On an afternoon in late April, 14 Johns Hopkins doctors and nurses fanned out through an Ellicott City nursing home. They tested residents for COVID-19, assessed the health of those who had the disease, talked with staff members about infection-prevention strategies and provided moral support.
The facility wasn’t the first in Maryland to contend with COVID-19. But it was one of the first to get help from the Johns Hopkins Go Team — a disaster response unit formed a decade ago to provide clinical and logistical support to communities around the world that are reeling from hurricanes, earthquakes and other catastrophes.
Now, the Go Team is being deployed closer to home.
“Nursing homes are struggling right now,” says Christina Catlett, M.D., Go Team director and associate director of the Johns Hopkins Office of Critical Event Preparedness and Response. “We’re trying to be proactive in helping them manage their ill patients and make the hard decisions about when to send them to the hospital.”
“It’s really the first time in my 20 years of being a disaster expert that I’ve seen this level of collaboration in the state of Maryland...this pandemic is larger than all of us. There’s no way we could have managed this as a single system.” - Christina Catlett, M.D.
Disproportionately elderly and frail, nursing home residents account for about half of COVID-19 deaths in Maryland, according to state records. At least six nursing homes in the state have each reported 100 or more cases of COVID-19.
On April 7, Maryland Gov. Larry Hogan launched an initiative to address that troubling reality. The state program creates “strike teams” that nursing homes can tap for COVID-19 testing and guidance. These strike teams include state and local health officials, members of the National Guard, health responders from U.S. Department of Health and Human Services, and clinicians from local health systems, including members of the Johns Hopkins Go Team.
On April 29, Hogan mandated COVID-19 testing for all residents and staff members in Maryland nursing homes.
“It’s really the first time in my 20 years of being a disaster expert that I’ve seen this level of collaboration in the state of Maryland,” says Catlett. “This pandemic is larger than all of us. There’s no way we could have managed this as a single system.”
Infected and Asymptomatic Residents
The Go Team benefits from existing relationships between the Johns Hopkins health System and nursing homes in the region. “We share some of the most vulnerable patients,” says Michele Bellantoni, M.D., clinical director of the Division of Geriatric Medicine and Gerontology at the Johns Hopkins University School of Medicine. “Having the ability to work together is critical.”
Because of those relationships, Morgan Katz, M.D., M.H.S., director of antimicrobial stewardship at Johns Hopkins Bayview Medical Center, was already researching protection from infection in nursing homes.
When the pandemic began, she brought Johns Hopkins teams to nursing homes to test residents for COVID-19. “If there were several symptomatic patients or a developing outbreak, we would go in and test an entire unit or facility,” she says.
The results, in her words, “were stunning.”
In facilities with one or two residents with COVID-19 symptoms, as many as 75% tested positive for the new coronavirus, she says. Of those, 60% to 70% exhibited no symptoms.
When all staff members could be tested, she says, they found that as many as half tested positive for the new coronavirus but showed no symptoms — of particular concern because many nursing home employees work at more than one facility and can spread the virus among locations.
“What they really need and want is testing and also just support,” Katz says of the nursing home employees. “So many of the staff members are overworked and feeling alone. The strike teams give them a little morale boost, let them know we’re looking out for them.”
“I think it was helpful for them to know that people from the outside were there to help and not judge.” - Matthew McNabney, M.D.
Strategizing in the Parking Lot
On that recent spring afternoon in Ellicott City, members of the strike team, including clinicians from Johns Hopkins and the National Guard, met in the parking lot of the nursing home.
They stood at least 6 feet from one another while the facility’s leaders, using flip charts propped against the side of an SUV, described the building’s layout and where residents with COVID-19 were being treated.
“We devised a strategy about how we would divide ourselves and disperse through the building,” says participant Matthew McNabney, M.D., director of the fellowship training program for geriatric medicine and gerontology at Johns Hopkins, and medical director of Johns Hopkins’ Program of All-Inclusive Care for the Elderly.
Third-year Johns Hopkins medical student Benjamin Bigelow coordinated testing, ensuring that every resident was swabbed and that the materials were taken back to Johns Hopkins for analysis in properly labeled and sealed bags. (A day later, the results showed that slightly more than half of the residents tested positive but exhibited no symptoms.)
McNabney, meanwhile, teamed with emergency medicine and palliative care providers to assess residents in the COVID-19 unit. Many residents received lung evaluation by Johns Hopkins emergency physicians using bedside ultrasound devices, he says. The providers also discussed goals of care with residents.
They determined that the residents with COVID-19 were stable and breathing comfortably, and that the facility was doing what it could to prevent the spread of the virus, including taking the temperature of everyone going in, requiring staff members to wear personal protective gear and keeping residents who tested positive separate from others.
“You could feel their anxiety and tell they’re trying to do the right thing,” McNabney says. “I think it was helpful for them to know that people from the outside were there to help and not judge.”