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Commentary: COVID in Care Homes-Challenges and Dilemmas in Healthcare Delivery
Abstract
The COVID-19 pandemic has disproportionately affected care home residents internationally, with 19-72% of COVID-19 deaths occurring in care homes. COVID-19 presents atypically in care home residents and up to 56% of residents may test positive whilst pre-symptomatic. In this article, we provide a commentary on challenges and dilemmas identified in the response to COVID-19 for care homes and their residents. We highlight the low sensitivity of PCR testing and the difficulties this poses for blanket screening and isolation of residents. We discuss quarantine of residents and the potential harms associated with this. Personal Protective Equipment (PPE) supply for care homes during the pandemic has been suboptimal and we suggest that better integration of procurement and supply is required. Advance care planning has been challenged by the pandemic and there is a need to for healthcare staff to provide support to care homes with this. Finally, we discuss measures to implement augmented care in care homes, including treatment with oxygen and subcutaneous fluids, and the frameworks which will be required if these are to be sustainable. All of these challenges must be met by healthcare, social care and government agencies if care home residents and staff are to be physically and psychologically supported during this time of crisis for care homes.
... Care homes (or long-term care facilities) worldwide faced multiple and significant challenges during the early waves of the COVID-19 pandemic [1][2][3][4][5][6]. Due to their communal occupancy and the physical vulnerability of residents, care homes were heavily impacted in terms of illness and mortality. ...
... Other studies have focused specifically on the impact of the pandemic on the well-being of care home staff. During the first waves of the pandemic, attention was drawn to the risk factors for emotional impact in this group of workers, with some authors referencing pre-pandemic challenges already faced by the sector [2,10,19]. Pandemic aside, the nature of care work presents a complex and challenged picture. The sector has a historically low-paid, often under-recognised workforce providing care for residents with multiple and complex health and social care needs [1,10]. ...
... Thematic analysis generated four key themes relating to the emotional impact of the pandemic and how staff managed its challenges; (1) Anxiety and distress, (2) Overwhelming workload, (3) Pulling through; and (4) an overarching theme of Resilience in a time of crisis. In interviews, staff described how the arrival of COVID-19 profoundly impacted many aspects of their work and personal life and was experienced as stressful. ...
Background
Care homes (long-term care facilities) were profoundly impacted early in the COVID-19 pandemic, both in terms of resident mortality and restrictions for infection control. This study investigated the impact on the emotional well-being of care home staff of challenges faced at this time, and the strategies used to manage them.
Methods
Semi-structured interviews conducted October 2020-June 2021 with care home staff and health service staff working with them explored the impact of the early waves of the COVID-19 pandemic (March 2020-June 2021). Interview data were analysed using reflexive thematic analysis.
Results
Interview participants were 16 care home staff and 10 health service staff. Analysis generated four key themes: 1)Anxiety and distress, 2)Overwhelming workload, 3)Pulling through; and 4)Resilience in a time of crisis. Care home staff experienced Anxiety and distress due to uncertainty of what to expect; witnessing illness and deaths of residents; concerns regarding their own health, and sometimes feeling their work was under-recognised. They also experienced an Overwhelming workload due to infection control measures, caring for sick residents and reduction in external healthcare support. Our theme of Pulling through reflects the peer support and problem-solving strategies with which care home staff managed the impact of the pandemic, along with a sense of responsibility and meaning towards their work. An overarching theme of Resilience in a time of crisis drew on the other three themes and describes how many staff managed, maintained, and often increased their work despite the challenges of the pandemic. Participants also described increasing emotional fatigue as the pandemic continued.
Conclusions
This paper builds on literature on the emotional impact of the pandemic on care home staff, also exploring ways that staff responded to this impact. These findings can help inform planning for future crises including disease outbreaks, and raise important questions for further work to develop pandemic preparedness in care homes and beyond. They also raise wider questions about the current cultural status of care work, which may have exposed care home staff to greater risk of distress, and which contrasts with the professionalism and responsibility shown by staff in response to pandemic challenges.
... Despite searching and reviewing more recent studies, as presented in Figure 1, the most recent study to match our inclusion and exclusion criteria and to contribute relevant data to our research aim and questions was published in 2020 (see Figure 1 for reasons for exclusion and Table 1 for further details on the literature search strategy, including the inclusion and exclusion criteria). This may partly be explained by COVID-19 and quarantining regulations to protect people living and working in LTCFs which also restricted access to LTCFs among external visitors, including researchers (Gordon et al., 2020;World Health Organization, 2022). The disruption of everyday research activities has been referred to as "scholarly displacement" and is salient to participatory research approaches due to the emphasis on actions in situ and in collaboration with various actors (Auerbach et al., 2022). ...
... The disruption of everyday research activities has been referred to as "scholarly displacement" and is salient to participatory research approaches due to the emphasis on actions in situ and in collaboration with various actors (Auerbach et al., 2022). As our findings show, participatory research approaches typically involve group activities in collaborative places (i.e., common areas), which were particularly affected by changes in social, organizational, and environmental aspects of LTCFs due to COVID-19, such as isolation of older adults in their private rooms (Gordon et al., 2020;World Health Organization, 2022). Future research may build on this meta-ethnography to ascertain similarities and differences in the conceptualizations and uses of participatory research approaches before, during, and after COVID-19. ...
Purpose
There is growing interest in the potential of participatory research approaches to democratize research, empower participants and contribute to targeted health and social care. Participatory research approaches are emphasized in ethical and funding applications regarding patient and public involvement; however, less is known about their use in long-term care facilities for older adults. This meta-ethnography seeks to provide an increased understanding and novel conceptualization of participatory research approaches in long-term care facilities for older adults.
Methods
A meta-ethnography was used to synthesize qualitative literature on participatory research approaches in long-term care facilities for older adults. In total, 1,736 articles were screened at title and abstract level, 35 studies were eligible for full-text review and 10 articles were included.
Results
The following third-order constructs were identified as salient to the conceptualization and use of participatory research approaches in long-term care facilities for older adults: 1) participatory backdrops, 2) collaborative places, 3) seeking common ground and solidarity, 4) temporal considerations, and 5) empowerment, growth, and cultural and social change.
Conclusion
This meta-ethnography contributes a novel conceptualization and six recommendations to enhance the design and implementation of participatory research approaches as democratic spaces of exchange and collaboration for older adults.
... Information on individuals can enhance care within the home and be invaluable when communicating with external services. Aggregate data may be used for planning, evaluating quality of care, and monitoring health trends at a population level (Gordon et al., 2020;Peryer et al., 2022). Despite all of these potential benefits, in many countries there is no standardised data collection in care homes. ...
... In England, government plans to develop digital social care records have increased interest in the concept of a minimum dataset for care homes (DHSC, 2020). Local and national authorities' demands for information from care homes grew during the COVID-19 pandemic, when care homes experienced some of the highest infection and mortality rates (Comas-Herrera A et al., 2021;Gordon et al., 2020). In the absence of a core set of information from all care homes, care home resources were diverted to collect, collate and communicate data to a range of different organisations. ...
Context: In many countries, there is a specification for information that should be collected by care homes. So-called ‘minimum data-sets’ (MDS) are often lengthy, and report on resident health and wellbeing, staff, and facilities. In the UK, the absence of any easily accessible data on the care home population was highlighted at the start of the COVID-19 pandemic. Care homes faced multiple requests for data from external agencies who had little knowledge of what care homes were already collecting. Objective: This study aimed to identify the range (and method) of data collected by care home organisations, in a country without a mandated MDS. Methods: Online survey of care homes (with/without nursing) in England. Care homes recruited via research and care home networks, social media. Questions covered data content, storage, and views on data sharing, analysed with descriptive statistics. Findings: 273 responses were received, representing over 5,000 care homes. Care homes reported extensive data on the health, care and support needs of individual residents, their preferences, and activities. Clinical measures and tools adopted from health were commonly used, but few collected information on quality-of-life. Care homes reported uses of these data that included monitoring care quality, medication use, staff training needs, budgeting, and marketing. Concerns over privacy and data protection regulations are potential barriers to data sharing. Implications: These findings challenge the notion that incentives or mandates are required to stimulate data collection in care homes. Care home organisations are collecting an extensive range of resident-level information for their own uses. Countries considering introducing social care records or an MDS could start by working with care home organisations to review existing data collection and evaluate the implications of collecting and sharing data. A critical approach to the appropriateness of health-related tools in this setting is overdue.
... Commentaries noted that in many aged and acute care settings, ACP was recommended for all patient (or resident) admissions (40,41). Mooted options to increase uptake included sharing the ACP role with non-medical staff-social workers (42), nurses, or volunteers (19,40,43). ...
... was seen from descriptions of the potentially-dying patient deprived of in-person visits (41,46,48,52,58,62,64,69), to reported feelings of being abandoned by medical staff (76). Stigma surrounding COVID, reinforced by the infection control protocols, exacerbated these difficulties and created barriers to ACP (73). ...
Background: The importance of advance care planning (ACP) has been highlighted by the advent of life-threatening COVID-19. Anecdotal evidence suggests changes in implementation of policies and procedures is needed to support uptake of ACPs. We investigated the barriers and enablers of ACP in the COVID-19 context and identify recommendations to facilitate ACP, to inform future policy and practice.
Methods: We adopted the WHO recommendation of using rapid reviews for the production of actionable evidence for this study. We searched PUBMED from January 2020 to April 2021. All study designs including commentaries were included that focused on ACPs during COVID-19. Preprints/unpublished papers and Non-English language articles were excluded. Titles and abstracts were screened, full-texts were reviewed, and discrepancies resolved by discussion until consensus.
Results: From amongst 343 papers screened, 123 underwent full-text review. In total, 74 papers were included, comprising commentaries (39) and primary research studies covering cohorts, reviews, case studies, and cross-sectional designs (35). The various study types and settings such as hospitals, outpatient services, aged care and community indicated widespread interest in accelerating ACP documentation to facilitate management decisions and care which is unwanted/not aligned with goals. Enablers of ACP included targeted public awareness, availability of telehealth, easy access to online tools and adopting person-centered approach, respectful of patient autonomy and values. The emerging barriers were uncertainty regarding clinical outcomes, cultural and communication difficulties, barriers associated with legal and ethical considerations, infection control restrictions, lack of time, and limited resources and support systems.
Conclusion: The pandemic has provided opportunities for rapid implementation of ACP in creative ways to circumvent social distancing restrictions and high demand for health services. This review suggests the pandemic has provided some impetus to drive adaptable ACP conversations at individual, local, and international levels, affording an opportunity for longer term improvements in ACP practice and patient care. The enablers of ACP and the accelerated adoption evident here will hopefully continue to be part of everyday practice, with or without the pandemic.
... Crucially, elderly individuals residing in nursing homes represent a group with a high incidence of chronic diseases, highlighting the need for focused attention on this population (Zhu et al., 2023). However, in most nursing homes in China, while basic medical and living support can be provided, there is often insufficient attention to promoting the overall well-being of the elderlyincluding physical, psychological, and social dimensions (Gordon et al., 2020;Wang et al., 2018). Existing research indicates that healthy aging requires more than just the treatment of diseases; it is crucial to adopt preventive measures, including enhancing the social and positive psychological capital of the elderly to support their health-promoting behaviors (Xu and Zhao, 2022;Afrashteh et al., 2024;Ye et al., 2024;Jeste et al., 2022). ...
Objective
This study aims to explore the interactions between social capital, positive psychological capital, and health-promoting behaviors among elderly residents in nursing homes in the Xiangxi region of China.
Methods
A random cluster sampling method was employed to select elderly individuals from 27 nursing homes in the Xiangxi area. Data were collected using the general information questionnaire, the Social Capital Scale, the Positive Psychological Capital Scale, and the Health-Promoting Behaviors Scale. The mediating role of positive psychological capital between social capital and health-promoting behaviors was analyzed.
Results
A total of 341 questionnaires were collected from 27 nursing homes. The data reveals mean scores of 46.83 ± 10.26 for social capital, 72.48 ± 6.39 for positive psychological capital, and 68.25 ± 10.85 for health-promoting behaviors. Mediation analysis shows that the total effect of social capital on health-promoting behaviors was 0.800 (95% CI: 0.726, 0.873), with a direct effect of 0.478 (95% CI: 0.379, 0.577), accounting for 59.75% of the total effect. The indirect effect, mediated by positive psychological capital, was 0.321 (95% CI: 0.233, 0.409), contributing to 40.13% of the total effect.
Conclusion
Positive psychological capital acts as a mediating variable between social capital and health-promoting behaviors. Future interventions designed to enhance health-promoting behaviors must consider both social and psychological capitals to fully leverage their interplay and further promote healthy aging.
... 2 3 Initial responses to the crisis were heavily focused on acute services (eg, hospitals), leaving care homes vulnerable due to inadequate supplies of personal protective equipment (PPE) and staff shortages. 4 5 There has also been increased pressure on healthcare services and an increase in telehealth, with some evidence that people living with dementia experienced STRENGTH AND LIMITATIONS OF THIS STUDY ⇒ In-depth interviews generated rich data and captured a range of perspectives from care home managers. ⇒ A diverse sample of participants was recruited with respect to the types of care homes in which they worked, geographic location, size of care home and number of years of experience as a care home manager. ...
Objectives
To explore care home managers’ views and experiences of optimising medicines use for residents with dementia during the COVID-19 pandemic.
Design, setting and participants
A descriptive exploratory qualitative study using semistructured interviews (conducted via telephone or online videoconferencing platform), with care home managers across Northern Ireland, purposively sampled from care homes that provided care for residents with dementia. Care home managers were asked to describe their experiences of accessing primary healthcare services (such as those provided by general practitioners and community pharmacists), how medicines use by residents with dementia was affected by the pandemic, and what they had learnt from their experiences. Data were analysed using inductive thematic analysis.
Results
Fourteen interviews were conducted between January and July 2022. Four themes, ‘isolation’, ‘burden’, ‘disruption’ and ‘connection and communication’, were identified; isolation was a cross-cutting theme that permeated the other themes. Care home managers described feeling isolated from healthcare professionals, healthcare services and residents’ family members. This isolation placed additional burden on care home staff and residents with dementia by increasing staff workload and negatively affecting residents’ well-being. Participants reported that disruption to primary healthcare service provision, particularly services provided by general practices, had significant impact on residents with dementia. Participants described a lack of face-to-face contact with healthcare professionals, and medication reviews often ceased to take place. The connection and communication between key stakeholders were perceived to be important when optimising medicines for residents with dementia.
Conclusions
This study has highlighted the challenges and initial impact of the COVID-19 pandemic on medicines optimisation for care home residents with dementia, which was characterised by isolation. Further research is needed to determine the extent of the long-term impact of the COVID-19 pandemic on this resident population. In future public health crises, better communication is needed between healthcare professionals and care homes.
... For example, social care minimizes costly hospitalization and enables "ageing in place" and this mitigates the effects of population ageing on our system (56). On the other hand, however, social and medical care also compete for the same pool of scarce and dwindling resources, such as human resources and personal protective equipment (57). Hence, the making of optimal decisions of allocating resources between medical and social care requires that data on social care costs and outcomes, while potentially sourced from different sectors, be linked together and then parameterized into a common measure. ...
Background
Homecare, a cornerstone of public health, is essential for health systems to achieve the Sustainable Development Goal (SDG) of universal health coverage while maintaining its own sustainability. Notwithstanding homecare’s system-level significance, there is a lack of economic evaluations of homecare services in terms of their system-wide cost-savings. Specifically, decisions informed by a joint medical-social budgetary perspective can maximize the allocative efficiency of assigning a diverse service mix to address the complex needs of the older adult population. However, little is known regarding which homecare service mix is most system-wide cost-effective when paired with which clinical profiles.
Methods
Valuation of homecare’s complex interventions was performed under a generalized cost-effectiveness analysis (GCEA) framework with proportional hazard-adjusted metrics representing the common numeraire between medical and social care.
Results
Instrumental homecare, on its own or combined with either one or both of the other homecare services, yielded the greatest cost savings compared to other services or the lack thereof. When expressed under a joint medical-social budgetary perspective, instrumental homecare can reduce medical costs of HK4.40) and HK10.84) for every HK0.13) invested in instrumental and instrumental-restorative homecare, respectively.
Conclusion
Instrumental homecare can increase hospitalization-free days among community-dwelling older adult and yield significant net system-wide cost savings. Thus, the current study demonstrated the feasibility of data-informed decision-making in system-wide resource allocation under a joint medical-social budget perspective.
... Before the pandemic, care home residents in England aged ≥65 years had a 10-fold higher mortality than older people in private homes, but in the first wave of the pandemic, this rose to an 18-fold difference [10]. At least for the first months of the pandemic, care homes experienced substantial, widely reported challenges in accessing COVID-19 testing and in isolating residents and a lack of availability of personal protective equipment (PPE; eg, gloves, face masks, and aprons) [11,12]. Other systemic problems linked to a higher risk of COVID-19 outbreaks included a lack of statutory sick pay for staff (thereby discouraging staff to take time off work) and reliance on agency workers (who work across multiple sites) to address workforce shortages [13]. ...
Background
Infection prevention and control (IPC) is vital in care homes as it can reduce morbidity and mortality by 30%. Ensuring good IPC practice is a perennial challenge in the varied and complex context of care homes. Behavior change interventions delivered via digital technology may be effective in improving IPC among care home staff.
Objective
This study aimed to evaluate how an evidence-based, digital behavior change intervention called Germ Defence can be rapidly adapted to meet the needs of care homes.
Methods
This study applied the person-based approach, which emphasizes iterative approaches to optimizing interventions via individual user feedback. Phase 1 involved initial edits to the website by the research team to create Germ Defence for Care Homes (GDCH) version 1. Phase 2 consisted of stakeholder consultation on GDCH version 1 followed by edits to create GDCH version 2. The formal research (phases 3 and 4) involved individual think-aloud interviews with 21 staff members from management, care, and ancillary positions in 4 care homes providing real-time feedback as they worked through GDCH. Edits were made to create GDCH version 3 between phases 3 and 4. During the development of GDCH versions 2 and 3, it became clear that the intervention would need more fundamental changes beyond the pragmatic, incremental changes that would be possible within the scope of this study. Analysis was completed via a rapid, qualitative descriptive approach to develop a high-level summary of key findings from the interview data.
Results
There were mixed results about the attractiveness of GDCH and its suitability to the care home context. Participants felt that the images needed to be aligned much more closely with the meaning of adjacent text. Many participants felt that they would not have time to read a text-based website, and some suggested that more engaging content, including audio and video, may be preferable. Most participants felt that the overall concept of Germ Defence was clearly relevant to their context. Some felt that it might be a useful introduction for new staff members or a refresher for current staff, but others felt that it did not add anything to their existing IPC training. There were mixed opinions about the level of detail provided in the information offered by the site. While the goal-setting behavior change mechanism may have potential, the findings suggested that it may be unsuitable for care homes and more work is needed to refine it.
Conclusions
Much more work needs to be done to make Germ Defence more engaging, accessible, and relevant to the care home workforce. Our study highlights the challenges of rapidly adapting an existing intervention to a new context. Future research in this area will require a pragmatic methodological approach with a focus on implementation.
... Residents in nursing homes were completely cut off from visitors due to pandemic-related restrictions, and they may have witnessed fellow residents dying more frequently. 30 Therefore, feelings of loneliness and depression can be more severe among that population compared to the population in this study. ...
Objective
This study investigates the longitudinal effects of changes in the associations between two distinct aspects of social connections—i.e., social connectedness and loneliness—on depressive symptoms among community-dwelling Korean adults. This study also examines whether these associations vary across three age groups (45–64, 65–74, and 75 or above).
Methods
Using data from the Korean Longitudinal Study of Ageing collected between 2014 and 2020 (n=3,642 individuals), fixed effects models were used to examine the age-specific associations between the two distinct aspects of social connections and depressive symptoms (Center for Epidemiologic Studies-Depression Scale) while, accounting for time-invariant individual heterogeneity. Social connectedness is measured by asking the frequency of interactions with friends, relatives, or neighbors.
Results
The findings indicate that the impact of loneliness on depressive symptoms outweighs that of social disconnectedness. Notably, this study unveils age-specific patterns concerning the impact of the coronavirus disease-2019 pandemic on depressive symptoms and changes in the association between loneliness and depressive symptoms. Specifically, middle-aged individuals reported higher levels of depressive symptoms and loneliness along with a heightened impact of loneliness on depressive symptoms, despite maintaining stable social connections. Conversely, the oldest adults experienced reductions in both depressive symptoms and loneliness, despite a significant decrease in socializing.
Conclusion
These findings shed light on the differential effects of loneliness on depressive symptoms within distinct age groups before and during the pandemic. The implications of these findings are discussed with a focus on informing the development of targeted policy interventions tailored to the specific needs of different age groups.
... Following the declaration of the pandemic by the World Health Organization (WHO) in March 2020, reports emerged of severe outbreaks within LTCFs, particularly affecting the elderly. [1][2][3][4] Long-term care facilities are environments where frail older individuals predominate, with multiples morbidities. These factors increase the risk of developing severe forms of COVID-19. ...
Introduction
The COVID-19 pandemic has disproportionately affected individuals residing in Long-Term Care Facilities (LTCFs), necessitating tailored strategies to manage outbreaks. This study examines the outcomes of the ILPI BH project, a collaborative effort between the Municipal Health Department and the Hospital das Clínicas of the Federal University of Minas Gerais, designed to mitigate COVID-19 spread within LTCFs.
Methods
Prospective cohort of secondary data: 1,794 old residents in 99 long-term care facilities of Belo Horizonte, Brazil, were followed from May 2020 to January 2021. The study analyzed the prevention strategies, residents’ clinical data, and the characteristics of the long-term care facilities, correlating these variables with the number of infections, hospitalizations, and deaths from COVID-19. It checked absolute numbers and rates of incidence, hospitalization, mortality, and lethality.
Results
There have been 58 COVID-19 outbreaks in long-term care facilities. There were 399 cases among residents, 96 hospitalizations for COVID-19 and 48 deaths from COVID-19 (2.7 % of the cohort), with a case fatality rate of 12 %. After multivariate analysis, the intrinsic variables to residents associated with higher mortality risk were higher degree of frailty (OR=1.08; p = 0.004) and the fact of living in a long-term care facility with a considerable proportion of residents’ coverage by health plans (OR = 1.01; p = 0.028). Early geriatric follow-up showed an association with a reduction in the number of hospitalizations due to COVID-19.
Conclusion
The correct classification of the degree of frailty of institutionalized older people seems to have been relevant for predicting mortality from COVID-19. The extensive assistance by private health plans, contrary to what is supposed, did not result in better health protection. Early geriatric follow-up was beneficial and may be an attractive strategy in the face of health emergencies that affect long-term care facilities to reduce hospital admissions.
... In the same vein, a number of studies highlighted the involvement of ACP and palliative care experts, such as geriatricians, nurse practitioners, trained ACP clinicians, specialist palliative care clinicians, and chaplains, as an important facilitator of ACP [124,134,144,147,148]. ACP and palliative care experts can help to ensure that ACP is conducted with a high level of expertise and sensitivity, especially in complex and difficult cases or in those with advanced illness, of which there were many during the pandemic. ...
The COVID-19 pandemic highlighted the need for advance care planning (ACP) as a way to help mitigate the various care concerns that accompanied the healthcare crisis. However, unique obstacles to typical ACP practice necessitated the need for guidance and innovation to help facilitate these vital conversations. The aim of this systematic review was to identify the various ACP barriers and facilitators that arose during the pandemic and determine how ACP practice was affected across different contexts and among different populations. This systematic review (PROSPERO registration number: CRD42022359092), which adheres to the PRISMA guidelines for reporting systematic reviews, examined studies on ACP in the context of the COVID-19 pandemic. The review involved searches of five databases, including MEDLINE and Embase. Of the 843 identified studies, 115 met the inclusion criteria. The extracted ACP barriers and facilitators were codified and quantified. The most frequently occurring ACP barrier codes were: Social distancing measures and visitation restrictions, Uncertainty surrounding the COVID-19 prognosis, and Technological/Telehealth barriers. The most frequently occurring ACP facilitator codes were the following: Telehealth/virtual ACP platforms, Training for clinicians, and Care team collaboration. Identifying the ACP barriers and facilitators is essential for developing effective, resilient ACP promotion strategies and improving its delivery, accessibility, and acceptability.
... In Switzerland, as in many other countries, nursing home directors (NDs) are responsible for the governance of structures, procedures and outcomes of healthcare in their nursing home facilities, in order to guarantee the quality of care for residents (13). Nursing home directors (ND), in their function to manage the nursing staff and overall nursing operations of their healthcare facility, were in a difficult situation and faced a dilemma (14): On one hand, they were responsible for the protection of nursing home residents from infection with a potentially life-threatening disease. On the other hand, they perceived that the protective measures negatively affected their nursing home residents (15). ...
Background
Coronavirus pandemic (COVID-19) particularly affected older adults, with the highest risks for nursing home residents. Stringent governmental protective measures for nursing homes unintendedly led to social isolation of residents. Nursing home directors (NDs) found themselves in a dilemma between implementing protective measures and preventing the social isolation of nursing home residents.
Objectives
The objectives of this study were to describe protective measures implemented, to investigate NDs’ perception of social isolation and its burden for nursing home residents due to these measures, and to explore experiences of NDs in the context of the dilemma.
Methods
Cross-sectional embedded mixed-method study carried out by an online survey between April 27 and June 09, 2022, among NDs in the German-speaking part of Switzerland. The survey consisted of 84 closed-ended and nine open-ended questions. Quantitative findings were analyzed with descriptive statistics and qualitative data were evaluated using content analysis.
Results
The survey was completed by 398 NDs (62.8% female, mean age 55 [48–58] years) out of 1′044 NDs invited.
NDs were highly aware of the dilemma. The measures perceived as the most troublesome were restrictions to leave rooms, wards or the home, restrictions for visitors, and reduced group activities. NDs and their teams developed a variety of strategies to cope with the dilemma, but were burdened themselves by the dilemma.
Conclusion
As NDs were burdened themselves by the responsibility of how to deal best with the dilemma between protective measures and social isolation, supportive strategies for NDs are needed.
... 29 Undoubtedly, failures in nursing home management were the most glaring. 30 But there were other decisions with psychiatric consequences which are slowly unraveling. 31,32 Theme 3: The phenomenon of digital media: The benefits of communication versus the harms of its abuse. ...
Background
During the most critical phases of COVID-19 pandemic, dramatic situations were experienced in hospitals and care centers that nurses could hardly verbalize. Especially relevant were deep challenges related to terminal illness, situations of extreme sacrifice, as well as reflections on protective measures mixed with beliefs. We intend to analyze which problems had the greatest impact on professionals.
Aim
The aim is to explore the ultimate basis for action when making decisions and the orientation of their behavior in the face of moral conflicts.
Method
The methodological strategy is an interpretive synthesis. Narrative review of academic articles that analyzed ethical dilemmas during the pandemic was carried out by searching five databases (Pubmed, Scopus, Psycinfo, CINHAL, and WOS) between January 2020 and December 2022. Finally, 43 articles were selected.
Ethical Considerations
Ethical requirements were respected in all study phases.
Results
The reading and review of the 43 articles initiated the first phase of inductive coding which resulted in 14 initial sub-themes. Based on this structure, a second phase of coding was carried out, giving rise to six categories or emerging themes. To facilitate the process of identifying the central category, the authors agreed to carry out a phase of synthesis, grouping the six themes into three meta-themes: the identification and acceptance of human vulnerability; the discovery of positive paradigms in traumatic situations in society; the prevalence of the common good over the particular interest, as the core structure of any society.
Conclusion
The study has shown the need to consider healthcare benevolence as a new dimension of health care upon global vulnerability. Responsibility is required to ensure the well-being of a global society, prioritizing the common good over particular interests and building solutions on solid moral structures. A new ethical landscape is essential, starting with a humanistic curricular training of all healthcare professionals.
... A highquality workforce is needed in LTC, and the COVID-19 pandemic only worsened availability of limited personnel across multiple countries [32]. All post-industrial nations face similar challenges as Canada with high costs, a workforce that is underpaid and receives inadequate training, workforce shortages and concerns with the quality of care delivered [33][34][35][36][37]. In addition, policymakers and administrators should consider how to respond to the homelevel characteristics known to be associated with adverse outcomes amongst residents. ...
Background
The relative contributions of long-term care (LTC) resident frailty and home-level characteristics on COVID-19 mortality has not been well studied. We examined the association between resident frailty and home-level characteristics with 30-day COVID-19 mortality before and after the availability of SARS-CoV-2 vaccination in LTC.
Methods
We conducted a population-based retrospective cohort study of LTC residents with confirmed SARS-CoV-2 infection in Ontario, Canada. We used multi-level multivariable logistic regression to examine associations between 30-day COVID-19 mortality, the Hubbard Frailty Index (FI), and resident and home-level characteristics. We compared explanatory models before and after vaccine availability.
Results
There were 11,179 and 3,655 COVID-19 cases in the pre- and post-vaccine period, respectively. The 30-day COVID-19 mortality was 25.9 and 20.0% during the same periods. The median odds ratios for 30-day COVID-19 mortality between LTC homes were 1.50 (95% credible interval [CrI]: 1.41–1.65) and 1.62 (95% CrI: 1.46–1.96), respectively. In the pre-vaccine period, 30-day COVID-19 mortality was higher for males and those of greater age. For every 0.1 increase in the Hubbard FI, the odds of death were 1.49 (95% CI: 1.42–1.56) times higher. The association between frailty and mortality remained consistent in the post-vaccine period, but sex and age were partly attenuated. Despite the substantial home-level variation, no home-level characteristic examined was significantly associated with 30-day COVID-19 mortality during either period.
Interpretation
Frailty is consistently associated with COVID-19 mortality before and after the availability of SARS-CoV-2 vaccination. Home-level characteristics previously attributed to COVID-19 outcomes do not explain significant home-to-home variation in COVID-19 mortality.
... A possible suggestion for the moderate score on the CD-RISC-despite the prolonged challenges of the pandemic-is that significant challenges relating to systems, resources and support existed before the pandemic [88]. It could also be the case that the pandemic may have released an 'untapped capacity' within this workforce [19,89], allowing assets to emerge, which had not been required previously [6]. ...
Resilience is considered a core capability for nurses in managing workplace challenges and adversity. The COVID-19 pandemic has brought care homes into the public consciousness; yet, little is known about the resilience of care home nurses and the attributes required to positively adapt in a job where pressure lies with individuals to affect whole systems. To address this gap, an online survey was undertaken to explore the levels of resilience and potential influencing factors in a sample of care home nurses in Northern Ireland between January and April 2022. The survey included the Connor–Davidson Resilience Scale, demographic questions and items relating to nursing practice and care home characteristics. Mean differences and key predictors of higher resilience were explored through statistical analysis. A moderate level of resilience was reported among the participants (n = 56). The key predictors of increased resilience were older age and higher levels of education. The pandemic has exposed systemic weakness but also the strengths and untapped potential of the care home sector. By linking the individual, family, community and organisation, care home nurses may have developed unique attributes, which could be explored and nurtured. With tailored support, which capitalises on assets, they can influence a much needed culture change, which ensures the contribution of this sector to society is recognised and valued.
... Corona virus adalah kondisi pandemi yang memengaruhi kondisi di seluruh dunia. Penyakit ini bermula dari infeksi saluran pernapasan akibat infeksi ini di Wuhan pada Desember 2019 (Gordon et al., 2020). Kesehatan mental masyarakat terganggu akibat meningkatnya kasus Covid-19, terutama para lansia. ...
Kegiatan pengabdian kepada masyarakat ini bertujuan untuk meningkatkan pengetahuan lansia tentang penyakit kronis; melakukan pemeriksaan kesehatan yaitu cek tekanan darah, gula darah, dan asam urat; serta memberikan motivasi kepada lansia terkait pentingnya kesadaran untuk melakukan pemeriksaan secara rutin. Sasaran kegiatan ini adalah warga lansia dan pra lansia. Kegiatan pengabdian masyarakat ini dilaksanakan melalui metode pemeriksaan kesehatan dengan teknik door to door dan pendidikan kesehatan. Hasil dari kegiatan ini adalah pemeriksaan kesehatan diikuti oleh 16 orang lansia, terdapat peningkatan pengetahuan yang ditunjukkan dengan hasil penilaian checklist wawancara akhir lebih besar dibandingkan checklist wawancara awal oleh sebagian besar lansia (13 orang atau 81,25%), serta seluruh peserta termotivasi untuk melakukan pemeriksaan kesehatan rutin. Metode door to door dapat meningkatkan pengetahuan dan motivasi peserta. Perlu adanya bimbingan dari tenaga kesehatan setempat untuk terus konsisten dalam memberikan pelayanan kesehatan, penyuluhan, informasi, dan monitoring kepada para lansia.
... Menurut World Helath Organization diperkirakan peningkatan pada wanita usia 50 tahun dari 500 juta meningkat menjadi lebih dari 1 milyar pada tahun 2030, sedangkan wanita menopause di Asia pada tahun 2025 diperkirakan akan terjadi lonjakan dari 107 juta jiwa menjadi 373 juta jiwa (Sumiaty & Restu, 2016 Data dari Dinas kesehatan Kabupaten Balangan tahun 2021 menunjukkan wanita menopause yang mengalami hipertensi sebesar 50,9% sedangkan bulan Januari -Oktober 2022 sebesar 39,4%. Salah satu gejala fisik yang dapat ditimbulkan dari masa menopause antara lain rasa panas yang tiba-tiba menyerang bagian atas tubuh keluar keringat yang berlebihan pada malam hari, sulit tidur, iritasi pada kulit, gejala pada mulut dan gigi, kekeringan vagina, kesulitan menahan buang air kecil, dan peningkatan berat badan (Gordon et al., 2020). ...
Menopausal women have a higher risk of hypertension than those who have not been menopausal. Hypertension can damage organs and cause stroke, kidney failure and heart attack. The purpose of the study was to determine the incidence of hypertension in menopausal women in the Working Area of the Lok Batu Health Center. This research method uses quantitative analytical surveys with a cross sectional approach. The population is all menopausal women in the Working Area of Lok Batu Health Center as many as 156 people with purposive sampling techniques as many as 61 respondents. Chi square data analysis technique. The results showed that the majority of the incidence of level 2 hypertension was 33 respondents (54.1%), hormonal birth control history was 42 respondents (68.9%), normal BMI was 33 respondents (54.1%), basic education was 57 respondents (93.4%), working as many as 40 respondents (65.6%). The results of statistical tests using chi square had no relationship between family planning history p = 0.531 (p > 0.05), body mass index p = 0.458 (p > 0.05), education p = 0.403 (p > 0.05) and work p = 0.399 (p > 0.05) with the incidence of hypertension in menopausal women in the working area of the Lok Batu Health Center.
... We conducted a rapid systematic review, spanning January 2020 to July 2022. It highlighted 14 international papers, [8][9][10][11][12][13][14][15][16][17][18][19][20][21] published in English. No studies used an experimental design, and none reported, or evaluated, interventions designed to improve compliance with SARS-CoV-2 testing. ...
Introduction:
Care home residents have experienced significant morbidity, mortality and disruption following outbreaks of SARS-CoV-2. Regular SARS-CoV-2 testing of care home staff was introduced to reduce transmission of infection, but it is unclear whether this remains beneficial. This trial aims to investigate whether use of regular asymptomatic staff testing, alongside funding to reimburse sick pay for those who test positive and meet costs of employing agency staff, is a feasible and effective strategy to reduce COVID-19 impact in care homes.
Methods and analysis:
The VIVALDI-Clinical Trial is a multicentre, open-label, cluster randomised controlled, phase III/IV superiority trial in up to 280 residential and/or nursing homes in England providing care to adults aged >65 years. All regular and agency staff will be enrolled, excepting those who opt out. Homes will be randomised to the intervention arm (twice weekly asymptomatic staff testing for SARS-CoV-2) or the control arm (current national testing guidance). Staff who test positive for SARS-CoV-2 will self-isolate and receive sick pay. Care providers will be reimbursed for costs associated with employing temporary staff to backfill for absence arising directly from the trial.The trial will be delivered by a multidisciplinary research team through a series of five work packages.The primary outcome is the incidence of COVID-19-related hospital admissions in residents. Secondary outcomes include the number and duration of outbreaks and home closures. Health economic and modelling analyses will investigate the cost-effectiveness and cost consequences of the testing intervention. A process evaluation using qualitative interviews will be conducted to understand intervention roll out and identify areas for optimisation to inform future intervention scale-up, should the testing approach prove effective and cost-effective. Stakeholder engagement will be undertaken to enable the sector to plan for results and their implications and to coproduce recommendations on the use of testing for policy-makers.
Ethics and dissemination:
The study has been approved by the London-Bromley Research Ethics Committee (reference number 22/LO/0846) and the Health Research Authority (22/CAG/0165). The results of the trial will be disseminated regardless of the direction of effect. The publication of the results will comply with a trial-specific publication policy and will include submission to open access journals. A lay summary of the results will also be produced to disseminate the results to participants.
Trial registration number:
ISRCTN13296529.
... Due to early PPE shortages, carers reported feeling uncomfortable and unprotected from the virus while working during this period. The absence of PPE for caregivers has been discussed in the literature and the media [22], but the current study further explored the psychological and physical effects this shortage has on workers. According to our research, staff members were compelled to adjust in the short term, accepting low or reused PPE while sensing racial prejudice in the equitable distribution of PPE. ...
COVID-19 has drastically impacted care home residents, families, and staff. However, little is known about the impact of this pandemic on carers from the ethnically minoritised background. The present research explored the experiences of UK’s black carers during COVID-19. A semi-structured interview-based qualitative study was conducted involving black carers from Berkshire, Hampshire, and Oxfordshire. Interviews were conducted online through Microsoft Teams, and a thematic analysis was performed on verbatim transcribed interviews. The present study included 15 participants from three UK counties which have a large number of care homes. The analysis of interviews resulted in the development of seven themes: 1) reactions to COVID, 2) infection control in the work environment, 3) workplace discrimination, 4) impact of COVID on well-being, 5) coping mechanisms and impact of deaths, 6) reflection on challenges, and 7) recommendations to care home managers. In conclusion, the black carers reported a substantial impact on their mental and physical health. They recognized the need for timely information, sufficient and fair availability of PPEs, more support, better communication, and equitable work distribution to maintain their mental and physical health.
... Less consideration was given to staff working in care homes for the elderly, and other wider social care settings. This was despite care home residents having the highest risk of morbidity and mortality from the virus, (Gordon et al., 2020;Oliver, 2020), despite the sector having bed numbers three times greater than that of the NHS (Illife et al., 2015), despite the overall UK adult social care workforce outnumbering that of the NHS, specifically 1.6 million social care employees compared to 1.4 million in the NHS. (Kings Fund, 2012). ...
... Pausing group activity, exercise and outdoor activity exacerbated sarcopenia and frailty [42] and inadequate government policy and guidance contributed to ineffective isolation practices [43][44][45]. Gordon et al. [46] contend that isolating people with a cognitive impairment in bedrooms and the staffing challenges this causes potentially places residents at risk of falls and injury due to lack of direct supervision. Resolving the conflict between restricting the spread of COVID-19 and retaining residents' liberty involves seeing each individual within the communal context and advocating for them in light of their particular needs and rights [30]. ...
Background
Care home residents transitioning from hospital are at risk of receiving poor-quality care with their safety being challenged by the SARS-CoV-2 virus (COVID-19) pandemic. Little is known about how care home staff worked with hospital staff and other healthcare professionals to address these challenges and make improvements to increase patient safety.
Objective
To gain insight into how the COVID-19 pandemic influenced the safety of transitions between hospital and care home.
Method
Semi-structured interviews were conducted with care home staff and healthcare professionals involved in hospital to care home transitions including doctors, nurses, paramedics, pharmacists, social workers, and occupational therapists. Commonalities and patterns in the data were identified using thematic analysis.
Results
Seventy participants were interviewed. Three themes were developed, first, ‘new challenges’, described care homes were pressurised to receive hospital patients amidst issues with COVID-19 testing, changes to working practices and contentious media attention, which all impacted staff negatively. Second, ‘dehumanisation’ described how care home residents were treated, being isolated from others amounted to feelings of being imprisoned, caused fear and engendered negative reactions from families. Third, ‘better ways of working’ described how health and social care workers developed relationships that improved integration and confidence and benefited care provision.
Conclusion
The COVID-19 pandemic contributed to and compounded high-risk hospital-to-care home discharges. Government policy failed to support care homes. Rapid discharge objectives exposed a myriad of infection control issues causing inhumane conditions for care home residents. However, staff involved in transitions continued to provide and improve upon care provision.
... Researchers have suggested that infection prevention measures have to be weighed carefully against their potential harms [16] and person-centered care [17; 18; 19] in order to maintain residents" well-being. However, how these considerations are to be made in practice is not described [16; 17]. ...
Background
COVID-19 infection prevention measures can negatively impact nursing home residents’ well-being. Society has been concerned about the imbalance between infection prevention and residents’ well-being, and about nursing home residents’ autonomy in COVID-19 policymaking.
Objective
This study explores consensus among nursing home staff about which measures they found to be most important in contributing to preventing infections and to maintaining well-being of residents during COVID-19 outbreaks. In addition, this study explores the decision-making processes regarding COVID-19 measures and the involvement of residents or their representatives.
Design
Mixed methods based on an online nominal group technique.
Setting(s)
Dutch nursing homes, June–November 2020.
Participants
Managers, policy advisors, elderly care physicians, psychologists, a spiritual counselor, nurses, care assistants, and resident representatives (N = 35).
Methods
Four panels from the viewpoint of infection prevention, and four panels from the viewpoint of well-being were performed with 3 to 7 participants per panel. Participants individually selected the measure they found most important, discussed these measures together in an online conversation, and rated the importance and urgency of these measures during COVID-19 outbreaks on a 5-point Likert scale. The measures that were rated as (very) important and (very) urgent by all members of that panel were defined as ‘prioritized in consensus’. Panels also discussed the decision-making process regarding COVID-19 measures and the involvement of residents or their representatives. These conversations were transcribed verbatim and thematically coded using an inductive approach.
Results
The infection prevention panels prioritized isolation measures; testing measures; testing and isolation combinations; use of personal protective equipment around (suspected) infected residents; and preparation for outbreaks by COVID-19 outbreak teams. The well-being panels prioritized cohort isolation, testing combined with cohort isolation and with isolation in residents’ rooms, exceptions to visitor bans, maximum numbers of visitors, and registration and accompanying visitors to the residents’ rooms. Resident representatives and staff were dissatisfied with their reduced involvement in policy making during the first months of the COVID-19 pandemic, although they understood that decisions had to be made quickly.
Conclusions
Staff and resident representatives should be involved in COVID-19 policy making. According to them, priority COVID-19 measures should include: cohort isolation, testing and isolation combinations, use of personal protective equipment, crisis management by COVID-19 outbreak teams, and nursing home visit regulations and instruction of visitors. Combining these measures may be a first step towards packages of COVID-19 measures that better balance infection prevention and maintaining residents’ well-being.
Registration
N/A
Tweetable abstract
Priority COVID-19 nursing home measures are isolation, testing, testing and isolation combinations, PPE use, preparations by outbreak teams, and visit regulations @wilcoachterberg
... The pandemic exposed another vulnerable group of those who reside in residential care with almost twothirds of COVID-19 deaths occurring in nursing homes [33]. Contingency plans for enhanced staffing to maintain optimal care provision will be required for future outbreaks as well as education and implementation of infection prevention and control experts [34]. COVID-19 has highlighted the need for a more integrated working relationship between the state and the residential care sector [35]. ...
The formal announcement of the end of the COVID-19 pandemic by the WHO came on the 5th of May 2023; however, unlike the pandemic onset, the pandemic end date was not met with any significant media coverage or news reporting in Ireland. Additionally, there were no series of contemplations either in newspapers or other media about the impact of the decision to formally end the pandemic despite having financial and legislative impacts on a wide number of people. Given the potential impact of the removal of government subsidies on health and occupations, government and media coverage of the decisions and potential implications would have been helpful. The opportunity for a significant debriefing of the pandemic outlining what we have learned from the COVID-19 pandemic response may have been missed.
... The COVID-19 pandemic, whilst highlighting the exceptional care provided by this sector, also identified a significant gap in support and the lack of prioritization for the residents and staff in care homes (Gordon et al., 2020;Thomas and Quilter-Pinner, 2020). Work in the care home sector is often recognized as a stressful occupation (Islam et al., 2017) and the COVID-19 pandemic highlighted again the differences felt between care home staff and their colleagues in hospital settings (Blanco-Donoso et al., 2021), Nonetheless, (Marshall et al., 2021) identified that local communities ''valued care homes, their staff and the work that they do' and that care home managers were central to ensuring continuity of care. ...
... This was in response to a significant decrease in the number of people with a recorded diagnosis of dementia and increased waiting lists in memory assessment services as a result of the coronavirus disease 2019 (COVID-19) pandemic (NHS Digital 2022). Residents and staff in care homes in West Norfolk, as in other areas of the country, had been negatively affected by the pandemic, notably through increased mortality (Gordon et al 2020), and care home residents were less likely than before the pandemic to receive a diagnosis of dementia (NHS England 2021). ...
It has been estimated that 70% of care home residents have dementia on admission or develop it after admission but that many of these residents do not have, or receive, a formal diagnosis of dementia. People with dementia often have significant care needs, so it is important that the condition is diagnosed, even at an advanced stage, so that people’s care needs can be predicted, appropriate care plans can be developed and pre-emptive decisions can be made.
In 2021-22, a quality improvement project took place in care homes in West Norfolk, where the use of an abbreviated memory assessment model based on the Diagnosing Advanced Dementia Mandate (DiADeM) tool was piloted to increase the rate of diagnoses among residents showing signs and symptoms of cognitive impairment but not formally diagnosed with dementia. Out of 109 residents assessed, 95 were diagnosed with dementia. The pilot is being extended locally and replicated across England.
Background
General practice provides first-line National Health Service care for around 400,000 care home residents. Good primary care can enhance residents’ health and well-being and optimise use of hospital services.
Objectives
This study aimed to explore the relationships between organisation of general practice and the perspectives and experiences of residents, general practice and care home staff, outcomes and costs.
Design
Survey of general practices (2018), qualitative study (2019), analysis of primary care data (2019–21).
Policy context
National Health Service England Vanguard funded innovation in services for care homes in five areas (2015–8); Enhanced Health in Care Homes introduces standardised care home healthcare processes in England (2020–4).
Setting
England: national survey; qualitative work in three areas (two Vanguards); analysis of national primary care data across early implementation of Enhanced Health in Care Homes and the COVID-19 pandemic.
Participants
One hundred and fifty general practice survey respondents; 101 interviewees (general practitioners, practice managers, receptionists, care home managers, nurses, senior carers, residents, relatives, commissioners) in three areas; 103,732 care home residents ≥ 75 years, registered with participating practices in Clinical Research Datalink Aurum 2019–21.
Results
Qualitative analysis identified three themes concerned with general practitioner services to care homes: relational processes, communication and organisation. Continuity of care, sensitivity to the skills of care home staff and routines of the home, along with a willingness to dedicate time to patients, are all crucial. Different structures (e.g. scheduled visits) provide opportunities to develop effective, efficient care, but flounder without established, trusting relationships. The way in which new initiatives are implemented is crucial to acceptance and ultimate success: telemedicine was an example that generated efficiencies for the National Health Service, but could be a burden to care homes, resented by staff and perceived as a barrier to overcome. One hundred and fifty practices responded to our survey, a majority staffed by ≤ 5 general practitioners. Larger practices were more likely to have a nominated general practitioner for care homes and make weekly scheduled visits. Analysis of primary care data found that in practices with a higher number of care home residents, patients had more contacts with primary care and fewer urgent referrals. Between 2019 and 2021, total contacts and estimated costs increased, and urgent referrals and polypharmacy fell.
Limitations
Sparse evidence of systematic change in Vanguard areas limited our conclusions about specific initiatives. Implementation of national policy during the COVID-19 pandemic complicates data interpretation.
Conclusions
Larger practices or those with higher numbers of care home residents were more likely to adopt ways of working that are associated with higher-quality care. However, trusting relationships between care homes and a motivated, adequately resourced primary care workforce may be more important than models of care, in enhancing primary care for care homes. General practices and care homes find creative ways around initiatives that are not perceived to offer any benefits, emphasising the need for local flexibility when implementing national initiatives.
Future work
Future work could address how best to promote ways of working that prioritise trusting relationships; the absence of care pathways specific to care home patients, and the impact of Enhanced Health in Care Homes on system-wide costs.
Funding
This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 14/196/05) and is published in full in Health and Social Care Delivery Research; Vol. 13, No. 11. See the NIHR Funding and Awards website for further award information.
Background
Early in the COVID-19 pandemic, care homes (long-term care facilities) globally were severely impacted in many ways, including end-of-life care and death of residents. They experienced significantly elevated mortality rates amongst residents, compounded by restrictions on support from external healthcare and specialist palliative care providers. Family access to dying residents was often severely restricted. This paper explores experiences of deaths, dying and end-of-life care in care homes during the first year of the pandemic (Spring 2020–2021).
Methods
As part of a wider study of experiences in care homes in Northern England during the early pandemic, we conducted semi-structured interviews with care home staff (16), residents (3), family members (5) and health service staff (10). Interviews were analysed using reflexive thematic analysis, this secondary analysis focusing on experiences of death and dying over the period.
Results
Thematic analysis generated three key themes: (1) Preparing for large scale deaths: Care home staff reported a sense of foreboding at requirements to prepare for large scale resident deaths, sometimes feeling left with minimal external support to manage this, and uneasy about the rapid roll-out of emergency care planning to residents; (2) Balancing support and policing visiting during the terminal phase: The requirement to restrict access for family members when their relatives were dying was experienced as distressing for both family members and care home staff; and, (3) Distress surrounding deaths for staff and families: Care home staff were distressed by the frequency and speed of deaths that they witnessed when their care home had a COVID-19 outbreak. Family separation near time of death was a source of distress for everyone involved, with suggestions that this led to regrets in bereavement for family members, and moral distress in staff.
Conclusions
The experience of death and dying in care homes in the early waves of the COVID-19 pandemic was extremely challenging for care home staff and family members. Our analysis suggests that the ramifications of stringent visitation policies and the consequent distress may shape experiences in bereavement. Monitoring for longer term consequences, such as prolonged grief and moral injury, should be a priority.
Introduction
The delivery of medical services by primary care physicians (PCPs) in long-term care (LTC) homes lacks consistency. There is no Canadian standard for PCP commitment in the LTC home setting, which can influence the quality of care delivered and resident health outcomes. The PCP’s commitment to LTC practice is theorised as the proportion of a physician’s practice dedicated to LTC, the number of residents for whom they provide care and the time spent on individual resident encounters. We aim to establish consensus on expectations concerning PCP commitment in Canadian LTC homes.
Methods and analysis
We describe a protocol for a two-round modified e-Delphi study assessing the consensus of an expert panel, guided by the RAND methodological guidance for conducting Delphi panels and the ACcurate COnsensus Reporting Document (ACCORD) guideline for healthcare-based consensus studies. We will recruit pan-Canadian experts who demonstrate extensive knowledge and experience in medical care delivery and medical practice models in the Canadian LTC sector. A literature review will generate a candidate list of statements constituting PCP commitment. The first round evaluates the relevance and feasibility of candidate statements through an online questionnaire. Panellists may also write open-ended, qualitative responses to add rationales, suggest alternatives and share new ideas. We will then host a virtual synchronous meeting to have an in-depth discussion about the results from round one. A second questionnaire will be distributed to evaluate the remaining statements that have not reached consensus, and any new statements added based on the same criteria.
Ethics and dissemination
The Hamilton Integrated Research Ethics Board (Project ID #17321) approved our study. The findings will be disseminated through manuscripts, presentations, and the lead author’s thesis.
Trial registration number
The ISRCTN Registry: #35125526.
COVID-19-related lockdowns resulted in strict visiting restrictions in care homes, placing a vulnerable population at further risk of functional and cognitive decline, and psychological difficulties due to isolation. Experiences of vulnerable minority groups of older persons who reside in care homes are not well researched. In New Zealand, the Chinese community is a fast-growing ethnic group that faces challenges such as language barriers, differing cultural beliefs and COVID-19-related discrimination. The aim of this study was to explore the experiences of Chinese care home residents in New Zealand during COVID-19 lockdowns. In this qualitative study, we interviewed residents ( n = 6), family members ( n = 6) and facility staff ( n = 6) across two Chinese-run care homes in Auckland, New Zealand. Resident and family member participants were exclusively Chinese. Interviews were conducted and transcribed in either English or Mandarin Chinese. Transcripts were coded and analysed to synthesise themes. We identified five themes: (a) acceptance and pragmatism; (b) attitudes towards authority; (c) the concept of máfan: 麻烦 (to trouble); (d) challenges to fulfilling filial duties; and (e) responding to pandemic challenges. This research reframes the narrative of older Chinese care home residents during COVID-19-related restrictions. We recommend integrating the findings and philosophical values identified in this study to develop future protocols that consider the cultural and language needs of Chinese care home residents.
Objectives: This research paper explores the intricate landscape of healthcare delivery in metropolitan cities, focusing on addressing challenges such as environmental impact, resource management, and patient accessibility. Theoretical Framework: This paper investigates the integration of Green Healthcare System principles with Healthcare 4.0 technologies in metropolitan cities The study applies concepts of sustainability from Green Healthcare Systems and technological advancements from Healthcare 4.0 to explore their synergy in enhancing urban healthcare delivery. Method: Using NVivo Pro 12, the research employs qualitative analysis of interviews and field observations to identify key factors, challenges, and opportunities associated with implementing these systems in metropolitan settings. Findings reveal that leadership commitment, stakeholder collaboration, financial resources, and regulatory frameworks are crucial for successful integration. Results and Discussion: The findings reveal the transformative potential of combining green healthcare practices with digital technologies, underscoring the importance of stakeholder collaboration, leadership, and supportive policies in realizing sustainable healthcare delivery. The integration offers a comprehensive approach to meeting Sustainable Development Goals (SDGs) and advancing urban healthcare systems. Research Implications: The research contributes to understanding sustainable healthcare practices in urban environments and provides a roadmap for integrating green initiatives with advanced technologies to enhance healthcare accessibility and quality. Originality/Value: This study enriches the literature on sustainable healthcare by exploring synergies between Green Healthcare System and Healthcare 4.0, offering valuable insights for researchers and practitioners in metropolitan settings.
Background
Older people living in care homes are at high risk of poor health outcomes and mortality if they contract coronavirus disease 2019. Protective measures include social distancing and isolation, although implementation is challenging.
Objectives
To explore the real-life experiences of social distancing and isolation in care homes for older people, and to develop a toolkit of guidance and resources.
Design
A mixed-methods, phased design.
Setting
Six care homes in England caring for older adults.
Participants
Care home staff ( n = 31), residents ( n = 17), family members ( n = 17), senior health and care leaders ( n = 13).
Methods
A rapid review to assess the social distancing and isolation measures used by care homes to control the transmission of coronavirus disease 2019 and other infectious diseases (phase 1), in-depth case studies of six care homes, involving remote individual interviews with staff, residents and families, collection of policies, protocols and routinely collected care home data, remote focus groups with senior health and care leaders (phase 2) and stakeholder workshops to co-design the toolkit (phase 3). Interview and focus group data and care home documents were analysed using thematic analysis and care home data using descriptive statistics.
Results
The rapid review of 103 records demonstrated limited empirical evidence and the limited nature of policy documentation around social distancing and isolation measures in care homes. The case studies found that social distancing and isolation measures presented moral dilemmas for staff and often were difficult, and sometimes impossible to implement. Social distancing and isolation measures made care homes feel like an institution and denied residents, staff and families of physical touch and other forms of non-verbal communication. This was particularly important for residents with cognitive impairment. Care homes developed new visiting modalities to work around social distancing measures. Residents and families valued the work of care homes to keep residents safe and support remote communication. Social distancing, isolation and related restrictions negatively impacted on residents’ physical, psychological, social and cognitive well-being. There were feelings of powerlessness for families whose loved ones had moved into the care home during the pandemic. It was challenging for care homes to capture frequent updates in policy and guidance. Senior health and care leaders shared that the care home sector felt isolated from the National Health Service, communication from government was described as chaotic, and trauma was inflicted on care home staff, residents, families and friends. These multiple data sources have informed the co-design of a toolkit to care for residents, families, friends and care home staff.
Limitations
The review included papers published in English language only. The six care homes had a Care Quality Commission rating of either ‘good’ or ‘outstanding’. There was a lack of ethnic diversity in resident and family participants.
Conclusions
Care homes implemented innovative approaches to social distancing and isolation with varying degrees of success. A legacy of learning can help rebuild trust at multiple levels and address trauma-informed care for residents, families, friends and staff. Future work can include evaluation of the toolkit, research to develop a trauma-informed approach to caring for the care home sector and co-designing and evaluating an intervention to enable residents with different needs to transition to living well in a care home.
Funding
This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR132541) and is published in full in Health and Social Care Delivery Research ; Vol. 12, No. 45. See the NIHR Funding and Awards website for further award information.
Objectives: This research paper explores the intricate landscape of healthcare delivery in metropolitan cities, focusing on addressing challenges such as environmental impact, resource management, and patient accessibility. Theoretical Framework: This paper investigates the integration of Green Healthcare System principles with Healthcare 4.0 technologies in metropolitan cities The study applies concepts of sustainability from Green Healthcare Systems and technological advancements from Healthcare 4.0 to explore their synergy in enhancing urban healthcare delivery. Method: Using NVivo Pro 12, the research employs qualitative analysis of interviews and field observations to identify key factors, challenges, and opportunities associated with implementing these systems in metropolitan settings. Findings reveal that leadership commitment, stakeholder collaboration, financial resources, and regulatory frameworks are crucial for successful integration. Results and Discussion: The findings reveal the transformative potential of combining green healthcare practices with digital technologies, underscoring the importance of stakeholder collaboration, leadership, and supportive policies in realizing sustainable healthcare delivery. The integration offers a comprehensive approach to meeting Sustainable Development Goals (SDGs) and advancing urban healthcare systems. Research Implications: The research contributes to understanding sustainable healthcare practices in urban environments and provides a roadmap for integrating green initiatives with advanced technologies to enhance healthcare accessibility and quality. Originality/Value: This study enriches the literature on sustainable healthcare by exploring synergies between Green Healthcare System and Healthcare 4.0, offering valuable insights for researchers and practitioners in metropolitan settings.
Health economics of prevention is fundamental to improving our health and well-being. In this book we advocate the concept of ‘well-becoming’. This is how we create life-course health and well-being opportunity architecture in society. Fifty percent of mental health problems emerge before the age of fourteen years and 75 per cent by age twenty-four. Likewise, the lifestyle choices we make in our fifties determine how we age. In this book, we ask the reader to think about the life-course and where we should be investing in cost-effective interventions to support the prevention of chronic disease, disability, and premature death.
Life expectancy in the United Kingdom has fallen due to over a decade of austerity prior to the COVID-19 pandemic. Brexit and the war in Ukraine have contributed to the current cost of living crisis, adversely affecting the worst off in society. In this book we draw on the work of Professor Sir Michael Marmot on the widening inequalities in healthy life expectancy. This is set to persist in an increasingly unequal society. The economic and health economics evidence we present, drawing on systematic review evidence where possible, provokes discussion of the tension between prevention and cure in our health and social care systems.
We introduce our new infographic called the ‘Well-being and well-becoming wheel’. We set out an agenda for health economics research and policy support in the field of public health and prevention economics relating to well-being and well-becoming. We close the book with consideration of global priorities for health economics research with an increased emphasis on sustainability and climate change as a fundamental basis for future human well-being and well-becoming. We hope this book will be of interest to health economists working in public health and prevention, social care economics, public health and local authority decision-makers, and students in health economics, public health, public policy, and medicine.
Jade Bruce and colleagues explore the CovPall Care Home study, which investigated the response of UK care homes to meet the increasing need for palliative and end-of-life care for residents during the COVID-19 pandemic. Based on the findings of this study, the authors outline five policy recommendations to equip care homes with the resources and capacity to enable the delivery of high-quality care.
Introduction
Deaths in care homes and “at home” are anticipated to account for a third of UK deaths by 2040. Currently, palliative and end of life care are not part of statutory training in care homes. Reflective practice is a tool that can facilitate practice‐based learning and support. Following a feasibly study to test “online” supportive conversations and reflection sessions (OSCaRS) to support care home staff in relation to death/dying during the first months of the COVID pandemic, a one‐year practice development follow‐up project was undertaken with the aim to create a team of NHS/specialist palliative care (SPC)‐based facilitators to lead and support OSCaRS provision in up to 50 care homes in one region in Scotland—the focus of this paper.
Methods
Forty care home managers attended an on‐line session explaining the project, with a similar session held for 19 NHS/SPC‐based nurses external to care homes. Those interested in facilitating OSCaRS then attended three education sessions. Data collected: records of all activities; reflective notes on OSCaRS organised/delivered; a summary of each OSCaRS reflection/learning points; final interviews with NHS/SPC trainee facilitators.
Results
A total of 19 NHS/SPC facilitators delivered one or more OSCaRS in 22 participating care homes. However, as of January 2022 only six trained facilitators remained active. Out of the 158 OSCaRS arranged, 96 took place with a total of 262 staff attending. There were three important aspects that emerged: the role, remit, and resources of NHS/SPC supporting OSCaRS; requirements within care homes for establishing OSCaRS; and, the practice‐based learning topics discussed at each OSCaRS.
Conclusion
Attempts to establish a team of NHS/SPC facilitators to lead OSCaRS highlights that end of life care education in care homes does not clearly fall within the contractual remit of either group or risks being missed due to more pressing priorities.
The outbreak of COVID-19 severely affected the achievement of the sustainable development goals. The American Hospital Association estimated an average loss of US52 billion per month to effectively manage COVID-19. This current study, therefore, sought to assess how risk management practices could moderate the relationship between supply chain risk and healthcare delivery, during the COVID-19 pandemic. A survey research design was adopted, with a quantitative research approach. The study adopted purposive sampling technique to select 216 respondents (senior/management members from procurement, stores/inventory, pharmacy, and administration) of the selected public hospitals. Structural Equation Modelling (SEM) was run in Amos (v.23), to estimate the path coefficients. The study concludes that supply chain risk had a significant negative effect on healthcare delivery among public hospitals in Ghana. Also, supply chain risk management had a significant positive effect on healthcare delivery among public hospitals in Ghana. Finally, it was concluded that risk management practices positively moderated the negative effect on supply chain risk on healthcare delivery.
Background:
To limit spread of COVID-19, many U.S. states adopted policies affecting access to older adults, including those in hospice. This study aimed to assess differences in hospice quality measures from before COVID-19 to during the COVID-19 pandemic and to evaluate for any correlation with these state policies.
Methods:
Scores (treatment preferences, believes/values, pain screening and assessment, dyspnea screening and treatment, bowel regimen, and a composite score) and Denominators (population being measured) for CMS's Hospice Item Set were compared using a paired t-test between a pre-pandemic period (01/2019-12/2019) and a period early in the pandemic in the U.S (7/2020-6/2021). Correlations between HIS composite scores from 9 months (7/2020-3/2021) and exposure to state policies for older adult protection, and covariates, were assessed by linear regression.
Results:
Data were collected on 3535 hospices. Seven of 8 HIS scores increased during the pandemic period. The remaining score was unchanged. All Denominators decreased. There was negative correlation between composite score (7/2020-3/2021) and exposure to state policies for protecting older adults. There were positive correlations with hospice age, for-profit status, 2019 average daily census, and 2019 composite score.
Conclusion:
Most HIS scores increased during this COVID-19 pandemic period; there was a small, significant negative correlation between the composite quality score and exposure to state policies for older adult protection. Further research is needed to better understand the effects of the COVID-19 pandemic on hospice care in the U.S. and globally, and future additions in quality reporting may facilitate real-time assessment during future public health emergencies.
Background: Faecal incontinence is an under-reported but debilitating health problem that affects people of all ages, and particularly older people aged 65 years and above living in care homes, many of whom have comorbidity such as dementia. Prevalence of faecal incontinence is high in the group, but the exact prevalence is unclear. Faecal incontinence can have significant negative impact, including low self-esteem, feeling stigmatised (and leading to social isolation), and sometimes death. In older people, faecal incontinence is not only the consequence of age-related anorectal deficits such as reduced anal sphincter pressure, but also cognitive decline, care home placement, diarrhoea, constipation and/or effects of polypharmacy. However, faecal incontinence remains a taboo subject because people with the condition are too embarrassed to discuss their symptoms with their family or health care workers. Health care workers, on the other hand, do not routinely broach the topic with patients perhaps because of therapeutic nihilistic attitudes (the belief that nothing can be done to help). In a care home, where most residents live with dementia, this nihilism can mean that residents are not assessed to find out why they are incontinent, thus resulting in the routine use of incontinence pads by care staff. Within the care homes, intimate care such as continence care, bathing and dressing of residents is mostly carried out by care assistants (and occasionally by registered nurses). The care home managers often avoid these messier dirty works because care work for the older people involve bodily dysfunctions and discharges such as blood, vomit, urine, faeces, illness, and death. Therefore, the emotional labour of the care homes’ care workers is an important skill that has therapeutic value to both the care staff and the residents experiencing faecal incontinence. The development of a theory-driven, context-dependent intervention to manage FI is needed for this population.
Methods: The overall aim of this thesis was to develop a context-dependent, complex intervention for the management of faecal incontinence in people living with dementia in care homes and test it for feasibility and potential efficacy. Underpinned by realist programme theories situated within the UK Medical Research Council framework for development and feasibility phases of intervention development, three steps of the framework were iteratively followed. A systematic review (PhD Paper 1) identified the burden and correlates of faecal incontinence among older people living in care homes, and potential modifiable risks factors. A Cochrane systematic review of interventions for faecal incontinence in care homes (PhD Paper 2) did not find any intervention that accounted for the care home residents’ characteristics or dementia. Therefore, some previously published realist programme theories were tested with care home stakeholders using realist evaluation approaches to develop an intervention for faecal incontinence that is context dependent. The intervention developed included toileting exercises (scheduled and prompted toileting), physical exercises (mobility and upper arms movement), conservative management (dietary and fluid intake, and review of polypharmacy) and staff education. Lastly, a pre/post feasibility study (nested in multiple case studies) was carried out in 16 care home residents from two care home units, all of whom had faecal incontinence at baseline and had dementia.
Results: Paper 1 included 23 studies and found the medians for reported prevalence of isolated faecal incontinence, double incontinence, and all types of faecal incontinence in care home residents as 3.5% [interquartile range (IQR) = 2.8%], 47.1% (IQR = 32.1%), and 42.8% (IQR = 21.1%), respectively. The Cochrane review (PhD Paper 2) included only four randomised controlled trials and found no clear evidence on what interventions work for this group. Stakeholder consultation was used to refine previous programme theories and then to develop an intervention. During feasibility testing of this intervention, the study was undermined by poor engagement by the care home staff. It was unclear what intervention had been carried out in one of the two units due to very poor documentation by the care staff. There was no overall significant difference in frequency of faecal incontinence episodes among the care home residents between baseline (four weeks prior to the intervention) and the last four weeks at the end of the 8-week intervention (mean and standard deviation (SD) of faecal incontinence episodes over the four weeks: 50.63 and 52. 94 (p=0.77). When the two care home units are compared, there were also no significant changes in the mean (SD) number of faecal incontinence episodes among the residents of Unit-1 and Unit-2 at baseline [52.50 (± 19.54) and 48.75 (± 20.31)], and four weeks to the end of the intervention [53.13 (± 23.33) and 52.75 (± 24.52)] respectively.
Conclusion: Although there were some changes in stool consistency among individual residents, the changes did not result in an overall reduction of faecal incontinence episodes in the participating care home units. In practice, unless regulatory bodies such as the Care Quality Commission include measures to reduce faecal incontinence (and as a safeguarding issue such as falls and pressure areas), or the care staff believe that incontinence among older people living with dementia in care homes can be ameliorated by intervention, the management of faecal incontinence is likely to remain as reactive measures by the care staff. Research in this context needs to be influenced by the care home managers who run the day-to-day activities of the care home, or risk implementation failure.
The United Kingdom (UK) as a whole has a long-established decades-old history as an early adopter of the concepts of Advance Care Planning (ACP), with significant integration into mainstream national policy and widespread implementation. The ACP term itself, its processes, means, inclusions and implementations vary considerably within the UK and between its four nations, but the overall impression is of a strongly uniting consensus on the positive impact, value and vital importance of ACP in enabling better care for people in the final years of life, and at earlier life stages. Though there is always more work to do and more lessons to learn, those of us who have watched this world-wide movement grow over recent decades, find the overall direction of travel of commitment to mainstreaming ACP in the UK to be inspiring and encouraging, and gives us hope for the future. Across the UK, there is much shared history, policy, objectives, and regulation related to ACP, and at the same time, many variations in approach, tone, emphasis and detail within and between the four nations of the UK. The 2022 Office of National Statistics reports that the four nations of the UK have a combined population of 67 million (England 56.5 million, Scotland 5.5 million, Wales 3.1 million, Northern Ireland 1.9 million). All four nations are prioritising ACP as part of national policy, aiming to deliver more personalised care, particularly but not exclusively for those nearing the end of life, with a wide variety of best practice examples. Here we describe some common areas and variations across the UK history, policy and legal perspectives, some examples of best practice, resources, and exciting developments across all four nations which, although not exhaustive and within the limitations of our brief, reflect the flavour of our shared commitment. We are most grateful to all the contributing authors.
Пандемия COVID‑19 стала угрозой для здоровья и жизни жителей учреждений стационарного ухода, так как бóльшая часть из них имела заболевания, вызывающие осложнения несовместимые с жизнью, а высокая плотность размещения способствовала быстрому распространению инфекции. Статья посвящена анализу моделей адаптации учреждений ухода к вызовам пандемии, таким как необходимость соблюдения мер социальной дистанции, незапланированные траты, снижение доступности медицинской помощи на местах, трансформация режима жизни и работы сотрудников, изоляция постояльцев и связанные с этим психологические сложности. Собрано 25 полуструктурированных интервью с руководителями частных и государственных стационарных учреждений в 12 субъектах РФ, а также пять интервью с представителями региональных органов власти и НКО. Анализ трансформации деятельности учреждений проведен с позиции концепции кризисного управления. Выделены модели адаптации, которые построены на базе трех основных характеристик, описывающих действия учреждений – типы агентности, контроль и управление организацией, инструменты решения проблем. На пересечении соответствующих осей определены пять моделей адаптации, которые подчеркивают высокую роль проактивной позиции и трансформирующего действия в преодолении вызовов пандемии. Развитие теории трансформирующей агентности связано с выделением трех типов агентности – опосредованной, индивидуальной и коллективной, в зависимости от того, кто является инициатором действия и осуществляет контроль – внешний агент или структура, отдельный агент (лидер) или коллектив соответственно. Понимание механизмов перестройки деятельности в условиях вынужденной адаптации к пандемии может стать основой для выстраивания социальной структуры таких организаций в условиях трансформации действующей системы социального обслуживания в России, начатого в 2018 г.
Objectives:
To explore care home managers' experiences of systems working with various organisations, including statutory, third sector and private, during the second wave of the COVID-19 pandemic from Sept 2020 to April 2021 DESIGN: An exploratory qualitative interview study using a systems theory approach focussing on the intersections of relationship interdependencies with other organisations.
Setting:
Conducted remotely with care home managers and key advisors who had worked since the start of the pandemic in/with care homes for older people across the East Midlands, UK.
Participants:
8 care home managers and 2 end-of-life advisors who participated during the second wave of the pandemic from Sept 2020. A total of 18 care home managers participated in the wider study from April 2020 to April 2021 RESULTS: Four organisational relationship interdependencies were identified: care practices, resources governance and wise working. Managers identified changes in their care practices as a shift towards the normalisation of care, with an emphasis on navigating pandemic restrictions to fit the context. Resources such as staffing, clinical reviews, pharmaceutical and equipment supplies were challenged, leading to a sense of precarity and tension. National polices and local guidance were fragmented, complex and disconnected from the reality of managing a care home. As a response a highly pragmatic reflexive style of management was identified which encompassed the use of mastery to navigate and in some cases circumvent official systems and mandates. Managers' experience of persistent and multiple setbacks were viewed as negative and confirmed their views that care homes as a sector ere marginalised by policy makers and statutory bodies.
Conclusions:
Interactions with various organisations shaped the ways in which care home managers responded to and sought to maximise residents and staff well-being. Some relationships dissolved over time, such as when local business and schools returned to normal obligations. Other newly formed relationships became more robust including those with other care home managers, families, and hospices. Significantly, most managers viewed their relationship with local authority and national statutory bodies as detrimental to effective working, leading to a sense of increased mistrust and ambiguity. Respect, recognition and meaningful collaboration with the care home sector should underpin any future attempts to introduce practice change in the sector.
COVID-19 has had unprecedented impacts on urban life on a global scale, representing the worst pandemic in living memory. In this introduction to the first of two parts of a Special Issue on urban public health emergencies, we suggest that the COVID-19 outbreak, and associated attempts to manage the pandemic, reproduced and ultimately exacerbated the social and spatial divides that striate the contemporary city. Here, we draw on evidence from the papers in Part 1 of the Special Issue to summarise the uneven urban geographies of COVID-19 evident at the inter- and intra-urban level, emphasising the particular vulnerabilities and risks borne by racialised workers who found it difficult to practise social distancing in either their home or working life. Considering the interplay of environmental, social and biological factors that conspired to create hotspots of COVID-19 infection, and the way these are connected to the racialised capitalism that underpins contemporary urban development, this introduction suggests that reflection on public health emergencies in the city is not just essential from a policy perspective but helps enrich theoretical debates on the nature of contemporary urbanisation in its ‘planetary’ guise.
Background: False negative results of SARS-CoV-2 nucleic acid detection pose threats to COVID-19 patients and medical workers alike.
Objective: To develop multivariate models to determine clinical characteristics that contribute to false negative results of SARS-CoV-2 nucleic acid detection, and use them to predict false negative results as well as time windows for testing positive.
Design: Retrospective Cohort Study (Ethics number of Tongji Hospital: No. IRBID: TJ-20200320)
Setting: A database of outpatients in Tongji Hospital (University Hospital) from 15 January 2020 to 19 February 2020.
Patients: 1,324 outpatients with COVID-19
Measurements: Clinical information on CT imaging reports, blood routine tests, and clinic symptoms were collected. A multivariate logistic regression was used to explain and predict false negative testing results of SARS-CoV-2 detection. A multivariate accelerated failure model was used to analyze and predict delayed time windows for testing positive.
Results: Of the 1,324 outpatients who diagnosed of COVID-19, 633 patients tested positive in their first SARS-CoV-2 nucleic acid test (47.8%), with a mean age of 51 years (SD=14.9); the rest, which had a mean age of 47 years (SD=15.4), tested negative in the first test. Ground glass opacity in a CT imaging report was associated with a lower chance of false negatives (aOR, 0.56), and reduced the length of time window for testing positive by 26%. Consolidation was associated with a higher chance of false negatives (aOR, 1.57), and extended the length of time window for testing positive by 44%. In blood routine tests, basophils (aOR, 1.28) and eosinophils (aOR, 1.29) were associated with a higher chance of false negatives, and were found to extend the time window for testing positive by 23% and 41%, respectively. Age and gender also affected the significantly.
Limitation: Data were generated in a large single-center study.
Conclusion: Testing outcome and positive window of SARS-CoV-2 detection for COVID-19 patients were associated with CT imaging results, blood routine tests, and clinical symptoms. Taking into account relevant information in CT imaging reports, blood routine tests, and clinical symptoms helped reduce a false negative testing outcome. The predictive AFT model, what we believe to be one of the first statistical models for predicting time window of SARS-CoV-2 detection, could help clinicians improve the accuracy and efficiency of the diagnosis, and hence, optimizes the timing of nucleic acid detection and alleviates the shortage of nucleic acid detection kits around the world.
Primary Funding Source: None.
Advance care planning (ACP), involving discussions between patients, families and healthcare professionals on future healthcare decisions, in advance of anticipated impairment in decision-making capacity, improves satisfaction and end-of-life care while respecting patient autonomy. It usually results in the creation of a written advanced care directive (ACD). This systematic review examines the impact of ACP on several outcomes (including symptom management, quality of care and healthcare utilisation) in older adults ( > 65 years) across all healthcare settings. Nine randomised controlled trials (RCTs) were identified by searches of the CINAHL, PubMed and Cochrane databases. A total of 3,646 older adults were included (range 72-88 years). Seven studies were conducted with community dwellers and the other two RCTs were conducted in nursing homes. Most studies did not implement a standardised ACD, or measure the impact on quality of end-of-life care or on the death and dying experience. All studies had some risk of bias, with most scoring poorly on the Oxford Quality Scale. While ACP interventions are well received by older adults and generally have positive effects on outcomes, this review highlights the need for well-designed RCTs that examine the economic impact of ACP and its effect on quality of care in nursing homes and other sectors.
UK care home residents are often poorly served by existing healthcare arrangements. Published descriptions of residents' health status have been limited by lack of detail and use of data derived from surveys drawn from social, rather than health, care records.
to describe in detail the health status and healthcare resource use of UK care home residentsDesign and setting: a 180-day longitudinal cohort study of 227 residents across 11 UK care homes, 5 nursing and 6 residential, selected to be representative for nursing/residential status and dementia registration.Method: Barthel index (BI), Mini-mental state examination (MMSE), Neuropsychiatric index (NPI), Mini-nutritional index (MNA), EuroQoL-5D (EQ-5D), 12-item General Health Questionnaire (GHQ-12), diagnoses and medications were recorded at baseline and BI, NPI, GHQ-12 and EQ-5D at follow-up after 180 days. National Health Service (NHS) resource use data were collected from databases of local healthcare providers.
out of a total of 323, 227 residents were recruited. The median BI was 9 (IQR: 2.5-15.5), MMSE 13 (4-22) and number of medications 8 (5.5-10.5). The mean number of diagnoses per resident was 6.2 (SD: 4). Thirty per cent were malnourished, 66% had evidence of behavioural disturbance. Residents had contact with the NHS on average once per month.
residents from both residential and nursing settings are dependent, cognitively impaired, have mild frequent behavioural symptoms, multimorbidity, polypharmacy and frequently use NHS resources. Effective care for such a cohort requires broad expertise from multiple disciplines delivered in a co-ordinated and managed way.
Background
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection can spread rapidly within skilled nursing facilities. After identification of a case of Covid-19 in a skilled nursing facility, we assessed transmission and evaluated the adequacy of symptom-based screening to identify infections in residents.
Methods
We conducted two serial point-prevalence surveys, 1 week apart, in which assenting residents of the facility underwent nasopharyngeal and oropharyngeal testing for SARS-CoV-2, including real-time reverse-transcriptase polymerase chain reaction (rRT-PCR), viral culture, and sequencing. Symptoms that had been present during the preceding 14 days were recorded. Asymptomatic residents who tested positive were reassessed 7 days later. Residents with SARS-CoV-2 infection were categorized as symptomatic with typical symptoms (fever, cough, or shortness of breath), symptomatic with only atypical symptoms, presymptomatic, or asymptomatic.
Results
Twenty-three days after the first positive test result in a resident at this skilled nursing facility, 57 of 89 residents (64%) tested positive for SARS-CoV-2. Among 76 residents who participated in point-prevalence surveys, 48 (63%) tested positive. Of these 48 residents, 27 (56%) were asymptomatic at the time of testing; 24 subsequently developed symptoms (median time to onset, 4 days). Samples from these 24 presymptomatic residents had a median rRT-PCR cycle threshold value of 23.1, and viable virus was recovered from 17 residents. As of April 3, of the 57 residents with SARS-CoV-2 infection, 11 had been hospitalized (3 in the intensive care unit) and 15 had died (mortality, 26%). Of the 34 residents whose specimens were sequenced, 27 (79%) had sequences that fit into two clusters with a difference of one nucleotide.
Conclusions
Rapid and widespread transmission of SARS-CoV-2 was demonstrated in this skilled nursing facility. More than half of residents with positive test results were asymptomatic at the time of testing and most likely contributed to transmission. Infection-control strategies focused solely on symptomatic residents were not sufficient to prevent transmission after SARS-CoV-2 introduction into this facility.
The pandemic of coronavirus disease of 2019 (COVID‐19) has global impact unseen since the 1918 worldwide influenza epidemic. All aspects of life have changed dramatically for now. The group most susceptible to COVID‐19 are older adults and those with chronic underlying chronic medical disorders. The population residing in long‐term care facilities generally are those who are both old and suffering from multiple comorbidities. In this article we provide information, insights, and recommended approaches to COVID‐19 in the long‐term facility setting. Since the situation is fluid and changing rapidly, readers are encouraged to access the resources cited in this article frequently.
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The health and well-being consequences of social isolation and loneliness in old age are increasingly being recognised. The purpose of this scoping review was to take stock of the available evidence and to highlight gaps and areas for future research. We searched nine databases for empirical papers investigating the impact of social isolation and/or loneliness on a range of health outcomes in old age. Our search, conducted between July and September 2013 yielded 11,736 articles, of which 128 items from 15 countries were included in the scoping review. Papers were reviewed, with a focus on the definitions and measurements of the two concepts, associations and causal mechanisms, differences across population groups and interventions. The evidence is largely US-focused, and loneliness is more researched than social isolation. A recent trend is the investigation of the comparative effects of social isolation and loneliness. Depression and cardiovascular health are the most often researched outcomes, followed by well-being. Almost all (but two) studies found a detrimental effect of isolation or loneliness on health. However, causal links and mechanisms are difficult to demonstrate, and further investigation is warranted. We found a paucity of research focusing on at-risk sub-groups and in the area of interventions. Future research should aim to better link the evidence on the risk factors for loneliness and social isolation and the evidence on their impact on health.
Nursing homes have an important role in the provision of care for dependent older people. Ensuring quality of care for residents in these settings is the subject of ongoing international debates. Poor quality care has been associated with inadequate nurse staffing and poor skills mix.
To review the evidence-base for the relationship between nursing home nurse staffing (proportion of RNs and support workers) and how this affects quality of care for nursing home residents and to explore methodological lessons for future international studies.
A systematic mapping review of the literature.
Published reports of studies of nurse staffing and quality in care homes.
Systematic search of OVID databases. A total of 13,411 references were identified. References were screened to meet inclusion criteria. 80 papers were subjected to full scrutiny and checked for additional references (n=3). Of the 83 papers, 50 were included. Paper selection and data extraction completed by one reviewer and checked by another. Content analysis was used to synthesise the findings to provide a systematic technique for categorising data and summarising findings.
A growing body of literature is examining the relationships between nurse staffing levels in nursing homes and quality of care provided to residents, but predominantly focuses on US nursing facilities. The studies present a wide range and varied mass of findings that use disparate methods for defining and measuring quality (42 measures of quality identified) and nurse staffing (52 ways of measuring staffing identified).
A focus on numbers of nurses fails to address the influence of other staffing factors (e.g., turnover, agency staff use), training and experience of staff, and care organisation and management. 'Quality' is a difficult concept to capture directly and the measures used focus mainly on 'clinical' outcomes for residents. This systematic mapping review highlights important methodological lessons for future international studies and makes an important contribution to the evidence-base of a relationship between the nursing workforce and quality of care and resident outcomes in nursing home settings.
Intramuscular (IM) influenza vaccines are about 50% effective in preventing respiratory illness among the elderly. The aim of this study was to identify factors associated with immune response to influenza vaccination among nursing home and community-residing elderly. 114 nursing home (NHE) and 62 community residing elderly (CE) were vaccinated with a commercial IM vaccine. Serum antibodies were evaluated by HIA, and the impact of subjects' clinical characteristics on seroconversion was determined. Factors that were associated with low seroconversion among NHE, included: type II diabetes [for B/Harbin: p=0.044, OR 0.12, (CI: 0.015-0.94)], and antibody titer prior to vaccination A/(H1N1): p=0.03, OR 2.38, (CI: 1.09-5.22); A/(H3N2): p=0.015, OR 2.68 (CI: 1.22-5.92), B/Harbin: p=0.057, OR 4.46 (CI: 0.96-20.85)]. Factors that were associated with lower seroconversion CE elderly, included older age [A/(H1N1): p=0.008, OR 0.846, (CI 0.75-0.96), B/Harbin: p=0.016, OR 0.812, (CI:0.69-0.96)], and antibody titer prior to vaccination A/(H1N1): p=0.029, OR 4.08, (CI: 1.16-14.37); A/(H3N2): p<0.0001, OR 11.495 (CI: 3.18-41.55)]. There was no significant difference in seroconversion between nursing home residing elderly and community elderly. We conclude that Type-II diabetes and antibody titer>1:40 prior to vaccination are associated with reduced response to the influenza vaccination in nursing home elderly.
Coronavirus: Millions More to be Eligible for Testing
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New Care Models: The Framework for enhanced health in care homes
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COVID-19: Managing the COVID Pandemic in Care Homes for Older People
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Care Homes Struggle with Wave of COVID-19 Cases
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