Early in the COVID-19 pandemic, some states allowed COVID-19 patients to be discharged from hospitals to skilled nursing facilities (SNFs), and even offered financial incentives to SNFs to take in patients to deal with hospital bed shortages.
"The potential human cost of these policies continues to be controversial," the authors wrote. "Some observers have argued that the policies had little impact, while other observers have blamed admissions for seeding or worsening COVID-19 outbreaks in SNFs."
The potential human cost of these policies continues to be controversial
Now a study in JAMA Internal Medicine shows this practice led to preventable COVID-19 cases in the SNFs and increased death rates. Furthermore, SNFs that reported staff and personal protective equipment (PPE) shortages saw bigger increases in COVID-19 morbidity and mortality.
Two additional deaths per 100 residents
The study was conducted by comparing matched groupings of 264 SNFs with initial admission of COVID-19–positive patients (exposed facilities) and 518 comparator SNFs without initial admission (control facilities) from June 2020 to March 2021. Outcomes were assessed during a 15-week follow-up period.
The authors found that exposed SNFs had a cumulative increase of 6.94 (95% confidence interval [CI], 2.91 to 10.98) additional COVID-19 cases per 100 residents compared with control SNFs, a 31.3% increase.
Exposed facilities saw 2.31 (95% CI, 1.39-3.24) additional cumulative COVID-19–related deaths per 100 residents compared with control facilities, representing a 72.4% increase compared with the sample mean (SD) of 3.19.
The authors defined PPE shortage as less than a 7-day supply of N95 respirators or surgical masks. Facilities with PPE shortages had an additional 14.81 [95% CI, 2.38 to 27.25] cases per 100 residents compared with those without such shortages.
Commentary expresses outrage
In an invited commentary, James S. Goodwin, MD, and Huiwen Xu, PhD, said the findings of the study should result in outrage. Even in the earliest days of the pandemic, state public health leaders knew SNFs were unprepared to quarantine patients with COVID-19, they said, with inadequate staff, space, PPE, training, and protocols.
Also the earliest and deadliest outbreaks in the United States were occurring in nursing facilities, they wrote. In the first months of the pandemic, half of the nation's deaths occurred in nursing homes, even though they housed only 0.4% of US citizens.
"To the question, 'What else could we have done?' the answer is anything but this, anything but a move that fed the flames of the pandemic, creating more infections, more hospitalizations, and more deaths," Goodwin and Xu wrote.
