Table 2.
COVID-19 outcomes related to the nature of long-term care facilities
| Study | Facilities | Outcomes |
| Abrams et al17 | Facilities | Average number of cases was 19.8 (range 1–256). New Jersey (88.6%, OR 7.16) and Massachusetts (78.0%, OR 4.36) had a higher number of affected facilities. Probability of having a COVID-19 case: Facility size (relative to small): large OR=6.52; medium OR=2.63. Location (relative to rural): urban OR=3.22. % African American residents (relative to low %): greater % OR=2.05. Nursing home chain status (relative to non-chain status): chain status OR=0.89. States were significantly related to the probability of having COVID-19 case. Outbreak size associations: Facility size (relative to small facility size): large=−15.88; medium=−10.8 (percentage point change). For-profit status (relative to non-profit status)=1.88. State. Medicaid dependency, ownership, five-star rating and prior infection violation were not significantly related to COVID-19 cases. |
| Brainard et al37 | Facilities | Risk of infection: Facility employee numbers (relative to <10 workers): 11–20 non-care workers HR=6.502 (95% CI 2.614 to 16.17); 21–30 non-care workers HR=9.870 (95% CI 3.224 to 30.22); >30 non-care workers HR=18.927 (95% CI 2.358 to 151.90). Predictors of spread and increase in cases per unit after 5 April risk increased 1.0347 (95% CI 1.02 to 1.05) p<0.001, reduced availability of PPE for eye protection increased risk 1.6571 (95% CI 1.29 to 2.13) p<0.001, PPE for facemasks 1.2602 (95% CI 1.09 to 1.46) p=0.002, count of care workers employed 1.0379 (95% CI 1.02 to 1.05) p<0.001 count of nurses employed (in bands of 0–10,11–20, 21–30 and 31+) 1.1814 (95% CI 1.13 to 1.24) p<0.001. |
| Brown et al42 | Facilities | Incidence in high crowding index homes was 9.7% vs 4.5% in low crowding index homes (p<0.001), while COVID-19 mortality was 2.7% vs 1.3%. Likelihood of COVID-19 introduction did not differ (31.3% vs 30.2%, p=0.79). After adjustment for a regional nursing home, and resident covariates, the crowding index remained associated with increased risk of infection (RR=1.72, 95% CI 1.11 to 2.65) and mortality (RR=1.72, 95% CI 1.03 to 2.86). Simulations suggested that converting all 4-bed rooms to 2-bed rooms would have averted 988 (18.9%) infections of COVID-19 and 271 (18.7%) deaths. |
| Burton et al38 | Facilities | Significant associations between the presence of an outbreak and number of beds (OR per 20-bed increase 3.50), a history of multiple outbreaks (OR 3.76) and regulatory risk assessment score (OR high-risk vs low 2.19). However, in the adjusted analysis, only number of beds (OR per 20-bed increase 3.50, 95% CI 2.06 to 5.94 per 20-bed increase). |
| Dutey-Magni et al39 | Facilities | COVID-19 outbreak recorded in 121 of 179 facilities (67.6%). Large LTCF had greater rates of infection (aHR=1.8 (95% CI 1.4 to 2.4) for LTCF with ≥70 beds versus <35 beds. The adjusted HR for confirmed infection was 2.5 times (95% CI 1.9 to 3.3) greater in LTCF with 0.85–1 resident per room vs LTCF with 0.7–0.85 resident per room. A 10-percentage point increase in the bed to staff ratio was associated with a 23% increase in infection (aHR=1.23 (95% CI 1.17 to 1.31)). |
| Fisman et al43 | Facilities | COVID-19 cases higher in for-profit operators 165/361 (45.7%) compared with charitable 18/57 (31.6%). |
| Hand et al24 | Facilities | Residents noted to share rooms, walk throughout the facility and spent time in shared areas (eg, gym, dining rooms and recreational rooms). Because all case-patients had visited the gym at the facility for recreation or physical therapy before becoming ill, environmental cleaning of this area was performed. |
| Heung et al47 | Facilities | 67 of 90 residents participated. 26 of 32 staff participated. Two residents and one staff member were positive during the outbreak. None of the remaining participants was positive for SARS-CoV antibodies. Residents were aged 65+ years, 79% were female, 93% were ambulant, 90% did activities with others, 79% went out. Review of residents who died: resident A transferred from the hospital and was chair bound and dependent with care needs. Resident B was chair bound and had not left home or had visitors. She was brought to a shared sitting room during mealtimes. This was only time residents A and B were located near each other. One resident shared a room with patient B and tested positive. Staff C was a domestic worker, and contact was via clinical waste in resident A room. Low seroprevalence attributed to precautionary measures taken in the facility to reduce droplet and prevent contact transmission. Risks noted of SARS via fomites possible. |
| Ho et al48 | Facilities | 3 residents positive for SARS. 1 employee positive for SARS. 3 visitors positive for SARS. The index case was a single resident who was infected during a hospital stay, returned to the LTCF, and the virus spread to another six people. Transmission of the virus occurred due to lack of isolation rooms in nursing homes, lack of restricted movement of other patients and relatives, lack of infection control precautions, lack of knowledge among staff. |
| Iritani et al 52 | Facilities | Larger cluster sizes in long term care hospitals/facilities were significantly positively associated with higher morbidity (ρ=0.336, p=0.006) and higher mortality (ρ=0.317, p=0.009). Multivariate logistic regression showed larger cluster size (OR=1.077, 95% CI 1.017 to 1.145) and larger cluster number (OR=2.019, 95% CI 1.197 to 3.404) associated with mortality. |
| Kennelly et al51 | Facilities | Outbreak recorded in 75.0% (21/28) of facilities—four public and seventeen private. During the study period, 40.1% of residents in 21 nursing homes with outbreaks had a laboratory diagnosis of COVID-19. Correlation between the proportion of symptomatic staff and number of residents with confirmed/suspected COVID-19 (ρ=0.81). No significant correlation between the proportion of asymptomatic staff and number of residents with confirmed/suspected COVID-19 (ρ=0.18 p=0.61). |
| Kim53 | Facilities | After the management of the outbreak, there were no more infected persons. All patients and employees tested negative 14 days from the start of quarantine. |
| McMichael et al29 | Facilities | 28 February 2020, four cases COVID-19 identified in county. One person identified as index case from facility A. Staff roles for confirmed cases reported: therapists, nurses, nurse assistants, health information manager, physician and case manager. Paper reports that 30 facilities in county had confirmed cases and provides detail on the first 9 (facilities A to I). Facility A shared staff with another facility and two resident transfers from facility A. Surveillance reported inadequate PPE, training, infection control practices, lack of documentation signs and symptoms, working in unfamiliar facilities or sharing staff. On 10 March 2020, the governor of Washington implemented mandatory screening of healthcare workers and visitor restrictions for all licensed nursing homes and assisted living facilities including screening, testing, policies around visiting, excluding symptomatic staff, close monitoring of residents, testing, training and PPE. Monitoring of staff absences. |
| Office for National Statistics40 | Facilities | For each additional member of infected staff working at the care home, the odds of resident infection increase by 11%, that is, OR=1.11 (95% CI 1.1 to 1.11). Care homes using bank or agency nurses or carers most or every day more likely to have cases in residents (OR=1.58, 95% CI 1.5 to 1.65) compared with those who never use bank or agency staff. Residents in care homes outside of London had a lower chance of infection, except West Midlands (OR=1.09, 95% CI 1.0 to 1.17). Homes where staff receive sick pay are less likely to have resident cases (OR=0.82 to 0.93, 95% CI 7% to 18%), compared with homes where no sick leave. For each additional infected resident at a home, the odds of staff infection increase by 4% OR=1.04 (95% CI 4% to 4%). Care homes using bank or agency staff most or every day OR=1.88 (95% CI 1.77 to 2.0) compared with homes not using. Homes where staff regularly work elsewhere (most or every day) increase odds (OR=2.4, 95% CI 1.92 to 3.0) compared with homes who never work elsewhere. Staff at homes outside London had higher odds of COVID-19 infection. |
| Patel et al30 | Facilities | First resident unwell 9 March, female aged in her 60s with cough and fever. Hospitalised 11 March and tested positive COVID-19 13 March. 14 residents who were positive developed symptoms over 30-day follow-up. 21% (n=7) confirmed cases lived in single occupancy rooms. 55% (n=18) were in a double room with another confirmed case, and 24% (n=8) were in a double room with a resident who was negative 15 March. Screening visitors and staff for symptoms, restricting visiting hours from 6 March. No visitor access from 12 March. Universal masking of all staff and residents from 14 March. 15−19 March on-site team implemented assessment of symptoms, resident cohorting. Staff testing positive isolated and return 7 days or after 72 hours of symptoms resolving. Education and training to staff in facility A infection control, PPE, vital signs. |
| Quigley et al32 | Facilities | For-profit=67.86%, non-profit=26.79% and government-owned=5.36%. 37.5% were part of a chain. 54% have COVID-19 plans. All had staff training for COVID-19 and 100% processes to restrict/ limit visitors. 29% conducted COVID-19 simulation training. Communication with local Public Health—96% and 68% linked to local hospital referral. 66% reported access to COVID-19 tests—available for all residents and 53% of staff. 72% reported inadequate PPE supplies. 83% expected staff shortages. Solutions for staff included staff volunteer for more shifts (55%), non-clinical staff used (45%). 19% reported they would use agency staff. |
| Sacco et al46 | Facilities | Restrictions on residents from 16 March—social distancing, remain in single rooms, no communal dining or group activities. No visitors since 10 March, individual walks outside only in the presence of one staff member. Mail and packages stored 24 hours before being delivered to residents. Enhanced hygiene and cleaning. Staff had permanent face masks and additional hand hygiene. |
| Sanchez et al34 | Facilities | Of the 12 facilities in the final survey, 8 had implemented cohorting in a dedicated COVID-19 unit before first follow-up. 4 remaining initiating cohorting after receiving results. 4 facilities did not assign dedicated personnel to care for residents with COVID-19 due to staff shortages. Final survey census 80 residents (range 36–147). 373 of 1063 (35%) had received positive results first follow-up. |
| Stall et al44 | Facilities | Adjusted modelling odds of COVID-19 outbreak associated with for-profit status aOR 1.01 (95% CI 0.64 to 1.57), municipal aOR 0.83 (95% CI 0.45 to 1.54). Model 2+ Health Region aOR 2.02 (95% CI 1.20 to 3.38) population <10 000 rural aOR 0.27 (95% CI 0.13 to 0.58); and model 3+ home characteristics. Number of residents (unit of 50) aOR 1.38 (95% CI 1.18 to 1.61), older design aOR 1.55 (95% CI 1.01 to 2.38), chain ownership vs single home aOR 1.47 (95% CI 0.86 to 2.51) and staff (full time equivalent/bed ratio aOR 1.98 (95% CI 0.39 to 9.97). The extent of a COVID-19 outbreak with profit aRR 1.83 (95% CI 1.18 to 2.84) vs municipal aRR 0.60 (95% CI 0.28 to 1.30) compared with non-profit. Health Region aRR 1.65 (95% CI 1.02 to 2.67), older design standards aRR (95% CI 1.27 to 2.79), chain ownership aRR 1.84 (95% CI 1.08 to 3.15) and staff/bed ratio aRR 0.73 (95% CI 0.10 to 5.35). Deaths accounted for 6.5% of all residents in for-profit homes vs 5.5% in non-profit vs 1.7% municipal LTCF. For-profit associated with total COVID-19 deaths aRR 1.78, (95% CI 1.03 to 2.07). Adjusted model increased risk of death with for-profit aRR 0.82 (95% CI 0.44 to 1.54), older design facilities aRR 2.08 (95% CI 1.28 to 3.36) and chain ownership aRR 1.89, (95% CI 1.00 to 3.59). Number of active residents was protective aRR 0.81 (95% CI 0.70 to 0.95)/50 beds. |
| Unruh et al36 | Facilities | 184 nursing homes (15.8%) had 6 or more COVID-19 deaths. Deaths associated with Medicaid patients (quintile 5: 8.6 PP greater probability vs quintile 1). Patients with higher ADL scores (2.6 (95% CI 1.4 to 3.8) PP, p<0.001), more total beds (0.1 (95% CI 0.0 to 0.1) PP, p<0.001), higher occupancy (0.3 (95% CI 0.1 to 0.5) PP, p<0.009), for-profit status (4.8 (95% CI 0.8 to 8.8) PP, p=0.019). Comparing states: higher mortality in those with Medicaid (quintile 5: 6.1 (95% CI 0.0 to 12.1) PP, p=0.048). Not significant for other states. More direct care hours per patient day associated with lower COVID-19 deaths. All states (−4.8 (95% CI −9.4 to−0.03) PP, p<0.04). |
ADL, activities of daily living; aHR, adjusted HR; aOR, adjusted OR; aRR, adjusted relative risk; LTCF, long-term care facility; PP, percentage points; PPE, personal protective equipment.