Abstract
In 2023, Seosan City and the Chungnam Center for Infectious Diseases Control and Prevention conducted onsite inspections of coronavirus disease 2019 (COVID-19) infection management in nursing homes within Seosan City. These inspections spanned approximately six months, from March to September 2023, targeting 14 nursing facilities, with two visits each. The initial round of inspections (March 17 to April 24, 2023) assessed the current state of COVID-19 infection management at each facility and proposed necessary improvements. Upon request from the facilities, infection management training and practice were provided. The inspections utilized the COVID-19 prevention and response checklist (Ministry of Health and Welfare, 2021). Approximately 4–5 months later, the second round of inspections (August 1 to September 5, 2023) revisited the facilities using the same checklist to evaluate improvements in COVID-19 infection management and address deficiencies. The number of facilities with established COVID-19 response plans increased from three to nine following the initial and subsequent inspections. Improvements in designating personal protective equipment changing areas, establishing rapid treatment systems, preparing isolation rooms for potential COVID-19 patients, and separating the aisle and contaminated areas improved by 83.3%, 16.7%, and 16.7% respectively, compared to the first inspection. Ventilation in nursing facilities, relying solely on natural ventilation in 57.1% of cases, indicated the need for enhancements in air conditioning systems. Additionally, tailored infection management strategies that consider the characteristics of residents of the facility are necessary, particularly due to the low mask-wearing rate among residents (14.3% to 21.4%).
Keywords: Coronavirus disease 2019, Infections, Aged, Nursing homes, Homes for the aged
Key messages
① What is known previously?
Coronavirus disease 2019 (COVID-19) has a higher severity and mortality rate among the elderly, and elderly care facilities are vulnerable to infections, necessitating priority management.
② What new information is presented?
The current status of COVID-19 infection management in elderly care facilities was identified, highlighting the need for improvements.
③ What are implications?
Facility-specific guidance and management are necessary for effective infection control in elderly care facilities.
Introduction
Since the first confirmed case of coronavirus disease 2019 (COVID-19) in January 2020 until the end of the surveillance period on August 31, 2023, there have been 34,572,554 cumulative confirmed cases (67.4% of the total population of 51,325,329 as of December 31, 2023) and 35,606 cumulative deaths. The old age over 65 years is a risk factor for progressing to severe COVID-19. As of December 31, 2022, among the total COVID-19 deaths of 32,349, 26,670 deaths (82.4%) were among individuals aged 70 years and above [1, 2].
Facilities vulnerable to infection, such as nursing long-term care hospitals and facilities, mental health promotion centers, and facilities for people with disabilities, have experienced significant COVID-19 outbreaks with high severity. As a response, the need for prioritized management was raised, and dedicated response teams for infection-vulnerable facilities were established in each local government as of May 2022. These teams conduct pre-inspections of facilities, provide preventive education, and respond to outbreaks on-site. Even after COVID-19 was categorized as a Level 4 statutory infectious disease, management of infection-vulnerable facilities has continued [3].
In 2023, Seosan City, in collaboration with tthe Chungnam Center for Infectious Diseases Control and Prevention, conducted on-site inspections for COVID-19 response in long-term care facilities to manage COVID-19 infections.
This study aimed to present the status of COVID-19 infection management in long-term care facilities as identified through on-site inspections and to offer suggestions for improvement.
Methods
1. Selection of Target Facilities
A briefing session for on-site inspections of COVID-19 infection management was held for 21 long-term care facilities within Seosan City's jurisdiction. Requests to participate in the inspection were sent to each facility, and 16 facilities applied to participate. This study presented the results from the 14 facilities that participated in the first and second on-site inspections.
2. On-Site Inspection, Training, and Practice
1) On-site inspection
The on-site inspections were conducted twice for each facility. The first inspection (March 17 to April 24, 2023) was conducted to assess the status of COVID-19 infection management and propose improvement measures. Meanwhile, the second inspection (August 1 to September 5, 2023) was conducted to evaluate the status of infection management and implement improvement measures suggested during the first on-site inspection. Two members of the Chungnam Center for Infectious Diseases Control and Prevention and an infectious disease officer from the Seosan Public Health Center conducted the inspections. Facility directors and infection control personnel participated in interviews, document reviews, and on-site observations.
2) On-site checklist
During the inspections, the COVID-19 Infection Control Checklist (Ministry of Health and Welfare, 2021) was utilized [4]. The checklist consists of 23 items across five categories: (1) Response system, (2) Facility and environmental management, resource supply, education, (3) Staff and caregiver management, (4) Resident management, and (5) Visitation and visitor management. The checklist offers three response options: “Yes,” “No,” and for some items, “Partial implementation.” The item regarding (5) Visitation and visitor management was modified due to changes in infection control guidelines for long-term care facilities. In addition, the question "Are you guiding and adhering to regulations regarding visitation and visitor restrictions?" was revised to "Are you guiding and adhering to regulations regarding visitation and visitors?" The question "Are you checking for respiratory symptoms and vaccination history of visitors?" was also revised to "Are you checking for respiratory symptoms of visitors?" [5].
3) Infection control education and practice
When requested by long-term care facilities, infection management education and practical training were conducted during the on-site inspections. The education covered an overview of COVID-19 infections, principles of infection management (standard, contact, droplet, and airborne precautions), ventilation methods, and disinfection methods. Practical infection management training included hand hygiene using a view-box, measurement of hand hygiene and environmental contamination using an adenosine triphosphate (Accepta Ltd.), testing device, and donning and doffing personal protective equipment.
Results
1. Characteristics of Participating Facilities and Interviewees
Participating facilities included 14 (66.7%) out of 21 long-term care facilities in Seosan City. The basic characteristics of participating facilities regarding the number of staff (median [range]) were 26.5 (7–78) individuals during the first inspection and 23.5 (7–86) individuals during the second inspection. The number of residents was 33.5 (9–103) during the first inspection and 33 (9–122) individuals during the second inspection. Interviewees consisted of facility directors and infection control personnel, including registered nurses and nurse assistants (36.4% and 40% for the first and second inspections, respectively), social workers (18.2% and 24.0%), directors (18.2% and 20.0%), and office managers (22.7% and 16.0%) (Table 1).
Table 1. Coronavirus disease 2019 infection control on-site inspections in homes for the aged in Seosan City, 2023 (repetitive inspections of the same institution) characteristics of facilities and interviewees.
| Category | 1st round | 2nd round |
|---|---|---|
| Number of participating facilities | 14 | 14 |
| Staff size of participating facilities (median [range]) | 26.5 (7–78) | 23.5 (7–86) |
| Number of residents in participating facilities (median [range]) | 33.5 (9–103) | 33.0 (9–122) |
| Total number of interviewees | 22 | 25 |
| Number of Interviewees per facility (median [range]) | 1 (1–3) | 2 (1–3) |
| Composition of Interviewees | ||
| Director | 4 (18.2) | 5 (20.0) |
| Office manager | 5 (22.7) | 4 (16.0) |
| Nurses and nursing assistants | 8 (36.4) | 10 (40.0) |
| Social workers | 4 (18.2) | 6 (24.0) |
| Caregivers | 1 (4.5) | 0 (0.0) |
Unit: number of facilities, number of people (%).
2. Coronavirus Disease 2019 Infection Control Inspection Results and Improvement Measures
1) Coronavirus disease 2019 response system
The establishment of a COVID-19 response plan for the facilities include the formation of response teams, specifying the roles of each team member (division of duties), regulations for excluding personnel from their duties in the event of COVID-19 occurrence and related measures, procedures for responding to symptoms or confirmed cases of COVID-19 in residents or staff, and dissemination of contact information for external agencies responsible for COVID-19 response, such as the health authorities [6]. During the first inspection, three facilities (21.4%) established COVID-19 response plans, while 10 facilities (71.4%) only partially implemented them. One facility, which opened in December 2022, did not have a response system. Nine facilities (64.3%) established a response plan during the second inspection after addressing deficiencies.
During the first inspection, all facilities had designated infection control personnel who had completed COVID-19 infection prevention training within the past year. Experience with training for COVID-19 response situations was reported in 13 facilities (92.9%) in the first inspection and all 14 facilities (100.0%) during the second inspection. Most facilities (n=10;71.4%) conducted response and system checks following actual COVID-19 outbreaks rather than simulated training in the first and second inspections. During the first inspection, 12 facilities (85.7%) reported having established a rapid treatment system, which involved the utilization of a mobile medical unit, designating one to three medical institutions per city, county, or district to provide face-to-face medical treatment, including providing of prescriptions for confirmed COVID-19 patients in long-term care facilities or the offering of regular and occasional consultations. In the second inspection, all 14 facilities (100.0%) established a rapid treatment system (Table 2).
Table 2. Status of coronavirus disease 2019 response system establishment, facility and environmental management, resource supply, and education in homes for the aged in Seosan City, 2023.
| Category | 1st round | 2nd round | % change (%)a) | ||
|---|---|---|---|---|---|
| COVID-19 response system establishment | COVID-19 response plan | Yes | 3 (21.4) | 9 (64.3) | 200.0 |
| Partially implemented | 10 (71.4) | 5 (35.7) | –50.0 | ||
| Epidemic manager appointment | Yes | 14 (100.0) | 14 (100.0) | 0.0 | |
| Epidemic manager’s COVID-19 infection prevention training (within 1 yr) | Yes | 13 (92.9) | 14 (100.0) | 7.7 | |
| COVID-19 response training | Yes (simulation training) | 3 (21.4) | 4 (28.6) | 7.7 | |
| Yes (outbreak, system check) | 10 (71.4) | 10 (71.4) | 0.0 | ||
| Rapid medical response system | Yes (medical mobile team, etc.) | 12 (85.7) | 14 (100.0) | 16.7 | |
| Facility and environmental management, resource supply, education | Establishment of quarantine rooms for confirmed (suspected) COVID-19 cases | Yes | 12 (85.7) | 14 (100.0) | 16.7 |
| Planning for separation of movement pathways and designation of contaminated zones | Yes | 11 (78.6) | 13 (92.9) | 16.7 | |
| Ventilation for each area within the facility | Yes (mechanical ventilation+natural ventilation) | 6 (42.9) | 6 (42.9) | 0.0 | |
| Partially implemented (natural ventilation) | 8 (57.1) | 8 (57.1) | 0.0 | ||
| Designation of areas for donning and doffing PPE, and placement of necessary items | Yes | 6 (42.9) | 11 (78.6) | 83.3 | |
| Proper cleaning and disinfection of environmental surfaces | Yes | 12 (85.7) | 13 (92.9) | 7.7 | |
| Employee education and training on COVID-19 infection prevention methods (within 1 yr) | Yes | 12 (85.7) | 13 (92.9) | 7.7 | |
| Partially implemented | 2 (14.3) | 0 (0.0) | –100.0 | ||
| Supply of PPE and other infection control materials | Yes | 14 (100.0) | 12 (85.7) | –16.7 | |
| Placement of hand sanitizers in areas used by multiple people | Yes | 14 (100.0) | 14 (100.0) | 0.0 | |
Unit: number of facilities (%). PPE=personal protective equipment; COVID-19=coronavirus disease 2019. a)% change calculated as [(2nd round–1st round)/1st)]×100%.
2) Facility and environmental management, resource supply, and educational status
Setting up provisional isolation rooms to prevent contact with non-infected residents in the event of confirmed or suspected COVID-19 cases was established by 12 facilities (85.7%) during the first inspection and by all 14 facilities (100.0%) during the second inspection. Setting up plans to designate areas with separate pathways to prevent contact with non-infected residents in the event of confirmed or suspected COVID-19 cases was established by 11 facilities (78.6%) during the first inspection and by 13 facilities (92.9%) during the second inspection. Ventilation in each facility area included a combination of air conditioning and natural ventilation in six facilities (42.9%) during the first and second inspections, whereas eight facilities (57.1%) had natural ventilation that was used only through entry doors and windows, without air conditioning. During the first inspection, six facilities (42.9%) had designated personal protective equipment (PPE) and changing areas physically separated and equipped with necessary items (hand sanitizer, instructions for donning, mirrors, and waste bins), while eight facilities (57.1%) did not have designated PPE-donning areas. During the second inspection, 11 facilities (78.6%) established physically separated donning areas for PPE. Twelve facilities (85.7%) had guidelines specifying the use of appropriate disinfectants and disinfection methods, properly cleaning and disinfecting environmental surfaces, and 13 (92.9%) had these guidelines during the second inspection. In the past year, employee education and training on COVID-19 infection prevention were conducted at 12 facilities (85.7%) during the first inspection and at 13 facilities (92.9%) during the second inspection. During the first inspection, all 14 facilities (100.0%) reported having sufficiently secured and supplied disinfection items, including PPE, with quantities that could last approximately 2 months, although this number decreased to 12 facilities (85.7%) during the second inspection, which was attributed to adjusting the COVID-19 crisis alert level from “serious” to “cautious” on June 1, 2023 [7]. All facilities appropriately provided hand sanitizers in areas, such as resident care spaces and shared areas (sanitizers placed where needed, not expired or empty), during the first and second inspections (Table 2).
3) Management of employees and caregivers
Regarding whether all staff and caregivers always wear masks in the space with residents, 14 facilities (100.0%) reported to have worn them at all times during the first inspection, but the number decreased to 11 (78.6%) during the second inspection. During the first inspection, hand hygiene was performed in recommended situations (before starting work, before and after contact with residents, after handling contaminated materials, after using the restroom, before meals, after completing work, and after touching contaminated surfaces) in 11 facilities (78.6%), which improved to 13 facilities (92.9%) during the second inspection. During the first inspection, all 14 facilities (100.0%) were conducting daily symptom checks for staff and caregivers, including temperature checks at least once a day, preemptive polymerase chain reaction (PCR) testing once a week, rapid antigen testing (RAT) in case of symptoms, and excluding staff from duty if symptomatic. During the second check, temperature checks were maintained, but due to revised guidelines following the downgrade of the crisis level, preemptive diagnostic testing for staff was only recommended instead of being mandated. As a result, the daily confirmation of COVID-19 infection symptoms among staff and caregivers decreased to 12 (85.7%). During the first inspection, 11 facilities (78.6%) enforced distancing measures among caregivers and restricted movement to designated areas only. However, during the second inspection, due to the downgrade of the crisis level, 10 facilities (71.4%) practiced distancing measures only between break areas and mealtimes (Table 3).
Table 3. Management of staff, caregivers, residents, visitors, and guests in homes for the aged in Seosan City, 2023.
| Category | 1st round | 2nd round | % change (%)a) | ||
|---|---|---|---|---|---|
| Staff & caregiver management | Always wearing masks | Yes | 14 (100.0) | 11 (78.6) | –21.4 |
| Hand hygiene | Yes | 11 (78.6) | 13 (92.9) | 16.7 | |
| Partially implemented | 3 (21.4) | 1 (7.1) | –16.7 | ||
| COVID-19 symptom check | Yes | 14 (100.0) | 12 (85.7) | –16.7 | |
| Limiting caregivers’ movement between areas | Yes | 11 (78.6) | 10 (71.4) | –7.7 | |
| Resident management | Education and guidance on infection prevention management for residents | Yes | 11 (78.6) | 11 (78.6) | 0.0 |
| Mask wearing by residents | Yes (≥80%) | 3 (21.4) | 2 (14.3) | –7.7 | |
| Partially implemented (≥50%) | 7 (50.0) | 7 (50.0) | 0.0 | ||
| Checking residents for COVID-19 symptoms | Yes | 13 (92.9) | 13 (92.9) | 0.0 | |
| Visitor management | Guidance and compliance with visitation and guest regulations | Yes | 13 (92.9) | 14 (100.0) | 7.7 |
| Checking for respiratory symptoms | Yes | 12 (85.7) | 12 (85.7) | 0.0 | |
| Guidance on mask wearing, hand sanitizing, and social distancing | Yes | 14 (100.0) | 12 (85.7) | –16.7 | |
Unit: number of facilities (%). COVID-19=coronavirus disease 2019. a)% change calculated as [(2nd round–1st round)/1st)]×100%.
4) Resident management
During the first and second inspections, education or guidance on infection control for residents (hand hygiene, wearing masks, physical distancing, and restriction of movement outside designated areas) was conducted in 11 facilities (78.6%). Regarding the number of facilities where residents wore masks, there were three facilities (21.4%) during the first inspection and two (14.3%) during the second inspection where more than 80% residents wore masks. Regarding daily checks for COVID-19 infection symptoms in residents and taking measures, such as testing and isolation if suspected, 13 facilities (92.9%) conducted diagnostic tests upon admission, daily temperature checks, preemptive tests, and diagnostic tests in case of symptoms during the first inspection. After the downgrade of the crisis level of COVID-19, 13 facilities (92.9%) conducted daily temperature checks and diagnostic tests in cases of symptoms in accordance with the eased guidelines during the second inspection (Table 3).
5) Visitor management
Guidelines on visitation, including pre-booking, setting up visitation spaces outdoors using separate containers, providing of time limits (approximately 20 minutes), and entry restrictions to residents' rooms, were provided, and 13 facilities (92.9%) adhered to these guidelines during the first inspection. Even after the relaxation of COVID-19 restrictions, all 14 facilities (100.0%) maintained visitation intervals, and visitations required prior reservation. Confirmation of respiratory symptoms for visitors was conducted in 12 facilities (85.7%) during the first and second inspections, involving temperature checks and RATs. During the first inspection, all 14 facilities (100.0%) ensured mask-wearing, hand sanitization, and social distancing guidance for visitors. However, during the second inspection, this decreased to 12 facilities (85%) (Table 3).
Discussion
The Chungnam Center for Infectious Diseases Control and Prevention jointly conducted on-site infection control inspections at 14 long-term care facilities in Seosan City in 2023. The COVID-19 Infection Control Checklist (Ministry of Health and Welfare, 2021) was used for the second round of inspections, and the level of COVID-19 infection control measures and areas for improvement in long-term care facilities were identified.
The items that improved the most during the first and second inspections were establishing a COVID-19 response plan and the designation of a changing area for PPE (Figure 1). The COVID-19 response plan includes the formation of a COVID-19 response team with assigned tasks and responsibilities, designation of personnel, specification of protocols for excluding staff from duties in the event of COVID-19, procedures for responding to confirmed or suspected cases of COVID-19, and dissemination of contact information for external collaborative agencies, such as city and county public health centers. The designation of the changing area for PPE was established to distinguish contaminated and clean areas, as well as to be aware of the space and air circulation so that people can wear clothes in the clean area and change in the contaminated area.
Figure 1. The key results from the first and second on-site inspections of coronavirus disease 2019 infection management at elderly care facilities in Seosan City.
Many long-term care facilities rely solely on natural ventilation for environmental management, although some may require air conditioning systems depending on the facility's structure. Therefore, additional investigation and support from local and central governments may be necessary to construct air conditioning systems. Additionally, since many residents in long-term care facilities are older adults and may have cognitive impairments, the adherence to wearing masks was low. Therefore, infection prevention and control measures in facilities need to be enhanced by considering the characteristics of residents. For bedridden residents, environmental hygiene management and regular ventilation should be strengthened. For those with cognitive impairments but no mobility issues, measures, such as managing symptomatic individuals during group activities, maintaining social distancing, promoting personal hygiene, and ensuring that caregivers and education staff wear masks, should be implemented.
COVID-19 outbreaks have led most long-term care facilities to cohort patients. Long-term care facilities adhered to concepts related to environmental management, resident management, and visitor management for infection control. However, there are challenges in establishing infection control systems, designating contaminated areas, and applying them according to each institution's personnel and facility characteristics. Therefore, it is necessary for local governments to provide ongoing on-site guidelines and practical manuals for effective implementation.
The COVID-19 response checklist used in these on-site inspections was designed to assess the COVID-19 response status of infection-vulnerable facilities, allowing for an overall understanding of the institution's COVID-19 response. However, it did not quantify the level of infection control measures. If the checklist is quantified in the future and developed into a checklist that can be generally used for respiratory infectious diseases management, such as influenza, it would be highly beneficial for the management of respiratory infectious diseases in vulnerable facilities. These results are based on on-site inspections conducted in only one city, so generalizing them may be limited. Further follow-up investigations are warranted to provide improvement and management strategies tailored to the characteristics of vulnerable facilities.
Acknowledgments
None.
Funding Statement
Funding Source: None.
Declarations
Ethics Statement: Not applicable.
Conflict of Interest: The authors have no conflicts of interest to declare.
Author Contributions: Conceptualization: JAL, DHH, DKC, YHC, SHJ, SOW. Data curation: JAL, DHH, DKC, SHJ, SOW. Formal analysis: JAL, DHH. Investigation: JAL, DHH. Methodology: JAL, DHH, OHC. Project administration: JAL, DHH, DKC, YHC. Resources: DHH. Software: JAL, DHH. Supervision: JAL, DHH. Writing – original draft: JAL, DHH. Writing – review & editing: JAL, OHC.
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