Grand Rounds is a monthly blog series developed by EMS World and FlightBridgeED that will feature top EMS medical directors exploring the intricacies of critical care in EMS practice. In this installment FlightBridgeED Chief Medical Director Jeffrey Jarvis, MD, MS, EMT-P, reviews the experience of COVID-19 in nursing homes.
Most EMS providers are familiar with long-term skilled nursing facilities, yet most of us don’t think much about them. We certainly don’t think they can teach us much. Nursing homes have been hit hard by COVID-19 and are often the epicenter of the worst effects of this pandemic. If we pay attention to their experience, we can elicit lessons to protect our workforce better.
A beneficial paper published recently describes an outbreak in King County, Wash. A descriptive study of the prevalence of SARS-CoV-2 in a single nursing home, it demonstrates the danger of COVID’s asymptomatic spread.1
The first reported U.S. case of COVID was January 20th in Snohomish County, above Seattle. In late February the infamous incident in the Kirkland nursing home happened. This increased awareness of the dangers of COVID in nursing homes.
In the subject facility, a staff member with symptoms came to work on February 26th and 28th. She worked on a single unit. She tested positive on March 1st. On March 2nd a resident on that unit developed symptoms and was hospitalized. On March 5th they tested positive. From this point on the unit instituted enhanced infection-control procedures. Visitors were severely restricted, communal activities canceled, and all staff members wore full PPE, but only when working with symptomatic residents.
On March 8th an epidemiology team from local public health and the CDC arrived on site and started their investigation. It initially focused only on the unit with the positive resident and staff member. They offered nasopharyngeal PCR testing to all 15 residents in that unit; 13 accepted, and six (46%) were positive. Of these, two (33%) were asymptomatic.
On March 9th the facility went to universal droplet precautions for every resident of the unit, regardless of symptoms. On March 10th every resident in the facility (not just the impacted unit) was offered testing. This initial round of tests was repeated a week later. Every resident also had a comprehensive symptom survey conducted that covered any symptom in the previous 14 days.
Ultimately, 64% of residents in this facility tested positive within a bit over three weeks from the first positive case. This virus spreads like wildfire in a group living facility! This rapid spread is particularly dangerous in skilled nursing facilities with elderly residents who have many comorbidities. While I would expect the mortality in other facilities to be lower, I would expect the spread to be similar in jails, cruise ships, dormitories, and aircraft carriers. Importantly for us, EMS and fire stations are likely to be at the same risk.
More than half (56%) of those testing positive on the initial screen were asymptomatic. Of these, 89% became symptomatic within the next week. Almost a fifth (19%) of all full-time staff tested positive. Of all positive residents, 19% required hospitalization, and 26% died.
The facility initially started only requiring full PPE around symptomatic patients. Due to the percentage of asymptomatic patients and their ability to spread the virus when asymptomatic, it moved to universal PPE for everyone, regardless of symptoms.
Lessons for EMS
The combination of this virus’ contagion with asymptomatic spread makes it challenging to contain. This obviously impacted nursing homes but can also impact EMS. My department, Williamson County (Tex.) EMS, had a similar experience. We had a single medic who developed symptoms and tested positive. They never came to work with symptoms, but because of asymptomatic spread, they ended up unknowingly infecting other paramedics and firefighters who worked with them. Ultimately we ended up with just under 8% of our medics testing positive and 25% of our workforce out on isolation or quarantine.
Once we instituted universal mask use and social distancing at our stations and performed systemwide testing to identify and isolate asymptomatic positives, the outbreak ended. The lesson we learned from this experience matches that of the nursing home in this paper: We can’t depend only on the presence of symptoms to start taking infection control steps.
By learning from our nursing home colleagues, we can do a better job caring for our own workforce.
1. Arons MM, Hatfield KM, Reddy SC, et al. Presymptomatic SARS-CoV-2 Infections and Transmission in a Skilled Nursing Facility. N Engl J Med, 2020; 382(22): 2,081–90.
Jeffrey L. Jarvis, MD, MS, EMT-P, FACEP, FAEMS, is the chief medical director for FlightBridgeED, LLC, and cohost of the FlightBridgeED EMS Lighthouse Project podcast. He also serves as an EMS medical director for the Williamson County EMS system and Marble Falls Area EMS and an emergency physician at Baylor Scott & White Hospital in Round Rock, Tex. He is board certified in emergency medicine and EMS. He began his career as a paramedic with Williamson County EMS in 1988 and continues to maintain his paramedic license.