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EP Exposed COVID-19 Outbreak at Nursing Home

SoRelle, Ruth MPH

Emergency Medicine News: June 2020 - Volume 42 - Issue 6 - p 5
doi: 10.1097/01.EEM.0000669308.41518.a7
    coronavirus, COVID-19

    John Bream, MD, was working in his North Carolina ED on April 4 when a patient was brought in from a nearby nursing home. That wasn't unusual; the ED was just 10 minutes away from the Citadel Salisbury. But this time, the patient turned out to be the first to test positive for COVID-19 at the long-term care facility, and would turn Dr. Bream into something of a crusader.

    Over the next three days, the ED at Novant Health Rowan Medical Center in Salisbury admitted several more patients from the Citadel, a nursing home owned by the New Jersey-based Accordius Health.

    Dr. Bream, the director of the emergency department at Novant Health, said he knew they had a problem right away. “It was obvious an outbreak was going on,” he said, but they never heard anything about it from the hospital or the Rowan County Health Department, so he and others in the emergency department began to plan.

    When the hospital leadership and health department joined the effort, they found that the health department had only two test kits on hand. The hospital agreed to give the nursing home test kits, but the tests had to be run at the state laboratory in Raleigh. They were run on April 11 and reported the next day, Dr. Bream said, and that doubled the county's COVID-19 cases from about 90 to 180, with the nursing home responsible for most of the increase.

    Nursing Home Hotspot

    This was not the first time a nursing home was a hotspot for COVID-19. The first major outbreak occurred in February in the Life Care Center in Kirkland, WA. A red flag was raised when the number of 911 calls that Life Care made rose from seven in January to 30 in February, according to an article in the National Review. (March 24, 2020; “But life went on at the facility as usual for its 120 residents and 180 staff. Visitors came and went, and patients were routinely discharged or moved to other nursing facilities,” the article noted.

    County officials there finally went public with the fact that 50 people associated with Life Care were being tested for the virus, four patients had died, and 25 firefighters who had responded to 911 were in quarantine. It became the first big outbreak in the United States. The virus spread all the way across the country when a visitor to Life Care brought it back to North Carolina, becoming the state's first confirmed case, according to the National Review.

    Back in Salisbury, tests run at the Citadel revealed that 85 patients were positive, 15 were negative, and 15 were not tested. Seventeen of the 32 workers were positive, Dr. Bream said. “How did the whole facility get infected? That's the R0 of measles, not coronavirus,” he said.

    The emergency department continued to see patients from the nursing home, but April 13 proved the tipping point for Dr. Bream. His first patient that day was from the Citadel, and was positive for COVID-19 and in serious condition. And he learned that the patient's family did not know their loved one was infected. That patient died the next day, and just an hour later, he saw a worker from the nursing home who said the facility refused to let workers wear masks or gowns until patients began to get sick. By that time, it was too late.

    Families Unaware

    A few hours later, Dr. Bream said he saw another Citadel patient, and discovered that that person's family also did not know about the infection. His last patient of that day was from the same facility and in critical condition, and the family had no idea, he said. He called the patient's daughter on FaceTime so she could tell her father she loved him one last time. He died 18 hours later.

    Dr. Bream said that was when he decided to contact public health authorities and the nursing home's owners. No one responded, he said. Frustrated, he submitted an opinion piece to the Salisbury Post, where editors scrutinized the piece, tried to contact those same authorities, and sent it to their attorneys for review. It appeared in the newspaper on April 20. (

    “These events are obviously concerning to me as a human being, not only as a physician and the medical director of the emergency department,” Dr. Bream wrote. “[W]hat we have seen relating to the Citadel situation from the Rowan County Health Department and Accordius is a blueprint for exactly what not to do in a crisis.”

    Patients died at the Citadel without family members being notified, he noted in the article, and families were denied one last meaningful interaction with their loved ones. There were, he wrote, “at least 96 positive cases among this facility's residents, at least 17 employees who have tested positive and multiple (but an unknown number of) fatalities. ... Employees were wrongly denied personal protective equipment. There has been no transparency.”

    Doing the Right Thing

    Dr. Bream's frustration is palpable in the article. “Met with continued inaction and exasperation about the lack of transparency about the Citadel situation,” he wrote, “I continued to implore, especially the Rowan County Health Department, to simply do the right thing and tackle these issues head-on. This has not occurred.”

    Dr. Bream said he submitted his piece to the newspaper and hoped other leaders in North Carolina would follow suit. “Faced with the difficult decision to remain quiet or do the right thing, I choose to do the right thing,” he wrote.

    Nina Oliver, the Rowan County public health director, said while they appreciated Dr. Bream's “passion and concern, the frustration expressed in his letter is misdirected.” (April 21, 2020; At EMN's press time, she said 17 of the county's 22 COVID-19 deaths were from the Citadel Salisbury. (April 28, 2020;

    The Citadel Salisbury said in a statement that it “remains committed to keeping our residents safe and care [sic] for. We are continuously monitoring our residents' health and reviewing our COVID response plan. The Health Department and our hospital partners are actively involved with the Citadel Salisbury's operational and clinical leadership. Physicians are onsite frequently if not daily. They are in direct contact with infectious disease specialists that are providing additional collaboration. We are seeing less symptoms and expecting that most will recover.” (

    The family of one Citadel resident has filed a negligence suit against the nursing home. (Charlotte Observer. April 22, 2020;

    The federal Centers for Medicare and Medicaid Services announced April 19 it was reinforcing an existing requirement for nursing homes to inform residents, their families, their representatives, state and local health departments, and the Centers for Disease Control and Prevention of all communicable disease, health care-associated infections, and potential outbreaks. (

    Ms. SoRellehas been a medical and science writer for more than 40 years, previously at the University of Texas MD Anderson Cancer Center, the Houston Chronicle, and Baylor College of Medicine. She has received more than 60 awards, including the Texas Human Rights Foundation Award. She has been a contributor to EMN for more than 20 years.

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