Relationship between nursing home COVID-19 outbreaks and staff neighborhood characteristics

Four Years And More Than 200,000 Deaths Later: Lessons Learned From The COVID-19 Pandemic In US Nursing Homes

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.

Drivers of COVID-19 Outcomes in Long-Term Care Facilities Using Multi-Level Analysis: A Systematic Review

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.

Nursing Home Residents' COVID-19 Infections in the United States: A Systematic Review of Personal and Contextual Factors

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.

Potential determinants of the quantity and duration of COVID-19 outbreaks in geriatric long-term care facilities

BACKGROUND

We analyzed potential factors for the number and duration of COVID-19 outbreaks in nursing homes based on routine and structural data.

METHODS

All outbreaks during 03/2020-01/2022 in N = 687 of a total of 879 geriatric long-term care facilities (LTCFs) in the Federal State of Hesse, Germany were analyzed using t-tests and logistic regressions in a retrospective cohort study.

RESULTS

Larger LTCFs have more (+ 1.57, p = .009) and longer outbreaks (+ 10.04 days, p > .001). A higher proportion of registered nurses reduces the number (-0.1, p = .036) and duration (-6.02 days, p > .001) of outbreaks. Single-bed rooms provide less duration of outbreaks (-4.5, p = .004). A higher proportion of infected residents (+ 24.26 days, p < .001) and staff (+ 22.98 days, p < .001) prolong outbreaks the most. LTCFs in areas with intermediate population density have an increased risk of prolonged outbreaks (OR: 1.537, p = .036).

CONCLUSIONS

To prevent outbreaks and shorten their duration, LTCFs should increase the proportion of registered nurses and single-bed rooms, and control staff infections.

Wastewater Monitoring for Infectious Disease: Intentional Relationships between Academia, the Private Sector, and Local Health Departments for Public Health Preparedness

The public health emergency caused by the COVID-19 pandemic stimulated stakeholders from diverse disciplines and institutions to establish new collaborations to produce informed public health responses to the disease. Wastewater-based epidemiology for COVID-19 grew quickly during the pandemic and required the rapid implementation of such collaborations. The objective of this article is to describe the challenges and results of new relationships developed in Detroit, MI, USA among a medical school and an engineering college at an academic institution (Wayne State University), the local health department (Detroit Health Department), and an environmental services company (LimnoTech) to utilize markers of the COVID-19 virus, SARS-CoV-2, in wastewater for the goal of managing COVID-19 outbreaks. Our collaborative team resolved questions related to sewershed selection, communication of results, and public health responses and addressed technical challenges that included ground-truthing the sewer maps, overcoming supply chain issues, improving the speed and sensitivity of measurements, and training new personnel to deal with a new disease under pandemic conditions. Recognition of our complementary roles and clear communication among the partners enabled city-wide wastewater data to inform public health responses within a few months of the availability of funding in 2020, and to make improvements in sensitivity and understanding to be made as the pandemic progressed and evolved. As a result, the outbreaks of COVID-19 in Detroit in fall and winter 2021-2022 (corresponding to Delta and Omicron variant outbreaks) were tracked in 20 sewersheds. Data comparing community- and hospital-associated sewersheds indicate a one- to two-week advance warning in the community of subsequent peaks in viral markers in hospital sewersheds. The new institutional relationships impelled by the pandemic provide a good basis for continuing collaborations to utilize wastewater-based human and pathogen data for improving the public health in the future.

The Benefits of Nursing Home Air Purification on COVID-19 Outcomes: A Natural Experiment

OBJECTIVES

Improving indoor air quality is one potential strategy to reduce the transmission of SARS-CoV-2 in any setting, including nursing homes, where staff and residents have been disproportionately and negatively affected by the COVID-19 pandemic.

DESIGN

Single group interrupted time series.

SETTING AND PARTICIPANTS

A total of 81 nursing homes in a multifacility corporation in Florida, Georgia, North Carolina, and South Carolina that installed ultraviolet air purification in their existing heating, ventilation, and air conditioning systems between July 27, 2020,k and September 10, 2020.

METHODS

We linked data on the date ultraviolet air purification systems were installed with the Nursing Home COVID-19 Public Health File (weekly data reported by nursing homes on the number of residents with COVID-19 and COVID-19 deaths), public data on data on nursing home characteristics, county-level COVID-19 cases/deaths, and outside air temperature. We used an interrupted time series design and ordinary least squares regression to compare trends in weekly COVID-19 cases and deaths before and after installation of ultraviolet air purification systems. We controlled for county-level COVID-19 cases, death, and heat index.

RESULTS

Compared with pre-installation, weekly COVID-19 cases per 1000 residents (-1.69; 95% CI, -4.32 to 0.95) and the weekly probability of reporting any COVID-19 case (-0.02; 95% CI, -0.04 to 0.00) declined in the post-installation period. We did not find any difference pre- and post-installation in COVID-19-related mortality (0.00; 95% CI, -0.01 to 0.02).

CONCLUSIONS AND IMPLICATIONS

Our findings from this small number of nursing homes in the southern United States demonstrate the potential benefits of air purification in nursing homes on COVID-19 outcomes. Intervening on air quality may have a wide impact without placing significant burden on individuals to modify their behavior. We recommend a stronger, experimental design to estimate the causal effect of installing air purification devices on improving COVID-19 outcomes in nursing homes.

Nursing homes and mortality in Europe: Uncertain causality

The current health crisis has particularly affected the elderly population. Nursing homes have unfortunately experienced a relatively large number of deaths. On the basis of this observation and working with European data (from SHARE), we want to check whether nursing homes were lending themselves to excess mortality even before the pandemic. Controlling for a number of important characteristics of the elderly population in and outside nursing homes, we conjecture that the difference in mortality between those two samples is to be attributed to the way nursing homes are designed and organized. Using matching methods, we observe excess mortality in Sweden, Belgium, Germany, Switzerland, Czech Republic and Estonia but not in the Netherlands, Denmark, Austria, France, Luxembourg, Italy and Spain. This raises the question of the organization and management of these nursing homes, but also of their design and financing.

Association of COVID-19 Vaccination Rates of Staff and COVID-19 Illness and Death Among Residents and Staff in US Nursing Homes

IMPORTANCE

It is important to understand the association between staff vaccination rates and adverse COVID-19 outcomes in nursing homes.

OBJECTIVE

To assess the extent to which staff vaccination was associated with preventing COVID-19 cases and deaths among residents and staff in nursing homes.

DESIGN, SETTING, AND PARTICIPANTS

This longitudinal cohort study used data on COVID-19 outcomes in Medicare- and Medicaid-certified nursing homes in the US between May 30, 2021, and January 30, 2022. Participants included the residents of 15 042 US nursing homes that reported COVID-19 data to the Centers for Disease Control and Prevention and passed Centers for Medicare & Medicaid Services data quality checks in the National Healthcare Safety Network.

EXPOSURES

Weekly staff vaccination rates.

MAIN OUTCOMES AND MEASURES

Main outcomes are weekly COVID-19 cases and deaths among residents and weekly COVID-19 cases among staff. The treatment variable is the primary 2-dose staff vaccination rate in each facility each week.

RESULTS

In the primary analysis of 15 042 nursing homes before the Omicron variant wave (May 30 to December 5, 2021) using fixed effects of facility and week, increasing weekly staff vaccination rates by 10 percentage points was associated with 0.13 (95% CI, -0.20 to -0.10) fewer weekly COVID-19 cases per 1000 residents, 0.02 (95% CI, -0.03 to -0.01) fewer weekly COVID-19 deaths per 1000 residents, and 0.03 (95% CI, -0.04 to -0.02) fewer weekly COVID-19 staff cases. In the secondary analysis of the Omicron wave (December 5, 2021, to January 30, 2022), increasing staff vaccination rates were not associated with lower rates of adverse COVID-19 outcomes in nursing homes.

CONCLUSIONS AND RELEVANCE

The findings of this cohort study suggest that before the Omicron variant wave, increasing staff vaccination rates was associated with lower incidence of COVID-19 cases and deaths among residents and staff in US nursing homes. However, as newer, more infectious and transmissible variants of the virus emerged, the original 2-dose regimen of the COVID-19 vaccine as recommended in December 2020 was no longer associated with lower rates of adverse COVID-19 outcomes in nursing homes. Policy makers may want to consider longer-term policy options to increase the uptake of booster doses among staff in nursing homes.

Long-Term Care Home Size Association with COVID-19 Infection and Mortality in Catalonia in March and April 2020

We aim to assess how COVID-19 infection and mortality varied according to facility size in 965 long-term care homes (LTCHs) in Catalonia during March and April 2020. We measured LTCH size by the number of authorised beds. Outcomes were COVID-19 infection (at least one COVID-19 case in an LTCH) and COVID-19 mortality. Risks of these were estimated with logistic regression and hurdle models. Models were adjusted for county COVID-19 incidence and population, and LTCH types. Sixty-five per cent of the LTCHs were infected by COVID-19. We found a strong association between COVID-19 infection and LTCH size in the adjusted analysis (from 45% in 10-bed homes to 97.5% in those with over 150 places). The average COVID-19 mortality in all LTCHs was 6.8% (3887 deaths) and 9.2% among the COVID-19-infected LTCHs. Very small and large homes had higher COVID-19 mortality, whereas LTCHs with 30 to 70 places had the lowest level. COVID-19 mortality sharply increased with LTCH size in counties with a cumulative incidence of COVID-19 which was higher than 250/100,000, except for very small homes, but slightly decreased with LTCH size when the cumulative incidence of COVID-19 was lower. To prevent infection and preserve life, the optimal size of an LTCH should be between 30 and 70 places.