Tip of the Hat to Ray Songtree – Lipstick & War Crimes
Those living in nursing homes or other long-term care facilities are the people most susceptible to infectious diseases. So, it is no surprise that nursing home residents make up a huge part of the U.S.’s COVID-19 deaths. At the end of April 2020, COVID-19 deaths in nursing home reached nearly 12,000.1 According to The Washington Post, almost 1 out of 10 U.S. nursing homes has COVID-19 cases.2
There are clear reasons for the high number of COVID-19 deaths in nursing homes and other long-term care settings like assisted-living facilities, group homes and rehabilitation and psychiatric centers. The residents often have poor overall health and weakened immune systems and they live in close quarters. Moreover, such facilities have frequent visitors and shared staff, both of which can introduce pathogens.
Still, the lack of transparency of COVID-19 cases and deaths among nursing home residents and staff is shocking. Many states release no or only partial information about nursing home outbreaks.3 Some suggest the data embargo is an attempt to hide substandard infection control and medical oversight. Patients’ families, patient advocates, staff and, increasingly, lawmakers are demanding change.4
Nursing Homes Are Loosely Regulated
There are 15,600 nursing homes in the U.S, housing 1.3 million people.5 Nearly 70% of the facilities are operated by for-profit companies with 57% run by chains.6 Genesis Healthcare, whose Milford, Delaware, location reported 12 resident deaths and 61 presumed COVID-19 cases in April 2020,7 runs 426 nursing homes.8
Life Care Centers Of America Inc., whose Kirkland, Washington, facility experienced 37 deaths when the U.S. COVID-19 outbreak first began,9 operates 214 nursing homes.10
Nursing homes are lightly regulated by the federal government with most oversight falling to the states,11 including disclosure of COVID-19 cases and deaths.12 Family and staff members have been kept in the dark about COVID-19 infections, and risks and outbreaks have been deliberately downplayed.13
When USA Today probed why there was not greater federal oversight of nursing homes, especially during the COVID-19 crisis, the answers they received were not satisfying.14
“A spokeswoman for the Centers for Medicare and Medicaid Services said nursing homes are required to follow their local and state reporting requirements, but she did not respond to questions about why the agency is not tracking the number nationally.
CDC spokesman Scott Pauley said the agency used “informal outreach” to state health departments late last month to estimate that 400 nursing homes had positive cases.”
In April 2020, federal lawmakers pressed the federal government to release COVID-19 cases in nursing homes. In a letter to the director and administrator of the CDC, Sen. Ron Wyden, D-Ore., ranking member of the Senate Finance Committee, and Sen. Bob Casey, D-Pa., ranking member of the Senate Special Committee on Aging, wrote:15
“As we work to track and mitigate the spread of this virus … we are alarmed by reports that the Centers for Medicare & Medicaid Services (CMS) and Centers for Disease Control and Prevention (CDC) are maintaining a list of facilities that have had one or more cases of COVID-19, and yet, have declined to make this information public.
As our nation faces a crisis unlike we have ever experienced, we write to urge you to release this list of facilities immediately and request information on what you are doing to keep nursing home residents, their families and health professionals informed.”
Rep. Jan Schakowsky, D-Ill., and 77 House Democrats wrote Health and Human Services (HHS) Secretary Alex Azar and CMS Administrator Seema Verma asking them to collect and publicly report COVID-19 cases and deaths in nursing homes.16
Nursing Home Problems Existed Even Before COVID-19
Problems at U.S. nursing homes preceded the COVID-19 outbreak. According to City Journal, almost 51,000 of the 61,099 total deaths from the 2017-2018 flu season occurred in those of nursing home age.17 Moreover, the facilities often flunk their inspections, writes the newspaper:18
“Seventy-five percent of U.S. nursing homes have been cited for failing to properly monitor and control infections in the past three years, according to a USA TODAY analysis of federal inspection data …
Those citations have been as mild as a paperwork problem and as serious as failing to inform state officials that unmonitored workers had spread disease to patients in an outbreak.”
Up to 40% of U.S. nursing homes are cited for deficient infection-control procedures, City Journal reported, including the Kirkland, Washington, Life Care Centers of America facility where COVID-19 was first recognized in the U.S.19
Nursing homes are supposed to have an infection-control staffer, but 60% lacked specialized training, according to a 2018 survey, reports the journal.20 According to The Washington Post:21
“Nearly 45 percent of the nursing homes with known coronavirus cases nationwide were repeatedly cited in recent years for violating federal rules meant to protect residents from the spread of infections …
In Oregon … [a] facility failed to screen staffers before they entered the building or ensure that caregivers washed their hands or wear personal protective equipment, inspectors found.
In New Mexico, the state attorney general is investigating a nursing home with at least 13 deaths, saying managers did not require staff members to wear gloves or enforce social distancing.”
CMS inspections conducted post-COVID-19 discovered that over a third of facilities were not observing proper hand-washing and one-fourth were not using protective gear correctly.22 In an opinion piece in The Wall Street Journal, Dr. Michael Segal expresses shock that scrubs are now commonly worn on the street, defeating the whole purpose of them being sterile:23
“When I was being trained as a doctor in the 1980s, we were forbidden to leave the hospital in scrubs. You changed clothes in the hospital to avoid bringing in infections out on scrubs or bringing dirt in. At some point that changed and health care workers started removing scrubs at home and washing them there.”
Patients and Families Not Told of Outbreaks
Nursing homes and long-term care facilities that do not report their COVID-19 cases publicly also likely do not inform residents and their families. According to KUSA TV in Colorado, a woman who went through rehabilitation at the Orchard Park Health Care Center in Greenwood Village after a fall and her son were not told of a COVID-19 outbreak she was exposed to.24
After discharge, she was admitted to a hospital where she tested positive for COVID-19 and died a week later. According to KUSA TV, her son, Jim Wilson:25
“… said he was never told about the outbreak, even after his mother died. ‘I think we should have been told when she was in there. She should have been tested when she was in there, said Wilson. ‘They should inform all future, current and past residents of what’s going on.'”
Jan Ransom, a reporter for The New York Times, was also not told that a nursing home in the Bronx where her father lived had cases of COVID-19, which he had caught. Ransom writes in Pro Publica:26
“What I did not know was that he already had the virus. Shortly after being admitted to the hospital, he tested positive for COVID-19. Hours later, I called the nursing home to alert the staff. A nursing home staffer told me that my father was not the first resident to test positive. He was the fourth. I was stunned …
After realizing my dad’s nursing home had left me in the dark, I started to make some calls. I thought about my father’s roommate and the families of other residents at the facility who were unaware of the storm brewing inside. I was certain I should have been alerted that the virus had been detected in the home they shared. I was wrong.
When I called the state Department of Health to complain on my family’s behalf, I was informed that nursing homes in New York — the epicenter of the crisis in the United States — were not obligated to tell families when the virus is detected in other residents.”
According to National Public Radio, nursing home residents who are poor or of color are also more likely to be exposed to COVID-19.27
“Seven of the 11 nursing homes with the highest number of deaths report that 46 percent or more of their residents are ‘non-white.’ Most of these ‘non-white’ residents are black and latinx. At one facility, the Franklin Center for Rehabilitation and Nursing in Queens, which reported 45 deaths, 80 percent of the residents are minority, including 47 percent who are Asian.”28
Nursing Home Workers Endure COVID-19 Abuses
A nursing home or long-term care facility that does not report COVID-19 outbreaks to authorities or families is unlikely to let staff know the virus risks, either. This puts both residents and staff at risk. Just as heart-breaking as the COVID-19 patients are the deaths of heroic health care workers.29 According to USA Today:30
“Francine Rico, who has worked at Villa at Windsor Park [Illinois] for nearly 23 years, said she found out that a resident she had worked with had tested positive for COVID-19 from a co-worker who happened to take the call from the hospital where the resident was tested. She said her facility’s administrators were not upfront.
‘I’m mad because we are frontline workers but we have been lied to,’ she said. ‘They put our lives on the line. They have put our residents’ lives on the line.'”
Another employee, Tainika Somerville, working at Bridgeview Health Care Center in Illinois, was also kept in the dark. According to USA Today:31
“… she, too, worked directly with a resident who tested positive for COVID-19 and later died. She said no one at the Bridgeview Health Care Center in Illinois told her she’d been in contact with someone who had it. Instead, she learned about it through news articles and social media.”
Nursing home workers, among the lowest paid of all health care workers, have expressed their plans to strike over the lack of protection against COVID-19.32
Nursing Home Risks Starting To Be Acknowledged
There are signs that the great risks nursing home residents and employees face from COVID-19 are being acknowledged. In Pennsylvania, nursing home administrators outside of Pittsburgh announced they would no longer just test for symptoms, but presume all residents to be positive.33
A study in the New England Journal of Medicine confirms that testing only symptomatic residents for COVID-19 is dangerously inadequate and that asymptomatic residents must be included.34
“The data presented here suggest that sole reliance on symptom-based strategies may not be effective to prevent introduction of SARS-CoV-2 and further transmission in skilled nursing facilities.
Impaired immune responses associated with aging and the high prevalence of underlying conditions, such as cognitive impairment and chronic cough, make it difficult to recognize early signs and symptoms of respiratory viral infections in this population.”
With increasing reports of underreported nursing home COVID-19 cases and deaths, CMS issued new guidelines. According to City Journal:35
“In the wake of coronavirus’s emergence, the Centers for Disease Control advised nursing homes to initiate strict controls, including restricting outside visitors, examining all residents for early signs of respiratory distress, and isolating where possible those who test positive for Covid-19.
The CMS followed up with more instructions, including beginning symptom screenings such as temperature checks for all residents. And the federal government instructed states to make nursing homes a priority for receiving medical supplies.”
A few days later, on April 19, 2020, the CMS mandated that nursing homes inform residents, their families and the federal government about cases of COVID-19, which the agency will collect.36 CMS also admitted that nursing homes have become “an accelerator” for the virus.37
But the growing awareness does not assure the transparency and containment of COVID-19 infections. According to NBC News, the nursing home industry is fighting back and seeking to get states to provide immunity from lawsuits to the owners and employees of U.S. nursing homes.38
“So far at least six states have provided explicit immunity from coronavirus lawsuits for nursing homes, and six more have granted some form of immunity to health care providers, which legal experts say could likely be interpreted to include nursing homes …
Of the states that have addressed nursing home liability as a response to the outbreak, two — Massachusetts and New York — have passed laws that explicitly immunize the facilities. Governors in Connecticut, Georgia, Michigan and New Jersey have issued executive orders that immunize facilities.”
While nursing home risks have rarely been clearer, the reaction of too many nursing homes is to circle the wagons rather than improve their conditions. If immunity is granted to nursing homes, it is safe to say the risks from COVID-19 will only get worse.
Lying in the prone (face down) position, in which your chest is down and your back is up, could be a simple way to improve outcomes in cases of severe respiratory distress. This topic has received renewed attention during the COVID-19 pandemic, as invasive mechanical ventilation is conventionally delivered with the patient in the supine (face up) position, which refers to lying on your back.
“Mechanical ventilation is the main supportive treatment for critically ill patients” infected with novel coronavirus 2019 (COVID-19), according to a February 2020 study published in The Lancet Respiratory Medicine.1 However, reports suggest that many COVID-19 patients put on ventilators don’t make it.
In a JAMA study that included 5,700 patients hospitalized with COVID-19 in the New York City area between March 1, 2020, and April 4, 2020, mortality rates for those who received mechanical ventilation ranged from 76.4% to 97.2%, depending on age.2 There are many reasons why those on ventilators have a high risk of mortality, including being more severely ill to begin with.
However, given the poor outcomes, some physicians are now trying to keep patients off ventilators as much as possible by using alternative measures, including having patients lie on their stomachs (prone) to allow for better lung aeration.3
It’s also possible that prone ventilation, which is ventilation delivered with the patient lying in the prone position, may help patients who aren’t responding to conventional ventilation in the supine position,4 as well as reduce mortality in those with acute respiratory distress syndrome (ARDS).5
Prone Positioning Lowers Death Rate in Those With ARDS
ARDS is a lung condition that causes low blood oxygen and fluid buildup in the lungs. As fluid builds up in the lungs and surfactant, which helps the lungs fully expand, breaks down, the lungs are unable to properly fill with air.6 A person with ARDS will have shortness of breath, which can progress to low blood oxygen, rapid breathing and rattling sounds in the lungs when breathing.
ARDS is a common complication among seriously ill COVID-19 patients, with one study suggesting that 100% of COVID-19 patients who died in one study were suffering from ARDS.7
In 2013, a study published in The New England Journal of Medicine found that early application of prone positioning may improve outcomes in people with severe ARDS.8 During the study, 466 patients with severe ARDS were randomly assigned to receive prone-positioning sessions of at least 16 hours or to stay in the supine position.
After 28 days, 32.8% in the supine group had died, compared to 16% in the prone group. After 90 days, the supine group had a mortality rate of 41%, compared to 23.6% in the prone group, with researchers concluding, “In patients with severe ARDS, early application of prolonged prone-positioning sessions significantly decreased 28-day and 90-day mortality.”9
Not only have previous studies found that oxygenation is significantly better among patients in the prone position compared to the supine position, but prone positioning may also prevent ventilator-induced lung injury.10
Why Prone Positioning Benefits ARDS Patients
In the video above, Jonathan Downham, an advanced critical care practitioner in the U.K., explains why prone positioning can be so beneficial for those with ARDS. Using a simple example of a sponge filled with fluid, he shows how the direction of drainage changes depending on the sponge’s position.
In ARDS, the lung’s air sacs, or alveoli, become damaged. Fluid leaks through the air sacs’ damaged walls and collects.11 Fluid in the lung will increase its weight, which then squeezes out the gas from the dependent regions. If the sponge represents a fluid-filled lung, in the supine position the dependent regions are at the back of the lung.
While the fluid in an ARDS patient’s lung is more evenly distributed than the sponge model suggests, it helps to show how the increased lung mass squeezes out the gas of the gravity-dependent lung regions, and why the lung densities shift when moving from the supine to the prone position.
According to Downham, this shift can occur in a matter of minutes after changing a person’s position. Differences in shape of the lungs and chest wall also come into play. Lungs are normally conical, with the dependent side being the base and the non-dependent side being the apex. When supine, your lung is in this configuration.
The chest wall, however, has a cylindrical shape, and because of this difference the lung must expand its upper regions more than the lower regions, which leads to a greater expansion of the nondependent alveoli and a lesser expansion of the dependent alveoli.
Imagining that the lung is like a slinky, Downham then shows how, when a patient is in the prone position, the weight becomes much more evenly distributed, allowing for better ventilation.
Taken together, when in the supine position, gravitational forces, increased pressure from the wet lung and shape-matching issues all combine to act in the same direction to have a detrimental effect on the dependent alveoli. The prone patient, however, suffers less from these effects. Other benefits also occur with prone positioning, including:
- Removing some of the weight of the heart from the dependent lung12
- Rapid, significant and persistent improvement in oxygenation in the ARDS patient with heart failure
- Removing some of the weight of the abdominal contents from the better ventilated posterior aspect of the lung13
Prone positioning can also help with stress and strain on the lung, with stress referring to the tension in the fibrous skeleton when distending force is applied and strain being the volume increase caused by the applied force relative to the resting volume of the lungs. It also reduces lung inflammation in ARDS patients14 and may reduce the severity and the extent of lung injury caused by mechanical ventilation.15
Support for Early Use of Prone Positioning
Increasing research suggests that prone positioning should be used “systematically” in the early management of severe ARDS, and not reserved as a “rescue maneuver or a last-ditch effort.”16 As noted by a pathophysiology-based review published in the World Journal of Critical Care Medicine:
“Current evidence strongly supports that prone positioning has beneficial effects on gas exchange, respiratory mechanics, lung protection and hemodynamics as it redistributes transpulmonary pressure, stress and strain throughout the lung and unloads the right ventricle.”17
The researchers suggested that prone positioning seemed to be beneficial in most cases of ARDS and recommended that “early use of prolonged prone positioning in conjunction with lung-protective strategies decreases mortality significantly.”18 For best results, other researchers have suggested that prone ventilation sessions should last 12 to 18 hours per session and should be begun early, within 36 hours of diagnosis.19
A small study of patients with severe COVID-19-related ARDS who required mechanical ventilation in Wuhan, China also revealed that lying in the prone position for 24-hour periods was better for the lungs.20,21 Unfortunately, despite the many potential benefits, prone positioning remains an underused technique. One study suggested that only 13.7% of patients with ARDS, and 32.9% of patients with severe ARDS, were placed in the prone position.22
Awake Proning Is Also Beneficial
Much of the research into prone positioning for respiratory distress has focused on its use during mechanical ventilation. However, at least one study has been planned to determine whether the use of prone positioning in awake self-ventilating patients with COVID-19-induced ARDS could improve gas exchange and reduce the need for invasive mechanical ventilation.23
Previous research also suggests that awake, spontaneously breathing patients who are not intubated can also benefit from prone positioning, which leads to improved oxygenation.24 Another study of care involving critically ill COVID-19 patients in China’s Jiangsu Province recommended the use of awake prone positioning, which, the researchers noted, “showed significant effects in improving oxygenation and pulmonary heterogeneity.”25
It’s also been suggested that the physiological changes that occur with prone positioning may be even more favorable in spontaneously breathing patients than in those who are intubated.
A 2003 study found, in fact, that the prone position led to a rapid increase in partial pressure of oxygen, or PaO2, which is a measure of how well oxygen moves from the lungs to the blood, among patients with respiratory failure.26 All of the patients in the study were able to avoid mechanical ventilation.
In the case of COVID-19, some experts suggest that all patients who are awake and able to adjust their own position should use the prone position for two- to four-hour sessions, two to four times a day. Massachusetts General Hospital also released a prone positioning protocol for nonintubated COVID-19 patients, which states:27
“… [P]atients admitted with hypoxemia should be encouraged to adopt the prone position where practical and prone positioning may be used as a rescue therapy in patients with escalating oxygen needs.”
How to Use Prone Positioning at Home
Some hospitals have also released instructions for self-proning, which can be used at home for people with cough or trouble breathing. If you’re struggling to breathe, you should seek emergency medical care. However, in cases of cough or mild shortness of breath being treated at home, guidelines from Elmhurst Hospital recommend not spending a lot of time lying flat on your back.28,29
Instead, it suggests “laying [sic] on your stomach and in different positions will help your body to get air into all areas of your lung.” The guidelines recommend changing your position every 30 minutes to two hours, including:
- Lying on your belly
- Lying on your right side
- Sitting up
- Lying on your left side
This is a simple way to potentially help ease breathing difficulties at home and, if you or a loved one is hospitalized, can be used there too. If your health care providers don’t suggest it, ask whether prone positioning could help.
Russ on Tuesday once again joined the intrepid Eric Gajewski of TradCatKnight for their monthly podcast. The two see eye to eye on the on the COVID-1984 crisis, as a New Underworld (dis)Order manipulation to […]
By Anna Von Reitz
By Anna Von Reitz
Woodstock Occurred in the Middle of a Pandemic. Stock markets didn’t crash. Congress passed no legislation.
Nothing closed. Schools stayed open. All businesses did too. You could go to the movies. You could go to bars and restaurants.