Skilled Nursing Facilities Face Spikes in Deaths, Drops in Admissions

Deaths have skyrocketed at skilled nursing facilities (SNFs) during the coronavirus (COVID-19) pandemic even as admissions and patient census have declined, according to a new study.

“SNFs are facing an unprecedented crisis—a rapid wave of infection and mortality that could bring any organization to its knees,” lead author Michael L. Barnett, MD, MS, assistant professor, health policy and management, Harvard T. H. Chan School of Public Health, told Contagion^®. “The rapidity and magnitude of this crisis means that SNFs need as much help as they can get from federal and state agencies.”

The study, published recently in JAMA Network, examined mortality, admissions, and patient census at 189 skilled nursing facilities in Detroit, New York City and Cleveland, representing 34% of SNFs in those cities. From March through May, 3,853 all-cause in-facility deaths were reported at the sample facilities, up 118% from 1,765 deaths during the same time period a year ago.

“We were not prepared for the magnitude of the mortality spike in the SNFs in our sample. It was sobering and tragic,” Barnett said.

While the study did not include cause of death, it noted that the rise in mortality followed a similar pattern to coverall COVID-19 deaths regionally. In 41 states reporting deaths at SNFs, 50,185 residents died of COVID-19 as of June 18, accounting for 45% of statewide COVID-19 deaths, according to a report from Henry J. Kaiser Family Foundation.

“Long-term care is at the center of the COVID-19 pandemic and will not recover without our advocacy and attention,” Barnett said.

The study assessed data from SNF electronic health records aggregated by CarePoint Health. Mortality rates at sample SNFs in Cleveland rose to 6.3 per 1,000 residents per week during March-May compared with 4.9 during the same time in 2019. In Detroit, the mortality rate rose to 7.9 from 3.5, and New York City saw an ever greater rise to 13.8 from 4.1. During the peak week in April, mortality rates were 17.4 per 1000 residents per week in Detroit and 36.3 in New York City.

Weekly admissions declined during the March-May time period compared with a year early with adjusted incidence rate ratios of 0.59 in Cleveland, 0.63 in Detroit and 0.75 in New York City. Patient census also declined to an average of 90.6 in 2020 vs 104.5 in 2019 in Cleveland, 102.7 vs 129.7 in Detroit and 235.2 vs 283.6 in New York City.

The drop in patient census may reduce revenue at SNFs during a time when the facilities saw the greatest need for more resources to address the pandemic.

“We need to better understand how to enable SNFs to avoid the spread of infection once established in their facility,” Barnett said.

In March, the World Health Organization, Centers for Disease Control and Prevention and Centers for Medicare & Medicaid Services issued guidance to help long-term care facilities protect residents and staff during the pandemic. Guidance included establishing an infection prevention and control (IPC) focal point to provide training to all employees; provide information sessions for residents; regularly audit IPC practice compliance; emphasize hand hygiene and respiratory etiquette; and conduct surveillance of patient status and appropriate response. Other measures included limitations on visitors and nonessential personnel and considerations for transferring residents with COVID-19.

Since then, ongoing research has continued to shed light on the novel coronavirus, SARS-CoV-2, which causes COVID-19, such as the role of asymptomatic transmission and consideration of pool testing to monitor and control spread of the disease.