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Characteristics of U.S. Nursing Homes with COVID ‐19 Cases
Abstract
Background
COVID‐19 has been documented in a large share of nursing homes throughout the United States. This has led to high rates of mortality for residents. In order to understand how to prevent and mitigate future outbreaks, it is imperative that we understand which nursing homes are more likely to experience COVID‐19 cases.
Objective
To examine the characteristics of nursing homes with documented COVID‐19 cases in 30 states reporting individual facilities affected.
Design and setting
We constructed a database of nursing homes with verified COVID‐19 cases as of May 11, 2020 via correspondence with and publicly available reports from state departments of health. We linked this information to nursing home characteristics and used regression analysis to examine association between these characteristics and the likelihood of having a documented COVID‐19 case.
Results
Of 9,395 nursing homes in our sample, 2,949 (31.4%) had a documented COVID‐19 case. Larger facility size, urban location, greater percentage of African American residents, non‐chain status, and state were significantly (p<0.05) related to increased probability of having a COVID‐19 case. Five‐star rating, prior infection violation, Medicaid dependency, and ownership were not significantly related.
Conclusions
COVID‐19 cases in nursing homes are related to facility location and size and not traditional quality metrics such as star rating and prior infection control citations.
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... The organizational factors that consistently emerged and were supported by a substantial body of evidence with relation to outbreak include staffing levels [26,28,34,48,56,59,70,72,76,79,80,82,84,91,92,94,97,99,106,113], star/subset domains ratings [59,63,69,71,74,76,79,82,83,88,89,94,99,106,111,113], LTCFs with a higher proportion of racial and ethnic minorities [67,70,73,77,81,83,84,89,94,95,99,101,105,106,109], type of ownership (for-profit facilities) [6,24,26,30,37,57,63,72,79,82,84,89,97,113], LTCFs with higher Medicaid-insured residents [71][72][73]91,94,95,97], presence of infected staff [36,42,47,54,56,89,113], quality performance [31,34,43,71,106], and chain membership status [21,30,70,97]. Table S5 contains details about the organizational factors associated with COVID-19 outbreaks in LTCFs. ...
... The organizational factors that consistently emerged and were supported by a substantial body of evidence with relation to mortality include LTCF's racial and ethnic composition [2,63,67,70,75,81,83,85,89,95,96,103,109,110], for-profit and/or private ownership [2,24,30,56,63,83,87,98,102,104,113], nursing staffing levels [2,48,56,75,80,81,92,94,98,110], star rating and subdomains (inverse association) [63,74,81,87,88,98,111,113], infected staff [27,56,66,89,113], chain membership [33,70,75,102,104], quality performance [29,40,62,75]. Table S6 depicts detailed information about the impact of organizational factors on COVID-19-related death. ...
... The environmental factors frequently emerged and supported by a substantial body of evidence linked to outbreaks include a higher number of beds, occupancy rate [21,25,26,30,31,34,47,54,56,60,61,63,65,67,72,73,[82][83][84]91,94,97,106], presence of outbreaks in surrounding counties/communities [6,26,[29][30][31]37,38,60,69,79,80,84,91,93,99,104], high-density communities [21,29,56,67,73,106] socioeconomic status of the community, [24,64,77,84,97,106], the structural design of the rooms [21,25,26,104,113], the racial/ethnic composition of the community [63,70,84,113], the location of the LTCF [21,24,43,56], older design and facility age [30,31,56,83]. ...
This study aimed to identify the individual, organizational, and environmental factors which contributed to COVID-19-related outcomes in long-term care facilities (LTCFs). A systematic review was conducted to summarize and synthesize empirical studies using a multi-level analysis approach to address the identified influential factors. Five databases were searched on 23 May 2023. To be included in the review, studies had to be published in peer-reviewed journals or as grey literature containing relevant statistical data. The Joanna Briggs Institute critical appraisal tool was employed to assess the methodological quality of each article included in this study. Of 2137 citations identified after exclusions, 99 records met the inclusion criteria. The predominant individual, organizational, and environmental factors that were most frequently found associated with the COVID-19 outbreak comprised older age, higher dependency level; lower staffing levels and lower star and subset domain ratings for the facility; and occupancy metrics and co-occurrences of outbreaks in counties and communities where the LTCFs were located, respectively. The primary individual, organizational, and environmental factors frequently linked to COVID-19-related deaths comprised age, and male sex; higher percentages of racial and ethnic minorities in LTCFs, as well as ownership types (including private, for-profit, and chain membership); and higher occupancy metrics and LTCF’s size and bed capacity, respectively. Unfolding the risk factors collectively may mitigate the risk of outbreaks and pandemic-related mortality in LTCFs during future endemic and pandemics through developing and improving interventions that address those significant factors.
... High infection rates and mortality during the early months of the pandemic were a result of a multitude of factors; the pandemic was in an evolving state with ever-changing control guidance, limited availability of testing, limited staffing in facilities, and inadequate surveillance systems due to lack of infection prevention and control (IPC) systems. [1][2][3][4] Efforts were hampered by under-resourced facilities, inadequate supply of personal protective equipment (PPE), lack of sufficient environmental facility controls, and unclear policies and guidelines. [1][2][3][4] In early 2020, a survey of residents in 26 SNFs in Detroit revealed an attack rate of 44%, a hospitalization rate of 37%, and case fatality rate of 24%. 2 In this report, we provide information on effective intervention measures for SARS-CoV2 in SNFs. ...
... [1][2][3][4] Efforts were hampered by under-resourced facilities, inadequate supply of personal protective equipment (PPE), lack of sufficient environmental facility controls, and unclear policies and guidelines. [1][2][3][4] In early 2020, a survey of residents in 26 SNFs in Detroit revealed an attack rate of 44%, a hospitalization rate of 37%, and case fatality rate of 24%. 2 In this report, we provide information on effective intervention measures for SARS-CoV2 in SNFs. We present a stepwise bundled approach that is intended to serve as a model to prevent and control infection of emerging communicable diseases in the SNF population. ...
... In response to the March 2020 surge in COVID-19 cases among SNF residents, the Detroit Health Department (DHD), in collaboration with the Centers for Disease Control and Prevention (CDC), local government, academia, and healthcare partners, initiated IPC measures across Detroit SNFs until April 2021. [2][3][4][5][6] This included guidance on managing positive cases, isolation, and cohort isolation. A specialized team conducted onsite assessments, with biweekly testing that provided results within 24 hours. ...
An infection prevention bundle that consisted of the development of a response team, public–academic partnership, daily assessment, regular testing, isolation, and environmental controls was implemented in 26 skilled nursing facilities in Detroit, Michigan (March 2020–April 2021). This intervention was associated with sustained control of severe acute respiratory coronavirus virus 2 infection among residents and staff.
... Larger nursing home facilities or those who failed to pass quality assurance had more residential COVID-19 infections (Gmehlin et al., 2021;Lane et al., 2022;Yin et al., 2021). Also, those who were privately owned and had low mask usage were also associated with higher COVID-19 infection rates (Abrams et al., 2020;Figueroa et al., 2020;Simoni-Wastila et al., 2021;Yin et al., 2021). However, in contrast, larger size nursing homes often had better resourcing and higher quality ratings, which would minimize risk for COVID-19 infections (Figueroa et al., 2020;Gopal et al., 2021). ...
... Another correlated factor was that nursing homes with a higher percentage of African American residents were more reported to be likely to experience staff shortages and financial restrictions and have Medicaid-dependent residents (Travers et al., 2021). There were severe health disparities in COVID-19 prevalence and its related mortality during the pandemic (Abrams et al., 2020). ...
... Specifically, in many studies, larger facilities experienced a higher possibility of COVID-19 outbreaks and infections due to more employees and admissions (Gmehlin et al., 2021;Kosar & Rahman, 2021;Mattingly et al., 2021;Ryskina et al., 2021;Zimmerman et al., 2021). Inversely, smaller nursing home facilities experience fewer infections (Abrams et al., 2020). ...
Background: This mixed methods systemic review synthesizes the evidence about nursing home risks for COVID-19 infections. Methods: Four electronic databases (PubMed, Web of Science, Scopus, and Sage Journals Online) were searched between January 2020 and October 2022. Inclusion criteria were studies reported on nursing home COVID-19 infection risks by geography, demography, type of nursing home, staffing and resident’s health, and COVID-19 vaccination status. The Mixed Methods Appraisal Tool (MMAT) was used to assess the levels of evidence for quality, and a narrative synthesis for reporting the findings by theme. Results: Of 579 initial articles, 48 were included in the review. Findings suggest that highly populated counties and urban locations had a higher likelihood of COVID-19 infections. Larger nursing homes with a low percentage of fully vaccinated
residents also had increased risks for COVID-19 infections than smaller nursing homes. Residents with advanced age, of racial minority, and those with chronic illnesses were at higher risk for COVID-19 infections. Discussion and implications: Findings suggest that along with known risk factors for COVID-19 infections, geographic and resident demographics are also important preventive care considerations. Access to COVID-19 vaccinations for vulnerable residents should be a priority.
age, of racial minority, and those with chronic illnesses were at higher risk for COVID-19 infections. Discussion
and implications: Findings suggest that along with known risk factors for COVID-19 infections, geographic and
resident demographics are also important preventive care considerations. Access to COVID-19 vaccinations for
vulnerable residents should be a priority.
... This observation was corroborated by members of OMTs and RACHs, who recognised that larger homes, as well as those with complex layouts and shared rooms, often posed as barriers to establishing effective cohorting and infection control measures. These findings are consistent with existing research internationally and in Australia, which have similarly isolated home size and design as key contributors to higher outbreak risk [32,[43][44][45][46][47][48][49][50][51]. Furthermore, homes that had dementia residents or dementia-specific units were also associated with worse COVID-19 outcomes. ...
... In a similar vein, homes belonging to broader organisations that administered multiple homes had lower rates of COVID-19 compared to single standing homes. These findings are congruent with a large US study which found that 'chain' homes were less likely to have at least one COVID-19 case [45]. Homes administered by larger organisations also likely have greater capacity to centralise resources, such as PPE, testing, education and staff, across their sites, resulting in better resilience and capability to manage or prevent outbreaks. ...
Outbreaks of the novel respiratory viral disease, SARS-CoV-2 (COVID-19), have caused disproportionate morbidity and mortality for older people living in residential aged care homes. Between June 2021 and December 2022, the Delta and Omicron variants of COVID-19 were responsible for widespread outbreaks in homes across Western Sydney, New South Wales, Australia. To manage outbreaks in affected homes, a targeted response strategy was prepared and deployed in the form of outbreak management teams. This study utilised the Donabedian framework and a two-phase mixed methods design to evaluate the structures, processes and outcomes of the outbreak management teams at the level of the local health district. Phase 1 involved the descriptive analysis of outbreak data from Western Sydney aged care homes, created between June 2021 and December 2022. Phase 2 involved the completion of in-depth semi-structured interviews with 35 participants to explore the outbreak management team response from the perspective of its members and staff from residential aged care homes. Between June 2021 and December 2022, there were 281 outbreaks, 4113 resident cases, 346 hospitalisations and 127 deaths in residential aged care homes across Western Sydney. Structural factors that facilitated the outbreak management response and improved outcomes included smaller home sizes, the absence of shared rooms and bathrooms, adequate staffing and resources, suitable infrastructure, and the integration of the response with wider public health systems. Process facilitators included multi-disciplinary team membership, open communication channels, structured and streamlined procedures and roles, onsite infection control support and education, and long-term capability building. The lessons drawn from participants’ experiences aim to improve the outcomes and sustainability of current and future outbreak management strategies.
... Firstly, once COVID-19 entered a nursing home, it was difficult to minimize spread of the infection to other older adults and the staff. Secondly, facility characteristics seemed to play a role, both related to parttime and temporary staff, and to the architecture and physical environment (Abrams et al., 2020;Jacobsen et al., 2021;Sabatino and Harrington, 2021). ...
... Regarding infection control, the size of nursing homes has been found to be correlated with higher numbers of infected older adults. Large facilities were associated with a significantly higher incident of COVID-19 infections than smaller facilities in both North American (Abrams et al., 2020;Mathematica, 2020;Sabatino and Harrington, 2021) and Australian studies (Ibrahim et al., 2021). In particular, nursing homes that are both large and old have proved vulnerable to outbreaks of COVID-19 (Stall et al., 2020). ...
Aim
This position paper focuses on healthy ageing for the frailest and institutionalized older adults in the context of the recent pandemic. The paper aims to identify and discuss hindering and promoting factors for healthy ageing in this context, taking both health safety and a meaningful social life into account, in a pandemic situation and beyond.
Background
The recent COVID-19 pandemic has highlighted the vulnerability of frail older adults residing in long-term care institutions. This is a segment of the older population that does not seem to align well with the recent policy trend of healthy and active ageing. The need for healthy ageing in this population has been voiced by professionals and interest organizations alike, alluding to inadequate support systems during the pandemic, conditioned by both previous and newly emerging contextual factors. Supporting healthy ageing in older adults in nursing homes and other residential care settings calls for attending to meaningful social life as well as to disease control.
Methods
Findings and early conclusions leading up to the position paper were presented with peer discussions involving healthcare professionals and researchers at two joint EFPC PRIMORE workshops 2021 and 2022, as well as other international research seminars on long-term care. The following aspects of long-term care and COVID-19 were systematically discussed in those events, with reference to relevant research literature: 1. Long-term care policies, 2. pre-COVID state of long-term care facilities and vulnerability to the pandemic, 3. factors influencing the extent of spread of infection in long-term care facilities, and 4. the challenge of balancing between strict measures for infection control and maintaining a meaningful social life for residents and their significant others.
Findings
A policy shift towards ageing at home and supporting the healthiest of older adults seems to have had unwarranted effects both for frail older adults, their significant others, and professional care staff attending to their needs. Resulting insufficient investment in primary health care staff and in the built environment for frail older adults in nursing homes were detrimental both for the older adults living in nursing homes, their significant others, and staff. More investment in staff and in physical surroundings might improve the quality of care and the social life of older adults in nursing homes in a non-pandemic situation and be a resource for primary health care staff ensuring both protection from health hazards and a meaningful social life for frail older adults in a pandemic or epidemic situation. As for investing in the physical surroundings, smaller nursing homes are advantageous, with singular resident rooms and for developing out-and indoor spaces for socializing and for meeting with families and other visitors. Regarding investment in staff, there is a documented need for educated staff in full-time positions. Use of part-time or temporary staff should be limited.
... In light of the ongoing prevalence of COVID-19 and the potential emergence of new variants or other contagious diseases capable of triggering future outbreaks, it is crucial to comprehend the connection between nursing home characteristics, particularly those within their control, and the incidence of COVID-19. Several studies have explored the link between COVID-19 infections and/or mortality rates and nursing home quality (Abrams et al. 2020;Figueroa et al. 2020;He et al. 2020;Li et al. 2020a, b;Bowblis and Applebaum 2020) as well as nurse staffing levels (Li et al. 2020a, b;Gorges and Konetzka 2020;Harrington et al. 2020). However, these studies produced mixed findings, partly due to their early execution in the pandemic, limiting their applicability to different states and varying time periods with distinct COVID-19 infection rates. ...
... In addition, COVID related variables reflect how well a facility manages infection outbreaks-a critical component of healthcare delivery in high-risk environments like nursing homes. Facilities that effectively manage these aspects are likely to be more efficient in their overall operations, thus these variables serve as key indicators of preparedness and response effectiveness (Abrams et al. 2020). ...
Assessing the performance of nursing homes during pandemics such as COVID-19 is critically important, particularly in light of an aging global population and the heightened need for long-term care. This urgency has led to a heightened global emphasis on optimizing nursing home resources. To address this objective, we developed a hybrid method that integrates Data Envelopment Analysis (DEA) with Machine Learning (ML) techniques to improve and predict the performance of these facilities. We applied this innovative approach to over 500 nursing homes across Pennsylvania. Given the complex regulatory and funding environments, with significant variations across regions, we performed a comparative efficiency analysis using DEA across three Pennsylvania regions: West, East, and Central. Once we identified the sources of inefficiency, we suggested actionable solutions to improve these facilities. We further utilized ML techniques to predict efficiency of nursing homes. Our results showed that the number of citations, complaints, COVID-19 cases, and COVID-19 related deaths as critical factors affecting nursing home efficiency. Comprehensive approaches to address these factors include refining staff training programs, adopting regular feedback mechanisms, enhancing regulatory compliance, strengthening infection control practices, and managing resources effectively. These measures are vital for improving the quality of care and operational efficiency in nursing homes.
... Covariates included nursing home characteristics such as nursing home location, percentage of residents who are Medicaid recipients, and ownership status according to the CMS. 3 Ownership status was categorized as follows: (1) corporate, for profit; (2) corporate, not for profit; ...
... Nursing home staffing levels and facility size have been found to be strongly associated with their COVID-19 outcomes. 3,11,32 Thus, the regression model for staff cases was also adjusted for the number of nursing staff (full time equivalent [FTE]), and the model for resident cases was adjusted for nursing staff ratio and facility bed count. We did not have access to the number of individual nursing staff members in our data; hence, a measure of nursing staff FTE derived from the staffing hours per patient day and resident count was used as a proxy. ...
Objective
The cross-sectional study evaluates if the pre-pandemic work environments in nursing homes predict COVID-19 cases among residents and staff, accounting for other factors.
Method
Leveraging data from a survey of California and Ohio nursing homes (n = 340), we examined if Workplace Integrated Safety and Health domains - Leadership, Participation, and Comprehensive and Collaborative strategies predicted cumulative COVID-19 cases among nursing home residents and staff.
Results
In Ohio, a 1-unit increase in Leadership score was associated with 2 fewer staff cases and 4 fewer resident cases. A 1-unit increase in Comprehensive and Collaborative Strategies score in California showed an average marginal effect of approximately 1 less staff case and 2 fewer resident cases.
Conclusion
These findings suggest that leadership commitment and inter-department collaboration to prioritize worker safety, may have protected against COVID-19 cases in nursing homes.
... The highest outbreak rate (85.7%) occurred in long-term care health facilities; many of these facilities had a relatively large capacity. In the United States, the incidence of COVID-19 was related to the location and size of the facility [25]. Aalto et al. compared ...
... The highest outbreak rate (85.7%) occurred in long-term care health facilities; many of these facilities had a relatively large capacity. In the United States, the incidence of COVID-19 was related to the location and size of the facility [25]. Aalto et al. compared the prevalence of COVID-19 and associated mortality of individuals living in nursing homes in 14 countries and observed a significant correlation between the average nursing home size and death attributable to COVID-19 [26]. ...
There are several types of facilities for elderly individuals in Japan. Infection control efforts, such as care provision and medical care access, differ according to the type of facility. Elderly individuals at these facilities who were infected with coronavirus disease 2019 (COVID-19) experienced severe illness and mortality. This study aimed to determine the characteristics of concentrated COVID-19 outbreaks that occurred in nursing homes and care facilities in Suita City. During this study, twenty-five elderly facilities in Suita City with a capacity of 40 or more individuals where an outbreak occurred during the sixth or seventh wave of infection were included. We investigated whether there was a difference in the COVID-19 incidence and the percentage of positive cases according to the type of facility. We also investigated the relationship between the facility capacity and positive case rate and that between the number of positive cases and outbreak duration. The incidence rate of COVID-19 was significantly different according to the facility type (p < 0.001). No association was found between the facility capacity and positive case rate. The outbreak duration increased as the number of positive cases increased (p = 0.004).
... In order to understand the differences between these NH, a number of studies, mainly from the United States and Canada, studied risk factors related to the residential care facility and proxy variables for the surrounding regional infection incidence. Risk factors that are commonly (but not consistently) related to introduction of SARS-CoV-2 in the NH, and/or transmission rates and/or higher prevalences in these studies are higher number of beds [7,[10][11][12], higher incidence of COVID-19 in the region or county [7,8,11,13,14], larger community population size [8,10,13], higher crowding or density of residents within NH [8,13] and lower NH quality ratings [14]. Generally, a lot of outbreaks in NH have been attributed to inadequate implementation of infection control [15], test strategy, early diagnosis and contact restriction [16]. ...
... In order to understand the differences between these NH, a number of studies, mainly from the United States and Canada, studied risk factors related to the residential care facility and proxy variables for the surrounding regional infection incidence. Risk factors that are commonly (but not consistently) related to introduction of SARS-CoV-2 in the NH, and/or transmission rates and/or higher prevalences in these studies are higher number of beds [7,[10][11][12], higher incidence of COVID-19 in the region or county [7,8,11,13,14], larger community population size [8,10,13], higher crowding or density of residents within NH [8,13] and lower NH quality ratings [14]. Generally, a lot of outbreaks in NH have been attributed to inadequate implementation of infection control [15], test strategy, early diagnosis and contact restriction [16]. ...
In a previous study in Belgian nursing homes (NH) during the first wave of the COVID-19 pandemic, we found a SARS-CoV-2 seroprevalence of 17% with a large variability (0–45%) between NH. The current exploratory study aimed to identify nursing home-specific risk factors for high SARS-CoV-2 seroprevalence. Between October 19th, 2020 and November 13th, 2020, during the second COVID-19 wave in Belgium, capillary blood was collected on dried blood spots from 60 residents and staff in each of the 20 participating NH in Flanders and Brussels. The presence of SARS-CoV-2-specific IgG antibodies was assessed by ELISA. Risk factors were evaluated using a questionnaire, filled in by the director or manager of the NH. Assessed risk factors comprised community-related factors, resident-related factors, management and performance features as well as building-related aspects. The relation between risk factors and seroprevalence was assessed by applying random forest modelling, generalized linear models and Bayesian linear regression. The present analyses showed that the prevalence of residents with dementia, the scarcity of personal protective equipment (surgical masks, FFP2 masks, glasses and face shields), and inadequate PCR test capacity were related to a higher seroprevalence. Generally, our study put forward that the various aspects of infection prevention in NH require more attention and investment. This exploratory study suggests that the ratio of residents with dementia, the availability of test capacity and personal protective equipment may have played a role in the SARS-CoV-2 seroprevalence of NH, after the first wave. It underscores the importance of the availability of PPE and education in infection prevention. Moreover, investments may also yield benefits in the prevention of other respiratory infections (such as influenza).
... More than any event in recent memory, the COVID pandemic compelled people around the world to confront how decisions made at the top levels of institutions led to devastating consequences for citizens and exacerbated pre-existing inequalities. Elders, the mentally and physically disabled, and members of historically marginalized groups contracted and died of COVID at disproportionately high rates (Abrams et al. 2020, Williamson et al. 2020). In addition, people who typically experience a great deal of privilege were forced to reckon with the fact that the systematic failure of structure could impact them directly in previously unimagined ways. ...
More than any event in recent memory, the COVID pandemic compelled people worldwide to confront how decisions made at the top levels of institutions led to devastating consequences and exacerbated inequalities. People who typically experience a great deal of societal privilege were forced to reckon that the systematic failure of structure could impact them directly in previously unimagined ways. This article explores how COVID was both a gift and a curse for those who live at the intersection of invisible disabilities and other social identities. For individuals with class privilege and invisible disabilities, COVID required employers to accommodate work-from-home and flexible scheduling options on a scale previously unavailable to most workers. While this may have supported productivity for some individuals, those gains were not available to all. Given that we do not yet know how many survivors of COVID will experience long-term side effects, societies will continue to wrestle with supporting large numbers of workers who find themselves in the disabled category for the first time. This article examines how invisible disability intersects with existing social statuses in a way that holds up a mirror to society more broadly, forcing it to confront its able-bodied privilege.
... The present study highlights the adverse effects of shared staff in relation to the transmission of infectious diseases, especially during an outbreak in a nursing home with a high occupancy rate (see Sect. "Infection and mortality hazard ratios"). Addressing issues related to inadequate wages and the absence of financial incentives is the first step in enhancing the recruitment and retention of employees [1,32]. This can mitigate the prevalent staff shortages in nursing homes and reduce the occurrence of staff members working across multiple facilities. ...
Infectious diseases can propagate between nursing homes through asymptomatic staff members who are employed at multiple facilities. However, the transmission dynamics of infections, both within individual nursing homes and across facilities, has been less investigated. To fill this gap, we developed an agent-based model of two nursing homes extendible to a network of n nursing homes connected with different percentages of shared staff. Focusing on the outbreaks of COVID-19 in U.S. nursing homes, we calibrated the model according to the COVID-19 prevalence data and estimated levels of shared staff for each State. The model simulations indicate that reducing the percentage of shared staff below 5% plays a significant role in controlling the spread of infection from one nursing home to another through personal protective equipment usage, rapid testing, and vaccination. As the percentage of shared staff increases to more than 30%, these measures become less effective, and the mean prevalence of infection reaches a steady state in both nursing homes. The hazard ratios for infection and mortality indicate that nursing homes with higher occupancy rates are more significantly affected by increased staff-sharing percentages. In conclusion, the burden of infection significantly increases with greater staff sharing between nursing homes, particularly in high-occupancy facilities, where transmission dynamics are amplified due to greater resident density and staff interactions.
... Long-term care facilities (LTCFs) experienced severe impacts during the global COVID-19 pandemic [1][2][3][4]. The residents of LTCFs, typically elderly individuals, often contend with underlying medical conditions that heighten their susceptibility to infections [5][6][7]. The elevated prevalence of functional impairment necessitates frequent close physical contact between residents and healthcare workers (HCWs). ...
Introduction
Residents and healthcare workers in long-term care facilities are at increased risk of infection during respiratory epidemics. Proper compliance with infection prevention and control measures is therefore paramount. Our study aimed to uncover and understand factors influencing compliance with personal protective equipment guidelines among healthcare workers in long-term care facilities in Finland during the COVID-19 pandemic.
Methodology
We conducted a mixed-methods study by using the methods and framework of behavioral insights, specifically the Theoretical Domains Framework. Data were collected through a web-based survey and qualitative in-depth telephone interviews using convenience sampling. Participants for the anonymous survey were recruited through regional infection control experts during May-June 2022. Survey data were analyzed by using logistic regression; difficulties in complying with personal protective equipment guidelines were the outcome. Volunteer survey respondents were interviewed, and the data were analyzed thematically.
Results
A total of 373 healthcare workers participated in the survey; 56% had received personal protective equipment training. Two domains of the Theoretical Domains Framework were associated with experiencing difficulties in compliance with the personal protective barriers: organization linked with insufficient human resources and the presence of negative emotions linked with stress. Twenty-two healthcare workers participated in the interviews which resulted in the identification of several themes, suggesting how insufficient human resources and negative emotions affected personal protective equipment use and the type of coping mechanism that healthcare workers used to overcome these barriers.
Conclusions
The behavioral insights derived from our study can contribute to enhanced healthcare worker compliance with personal protective equipment use. These findings underscore the importance of access to training, interventions addressing stress and ensuring sufficient workforce.
... 2 During the COVID-19 pandemic, NH residents were 23 times more likely to die of COVID-19 than communitydwelling older adults. 3 NH deaths due to COVID-19 have received much scientific and media attention, but there has been less focus on disparities among NHs. Health disparities are measurable differences among population groups resulting from racial, social, economic, ethnic, geographic, or other factors. ...
Introduction: Disasters have disproportionately impacted nursing home (NH) residents. COVID-19 impacted NH more so than the community-dwelling population, but there was much variation in mortality rates among NH residents. These disparities have been studied, but place-based disparities have received less attention. Place-based disparities are differences in health due to physical location, including factors like rurality, local socioeconomic conditions, and the physical environment.
Methods: We searched three databases for peer-reviewed studies of place-based factors associated with mortality in U.S. NHs during the COVID-19 pandemic, ending in January 2024. Data were organized using the National Institute on Minority Health and Health Disparities research framework.
Results: We identified 27 articles that included individual, interpersonal, community, and societal place-based factors associated with mortality during the pandemic. Differences in mortality were related to local community socioeconomic factors, staff neighborhood socioeconomic factors, urbanity, community viral spread, and state-level factors, including political leaning and social distancing policies. Rurality was associated with lower mortality but was also associated with racial disparities.
Discussion: Place-based disparities at the individual, organizational, community, and societal levels were identified. Rurality and local COVID-19 spread were the most commonly studied place-based factors associated with NH deaths during the pandemic. Neighborhood factors may be most impactful through the impact on NH staff. Racial disparities were linked with location, highlighting the effects of historical systemic racism on NHs. Policies to protect NH residents during disasters must be sensitive to local characteristics.
... Some participants in our study highlighted that the proximity of residents to each other made it difficult to comply with physical distancing requirements and created difficulties for appropriate IPC practices. Other reports in the literature present similar issues related to staff movement between different sections of these facilities, having one large building instead of small unit facilities, availability of communal areas for residents, poor ventilation, inappropriate facilities for isolation, and overcrowding [38][39][40][41][42]. In pre-COVID-19 times in Ireland, the emphasis was placed on creating a homely environment for residents that made the nursing homes cosy and pleasant. ...
Background
A review of key learnings from the response to the COVID-19 pandemic in nursing homes in Ireland can inform planning for future pandemics. This study describes barriers and facilitators contributing to COVID-19 outbreak management from the perspective of frontline teams.
Methods
A qualitative study involving ten online focus group meetings was conducted. Data was collected between April and June 2023. The focus group discussions explored the views, perceptions and experiences of COVID-19 Response Team (CRT) members, clinical/public health experts who worked with them, and care professionals who worked in frontline managerial roles during the pandemic. All nine Community Healthcare Organisations and six Public Health Areas in Ireland were represented. Inductive reflexive thematic analysis was carried out using NVivo Pro 20.
Results
In total, 54 staff members participated in focus group meetings. Five themes were developed from a thematic analysis that covered topics related to (1) infection prevention and control challenges and response to the pandemic, (2) social model of care and the built environment of nursing homes, (3) nursing home staffing, (4) leadership and staff practices, and (5) support and guidance received during the pandemic.
Conclusions
The response to the COVID-19 pandemic has resulted in a steep learning curve, internationally and in Ireland. Preparing better for future pandemics not only requires changes to infection control and outbreak response but also to the organisation and operation of nursing homes. There is a great need to strengthen the long-term care sector’s regulations and support around staffing levels, nursing home facilities, governance, use of technology, infection prevention and control, contingency planning, and maintaining collaborative relationships and strategic leadership. Key findings and recommendations from the Irish example can be used to improve the quality of care and service delivery at local, national, and policy levels and improve preparedness for future pandemics, in Ireland and internationally.
... By occupation, prevalences were high among several Healthcare Practitioner and Technical and Healthcare Support occupations. Healthcare workers faced outbreaks in nursing homes33,34 and most continued to work in person. Healthcare workers also had elevated aPRs for Long COVID, despite, for example, more than 70% of hospital workers being up to date on COVID-19 vaccination in a survey in the spring of 2022.35 ...
Background
Workers in healthcare and other essential occupations had elevated risks for COVID‐19 infection early in the pandemic. No survey of U.S. workers to date has comprehensively assessed the prevalence of both COVID‐19 and Long COVID across industries and occupations (I&O) at a detailed level.
Methods
Behavioral Risk Factor Surveillance System data for 2022 from 39 states, Guam, and the U.S. Virgin Islands were used to estimate prevalence of self‐reported history of COVID‐19 and Long COVID, as well as the prevalence of Long COVID among those reporting prior COVID‐19, by broad and detailed I&O. Adjusted prevalence ratios were used to compare outcome prevalence in each I&O to prevalence among all other workers combined.
Results
By broad I&O, workers in healthcare, protective services, and education had elevated prevalences of COVID‐19. The prevalence of Long COVID was elevated in healthcare and protective service but not education workers. Detailed I&O with significantly elevated prevalences of COVID‐19 but not Long COVID included Dairy Product Manufacturing industry workers and subsets of mining workers. Both COVID‐19 and Long COVID were elevated among bartenders/drinking places and personal care and appearance workers. The prevalence of Long COVID was elevated among farmworkers who reported having had COVID‐19.
Conclusions
Industries and occupations with elevated levels of COVID‐19 or Long COVID in this study may warrant increased measures to prevent transmission of airborne respiratory viruses. Accommodations are a key component for supporting workers in all workplaces. This new information about the distribution of Long COVID by I&O suggests where employer understanding and implementation of tailored workplace supports and accommodations are most needed to support continued employment of affected workers.
... In this setting, some of the factors that contributed to the expansion and lethality of the virus were community living, lack of personal protective equipment for workers, restrictive access to the SARS-CoV-2 polymerase test reaction (PCR) test, the resident's health vulnerability due to comorbidities or geriatric syndromes (i.e. frailty, dependence, dementia), and their low immune response [2]. In this regard, the initial interaction between the virus and the host respiratory mucosa triggers a cascade of innate and adaptive immune responses through diverse mechanisms [3,4]. ...
Background
The function of mucosal secretory IgA (SIgA) seems to be paramount in the immune response against SARS-CoV-2 however, there are few studies addressing this issue specifically in the institutionalized older population. This study aims to determine the levels of secretory IgA against the S1 domain of the SARS-CoV-2 spike (SIgA-S1) in older people living in nursing homes (NH) and to investigate the differences in baseline characteristics, severity of COVID-19, duration of symptoms, 30-day mortality, and reinfection according to the levels of SIgA-S1.
Methods
In this multicentre longitudinal study, conducted in two NHs attended in coordination with a hospital-based Geriatric team, 305 residents (87.3 years, 74.4% female) were included. A massive collection of nasopharyngeal samples was carried out after the first wave of COVID-19 in May 2020 and an ELISA analysis of SIgA-S1 was performed on frozen samples in May 2023. Values of SIgA-S1 ≥ 57.6 U/mL (“cut-off point”) were considered “induced”. Resident medical records were reviewed to assess symptoms, comprehensive geriatric assessment (CGA), reinfection, and overall 30-day mortality.
Results
At the time of sample collection, 274 residents (89.8%) exhibited “induced” SIgA-S1 levels (≥ 57.6 U/mL), 46 (15.1%) tested positive for PCR SARS-CoV-2, and 170 (57%) had experienced COVID-19 symptoms. “Induced” SIgA-S1 patients were more likely to be symptomatic (60.3% vs. 29%; p < 0.001) and exhibited upper respiratory tract symptoms more frequently (25.1% vs. 6.5%; p = 0.020) compared to “non-induced” patients. Patients with severe disease and duration of symptoms > 10 days had higher levels of SIgA-S1 than those with mild disease (252 vs.192.6 U/mL; p = 0.012) or duration ≤ 10 days (270.5 vs. 208.1 U/mL; p = 0.043), respectively. No significant differences were observed in age, sex, CGA, duration of symptoms, disease severity, overall 30-day-mortality, or reinfection between “induced” and “non-induced” residents.
Conclusions
Levels of SIgA-S1 are associated with the duration and type of COVID-19 symptoms, along with the severity of infection. While these findings shed light on the knowledge of SIgA-S1, further interdisciplinary studies are warranted to better understand the immune response to SARS-CoV-2 infection.
... 16 Prior research has shown that individual-level patient characteristics, such as membership in marginalized groups that experience structural racism and ageism, contributed to poor health outcomes during the COVID-19 pandemic in SNFs. 17 More research needs to be done to understand the role of individual risk factors in addition to the neighborhood risk factors that may contribute to multidrugresistant organism (MDRO) transmission. ...
Background:Candida auris is an emerging fungal pathogen increasingly recognized as a cause of healthcare-associated infections including outbreaks.
Methods:We performed a mixed-methods study to characterize the emergence of C. auris in the state of Maryland from 2019 to 2022, with a focus on socioeconomic vulnerability and infection prevention opportunities. We describe all case-patients of C. auris among Maryland residents from June 2019 to December 2021 detected by Maryland Department of Health. We compared neighborhood socioeconomic characteristics of skilled nursing facilities (SNFs) with and without C. auris transmission outbreaks using both the social vulnerability index (SVI) and the area deprivation index (ADI). The SVI and the ADI were obtained at the state level, with an SVI ≥ 75th percentile or an ADI ≥ 80th percentile considered severely disadvantaged. We summarized infection control assessments at SNFs with outbreaks using a qualitative analysis.
Results:A total of 140 individuals tested positive for C. auris in the study period in Maryland; 46 (33%) had a positive clinical culture. Sixty (43%) were associated with a SNF, 37 (26%) were ventilated, and 87 (62%) had a documented wound. Separate facility-level neighborhood analysis showed SNFs with likely C. auris transmission were disproportionately located in neighborhoods in the top quartile of deprivation by the SVI, characterized by low socioeconomic status and high proportion of racial/ethnic minorities. Multiple infection control deficiencies were noted at these SNFs.
Conclusion:Neighborhood socioeconomic vulnerability may contribute to the emergence and transmission of C. auris in a community.
... Also, living in an urban area was a stronger predictor of mortality in people residing in LTC facilities than in non-institutionalized. These results are in line with other publications [36,37]. This could be related to factors associated with LTC facilities characteristics, such as private ownership [38], which may have led to excess risk in the urban environment. ...
Background
The objective of our study is to analyze the health care received by older adults with COVID-19 according to their place of residence (whether or not they live in a long-term care [LTC] facility) and to find out the effect of health care on mortality.
Methods
Retrospective cohort study based in Aragón (Spain) from March 2020 to March 2021 in patients aged 65 years or older with a confirmed COVID-19 infection. The population was classified according to their place of residence (living in a LTC or not). A propensity score was used to match individuals by sex and age. The effect of living in a LTC facility on healthcare delivery and mortality was conducted using adjusted multivariate models. Varimp was used to estimate the best predictors of mortality for both groups.
Results
Healthcare services utilization varied depending on whether the patients lived in a LTC facility or not. The time to diagnosis was shorter in institutionalized patients, but the time to hospital admission was longer. Length of hospital stays, risk of ICU admission and 30-day mortality were also different and remained statistically significant in the adjusted models. The variables that were more important in the association between healthcare utilization and mortality were those associated with greater severity of COVID-19.
Conclusions
There were differences in health care for older adults diagnosed with COVID-19 according to their place of residence. There is a need to strengthen collaboration between professionals in LTC centers and health services to provide equitable health care.
... 8 Furthermore, the first outbreak of COVID-19 primarily affected older adults. Internationally, case fatality rates among Nursing Home (NH) residents ranged from 26% to 34%, [12][13][14] and NH deaths accounted for 21% to 50% of all COVID-19 fatalities. 15 As specifically concerns Italy, by the end of April 2020 25.3% of the infections and 55.3% of the deaths occurred among citizens over 80. 16 This high mortality rate especially concerned residents in long-term care facilities, and it had a significant impact on medical staff, in terms of increased workload, stress, and emotional burden. ...
Background. As limited evidence is available on health professionals’ experience during the post-pandemic period, the interplay between job satisfaction components, mental distress, and well-being was investigated among workers of an Italian geriatric institution.
Methods. In Spring 2022, 205 participants (females =75.6%), primarily healthcare assistants (36.6%), nurses (16.6%), and rehabilitation professionals (14.1%), completed the General Health Questionnaire (GHQ), the Mental Health Continuum-Short Form (MHC-SF), and the Job Satisfaction Questionnaire. Data analyses comprised Multiple Regressions, Relative Weight Analyses, and ANOVA.
Findings. Satisfaction with working conditions and leadership exhibited negative associations with distress, while satisfaction with patients, colleagues, results, and leadership were positively correlated with well-being. Participants with high well-being levels scored significantly lower across mental distress dimensions than participants reporting poor well-being levels.
Conclusions. Results showed that specific job satisfaction components relate differently to distress and well-being, suggesting the need for implementing organizational resources, psychological support, and interprofessional collaboration in healthcare services.
... Facility factors such as occupancy, incidence rates in staff, resident/staff ratio, large size, and building condition impact the risk of infection. [5][6][7][8][9] Resident characteristics such as frailty, comorbidities, and level of contact with staff and caregivers may also increase the risk of infection. Wandering behavior, however, has not been clearly linked to SARS-CoV-2 infection. ...
... Therefore, the findings on smaller number of residents to prevent and control infection seem to be more relevant to discuss in relation to facility size rather than population density. A growing body of evidence suggests that larger care homes with a larger number of residents are associated with increased risks of COVID-19 outbreaks (Abrams et al., 2020;Morciano et al., 2021;Shallcross et al., 2021;Smittskydd Stockholm., 2020;Stall et al., 2020). Yet larger facilities do not necessarily face large outbreaks, possibly thanks to greater financial resources allowing for purpose-built facilities and more staff resulting in greater ability to isolate infected sections and less cross-over of staff between residents (Halloran et al., 2020;Stall et al., 2020). ...
Aim
To examine the perceptions of managers of elder care homes on the impact of facility and staff characteristics on infection control of COVID‐19.
Design
Case study.
Methods
Six purposively sampled care home managers in the city of Stockholm were interviewed. Through content analysis, three categories and nine subcategories were identified.
Results
According to the interviewed care home managers, a home‐like environment that allows for isolation of residents and possibilities for staff to get changed and store personal protective equipment outside each resident's room was considered ideal. Experienced employees were reported as invaluable when facing an infectious outbreak. A mix of permanent and temporary staff was considered essential although some thought that temporary staff who work in multiple care homes might negatively influence the spread of infection. Language barriers among staff were considered an obstacle when trying to disseminate information.
... For example, NHs with more beds were associated with more PPE shortages. This finding suggests that larger facilities with more residents and staff potentially faced higher risk of COVID-19 transmission, 44 leading to an increased demand for PPE. Having any staff COVID-19 infection, but not staffing level, was associated with PPE shortages. ...
... Portugal destaca-se no conjunto dos países da Europa como sendo um dos mais envelhecidos (envelhecimento da população =182,1) jovens (Pordata, 2023), sendo também referenciado como um país híper envelhecido (Luz, 2019). O envelhecimento populacional é um preditor de vulnerabilidades e da ocorrência de situações de dependência fundamentalmente para pessoas com idade avançada (Abrams, Loomer,Gandhi, & Grabowski, 2020), revertendo desafios para as políticas públicas no que concerne ao desenvolvimento de respostas institucionais adequadas à prestação de cuidados de saúde e sociais (Batista & Perista, 2018). ...
O cuidado a pessoas idosas enquadrado em estruturas residenciais (i.e., ERPI) tem vindo a revelar-se crescente dado o avolumar de pessoas que alcançam idades cada vez mais longevas sendo estas acompanhadas de múltiplas vulnerabilidades. Ainda que a importância do cuidado seja indiscutível, o conhecimento do valor social que o mesmo representa permanece por explorar, sobretudo numa vertente não económica. Este estudo pretendeu compreender qual a perspetiva dos participantes sobre o conceito de valor social do cuidado a pessoas idosas institucionalizadas. Foi realizado um estudo exploratório de natureza qualitativa através da aplicação de um questionário online a amostra não probabilística por conveniência abrangendo de 28 participantes (estudantes e profissionais da área social e da saúde). O questionário, elaborado e aplicado através da plataforma Google forms, e integra numa primeira parte elementos para a caraterização sociodemográfica dos participantes e numa segunda parte, uma questão aberta relativa à perspetiva sobre o conceito de valor social do cuidado em contexto residencial. O estudo revelou que a perspetiva do conceito de valor social do cuidado dos participantes está ligada à salvaguarda dos direitos da pessoa idosa, promoção da qualidade de vida, forma como o cuidado é prestado, contexto organizacional e reconhecimento social. Os resultados obtidos acentuam a prioridade da implementação de práticas humanizadas nas organizações que cuidam de pessoas idosas, sugerindo que aquelas são o elemento central que acresce valor social aos cuidados.
... For example, NHs with more beds were associated with more PPE shortages. This finding suggests that larger facilities with more residents and staff potentially faced higher risk of COVID-19 transmission, 44 leading to an increased demand for PPE. Having any staff COVID-19 infection, but not staffing level, was associated with PPE shortages. ...
Many nursing homes operated at thin profit margins prior to the COVID-19 pandemic. This study examines the role of nursing homes’ financial performance and chain affiliation in shortages of personal protection equipment (PPE) during the first year of the COVID-19 pandemic. We constructed a longitudinal file of 79 868 nursing home-week observations from 10 872 unique facilities. We found that a positive profit margin was associated with a 21.0% lower probability of reporting PPE shortages in chain-affiliated nursing homes, but not in non-chain nursing homes. Having adequate financial resources may help nursing homes address future emergencies, especially those affiliated with a multi-facility chain.
... We constructed the analytical sample as follows: 85% or higher Medicaid census, and consistent with the prior approaches, we excluded nursing homes with 10% or higher private pay and/or 8% or higher Medicare (Abrams et al., 2020;Mor et al., 2004). Our final sample size was 1050; we received 391 survey completes for a response rate of 37%. ...
... However, in most developed countries, the older population resides at facilities like nursing homes; this had an essential role in the transmission of COVID-19 in countries like Italy, 10 Canada, 14 and the United States. 15 Males were 57.4%, and females 42.6%. Few studies suggested males had a higher risk of mortality, 2,16,17 but our study did not find any such significance. ...
Background: The older population is often disproportionately and adversely affected during humanitarian emergencies, as has also been seen during the COVID-19 pandemic. Data regarding COVID-19 in older adults is usually over-generalized and does not delve into details of the clinical characteristics in them. This study was conducted to analyze clinical and laboratory characteristics, risk factors, and complications of COVID-19 between older adults who survived and those who did not.
Methods: We conducted a case-control study among older adults(age> 60 years) admitted to the Intensive Care Unit(ICU) during the COVID-19 pandemic. The non-survivors(cases) were matched with age and sex-matched survivors (control) in a ratio of 1: 3. The data regarding socio-demographics, clinical characteristics, complications, treatment, laboratory data, and outcomes were analyzed.
Results: The most common signs and symptoms observed were fever (cases vs controls)(68.92 vs. 68.8%), followed by shortness of breath (62.2% Vs. 52.2%), and cough(47.3% Vs. 60.2%). Our analysis found no association between the presence of any of the comorbidities and mortality. At admission, laboratory markers such as LDH(Lactate Dehydrogenase), WBC(White Blood Count), creatinine, CRP(C-Reactive Protein), D-dimer, ferritin, and IL-6 were found to be significantly higher among the cases than among the controls. Complications such as the development of seizure, bacteremia, acute renal injury, respiratory failure, and septic shock were seen to have a significant association with non-survivors.
Conclusions: Hypoxia, tachycardia, and tachypnoea at presentation were associated with higher mortality. The older adults in this study mostly presented with the typical clinical features of COVID-19 pneumonia. The presence of comorbid-illnesses among them did not affect mortality. Higher death was seen among those with higher levels of CRP, LDH, D-dimer, and ferritin; and with lower lymphocyte counts.
The purpose of this study was to determine the feasibility of facility-level wastewater surveillance in the detection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in skilled nursing facility (SNF) wastewater using three concentration methods, as well as a proof-of-concept for antimicrobial resistance (AR) genes/organisms detection. Wastewater effluent samples were collected from an SNF over an 8-week period. Wastewater was concentrated using electronegative membrane filtration (enMF), polyethylene glycol precipitation, or Nanotrap® magnetic virus particles (NP). Quantification of the genome copy concentration from SARS-CoV-2 and bovine respiratory syncytial virus (BRSV), a SARS-CoV-2 surrogate spiked into all samples, was performed with droplet digital polymerase chain reaction (PCR). Wastewater sample aliquots were also enriched in microbiological culture media and screened for organisms with AR phenotypes on selective and differential agars. Multiplex real-time PCR was used to detect a broad array of carbapenem resistance genes. SARS-CoV-2 was detected and quantified from a single enMF-concentrated wastewater sample. The highest concentration of BRSV came from enMF-concentrated samples. Klebsiella, Enterobacter, Citrobacter, and Escherichia coli exhibiting AR phenotypes were successfully detected using culture-dependent approaches. Culture-independent, multiplex PCR indicated that blaKPC was the main carbapenemase gene detected in wastewater samples. Facility-level wastewater surveillance could be a useful strategy for SNFs.
Introduction
We retrospectively evaluated the impact of COVID-19 testing among residents and staff in social care homes in England.
Methods
We obtained 80 million reported PCR and lateral flow device (LFD) test results, from 14 805 care homes (residents and staff) in England, conducted between October 2020 and March 2022. These testing data were then linked to care home characteristics, test costs and 24 500 COVID-19-related deaths of residents. We decomposed the mechanism of outbreak mitigation into outbreak discovery and outbreak control and used Poisson regressions to investigate how reported testing intensity was associated with the size of outbreak discovered and to uncover its association with outbreak control. We used negative binomial regressions to determine the factors influencing COVID-19-related deaths subsequent to outbreaks. We performed a cost-effectiveness analysis of the impact of testing on preventing COVID-19-related deaths of residents.
Results
Reported testing intensity generally reflected changes in testing policy over time, although there was considerable heterogeneity among care homes. Client type was the strongest determinant of whether COVID-19-related deaths in residents occurred subsequent to testing positive. Higher staff-to-resident ratios were associated with larger outbreak sizes but rapid outbreak control and a decreased risk of COVID-19-related deaths. Assuming our regression estimates represent causal effects, care home testing in England was cost-effective at preventing COVID-19-related deaths among residents during the pandemic and approximately 3.5 times more cost-effective prior to the vaccine rollout.
Conclusions
PCR and LFD testing was likely an impactful intervention for detecting and controlling COVID-19 outbreaks in care homes in England and cost-effective for preventing COVID-19-related deaths among residents. In future pandemics, testing must be prioritised for care homes, especially if severe illness and death particularly affect older people or individuals with characteristics similar to care home residents, and an efficacious vaccine is unavailable.
This systematic review investigates disparities in COVID-19 outcomes (infections, hospitalizations, and deaths) between urban and rural populations in the United States. Of the 3,091 articles screened, 55 were selected. Most studies ( n = 43) conducted national analyses, using 2020 data, with some extending into 2021. Findings show urban areas had higher COVID-19 cases and hospitalizations in 2020, while rural areas saw increased cases in 2021 and mixed hospitalization results. Urban areas also had higher mortality rates in 2020, with rural rates rising in 2021 and 2022. Most studies did not explore reasons for urban/rural differences. The few that did found that vulnerable groups, including racially and ethnically minoritized populations, older adults, and those with comorbidities and lower socioeconomic status and vaccination rates, experienced exacerbated disparities in rural regions. COVID-19 outcomes varied over time and by area due to population density, healthcare infrastructure, and socioeconomic factors. Tailored interventions are essential for health equity and effective policies.
The COVID-19 outbreak, which most severely impacted older citizens, served as a stress test for residential eldercare facilities. The mortality rates of care home residents varied widely across countries in 2020 before vaccinations became available. Why have some countries been better (or less) able to protect their older citizens in care homes? This article examines the role of specific characteristics of national systems of residential care in enhancing or weakening the capacity of these systems to protect their residents from the pandemic and seeks to draw some lessons for the future. Because the mortality rate in care homes strongly correlates with the overall infection rate within the community, this article adopts an innovative approach to conceptualize and measure the protection capacity of national residential care systems more specifically – that is net of mortality rates within the community. The study makes important contributions to the care policy field. The traditional care regime typology fails to explain cross-national variations in the protective capacity of care homes. Governmental spending on long-term care systems certainly matters for protective capacity but we find that a factor previously neglected by care regime scholars also matters. More specifically, we show that the pattern of staff organization affects protective capacity. Our findings call for a rethinking of care systems in the face of future pandemics.
Background
COVID-19 deaths in nursing homes accounted for 30.2% of all COVID-19 deaths in the United States during the early weeks (1-January to 26-July, 2020) of the pandemic. This study presents the geographic diffusion of COVID-19 cases and deaths in nursing homes during this time period, while also providing explanation of regional risk factors.
Methods and findings
Nursing home COVID-19 data on confirmed cases (n = 173,452) and deaths (n = 46,173) were obtained from the Centers for Medicare and Medicaid Services. Weekly COVID-19 case counts were spatially smoothed to identify nursing homes in areas of high COVID-19 infection. Bivariate spatial autocorrelation was used to visualize High vs. Low-case counts and related deaths. Zero-inflated negative binomial models were estimated within Health and Human Service (HHS) Regions at three-week intervals to evaluate facility and area-level risk factors. The first reported nursing home resident to die of COVID-19 was in the state of Washington on 28-February, 2020. By 24-May, 2020 there were simultaneous epicenters in the Northeast (HHS Regions 1 and 2) and Midwest (HHS Region 5) with diffusion into the South (HHS Regions 4 and 6) from 15-June to 5-July, 2020. The case-fatality rate was highest from 25-May to 14-June, 2020 (30.9 deaths per 1000 residents); thereafter declining to 24.1 (15-June to 5-July, 2020) and 19.4 (6-July to 26-July, 2020) (overall case-fatality rate 1-January to 26-July = 26.6). Statistically significant risk factors for COVID-19 deaths were admission of patients with COVID-19 into nursing homes, staff confirmed infections and nursing shortages. COVID-19 deaths were likely to occur in nursing homes in high minority and non-English speaking neighborhoods and neighborhoods with a high proportion of households with disabilities.
Conclusions
Enhanced communication between HHS regional administrators about “lessons learned” could provide receiving state health departments with timely information to inform clinical practice to prevent premature death in nursing homes in future pandemics.
Introduction
Older adults in care homes experienced some of the highest rates of mortality from SARS-CoV-2 globally and were subjected to strict and lengthy non-pharmaceutical interventions, which severely impacted their daily lives. The VIVALDI ASCOT and Ethnography Study aims to assess the impact of respiratory outbreaks on care home residents’ quality of life, psychological well-being, loneliness, functional ability and use of space. This study is linked to the VIVALDI-CT, a randomised controlled trial of staff’s asymptomatic testing and sickness payment support in care homes (ISRCTN13296529).
Methods and analysis
This is a mixed-methods, longitudinal study of care home residents (65+) in Southeast England. Group 1—exposed includes residents from care homes with a recent COVID-19 or other respiratory infection outbreak. Group 2—non-exposed includes residents from care homes without a recent outbreak. The study has two components: (a) a mixed-methods longitudinal face-to-face interviews with 100 residents (n=50 from group 1 and n=50 from group 2) to assess the impact of outbreaks on residents’ quality of life, psychological well-being, loneliness, functional ability and use of space at time 1 (study baseline) and time 2 (at 3–4 weeks after the first visit); (b) ethnographic observations in communal spaces of up to 10 care homes to understand how outbreaks and related restrictions to the use of space and social activities impact residents’ well-being. The study will interview only care home residents who have the mental capacity to consent. Data will be compared and integrated to gain a more comprehensive understanding of the impact of outbreaks on residents’ quality of life and well-being.
Ethics and dissemination
The VIVALDI ASCOT and Ethnography Study obtained ethical approval from the Health Research Authority (HRA) Social Care REC (24/IEC08/0001). Only residents with the capacity to consent will be included in the study. Findings will be published in scientific journals.
Background
The COVID-19 pandemic wreaked havoc on long-term care facilities (LTCFs). Some LTCFs performed better than others at slowing COVID-19 transmission. Emerging literature has mostly described infection prevention and control strategies implemented by LTCFs during the pandemic. However, there is a need for a comprehensive review of factors that influenced the performance of LTCFs in containing COVID-19 spread to inform public health policy.
Objective
To build on the existing literature, we conducted a scoping review of factors that influenced LTCF performance during the COVID-19 pandemic using a multidimensional conceptual framework of performance.
Methods
We followed the Joanna Briggs Institute’s methodology for scoping reviews. We queried CINAHL, MEDLINE (Ovid), CAIRN, Science Direct, Scopus, and Web of Science for peer-reviewed literature in English or French published between January 1st, 2020 and December 31st, 2021. Retrieved records were screened for context (COVID-19 pandemic), population (LTCFs), interest (internal and external factors that influenced LTCF performance), and outcomes (dimensions of performance: equity, accessibility, reactivity, safety, continuity, efficacy, viability, efficiency). Descriptive characteristics of included articles were summarized. Dimensions of performance as well as internal (e.g., facility characteristics) and external (e.g., visitors) factors identified to have influenced LTCF performance were presented.
Results
We retained 140 articles of which 68% were classified as research articles, 47% originated in North America, and most covered a period between March and July 2020. The most frequent dimensions of performance were “efficacy” (75.7%) and “safety” (75.7%). The most common internal factors were “organizational context” (72.9%) and “human resources” (62.1%), and the most common external factors were “visitors” (27.1%) and “public health guidelines” (25.7%).
Conclusions
Our review contributes to a global interest in understanding the impact of the COVID-19 pandemic on vulnerable populations residing and working in LTCFs. Though a myriad of factors were reported, a lack of randomized controlled trials makes it impossible to establish causality between the identified factors and LTCF performance. The use of a multidimensional framework can be recommended to evaluate healthcare system performance not merely in terms of efficacy and safety, but alongside other critical dimensions such as efficiency and equity.
Trial registration
Research Registry ID: researchregistry7026
Nursing home residents and staff were disproportionately affected by the COVID-19 pandemic, drawing attention to long-standing challenges of poor infection control, understaffing, and substandard quality of care in many facilities. Evolving practices and policies during the pandemic often focused on these challenges, with little effect. Despite the emergence of best practices to mitigate transmission of the virus, even the highest-quality facilities experienced outbreaks, indicating a larger systemic problem, rather than a quality problem at the facility level. Here we present a narrative review and discussion of the evolution of policies and practices and their effectiveness, drawing on evidence from the United States that was published during 2020-23. The lessons learned from this experience point to the need for more fundamental and nuanced changes to avoid similar outcomes from a future pandemic: greater integration of long-term care into public health planning, and ultimately a shift in the physical structure of nursing homes. More incremental measures such as vaccination mandates, higher staffing, and balancing infection control with resident quality of life will avoid some adverse outcomes, but without more systemic change, nursing home residents and staff will remain at substantial risk for repetition of the poor outcomes from the COVID-19 pandemic.
Introduction
We retrospectively evaluated the impact of COVID-19 testing among residents and staff in adult social care homes in England.
Methods
We obtained 80 million reported polymerase chain reaction (PCR) and lateral flow device (LFD) test results, from 14,805 care homes (residents and staff) in England, conducted between October 2020 and March 2022. These testing data were then linked to care home characteristics, test costs and 24,500 COVID-19-related deaths of residents. We decomposed the mechanism of outbreak mitigation into outbreak discovery and outbreak control and used Poisson regressions to investigate how reported testing intensity was associated with the size of outbreak discovered and to uncover its association with outbreak control. We used negative binomial regressions to determine the factors influencing COVID-19-related deaths subsequent to outbreaks. We performed a cost-effectiveness analysis of the impact of testing for preventing COVID-19-related deaths of residents.
Results
Reported testing intensity generally reflected changes in testing policy over time, although there was considerable heterogeneity among care homes. Client type was the strongest determinant of whether COVID-19-related deaths in residents occurred subsequent to testing positive. Higher staff-to-resident ratios were associated with larger outbreak sizes but rapid outbreak control and a decreased risk of COVID-19-related deaths. Assuming our regression estimates represent causal effects, care home testing in England was cost effective at preventing COVID-19-related deaths among residents during the pandemic and approximately 3.5-times more cost effective prior to the vaccine rollout.
Conclusions
PCR and LFD testing was likely an impactful intervention for detecting and controlling COVID-19 outbreaks in care homes in England and cost effective for preventing COVID-19-related deaths among residents. In future pandemics, testing must be prioritised for care homes, especially if severe illness and death particularly affects older people or individuals with characteristics similar to care home residents, and an efficacious vaccine is unavailable.
Key Messages
Evidence before this study
Mass diagnostic testing plays a key role in any pandemic response. COVID-19 testing in the adult social care sector in England was implemented by NHS Test and Trace (later the UK Health Security Agency, UKHSA). Prior to the large-scale evaluation we report here, a pilot testing evaluation programme had been conducted in Liverpool.
Added value of this study
This study represents the first large-scale evaluation of England's COVID-19 testing programme in adult social care homes. It encompasses data from residents and staff from 14,805 adult social care homes in England. Our findings show that testing was an important and useful public health intervention that had a considerable impact. It was also cost effective at preventing COVID-19-related deaths in adult social care home residents.
Implications of all the available evidence
Our study has implications for the development of testing policies in adult social care homes in any future pandemic, particularly if it involves a respiratory disease similar to COVID-19. We found that while testing was a crucial public health intervention in adult social care homes, there were also large heterogeneities seen among care homes. Policymakers thus need to consider whether a one-size-fits-all policy for care home testing is the most effective approach to take in the face of any future pandemic.
Background
The impact of the COVID-19 pandemic on long-term care residents remains of wide interest, but most analyses focus on the initial wave of infections.
Objective
To examine change over time in: (i) The size, duration, classification and pattern of care-home outbreaks of COVID-19 and associated mortality and (ii) characteristics associated with an outbreak.
Design
Retrospective observational cohort study using routinely-collected data.
Setting
All adult care-homes in Scotland (1,092 homes, 41,299 places).
Methods
Analysis was undertaken at care-home level, over three periods. Period (P)1 01/03/2020-31/08/2020; P2 01/09/2020-31/05/2021 and P3 01/06/2021–31/10/2021. Outcomes were the presence and characteristics of outbreaks and mortality within the care-home. Cluster analysis was used to compare the pattern of outbreaks. Logistic regression examined care-home characteristics associated with outbreaks.
Results
In total 296 (27.1%) care-homes had one outbreak, 220 (20.1%) had two, 91 (8.3%) had three, and 68 (6.2%) had four or more. There were 1,313 outbreaks involving residents: 431 outbreaks in P1, 559 in P2 and 323 in P3. The COVID-19 mortality rate per 1,000 beds fell from 45.8 in P1, to 29.3 in P2, and 3.5 in P3. Larger care-homes were much more likely to have an outbreak, but associations between size and outbreaks were weaker in later periods.
Conclusions
COVID-19 mitigation measures appear to have been beneficial, although the impact on residents remained severe until early 2021. Care-home residents, staff, relatives and providers are critical groups for consideration and involvement in future pandemic planning.
Objective
The recent consolidation of the Australian residential aged care market has raised concerns about the potential adverse effects of acquisition activity on quality of care (QoC). We examined changes in QoC outcomes within acquired homes and the influence of the acquiring providers' characteristics on these post‐acquisition outcomes.
Methods
A retrospective observational study was conducted using de‐identified data sets obtained under the legal authority of the Royal Commission into Aged Care Quality and Safety. Regression analysis was used to investigate post‐acquisition changes in QoC outcomes for 225 Australian home acquisitions between 2015 and 2019. The outcomes were analysed for the first two full financial years before and after the acquisition.
Results
After controlling for other factors, we find acquired homes were associated with significantly worse QoC outcomes in the 2 years after acquisition, with higher rates of hospitalisations and reported complaints to the regulator. However, these results were driven by homes acquired by providers that were smaller in scale, for‐profit or had comparatively poorer average quality across the other homes they operated.
Conclusions
Our finding that homes' QoC on average declines in the first 2 years following acquisition, are consistent with studies in other countries and points to the potential risks that consolidation poses to the care delivered to older people in Australia during that period.
As in many countries around the globe, older citizens in long-term care facilities (LTCFs) in Sweden were hit hard by the Coronavirus pandemic, but mortality varied greatly between different facilities. Current knowledge about the causes of this variation is limited. This article closes this gap by focusing on the link between the structural characteristics of LTCFs—ownership, size, and staffing—and the risk of dying from COVID-19 in Sweden during 2020. Having utilized both individual- and facility-level data, our results suggest that lower staff turnover, having a nurse employed at the facility, and smaller facility size are associated with an decreased risk of dying from COVID-19. Ownership type is not directly associated with COVID-19-related mortality, but public facilities have lower staff turnover and fewer personnel with additional employment than privately run facilities, while privately run LTCFs more often have a nurse employed at the facility.
Introduction:
Incontinence impacts the quality-of-life of people suffering from the disease. However, there is limited information on the prevalence of incontinence due to the stigma, lack of awareness, and underdiagnosis.
Objective:
This study aims to conduct a systematic review and meta-analysis of overactive bladder (OAB) and nonobstructive urinary retention (NOUR).
Methods:
The authors conducted a systematic review following the PRISMA guidelines using Embase, MEDLINE, and PubMed databases to identify the relevant publications in the English language. Two reviewers independently assessed the articles and extracted the data. Review papers were assessed for content and references. A meta-analysis of proportions was conducted using the RStudio software. To address the age heterogeneity, a subanalysis was conducted. Pooled data were overlayed on the Canadian population and a sample of 10 populous countries to estimate the number of people suffering from incontinence.
Results:
Twenty-eight and eight articles were selected for OAB and NOUR, respectively. The pooled prevalence of OAB in men and women was 12% (95% CI: 9%-16%) and 15% (95% CI: 12%-18%), respectively. The estimated prevalence of NOUR was 15.6%-26.1% of men over 60 and 9.3%-20% of women over 60. The subanalysis pooled prevalence of OAB in men and women was 11% (95% CI: 8%-15%) and 12% (95% CI: 9%-16%), respectively. We estimated that 1.4-2.5 million women and 1.3-2.2 million men suffer from OAB in Canada.
Conclusion:
Urinary incontinence is an under-reported and underdiagnosed prevalent condition that requires appropriate treatment to improve a patient's quality-of-life.
The current retrospective study aimed to investigate the association between organizational factors and nursing staff in geriatric hospitals and coronavirus disease 2019 (COVID-19) incidences and deaths using secondary data from governments nationwide in Korea. We used data on the number of COVID-19–confirmed cases and deaths among older adults in geriatric hospitals and nursing staff levels in those hospitals. We found that when the RN level was higher than the sample mean, the number of COVID-19–confirmed cases by geriatric hospital was significantly lower (4.3%; p = 0.05) and the number of deaths by geriatric hospital was marginally significantly lower (1.4%; p = 0.05). This study presented the national description of geriatric hospitals during the COVID-19 pandemic in terms of organizational and nursing staff factors. Findings highlight the impact of nursing staff skill mix and number of geriatric hospitals during the COVID-19 pandemic in Korea. It is necessary to allocate a realistic designation of infection control staff and establish a clear standard so infection control activities in geriatric hospitals can proceed systematically. [Research in Gerontological Nursing, 16(6), 302–311.]
Context: COVID-19 exerted severe challenges on skilled nursing facility (SNF) residents and staff. A combination of internal and external factors predisposed SNFs to an increased propensity of COVID-19 spread.
Objective: The purpose of this paper is to examine which facility characteristics may have contributed to COVID-19 outbreaks within urban and rural North Dakota skilled nursing facilities.
Methods: A 23-question survey regarding facility characteristics was developed and distributed to all 78 North Dakota skilled nursing facilities (SNF).
Findings: Of the North Dakota SNF, 40 out of 78 total facilities (51.2%) participated in the survey. Of those participating, 38 of 40 (95%) were in counties with populations under 50,000, with the smallest county population being 1,876. A Spearman’s rank test suggested a relationship between the community spread of COVID-19 and the COVID-19 positivity of SNF residents. Spearman’s rank also suggested a positive association between the SNF resident COVID-19 positivity in relation to staff positivity (p-value 0.042) and county rates (p-value 0.045).
Limitations: While this is a comprehensive survey with a very good response rate, two key limitations are identified. First, the survey relies on self-reported data from SNF staff. Second, it is not clear what data would have been received from non-responding SNFs.
Implications: Substantial lessons have been learned, which may not only aid future pandemic preparedness but improve the quality of care for nursing home residents during a pandemic or other respiratory disease outbreaks. Proactively knowing susceptibilities and vulnerabilities ahead of time will allow local and state leaders to plan and allocate resources. Future state and local pandemic emergency plans need to be reviewed with the prioritization of skilled nursing facilities as front line facilities during a pandemic, rather than placing their “traditional” emphasis of emergency preparedness on hospitals.
Coronavirus disease 2019 (COVID-19) has led to a surge of patients requiring post-acute care. In order to support federal, state and corporate planning, we offer a four-stage regionally oriented approach to achieving optimal systemwide resource allocation across a region's post-acute service settings and providers over time. In the first stage, the post-acute care system must, to the extent possible, help relieve acute hospitals of non-COVID-19 patients to create as much inpatient capacity as possible over the surge period. In the second stage after the initial surge as subsided, post-acute providers must protect vulnerable populations from COVID-19, prepare treat-in-place protocols for non-COVID-19 admissions, and create and formalize COVID-19 specific settings. In the third stage after a vaccine has been developed or an effective prophylactic option is available, post-acute care providers must assist with distribution and administration of vaccinations and prophylaxis, develop strategies to deliver non-COVID-19 related medical care, and begin to transition to the post-COVID-19 landscape. In the final stage, we must create health advisory bodies to review post-acute sector's response, identify opportunities to improve performance going forward, and develop a pandemic response plan for post-acute care providers.
More than 2,200 coronavirus deaths in nursing homes, but federal government isn't tracking them
- S Khimm
- L Strickler
- A Blankstein
- P Georgiev
Khimm S, Strickler L, Blankstein A, Georgiev P. More than 2,200 coronavirus deaths in
nursing homes, but federal government isn't tracking them. NBC News, April 10, 2020.
(https://www.nbcnews.com/news/us-news/more-2-200-coronavirus-deaths-nursing-homesfederal-government-isn-n1181026)
State reporting of cases and deaths due to COVID-19 in long-term care facilities. Kaiser Family Foundation
- Chidambaramp
Chidambaram P. State Reporting of Cases and Deaths Due to COVID-19 in Long-Term Care
Facilities. Kaiser Family Foundation, April 23, 2020. (https://www.kff.org/coronavirus-covid-19/issue-brief/state-reporting-of-cases-and-deaths-due-to-covid-19-in-long-term-care-facilities/)
Nearly 1 in 10 nursing homes nationwide report coronavirus cases
- D Cenziper
- J Jacobs
- S Mulcahy
Cenziper D, Jacobs J, Mulcahy S. Nearly 1 in 10 nursing homes nationwide report
coronavirus cases. Washington Post, April 20, 2020.
(https://www.washingtonpost.com/business/2020/04/20/nearly-one-10-nursing-homesnationwide-report-coronavirus-outbreaks/)
More than 2 200 coronavirus deaths in nursing homes but federal government isn’t tracking them.NBC News
- Khimms Stricklerl
- Blanksteina Georgievp
Nearly 1 in 10 nursing homes nationwide report coronavirus cases
- Cenziperd Jacobsj Mulcahys