Abstract
Long-term care facilities (LTCFs) have had a disproportionally high mortality rate due to COVID-19. We describe a rapidly escalating COVID-19 outbreak among 116 LTCF residents in Rhode Island, USA. Overall, 111 (95.6%) residents tested positive and, of these, 48 (43.2%) died. The most common comorbidities were hypertension (84.7%) and cardiovascular disease (84.7%). A small percentage (9%) of residents were asymptomatic, while 33.3% of residents were pre-symptomatic, with progression to symptoms within a median of three days following the positive test. While typical symptoms of fever (80.2%) and cough (43.2%) were prevalent, shortness of breath (14.4%) was rarely found despite common hypoxemia (95.5%). The majority of patients demonstrated atypical symptoms with the most common being loss of appetite (61.3%), lethargy (42.3%), diarrhea (37.8%), and fatigue (32.4%). Many residents had increased agitation (38.7%) and anxiety (5.4%), potentially due to the restriction measures or the underlying mental illness. The fever curve was characterized by an intermittent low-grade fever, often the first presenting symptom. Mortality was associated with a disease course beginning with a loss of appetite and lethargy, as well as one more often involving fever greater than 38 °C, loss of appetite, altered mental status, diarrhea, and respiratory distress. Interestingly, no differences in age or comorbidities were noted between survivors and non-survivors. Taking demographic factors into account, treatment with anticoagulation was still associated with reduced mortality (adjusted OR 0.16; 95% C.I. 0.06–0.39; p < 0.001). Overall, the clinical features of the disease in this population can be subtle and the symptoms are commonly atypical. However, clinical decline among those who did not survive was often rapid with patients expiring within 10 days from disease detection. Further studies are needed to better explain the variability in clinical course of COVID-19 among LTCF residents, specifically the factors affecting mortality, the differences observed in symptom presentation, and rate of clinical decline.
Highlights
The current pandemic has put long-term care facilities (LTCFs) into crisis, with the high mortality among residents challenging the health care infrastructure [1]
In addition to the infection control recommendations for Long-term care facilities (LTCFs) issued by the Centers for Medicare and Medicaid Services (CMS) in consultation with the Centers for Disease Control and Prevention (CDC) [8], insight into the clinical presentation of these patients is important for prompt identification of infected cases, subsequent isolation and quarantine measures, and improvement of clinical outcomes
The use of N95 masks was initiated on 14 April 2020 when the first resident tested positive and full personal protective equipment (PPE) was used only in the COVID-19 positive wings or during interaction with symptomatic residents, regardless of the test result
Summary
The current pandemic has put long-term care facilities (LTCFs) into crisis, with the high mortality among residents challenging the health care infrastructure [1]. Compared to community-dwelling older individuals, the elderly who reside in LTCFs are at higher risk for infection and mortality from SARS-CoV-2 [3], given the congregate care setting and population of individuals with cognitive impairment, challenging infection control measures [3]. Few studies assessed the clinical course and past initial symptom status of residents, as it relates to mortality outcomes [19,20,21], especially in a non-hospital setting [22,23], with an infection and mortality rate as high as those documented here. We report a COVID-19 outbreak among 116 residents of a nursing home with a very high infection and mortality rates, with a specific focus on the clinical presentation and characteristics associated with mortality
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