Leon Kraybill

Leon Kraybill

COVID-19 infections started appearing in Lancaster area nursing homes in March. Our community’s long-term care facilities responded with progressively restrictive infection-control measures — visitation was discontinued; staff health screenings, universal mask use and eye protection were implemented; resident exposures were limited; and health care provider visits were shifted to telemedicine.

Despite taking appropriate preventive steps while continuing excellent care, many facilities were devastated by COVID-19 illness and death. Many staff members became infected.

Fortunately, the number of nursing home residents with active COVID-19 symptoms has significantly declined and deaths are less common. But COVID-19 infections have not gone away, and risk of disease remains a top nursing home priority.

Universal COVID-19 testing of residents and staff without symptoms is underway at many facilities. Preliminary returns show asymptomatic positive results in some residents and staff. It is unclear how contagious these people are. Medical guidelines are evolving.

Infection prevention measures result in decreased social interaction for long-term care residents, leading to isolation and emotional distress. Family members yearn to visit loved ones to give and receive nurture. Everyone is tired of the new normal of protective equipment.

Our societal frustration about an infectious disease starts to boil over into anger at restrictions, unhelpful discussions of freedom versus precautions, and loss of collaboration. To combat this, we must understand COVID-19 as best we can, see it as a threat to community health, and respond in a unified way.

To help that process, a few points about COVID-19 from a nursing home perspective are listed below:

1. COVID-19 is a current significant daily risk for long-term care residents, families and facilities. It likely will be a major concern for at least the next year. We must not let down our guard due to COVID-19 fatigue.

2. COVID-19 is a very contagious infectious disease that can spread before the individual shows symptoms. There are simple and proven measures to decrease spread — mask-wearing and physical distancing.

3. COVID-19 restrictions are based on the benefits to all residents of the building and cannot be ethically made on an individual basis.

4. COVID-19 enters a long-term care facility through people — staff members, medical providers, family members, visitors. If these people do not come to the facility, then the risk to residents is low.

5. Once COVID-19 is present in a facility, it is very difficult to prevent spread, illness and death.

6. Many facilities who give meticulous attention to infection prevention measures still have COVID-19 infections. The presence of COVID-19 infection does not imply substandard care. Rather, it emphasizes how difficult it is to identify and manage this disease.

Following are some frequently asked questions.

When can I visit my mother?

There probably will be limitations for months. All facilities are eager to allow visitors, but they will assess the risk and decide for their residents. The Pennsylvania Department of Health has provided guidelines on restarting visitation, with variation by facility, based on the presence of infection. It requires an extensive plan for testing residents and staff, cohorting — that is, grouping — residents with infection, symptom screening and adequate staff protective equipment. Visitors must wear protective equipment and practice social distancing. Visitation must occur outdoors or in an area unexposed to other residents. If a new case of COVID-19 occurs in the building, then the facility must re-quarantine for at least 14 days.

I haven’t been sick, and my dad says he cares more about my visits than getting COVID-19. Why can’t we make our own choices and accept the consequences?

That might be possible if the only risk was to you and your father. But your entry into the building potentially results in death of a roommate, the other residents on his nursing unit, or the entire building. And the evidence is clear: You can still be contagious to your father even if you have no symptoms.

When can my grandfather go to see his cardiologist?

Every time a resident leaves the facility, there is extra exposure and more risk to the individual and other residents. Low-priority visits should be delayed when possible. High-priority visits can occur, decided on case-by-case details. Many medical providers and long-term care facilities are coordinating telemedicine visits that allow specialty input without exposure risk. Ask your loved one’s facility and specialist about this.

There have always been influenza and other infections in nursing home — is COVID-19 really that much different?

Yes! Any nursing home medical provider can give you details of how COVID-19 is more contagious, more deadly, more challenging to control, more variable in symptoms, and more difficult than other common infections.

My grandma calls every day in tears due to the isolation. What can I do to support her?

Talk with the social service and activities departments to see what is available. The activity needs to be appropriate for her — her memory, her vision, her hearing.

Be creative. Use telephone calls, emails, video chats. Make a video recording for staff to share. Have a weekly family group video chat that includes her. Create video clips of family, activities, children, animals or games. Call in daily with a poem or religious reading. Find digital books or recordings. Play a group online game. Send in letters, posters, children’s drawings, poetry or artwork. Subscribe to an online music app and create a daily playlist that staff can initiate.

Have “window visits” to see her in person, ideally with phone conversation. Create visual images that express care — ribbons on trees or benches, flowers, posters or banners. Send care packages of photos, snacks, books, magazines or puzzles. Request dedications on the in-house cable channel for songs, poems, movies or television shows. The most important thing is to reassure the one you love of your love.

Dr. Leon Kraybill is the chief of Penn Medicine Lancaster General Health’s geriatric division and post-acute care, and medical director at Luther Acres in Lititz.