Coronavirus Disease19 in Geriatrics and Long‐Term Care: An Update

We finished drafting an article on coronavirus disease 2019 (COVID-19) in geriatrics and long-term care just over a week ago that is now available on the journal website. As we suggested, the fluidity and evolution of the COVID-19 pandemic related to long-term care facilities (LTCFs) has already made it outdated. This editorial provides some key updates and resources. Readers should continue to monitor the Centers for Disease Control and Prevention (CDC) and the Centers for Medicare and Medicaid Services (CMS) websites, as well as the many organizational websites and journals that are posting and publishing up-to-date information. Many state licensing agencies and local and state governments also continue to publish additional directives for healthcare providers across the United States, especially in regard to the screening requirements for team members and visitors. It has become clear that many LTCFs will care for patients/residents who have documented COVID-19 if they are not among those who have done so already. This is because many LTCF staff may be infected with no or minimal symptoms and spread the virus to other staff and patients/residents unknowingly. In addition, many caregivers and nurses work for more than one healthcare provider, increasing the possibility of the spread of COVID-19 between sites. Moreover, it appears, based on early experience in the state of Washington, just over half of LTCF patients/residents who are COVID-19 positive have no or atypical symptoms and are shedding enough virus to be infectious to others, including staff, patients/residents, and visitors. Until more rapid COVID-19 testing is available that will enable us to test all patients and staff, cases of COVID-19 infection are likely to continue to increase in the LTCF setting. To complicate matters, LTCFs will be asked to accept patients with possible or known COVID-19 from hospitals if the local or state government has not required the suspension of admissions during the presence of active COVID-19 cases. The CDC offers interim guidance on a test/no test strategy for LTCFs to accept patients with known COVID-19 infection. Where testing is available, this requires two negative tests 24 hour apart. For patients without known COVID-19 infection, most LTCFs will understandably require a negative test. In Louisiana, hospitals are prohibited from discharging patients with COVID-19 or those with symptoms to nursing homes. In contrast, New York requires all LTCFs across the state to accept these patients, including those without any test results, regardless of the local availability of hospital and intensive care unit (ICU) beds. AMDA/The Society for PostAcute and Long-Term Care Medicine/American Medical Directors Association (AMDA-PALTC), the American Health Care Association (AHCA), and the National Center for Assisted Living objected to mandates to accept all patients without testing in a joint statement. They recommended the creation of dedicated wings or units within a facility to accommodate hospital discharges or consolidate residents between facilities to create “new” facilities to accept hospital discharges. Another approach might be the development of “centers of excellence” and the use of swing beds in critical access hospitals for care of COVID-19 patients outside the hospital where feasible, but will not mitigate the critical situation that is emerging in some areas. Because older LTCF patients have multiple comorbidities, the mortality rate from COVID-19 infection will be high. Early reports suggest the case fatality rate for those older than 80 years, which constitutes nearly half of LTC residents, is over 15%. Thus, the importance of advance care planning and well-documented advance directives cannot be overemphasized. In areas where there is a shortage of ICU beds and respirators, even the most carefully thought out ethical approaches to rationing these resources will place our older patients at a lower priority. Below, several key points are listed that we hope will be helpful. Undoubtedly, the situation will change even before this comes online. Further updates will be necessary, which the journal and the American Geriatrics Society (AGS) are committed to providing.