Universal Testing‐Based Response to COVID‐19 Outbreak by a Long‐Term Care and Post‐Acute Care Facility

Abstract

To the Editor: Earlier in the pandemic, discussion regarding coronavirus disease 2019 (COVID-19) patient and resource management focused on hospital-based acute care. Until recently, the importance of post-acute and long-term care as an essential healthcare systems partner has been underrecognized, especially regarding hospital resource management in the time of a pandemic. Hebrew Rehabilitation Center (HRC) is a 723-bed multicampus organization that provides both long-term care and post-acute rehabilitation services, with 625 and 98 beds, respectively. In many ways, HRC is not a typical long-term care organization as it operates within an integrated senior healthcare organization with a continuum of care that includes home- and community-based services and assisted living and independent living units. Additionally, medical care is provided by employed clinical staff and, notably, dedicated infection control preventionists. The average age of HRC's patients is 89 years, whose frailty and comorbidities increase their risk for worse outcomes from COVID-19 infection, which was shown in early reports from China, revealing a 21.9% mortality rate in patients older than 80 years.1 In February 2020, after confirmed cases of COVID-19 were reported at a Washington state nursing home, we began preparing for COVID-19 patients. We present steps taken in our long-term care and post-acute rehabilitation facilities during the early surge. HRC has demonstrated success in containing prior outbreaks with serious pathogens, such as norovirus. Clinical and operational leaders convened with two major goals—avoidance or delay in emergence of COVID-19 infections and preparedness for possible outbreaks in any of our sites. We closely followed recommendations from the Centers for Disease Control and Prevention and the Massachusetts Department of Public Health, building on the infection control infrastructure already present at HRC for rapid institution of isolation procedures, staff training, and appropriate use of personal protective equipment. Within 2 weeks, visitors were restricted from all campuses, nonclinical personnel began working remotely, daily staff temperature and symptom screenings were performed, and social distancing procedures for patients were instituted at all sites. Although strong infection control protocols were most helpful in delaying the first case, what was critical in mitigating spread was the development of testing protocols in partnership with Beth Israel Deaconess Medical Center (BIDMC), a major acute-care Boston, MA, teaching hospital, which enabled us to promptly deploy universal testing in our inpatient facilities. Universal testing allowed assessment of penetration of infection on each unit and floor and execution of data-driven decisions. These included strict isolation of patients, application of proper precautions, proactive discussion of goals of care, and even division of some units into COVID-19 positive and negative sections. It also helped to minimize COVID-19–related acute transfers to hospitals. Identification of asymptomatic COVID-19–positive cases was a major advantage delivered by the universal testing approach, given substantial prevalence of asymptomatic presentation.2 At HRC, rapid implementation of extensive testing procedures and daily tracking of COVID-19–positive cases, directed by the infection control team, enabled appropriate clinical management, cohorting of patients, and education of staff. None of this would have been possible without a strong partnership with BIDMC and access to effective, universal testing. Collectively, these initiatives significantly reduced spread of COVID-19 in the long-term care units. Initially, before universal testing, new cases tripled weekly. Following implementation of universal testing and associated containment measures, new cases declined to approximately 14% weekly increase for the following 2 weeks. Sustainability and long-term effects of these measures are yet to be assessed. Acute-care hospitals are equipped with well-established infection control teams and sophisticated in-house laboratories. Unfortunately, critically needed infection control expertise and laboratory testing are unavailable in many long-term care facilities, increasing their risk of igniting community spread. Our experience highlights the importance of careful planning, universal testing, cohorting, and an acute hospital and long-term care facility partnership to limit the effects of disease outbreaks during a pandemic. The authors have no conflicts of interest. I affirm that I have listed everyone who contributed significantly to the article. All authors meet the criteria for authorship stated in the Uniform Requirements for Manuscripts Submitted to Biomedical Journals. All authors have substantially contributed to design of the approaches described in the article, performed collection and interpretation of data, as well as drafted, revised, and approved the final version of the article. There were no sponsors.

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