Help for nursing homes
Doctors Without Borders arrive in state to assist caregivers with pandemic
As an international medical humanitarian organization Doctors without Borders/ Médecins Sans Frontières (MSF) has spent decades helping the world deal with the latest pandemic.
They are the experts when it comes to patient care of infectious disease.
That is why they came to Michigan. “When we saw the huge mortality rates among seniors in long-term care facilities, we asked ourselves what we could do to help,” said Heather Pagano, MSF’s emergency coordinator in Michigan during a phone interview from her hometown of St. Louis, Mo.
MSF was in Italy at the time, where it had already become clear the novella coronavirus was extremely dangerous among the elderly populations.
A February report by academics based at the London School of Economics found that in Italy along with Spain and Belgium, between 42% and 57% of all deaths from the virus had taken place in nursing homes.
“Patient care of infectious disease is hard enough for hospitals, but it was especially so for nursing homes,” Pagano said.
At the start of the pandemic, long-term care facilities were left to fend for themselves without personal protection equipment (PPE) or adequate infection prevention and control training. And while staff might have had some degree of knowledge in dealing with infectious diseases, the novella virus was unlike anything they might have experienced.
So, building upon decades of epidemic-response experience, and on more recent knowledge gained while assisting care homes in Italy, Belgium and Spain, MSF extended its expertise to more than 50 long-term care facilities — including 31 nursing homes and 24 adult foster care facilities — in Michigan between the end of May and July 31.
Among the places they visited was Advantage Living Center in Roseville.
“We were shocked by what we saw,” Pagano said. “Staff told us that they were overwhelmed and confused, drowning in guidance and regulations on safety measures from many sources but without the on-theground support that can make all the difference.”
By then the data supported their claims with a third of all deaths related to COVID-19 being among the elderly.
In some countries, the tragedy among nursing homes has been referred to as the silent massacre.
As the losses at the start of the pandemic multiplied daily, no one was keeping tab on the number of cases or deaths. The Michigan Department of Health and Human Services began collecting data on April 23, and has since enhanced its collection process to improve accuracy, timeliness, and to align with new guidance from the federal Center for Medicare and Medicaid Services.
Still, only 98% of the state’s long-term care facilities are reporting their numbers and it does not include foster care homes.
Last count
Advantage Living is among the long-term care facilities that report their data to the state.
Their numbers included: 72 confirmed cases and 20 deaths related to COVID-19. Nine of their staff members also tested positive for the virus, one of whom died.
The number of nursing home cases reported in Macomb County as of Aug. 19 included: 1,289 confirmed cases and 382 deaths among residents; 591 cases and five deaths among staff members.
Oakland County has had 1,436 confirmed cases among its nursing home residents and 347 deaths. Confirmed cases of COVID-19 cases among staff was 626, and two deaths.
Wayne County nursing homes ha 2,881 residents who tested positive for COVID-19 and 742 deaths. Among the staff were 1,202 confirmed cases and 10 deaths.
Statewide reports include: 8,044 confirmed cases and 2,083 deaths; along with 4,178 confirmed cases and 21 deaths among nursing home staff.
Nationally the silent massacre has included: 177,129 confirmed cases; 109,253 suspected cases; and 45,958 deaths.
Providing support
During their visit to Roseville and other Detroit-area nursing homes Pagano and her team of doctors provided direct, in-person support to improve the environment for residents and staff.
The most common topic that MSF addressed involved proper separation of confirmed, potentially exposed, or newly arrived residents, hand hygiene, and proper use of personal protective equipment.
“It’s important to determine who is sick, who is
not sick and who is at risk of getting sick,” Pagano said.
These measures help to reduce COVID-19 transmission in shared spaces. Also, among the tricks of the trade that Pagano and her team shared with staff members were the intricate steps involved with PPE. Every piece has to be put on and taken off in a certain order otherwise you run the risk of exposure.
Practical training was also essential for non-clinical staff as well as clinical staff. Pagano said this was especially true for environmental services staff, such as housecleaning. These people play a vital role in infection control but often do not receive dedicated training said Pagano.
Another priority involved helping the understaffed and overworked teams cope with the heightened emotional stress that surrounds the risk of COVID-19 to their residents, themselves and their families. Pagano said her team made it clear to the nursing home staff that they were not there to judge, only to help.
“It is sad,” Pagano said. “Health care workers have been rightly praised but nursing home staff, and especially those in the public eye have been ostracized and blamed for the fatalities they’ve had. If you’re looking for blame don’t go looking at the staff. Many of them work for very little money. Yet, they still keep going back to work and have been working flat out for months.”
No time to grieve
Among the staff members that Pagano had the opportunity to work with at Advantage Living Center in Roseville was Tiffany Bell, a registered nurse, who remembers hearing a report on television about a virus that was going around killing people.
She was horrified but never imagined she would witness COVID-19 firsthand.
“I was a CNA (certified nursing assistant) when it first started,” said Bell, during an interview with an MSF wellness officer. “I would be taking care of my patients and they would be telling me, “Something is wrong, I don’t feel good,” and at that time it was just signs and symptoms of the flu. We had no idea that the virus we were hearing about on TV had come so close to us.”
Then everybody started passing away.
Bell said it was unimaginable, and while they did everything they could, they still didn’t know what they were dealing with, and like many other health care workers, were learning along the way.
“It’s hard. We did lose a lot of people,” said Sharon Gevedon, a certified nursing assistant who works with Bell at Advantage Living. “It’s hard because we care for our residents. That’s why we do what we do and why we’re still here. We grow such a bond with our residents. We take care of them every day, every day and to not see those faces now? Thank God for the ones that we do still have.”
Among those who fell during the battle was a coworker.
“He was more than a coworker, he was like family. He was really something special to the facility,” Bell said, recalling how brave he tried to be during a Facetime call with she and other members of the staff while he was in the hospital.
“He would be like, ‘I’m fighting. I’m trying to come back. I’m trying to get better,” she said.
But he didn’t come back. He didn’t get better.
The same scenario played out in other nursing homes, which was right around the time people were still being told to stay at home and stay safe.
“We were terrified, but we had 100 souls counting on us and we couldn’t just walk away and lock ourselves in our home like everybody else was told to do,” said Connie Flannigan, director of nursing at Advantage Wayne in Detroit and among the facilities to receive WSF training. “We had to figure out a way to get out here and take care of these souls.”
Advantage Wayne has had 68 cases of COVID-19 and 24 deaths among its residents.
There have been no deaths among its staff members but 12 have tested positive for COVID-19.
“When I hear something that someone says about the nursing homes, I take that to heart because I work very hard,” Flannigan said. “My heart is here. I would like the public to know that when you can’t be here to be their family, we are. And we choose to be. We spend 12 and 14 hours a day here, because this is where we want to be.”
Bell concurred.
“I know that a lot of people left and they quit, they were scared, they have kids at home, they didn’t want to get their family sick,” Bell said. “We stayed because if we would have left, who were they going to have?”
“The need was here,” Gevedon said. “We’re all scared. This is our profession and we know what is entailed in that and the bottom line is the need was here.”
That doesn’t mean there weren’t times when she had to get away, if only for a second.
“Okay, I’m going to be out, it’s okay,” she would say. Then as soon as she hit the door she would break down and cry. “You have to step away, or you’re crying together,” Gevedon said. “I’m talking from dietary to housekeeping.”
“Everybody,” added Bell, who found herself in situations where she couldn’t leave, or hold back the tears.
“I moved a resident one time. This was when I became a nurse,” said Bell, who was a certified nursing assistant before becoming an R.N. “I told him, I said, ‘Well, we’re going to send you down to the COVID unit,’ and he was like, ‘I’m probably going to die. I’m probably going to never see you again.’ Nothing can prepare you for that, to hear that. “
Critics of the nursing home situation have asked why COVID-19 patients were sent to a place that was housing the state’s most vulnerable population in the first place, or why those who tested positive for the virus were not removed.
“I don’t think there is one easy answer,” Pagano said. In some cases patients require 24-hour care and monitoring, which might not be accessible at another facility. Moving patients with dementia to a facility they’re not familiar with can also be very dramatic, emotionally and physically. Plus, moving them all does not mean you can keep the nursing home COVID-19 free because there are still workers coming and going who are asymptomatic, which is a person who has
COVID-19 but never develops symptoms.
“I think the better questions to ask is why nursing homes are so short staffed, and so under-resourced,” Pagano said. “How do we think about our elderly? How should we look after the people who looked after us? How do we compensate properly the people who are doing the really difficult work of caring for them?”
Regulation and oversight play an important role in protecting residents and staff of long-term care facilities but punitive measures alone will not help under-resourced nursing homes perform better, nor will they address the challenges presented by this unprecedented global pandemic. In-person support is fundamental.
“Just being there, in person, helping alongside the staff made a difference,” said Pagano. “Saying you’re not alone, we’re not here to punish you, we’re here to be in support with you-this indirectly provided its own mental health benefits.”
Among the Macomb County officials who helped MSF connect with facilities in need of infection control guidance, PPE support, and access to testing was William Ridella.
“Any time a long-term care facility can get access to in-person, on-the-ground tailored infection prevention and control measures is an opportunity to add value and expertise to the care they deliver,” said the director and health officer for the Macomb County Health Department. “This type of technical assistance helps staff be better prepared for the challenges associated with COVID-19 and hopefully, result in better care and safety for residents and staff at the facility.”
This certainly rang true for Bell and Gevedon.
“Nobody was really educated on what is COVID-19 and nobody expected it to run through a facility like a hurricane,” Bell said. “But now the supplies have been much better as well as the knowledge that comes from being educated on the actual virus.”
“I think it is improving,” Gevedon said. “I think we have a better grasp on the situation. Just from, like she said, not knowing about it. And I feel we’re improving. I do feel we’re improving. “
Changes for the better
Michigan is one of several states that have been supported by the MSF team, which is now in Texas assessing the need for a similar program of on-site support to long-term care facilities there.
In its effort to prevent and mitigate the consequences of COVID-19 in skilled nursing facilities further, MSF proposed the following recommendations to health departments and policy-makers:
• Provide direct, handson on-site support for skilled nursing facilities. This includes one-on-one coaching, targeted refresher courses and practical training sessions on infection control for all staff.
• Develop a more collaborative oversight process with on-site training and support that is constructive and non-judgmental. Regulation plays an important role but cannot be the primary tactic to affect true behavior change and improve health outcomes for residents and staff.
• Increase support for staff wellness and improve access to mental health resources. Staff faces a dual burden: stress, anxiety, grief, and fear in their dayto-day reality, having lost colleagues and residents, while simultaneously suffering stigma in their sector. This is on top of an increased workload due to the closure of the facilities to family who previously helped provide companionship and care.
• Provide clear guidance for re-opening facilities to visitors. Staff regularly report serious concerns about the cognitive decline of their residents. Loneliness and isolation also pose a great threat to their health.
• Conduct in-service training for non-clinical staff. Environmental services staff are the least likely to have received adequate training on infection control in their critical position, or on the proper use of personal protective equipment (PPE).
• Ensure more supportive leadership from corporate, administration, and directors of nursing. This, perhaps above all, is the key indicator of success for crucial infection control measures to be implemented to best protect residents and staff alike.
• Promptly disseminate testing results to facilities and conduct regular health education for both staff and residents regarding the rationale and importance of regular testing. Timely testing is essential for monitoring of infections and organization of care.