September 2020

In This Issue: How Research Helps Combat COVID-19
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Detecting COVID-19 in VA Community Living Centers

Feature Article

Takeaway:Study results will improve our understanding of the vital signs and COVID-19 infection relationship, which may provide critical guidance on how to modify infection control practices to better address the needs of Community Living Center staff and vulnerable residents. In addition, findings should provide a better understanding of patients who have COVID-19 but are asymptomatic, which has become a nation-wide public health concern.

COVID-19 poses the greatest risk to older people with chronic illness, which is why Veterans residing in VA Community Living Centers (CLCs) are a priority for early detection. Standard CLC infection control screening practices for COVID-19 center on assessing daily temperatures; however, COVID symptoms have become increasingly diffuse in the past months, including fever (37-98%), tachycardia (43%), tachypnea (17%), fatigue (70%), and dry cough (59%). Investigators conducting this ongoing HSR&D-funded study (June 2020 – February 2021) will determine the vital sign trend for Veterans residing in community living centers, individually, and as a ward, to determine whether it can effectively identify Veterans and their CLC units with and without COVID-19.

Methods

Investigators are working to:

• Characterize the association between vital signs in the week prior to testing and COVID-19 positive criteria among Veterans who develop COVID. Investigators hypothesize that CLC residents with COVID-19 will be more likely to have vital sign perturbations that do not meet the threshold for retesting. This analysis will directly feed into the operations protocol for retesting.
• Characterize the trend in the average ward vital signs in the week prior to identification of a CLC resident diagnosed with COVID-19 without inclusion of this resident's data. Investigators hypothesize that the average daily ward vital signs will be elevated in the week prior to the first COVID-19 diagnosis. This analysis will be incorporated into their vital sign monitoring system as an early warning system.
• Identify the mortality, hospitalization, and ICU utilization rates of asymptomatic CLC residents with COVID-19 positive test results. Investigators hypothesize that asymptomatic COVID-19 positive Veterans will have worse outcomes relative to COVID-19 negative Veterans. This analysis will feed into the CLC testing and isolation strategies for COVID-19 outbreaks.
  

Findings

As part of this study, investigators compared temperature trends to identify maximum temperatures in nursing home residents 14 days prior to and following systematic testing among 7,325 Veterans residing in VA community living centers. They found that a single temperature screening is unlikely to accurately detect COVID-19 in nursing home residents, as only 27% of residents who tested positive for the virus met the temperature threshold (38°C or 100.4°F) during the study period. Study results suggest that the current fever threshold for COVID-19 screening should be reconsidered. Repeated temperature measurement with a patient-derived baseline could increase sensitivity for surveillance purposes when applied to a nursing home population.

Anticipated Impact

Study results can be used to retest for COVID-19 and trigger infection control practices that may improve outcomes. In addition, findings should provide a better understanding of patients who have COVID-19 but are asymptomatic, which has become a nation-wide public health concern. Improved understanding of the vital sign and infection relationship may provide critical guidance on how to modify infection control practices to better address the needs of CLC staff and vulnerable residents. 

Study results were presented to the Centers for Disease Control and Prevention (CDC) on May 27, 2020, and the CDC updated temperature guidance for nursing homes less than a month later.

Principal Investigator: James Rudolph, MD, leads HSR&D’s Center of Innovation in Long-Term Services and Supports for Vulnerable Veterans in Providence, RI.

Publications

Rudolph J, Halladay C, Barber M, et al. Temperature in nursing home residents systematically tested for SARS-CoV-2. Journal of the American Medical Directors Association. July 2020:21(7);895-899.

View study abstract