines and recommendations, CMS also provided guidance on April 2, that they would begin targeted inspections of long-term care facilities “in areas the virus is likely to strike next.” Regular CMS inspections have been suspended in order to focus on these targeted inspections and to put full attention on infection control. CMS also recommended long-term care facilities use separate staffing teams for COVID-19 positive residents and if possible, designate separate facilities or units within a facility to separate COVID-19 positive residents.
On April 13, the ODA provided a checklist for Ohio long-term care facilities that included language from an ODH order that suspended visitation to long-term care facilities. The order makes an exception for end-of-life care and allows only for personnel who are necessary for facility operation. Facilities were also ordered to keep a log of all people granted access to the facility. The checklist also includes a number of recommendations to reduce feelings of isolation among residents, to implement screening procedures among staff, to cancel communal gatherings and to increase the frequency of cleaning among other recommendations.
Another order issued on April 15, outlined stipulations related to notifying those associated with facilities of positive and probable cases of COVID-19, including the following language: “All nursing homes and residential care facilities in the State of Ohio shall notify the residents, the residents’ sponsor and/or the residents’ guardians of positive or probable cases of COVID-19 within the facility. This Order applies to both residents and staff who test positive for COVID-19 or have a probable diagnosis of COVID-19.” On the same day, the number of cases that originated in long-term care facilities was added to the ODH COVID-19 Dashboard, however as noted above, the data was removed due to inconsistencies and reinstated on April 22.
The state does not recommend removing residents from long term-care facilities, as often the person resides in the facility because they cannot receive the same level of care within a home or community-based setting. Instead the state recommends residents and their families monitor residents’ health closely and ask the facility the following questions:
- What are you doing currently to protect residents from COVID-19?
- What precautions do you take when you identify a person who is symptomatic of COVID-19?
- How are families kept apprised of changes related to your infection control policies?
Even with all of the recommendations, guidelines and checklists from the CDC, CMS and ODA fully implemented, it is still true that long-term care facilities, by the very nature of what they provide to those who need a nursing home level of care, are likely to have and increased number of identified cases. With a population of older adults, and those with underlying medical conditions, necessarily in close proximity with others so they can receive needed care, the residents of long-term care facilities are at a higher risk to be infected infection and experience severe symptoms than those in the general population. With this population already at risk of experiencing feelings of social isolation and loneliness, we, as the general public, should take great measure to not isolate them further through stigmatization related to COVID-19. Public health officials have advised that is both safe and necessary to continue provide deliveries and supplies to long-term care facilities.