key: cord-0715830-rzk5rpn7
authors: Dykgraaf, Sally Hall; Matenge, Sethunya; Desborough, Jane; Sturgiss, Elizabeth; Dut, Garang; Roberts, Leslee; McMillan, Alison; Kidd, Michael
title: PROTECTING NURSING HOMES AND LONG TERM CARE FACILITIES FROM COVID-19: A RAPID REVIEW OF INTERNATIONAL EVIDENCE
date: 2021-08-03
journal: J Am Med Dir Assoc
DOI: 10.1016/j.jamda.2021.07.027
sha: e54ddcdc4c1b7f6eed87540d3aec3db869f4013f
doc_id: 715830
cord_uid: rzk5rpn7

Objectives The COVID-19 pandemic has highlighted the extreme vulnerability of older people and other individuals who reside in long term care, creating an urgent need for evidence-based policy that can adequately protect these community members. This study aimed to provide synthesized evidence to support policy decision-making. Design Rapid narrative review investigating strategies that have prevented or mitigated SARS-CoV-2 transmission in long term care. Setting and Participants Residents and staff in care settings such as nursing homes and long term care facilities. Methods PubMed/Medline, Cochrane Library and Scopus were systematically searched, with studies describing potentially effective strategies included. Studies were excluded if they did not report empirical evidence (for example commentaries and consensus guidelines). Study quality was appraised on the basis of study design; data were extracted from published reports and synthesised narratively using tabulated data extracts and summary tables. Results Searches yielded 713 articles; 80 papers describing 77 studies were included. Most studies were observational with no randomized controlled trials identified. Intervention studies provided strong support for widespread surveillance, early identification and response, and rigorous infection prevention and control (IPC) measures. Symptom or temperature based screening, and single point-prevalence testing, were found to be ineffective, and serial universal testing of residents and staff was considered crucial. Attention to ventilation and environmental management, digital health applications and acute sector support were also considered beneficial although evidence for effectiveness was lacking. In observational studies, staff represented substantial transmission risk and workforce management strategies were important components of pandemic response. Higher performing facilities with less crowding and higher nurse staffing ratios had reduced transmission rates. Outbreak investigations suggested that facility-level leadership, inter-sectoral collaboration and policy that facilitated access to critical resources were all significant enablers of success. Conclusions and Implications High quality evidence of effectiveness in protecting LTCFs from COVID-19 was limited at the time of this study, though continues to emerge. Despite widespread COVID-19 vaccination programs in many countries, continuing prevention and mitigation measures may be required to protect vulnerable long term care residents from COVID-19 and other infectious diseases. This rapid review summarises current evidence regarding strategies which may be effective.

Searches yielded 713 articles; 80 papers describing 77 studies were included. Most studies 23 were observational with no randomized controlled trials identified. Intervention studies 24 provided strong support for widespread surveillance, early identification and response, and 25 rigorous infection prevention and control (IPC) measures. Symptom or temperature based 26 screening, and single point-prevalence testing, were found to be ineffective, and serial 27 universal testing of residents and staff was considered crucial. Attention to ventilation and 28 environmental management, digital health applications and acute sector support were also 29 considered beneficial although evidence for effectiveness was lacking. In observational 30 studies, staff represented substantial transmission risk and workforce management 31 strategies were important components of pandemic response. Higher performing facilities 32 with less crowding and higher nurse staffing ratios had reduced transmission rates. 33 Outbreak investigations suggested that facility-level leadership, inter-sectoral collaboration 34 and policy that facilitated access to critical resources were all significant enablers of success. 35 Conclusions and Implications 36 High quality evidence of effectiveness in protecting LTCFs from COVID-19 was limited at the 37 time of this study, though continues to emerge. Despite widespread COVID-19 vaccination 38 programs in many countries, continuing prevention and mitigation measures may be 39 required to protect vulnerable long term care residents from COVID-19 and other infectious Introduction 44 Around the world, residential care settings such as nursing homes and long term care 45 facilities (LTCFs) have seen repeated COVID-19 outbreaks and been a conspicuous source of 46 COVID-19 morbidity and mortality.(1-3) [1] [2] [3] Age is an independent, non-modifiable risk factor 47 for COVID-19 related morbidity; poor prognostic outcomes increase with advancing age, and 48 mortality rates of up to 15% have been reported among people aged over 80 years. 4 Both 49 COVID-19 and the public health measures required to mitigate spread constitute a threat to 50 the health and wellbeing of older people. 5 Living in long-term care is also a significant risk 51 factor for COVID-19 mortality, 6 and LTCFs, especially those with elderly residents, have 52 become a common source of COVID-19 outbreaks. 7, 8 While 47% of early COVID-19 deaths 53 internationally were LTCF residents, 2 there is wide variability in disease transmission and 54 mortality rates between countries, and between facilities. 9 

Predictors of transmission in long-term care settings include congregate living, personal care 56 requirements that necessitate physical proximity, increased frailty or compromised health 57 status among residents, and behavioural and cognitive challenges that complicate infection 58 prevention and control (IPC) measures. [10] [11] [12] [13] Many elderly residents are in their last year of 59 life, 14 and have multiple health conditions, often coupled with physical dependency or 60 cognitive impairment. 15 Residents may be infectious while pre-symptomatic, 16 frequently 61 exhibit atypical symptoms, 17, 18 or are diagnosed with COVID-19 secondary to other 62 problems. 5 While carers working in LTCFs may be adept at supporting elders with cognitive 63 and physical impairment, they are often untrained in identifying and managing acutely 64 unwell residents 19 or managing complex IPC requirements. 65 J o u r n a l P r e -p r o o f Rationale for this review 66 The pronounced vulnerability of long-term care residents has been highlighted in many 67 countries, as harrowing accounts of the impact of the pandemic on nursing homes and 68 LTCFs emerge. 20, 21, 22 In Europe, LTCF residents have been deemed at particularly high risk as 69 a result of high probability of infection and very high impact of disease. 23 In the United 70 States, up to 61,000 cases and 5,000 deaths were being reported in LTCFs each week by 71 December 2020. 24 In the United Kingdom 53.1% of 5126 LTCFs participating in a national 72 survey reported COVID-19 cases. Protecting vulnerable individuals such as those living in 73 long-term care is a crucial policy response in the pandemic context, 6, 9 and has been 74 identified in previous infectious disease outbreaks and public health emergencies. 3 

Where policy-makers urgently require knowledge on which to base decisions, the World 76 Health Organization and others have advocated use of rapid review methodologies. [25] [26] [27] This 77 paper describes the results of a rapid review of international literature, conducted to 78 support federal policy decision-making in Australia at the end of 2020. As part of Australia's 79 public health response to COVID-19, policy makers had requested an urgent review of 80 international strategies which had been successful in preventing or reducing COVID-19 81 transmission in long-term care settings. 82 A number of high profile outbreaks had occurred in nursing homes during the first wave of 83 COVID-19 in Australia, 28,29 accompanied by substantial media attention and community 84 concern. 30,31 LTCF residents constituted 74.5% of total COVID-19 deaths at the time of 85 writing (30 June 2021). 32 These circumstances raised urgent policy questions about COVID- 86 19 mitigation and containment measures known to be effective in long-term care, and to 87 assist in being better prepared for future outbreaks of infectious disease. While several 88 J o u r n a l P r e -p r o o f inter-country comparisons of aged care outcomes and multiple guidelines and 89 recommendations were available there was little synthesised evidence available regarding 90 the effectiveness of specific strategies. 91 Many different terms are used to refer to long-term care across different sectors and 92 countries, 33 and while these overlap to some degree they are not directly interchangeable. 93 However, for simplicity and consistency with the international literature we use the 94 nomenclature LTCF to encompass the range of settings and terminology used. This approach 95 recognizes that long-term care is not exclusively for the elderly, and that the same risks and 96 challenges apply to settings such as disability care with respect to COVID-19. 97 Methods 98 We conducted a structured search of PubMed/Medline, Cochrane Library and Scopus 99 (Health & Medicine, Elsevier) to 24 November 2020 for English-language articles, using the 100 search string ["aged care" OR "long term care" OR "social care" OR "residential care" OR 101 "elder care" OR "nursing home" OR "care home"] AND [COVID OR SARS-CoV-2] AND 102 [prevent* OR limit* OR control OR manage OR mitigate OR contain OR interrupt OR 103 intervention]. We hand-searched reference lists of identified articles and other relevant 104 papers on COVID-19 in aged care settings. We also looked for country-based strategic 105 approaches documented in non-peer reviewed literature, and their perceived success or 106 otherwise; this included examining key websites such as the International Long-Term Care 107 Policy Network. 34 108 Studies were included if they described interventions, associations or investigations that 109 provided potential evidence for effectiveness in preventing or reducing COVID-19 110 transmission within LTCFs. Consistent with other rapid review methodologies, 35,36 title and 111 J o u r n a l P r e -p r o o f abstract screening was conducted by a single reviewer (SH or SM) with cross-validation of a 112 random sample by a second reviewer (AM, JD, GD, ES). Full text screening and data 113 abstraction were undertaken by a single reviewer for each paper (AM, JD, GD, SM, ES, SH) 114 using an agreed extraction template, with collective review if required. Given the rapid 115 speed with which the review was undertaken, and significant constraints on the nature of 116 the evidence-base due to its timing relatively early in the pandemic, risk of bias was not 117 examined in detail, with study quality assessed on the basis of study design and results 118 stratified accordingly. Due to study heterogeneity, data were synthesised narratively using 119 tabulated data extracts and summary tables. 120 

The review identified 713 unique records, with 197 full text articles assessed for eligibility 122 after title and abstract screening ( Figure 1 ). Eighty publications describing 77 studies were 123 included: four were systematic reviews (Table 1a) ; 37-40 38 assessed interventions (Table   124 1b); 11,16,41-76 21 examined risks and factors associated with the existence or severity of 125 outbreaks (Table 1c) ; 1,77-96 and 17 described epidemiological investigations of COVID-19 126 outbreaks in LTCFs, reflecting on the effectiveness of strategies or lessons learned (Table   127 1d). 28, 29, [97] [98] [99] [100] [101] [102] [103] [104] [105] [106] [107] [108] [109] [110] [111] [112] Overall, the evidence base is immature, comprised mainly of observational 128 studies with no randomised or controlled trials, and few rigorous systematic reviews. At this 129 time (November 2020), we found little evidence linking interventions or strategies to robust 130 data on effectiveness. Included studies are outlined by study type in Table 1 , with study 131 characteristics summarised in Table 2 . Noting differences in nomenclature identified 132 previously, facility types are collated according to the language used in the relevant paper. 133 J o u r n a l P r e -p r o o f We acknowledge that in some cases these 'types' represent different terminology for similar 134 or even identical organisations. 135 Potentially effective strategies 136 Multifocal infectious disease responses 137 Most papers, especially those detailing epidemiological investigations, describe multi- 138 faceted infectious disease responses to manage risk or potential outbreaks in LTCFs (Box 1). 139 Due to their retrospective, observational nature, high quality evidence of effectiveness was 140 limited. Approaches generally included some combination of IPC practices, public health 141 surveillance and mitigation measures, and administrative or policy support functions. A 142 number of studies concluded that early and pro-active identification, followed by isolation 143 of infected individuals, was the most important outbreak control method 144 used. 28, 37, 59, 63, 64, 67, [70] [71] [72] 75, 76, 100, 101, 105, [108] [109] [110] 112 A survey of French LTCFs identified 145 heterogeneity in implementation of IPC guidance, finding fewer COVID-19 occurrences 146 among public LTCFs and those with compartmentalised staffing zones and better self- 147 reported quality of implementation. 60 Lessons gleaned from outbreak investigations, 148 included the need for proactive and decisive leadership at both facility and jurisdictional 149 level; active and ongoing communication; sustainable, collaborative responses; contingency 150 plans for surge capacity in both staff and equipment supplies such as personal protective 151 equipment (PPE); experienced IPC guidance to counter deficiencies in IPC competence and 152 confidence among aged care workers, and balancing IPC with quality of life for 153 residents. 28,29,99,105-108,110,111 154 Universal, serial testing of residents and staff 155 J o u r n a l P r e -p r o o f 8   Thirty-seven articles described universal testing protocols for residents, staff or   156   both, 11,16,37,41,43,44,46-49,51-54,56,57,62-64,67,68,70-73,75,76,84,97,102-105,108-110,113 resulting in declines in   157   new case numbers, 37,41,51,73,110 and early detection of COVID-19 cases. 59,61,63,64,72,75,109   158 Widespread testing was usually accompanied by rigorous IPC measures including isolation 159 or cohorting of positive cases, 37, 47, 49, 67, 70, 73, 75, 76, 108, 110 and often serial testing until all tests 160 were negative. 44,75,110 Some facilities used serial point-prevalence studies of all staff and 161 residents as an indicator of IPC effectiveness. 46 One study demonstated the effectiveness of 162 a pooling strategy for detecting COVID-19 in LTCFs with low prevalence and recommended 163 serial pooled-testing once zero prevalance was achieved. 68 164 Mass testing using nasopharyngeal swab with reverse transcriptase Polymerase Chain 165 Reaction (rt-PCR) was considered superior to symptom screening for case identification in 166 light of high proportions of asymptomatic or presymptomatic infections among residents 167 and staff (≤40%), 37, 48, 53, 56, 63, 67, [70] [71] [72] 84, 103, [108] [109] [110] and atypical presentations among 168 residents. 11, 109 Mass testing identified greater COVID-19 prevalence when conducted in 169 response to known infection (responsive testing) than without indication (passive testing); 170 with possible merit in 'passive' testing as a preventive measure with 'responsive' testing to 171 support containment strategies. 63 Such graduated approaches were suggested when testing 172 availability was compromised, maintaining low symptom thresholds and incorporating 173 atypical symptom profiles. 113 

Staff confinement within facilities 175 In a cohort of 17 French LTCFs (only one with positive cases), staff voluntarily self-confined 176 with residents for more than 7 days, 24 hours per day, during March and April 2020. These Cautious control of visitors 191 Restricting visitors has been a widely utilised strategy to prevent introduction of SARS-CoV-2 192 into LTCFs (see Table 2 ). In recognition of the importance of social and family connection, practices and other initiatives that have been employed to protect LTCFs; however, high 258 quality evidence of effectiveness in the COVID-19 context is currently limited. 259 There is strong observational evidence for serial universal testing of LTCF residents and staff 260 to enable rapid identification and containment of potential cases. In facilities with COVID-19 quarantine and PPE burn rate. 113 contacts; and presentation of a health insurance card enabling linkage to immigration 297 data. 136, 140 In Singapore a "heightened vigilance" approach saw referral of all symptomatic 298 residents to hospital, followed by isolation in negative pressure rooms. Acknowledged 299 drawbacks of this approach included increased falls, use of restraints, difficult responses to 300 behavioural issues and cognitive impairment, and challenges related to use of robotic 301 technology. 139 Such measures were often positioned as a response to lessons learnt during 302 previous epidemics, and while these jurisdictions reported few LTCF COVID-19 infections, 303 they also exhibited low rates of community transmission. 114,137,138,143 304 Facility staff were a frequent source of risk through either introducing or transmitting 305 infection, and were also exposed to risk through attending residents' physical care needs; The impact of COVID-19 mitigation measures on resident safety and wellbeing has been 334 recognised, 163 and was a theme across many studies in this review. The need to balance 335 COVID-19 control with compassionate, person-centred care for elderly people, 164 J o u r n a l P r e -p r o o f Targeted testing for individuals with fever and lower respiratory symptoms, or with potential exposure to a confirmed or suspected case (n=35); hospitalizations (n=3); mortality (n=1)

Components included a secure, cloud-based web application for case / exposure triage and reporting; isolation and IPC training and procedures adapted from US CDC; mobileenabled screening app to prevent employees from attending work when ill. J o u r n a l P r e -p r o o f J o u r n a l P r e -p r o o f

Factors associated with SARS-CoV-2 infection and outbreaks in long-term care facilities in England: a national cross-sectional survey

Mortality associated with COVID-19 outbreaks in care homes: early international evidence. International Long Term Care Policy Network

COVID-19 highlights Canada's care home crisis

Characteristics of and Important Lessons From the Coronavirus Disease 2019 (COVID-19) Outbreak in China: Summary of a Report of 72 314 Cases From the Chinese Center for Disease Control and Prevention

COVID-19 in older people: a rapid clinical review

Long-term care facilities as a risk factor in death from COVID-19. VOX EU

COVID-19 in Italy: An Analysis of Death Registry Data

Is social connectedness a risk factor for the spreading of COVID-19 among older adults? The Italian paradox

COVID-19 related mortality and spread of disease in long-term care: a living systematic review of emerging evidence

COVID-19, frailty and long-term care: Implications for policy and practice

SARS-CoV-2 infection, clinical features and outcome of COVID-19 in United Kingdom nursing homes

COVID-19 in Nursing Homes: Calming the Perfect Storm

Nursing homes: the titanic of cruise ships -will residential aged care facilities survive the COVID-19 pandemic?

The COVID-19 Pandemic: A Pandemic of Lockdown Loneliness and the Role of Digital Technology

Presymptomatic SARS-CoV-2 infections and transmission in a skilled nursing facility

Coronavirus Disease 2019 in Geriatrics and Long-Term Care: The ABCDs of COVID-19

Altered Mental Status as a Novel Initial Clinical Presentation for COVID-19 Infection in the Elderly

New allegations of cover-up by Cuomo over nursing home virus toll. The New York Times

Home-Based Primary Care Led-Outbreak Mitigation in Assisted Living Facilities in the First 100 Days of Coronavirus Disease 2019

Early Intervention Reduces the Spread of COVID-19 in Long-Term Care Facilities in the Republic of Korea

Guidance for the Prevention of the COVID-19

Epidemic in Long-Term Care Facilities: A Short-Term Prospective Study

Temperature in Nursing Home Residents Systematically Tested for SARS-CoV-2

Initial and Repeated Point Prevalence Surveys to Inform SARS-CoV-2 Infection Prevention in 26 Skilled Nursing Facilities -Detroit

Mass Screening for SARS-CoV-2 Infection among Residents and Staff in Twenty-eight Long-term Care Facilities in Fulton County

Preventing COVID-19 Outbreaks in Long-Term Care Facilities Through Preemptive Testing of Residents and Staff Members -Fulton County

Allowing Visitors Back in the Nursing Home During the COVID-19 Crisis: A Dutch National Study Into First Experiences and Impact on Well-Being

Real-Time Digital Contact Tracing: Development of a System to Control COVID-19 Outbreaks in Nursing Homes and Long-Term Care Facilities

Asymptomatic SARS-CoV-2 infection in nursing homes

Pooling for SARS-CoV-2 control in care institutions

Heat Maps for Surveillance and Prevention of COVID-19 Spread in Nursing Homes and Assisted Living Facilities

Three-Tiered COVID-19 Cohorting Strategy and Implications for Memory-Care

Asymptomatic Spread of COVID-19 in 97 Patients at a Skilled Nursing Facility

Asymptomatic carriage rates and case-fatality of SARS-CoV-2 infection in residents and staff in Irish nursing homes

Temperature Screening for SARS-CoV-2 in Nursing Homes: Evidence from Two National Cohorts

COVID-19 Infection Control Measures in Long-Term Care Facility

Efficacy of a Test-Retest Strategy in Residents and Health Care Personnel of a Nursing Home Facing a COVID-19 Outbreak

Characteristics of U.S. Nursing Homes with COVID-19 Cases

Outbreaks in Nursing Homes -West Virginia

Association of Nursing Home Ratings on Health Inspections, Quality of Care, and Nurse Staffing With COVID-19 Cases

Risk Factors Associated With Mortality Among Residents With Coronavirus Disease 2019 (COVID-19) in Long-term Care Facilities in Ontario

Nurse Staffing and Coronavirus Infections in California Nursing Homes

Is There a Link between Nursing Home Reported Quality

Cases? Evidence from California Skilled Nursing Facilities

Asymptomatic SARS-CoV-2 infection in Belgian long-term care facilities

Increased risk of SARS-CoV-2 infection in staff working across different care homes: enhanced CoVID-19 outbreak investigations in London care Homes

COVID-19 Infections and Deaths among Connecticut Nursing Home Residents: Facility Correlates

High seroprevalence of SARS-CoV-2 in elderly care employees in Sweden

For-profit long-term care homes and the risk of COVID-19 outbreaks and resident deaths

COVID-19 cases before and after the "I Stay at home" decree

Mapping community-level determinants of COVID-19 transmission in nursing homes: A multi-scale approach

Variation in SARS-CoV-2 Prevalence in U.S. Skilled Nursing Facilities

Association Between Nursing Home Crowding and COVID-19 Infection and Mortality in Ontario, Canada

Mortality Rates From COVID-19 Are Lower In Unionized Nursing Homes

Workers at long-term care facilities and their risk for severe COVID-19 illness

Risk Factors, Presentation, and Course of Coronavirus Disease 2019 in a Large, Academic Long-Term Care Facility

Predicting Coronavirus Disease 2019 Infection Risk and Related Risk Drivers in Nursing Homes: A Machine Learning Approach

Transmission of SARS-CoV-2 Involving Residents Receiving Dialysis in a Nursing Home -Maryland

Outbreak of COVID-19 in a nursing home associated with aerosol transmission as a result of inadequate ventilation

Tall Pines Healthcare COVID-19 Outbreak Experience in Rural Waldo County

COVID-19 in a Long-Term Care Facility

Epidemiology of Covid-19 in a Long-Term Care Facility in King County, Washington

Outbreak Investigation of COVID-19 Among Residents and Staff of an Independent and Assisted Living Community for Older Adults in

Detection of SARS-CoV-2 Among Residents and Staff Members of an Independent and Assisted Living Community for Older Adults

COVID-19 in seniors: Findings and lessons from mass screening in a nursing home

Responding to a COVID-19 Outbreak at a Long-Term Care Facility

COVID-19 in long-term care facilities in Frankfurt am Main, Germany: incidence, case reports, and lessons learned

COVID-19 in long-term care homes in Ontario and British Columbia

Partnering with Local Hospitals and Public Health to Manage COVID-19 Outbreaks in Nursing Homes

Critical infection control adaptations to survive covid-19 in retirement communities

Halting a SARS-CoV-2 outbreak in a US Veterans Affairs nursing home

Unravelling the modes of transmission of SARS-CoV-2 during a nursing home outbreak: looking beyond the church super-spread event

Nursing recommendations for facing dissemination of COVID-19 in Brazilian Nursing Homes

Editorial: Diagnostic Testing for SARS-Coronavirus-2 in the Nursing Facility: Recommendations of a Delphi Panel of Long-Term Care Clinicians

Care Homes and COVID-19 in Hong Kong: how the lessons from SARS were used to good effect

COVID-19 and long-term care facilities: Does ownership matter?

A cross-sectional survey assessing the preparedness of the long-term care sector to respond to the COVID-19 pandemic in Ontario

Essential Long-Term Care Workers Commonly Hold Second Jobs and Double-or Triple-Duty Caregiving Roles

Prevalence of SARS-CoV-2 infection in general practitioners and nurses in primary care and nursing homes in the Healthcare Area of León and associated factors

Clusters of COVID-19 in long-term care hospitals and facilities in Japan from 16

Active testing of groups at increased risk of acquiring SARS-CoV-2 in Canada: costs and human resource needs

Improving Preparedness for and Response to Coronavirus Disease 19 (COVID-19) in Long-Term Care Hospitals in Korea

We are Alone in This Battle": A Framework for a Coordinated Response to COVID-19 in Nursing Homes

Center quality and safety

Use the Environment to Prevent and Control COVID-19 in Senior-Living Facilities: An Analysis of the Guidelines Used in China

Impact of Coronavirus Disease 2019 (COVID-19) Outbreak on ST-Segment Elevation Myocardial Infarction Care in Hong Kong, China

Preventing and managing COVID-19 across long-term care services. Policy brief

Long-Term Care, Residential Facilities, and COVID-19: An Overview of Federal and State Policy Responses

A framework for patient-centered telemedicine: Application and lessons learned from vulnerable populations

High impact of COVID-19 in long-term care facilities, suggestion for monitoring in the EU/EEA

Israel Ad Hoc COVID-19 Committee: Guidelines for Care of Older Persons During a Pandemic

Stopping the SARS-CoV-2 surge in the USA-CDC recommendations and ground realities

Prevention and control of COVID-19 in nursing homes, orphanages, and prisons

Policy Recommendations Regarding Skilled Nursing Facility Management of Coronavirus 19 (COVID-19): Lessons from New York State

Diagnostic Testing for SARS-Coronavirus-2 in the Nursing Facility: Recommendations of a Delphi Panel of Long-Term Care Clinicians

Infection prevention and control guidance for long-term care facilities in the context of COVID-19 update. WHO

Preparing for COVID-19: The experiences of a longterm care facility in Taiwan

COVID-19 and Long-Term Care Policy for Older People in Hong Kong

Maintaining Zero Coronavirus Disease 2019 Infection Among Long-Term Care Facility Residents in Hong Kong

Preventing the Spread of COVID-19 to Nursing Homes: Experience from a Singapore Geriatric Centre

Successful prevention of COVID-19 outbreak at elderly care institutions in Taiwan

Helping Nursing Homes to Manage the COVID-19 Crisis: An Illustrative Example from France

Telemedicine in nursing homes during the COVID-19 outbreak: A star is born (again)

Nursing homes: the titanic of cruise ships -will residential aged care facilities survive the COVID-19 pandemic?

Care Aides Working Multiple Jobs: Considerations for Staffing Policies in Long-Term Care Homes During and After the COVID-19 Pandemic

In Conversation with a Frontline Worker in a Care Home in Sweden during the COVID-19 Pandemic

Lessons learned -Outbreaks of COVID-19 in nursing homes

Learnings to operate LTC better from the COVID-19 crisis

Could we have done better with COVID-19 in nursing homes?

Appropriate Nurse Staffing Levels for U.S. Nursing Homes

Characteristics and outcomes of health and social care workers testing positive for SARS-CoV-2 in the Tayside region of Scotland

Drive-through testing for SARS-CoV-2 in symptomatic health and social care workers and household members: an observational cohort study

Seeking Answers for Care Homes during the COVID-19 pandemic (COVID SEARCH)

Nursing Home Social Workers Perceptions of Preparedness and Coping for COVID-19

Severe Staffing And Personal Protective Equipment Shortages Faced By Nursing Homes During The COVID-19 Pandemic

Safe Interorganizational Health Information Exchange During the COVID-19 Pandemic

Environmental detection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) from medical equipment in long-term care facilities undergoing COVID-19 outbreaks

Environmental contamination of SARS-CoV-2 on surfaces, air-conditioner and ventilation systems

Indoor transmission of SARS-CoV-2

Airborne transmission of covid-19

As death toll in nursing homes climbs, calls to redesign them grow. The New York Times

Caring for elderly Australians in a home-like setting can reduce hospital visits. The Conversation

Timely Lessons from a Pandemic on the Benefits of Person Centric Care in Long Term Care Facilities

COVID-19: Managing the COVID-19 pandemic in care homes for older people Online: British Geritrics Society

Achieving Safe, Effective, and Compassionate Quarantine or Isolation of Older Adults With Dementia in Nursing Homes

Preventing Social Isolation: A Holistic Approach to Nursing Interventions

The Coronavirus and the Risks to the Elderly in Long-Term Care

The neglect of adult social care during covid-19

Amid the COVID-19 Pandemic, Meaningful Communication between Family Caregivers and Residents of Long-Term Care Facilities is Imperative

Medicine is a social science: COVID-19 and the tragedy of residential care facilities in high-income countries

Protecting and Improving the Lives of Older Adults in the COVID-19 Era

Older Adults and Covid-19: The Most Vulnerable, the Hardest Hit

International COVID-19 Palliative Care Guidance for Nursing Homes Leaves Key Themes Unaddressed

A UK survey of COVID-19 related social support closures and their effects on older people, people with dementia, and carers

Family members' concerns about relatives in long-term care facilities: Acceptance of visiting restriction policy amid the COVID-19 pandemic

 Staff travel abroad prohibited and required to report weekend and vacation activities each week 138 Residents and staff subject to compulsory 14-day quarantine on return from overseas travel 106,137  Physical distancing +/-buddy system 103  Re-organisation of staff schedules and allocation (physical location), 136 with staff cohorting and crossover restrictions 60,67,70,108-111  Suspension of all non-essential medical services, including chronic illness care, 137 to reduce number of visiting doctors 137,138  Engagement of quality management staff as dedicated observers to prevent infection prevention and control (IPC) lapses 57,73,106,108