key: cord-0757793-7izl7d1i
authors: González de Villaumbrosia, Cristina; Martínez Peromingo, Javier; Ortiz Imedio, Juan; Álvarez de Espejo Montiel, Teresa; García-Puente Suárez, Laura; Navas Clemente, Iván; Morales Cubo, Sandra; Cotano Abad, Laura Elena; Suárez Sánchez, Yanira; Torras Cortada, Sonia; Oñoro Algar, Carlos; Palicio Martínez, Carolina; Plaza Nohales, Carmen; Barba Martín, Raquel
title: Implementation of an algorithm of cohort classification to prevent the spread of COVID-19 in nursing homes.
date: 2020-10-22
journal: J Am Med Dir Assoc
DOI: 10.1016/j.jamda.2020.10.023
sha: 241bc585d1d7ad341d0f735a8a184f89c8993374
doc_id: 757793
cord_uid: 7izl7d1i

Older adults living in nursing homes are the most vulnerable group of the COVID-19 pandemic. There are many difficulties in isolating residents and limiting the spread in this setting. We have developed a simple algorithm with a traffic light shape for resident classification and sectorization within nursing homes, based on basic diagnostic tests, surveillance of symptoms onset and close contact monitoring. We have implemented the algorithm in several centers with good data on adherence. Suggestions for implementation and evaluation are discussed.

Older adults are the most vulnerable group in the COVID-19 health crisis, since 12 it is the highest mortality-rate age group. In our country of Spain, mortality from 13 coronavirus in people over 80 years is 21%, compared to a 7.8% overall rate 1 . 14 Furthermore, 80% of all deaths occur in patients older than 70 years old 1 . 15

Nursing home residents are even more vulnerable than older adults in general 16 because of their age, dependency and comorbidities 2 . Moreover, disease 17 transmission in this setting is much higher than that of adults living in the 18 community, due to a greater difficulty to carry out isolation practices, because of 19 the preexisting close contact to other residents and staff who look after them 4 . 20

In general, nursing homes have structural problems that often make it difficult to 21 correctly isolate infected residents; in Spain, about 80% of residents share a 22 bedroom and common areas are not usually designed to keep the 23 recommended interpersonal distance of 1-2 meters. For all these reasons, the 24 COVID-19 pandemic is especially affecting nursing homes around the world 5 . 25

Public health recommendations for the sectorization of nursing home residents 26 have been published in Spain 6,7 . However, they are not easy to implement in 27 real life, due to the aforementioned difficulties. Our target was to make a 28 practical guide to optimize existing resources to effectively isolate residents and 29 prevent the spread of COVID-19 in nursing homes. 30

The pragmatic innovation consists of an algorithm that helps to classify 33 residents in order to separate them into three different areas ( Figure 1 ). This 34 approach was designed in the surge of the COVID-19 outbreak, when PCR 35 tests couldn't be performed to all nursing-home residents. However it wouldn't 36 be the recommended approach in a different clinical setting. 37

The first step in this algorithm is to perform a chromatographic immunoassay to 38 detect IgG/IgM antibodies against SARS-CoV-2 to all residents in the nursing 39 home using rapid point-of-care test Guangzhou Wondfo Biotech Co® 40 COVID-19 infection. Therefore, residents with a positive result would be placed 46 in the "red zone", assuming that the risk of transmission and reinfection 47 between them is low or nil according to the available data to date 8 . In keeping 48 with the current recommendations and scientific evidence available, residents 49 would be considered disease-free or non-contagious after being asymptomatic 50 J o u r n a l P r e -p r o o f for 14 days given the significant decrease in viral load in the nasopharynx after 51 that time 9-12 , and may be transferred to the "green zone". 52

In case of a negative result of the rapid point-of-care test, the resident would 53 initially be located in the "green zone". Two negative antibody tests would be 54 advisable as the false negative rates drop with testing twice. Early detection of 55 cases of COVID-19 in this area must be performed either by identification of 56 close contact to confirmed cases, or through daily surveillance of symptoms 57 (fever, cough, dyspnea, chest pain, odynophagia, myalgia, headache, 58 confusional state, diarrhea, rash, or atypical symptoms 13 ). In both situations 59 residents must be considered suspicious of being infected, and should be 60 immediately transferred to the "yellow zone". Further study must be undertaken 61 once in this area, including COVID-19 detection using the reverse transcriptase- Table 1 . The intervention was first implemented on April 24 th 2020. At the time of this 80 writing, the intervention has been held in 17 nursing homes, whose data on 81 adherence to the algorithm is shown in Table 2 The fact that this protocol is easy to understand, easy to carry out and that it 111 doesn´t need many diagnostic tests is among its strengths. 112

The main limitation of this approach is that it should be used only in case of an 113 outbreak of COVID-19 and lack of availability of PCR massive testing, because 114 of the limitations in reliability of rapid point-of care testing 16 . One way to improve 115 the current algorithm would be to replace the rapid point-of-care test with RT-116 PCR instead, given the high number of asymptomatic residents which are 117 responsible for virus transmission in nursing homes 17 . The second fundamental 118 way to improve the algorithm is to complement it with a similar one in which RT-119 PCR is actively performed in healthcare personnel. 120

We still lack much data on the COVID-19 emerging infection. This study tries to 121 shed light into dramatic problem of dealing with COVID-19 in nursing homes, 122

offering an affordable method to classify residents. However, further research is 123 necessary to assess its capacity in preventing viral spread. 124 The main strategy to avoid transmission is glove-changing and handwashing using hydroalcoholic solution in between patients, regardless of the zone.

*Complete personal protective equipment is composed of gloves, waterproof gowns, shoe covers, head covers, masks, eye protection, and face shields. **Note: The following practices are aimed towards diminishing transmission risk between the following groups. In the red zone the risk lies in patient to nursery home staff. In the yellow zone both fellow residents or staff are at risk of contagion from patients, and in the green zone the risk exists mainly in patient-patient transmission or staff-patient. 

Informes COVID-19

as a Fall in an Older Adult

Coronavirus Disease19 in Geriatrics and Long-Term Care

Coronavirus Disease

Geriatrics and Long-Term Care: The ABCDs of COVID -19

Diagnostic accuracy of 180 serological tests for covid-19: systematic review and meta-analysis

Asymptomatic Transmission, the Achilles

Heel of Current Strategies to Control COVID-19

We want to give special thanks to all nursing homes staff for welcoming our recommendations as well as for the courage and dedication shown during the hardship of COVID-19 pandemic.J o u r n a l P r e -p r o o f

* Number of residents reclassified in the first week after the intervention due to RT-PCR testing. † NH = Nursing home. ‡ Partial sectorization = Sectorization in two zones (usually red and green) was already made before the intervention. § No sectorization = Isolation was carried out in a timely manner in some rooms, without sectoring by identifiable areas. || Fully implemented = Sectorization in 3 different zones according to the characteristics described in figure 1 and table 1 was implemented. **Improvement = the sectorization was improved with respect to how it was previously done, but it did not meet all the characteristics recommended in this article, either because it did not create 3 different zones, or because in some of them the recommended practices were not carried out as described in Table 1 . † † Partially implemented = if there was no previous sectorization, a sectorization was implemented but it did not meet all the recommended characteristics, either because it did not