Management and Outcomes of a COVID-19 Outbreak in a Nursing Home With Predominantly Black Residents

Kimberly J. Beiting MD; Megan Huisingh-Scheetz MD, MPH; Jacob Walker MD; Jeffrey Graupner MPH; Michelle Martinchek MD, MPH; Katherine Thompson MD; Stacie Levine MD; Lauren J. Gleason MD, MPH, AGSF


J Am Geriatr Soc. 2021;69(5):1155-1165. 

In This Article

Abstract and Introduction


Background/Objectives: Few studies present clinical management approaches and outcomes of coronavirus disease 2019 (COVID-19) outbreaks in skilled nursing facilities (SNFs). We describe outcomes of a clinical management pathway for a large COVID-19 outbreak in an urban SNF with predominantly racial minority (>90% black), medically complex, older residents.

Design: Single-center, retrospective, and observational cohort study (March 1, 2020–May 31, 2020).

Setting and Participants: All subacute and long-term care residents at an urban SNF between March 1, 2020 and May 31, 2020 (Chicago, IL).

Intervention: A multicomponent management pathway was developed to manage a large COVID-19 outbreak in an SNF.

Measurements: Chart review was used to extract demographics, comorbidities, symptoms, lab results, and clinical outcomes over 12 weeks, which were summarized and compared between residents with and without COVID-19.

Results: A multicomponent clinical management pathway was used to care for residents with COVID-19, which included frequent scheduled clinical and laboratory evaluation, use of intravenous fluids, supplemental oxygen, antibiotics when indicated, and goals-of-care discussions. Of the 204 residents, 172 (84.3%) tested positive for SARS-CoV-2 during the 3-month period, with 50.5% symptomatic, 9.3% presymptomatic, and 24.5% asymptomatic, with a 30-day mortality rate of 15.7%. Predominant symptoms were low-grade fever >99 °F, anorexia, delirium, and fatigue. While in the facility, approximately one-quarter of residents experienced hypernatremia [Na > 145 mEq/L] (24.5%), acute kidney injury [Cr > 0.03 mg/dL or 1.5× baseline] (29.7%), or leukopenia [WBC < 4.8 1000/mm3] (39.4%).

Conclusion: We present the first available clinical strategy guiding the medical management of a COVID-19 syndrome in an urban SNF, caring for largely black residents, which may lead to improved mortality.


Older adults are disproportionally affected by coronavirus disease 2019 (COVID-19).[1–3] Hospitalization rates, risk of intensive care admission, and case fatality related to COVID-19 increase with age and comorbid illness.[1] Skilled nursing facilities (SNFs) that care for older, multimorbid residents are at high risk for severe outbreaks and poor outcomes related to COVID-19.[4,5] SNFs often have limited diagnostic and treatment capacity and are challenged by high asymptomatic and presymptomatic COVID-19 transmission rates.[6,7] COVID-19 outbreaks in SNFs are common,[8] and COVID-19 deaths in SNFs continue to represent about 40% of COVID-19 deaths in the United States.[9]

Furthermore, the COVID-19 pandemic has highlighted long-standing health disparities and inequity in the United States, with racial/ethnic minority populations, particularly black communities, experiencing higher rates of COVID-19 morbidity and mortality.[10–13] In some areas of the country, approximately 70% of COVID-19 deaths occur in black individuals who make up less than a third of the population.[11] SNFs with predominantly black and Latinx residents are more likely to experience outbreaks and higher mortality[14] than those with majority white population.[15–18] A study of a large cohort of COVID-19-positive SNF residents found that increased mortality from COVID-19 in black residents may be due to increased prevalence of COVID-19 in these facilities and the number of underlying comorbidities in the residents,[19] which highlights the need to develop and implement standardized clinical care policies to care for these residents who are most vulnerable.

There are guides that summarize a general approach to COVID-19 infection control in SNFs,[6,20] but literature guiding the clinical management of the COVID-19 disease and sequelae in SNFs remains sparse. Most COVID-19 management literature has focused on optimizing hospital-based management.[21–24] Many of the alternative respiratory support mechanisms (e.g., prone ventilation, hood ventilation) trialed in the hospital[25] are not possible in the SNF. Ongoing novel pharmacotherapy trials[26–30] largely target hospitalized or ambulatory patients, with few trials in SNFs. The equivalent literature on the clinical management of COVID-19-infected residents in the SNF is limited. SNFs continue to care for ongoing surges of COVID-19 driven by community spread and new mutations where infection and death rates may be as high or higher than in the spring of 2020.[31] As healthcare organizations shift lower-acuity COVID-19 patients from the hospital to long-term acute care hospitals or hospital-at-home models to mitigate the strain on acute care settings,[32,33] it is imperative to design robust clinical care management pathways to care for COVID-19-positive patients in SNFs.[34]

The objective of this manuscript is to: (1) present and summarize a novel clinical management pathway administered during a large COVID-19 outbreak at an urban SNF with a medically complex, predominantly black population and (2) to describe the demographics, clinical characteristics, course, and outcomes of the population in the SNF over a 12-week interval (March 1, 2020–May 21, 2020) during which the pathway was implemented shortly after outbreak onset.