PPE still lacking in nursing homes as COVID doubles down

Two new studies detail US nursing home preparedness amid the COVID-19 pandemic, one finding that 20% of facilities had less than 1 week's supply of at least one type of personal protective equipment (PPE), and the other showing that homes owned by private equity firms performed on par with those under other types of ownership in terms of coronavirus cases and deaths but stored less PPE.

Deficits worsened over the summer

The first report, published yesterday by the US Public Interest Research Group (US PIRG) and the Frontier Group, said that, 7 months into the pandemic, shortages of critical PPE like N95 respirators and medical gowns had worsened rather than improved. The shortages were reported to the US Centers for Medicare & Medicaid Services by 2,981 (19.9%) of the nation's 15,000 nursing homes; in total, the affected homes have 226,495 residents.

From May to August, 46% of all nursing homes reported that they didn't have even a week's supply of at least one type of PPE. The dearth of supplies worsened over the summer, with three times as many facilities reporting that they had no N95s, gowns, or eye protection in late August as in mid-July.

As of late August, about 2,500 homes (16.8%) were low on or out of N95s, 1,400 (9.3%) were low on surgical masks, 1,600 (10.7%) were nearly out of gowns, 1,250 (8.4%) were running out of eye protection, 700 (4.6%) were low on gloves, and 600 facilities (3.9%) had no hand sanitizer or were about to run out of it.

The report authors noted that a 1-week supply of PPE is the minimum acceptable amount because facilities can use up that supply in 1 or 2 days if an outbreak occurs, leading to PPE rationing or foregoing of it all together, amid uncertainty as to when the next shipment will arrive.

The supply shortages could be attributed to the US government offering provision of only a 2-week supply of PPE, supply chain interruptions, defective or expired PPE, large outbreaks that required much more PPE than usual, the reopening of businesses and the medical sector, limited finances, poor planning, politics, or a combination of these reasons, the report said.

Teresa Murray, US PIRG Education Fund consumer watchdog, said in the organization's press release that the way the country treats vulnerable people such as senior citizens is "appalling." “It's unconscionable that the United States is dealing with severe PPE shortages at this point in the pandemic," she said. "It's affecting everyone, including hospitals, businesses, and schools. …We can and must do better." 

The authors noted that although nursing homes house less than 0.5% of the US population, they have been the source of 3% of the country's COVID-19 cases and 27% of the deaths, because residents tend to be older and in poor health and must be in close contact with the healthcare staff without adequate PPE.

They said that the PPE crisis will persist if urgent action isn't taken. "We face the possibility of a brutal fall and winter if another wave of COVID-19 combined with a normal flu season further strains PPE supplies," the authors wrote in the report.

The report called for use of the Defense Production Act to increase US manufacture of PPE, allocation of money for nursing homes in any upcoming government stimulus package, federal and state prioritization of PPE for the most strapped facilities, passage of the Medical Supply Transparency and Delivery Act to centralize supply chains and stabilize PPE prices amid competition from different sectors, and, if it doesn't pass, creation of multistate consortiums to gird regional supply chains.

Likelihood of having N95 respirators, gowns

Published today in JAMA Network Open, the second study, led by researchers at Weill Cornell Medical College, evaluated the performance of US nursing homes owned by private equity firms.

While proponents of private equity–owned nursing homes say that they bring management expertise and health information technology resources, the authors prefaced the study by noting that these firms have long been suspected of taking on large amounts of debt to buy nursing homes in order to turn high short-term profits for investors with no plans to stay in business beyond 3 to 5 years.

Under inexperienced leadership, this model could lead the homes to cut costs by operating with as little PPE and few staff as possible, compromising patient care. These concerns have only been heightened by the pandemic, they said.

The study involved analysis of 11,470 nursing homes from May 17 to Jul 2. Mean rates of COVID-19 cases among residents were 8.8% at the 7,793 for-profit facilities, 6.7% at the 2,523 nonprofit homes, 4.0% at the 511 government-owned facilities, and 11.1% at the 543 private equity–owned homes.

Mean rates of coronavirus-related deaths were 6.2% at for-profit facilities, 6.6% at nonprofit homes, 5.6% at government-owned facilities, and 8.0% at private equity–owned homes. And mean rates of all-cause deaths were 7.8% at for-profit facilities, 9.2% at nonprofit homes, 6.8% at government-owned facilities, and 8.8% at private equity–owned homes.

After an adjusted analysis, government-owned facilities reported a 3.6% lower rate of coronavirus cases than those owned by private equity firms, but the rate of cases in private equity–owned facilities was not statistically different from those in for-profit or nonprofit facilities, and there was no significant difference in COVID-19 or all-cause deaths between for-profit, non-profit, government-owned, or private equity–owned nursing homes.

However, for-profit, nonprofit, and government-owned facilities were all more likely than private equity–owned homes to have at least 1 week's supply of N95 masks and medical gowns. And government nursing homes were 6.9 percentage points more likely than other types of homes to report nursing shortages.

"In this cross-sectional study, PE [private equity]-owned nursing homes performed comparably on staffing levels, resident cases, and deaths with nursing homes with other types of ownership, although their shortages of PPE may warrant monitoring," the authors concluded.

"Further study, including longitudinal studies, are needed to determine whether PE-owned nursing homes perform better or worse than non–PE-owned nursing homes on broader measures of clinical quality and whether they are associated with higher or lower health care spending."

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