The danger COVID-19 posed to Americans became crystal clear in late February and early March, when 81 residents, 34 staff members and 14 visitors contracted the novel coronavirus at the Life Care Center in Kirkland and 37 of those people died.

The outbreak demonstrated high attack rates of the virus and the damaging impact it can have on already vulnerable older adults in facilities.

After the first case was reported in Kirkland in late February, facilities elsewhere in the state had a small window of time to prepare for the virus to reach their doors, tracking down testing kits and personal protective equipment and essentially going into lockdown mode.

Under Centers for Medicaid and Medicare Services guidance issued on March 13, facilities have restricted visitors, regularly screened staff and residents, and identified staff members who work at multiple facilities.

But that hasn’t stopped COVID-19 from spreading to 252 long-term care facilities in Washington, according to the Department of Social and Human Services.

Supply chain problems that made it hard for many hospitals to access enough PPE were even more challenging for some long-term care facilities to navigate.

The Sentinel Network, which surveys health care centers statewide about their workforce, released two surveys of skilled nursing and assisted living facilities on April 21. About a dozen facilities responded to the surveys, and the message they conveyed was clear: It was hard to access the tools they needed to fight the virus.

“The need for a few different PPEs than what we typically keep on hand came up quickly and in much greater quantities, it is difficult to keep up,” one assisted living facility in Eastern Washington responded.

If PPE wasn’t a challenge, then staffing was. Long-term care facilities in Washington have historically had difficulty attracting and keeping a workforce, and COVID-19 made that problem even more apparent.

“Staffing was the biggest challenge in both nursing and housekeeping,” one nursing home responded to the Sentinel survey. “Information about this disease was evolving daily and staff were scared, testing was taking 7 + days. It was a daily challenge to keep adequate PPE available and following CDC recommendations on extending their life.”

In response, state health officials have worked to get some of their stockpiled PPE supplies to long-term care facilities.

“We know that getting enough PPE for facilities has been a challenge, but we have turned a corner,” Candace Goehring, director of residential care services at DSHS, said April 17.

PPE and masks are vital to preventing staff from inadvertently spreading the virus, which a person can carry without showing any symptoms

“It’s not to blame anyone that we know, (but) it’s the visitors bringing it in, whether they are medical people or staff or whoever they are,” Dorothy MacEachern, an infection preventionist with Washington State Department of Health, said last week.

Staff members are screened and not allowed in if they are sick, but asymptomatic people, who can spread the virus, won’t be found through a screening.

“That’s why masking is so critically important,” said MacEachern, who has been working with the Spokane Regional Health District on its virus response.

The virus’ spread to long-term care facilities hasn’t been even. Individual facilities have taken differing approaches and had different results. The same is true on the city and county level. Consider, for example, the Tri-Cities and Spokane.

Tri-Cities

The Benton Franklin Health District, which covers the Tri-Cities, announced its first case of COVID-19 on March 17.

The next day, officials reported the district’s first death due to COVID-19: a woman living in an assisted living facility who had recently traveled to the West Side of the state.

At the time, testing was in short supply.

Some facilities tracked down testing kits on their own, if they could not access them through the health department or through a resident’s health care provider, but there weren’t enough.

Even through the end of March, testing was hard to come by.

Heather Hill, communicable disease program manager at Benton Franklin Health District, said recently that “the Department of Health did offer us some testing supplies that we could directly distribute to long-term care partners,” but challenges have remained.

Testing has identified 250 residents or staff members at about 20 long-term care facilities in both Benton and Franklin Counties with COVID-19. And a majority of the deaths in the Tri-Cities – 37 of 50 – have been associated with long-term care facilities.

Facilities “have to be conscientious,” Hill said, to keep the virus out, a challenge when some employees work at multiple facilities and the virus can be transmitted by people without symptoms.

Life Care Center of Richland has had one of the most significant outbreaks in the region, with 39 confirmed cases and the health district estimating about 60 other “probable” cases in staff and residents.

Life Care has grouped its confirmed patients with 10 additional patients from Life Care in Kennewick in an isolated environment. So far, 12 residents at both Life Care Centers have died.

Officials from the company say they are working to ensure residents are safe.

“The safety and well-being of our residents remains our highest priority as we continue to work in partnership with the Washington State Department of Health and our local health department and follow the guidance they provide and to be a resource on the addressing the care needs of patients with COVID-19,” Russell Patterson, executive director of Life Care Centers, said in a statement.

Pasco’s Avalon Health and Rehabilitation Center, which treats both short-stay and long-term patients in a skilled nursing facility, created its own COVID-19 unit to treat the 14 residents who have tested positive for the virus.

Four residents there died in local hospitals due to the virus, and the facility is working with the county health department to have all residents tested this week.

Bonaventure Tri-Cities had one of the first documented cases and deaths due to COVID-19 in the community on March 18.

Since then, five residents died of the virus and eight have recovered, along with a staff member.

The 100-person facility is now COVID-19 free, a change administrators attribute to testing, new precautions and robust screening of staff.

“The other thing we implemented is a detailed contact tracing system, keeping staff limited to certain blocks of rooms,” said Jeremiah Gray, Bonaventure’s director of operations.

Bonaventure leaders are tracking which rooms staff members enter as well as what symptoms each staff member or resident displays, in order to tell who might need a test.

Gray said they began preparing in January, securing PPE and trying to stay ahead.

While some residents died from the virus, Gray believes the situation could have been far worse.

“We saved so many other lives by the steps we took,” Gray said.

This week, health officials at the Benton Franklin Health District took down its public list of long-term care facilities with confirmed cases, citing the widespread transmission of COVID-19 outside of those facilities.

Benton and Franklin counties have 759 total confirmed cases, with many residents affected by the outbreak at the area’s Tyson meat-processing plant.

Testing kits are now more accessible, and the Benton Franklin Health District has dedicated a long-term care team to coordinate with facilities that need more access to testing or PPE. But the challenges of containing the virus spread persist.

“One of the difficulties is we’re up to about 20 facilities that we’re observing and keeping an eye on, and we don’t have the staff capability to do the boots-on-the-ground approach at all facilities,” Hill said.

Spokane

Just two hours north of the Tri-Cities, Spokane has been a different story.

With the exception of the major outbreak at the Spokane Veterans Home, where three residents have died and nearly half the residents have tested positive, long-term care facilities in Spokane County so far have largely kept the virus at bay.

Where care facilities in the Tri-Cities have seen 250 confirmed cases of COVID-19, to date in Spokane County, 87 cases have been confirmed in 11 long-term care facilities, according to the Spokane Regional Health District. And the Spokane Veterans Home accounts for 61 of those cases, with 42 residents and 19 staff members testing positive.

Across the remaining 10 long-term care facilities, there are just 26 confirmed cases of COVID-19.

Spokane County Health Officer Dr. Bob Lutz credits those low figures to the proactive work of a dedicated infection preventionist who works with local long-term care facilities and to the coordinated “drop teams” MultiCare formed to assist facilities when they do have a confirmed case.

“Their prompt efforts, I believe, have lessened the potential outbreaks that could have happened in those situations,” he said.

When they saw the outbreak at Life Care Center of Kirkland, health care leaders in Spokane began brainstorming about how to plan for COVID-19 outbreaks in long-term care facilities here.

“The vulnerable populations in nursing home facilities are captive, and we did not want to replicate the tragedy that occurred there in Kirkland,” said Geoff Swanson, chief medical officer at MultiCare Rockwood clinics.

So they thought up the “drop team” concept, an on-call triage team of physicians, nurses and an infection preventionist that could go into a facility with short notice to offer medical expertise and support.

“Drop teams give us the opportunity to be reactive, almost like a SWAT team, within a couple hours,” Swanson said. “We had the ability to put together a team to go into facility and do an assessment of the patient who has symptoms, quarantine them, put appropriate barriers in place to prevent the spread and other issues between residents and staff.”

Other health care providers in Spokane County are pitching in to help support local long-term care facilities too.

Dr. Ben Kartchner, with MultiCare, said the drop teams are part of the collaboration between public health, Kaiser Permanente and Providence partners to ensure all local facilities have access to medical services if they need them.

“We’ve been in collaboration with all these facilities to provide blanket coverage of medical services to skilled nursing facilities and assisted living facilities in the area in the event that there’s an issue,” Kartchner said at a news conference last week.

Since April 2, the MultiCare drop teams have been in five facilities in Spokane County.

MacEachern is keeping a close eye on the county’s confirmed cases, working with their epidemiologists.

As soon as a case is connected to the long-term care facility, she picks up the phone and offers that facility a drop team visit. If they need the support, the county will prioritize sending them stockpiled PPE and testing kits.

Going forward

COVID-19 will remain a threat to long-term care facilities for the foreseeable future, and maintaining rigorous restrictions, cleaning standards and protective guidelines will be key to keeping the virus out of these settings in the coming months.

To ensure facilities have what they need, the MultiCare drop teams expect to be on call through the summer.

MacEachern was concerned about adult family homes, which house up to six adults who receive caregiver services every day, so last week the Spokane Regional Health District distributed 50 masks and other protective gear to 175 of those homes.

“It’s hard for them to do social distancing. Many of them have no PPE because that was not something they commonly had on hand,” MacEachern said. “They aren’t really medical facilities.”

It will also be important to provide care going forward for those residents of long-term care facilities who do recover from the virus.

At the Spokane Veterans Home, that meant creating a COVID unit at the Mann-Grandstaff VA Medical Center where residents with the virus can be isolated from those who don’t have it.

Not all facilities have the ability to isolate patients.

In the Tri-Cities, health officials are working to create a step-down facility for people who are recovering.

“When a person from a long-term care facility enters the hospital for COVID, entering them back in their facility can be very difficult,” Hill said. “We’ve been trying to find ways to create alternative care facilities for people who don’t need acute care but their long-term care environment isn’t ready to take them back.”

The pandemic has been hard on residents who are used to being out in their communities or socializing with one another and who now cannot see visitors or even their caregivers’ full faces.

“I am hopeful there will be a point where we will be able to dial back some of this,” said Dr. Tom Schaaf, chief medical officer for Providence home and community care.

Providence operates St. Joseph Care Center and Emilie Court in Spokane. Schaaf said masking can decrease some of the human contact patients need, especially those with memory loss or dementia.

“When the risk starts to drop, we need to assess how we find the balance of risk to their personhood versus the risk of transmitting disease,” Schaaf said. “We have to find ways of decreasing risk of transmitting disease to allow these folks to have more contact with their families and the like, which has been one of the hardest things about this for staff and patients.”