A 150-bed skilled nursing facility utilized heat mapping to characterize the dissemination and spread of a severe outbreak of SARS-CoV-2. This technique in this publication overlaid colored indicators on top of a designated mapping space, in this case the facility layout, to visually represent the density and spread of the SARS-CoV-2 outbreak within the facility at three different time points (March 29, March 31, & April 17).

Facility Characteristics

• 99% of residents had dementia diagnosis.
  • ~ 85% of residents had Do Not Resuscitate orders at the time of outbreak and ~33% had Do Not Hospitalize orders.
  • The facility was divided into 4 living units: A, B (dementia care, most intensive care), C, and D.

Testing & Dissemination Timeline, March 1-April 17, 2020

• March 1-10: The facility conducted daily symptom screens for all residents and visitors and ceased all communal dining and activities.
• March 10: A no visitation policy was implemented.
• March 11-13: All staff received training on SARS-CoV-2 symptomology, transmission precautions, and PPE usage.
• March 23-25: Six residents (1 Unit A; 5 Unit B) and two staff members developed symptoms (1 Unit A; 1 Unit B); none were tested and the symptomatic residents were put under contact and droplet precautions.
• March 26: Six testing kits were received, and employees implemented universal masking.
  • March 28: First positive resident test result was received and transmission precautions were implemented on the main symptomatic unit (Unit B).
  • By March 31: 3 more positive resident results were received.
• March 29: A cluster of symptomatic patients were being monitored (2 in Unit A and 16 in Unit B). See Figure 1.
• March 31: 9 residents in Unit A, 22 residents in Unit B, and 1 resident in Unit D were symptomatic. See Figure 2.
  • 3 tests were obtained to evaluate asymptomatic transmission to other units—the resident spot-tested in Unit A, whose roommate had early symptoms, later developed symptoms as well.
• April 17: SARS-CoV-2 dissemination was widespread in all 4 units of the facility. See Figure 3.
  • 56 residents across all units were currently symptomatic, while 30 residents had died.
  • 26 employees were out of work due to confirmed or presumed SARS-CoV-2 infection.

Takeaways

• Within 3 weeks, the virus disseminated throughout the facility despite visitor exclusion, frequent symptom assessments, contact and droplet precautions for symptomatic residents, aggressive social distancing, and universal masking.
• Authors conclude that insufficient availability and turnaround of testing hindered efforts to identify and cohort SARS-CoV-2 cases, undermining infection control efforts.
• Authors recommend that state testing capacities be increased to effectively address the testing needed in the coming weeks, as the reopening of skilled nursing facilities puts their residents and staff in contact with an increasingly mobile population.
• Frequent resident and staff testing may result in increasing numbers of asymptomatic positive staff, and authors recommend that states and long-term care providers coordinate in order to continue maintaining the staffing reserves necessary to supplement frontline staff.

An Illustration of SARS-CoV-2 Dissemination Within a Skilled Nursing Facility Using Heat Maps. Blackman C, Farber S, Feifer RA, Mor V, White EM. An Illustration of SARS-CoV-2 Dissemination Within a Skilled Nursing Facility Using Heat Maps. J Am Geriatr Soc. Published online June 13, 2020. doi:10.1111/jgs.16642

This review was posted on behalf of Lauren Albert, medical student at IU School of Medicine, and approved by Dr. Kathleen Unroe, IU School of Medicine associate professor, geriatrician, and IU Center for Aging Research Scientist.