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Coronavirus Updates and questions

Once we have information how are we going to use it?

For all the “we’re in this together” talk, no, we aren’t. Certain groups are much more at risk from respiratory viruses in general than others, and in the case of COVID-19 (which we will continue to call it for clarity purposes) younger people are typically only mildly impacted, but older people, especially people in their 70s and 80s are much more seriously affected.

Let’s look at some findings.

Here’s data collated in a Forbes post from May 26th. This is still (as of Jun 9th) the latest data, FYI.

https://www.forbes.com/sites/theapothecary/2020/05/26/nursing-homes-assi...

Estimates of the percentage of total US deaths from COCID-19 that have occurred in “nursing homes,” that is, assisted living and skilled nursing facilities typically inhabited by groups of elderly and/or disabled people, range from about 30 to 45 percent. Due to wide variances in transparency and criteria, it is not currently possible to get any more precise than this. But this is already high, and when you consider that this population makes up about .62 percent of the US population, it’s astounding.

Why is this so?

Firstly, it’s simply the nature of the population. This is the population that typically is hit hardest by respiratory infections. They are already old and sick. They are more likely to catch these diseases (we all have elderly relatives that caught “pneumonia,” often repeatedly, and perhaps died from it, but we, if we are relatively young, don’t seem get it) and once they have it, they have less ability to fight it off.

But also, it’s the nature of the institutions. This author as provided care to numerous assisted living facilities and skilled nursing facilities, and they are just not the greatest places. The lurid activities that some family members imagine, such as actual abuse or severe neglect from staff rarely happen. But these places are chronically understaffed, often by design, because they are run on a shoestring. The companies that run them depend on keeping costs low. That means keeping staffing as low as they can get away while they also keep salaries as low as possible.

Under staffing and underpaying is not the way to get the most well-trained and consistent workforce. Despite this, many amazingly dedicated, caring and hard-working people work in these places. But from a systems perspective, all too often burnout, overwork and lack of resources mean that corners have to be cut.

Sometimes this takes the form of staff being brusque, hurried or inattentive to patient’s needs. And when there is barely time to complete the minimum tasks necessary to keep the patient alive, “luxuries” like hand washing, PPE and isolating/sequestering patients just aren’t going to happen, or will typically be performed in a very perfunctory fashion.

But even with a meticulous staff, there are still the patients. Many of them are cognitively challenged and many are incontinent of body fluids. They will move about the facility, as they should, but smearing nasal secretions, cough remnants, urine and feces on all surfaces. It would be almost impossible to keep up with this even in a perfect world.

Basically, once a transmittable virus gets into a facility, conditions are perfect for rapid spread. And what happens outside the facility is also key. As the Forbes article linked to above points out, government and third party policies are also important. Because hospitals charge a lot there is intense pressure in the usual run of business to move people who are “merely” sick out of the hospital ASAP. And what a hospital fears most is getting stuck with a “placement” patient—someone that insurance companies or the government will not pay them for, but who lies in a bed costing them money.

In the harsh argot of healthcare, such a patient is known as a “dump,” as in the sending facility dropped them off and ran, in order to get rid of a problematic or overly expensive patient.

It is in this environment that you have Governor Cuomo of New York initially ordering nursing homes to take COVID infected patients, possibly due to advice or pressure from industry representatives. Of course, given what we’ve discussed above, that is a recipe for a perfect storm of viral related events and deaths, and may nursing home deaths may be the chief reason that New York’s fatality rate has been higher than most other places, as mentioned on this site in a previous blog post.

What can we learn? What can we change going forward?

Some things we cannot do much about. People are always going to age, and aging can be a messy process. Many of us will outlive our brains, or struggle through a sequence of debilitating health events before we die. Contrary to what you may have heard, Americans care deeply about their older relatives and often keep them at home or with them long past the point of it being really feasible to do so. But at some point, caring for them at home becomes impossible (how does a 65-year-old woman pick up a 90-year-old who weighs 200 pounds?) so we must have places for them to go.

What isn’t immutable is the financial situation that creates or exacerbates infection control problems.

Again, contrary to what you may have heard, more government regulation may not be the automatic answer. One of the best kept secrets about health care in the United States is how pervasive and intrusive the government is in this area, both in terms of paying for the care and in having thousands and thousands of government employees in dozens of giant bureaucracies monitoring and directing that care. Unfortunately, lots reports, inspections, regulations and paperwork does not always translate to the best care at the bedside.

And what about capitalism to the rescue? To paraphrase what Winston Churchill is supposed to have said about democracy, capitalism is the worst economic system we have tried, except for all the others. One of the strengths of capitalism is its plasticity in supply and demand. For health care that means that if people want it, someone will make it their business to sell it to them. But one of the weaknesses is that they will try and sell it to them using as low a cost to produce it as possible. Corporations that run assisted living and nursing facilities cut those costs at the frontline of care, again degrading the care at the bedside.

This is because staffing, especially in nursing care, is the single most important factor in the quality of care received. The government’s reimbursement policies and the profit motive both work against this care being provided in these settings.

Bottom line? It will take a lot of attention, and more money spent, to improve staffing and thus improve care, including infection control in our assisted living/nursing facilities. Once the news cycle has moved on, and we’ve all returned to baseline in our worry over infections, will we, as a country, have to will to provide the resources and changes to make it happen?