ACADEMIA Letters

Tactical Responses to COVID-19 in a Long-Term Care

Facility
Thomas Higgins
Bonnie Geld
Laurie Signorelli

Long-term care facilities (LTCF) have been disproportionately affected by COVID-19 infec-
tion. Residents of these facilities are at high risk owing to older age, frailty and chronic co-
morbidities which reduce physiologic reserve and complicate the differential diagnosis of vital
sign abnormalities including fever, tachycardia, tachypnea, dyspnea, or desaturation via pulse
oximetry1 . In the early phases of the pandemic, more than a third of coronavirus deaths in the
United States were linked to nursing homes2 . Similar disproportionate impact has been docu-
mented internationally3 . Early on, insufficient access to personal protective equipment (PPE),
lack of testing capacity to identify asymptomatic individuals spreading the virus, few on-site
staff with pandemic control experience, and conflicting messages from politicians stymied
attempts at robust infection control. The “learning curve” has been steep, and LTCFs have
typically not had the funding and resources afforded to acute care hospitals. Yet, many fa-
cilities are now documenting success with infection prevention. At one facility, which was
hard-hit by COVID-19 in March and April, three consecutive months (and counting) have
1
Childs A, Zullo AR, Joyce NR, McConeghy KW, van Aalst R, Moyo P et al: The burden of respi-
ratory infections among older adults in long-term care: a systematic review. BMC Geriatr 2019; 19:210.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6683564/ accessed 11-04-2020
2
Yourish K, Lai KKR, Ivory D, Smith M: One-Third of All U.S. Coronavirus Deaths are Nursing Home Resi-
dents or Workers. https://www.nytimes.com/interactive/2020/05/09/us/coronavirus-cases-nursing-homes-us.html
accessed 11-04-2020
3
ECDC Public Health Emergency Team, Danis K, Fonteneau L, Georges S, et al: High impact of COVID-
19 in long-term care facilities, suggestion for monitoring in the EU/EEA, May 2020. Euro Surveill. 2020
Jun;25(22):2000956. doi: 10.2807/1560-7917.ES.2020.25.22.2000956. PMID: 32524949.

Academia Letters, March 2021 ©2021 by the authors — Open Access — Distributed under CC BY 4.0

Corresponding Author: Thomas Higgins, higginstl@yahoo.com

Citation: Higgins, T., Geld, B., Signorelli, L. (2021). Tactical Responses to COVID-19 in a Long-Term Care
Facility. Academia Letters, Article 468. https://doi.org/10.20935/AL468.

1
passed without a resident becoming infected, despite asymptomatic employees testing posi-
tive for COVID-19, patients exposed during off-site medical visits to emergency departments
or dialysis centers, and visitors exposed to contagious individuals within the incubation win-
dow. Infection prevention measures are disruptive to resident routine, family visitation and
day-to-day employee workflow, but appear to be effective. We offer several mitigation strate-
gies that were successfully implemented.

1. Routine screening and availability of rapid testing has been essential to threading the
needle between complete lock-down and judicious operation, including visitation. In
accordance with CDC guidelines4 , all previously negative patients and staff are tested at
least monthly, and more frequently if community rates are elevated or internal exposure
to COVID-19 has occurred. In the past three months, two asymptomatic staff members
were identified and isolated before spreading the infection to residents or other staff.
We now appreciate the importance of requesting a cycle threshold5 result when it is
necessary to test previously positive individuals, as polymerase chain reaction (PCR)
testing is sensitive enough to pick up residual messenger RNA weeks after a patient
becomes non-infective. One early lock-down of the facility might have been averted had
this information been available at the time. The facility was also provided an Abbott ID-
Now rapid-swab device with COVID-19 test kits that has augmented infection control,
with the understanding that rapid antigen detection is less sensitive6 and may produce
false negatives in newly-infected individuals. Operational concerns preclude using the
rapid testing for mass screening, but allow for immediate (20 minute) initial clinical
determinations, which are confirmed with a negative PCR test before lifting isolation
or quarantine.

2. Written protocols and flow charts have been developed for fever evaluation, rapid test-
ing, and escalation or de-escalation of isolation and quarantine measures. These proto-
cols cannot cover all situations, but provide a standardized baseline that can be rapidly
4
Centers for Disease Control: Interim SARS-CoV-2 Testing Guidelines for Nursing Home Residents and
Healthcare Personnel Updated Oct. 16, 2020 https://www.cdc.gov/coronavirus/2019-ncov/hcp/nursing-homes-
testing.html accessed 11-04-2020.
5
Service RF: One number could help reveal how infectious a COVID-19 patient is. Should test results
include it? https://www.sciencemag.org/news/2020/09/one-number-could-help-reveal-how-infectious-covid-19-
patient-should-test-results accessed 11-04-2020.
6
Centers for Disease Control: Interim Guidance for Rapid Antigen Testing for
SARS-CoV-2. https://www.cdc.gov/coronavirus/2019-ncov/lab/resources/antigen-tests-
guidelines.html: :text=Antigen%20tests%20are%20immunoassays%20that,extraction%20buffer%20or%20reagent.
Accessed 11/9/20

Academia Letters, March 2021 ©2021 by the authors — Open Access — Distributed under CC BY 4.0

Corresponding Author: Thomas Higgins, higginstl@yahoo.com

Citation: Higgins, T., Geld, B., Signorelli, L. (2021). Tactical Responses to COVID-19 in a Long-Term Care
Facility. Academia Letters, Article 468. https://doi.org/10.20935/AL468.

2
 modified. All visitors and employees receive temperature, travel and symptom screen-
ing at a single entry point. With the onset of influenza season and the presence of other
respiratory viruses, careful attention is paid to alternative explanations for new symp-
toms and vital sign abnormalities, and when in doubt the patient or staff is immediately
isolated until a workup is completed. For residents who may share rooms, this would
involve isolating a confirmed positive patient at a community hospital, or quarantining
a negative (by rapid antigen test) patient in a separate room until PCR confirmation.
Outbreak control includes repeated staff education, internal and external communica-
tion strategies and posting life-sized “stand-up” models outside units to visually guide
changing PPE requirements. The local tertiary-care medical center was contracted to
provide infection control and hospital epidemiology services to augment in-house tal-
ent. The facilities team added enhanced cleaning routines including surface disinfec-
tion, Ultraviolet C disinfection devices, and physical plant changes to ensure social
distancing, especially in break rooms where other facilities have experienced outbreaks
among staff.

3. Non-essential patient travel has been curtailed with telemedicine substituting for office
visits when possible. Foot care services were brought in-house, physician visits to res-
idents were increased, and robust communication using HIPAA-compliant texting put
into place with the medical team at the local community hospital. However, residents of
LTCF have ongoing medical needs, such as renal hemodialysis, cancer chemotherapy
and radiation, subspecialty medical consultation, and visits to emergency departments
that require outside travel. These have all proven challenging, with inadvertent exposure
to COVID-19 (fortunately without infection) during transport to appointments.

4. Visitation has been significantly limited. While this avenue helps prevent the spread
of infection, it is not without consequences on resident and family emotional health.
During this time, at each point where there was a “person under investigation” (or PUI)
or known contact of a staff member or other resident with a person testing positive for
COVID-19, visits would cease, following state Department of Health and expert epi-
demiologist guidance. During “clear” times with no PUI or known contacts, visitation
was restricted during good weather to an outdoor covered pavilion with social distanc-
ing and logs kept for contact tracing. As the days became cooler, propane heaters were
placed, and eventually visitation migrated to the lobby, the largest open area which was
restructured with social distancing and the use of portable room dividers. Enhanced
cleaning and airing of the room were provided. Direct contact and hugging was allowed
only with full PPE and under the direction of clinical staff, and provided much satisfac-

Academia Letters, March 2021 ©2021 by the authors — Open Access — Distributed under CC BY 4.0

Corresponding Author: Thomas Higgins, higginstl@yahoo.com

Citation: Higgins, T., Geld, B., Signorelli, L. (2021). Tactical Responses to COVID-19 in a Long-Term Care
Facility. Academia Letters, Article 468. https://doi.org/10.20935/AL468.

3
 tion to residents and their families. Catholic Mass (for the predominant demographic
at this institution) was held outdoors, and the priest made telephonic and iPad visits
with interested residents. Recreation staff was increased during this time, and creative
ways of providing engagement and communication with residents, such as “doorway
BINGO”, were implemented. Mental health services were resumed onsite rather than
via telehealth after working with vendors on a testing, tracing and orientation plan.

5. Curtailment of internal movement posed significant challenges. When a 14-day quar-

antine is in effect, residents were unable to use common areas, the canteen (snack bar),
solariums or the cafeteria. The resultant loss of exercise programs, sunlight exposure
and socialization had significant effects on the mental health of patients and dormitory
residents housed in an independent living facility on campus. Occupational and physi-
cal therapies continued, but were relegated to in-room only during restricted visitation
periods, and liberalized to hall walking and patio visits when there were no PUI. In
response to a cluster of non-traumatic fractures, we launched a fracture reduction pro-
gram including testing for vitamin D levels and treating any deficiencies. In addition,
orientation to safe handling and body mechanics education was provided, along with
training for slide pads and other equipment.

6. Enhanced communication for residents, families, staff and partners in care has been a
challenge. To increase patient and family connection and communication, each resident
was provided with an iPad, to eliminate infection risk with shared technology. Resi-
dents able to operate the iPad after training were free to arrange and have face-to-face
communication with their loved ones. For some residents, particularly those with de-
mentia, it was not possible; recreational therapy then works to set up regular video calls
to decrease isolation. During this time, one-on-one communication with both residents
and family by staff (MD, NP, LISW, RN, recreational and administration) has been
critical due to the constraints on visitation and normal communication means. Regu-
lar broadcast emails and letters on a minimal weekly basis to residents, families and
staff are a priority. Remote web-based monthly family meetings with administration
and leadership helps address concerns and issues. Veteran advocacy and family ad-
vocacy councils were re-instituted on a remote basis or in small, distanced groups. A
survivor’s support group for grieving families and staff psychotherapeutic support in
1:1 or small groups are helping to heal the trauma from deaths occurring during first
wave of COVID-19. In addition, the need for consistent, clear messaging on a near
daily basis to the state, Board of Trustees, the media, and special interest and advocacy
groups required significant attention

Academia Letters, March 2021 ©2021 by the authors — Open Access — Distributed under CC BY 4.0

Corresponding Author: Thomas Higgins, higginstl@yahoo.com

Citation: Higgins, T., Geld, B., Signorelli, L. (2021). Tactical Responses to COVID-19 in a Long-Term Care
Facility. Academia Letters, Article 468. https://doi.org/10.20935/AL468.

4
 In this brief report, we can only touch upon possible strategies and tactics7 , and caution
that the state of the art is constantly changing. We recognize that even the best infection con-
trol practices do not guarantee that COVID-19 will not be re-introduced in to the facility. A
particular challenge for our workforce is an urban location with crowded multifamily apart-
ment housing arrangements, and persistently high community rates of COVID-19 infection.
While we have navigated the recovery phase of the first wave of COVID-19, constant vigilance
is a must!

7
Word Health Organization: Preventing and managing COVID-19 across long-term care services : policy brief.
Geneva: World Health Organization; 2020 (WHO/2019-nCoV/Policy_Brief/Long-term_Care/2020.1). Licence:
CC BY-NC-SA 3.0 IGO

Academia Letters, March 2021 ©2021 by the authors — Open Access — Distributed under CC BY 4.0

Corresponding Author: Thomas Higgins, higginstl@yahoo.com

Citation: Higgins, T., Geld, B., Signorelli, L. (2021). Tactical Responses to COVID-19 in a Long-Term Care
Facility. Academia Letters, Article 468. https://doi.org/10.20935/AL468.