Tentative plans to conduct more randomized surveillance testing at various elderly care facilities across the state are now on hold because of testing supply shortages and increasing prevalence of COVID-19 in the community, state health officials said Thursday.
Across the U.S., more than 40% of all COVID-19 related deaths have occurred in nursing homes, and elderly people are considered among the most vulnerable to suffering complications from the disease.
“Given this current landscape, we’ve had to change strategies a bit,” Dr. Sarah Park told lawmakers Thursday at a House committee hearing on COVID-19 that lasted several hours. “We had originally thought to do some more active surveillance testing in light of certain cases in long term care facilities, so now we’ve had to shift a little bit.”
On Wednesday, one of Hawaii’s largest laboratories said its supply chain has been cut as outbreaks in other states worsen. Park called Hawaii’s testing landscape “fluid” and “unstable.”
“We’re constantly having to shift gears in terms of what our plans are,” she said.
The House Committee on Health and the House Committee on Human Services and Homelessness held the informational briefing Thursday to discuss whether Hawaii’s nursing facilities and smaller caregiver homes are equipped to prevent the spread of COVID-19.
Many of the questions from lawmakers, including Rep. Joy San Buenaventura and Rep. Gene Ward, centered on whether or not the state was conducting sufficient testing of the homes — especially in light of reports from smaller care home operators, who say they need more protective equipment and assistance with telehealth services.
There is heightened concern among lawmakers as Hawaii prepares to allow travelers to bypass a 14-day quarantine if they provide negative COVID-19 test results. Clusters of the disease have been found in a large nursing facility on Oahu and other smaller care homes in Wahiawa and Kaneohe.
According to the health department, five care homes across the state have been impacted by COVID-19 within the past month, with 19 COVID-19 cases confirmed to date. Two care home residents have died, although department officials would not specify what type of care home setting they lived in.
To cope with supply shortages, the state has stockpiled some testing equipment. Diversification of equipment at different laboratories across the state helps to ensure that there will be back-up resources, she said.
But the recent events have made state health department officials more stringent and strategic in their testing protocol. Tests will be prioritized for essential workers or people in high-risk populations. They’ll be deployed in situations that pose a significant threat for an outbreak. Others that are not deemed a high risk will be sent to the mainland for testing.
Despite these mounting challenges, Park urged lawmakers to remember that tests offer a “point-in-time” snapshot and are not always reliable, and health department officials feel it is a more efficient use of resources to continue a rigorous symptom screening program for employees and residents. If cases do arise in vulnerable settings such as elderly care facilities, the state will be prepared to deploy testing.
The list of COVID-19 symptoms that health care providers check for among the general population — such as respiratory symptoms, or loss of sense of smell and taste — do not always apply to the elderly population.
“With long term care folks, especially the elderly, what we’ve noticed and also what’s being noted elsewhere is that sometimes when they become afflicted with COVID-19 they have a decreased mentation, or altered mental status,” said Park, who is also a medical doctor.
“We’re asking care home folks to be mindful of sudden changes of those things, because it may be an indication or a very subtle sign of COVID infection. If we find and identify a positive case in any long term care facility, (we’d) go ahead and test the remainder of the facility.”
State representatives asked Park if there was a state plan for quarantining elderly residents who test positive. She said the department’s disease outbreak control division is working with facilities to make sure they have a plan, but for smaller care homes, the state has yet to figure out a solution.
Of the 13,000 long-term care beds across all islands, only about 35% of them are in nursing home facilities. The rest are in adult residential care homes, assisted living facilities and community care foster family homes based in the owner’s residence. Smaller care homes don’t have a built-in hospital support structure, so many caretakers may not feel as equipped to prevent the transmission of the virus.
“It’s something we do need to figure out because these are homes, not facilities, so it’s a different situation,” Park said.
A recent outbreak at Hale Nani Rehabilitation and Nursing Center resulted in positive test results for 10 residents and six staff members, but many were discovered after routine testing was conducted by Hawaii Premier Medical Group, which was hired by the facility’s owner, Avalon Health.
The facility has also admitted two new COVID-19 positive residents to its COVID-19 dedicated isolation unit. They were transferred from a smaller care home elsewhere on Oahu.
Dr. Scott Miscovich, who led the testing at Hale Nani and whose team has conducted many drive-through testing events across the islands, said 40% of the positive cases they found were among asymptomatic elderly residents. No new cases have been discovered there for at least a week.
The Department of Health recommends all elderly care homes and facilities screen both workers and residents three times a day for symptoms or other potential early signs of COVID-19 infection. Active surveillance of staff is crucial, since they have a higher likelihood of introducing the virus to a facility, rather than the elderly residents who do not leave campus as often, if at all, Park said.
DOH does not endorse universal or blanket testing because there simply are not enough tests to do so, nor is it an efficient use of a limited resource, Park said. She also said that rapid blood tests and breathalyzer tests have not yet shown enough evidence to be reliable.
The collective testing capacity across the state at private and public laboratories had the potential to surge up to 5,000 tests per day, but that capacity has been reduced because of the worsening pandemic elsewhere in the nation. As of June 24, the average number of tests conducted daily in Hawaii was 1,289, according to DOH State Laboratories Division Administrator Edward Desmond.
If elderly people in private care homes test positive for COVID-19, there are few places in the state to house them while they recover, said Dr. Curtis Toma, Med-Quest medical director. About 7,500 Medicaid recipients are currently in community placements and about 2,300 others are in nursing homes.
“As you can imagine as the COVID-19 crisis grows and we have more cases, it’s going to be harder to place these patients,” he said. “When we had an outbreak in a foster home, it was a steep learning curve, and it required a lot of real-time interventions.”
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