Maria Davila lay dumb in a nursing home bed, and showed that her husband was talking to her, as her husband had taken her detached hand. Ms Davila, 65, has a long list of ailments, respiratory failure, kidney disease, high blood pressure, irregular heartbeat – and her ventilator and feeding feed keeps her alive.
Recently doctors have added another diagnosis to their medical chart: Candida auris, a highly contagious, drug-resistant fungus that has infected nearly 800 people since it came to the United States four years ago, with half of patients dying. within 90 days.
At least 38 other patients at Ms Davila's nursing home, Palm Gardens Nursing and Rehabilitation Center in Brooklyn, has been infected with C. auris, a severe and difficult to eradicate that some facilities will not take with patients. Now, while struggling to maintain pathogen, public health officials from cities, states and the federal government say that skilled nursing facilities such as Palm Gardens are expanding their spread.
“These are the dark drug resistant infection,” said Dr Tom Chiller, who heads the fungal division at the Disease Control and Prevention Centers, talking about skilled nursing facilities, particularly those with t ventilated patients, but not specifically Palm Gardens.
Suchhouses reeling in the spread in New York, where there are known to be 396 infected and 496 others carrying the germ without showing symptoms, are central to public health officials. In Chicago, half of the patients living on a dedicated ventilation floor in the city's skilled nursing homes are infected with C. auris on their bodies or are being harvested by them. Allison Arwady, active commissioner of the city's Department of Public Health.
Much of the blame focused on raising the number of drug-resistant infections such as C. auris, as well as efforts to combat them, over-use of antibiotics in humans and livestock, and hospital acquired infections. However, public health experts say that nursing facilities, and long-term hospitals in the healthcare system, are often poorly linked and often under-worked and are not able to enforce strict infection control, but patients who are continuously infected on the system. cycling, or those who carry the germs, into hospitals and back again.
“They are colonel seeding and re-reselling a hospital with bacteria that are even more dangerous,” said Betsy McCaughey, a former New York commander who guides the Non-Profit Committee to Reduce Infection Deaths. “You will never cost hospital patients until nursing homes are forced to clean up.”
(Read our other stories in our series on drug resistance, Deadly Gems, Lost Cures.)
The story is much more than one nursing home or one germ. Drug-resistant germs of all kinds grow in such situations when very ill and well-ventilated patients are infected and often take multiple antibiotics, which can encourage drug resistance. Resistant germs can then move from bed to bed, or from patient to family or staff, and then to hospitals and the public due to lax hygiene and poor staff.
These issues also introduced long-term acute hospitals, where patients usually stay for a month or less before going to a trained nursing home or other facility.
A recent inquiry by the New York Health Department found that a number of long-term hospitals tackling C. auris were failing to take basic measures, such as the use of disposable gowns and latex gloves, or warning signs. posting outside infected patient rooms. At one anonymous facility, he said, "hand baths were completely absent."
Officers at Palm Gardens did not respond to 240 requests for repeat applications traffic. In the past year, the number of patients infected with C. auris or carrying C. Since he grew, according to a nurse then and public health officials. The scores have fallen in the high 20s after refusing some patientsed or moved elsewhere.
New York health department issued a statement in response to New York Times inquiries: “The Department of Health has given high priority to the dissemination of C. auris and has extensive training and education in control policies and procedures. Infected Palm Gardens and other nursing home providers throughout this region. The health and welfare of nursing home residents is our primary concern and we take very seriously complaints about the quality of care. ”
Scientific research on nursing homes and drug resistance is rare, but some recent studies provide evidence of the problem. A study published in June In the Clinics Journal, Infectious Diseases found that patients and residents in long-term care settings have high rates of drug colonization, which means that they carry the germs on their skin or in the body, without being known. They usually have them invisible to staff, relatives or other patients. Older or sick people with weak immune systems who carry the germ have a high risk of infection. (Health officials in New York state 14 per cent of those now infected said that they started carrying it and then developed signs).
The study, which focused on Southern California, found that 65 per cent of residents of nursing homes in that region were in receipt of drug-resistant germs, as well as 80 per cent of long-term acute care hospital residents, where their status is unknown. “The facility.
The phenomenon is global. A The study published in 2017 found that the elderly residents of long-term care facilities in Britain were four times more likely to be infected with urinary tract infections that are drug resistant as elderly residents living at home. Long-term care facilities in Italy received high levels of resistance, a 2018 paper was found. A 2019 study found that long-term care facilities in Israel are a “major repository” of Enterobacteriaceae, which is carbapenem resistant, or CRE – a large family of germs. drug resistant – which contributes to its “rapid regional spread.” t
Experts said the problem is pronounced in the United States, because changing economies are pushing high-risk patients from hospitals and skilled nursing homes. The facilities are reimbursed at a higher rate to care for these patients, they said, t providing an economic incentive for facilities that are or are not well staffed to care for vulnerable patients t.
C. auris, resistant to major antibiotic medicines, first identified in 2009 in Japan and, as of 31 July, had 796 infected people in the United States, mainly in New York, Chicago and New Jersey, since its arrival in 2015, according to the DCFD. A further 1,540 persons were identified carry the microbe on their skin or body without showing signs.
C. auris close up
On the second floor of Palm Gardens, where Ms Davila lives and other ventilated patients, exterior signs provide almost all rooms with a warning to visitors and staff to wear gloves, gowns and masks. state requirement for those infected with C. auris.
However, during two recent visits by the Times reporter to Palm Gardens, Ms Davila's husband moved as a guest, orders, and nurses in and out of her room without the necessary protection.
“The nurses and jurors are not spreading this thing from room to room,” said her husband, Anthony Hernandez, on a visit in August, shortly after a nurse, who was t wearing gloves but no mask or dress, liquid liquid into a feeding tube of his wife. During a short interview in the lobby, Pamela Delacuadra, the centre's nursing director, said that employees were initially experiencing difficulties with the infection –control protocols required for C. auris.
“It was really great at first but with the help of the health department, it's much better,” she said.
Ms Davila's medical records, reviewed by The Times, do not recognize the specific date she received C. auris. She first tested positive as a carrier of the fungus in December 2018, and her records from Palm Gardens show. She was segregated to C. auris's patients, and subsequently her records referred to her as infectious diseases and taking antifungal medications to him.
Palm Gardens is located in a seven story nondescript brick building in a working class neighborhood in the center of Brooklyn. Magenta banners promote its dialysis center and adult day care services, as well as a “respiratory pavilion” for patients on life mechanical support.
Higher level officer from a local hospitalAt the same time, some patients of C. auris from nursing homes said Palm Gardens was a major source. He refused to be nominated because his employer had not authorized any traffic.
Palm Gardens Performance is badly rated by the federal government; he got two stars, a below average rating for staff and overall care, from the Centers to Medicare and Medicaid services, an agency that classifies nursing home scale care from one star to five. In 2018, the agency investigated the death of two ventilated patients at Palm Gardens, finding that employees failed to turn their ventilators back after carrying out mechanical checks. Patients died within minutes of each other, the report said.
C.M.S. he refused to comment on Palm Gardens.
Ownership Palm Gardens are controlled by a person known as Shimon Lefkowitz, according to the public filing.
Mr Lefkowitz did not respond to efforts to achieve it through Palm Gardens. A number of law firms representing Palm Gardens in jurisdictions have not been called back.
Not all residents of Palm Gardens with C. auris then contracted the germs, and it is unclear how much. Only The deceased patient was infected by Maimonides Medical Center in Brooklyn, according to the man's family.
Changing role in healthcare
Trained nursing homes and long-term care facilities now play a more important role in caring for seriously ill patients who have been staying longer in hospitals.
Due to the progress made in medical technology, the life of patients who are very ill can be extended, and changes in Medicare reimbursement rates created a financial incentive to expand such facilities, Neale Mahoney, economist in University of Chicago. industry growth study. There are now about 400 long-term care hospitals around the country, up from about 40 in the early 1980s, he said.
Since 2012, the number of trained nursing homes with ventilation units has increased to 436 from 367 – a significant jump but a fraction of the country's 15,000 nursing homes – according to C.M.S.
“The air conditioner units are the poster child, the best example of where there are challenges,” said Dr. Alexander Kallen, an outbreak expert at the DCC.
The federal government reimburses facilities for significantly higher aerated patients rates or in the case of other patients, in accordance with C.M.S. Ventilated patients $ 531 per day can be introduced compared to $ 200 d standard patient. That's about $ 16,000 a month compared to $ 6,000.
The reimbursement rates reflect the significant care required for vulnerable patients, t and the cost of the equipment.
C.M.S. the majority of well-trained nursing homes insist on overall staffing and care. But still some 1,400 nursing homes received a single star rating for staff in 2018 from the agency.
“It is impossible for them to do a good job with the way their staff are,” said Dr. Mary Hayden, professor at the Ross College of Medicine, studies the increase in drug-resistant infections in healthcare, building on the challenges of restricting drug-resistant infection: “How they are set up, they can't do it. ”
Ms Davila's path
Ms Davila C. Auris brought her on her journey through the healthcare system.
In early August, after a normal blood test got its white cell count plummeting, she was taken as an ambulance to the Methodist Hospital in Brooklyn for a transfusion. Doctors discovered an infection and put it on two different antibiotics. Heavy antibiotic use, although often needed, can kill the infectious infections and allow the resistant ones to be successful.
Her condition was stabilized after two weeks and she returned to Palm Gardens. It was one of at least a dozen trips she brought to the hospital since she first came to Palm Gardens.
Her sharp decline started in 2017 when she was hospitalized with suspected fever pain. As a lifelong smoker, Mr Davila had emphysema, which resulted in difficulties and infections, according to a review of his medical records.
Now she spends her days frozen in bed, led by a Latin music radio station and the mechanical bandit for her responder.
Mr Hernandez has doubts that his wife will come back. “If I can build my house with death and blessing,” he said.
He pulled the blanket higher, turned up the radio and told his wife that she liked it. She usually applied her eyes to her eyes and then she was hitting: “I love you, too.”
Benjamin Ryan reported.