New York State Department of Health issues report on COVID-19 in nursing homes

The New York State Department of Health recently released results of an in-depth analysis of nursing home data that found COVID-19 fatalities in nursing homes were related to infected nursing home staff. The full report can be found at https://health.ny.gov/press/releases/2020/docs/nh_factors_report.pdf. 

David L. Reich MD, president and COO of The Mount Sinai Hospital, stated, “Mount Sinai scientists published a report last week, demonstrating the presence of antibodies to SARS-CoV-2, the virus that causes COVID-19, in saved blood specimens as early as the week ending Feb. 23. This means that the virus was spreading in the New York City metropolitan region approximately three weeks earlier. The conclusions of the NYSDOH report of the root causes of nursing home fatalities in New York State are well supported by the data detailing nursing home staff COVID-19 illness, and epidemiological patterns, especially considering evidence of the duration of contagiousness for COVID-19 patients. We all hope to learn from these data and work with NYSDOH and nursing home partners to maximize safety for our most vulnerable citizens as this pandemic continues to evolve.”

Mr. Michael Dowling, CEO, Northwell Health, stated,​ “This important data-based study confirms what we saw in our own facilities and around the state – that when the virus hit our local communities, it quickly spread through asymptomatic carriers into our nursing homes, hospitals, places of worship and other congregate settings. This study highlighted a critically important fact that the overwhelming majority of hospital patients sent back into nursing homes were not only medically stable, they were no longer contagious, and that 81 percent of the nursing homes receiving COVID patients from New York’s hospitals already had the virus. This rigorous, fact-driven analysis provides critical insight as we move forward into the next phase of this pandemic and continue to look for new ways to improve health outcomes for patients.”

The executive summary to the report is as follows.

In an effort to learn for the future from the data now available from the earliest days of the first in a century pandemic that swept across the globe and into the United States, the New York State Department of Health (NYSDOH) conducted an in-depth analysis of self-reported nursing home data that finds that COVID-19 fatalities in nursing homes were related to infected nursing home staff. The NYSDOH analysis found that the timing of staff infections correlates with the timing of peak nursing home resident mortality across the state; Nursing home employee infections were related to the most impacted regions in the state; Peak nursing home admissions occurred a week after peak nursing home mortality, therefore illustrating that nursing home admissions from hospitals were not a driver of nursing home infections or fatalities; most patients admitted to nursing homes from hospitals were no longer contagious when admitted and therefore were not a source of infection; and, nursing home quality was not a factor in nursing home fatalities.

According to data submitted by nursing homes, in many cases under the penalty of perjury, approximately 37,500 nursing home staff members, one in four of the state’s approximately 158,000 nursing home workers, were infected with COVID-19 between March and early June 2020. Of the 37,500 nursing home staff infected, nearly 7,000 of them were working in facilities in the month of March; during the same period, more than a third of the state’s nursing home facilities had residents ill with the virus. Roughly 20,000 infected nursing home workers were known to be COVID-positive by the end of the month of April. These workforce infections are reflective of the larger geographic impact of the virus’s presence across the state.

NYSDOH further analyzed the timing of the COVID-positive staff infections and the timing of nursing home deaths. Based on published data, the average length of time between COVID-19 infections to death is between 18-25 days. 

Therefore, the link between the timing of staff infection and nursing home mortality is supported by the fact that the peak number of nursing home staff reported COVID-19 symptoms on March 16, 2020, 23 days prior to the date of the peak nursing home fatalities, which occurred on April 8, 2020. It is likely that thousands of employees who were infected in mid-March transmitted the virus unknowingly, through no fault of their own, while working, which then led to resident infection. 

NYSDOH also examined the potential impact of the NYSDOH’s March 25, 2020 admission policy. A survey conducted by NYSDOH shows that approximately 6,326 COVID-positive residents were admitted to facilities between March 25, 2020 and May 8, 2020; this finding is supported by an independent analysis done by the Associated Press on May 22, 2020.

However, an analysis of the timing of admissions versus fatalities shows that it could not be the driver of nursing home infections or fatalities. An individual nursing home-by-nursing home analysis of admissions versus fatalities further supports this finding. 

A causal link between the admission policy and infections / fatalities would be supported through a direct link in timing between the two, meaning that if admission of patients into nursing homes caused infection—and by extension mortality — the time interval between the admission and mortality curves would be consistent with the expected interval between infection and death. However, the peak date COVID-positive residents entered nursing homes occurred on April 14, 2020, a week after peak mortality in New York’s nursing homes occurred on April 8, 2020. If admissions were driving fatalities, the order of the peak fatalities and peak admissions would have been reversed.   

NYSDOH further analyzed the period of time patients stayed in hospitals prior to admission to nursing home facilities. Preliminary data show that residents were admitted to nursing homes a median of nine days after hospital admission. Health experts believe that individuals infected with the virus are most infectious two days before symptoms appear and that they are likely no longer infectious nine days after symptom onset – thus, by the time these patients were admitted to a nursing home after their hospital stay, they were no longer contagious. 

NYSDOH also considered the impact of visitation into nursing homes as a cause of infections. A review shows that prior to nursing home visitation being suspended completely on March 13, 2020, there was no tracking or testing of family and friends who were present in the facility, and any asymptomatic or symptomatic visitor could have been granted access. 

Given what we now know about how widespread the virus was in New York prior to testing availability in February and early March, there is a high likelihood, according to the report, that COVID-positive visitors entered nursing homes, although there is no specific data to support this assumption, and so ultimately this is inconclusive.

You can view the full report at https://health.ny.gov/press/releases/2020/docs/nh_factors_report.pdf.