COVID-19 Infection Prevention and the Medical Director

July 9, 2020

 JULY 2020

  Karl Steinberg, MD, CMD

The COVID-19 pandemic has been a nightmare for everyone associated with nursing facilities, with the most severe devastation landing on their residents. Outbreaks have wiped out a large swath of these precious, vulnerable elders, and this virus is even more cruel in that most of them have not been able to have loved ones at their side on their deathbed.

It is estimated that over 40 percent of the COVID deaths in the United States have occurred in the long term care setting, which constitutes only about 0.6 percent of the U.S. population. In other words, a nursing center resident is about 70 times more likely to die of the coronavirus than a person who lives in the community at large. Unavailability of personal protective equipment (PPE) and testing have been problematic.

Effects on Staff

The pandemic has also been extremely difficult for the nursing center workforce. These frontline heroes are placing themselves, and potentially their families, in harm’s way because they care about the people who reside in nursing centers, and they are doing it with grace and compassion. Some of them have died. Some staff work in multiple facilities, increasing the risk of transmission, and there is no simple solution to this problem. Staffing shortages can also occur when there are outbreaks, which can compound the difficulties nursing centers are facing.

COVID-19 has been an insidious, diabolical foe—the asymptomatic transmission, the unreliability of testing, the unknowns about immunity after infection, and the severe respiratory manifestations requiring prolonged mechanical ventilation are just a few of the factors that make it very different from, say, influenza A.

Numerous online resources are available on COVID from organizations like the American Health Care Association/National Center for Assisted Living (AHCA/NCAL), the Centers for Disease Control and Prevention (CDC), and the Centers for Medicare & Medicaid Services. Amid the plethora of helpful sites, AMDA – The Society for Post-Acute and Long-Term Care Medicine has excellent clinical and nonclinical COVID information, suitable for all professionals working in skilled nursing centers, but perhaps best shared with medical directors and other attending practitioners (

How the Pandemic is Playing Out

Clinicians have learned much since the early days of the pandemic, and they continue to learn rapidly and improve their processes accordingly. Medical information is coming out on a daily basis, and there is a reasonable hope that an effective vaccine may be available within a year.

At the same time, there has been a wide variability in how the federal government and the various states and county health departments have provided guidance to nursing centers, creating mixed messages and often—unfortunately—bringing a continued punitive and critical attitude toward their efforts to prevent COVID cases and to use best practices in using PPE, cohorting, quarantining, and treating outbreaks.

Some states, seemingly in the interest of ensuring hospitals did not become overburdened, created mandates for nursing centers—even those with no known or suspected COVID cases—to accept COVID-positive patients from hospitals, with predictably unfortunate results. AMDA and AHCA released a joint statement on March 29 opposing such policies forcing COVID patients into nursing centers, which almost certainly saved lives as some states and counties walked back or never initiated similar mandates.

The public sentiment and media coverage often vilify nursing centers, dredging up years-old, resolved infection control deficiencies (for example, one nurse assistant failed to wash her hands after checking a resident’s vital signs three years ago during survey) to somehow suggest that this is why a COVID outbreak has now occurred in 2020 in this facility.

Media posts and broadcasts similarly tend to emphasize perceived failings in nursing centers’ efforts and not the conscientious, diligent, and demanding endeavors to provide safe and appropriate care to its residents under the most extreme circumstances.