How a Morgantown nursing home avoided disaster amid outbreak
Sundale Nursing Home, nestled on a hillside in Morgantown, W.Va., roughly a two-minute walk from the Mon Health Medical Center, was just one month ago ground zero for COVID-19 in the state. Positive cases were increasing rapidly after the first was reported on March 22, and local officials feared a major outbreak.
Yet thanks to a combination of thorough testing, rapid isolation of symptomatic patients, cooperation with state and local health authorities and hospitals, and — according to Dr. Carl Shrader, the medical director at Sundale — some innovative treatment techniques, they managed to dodge the kind of mass fatalities seen at other nursing homes.
“We had some concerns that things could go south,” said Monongalia County health department executive director and county health officer Dr. Lee Smith. He cited the worrisome experience of the Kirkland Life Care Center near Seattle, an outbreak that led to over 100 cases and dozens of deaths, as an indicator of the danger the virus poses to long-term care facilities.
That hasn’t been the case at Sundale. As of midweek, just five patients at the 90-plus bed facility have died, and 33 additional residents have tested positive, most of whom have since recovered. Twelve cases are still being treated in the building, most of them asymptomatic. One asymptomatic dementia patient is in the hospital.
Fourteen staff out of 150 also tested positive; 11 of them were infected in the initial wave. Five employees remain asymptomatic and quarantined at home, while the rest have recovered.
“We’re getting to a point where we’re very stable,” Dr. Shrader said. He knocked his hand on the wooden table. “It seems that way.”
Testing, testing, testing
The first known patient, Dr. Shrader said, had been treated with antibiotics for what was
initially thought to be a urinary tract infection. After several days of escalating fever — not typically associated with a beaten UTI — the patient was sent to West Virginia University’s Ruby Memorial Hospital, a fiveminute drive away, at 3:00 a.m on March 22. She was tested, and 12 hours later, the results came back positive for COVID-19.
“It was the first community spread in West Virginia,” meaning that it was unconnected to any previously known case, Dr. Shrader said. “We knew it was inevitable to happen.”
Phone calls went out — to Dr. Darin Rogers, a vice president at WVU Medicine, and to Dr. Smith, who is also the director of nursing at Sundale.
“The reality of it settled in on us: This could be overwhelming very quickly if we didn’t have a strategy,” Dr. Shrader said.
Initially, four residents had fevers and respiratory symptoms. By the time the group of doctors decided to test the patients at the hospital, a fifth was showing rapidly escalating symptoms. To avoid overwhelming WVU’s limited isolation unit capacity, two patients at a time were sent out.
Of the five patients showing symptoms that night, three eventually tested positive, though the results were not known for several days.
In consultation with the local health department, it was decided that all residents in the east wing, where the outbreak seemed to be centered, would be tested, along with 12 employees and staff who had been in contact with the first known case. The state processed those tests quickly, and as the new positives rolled in, Dr. Shrader said it became clear the rest of the facility would need testing.
At 4:30 a.m. on March 24, the West Virginia National Guard called, offering to assist with testing so long as Dr. Shrader could secure materials. Between the two hospitals and several phone calls, he was able to acquire “95 or 96” swabs, enough for all the residents in the building plus a portion of the staff. Five new cases on the west side of the building eventually were identified.
Not all the testing progressed quickly. Dr. Shrader noted that one resident had been swabbed on March 20 — two days before the first case was identified — but the results for that test didn’t come back until April 6. The second round of tests took about a week to return results.
There were also a number of issues in distributing the tests and managing the results, including the need to alert families, educate patients, keep staff calm and inform the Morgantown community. One unexpected hurdle was internal frustration among Sundale staff.
“People felt like they ‘didn’t make the cut,’ that was a direct quote I heard,” Dr. Shrader said, referring to the second round of testing that only reached some staff. “‘Why wasn’t I important enough to test?’ ”
Over time, those concerns were addressed. Employees were able to get tested at a drive-thru site, and all staff received a pay bump: $2 per hour, $3 for those who worked with COVID-19 patients.
“We were making progress,” he said.
Dr. Shrader credits that initial wave of testing with the relative success of Sundale since.
“You have to advocate for testing for everyone, period,” he said. “From the beginning. All your staff, and all the residents.”
Ideally, he said, every nursing home should do a sweep every seven days, continuing to do so until the entire population is negative for two weeks, the incubation period of the virus. After partial testing, Sundale was able to do a full sweep of all employees and staff on April 22, when West Virginia Gov. Jim Justice ordered all residents and employees of every nursing home in the state to be retested.
That sweep caught nine asymptomatic cases at Sundale. However, no health care worker tested positive after the initial wave, and two wings of the building remained entirely negative for COVID-19 — meaning that their infection control measures were working, Dr. Shrader said.
‘Conscious sedation’
The east wing became the isolation wing. A cohort of nursing staff was dedicated to the unit so that interactions between the different wings were minimal. In the event that a resident needed to be moved to the hospital, a side exit was used rather than the main lobby. Over time, the focus moved to treating the positive cases, which was often difficult because of the unpredictability of the virus.
“We had a patient here, for instance, who, from time zero through day six had no symptoms. Never had any abnormal vitals, and we were doing vitals every four hours,” Dr. Shrader said. “Upon check of that patient four hours from the last vitals, they were found to have an oxygen saturation in the high 50s-low 60s [a normal oxygen level is above 90], and their heart rate was in the 130s, and their respiration rate was elevated. That’s how quickly it happened.”
He said that the immediate impulse is to send such a patient to the hospital to get them on a ventilator, but COVID-19 is “not like a typical infection.” Sundale has found more success, Dr. Shrader said, in finding a way to “bridge” a patient through the worst symptoms using a method he called “conscious sedation.”
The main problem with low oxygen levels is that the patient becomes hypercarbic, meaning there is a buildup of carbon dioxide in the bloodstream. Patients become agitated and panicked, Dr. Shrader said, making it difficult to maintain supplementary oxygen flow through a mask.
Normally, patients are put on a ventilator at that point, but instead, the Sundale staff tried a mild sedative. This calmed the patients enough that they could keep on an oxygen mask.
Combined with “proning” the patients — putting them on their stomachs for several hours at a time, then their backs, which seems to help expand lung capacity — this can, surprisingly, lead to recovery.
“If you could bridge them in that 24-48 hour window, we were able to bring them down, start weaning them off of the oxygen,” Dr. Shrader said. “It was pretty amazing to see, that very quick decompensation but a relatively fast recovery.”
His theory? Ventilators replace the functioning of the lungs, whereas this method allows the patient to regain the ability to breathe normally themselves with oxygen support.
“I think there is something about allowing them to do this with their own respiratory drive is what helps them pull through that, versus people who end up intubated on a ventilator,” Dr. Shrader said.
Walking through a nonisolation wing, he gestured to a short, white-haired woman with glasses and a purple sweater rolling down the hallway in a wheelchair.
“Do you remember, we talked about someone who needed conscious sedation? She was like a rag doll,” he said quietly. “And there she is. … If she had gone to the hospital and been intubated, I don’t think she’d be walking the halls with us right now.”
Suncrest Medical president Michael Hicks, who runs the company that manages Sundale, said that the approach has gotten the attention of other nursing homes.
“There are other nursing facilities across the country that have called and asked for [Dr. Shrader’s] expertise, and how did we address that,” Mr. Hicks said.
Dr. Smith pointed out another benefit: The strategy leaves intensive care beds open for other patients. Still, he cautioned that the “conscious sedation” technique, like other treatments, may not bear fruit when tested fully.
“We’re still early on in this. We’re under six months in our experience with coronavirus in this country,” he said.
‘Luck favors the prepared’
Sundale’s official death toll is still five residents, but Dr. Shrader says that number is somewhat misleading. Four of the patients who died were in or on the way to hospice care, had prognoses of less than six months and in some cases were asymptomatic. Just one resident, he said, had been “robbed” of their life by COVID-19.
Most of the remaining patients in the isolation ward have no symptoms; indeed, the wing is virtually indistinguishable from the others, except for the regularly placed carts of personal protective equipment and hand sanitizer, and the transition area set up between the wing and the rest of the building where staff change into protective gear. Several asymptomatic residents have been in the isolation wing for weeks, one for over 40 days.
Life has yet to return to normal for other residents. One woman who recently recovered complained energetically about her restricted privileges.
“I wanna go walkin’ in the woods, and they won’t let me out!” she complained to Dr. Shrader. “I’m a country girl; I used to climb trees and stuff!”
“Well, soon,” he replied. “Real soon.”
The pandemic will leave an impact on the facility. Dr. Shrader said they are working on plans to make the isolation wing permanent, with a negative pressure system for ventilation — the expectation being that they will “coexist” with COVID-19 into the future. Four rooms already have been converted.
Dr. Smith concurred. “We’re gonna be talking about COVID-19 for at least the next five years, if not the next decade,” he said.
Mr. Hicks said the pandemic had been “eye-opening” for him, despite his 35plus years of experience with nursing home management. “I’m working on my own room here,” he joked.
He said that Sundale’s independence — it is not part of a chain of long-term care facilities — allowed it to cut through layers of “bureaucracy” that he thinks would have slowed down their response.
The Morgantown community has provided support, Dr. Shrader said. Staff have been able to quarantine away from their families at a local hotel, which set up a side entrance to minimize interactions with hotel staff. Local restaurants have prepared food, and town residents — after an initial period of skepticism toward Sundale employees — have organized donation drives.
Still, the most critical cooperation is with local health authorities and hospitals, he said. Knowing individuals at the local hospitals ended up being crucial for securing PPE and tests.
Assistance from the National Guard was also critical; in addition to testing, the National Guard provided PPE training, spokesperson Maj. Holli Nelson said in an emailed statement.
Dr. Shrader listed suggestions for nursing homes across the country that may face a similar outbreak soon, in addition to the testing schedule he laid out: create a plan ahead of time; build relationships with local public health officials, hospitals, and businesses; and think in terms of testing and isolation.
“I’ve always been told,” he quipped, “that luck favors the prepared.”