COMMENTARY

One Doctor's Account of Long-term Care in the COVID Era

'It's Always Something Different'

Christian Bergman, MD, as told to Kat McGowan

April 15, 2021

The pandemic thrust the little-known world of long-term care (LTC) facilities into the headlines. About one third of coronavirus deaths nationwide occurred among LTC residents, who are far more likely to die from an infection than others. Staff, too, were affected. Over the winter, as COVID-19 ripped through nursing homes across the nation, medical directors like Christian Bergman, MD, were faced with the need to prevent infection, protect residents and staff, and maintain the quality of care under trying conditions.

Dr Christian Bergman

Bergman is also an assistant professor in the division of geriatric medicine at Virginia Commonwealth University. As an academic, he researches care coordination, transitions in care, and related subjects; as an administrator at an LTC facility, he coordinates and oversees a medical staff caring for complex and vulnerable nursing home residents; as a doctor, he sees those patients as a primary care physician.

As Bergman and his coworkers cope with burnout, the virus lingers and daily life is still not back to normal. A February CDC report suggests that roughly 78% of LTC residents nationwide have received at least one COVID-19 vaccine dose, but uptake among staff has been more modest. Bergman gave Medscape a look into the daily demands of his work, chronicling parts of the past 5 months. From November and December, and again in March, Bergman shared his thoughts amid the strains of this winter, the hope represented by the vaccines, and the possibility that nursing home medical care will soon be more widely recognized.

November 30, 2020:

Typically, the holidays are filled with families visiting. But residents haven't been able to see their families for the past 8 months, so it's very difficult to round now.

One resident I saw today had some nausea and abdominal pain. Those are atypical symptoms of COVID-19, so she was moved into the observation unit. She's doing OK, but the challenging part is that she also has moderate to severe dementia. She can't say: "I had nausea that started 5 days ago." She can't describe the pain. She just points to her stomach. Family members are typically very important. They can tell if somebody is off, not seeming like themselves, providing the collateral history. Family members have not been in these facilities, and that removes the opportunity for extra information.

Our facility had outbreaks early in the fall, and a few staff members got sick. Thankfully nobody passed away. Now we've had another exposure. A staff member called out sick on Wednesday, and test results came back positive Friday morning after Thanksgiving. This individual was a direct patient-care staff person, but luckily in the last week was working only on one unit. So we went through that unit of 25 residents, scrutinizing their charts, looking for symptoms. So far, nobody had any. This morning, everybody gets tested, all 120 staff members.

We also had our monthly meeting today. There's been a sense of frustration about the risk that the nursing staff is putting themselves through, for very low pay. Some people have already gone back to school. A lot of the CNA (certified nurse assistant) staff have left. Nursing staff can get paid more money elsewhere — for instance, in the spring someone quit and took a job for four times the pay in New York, during their crisis. We used to have a consistent nursing pool, mostly full time. Everybody knew each other and knew the protocols.

Now, we have a smaller work pool, and one third of our direct nursing staff are agency staff, temporary employees. People aren't used to the protocols. It's very demanding on the nursing leadership. And people are tired. We're losing focus on some of the targets, things we were doing before COVID-19 hit: reducing falls, working with physical therapy. There were a lot of good projects underway. Now, all the focus has shifted to COVID.

December 1, 2020:

The day focused on a project that does remote education for nursing home staff and administrators regarding infectious prevention practices. It's part of a tele-education and mentorship program called Project ECHO that enables specialists to teach a larger audience. In Virginia we provide education for 140 nursing homes through Zoom calls. I'm one of the co-PIs.

The whole purpose is to reduce spread of COVID-19 inside long-term care facilities, so we presented a case: A new resident develops a low-grade fever overnight and GI symptoms. Would you move this resident and cohort them in a different area of the building, or isolate in place knowing the roommate might be exposed?

We had a good discussion. It's very challenging from a patient autonomy and rights perspective. People live here. These really are their homes, and if you move somebody you risk the resident not having access to their clothes, TV, belongings. Also, you have to quickly execute a plan. You want to make sure you have a staffing plan in place to do that, and you don't cross-contaminate. You need to isolate quickly, but you can't just open the door and roll the bed into the next room.

December 9, 2020:

Since our one case before Thanksgiving, two more staff members tested positive, and 12 residents. It happened very quickly.

Today, we had a monthly meeting with all of our 13 nursing home partners, the administrators and directors of nursing at various facilities, talking about the vaccine. The focus of our conversation was education. Staff ask: Will this vaccine alter my DNA, will it make me infertile, or give me COVID-19? The question is: Who delivers educational resources to staff? Who supervises a town hall? We've been trying to engage medical directors, and others, to sit with staff and answer their concerns. I'm excited about the vaccine, but I'm worried about vaccine hesitancy.

After the meeting, I went over to my facility and saw a few residents. One woman had a toothache. She says, "Hi Dr Bergman, my tooth hurts here," and points. The first thing I was struck by was that I didn't know she had no teeth in the back to begin with. All her upper teeth had been removed because of gingivitis and cavities. It's not clear to me that her oral care in the facilities has been enough. She's able to brush, and the staff give her a toothbrush and a cup, but she can't get to the mirror to see.

She needs proper dental care, and it's hard to get podiatry, dental care, psychiatry support in LTC. We used to have a mobile dentistry clinic, but because of COVID-19 a lot of those services don't want to come to nursing homes anymore. And it's hard to find a dental clinic that supports Medicaid. The school of dentistry has a free clinic, but it can take a few months. For her, the temporary measure to prevent a bacterial infection was an antibiotic mouth rinse, and I'm struggling to find a place for her to get into. That's my project for tomorrow.

December 10, 2020:

Tonight, I'll see one resident we've been trying to discharge for 2 or 3 months. It's difficult. Previously she lived by herself. She was hospitalized 3 months ago because of worsening mental health, and during that investigation was found to perhaps not be able to take care of herself. She was sent to skilled nursing to see if she could recover, and it's been a roller-coaster ride, with multiple complications.

Family can't come into the building to visit her, and her mental health has declined because of isolation and restrictions. She wants to go in the common room, the dining room. In a pre-COVID world she would have done very well. She could sit at the nursing station in her wheelchair and talk to people. But because of the restrictions, she can't cope.

Mental health and physical health are connected, especially in long-term care. In LTC everything is done for you. A lot of people struggle with that. The loss of independence is very difficult for people to accept, and the loss of functional and cognitive clarity leads to stages of denial. It's true for any human being.

December 16, 2020:

My days are never the same. That's common of clinicians in the nursing home setting. It's always something different. For the short-stay patients — rehab folks — we're dealing with complicated patients coming out of the hospital: Post-op surgical cases, wound care, often requiring specialized education. For our LTC patients, we essentially act as their primary care doctor.

This is my inpatient consult week on the geriatric consult service in the hospital. We're basically medical co-management for surgical patients over the age of 65 who've had trauma, orthopedic surgery, GI surgery. For nonsurgical patients, we deal with geriatric syndromes, polypharmacy, falls, and especially delirium.

Delirium is the bread and butter for the geriatric consult. Our patients are predisposed to it. LTC patients over the age of 65 have a 60% to 70% chance of having underlying dementia. Any underlying cognitive impairment puts folks at a higher risk of ICU delirium. In the hospital, the patient may not be able to advocate for themselves, and they may get medications that make delirium worse, and then complications that keep them there longer. They're very complex patients, with functional and cognitive impairments that make it challenging to take care of them.

December 17, 2020:

Today at the main hospital, I got the vaccine. The actual injection was nothing. I felt fine. No side effects, and now at the end of the day my arm feels fine. There was a general optimism in the room, a sense that we're trying to help each other out.

This whole week has been focused on vaccine education in the Project ECHO sessions. We've been doing polls. The people on our calls — primarily directors of nursing or infection prevention nurses — say they're likely to get the vaccine. However, today one facility stood out. There, 11% of the administrators and directors of nursing said they were very unlikely to get a vaccine. That number did not change even after our educational session. One of the comments in chat was, in all caps: THE FDA HAS NOT APPROVED THIS VACCINE. That caught me off-guard. It's very difficult in terms of staff confidence if the leadership is already saying they don't want the vaccine. There's still a long way to go to make sure people have access to objective data so they can make their own, independent decision.

March 22, 2021:

This has really been an Ironman marathon — longer than a regular marathon. We're all burned out, trying to do the right thing for our residents.

That third wave that started in November and didn't end until early February took a massive toll on LTC facilities. In January and February, many had large outbreaks that affected many of the residents. It felt insurmountable: every day, another case, another staff member sick.

Even into January, we had pretty regular cases, a combination of new admissions, hospitalized patients coming into the facility, and mini-outbreaks. Just last week, we had a resident test positive. They're asymptomatic but being closely monitored. We had to set up the COVID unit again, in case there's another surge.

But at the present, COVID-19 seems controlled. In our facility, 70% to 75% of our residents are vaccinated. We've started up with some smaller group activities and opened up two of the small dining halls. And we updated our policy a few weeks ago to start to allow visitors back in on visiting days. So we're encouraged.

Staffing is better now. All the medical staff has been vaccinated, and close to 75% among nursing staff. Where it drops off is among the part-time CNAs, about 50 people, and that drops our overall vaccination rate to about 45%.

A lot of CNAs might be working at several facilities, and only in our facility five times in a month. Part of the lag is that while we had three vaccination clinics, after the third in mid-February, we have not had access to offer vaccines inside the building. If a staff member wants the vaccine, we have to turn them over to community resources. If a new resident admission comes in, we basically have to say: Sorry, but when you get discharged, you can go to a site. It's frustrating that we don't have it onsite.

We just had our annual conference for LTC medicine last week. People are burned out. But we're encouraged that people are talking about nursing homes. It's a positive thing that the general public is thinking and talking about LTC. That's a huge change. I'm hopeful that there will be a wave of advocacy that follows this — there's so much pent-up demand on wanting change. I think you'll see state legislative bodies trying to put in place more resources and looking at better processes. There are longstanding issues that need to be addressed, and there's finally political momentum to address them.

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