Testing Every Resident: How a Veterans' Nursing Home in Los Angeles Stopped COVID-19, 2020

Long-term care skilled nursing facilities (SNFs) are at high risk of COVID-19 outbreaks, and many infected residents and staff have no symptoms — or none yet. This report, posted as an MMWR Early Release on May 22, 2020, describes how testing everyone, again and again, stopped an outbreak at a veterans' nursing home in Los Angeles.

Lessons from a skilled nursing facility that stopped a COVID-19 outbreak. Figure from CDC's report.

The facility

The Veterans Affairs Greater Los Angeles Healthcare System (VAGLAHS) has 150 long-term care beds in three wards: A and B in building 1, C in building 2. The buildings share no common areas, though residents may meet outsiders while getting care such as dialysis. Residents often need intravenous antibiotics, complex wound care, rehabilitation, dialysis, chemotherapy or radiation, and many have chronic obstructive pulmonary disease, high blood pressure, heart disease or chronic kidney disease. At the time, 99 beds (66%) were filled, and more than 95% of residents were men aged 50–100.

Precautions already in place:

The outbreak

• March 26–27: two ward A residents developed fever (and one a cough); both tested positive on March 28.
• March 29–31: every building 1 resident was tested, with or without symptoms. On March 29 a ward C resident fell ill and tested positive the next day, so all building 2 residents were tested on March 31.
• All three first patients went to the affiliated acute care hospital for isolation and care.

Infection control was reviewed with staff. From March 28, each staff member worked on one ward only; an infection control nurse monitored protective equipment use, and the PPE rules, based on CDC guidance, stayed the same throughout.

Testing the residents

Every infected resident was moved out at once — to the hospital, or later to ward A, which became a COVID-19 recovery unit for residents who were stable but still testing positive. That spared the hospital and let residents stay somewhere familiar.

In all, 19 of 99 residents (19.2%) had COVID-19: 3 found because of symptoms, and 16 by testing (2 of them with symptoms at the time).

• 14 of the 19 had no symptoms when tested;
• of those, 8 developed symptoms 1–5 days later (presymptomatic);
• one of the first three patients, a man over 90, died.

Testing the staff

From March 29 to April 10, all 136 staff were tested: 8 (6%) were infected — 3 registered nurses and 5 licensed vocational nurses, all on wards A or C. Four had symptoms and were tested within 2 days; one developed a fever at work and was sent home; none of the others worked while ill. Repeat testing of staff wasn't possible because supplies were short, but anyone with symptoms could be tested. No more staff cases were found.

What it showed

• Many infections are silent: most residents had no symptoms when diagnosed, so the virus can spread widely before anyone notices. A study in Italy found 43% of confirmed infections were asymptomatic.
• Repeat testing works: testing roughly weekly until everyone was negative caught the later cases.
• Staff matter: they can catch the virus in the community and bring it back.
• Isolation and cohorting, plus keeping staff to one ward, stopped spread: the outbreak was over on ward A within 1 week, on ward C within 2 weeks, and ward B had no cases.

At the time, Los Angeles County's criteria did not include testing people without symptoms; by April 30, it endorsed mass testing when a case is found in a long-term care facility. The Centers for Medicare & Medicaid Services recommends symptom screening of all SNF patients and separate staff teams for infected and uninfected patients, and Medicare expanded coverage of SARS-CoV-2 tests.

Conclusion: where people at high risk live together, universal and repeated testing is an effective way to find infections fast and limit spread.

Limits

• Residents' memory problems may have skewed symptom reports.
• Daily checks covered only fever and breathing symptoms — not, for example, loss of smell or taste — so some "asymptomatic" residents may have had symptoms.
• All the patients were men, so the results may not apply to other facilities.

Sources

Based on Dora AV, Winnett A, Jatt LP, et al., "Universal and Serial Laboratory Testing for SARS-CoV-2 at a Long-Term Care Skilled Nursing Facility for Veterans — Los Angeles, California, 2020," MMWR Morbidity and Mortality Weekly Report, volume 69, Centers for Disease Control and Prevention; a work of the United States government in the public domain; rewritten in hubnx's own words.