key: cord-0756216-06egid7v
authors: Ryskina, Kira L.; Yun, Hyunkyung; Wang, Hannah; Chen, Angela T.; Jung, Hye-Young
title: Characteristics of Nursing Homes by COVID-19 Cases among Staff: March to August 2020
date: 2021-02-11
journal: J Am Med Dir Assoc
DOI: 10.1016/j.jamda.2021.02.004
sha: 6625c28a58bfe24bb8d4ee1e07ed98de5264bb4d
doc_id: 756216
cord_uid: 06egid7v

Objective To measure the association between nursing home (NH) characteristics and COVID-19 prevalence among NH staff. Design Retrospective cross-sectional study. Setting and Participants: Centers for Disease Control COVID-19 database for US NHs between March and August 2020, linked to NH facility characteristics (LTCFocus database) and local COVID-19 prevalence (USA Facts). Methods We estimated the associations between NH characteristics, local infection rates, and other regional characteristics and COVID-19 cases among NH staff (nursing staff, clinical staff, aides, and other facility personnel) measured per 100 beds, controlling for the hospital referral regions in which NHs were located to account for local infection control practices and other unobserved characteristics. Results Of the 11,858 NHs in our sample, 78.6% reported at least one staff case of COVID-19. After accounting for local COVID-19 prevalence, NHs in the highest quartile of confirmed resident cases (413.5 to 920.0 cases per 1,000 residents) reported 18.9 more staff cases per 100 beds compared to NHs that had no resident cases. Large NHs (150 or more beds) reported 2.6 fewer staff cases per 100 beds compared to small NHs (<50 beds) and for-profit NHs reported 0.8 fewer staff cases per 100 beds compared to non-profit NHs. Higher occupancy and more direct care hours per day were associated with more staff cases (0.4 more cases per 100 beds for a 10% increase in occupancy, and 0.7 more cases per 100 beds for an increase in direct care staffing of 1 hour per resident day, respectively). Estimates associated with resident demographics, payer mix or regional socioeconomic characteristics were not statistically significant. Conclusions and implications These findings highlight the urgent need to support facilities with emergency resources such as back-up staff and protocols to reduce resident density within the facility which may help stem outbreaks.

Since the start of the COVID-19 outbreak in early 2020, almost 21 million cases have 29 been reported in the US. 1 Among the hardest hit have been residents of nursing homes (NHs), 30 who comprise less than 1% of the US population but account for more than 40% of deaths 31 attributed to NHs were particularly vulnerable to the outbreak due to a number of 32 longstanding structural deficiencies, including inadequate supply and access to personal 33 protective equipment (PPE) and staffing shortages. 3 Anecdotal reports from early days of the 34 pandemic documented the severe impact of these deficiencies on the mental health of NH staff as 35 a result of stress and fatigue. 4 To combat these issues and support nursing home staff, some 36 states have implemented policies that modify licensure laws 5 and increase compensation and 37 paid leave for NH healthcare workers. 6,7 However, properly understanding the impact of 38 COVID-19 on NH staff has been difficult because reliable reporting on NH staff cases and 39 deaths has been lacking. 8,9 40 This study presents the first national description of COVID-19 cases among NH staff 41 reported to the Centers for Disease Control (CDC) COVID-19 NH reporting database. The 42 database employs systematic quality assurance to identify instances where facilities may have 43 entered incorrect data. 10 We also identify facility-and community-level factors associated with 44 NH staff cases. Understanding these relationships is an integral step toward the further 45 development of policies and strategies to improve the safety of NH staff, address NH staffing 46 shortages, and improve the care quality for NH residents. Specifically, our objectives were to (1) measure the prevalence of COVID-19 among NH staff during the first wave of the pandemic 5 NH characteristics included resident demographics (average age of residents in the facility, percentage of residents who were female, percentage who were white), case mix 74 (percentage of patients insured by Medicare and Medicaid, respectively, and average functional 75 status measured using the activities of daily living (ADL) score), and facility factors (size, 76 ownership, occupancy, part of multi-facility chain, direct care staff hours per patient day, 77 presence of advanced practitioners on staff, and presence of a Alzheimer's specialty unit). 11-13

We also collected information on personal protective equipment (PPE) shortages reported by the 79 NHs in the CDC COVID-19 database. NHs reported whether they had sufficient supplies of 80 different classes of PPE over the last 7 days. PPE classes included N95 masks, surgical masks, 81 eye protective equipment, gowns, disposable gloves, and hand sanitizer. Facilities that did not 82 have sufficient supply to last 7 days were considered to be experiencing a shortage of the PPE.

Community characteristics measured at the county level included rural vs. urban location, 84 median household income, percentage of population over 75 years of age, prevalence of COVID-85 19 cases among NH residents (measured in cases per 1,000 residents), and community 86 prevalence of COVID-19 cases (measured in cases per 1,000 residents). Cases among NH staff 87 and NH residents were subtracted from the number of cases measured at the county level to 88 avoid double counting. Additionally, we included an indicator of whether a state had a NH 89 visitation ban during the study period.

Analyses were performed at the NH level. For the descriptive analyses, facilities were 91 stratified into four categories of COVID-19 cases among staff (no cases, more than 0 and less 92 than 5 cases, 5 or more and less than 15 cases, and 15 or more cases per 100 beds). Estimates of the sensitivity analysis using a negative binomial regression model were 155 largely consistent with those from our primary analysis (Appendix Table 1 ). Atlantic, and South of the US. Notably, facilities without any staff cases were often located in 160 the same regions with the exception of parts of the South (Figure) . week?" by PPE type and answers were collected in a binary Yes/No format. 2020. The bottom map shows nursing homes that reported no COVID-19 cases among staff.

Alaska was excluded from the analysis (no data).

Geographic Distribution of Nursing Home Staff COVID-19 Cases

The bottom map shows nursing homes that reported no COVID-19 cases among staff. Alaska was excluded from the analysis