Preventing the Spread of COVID-19 to Nursing Homes: Experience from a Singapore Geriatric Centre.

To the Editor:

COVID‐19 is a global pandemic with extensive community spread in many countries.1 Older adults and those with chronic medical comorbidities are seen as particularly vulnerable.2 The effects when COVID‐19 reaches nursing homes have been devastating,3 accounting for a disproportionate number of deaths, particularly in the United States.

Despite COVID‐19 reaching our shores nearly 2 months ago, there has not been a single case of transmission in nursing homes in Singapore. To date, only one case of possible COVID‐19 transmission has occurred in an acute hospital in Singapore.4

Since COVID‐19 hit Singapore, various measures have been rolled out nationally to mitigate the spread of the highly contagious virus including the restriction of visitors to all healthcare institutions, prescreening of visitors, and reduction in unnecessary transfer of patients.5

Nursing home patients admitted to the hospital have to be managed carefully. They have high rates of pneumonia6 and it can be difficult to differentiate between aspiration pneumonitis and pneumonia.7 Previously, selected nursing home residents with fever and respiratory symptoms could have a trial of oral antibiotics on site or be treated conservatively if they had an advanced care plan.

However, in view of the public health consequences of COVID‐19, nursing homes now refer all patients with fever and respiratory symptoms to acute hospitals to rule out the virus. All nursing home patients admitted to our institution with acute respiratory infections are isolated in negative pressure rooms and tested once for COVID‐19 if the clinical suspicion is low. If there is significant concern, some patients may even be subject to a repeat swab before transfer to a general ward. Contingency plans have been made to cohort patients with respiratory symptoms and pneumonia in designated wards if cases exceed the capacity of our isolation facilities. At present we have not yet had to resort to this alternative. In addition, on discharge, nursing homes have begun to request letters from hospitals to certify that returning residents do not have COVID‐19. Such heightened vigilance has prevented the spread of a single COVID‐19 case to nursing homes in Singapore.

The isolation of nursing home patients has led to some negative consequences. Fall rates in isolation facilities are much higher than that in general wards. Restraint use has also gone up, whereas our geriatric medicine ward practices a no‐restraint policy. Nursing home patients in particular have higher rates of dementia, delirium, and behavioral issues8 that require greater nursing care, which is challenging in isolation facilities, especially in the context of a global pandemic. These are inevitable given that protection of healthcare workers is a priority, and it is difficult for healthcare staff to attend promptly to patients in isolation facilities with behavioral issues and cognitive impairment because they would need to don full personal protective equipment before any patient contact. In addition, we have started to use technology such as the Beam robot9 to minimize patient contact, with plans to roll these out to other institutions. However, the use of technology has limitations, especially when dealing with older patients.

Preventing the spread of COVID‐19 to long‐term care institutions is a priority, and rigorous heightened measures should be put in place to ensure this.