To the Editor: An influenza pandemic would be expected to have major social and economic consequences. Hospital bed capacity may be quickly overwhelmed in an influenza pandemic,1 and government plans are looking at alternate care sites.2 Nursing homes care for a very vulnerable population and may be expected to help with hospital patient overflow. 3,4 The extent of influenza pandemic preparedness in nursing homes is largely unknown.5
Methods
All 656 state health department–registered nursing homes were identified in 2 states chosen as a convenience sample: Nebraska (n=231) and Michigan (n=425). A questionnaire to assess their pandemic preparedness was developed with input from various stakeholders and mailed to the directors of nursing in June 2007 with a follow-up mailing in July 2007. The questionnaire was designed to gather demographic data and information on aspects of influenza preparedness. Data on antiviral medications and ownership status were collected only from Michigan nursing homes. Categorical data were compared between groups with a χ2 test using SAS/STAT software (version 9.1.3; SAS Inc, Cary, North Carolina). A 2-sided P value of .05 was considered significant. The study was approved by the University of Nebraska Medical Center institutional review board.
Results
The overall response rate was 69% (Nebraska, 171/231 [74%]; Michigan, 280/425 [66%]), and the mean reported occupancy rate was 88% (Table 1). Michigan nursing homes were larger and had higher occupancy rates. For Michigan nursing homes, 167 (61%) of the responders were proprietary, 93 (33%) were nonprofit, and 20 (6%) were government-funded. This was similar to the national distribution: 9900 (61%) proprietary, 5000 (31%) nonprofit, and 1200 (8%) government-funded.6
Table 1.
Facility Demographics and Response Rates
| No. (%) of Nursing Homes | P Valuea | |||||
|---|---|---|---|---|---|---|
| Nebraska | Michigan | |||||
| Surveyed (n = 231) |
Responding (n = 171) |
Surveyed (n =25) |
Responding (n = 280) |
|||
| Total No. of licensed beds | ||||||
| 1–50 | 85 (37) | 45 (26) | 52 (12) | 30 (11) |  |
<.001 |
| 51–75 | 74 (32) | 65 (38) | 62 (15) | 35 (13) | ||
| 76–100 | 28 (12) | 22 (13) | 71 (17) | 51 (18) | ||
| 101–150 | 30 (13) | 29 (17) | 161 (38) | 103 (37) | ||
| >150 | 14 (6) | 10 (6) | 79 (18) | 61 (21) | ||
| Occupancy over the past quarter, % | ||||||
| 0–82 | NA | 61 (37) | NA | 43 (16) |  |
<.001 |
| 83–90 | NA | 63 (38) | NA | 89 (34) | ||
| 91–95 | NA | 29 (18) | NA | 58 (22) | ||
| >95 | NA | 11 (7) | NA | 72 (27) | ||
Abbreviation: NA, not applicable.
Comparison of Nebraska vs Michigan responding nursing homes by χ2 test.
Of the nursing home respondents, 97 (23%) had a separate pandemic plan (Table 2). One hundred ten (26%) had incorporated pandemic response within their general disaster response plan, and 221 (52%) did not have any pandemic plan. A large majority (345, 77%) of responding nursing homes had a designated person in charge of pandemic planning. The staff positions with this responsibility included infection control professionals (154, 45%), executive directors or administrators (72, 21%), directors of nursing (48, 14%), or safety coordinators (47, 14%). Half (216) of the nursing homes stock-piled some supplies: gloves (170, 38%), alcohol rub (156, 35%), surgical masks (152, 34%), linen (95, 21%), food (81, 18%), N95 masks (50, 11%), and antiviral medications (18 [6%] for Michigan nursing homes).
Table 2.
Planning Components for Pandemic Influenza in Nursing Homesa
| Respondents, No./Total (%) | P Valueb | ||||
|---|---|---|---|---|---|
| Nebraska (n = 171) |
Michigan (n = 280) |
Total (n = 451) |
|||
| Pandemic influenza plan | |||||
| Separate plan | 36/167 (22) | 61/261 (23) | 97/428 (23) |  |
.85 |
| Part of current plan | 42/167 (25) | 68/261 (26) | 110/428 (26) | ||
| Does not yet have a plan | 89/167 (53) | 132/261 (51) | 221/428 (52) | ||
| Staff position responsible for pandemic or disaster preparedness | 122/167 (73) | 223/279 (80) | 345/446 (77) | .09 | |
| Referred to the CDC nursing home pandemic preparedness checklist | 105/170 (62) | 171/276 (62) | 276/446 (62) | .97 | |
| Stockpiling supplies | 66/167 (40) | 150/264 (57) | 216/431 (50) | <.001 | |
| Plans to provide pandemic training | 70/148 (47) | 131/241 (54) | 201/389 (52) | .18 | |
| Staff given introductory pandemic education | 87/167 (52) | 104/248 (42) | 191/415 (46) | .04 | |
| Access to laboratory facilities for influenza detection | 118/147 (80) | 215/248 (87) | 333/395 (84) | .09 | |
| Plans to prioritize staff and residents for vaccine and antiviral distribution | 75/152 (49) | 156/249 (63) | 231/401 (58) | .009 | |
| Plans to brief family members, visitors, vendors, and consultants | 66/147 (45) | 141/247 (57) | 207/394 (53) | .02 | |
| Communication lines established with nearby hospitals | 53/138 (38) | 112/227 (49) | 165/365 (45) | .04 | |
| Communication lines with state and local public health officials | 65/136 (48) | 121/217 (56) | 186/353 (53) | .14 | |
| Conducted pandemic influenza outbreak exercises | 8/168 (5) | 20/264 (8) | 28/432 (6) | .25 | |
| Mental health and faith-based services available | 94/154 (61) | 185/239 (77) | 279/393 (71) | <.001 | |
| Nursing homes being counted on as alternative care sites for hospital overflow | 112/165 (68) | 137/272 (50) | 249/437 (57) | <.001 | |
| Additional beds could be made available | 79/171 (46) | 89/280 (32) | 168/451 (37) | .002 | |
| Will accept hospital overflow influenza patients requiring low level of care | 60/171 (35) | 110/280 (39) | 170/451 (38) | .37 | |
| Will accept hospital overflow noninfluenza patients requiring low level of care | 115/171 (67) | 148/280 (53) | 263/451 (58) | .003 | |
| Will discharge residents to open up beds | 7/171 (4) | 25/280 (9) | 32/451 (7) | .05 | |
| Will accept patients on ventilators | 8/171 (5) | 11/280 (4) | 19/451 (4) | .70 | |
| Will provide community care and services such as vaccination clinics | 62/171 (36) | 85/280 (30) | 147/451 (33) | .19 | |
Abbreviation: CDC, Centers for Disease Control and Prevention.
Responses of “do not know” were treated as missing data.
Comparison of Nebraska vs Michigan responding nursing homes using χ2 test.
Regarding surge capacity, 168 (37%) of the respondents reported they would have beds available to take hospital overflow, and few (32, 7%) would consider discharging residents to make room for patients (Table 2). Facilities were more likely to accept noninfluenza patients than influenza patients requiring low levels of care (263 [58%] vs 170 [38%]).
In general, Michigan and Nebraska nursing home respondents did not differ greatly in their reported levels of pandemic planning; however, Nebraska nursing homes were more likely to have given staff introductory pandemic education while Michigan nursing homes were more likely to have stockpiled supplies, have mental health services available, and have undertaken other planning activities (Table 2).
Comment
In these 2 states, we found that although many nursing homes have undertaken some pandemic influenza preparedness planning, only 23% have a specific pandemic response plan. Many nursing homes have staff training plans, adequate laboratory access, available mental health services, and procedures for handling family and visitors during a pandemic. However, about half had not established lines of communication with state and local public health officials or with nearby hospitals, suggesting the potential for improved community-wide coordination.
Study limitations included that the survey was from only 2 states and we did not perform any qualitative assessments. In addition, this was a self-administered questionnaire with a potential for reporter bias. There were no data to compare rural vs urban nursing homes. Nevertheless, these results may be useful to national public health planners to better define the role of nursing homes in an influenza pandemic.
Acknowledgments
Funding/Support: This study was supported by grants K23 AG028943 (L.M.) and T35 AG026738 (M.K.) from the National Institute on Aging, the ASP/AGS T. Franklin Williams Research Scholarship (L.M.), and Student Research Training in Aging for Medical Students (M.K.).
Role of the Sponsor: The sponsor had no role in the design and conduct of the study; in the collection, analysis, and interpretation of the data; or in the preparation, review, or approval of the manuscript.
Footnotes
Author Contributions: Dr P. W. Smith had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: P. W. Smith, Mody.
Acquisition of data: P. W. Smith, A. Smith, Kaufmann, Mody.
Analysis and interpretation of data: P. W. Smith, Shostrom, Kaufmann, Mody.
Drafting of the manuscript: P. W. Smith, A. Smith, Kaufmann, Mody.
Critical revision of the manuscript for important intellectual content: P. W. Smith, Shostrom, Mody.
Statistical analysis: Shostrom, Kaufmann, Mody.
Obtained funding: Mody.
Administrative, technical, or material support: A. Smith, Mody.
Study supervision: P. W. Smith, Mody.
Financial Disclosures: None reported.
Additional Contributions: Connie Wagner, RN, BSN, Nebraska Health Care Association, provided technical assistance with the survey, and Elaine Litton and Jane Meza, PhD, University of Nebraska Medical Center, assisted with the survey. None of these individuals received compensation for the project.
Contributor Information
Philip W. Smith, Email: pwsmith@unmc.edu, Department of Internal Medicine, College of Medicine.
Valerie Shostrom, College of Public Health, University of Nebraska Medical Center, Omaha.
Al Smith, Nebraska Center for Biopreparedness Education, Omaha.
Michael Kaufmann, Division of Geriatrics, University of Michigan, Ann Arbor.
Lona Mody, Geriatrics Research, Education and Clinical Center, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor.
References
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