By Thomas Goldsmith

When leaders at the Piedmont Crossing nursing home in Hickory learned that COVID-19 was terrorizing North Carolina, they recognized the threat, even if they didn’t know yet how deadly this virus could become.

That meant that the facility, owned and operated by the nonprofit United Church Homes and Services organization, had a head start as one of the North Carolina homes that protected virtually all cases and deaths from the pandemic. Leaders at Piedmont Crossing had trained staff to deal with other, generally less serious viruses such as the flu, giving them the ability to modify those approaches for the fight against COVID.

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Along with other Tar Heel providers, key personnel at Piedmont Crossing passed along several key factors that saved their residents from the deadly fate that touched more than 1,800 other nursing home residents. According to data from the Department of Health and Human Services, about 200 North Carolina nursing homes have had no deaths from COVID-19. And more than 100, or about one in four, have had not a single case.

Getting ahead of the virus

“Before the pandemic hit, we’ve always had a robust infection control and prevention plan in place,” Lee Syria, president of parent organization United Church Homes and Services, said in a phone interview.

“While COVID-19 was a new virus and a highly contagious virus that no one had experience dealing with, our staff are trained pretty comprehensively on how to deal with other types of infectious outbreak. So I think that we found ourselves very well to be able to deal with this one.”

Because of ongoing staff development, Piedmont Crossing also possesses a storehouse of knowledge including a sound basis for building personal relationships, at times despite residents’ barriers. That made it easier to deal with residents’ emotional and support needs.

This approach emerged in a pre-COVID application the facility made for a best-practice award from Friends of Residents in Long Term Care. Specially tailored for residents with dementia, the training came in handy with residents who had little or no ability to recognize or remember the pandemic and the major changes it brought.

Given memory loss, residents with dementia often could not understand why relatives weren’t visiting, why they were mostly confined to their rooms, or why they could no longer enjoy dining in a common area with their friends.

“We realize that even though a resident has absolutely no safety awareness, person-centered care can be delivered in new ways by simply acknowledging and validating that the resident may be scared or anxious and that it is perfectly okay,” wrote Jan Briggs, Piedmont Crossing health care administrator.

“We cannot ‘fix’ the emotions or reactions of our residents living with dementia, as caregivers often want to do. Our residents are doing the best that they can. We had to ‘fix’ ourselves.”

UNC-Chapel Hill researchers Dr. Philip Sloane and Cheryl Zimmerman noted the difficulties of caring for people with dementia in a Health Affairs paper.

“Thirty-eight percent of residents displayed a behavioral symptom of dementia, such as refusing to bathe or wandering,” they wrote.

People in long-term care have long shown such symptoms, but the demands of the pandemic have worsened the situations of people who, for example, can’t recognize staff members from day to day, or understand why relatives and friends can’t visit.

Staffing can affect care

The pandemic has meant that providers can have a tough time maintaining full staffing, a factor that’s usually recognized as key to best practices in long-term care. Both the disease and changes in family patterns can affect staffing levels, said Adam Sholar, president of the trade organization North Carolina Health Care Facilities Association.

“You may have a mom who works at one facility, a daughter who works at a different facility, there may be another family member who works in manufacturing or something like that in the same community,” Sholar said. “It’s something that we’ve certainly learned early on. But coming out of this, as a country and as a state, we really have to focus our attention on growing the number of caregivers to provide care for those who need it.

“That has been highlighted during this pandemic. That is something that we absolutely must address.”

One factor driving outbreaks in nursing homes is the larger rate of viral spread in the community. In short, the more cases in the surrounding area, the more likely facilities will have an outbreak, research shows. Industry figures, clinicians and front-line workers are beyond frustrated at the widespread failure of many to minimize or ignore common-sense measures with real data to show their efficacy.

“We have been begging people the last eight months to wear a mask, socially distance and to be careful,” Mark Parkinson, president and CEO of the American Health Care Association and National Center for Assisted Living told USA Today. “Unfortunately, the public has not listened or complied.”

Recent research from the National Institutes of Health shows that shortages have shown up during the pandemic among key employees such as registered nurses.

And a study published in Health Affairs found that residents of nursing homes with a staff represented by a labor union died at a 30 percent lower rate than residents of non-unionized facilities.

“Unions were also associated with greater access to PPE, one mechanism that may link unions to lower COVID-19 mortality rates,” the authors wrote after their study of 355 nursing homes in New York state.

There’s a long association between lower staffing and quality of resident care in nursing homes, so DHHS is adopting various means to bring in help.

“We’re doing work around staffing to support facilities,” Dr. Susan Kansagra, chief of the DHHS Division of Public Health’s Chronic Disease and Injury Section, said in an interview. ”Early on we had worked really hard to survey nurses across the state to create a roster of nurses available to support facilities, should they have an outbreak and need extra support.”

In addition, DHHS worked with strike teams to make sure nursing homes have sufficient staff and controls in place to prevent spread of the disease. And as often is the case, money becomes even more important as residents use state, federal and private funds to cover an increasing level of care necessary during the pandemic. Programs that offer more chances for staff advancement can also help with shortages.

“We have to keep talking to our policymakers about making sure that along with those career pathways there’s funding for wages and things like that to grow, and entice people into the profession,” Sholar said.

State DHHS Secretary Mandy Cohen addressed many of the same needs during a Nov. 5 briefing.

“We know that our nursing homes, and our hospitals, and our medical system need continued help,” she said. “We know that our community colleges and universities need help in order to keep people safe. It is a long list and I do believe that the Heroes Act has a lot of what we were looking for and that we have communicated our long list of needs to people in Washington.”

Testing protects, reveals

Kansagra, with the Division of Public Health, called testing the cornerstone of the state’s COVID response. It took a while to get going in nursing homes, but is firmly in place as a means of virus detection, even in facilities where there is no apparent infection.

“Our early recommendations, supported by [Centers for Disease Control and Prevention] and [Centers for Medicare and Medicaid Services] is that once there is one case detected in the facility that every resident and staff member should be tested every three to seven days until there are no further cases detected for a period of two weeks after the last positive.”

Testing also allows for the practice of cohorting, in which residents and staff can be separated based on their negative or positive status in results.

“Our testing capacity remains high, and I encourage people to get tested if they have symptoms or think they have been exposed to the virus,” Cohen said. “On our peak testing days, labs are reporting more than 40,000 tests per day.”

The officials interviewed stressed the idea that several links in the chain of care must work together in the fight against such an intractable enemy.

“Testing is a tool to try to slow the spread of this virus,” Sholar said. “It’s not a silver bullet; we are going to use a bunch of different tools to try to contain this virus. Screening symptoms is not a perfect tool, but it’s our tool —  the one we’ve had the longest.

“Frankly, using PPE is a tool, testing is a tool and the more of these we can put together, I think the better.”

Always vital, PPE

Briggs, of Piedmont Crossing, said it’s crucial for the home or chain to get ahead of matching staff’s and residents’ needs for masks, gloves, gowns and more. That means the staff has more time for meeting the vital needs of residents.

“I don’t think that when this first began that any health care facility had the PPE necessary to prevent the spread of COVID,” she said. “I think that long term care facilities were behind the hospital systems because it was in the hospital systems all over the news.

“What helped a great deal in obtaining PPE was the fact that the home office staff spent a great deal of time finding resources, working with our supplier to make sure that we had the stuff that we needed. That was while we were here educating and monitoring and staffing and screening, doing those things that were quite time intensive.”

North Carolina’s abundance of universities and teaching hospitals means that new information about protecting residents often arrives with links to area resources. In a recent issue of the Journal of the American Medical Directors Association, Triangle experts Dr. Philip Sloane and Cheryl Zimmerman published articles including tips advising providers to:

  • Think hard about reducing the nursing home’s CPR team to two staff members equipped with eyeshields and N95 masks. That allows one staff member to perform chest compression and the other to bag any particles respirated during the process. 
  • Provide eyeshields to all doctors and nurses during direct patient care and to cleaning crew and others while in patient areas.
    “This practice is becoming more common in both COVID positive and COVID negative areas as it is becoming clear that the main way to prevent spread is with aggressive personal protective equipment (PPE) use,” the authors wrote.
  • Provide a clean face mask each day to all residents to wear throughout the day if tolerated. Efforts especially should be made for COVID positive residents to wear their masks when staff is in the room.

This story has been updated to correct Dr. Susan Kansagra’s name. 

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Thomas Goldsmith worked in daily newspapers for 33 years before joining North Carolina Health News. Goldsmith is a native Tar Heel who attended the UNC-Chapel Hill, and worked at newspapers in Tennessee...