From North Carolina Health News: As COVID-19 threatened western N.C., a new approach to fighting it in long-term care

Editor’s note: These stories were originally published as a two-part series for North Carolina Health News. Part one can be found here, and part two can be found here.

By Thomas Goldsmith and Hannah Critchfield, North Carolina Health News

Jan. 31: U.S. Health and Human Services Secretary Alex Azar declares a domestic public health emergency.

Late in February, Mark Shepherd kept trying to tell people that Henderson County was heading for hard days, for trouble and sickness caused by a new virus that would spread like mountain wildfire.

Shepherd is a trauma and critical care physician assistant and assistant chief of the Henderson County Rescue Squad in western North Carolina. He wanted to deliver a warning about getting ready for COVID-19, compelled by his training in viral outbreaks and his observation of the disease’s eruption in China and Italy.

Well before COVID-19 reached Hendersonville, Shepherd had worked with the rescue squad to make sure all tools necessary to fight the disease were in place. That meant more training for the largely volunteer staff, taking stock of personal protective equipment or PPE, giving fitness tests, and making clear relationships among several groups and agencies. 

And when the pandemic arrived in western North Carolina as predicted, Shepherd helped drive what became known as the Henderson County “strike team” in responding to an outbreak at Cherry Springs Village, an assisted living center in Hendersonville. Their work likely helped save the lives of people such as Alicia Rodgers and Margaret Osteen, long-term care residents in Henderson County, even as the COVID-19 related death count mounted in their adult care home and in nearby long-term care facilities.

Jimmy Brissie, the county emergency management director, and Dr. Anna Hicks, a local geriatrician, put the team together with Shepherd’s rescue squad as a principal element. Despite its name, the strike team is not a paramilitary operation, but in Henderson County became a pioneering collaboration among Cherry Springs staff and owners at Affinity Living Group, physicians, nurses, county EMS staff and volunteers, area churches, the county health department, a family liaison, a local hospice and people to help with logistics.

“We started asking: How do we help break a bad situation into more manageable pieces? What does it look like?” Brissie said. “It looks like a strike team — it’s something we use a lot in the emergency world, where we bring in some additional resources to that facility to get them through that [crisis] mode.”

Comprising at least eight members, the strike team acts as extra staff in a broad variety of roles who arrive to help a facility within the first 48 to 72 hours of an outbreak. In the case of Cherry Springs, some of these outside staff would stay for 30 days.

“This is our community so everyone will be there as long as it takes,” Shepherd said.

The group took on such tasks as:

• Making sure the center could avoid evacuating residents by shoring up supplies of personal protective equipment (PPE), the national inadequacy of which has brought about countless infections and death, and training staff on exacting decontamination techniques.
• Setting up a “decon” tent so that staff could put on and take off PPE correctly, as well as monitoring all such equipment changes for 72 hours.
• Setting up additional vital equipment such as oxygen concentrators and IV drips.
• Checking on the sanitation of non-resident areas so that staff could take the right steps to stay clean.
• Ensuring important social interaction for residents with dementia by arranging check-ins by staff, a common sitting area and the chance to go outside.
• Providing counseling for residents and families by hospice people.
• Arranging peer support for staff members experiencing new levels of stress.

Feb. 5: Henderson County Department of Public Health confers with county EMS and other agencies, puts COVID information on its website.

March 3: Henderson County Public Health Department sends out COVID-19 public health advisory.

March 11: World Health Organization declares a global pandemic.

Across the state, viral outbreaks spread rapidly in long-term care facilities, accounting for nearly half of North Carolina’s COVID-19 cases and three in five deaths from the disease.

Cherry Springs was no exception. What these facilities have in common is that many people live together in relatively small spaces, staff must often have close personal contact with residents, and meals and activities take place in communal congregate settings.

As opposed to other COVID-19 incubators such as cruise ships and prisons, many of the residents are medically fragile and particularly at risk for the worst outcomes of the highly contagious virus.

By mid-March, county resident Laura Moore also had the sense that trouble was ahead. Moore’s sister Rodgers, 50, was a resident of Cherry Springs Village assisted living center, a congregate care facility where she was at risk of contracting the emerging coronavirus.

Rodgers, who has lived with a disability since an automobile accident 33 years ago, returned from a supervised outing on March 14. Cherry Springs staff told her on March 12 that the center had been locked down because of COVID-19 and that she would not be able to leave. They relented and she was allowed to go out for a brief birthday celebration.

But, upon her return, she lived in quarantine for two weeks.

March 21 – Henderson health officials learn of the first COVID-19 case in Henderson County

About 10 days after the first case of COVID-19 emerged in the county, Moore received troubling news about her sister.

“March 30 is when we knew that Alicia had a slight fever,” Moore said during a recent telephone interview. “It was not a very high fever, just enough for us to be a little concerned.”

The fever continued for several days.

“We were able to talk to a nurse outside the building at one time,” Moore said. “She said, ‘I just don’t know what’s going on with Alicia not getting over this fever.’”

As Rodgers, her roommate Osteen, other residents, and staff battled the disease using science and their hearts, the strike team gelled into a remarkable force, even when faced with heartbreaking results.

March 24: First North Carolina resident, from Cabarrus County, dies of COVID.

A sort of trial by pandemic — what one resident’s daughter called “two months of hell” — was unfolding at Cherry Springs Village. Eventually, 59 people there contracted the novel coronavirus. Beginning April 8, 10 Cherry Springs residents died because of it, according to federal regulators.

The team couldn’t save them all from the deadly new virus but kept working to prevent as many deaths as possible.

“People were dying, no matter what we did,” Hicks said. “And the emergency management team came to mind because it was like it was a disaster. It felt like being in a natural disaster.”

Cherry Springs Village wasn’t new to trouble. In 2019, state regulators cited the adult care home when a bedbug infestation had lasted for more than a year. But the pandemic was without precedent, both for residents and for the newly coordinated team that was learning to fight COVID on the fly.

March 27: NC Gov. Roy Cooper issues a statewide policy known as “Stay at Home.”

“In the emergency services world, if there’s a wildfire, we may send in a strike team of additional firefighters to help control it,” Brissie said. “And in a sense, this is very much like a wildfire. It’s just a communicable disease. The goal is to send additional resources in to control it.”

In long-term care facilities, a strike team’s first blow comes from health officials, who do rapid testing of staff and residents. The health department would arrive within 24 hours of the first positive case at Cherry Springs. Emergency management staff follow, bringing additional PPE supplies and setting up spaces where staff can remove contaminated equipment after use. Then comes the additional staffing.

When it comes to long-term care facilities, the most valuable resources consist largely of people who can do the necessary work. Many of the long-term care facilities that have seen high death rates also have low ratings for staffing by the Centers for Medicare and Medicaid Services.

Brissie said the team sought “people that have some special training or special skills that can come in and supplement what local resources are in place.”

Those skills include training in medical, rescue, decontamination, sanitation and logistics, but also take in the ability to work with people. Moore said her family originally was convinced that Cherry Springs Village would work for them because the staff was “nice” and offered activities that would appeal to Rodgers. With the cognitive level of a 14-year-old, she’s young compared to many long-term care residents, Moore said: “She’s a very outgoing person.”

That quality among the staff gave families reassurance at this dark time.

March 31: Cooper signs executive order 124, putting a lid on utility companies that shut off services and charge late or reconnection fees, tries to discourage evictions.

By now, several of the nearly 60 Cherry Springs residents who would catch COVID-19 were beginning to show symptoms consistent with the disease in geriatric patients —  sudden loss of appetite and fatigue, a dip in cognition, and a low fever.

April 1: State health officials say North Carolina has received a smaller number of high-quality N95 masks than requested, about 312,000 after asking for half a million.

April 1: The first resident at Cherry Springs is confirmed positive for COVID-19.
Dr. Kevin O’Neil, chief medical director at Affinity Living Group, notifies the local health department. 

Laura Moore, Alicia Rodgers’ sister, and Tammy Summey, daughter of Margaret Osteen, learned on April 1 that their kin would be tested for COVID-19.

It was a frightening time.

The coronavirus had relatively recently come to bedevil the nation and North Carolina. Moore knew that her sister’s fever could easily be a symptom of COVID-19.

“Thursday of that week, April 2, is when they tested Alicia, and they said there will be two days before the results come back,” Moore said, recalling the tension of the moment. “I’m thinking, two days, okay that will be a Saturday, Sunday night, we may not actually hear until Monday.”

There was nothing for them to do but wait.

April 2: President Donald Trump tells the nation that the United States is in “a very critical phase of our war against the coronavirus.” 

Henderson County Health Department begins mass testing of all residents and staff at Cherry Springs, including Alicia Rodgers and Margaret Osteen.

Part Two: WNC strike team fights back as long-term care residents contract COVID-19

The calls from Cherry Springs Village came at night.

Assisted-living roommates Alicia Rodgers, 50, and Margaret Osteen, 66, were getting results on April 4 from a test for the novel coronavirus that had been taken two days earlier.

The disease had infected both women, family members learned. And they weren’t the only ones.

“They called us and told us she had tested positive,” said Hendersonville resident Laura Moore, Rodgers’s sister. “They mentioned that several others had tested positive as well.”

Cherry Springs Village, a 60-bed Hendersonville assisted living center, had an outbreak on its hands and suddenly needed rapid help.

That became the mission of the Henderson County “strike team,” a locally organized effort that brought together county emergency management, county health officials, nurses and doctors, a hospice group, and additional players.

Such teams apply a disaster-response model, more suited to natural disasters such as hurricanes and wildfires, to combating COVID-19 outbreaks in long-term care facilities. North Carolina Health News retraced the strike team’s formation and work during the two-month-long outbreak at the facility.

Thanks to the county’s preparation and a rapid response from a variety of actors across government agencies and private industries, outside help would flood into Cherry Springs. About 50 people there recovered, but 10 residents would die of COVID-19 during the two-month outbreak. Many others died in nearby nursing homes.

The strike team would help mitigate the spread of COVID-19 and work to protect the lives of vulnerable people such as Rodgers and Osteen. It eventually became a model for preventing or tranquilizing COVID-19 outbreaks in assisted living facilities throughout western North Carolina.

April 3: Henderson County Rescue Squad arrives on site, delivering PPE to the facility staff.

Rodgers had moved into Cherry Springs in 2018 for help dealing with disabilities caused by a car wreck on her 17th birthday. Osteen has been living with dementia for five years after a lifetime of working in restaurants such as the diner-style Hasty Tasty.

“She said she wasn’t feeling good,” said Tammy Summey, Osteen’s daughter, recalling a conversation with Osteen the day after she tested positive. “But it was already affecting her dementia pretty bad — she didn’t even realize what she had, what was going on.”

April 6: Hospice chaplains and grief counselors from Four Seasons Hospice come to Cherry Springs as several residents’ conditions worsen.

Some bread-and-butter elements typify the care that strike teams provide. Early on, for instance, staff members have to be taught the proper use of personal protective equipment — the masks, gloves, biohazard clothes and other equipment that prevent the spread of infection further.

Especially the equipment prevents the spread to other staff. At Cherry Springs Village, a large percentage of employees who typically cared for residents were suddenly out sick.

Beyond education, there was another immediate, practical, need: Beefing up staffing.

“Almost everybody in the building got it,” said Dr. Anna Hicks, a local geriatrician who treats patients at Cherry Springs and helped shape the strike team, noting that there were ultimately 59 COVID-19 cases out of about 75 residents and staff.

The sick residents had far greater needs than usual.

April 8: A person in hospice care becomes the first Cherry Springs resident to die of COVID-19.

Despite a somewhat pugnacious name, strike teams are designed to adapt to existing systems, Hicks said, acting more as partners than as special agents doing an overhaul.

“It’s not like this SWAT team that comes in and dominates,” Hicks said. “It’s not prescriptive – it’s an extra set of hands that works with the facility to respond.”

April 8: Staff education on PPE use continues as the Henderson County Rescue Squad remains on site.

“What we know from Ebola and other infectious diseases, is that the time that you’re most likely to get contaminated as the health care worker is actually when you’re taking your PPE off,” said Mark Shepherd, head of the county rescue team and a physician assistant specializing in trauma and critical care.

“We actually set up a decontamination tent outside, so at the end of their shift, they could actually take their clothes off,” said Shepherd. “We had a really rigid way of how they would exit the building, the order in which they would take their PPE off. I had volunteers at every shift change for 72 hours, instructing on how to take off the PPE correctly”

Staff was only required to remove dirty PPE, according to Hicks, but some staff wanted and were able to change out of their work clothes fully “for their own peace of mind.”

Within a week of her diagnosis, Osteen was able to stand at the closed window of her room to see Summey, who wanted to make contact with her mother however she could.

Just days later, Osteen was “bedridden,” Summey said.

“She got to where she couldn’t eat, she couldn’t talk,” Summey said. “It was really heartbreaking because you can’t advocate for anybody if you’re not around.”

Rodgers, for her part, was having trouble breathing, and Moore worried when she heard talk of a ventilator and learned of more frequent checkups on her condition.

April 8: Nurses from a local rehab center and other Affinity Living Group facilities arrive from as far as three hours away to provide medical care at Cherry Springs.

Unlike many hospitals, congregate care facilities are not always robustly staffed with medical providers. This is especially true of assisted living facilities, which unlike their skilled nursing home counterparts, are residential living settings for people who need basic assistance with daily activities. Under normal circumstances, residents don’t need routine medical care, and thus medical staff isn’t required.

Cherry Springs doesn’t have full-time nursing staff – a Licensed Health Professional Support (LHPS) nurse typically visits the facility once a week. But suddenly and imminently, residents there needed far more intensive medical care.

“That was one of the things that we noticed early on — specifically in the assisted living facilities,” said Jimmy Brissie, the county emergency management director, who helped put together the strike team. “They typically don’t have as much in-house medical support as a skilled nursing facility.”

The team tried not to send residents unnecessarily to a hospital, where they risked further exposure and might take up beds other community members needed. So the strike team reached out and coordinated with other properties in the same corporate ownership throughout western North Carolina.

“We had to bring in staff just to help people eat,” Hicks recalled.

Many outside employees came in to help fatigued residents hold up iPads for telemedicine or do rapid assessments of patient vitals.

April 8: Communications specialist D.J. Buff arrives at Cherry Springs.

Rodgers was cared for by a nurse from a few hours down the road in Winston-Salem, according to Moore.

Dr. Kevin O’Neil is chief medical officer for Affinity Living Group, the private company that owns Cherry Springs and operates other assisted living facilities in eight states.

He said that for the first time, strike team members set up intravenous fluid drips and oxygen concentrators within the facility for patients like Osteen.

April 9: Henderson County Rescue Squad erects “decontamination tents” outside the facility. 

In any disaster, responders must account for the emotional toll on survivors.

Emergency response is fast — but that doesn’t mean it’s done without recognition of the people who are hit the hardest by the tragedy.

The strike team realized it could be no different now — someone would have to head up communication about the Cherry Hill outbreak to family, who were forced to worry about — and mourn —  their loved ones from a distance.

“When it all first hit, it was very frustrating because I couldn’t get through to anyone,” Summey said. “That was very stressful and very aggravating. But then they got a wonderful person out there, D.J. And he turned it all around, he did a wonderful job.”

April 27: The death toll at Cherry Springs rises to seven people.

There were times when several residents died in one day, Hicks said.

Cherry Springs and its corporate owners have not released the identities or other details about those who died.

The team brought in chaplains and music therapists from Four Seasons Hospice to provide trauma care to both family members and the staff, who watched residents that had become friends over the years pass away.

“The staff get very close to their residents,” Michael Wermuth, a chaplain from the palliative care facility, said. “And when you have a lot of loss like that, you have what our grief counselors call ‘complicated grief,’ because there’s so much loss so quickly. It’s hard for us to process sometimes.”

The counselors came twice a week to meet with the staff when they were on break.

One family watched through an outside window as their loved one died from the virus inside a room, Wermuth recalled. The chaplain remained sitting at a six-foot distance.

“Cherry Springs did a wonderful job of placing the patient’s bed next to the window, so they could be very close to their loved one,” Wermuth said. “But obviously they couldn’t touch them, and that was difficult.

“So we provide active listening, and help people to verbally process the challenges of not being able to be at their bedside.”

May 9: The last outside staffers, the remnants of the strike team, leave Cherry Springs as numbers of active COVID-19 cases drop.

By mid-May, the strike team members and outside staff had gone home – they were taking down the decontamination tents as COVID-19 cases within Cherry Springs fell to a handful, according to James Harvey, a spokesman for Affinity Living Group.

Meanwhile, the work of the strike team continues.

After the Cherry Springs outbreak, Henderson County officials started to use the strike team concept in other facilities. Two skilled nursing facilities in the county have used it to respond to outbreaks since.

Notably, the officials now want to use it to prevent COVID-19 outbreaks in residential adult care centers, not just respond once tragedy looms.

“After dealing with one outbreak in one facility, we started a conversation with Dr. Hicks and Dr. Russell, the doctors for Cherry Springs,” Brissie said. “We kind of brainstormed: In a perfect world, when this happens again, what’s the best model to bring some additional resources in place early on, to get them through that initial phase of an outbreak?”

May 30: NC DHHS removes Cherry Springs Village from its list of congregate living settings with an ongoing outbreak.

Members of the strike time have since visited every long-term care facility in Henderson County – educating them on proper PPE use, taking stock of the needs they’d have if an outbreak were to hit (Would it be staffing?  Medical supplies?), and simply letting them know the strike team exists and will be able to step in.

The idea is catching on in other western North Carolina counties: McDowell, Rutherford, Haywood, and Buncombe County have all begun to use strike teams of their own, according to Brissie.

“With this level of outbreak, no facility can stand alone,” said Hicks. “Really facilities, they need to be looking for partnerships in the community.”

Relatives such as Tammy Summey saw and appreciated the effects of the strike team’s work to fend off more deaths.

Nonetheless, she lived with stress that seemed never-ending through those days of fearing for her mother’s life. Like so many other relatives in this situation, Summey couldn’t shake the thought that someone who had brought her to life might face a solitary end.

“Unless you’ve been through it, you just don’t know, because your loved one can pass and you’re not going to be there,” Summey said. “They’re not going to have anybody there. They’re alone.”

June 8: DHHS releases daily count of COVID-19 cases and deaths in North Carolina’s long-term care facilities — 4,528 people have contracted the disease and 611 have died.

Correction: This story has been changed to reflect that Mark Shepherd is a critical care physician assistant.

These articles first appeared on North Carolina Health News and is republished here under a Creative Commons license. North Carolina Health News is an independent, non-partisan, not-for-profit, statewide news organization dedicated to covering all things health care in North Carolina.