Planning for the inevitable: How one nursing home stopped the COVID-19 spread

In late January, when Chinese health officials began warning that a dangerous new virus could be spread by seemingly healthy people, the staff at the Durham VA Health Care System began ordering supplies to protect workers and patients against an outbreak in North Carolina.

“As soon as we understood that there was a degree of presymptomatic and asymptomatic transmission, it was almost like you knew the train was coming and you just didn’t know how long it was gonna be or how hard it was going to hit,” said Dr. Chris Hostler, a staff physician in infectious diseases and associate hospital epidemiologist for the Durham VA Health Care System.

The VA staff pulled out their plans for responding to a pandemic and began revising them with what they knew about the new virus, a coronavirus called SARS-CoV-2 that seemed to be hitting older people with previous health issues particularly hard. They planned not just for possible effects on the hospital, but also in an associated nursing home — the Durham VA Community Living Center, which housed dozens of veterans with the kinds of health conditions that could make them vulnerable to contracting and dying from the virus.

More than 1 in 4 nursing homes in the country have had at least one case of coronavirus, according to data compiled from the states by The Washington Post. A full accounting is not available due to testing shortages and varied disclosure practices, but it’s clear that nursing homes have become deadly epicenters of COVID-19, the disease the virus causes.

In North Carolina, nursing home residents comprise more than half of the deaths related to the coronavirus.

At many facilities, infection spread quickly, affecting nearly every resident and many staff members. That wasn’t so when the virus showed up at the Durham VA Community Living Center. The facility had four residents and four staff members test positive.

Then, no more.

Soon, the VA staff was asked to consult with other facilities to try to replicate those results.

How to contain the virus

The News & Observer spoke with Hostler and several other VA leaders, including the facility’s medical director, Dr. Jack Twersky, and its acting chief nurse, Shenay R. Hargraves, about how they managed to curtail the virus’ spread. They credited early and thorough preparation, access to testing and personal protective equipment, frequent communication with staff and extensive teamwork for their success.

As part of the VA system, the Community Living Center had some distinct advantages. It could draw on the VA’s supply chain and its medical expertise. Unlike many other nursing homes, it had sufficient staff, testing and personal protective equipment, known as PPE.

The Community Living Center was also early to adopt social distancing measures, such as canceling group activities and communal dining. The facility banned visitors, except when a resident was near death, and started screening all employees for symptoms of COVID-19 weeks before those measures became required.

It reduced the number of veterans in the nursing home by more than 30% by discharging patients who completed rehabilitation and asking families if they would like to care for their loved ones at home. Many families did. A lower census — 27 or 28 patients instead of 41 — meant more staffing resources would be available in case of an outbreak.

It also meant more veterans would have their own rooms, which is helpful for preventing illness from spreading between roommates. Typically, most nursing home residents share a room.

Staffers also tried to minimize the chance that residents would catch the virus on a trip to get medical care. The Community Living Center is connected to the VA hospital and across the street from Duke University Hospital. But the nursing home trained nurses to perform some procedures that would normally have been performed by hospital staff and tried to reduce visits to the emergency department by having a doctor already in the building perform assessments. Residents who did leave for medical care were put under a 14-day quarantine.

The cleaning regimen, which already included the use of UV light to disinfect rooms, was increased, and staff began practicing for what they would do if they suspected a positive case. They drew up step-by-step instructions for how to set up a testing station outdoors and how to move residents through the hallway. In the process of rehearsing, they refined their plan, figuring out, for example, how best to divide staff working with residents suspected of having COVID-19 from those who aren’t. Carts were filled with the necessary PPE, ready to go.

On March 24, a universal masking policy took effect. Mindful that residents might find it alienating and stressful to no longer see their nurses’ faces, staff also began wearing a photo of themselves clipped to their clothes. The same day, they set up an area to house residents who test positive, just in case.

The first positive test result came March 30. A patient with a spinal cord injury had a fever. Test results showed he was negative for flu, but positive for COVID-19.

The patient was isolated in a prepared room. All of the other residents were temporarily deemed “persons under investigation” — treated as if they too had tested positive. No one could leave their room.

All residents and staff were tested. Three additional residents and four staff members tested positive. The staff members who got positive results went home with paid leave, and the rest of the staff quickly switched over to the plan they had rehearsed.

The simulations and drills “gave staff a comfort level” that made for a smooth response, said Benjamin McCathern, the Community Living Center’s nurse manager.

Testing was done repeatedly, staff got daily briefings, along with training and mindfulness exercises, and families got regular updates, leaders said.

No one at the facility has tested positive for three weeks.

Is an outbreak a scarlet letter?

The Durham VA’s Community Living Center is not the only nursing home in the state to stop the virus before it became pervasive in their facility.

Five other nursing homes, including Hillcrest Convalescent Center in Durham, had an outbreak with cases in the single digits that has now been deemed over. None contacted by The News & Observer chose to share their experience.

Hillcrest, however, has taken out ads in The N&O decrying the state’s practice of declaring an outbreak at any facility with two or more positive cases and saying “we should be very careful not to paint the entire profession with the same brush.”

The facility had two positive cases, state data show. One resident died.

The available evidence from facilities with the state’s largest outbreaks suggests they did not take many of the steps the VA did.

The management of The Citadel Salisbury, where 157 people have tested positive for the virus and 18 have died, discouraged staff from wearing masks and resisted getting residents tested even when they showed symptoms, current and former staff members said in sworn affidavits submitted as part of a lawsuit.

Margaret Blackwell, a former resident, said in an affidavit that communal activities and therapy continued even after an outbreak had begun.

The staff did not always have their temperature checked when they entered the facility and nurses sometimes wore the same gloves as they went from room to room, wrote Blackwell, who eventually contracted the virus.

Neither The Citadel nor the corporation that runs it, Accordius Health, responded to inquiries from The News & Observer on Wednesday about how the virus was able to spread throughout the facility. But the facility’s administrator, Sherri Stolzfus, said in an interview with The Salisbury Post last month that the nursing home had an emergency plan and adequate staffing and followed guidance from the U.S. Centers for Disease Control and Prevention.

Turning experience into advice

Since the Durham VA’s outbreak, a team of staff has gone into two other facilities serving veterans to help them respond to positive test results or suspected cases.

The VA “strike team” consults on the proper use of PPE and social distancing measures, and has helped with testing at facilities in Kinston and Wilson.

“We identify what questions they have in particular,” said Kate Murphy-McMillan, the Community Living Center’s nurse educator, “and a lot of times we bring up things they haven’t even thought of,” like where to set up a designated area for people awaiting test results.

At least two other strike teams in the state have helped facilities respond to likely infections.

The end of the outbreak at the VA doesn’t mean things have gone back to normal. Residents can leave their rooms, but they have to wear a mask. Rehabilitation happens in a resident’s room rather than in the gym. Residents meet with their doctors more often through telemedicine. Testing continues and will for some time, as long as the virus is prevalent in the larger community, Hostler, the infectious disease doctor, said.

“We know that as this continues to spread in our communities, we’ll have people who are positive,” Hostler said. “I think the real success story here is that we’re focused on aggressive identification and quick action to isolate.”

This story was originally published May 21, 2020 at 1:18 PM with the headline "Planning for the inevitable: How one nursing home stopped the COVID-19 spread."