COVID-19 Treatment Protocol for Nursing Homes
The recommended protocol for COVID-19 treatment in nursing homes should include strict isolation procedures, appropriate respiratory support, careful monitoring of symptoms, and targeted therapeutic interventions while balancing infection control with psychosocial needs of residents, particularly those with dementia. 1
Infection Control and Isolation Measures
Environmental Requirements
- Establish clear designation of clean areas, potentially contaminated areas, and contaminated areas with proper signage 1
- Implement single-room isolation for confirmed cases (priority strategy) or cohort isolation for confirmed patients together and suspected cases separately 1
- Ensure proper disinfection of environment and articles according to guidelines 1
- Manage medical waste properly using sealed double-layer yellow medical waste bags 1
Resident Movement Restrictions
- Limit resident movement within the facility 1
- When transport is necessary:
- Minimize escorts
- Use designated contaminated channels for transport
- Ensure patients wear N95 or surgical masks when outside their rooms 1
Diagnostic and Monitoring Approach
Initial Assessment
- Monitor for atypical COVID-19 presentations in elderly, especially those with dementia:
- Sudden cough and fever
- Diminished taste or smell
- Nausea and diarrhea
- Shortness of breath
- Falls
- Dehydration
- Delirium or confusion
- Disordered sleep 1
Ongoing Monitoring
- Document changes in health status, mood, or behavior as potential indicators of infection 1
- Monitor oxygen saturation regularly, even with seemingly mild symptoms, due to risk of silent hypoxemia 2
- Consider supplemental oxygen if SpO2 falls below 92% 2
- Perform daily fluid status assessment including:
- Clinical examination for peripheral perfusion
- Capillary refill
- Pulse rate and blood pressure
- Fluid balance monitoring (intake, output, weight) 2
- Laboratory monitoring:
Treatment Protocol
Respiratory Support
- For mild cases: Use nasal catheter or mask for oxygen therapy; adjust flow as appropriate based on patient condition 1
- For moderate to severe cases: Consider higher levels of respiratory support as needed
Pharmacological Treatment
- For eligible patients, consider remdesivir treatment:
- For adults and pediatric patients weighing at least 40 kg: Single loading dose of 200 mg on Day 1 via IV infusion, followed by once-daily maintenance doses of 100 mg from Day 2 3
- Treatment duration:
- For hospitalized patients requiring invasive mechanical ventilation/ECMO: 10 days
- For hospitalized patients not requiring invasive mechanical ventilation/ECMO: 5 days (may extend up to 10 days if no clinical improvement) 3
- For non-hospitalized high-risk patients with mild-to-moderate COVID-19: 3 days 3
- Administer only in settings where healthcare providers have immediate access to medications to treat severe infusion or hypersensitivity reactions 3
- Monitor hepatic function and prothrombin time before and during treatment 3
Special Considerations for Nursing Home Implementation
- Pre-hospital administration of remdesivir in nursing homes has been associated with increased odds of survival during outbreaks 4
- Consider the logistical feasibility of IV medication administration in your facility 4
Discharge and Recovery Criteria
Discharge Standards
- Body temperature returned to normal for more than 3 days
- Significant improvement in respiratory symptoms
- Obvious signs of absorption in lung inflammation
- Negative respiratory nucleic acid tests for two consecutive times (minimum one-day sampling interval) 1
Special Considerations for Residents with Dementia
Communication and Behavioral Management
- Use reassuring language and gestures to help residents follow safety regulations
- Interact frequently, validate feelings, and provide reassurance
- Avoid negative language (e.g., "crisis," "pandemic," "lockdown," "isolation")
- Maintain regular schedules and routines 1
Managing Challenging Behaviors
- For residents who resist safety instructions or exhibit wandering behavior:
- Use familiar objects, photographs, or songs for distraction
- Stimulate movement, exercise, and creative activities
- Collaborate with mental health professionals and dementia teams 1
Reducing Social Isolation
- Encourage families to drop off letters, drawings, or packages
- Facilitate participation in everyday activities (music, audiobooks)
- Arrange regular family check-ins via technology
- Maintain small group activities when possible with appropriate distancing
- Consider virtual reality technology to facilitate family connections 1
End-of-Life Considerations
- Weigh the importance of visits against infection risk when a resident is nearing end of life
- Address anticipatory grief by recognizing and validating emotions
- Provide information about bereavement preparation
- Connect residents and families to spiritual resources 1
Common Pitfalls and How to Avoid Them
Failing to recognize atypical COVID-19 presentations in elderly residents
- Solution: Maintain high index of suspicion; document and investigate any changes in condition
Overreliance on physical isolation without addressing psychological needs
- Solution: Balance infection control with psychosocial interventions to prevent delirium and worsening dementia
Inadequate preparation for medication administration
- Solution: Ensure staff are trained in IV administration and management of potential adverse reactions before implementing remdesivir treatment
Neglecting the needs of residents with dementia during isolation
- Solution: Implement person-centered isolation procedures that don't rely on physical or chemical restraints
Poor communication with families
- Solution: Establish regular updates and virtual visiting options to maintain family connections
By implementing this comprehensive protocol, nursing homes can effectively manage COVID-19 cases while maintaining quality of life and dignity for residents.