key: cord-0773437-1fwq882c
authors: Simoni-Wastila, Linda; Wallem, Alexandra; Fleming, Sean; Le, Tham; Kepczynska, Paulina; Yang, Jeanne; Qato, Danya M.
title: Staffing and protective equipment access mitigated COVID-19 Penetration and Spread in US nursing homes during the Third Surge
date: 2021-10-06
journal: J Am Med Dir Assoc
DOI: 10.1016/j.jamda.2021.09.030
sha: cc912b1f1c7c1d026e9f7240b662a094840045d3
doc_id: 773437
cord_uid: 1fwq882c

Objectives During the last quarter of 2020—despite improved distribution of personal protective equipment(PPE) and knowledge of COVID-19 management—nursing homes experienced the greatest increases in cases and deaths since the pandemic’s beginning. We sought to update COVID-19 estimates of cases, hospitalization, and mortality, and to evaluate the association of potentially modifiable facility-level infection control factors on odds and magnitude of COVID-19 cases, hospitalizations, and deaths in nursing homes during the third surge of the pandemic. Design Cross-sectional analysis Setting and Participants Facility-level data from 13,156 United States nursing home facilities Methods Two series of multivariable logistic regression and generalized linear models to examine the association of infection control factors (personal protective equipment and staffing) on incidence and magnitude, respectively, of confirmed COVID-19 cases, hospitalizations, and deaths in nursing home residents reported in the last quarter of 2020. Results Nursing homes experienced steep increases in COVID-19 cases, hospitalizations, and deaths during the final quarter of 2020. Four-fifths (80.51%;n=10,592) of facilities reported at least one COVID-19 case, 49.44%(n=6,504) reported at least one hospitalization, and 49.76% (n=6,546) reported at least one death during this third surge. N95 mask shortages were associated with increased odds of at least one COVID-19 case (OR: 1.21[95% Confidence Interval(CI), 1.05-1.40]) and hospitalization (OR: 1.26 [95%CI, 1.13-1.40]), as well as larger numbers of hospitalizations (OR: 1.11 [95%CI, 1.02-1.20]). Nursing aide shortages were associated with lower odds of at least one COVID-19 death (OR: 1.22 [95%CI, 1.12-1.34]) and higher hospitalizations (OR:1.09 [95%CI, 1.01-1.17]). The number of nursing hours per resident per day was largely insignificant across all outcomes. Of note, smaller (<50 beds) and mid-sized (50-150 beds) facilities had lower odds yet higher magnitude of all COVID outcomes. Bed occupancy rates > 75% increased odds of experiencing a COVID-19 case (OR:1.48 [95%CI, 1.35-1.62]) or death (OR: 1.25 [95%CI, 1.17-1.34]). Conclusions and Implications Adequate staffing and PPE—along with reduced occupancy and smaller facilities—mitigate incidence and magnitude of COVID-19 cases and sequellae. Addressing shortcomings in these factors is critical to the prevention of infections and adverse health consequences of a next surge among vulnerable nursing home residents.

day was largely insignificant across all outcomes. Of note, smaller (<50 beds) and mid-sized (50-25 150 beds) facilities had lower odds yet higher magnitude of all COVID outcomes. Bed 26 occupancy rates > 75% increased odds of experiencing a COVID-19 case (OR: 1 Conclusions and Implications:Adequate staffing and PPE-along with reduced occupancy and 29 smaller facilities-mitigate incidence and magnitude of COVID-19 cases and sequellae. 30

Addressing shortcomings in these factors is critical to the prevention of infections and adverse 31 health consequences of a next surge among vulnerable nursing home residents. The novel coronavirus (COVID-19) pandemic has disproportionately affected nursing 35 home residents. 1, 2 According to the U.S. Department of Health and Human Services, two in five 36

Medicare beneficiaries in nursing homes were diagnosed with COVID-19 in 2020, and all-cause 37 mortality in nursing homes increased from 17% to 22% from 2019 to 2020. 3 including viral-induced respiratory failure and multisystem involvement. 2,10 As a congregate care 49 setting, the nursing home itself heightens risk of infection and adverse events due to close 50 quarters and frequent interaction with and close proximity to staff and other residents. [10] [11] [12] As 51 well, staff turnover and infection control equipment shortages may exacerbate COVID-19 52 spread. 10, 13, 14 In prior research, higher staffing levels were consistently associated with fewer 53 cases and deaths. 15 31 We examined nursing homes during the last quarter of 2020 (the week beginning 81 September 28th, 2020 through the week ending December 27th, 2020). The CMS COVID-19 82

File includes counts of COVID-19 outcomes and nursing facility variables such as staff and 83 personal protective equipment (PPE) shortages, total beds, and occupancy rates. 4 The NHC data 84 regularly tracks nursing home organizational characteristics and quality of care, including 85 influenza vaccination rates. 29 The LTCFocus data provides facility-level sociodemographic and 86 clinical characteristics. 30 The NYT national data provides information on county-level 87 geographic variation in general population COVID-19 infections and deaths. 31 88

Primary outcomes assessed during the final quarter of 2020 included any incident and 90 confirmed COVID-19 cases, hospitalizations, and deaths. Within facilities with at least one 91 confirmed COVID-19 case, hospitalization, or death, respectively, we estimated the following 92 secondary outcomes: the magnitude of COVID-19 cases, hospitalizations, and deaths. These 93 were calculated as the total number of each specific COVID-19 outcome divided by the number 94 of occupied beds in a facility. 20 95

We focused on three potentially modifiable independent variables relevant to infection 97 control: one-week supply of N95 masks (yes/no) and shortages of nursing home aides (yes/no) at 98 baseline, and adjusted total nursing staff hours (≥ 4.1 hours or <4.1 hours per resident per day) 99 from 2017 LTCFocus. 32 We further adjusted for covariates deemed important in relevant 100 literature: 14-18,20-23,25 facility size (<50, 50-150, >150 beds) and occupancy level (≥75% or 101 <75%) measured from the study period baseline week beginning September 28 th ; and annual 102 influenza vaccination rates (≥90% or <90% of residents vaccinated) as of 2020 quarter 2. 33 Other 103 data from LTCFocus at the facility-level including profit status and chain affiliation; as well as 104 sociodemographic characteristics of residents [average age; proportion of non-white residents 105 (>25% or ≥25%) ; proportion of Medicaid (>85% or ≤85%); 20 acuity of care (average RUGS 106 NMCI)] were also included. For the baseline week of September 28 th , surrounding county-level 107 COVID-19 case rates were computed by dividing county-level non-nursing home COVID-19 108 related cases by 2019 population estimates from the U.S. Census Bureau; and surrounding 109 county-level COVID-19 death rates were computed by dividing county-level non-nursing home 110 COVID-19 related deaths by county-level COVID-19 cases for the same week. 34 111

We used chi-square and t-tests to compare baseline demographic and clinical 113 characteristics between nursing facilities that had any COVID-19 cases versus those that had 114 none. For each outcome, we fit two models due to the large number of facilities that did not 115 report a single incident of a respective outcome during the final quarter of 2020. First, 116 multivariable logistic regression models were used to quantify the odds of having: 1) any 117 COVID-19 case; 2) any hospitalization; and 3) any death in a nursing home. These findings 118 estimate the relationship between facility characteristics and any penetration of COVID-19 in 119 nursing homes. Among facilities with at least one confirmed COVID-19 case, COVID-19-related 120 hospitalization and/or death, we then ran separate generalized linear models with a log link, 121 assuming a gamma distribution, to quantify the association between nursing home facility 122 characteristics on COVID-19 outbreak size, reported as relative risk ratios (RRR). These results Of 15,392 nursing homes linked across all three data sources, 2,236 were excluded due to 132 missing covariate information, resulting in a final study sample of 13,156 nursing homes. Figure  133 1 illustrates weekly incident COVID-19 confirmed cases, hospitalizations, and deaths during the 134 entire period such data were collected until wide-scale vaccination distribution (week starting 135

May 25 th , 2020, through week ending December 27 th , 2020). Marked increases in all three 136 outcomes occurred during the third surge, with COVID-19 cases, hospitalizations, and deaths 137 peaking the week beginning December 14 th , 2020. That week, reports of cases (n=32,312) and 138 deaths (n=5,722) were nearly triple those of the peaks of the second surge (July 2020) for cases 139 (n=11,533) and deaths (n=2,002). 140

Compared to nursing homes with no reported COVID-19 cases, facilities with at least one 142 COVID-19 case were more likely to report N95 mask shortages and provide fewer than 4.1 total 143 nurse staffing hours per resident per day ( Table 1) . Facilities with at least one case were also 144 more likely to be larger facilities, have higher occupancy rates, have lower proportions of non-145 white and Medicaid-covered residents. In addition, nursing homes with COVID-19 cases had 146 higher proportions of high acuity patients and were more likely to be chain affiliated. The rates 147 of COVID-19 cases in nursing homes reflected COVID-19 case rates in surrounding 148 communities. The mean county COVID-19 case rates per 100,000 citizens were 108. 8 however, we found larger facilities experienced smaller relative outbreaks. Nursing homes with 242 more beds (regardless of whether they are occupied or not) may be able to more effectively 243 isolate residents with COVID-19 and implement social distancing among residents and staff. 244

Higher occupancy rates, however, increased odds of cases or deaths, likely due to difficulty in 245 providing better social distancing measures. Taken together, these findings further illustrate the 246 environmental challenges faced by nursing homes in preventing COVID-19 spread. 247

Our findings that nursing facilities with higher proportions of non-white residents had 248 lower cases and deaths vary from most studies conducted early in the pandemic which found 249 such facilities fared worse than those with lower non-white residents proportions. 14,17,18,20,22,23 250

One potential explanation underlying our discrepent finding is that the last surge markedly 251 differed from earlier periods with respect to the facility demographics as the pandemic migrated 252 toward the less racially diverse midwest and central states in the latter half of 2020. 38 and Hispanic patients, these data points were not included in our study. We did not account for 284 the time varying nature of staffing and PPE shortage covariates in our models; rather, these 285 variables were adjusted at baseline. Finally, we excluded nursing homes with any missing 286 variables of interest; thus, our findings of more than 85% of available nursing homes may not be 287 generalizable to all facilities. In addition, we did not control for prior counts of COVID-19 288 outcomes in our analysis due to: 1) the transience of residency in nursing homes, which has only 289 been exacerbated by COVID-19; and because 2) the extent and durability of protection conferred 290 by a prior COVID infection is still unknown, especially among vulnerable nursing home 291 residents. Finally, while we did incorporate resident RUGS into both our analytic models, we did 292 not have important information regarding staff case mix with respect to their relevant health 293 status and comorbidities. Such information, in addition to information related to vaccination 294 status, is important to incorporate in any future analyses. 295

Our research has notable strengths. First, our study utilizes multiple datasets during the 296 dire third surge of the COVID-19 pandemic to examine those most vulnerable to adverse 297 consequences-nursing home residents. Second, these data provide multiple facility-level and 298 modifiable factors related to resident, staffing, and facility characteristics, including occupancy 299 and influenza vaccination rates, which were seldom included in prior research. Third, this 300 research uses more current data and assesses infection and outcomes until COVID-19 301 vaccination became widely established. 40 Finally, our study investigates how nursing home 302 factors influence not only resident COVID-19 cases and deaths but also hospitalizations. 303

Our findings have important implications for preventive measures and management of 304 COVID-19 outcomes in nursing home settings. While facility-level determinants of COVID-19 305 cases and outcomes are complex and multi-factorial, modifiable factors such as staffing and PPE 306 supported mitigation of COVID-19 spread. We also found risk factors for cases and outcomes 307 differed over time. Thus, policy makers and stakeholders should take an agile approach when 308 designing public health intervention strategies. Key factors, such as N95 and staff shortages, are 309 important modifiable risk factors that can-and must-be addressed to prevent COVID-19 310 penetration and spread in nursing homes in subsequent surges. Indeed, nursing facilities facing 311 PPE and/or staff shortages, as well as larger facilities and/or those with high occupancy rates, 312 should carefully review and revise current protocols to effectively prevent and contain COVID-313 19 outbreaks. Finally, future research is needed to evaluate the impact of staff and resident 314 COVID-19 vaccination in conjunction with these modifiable risk factors on the prevention of 315 future COVID-19 surges. 316

Our study found numerous, potentially modifiable characteristics associated with 318 COVID-19 cases, hospitalizations, and deaths in the latter stage of the pandemic. Our findings 319 largely align with current understandings of COVID-19 risk and outcomes in nursing homes, 320 especially in regard to factors important to the mitigation of COVID-19. Other findings, 321 however, such as those related to the association between racial composition and COVID-19, 322 may differ from the narrative informed by earlier periods of the pandemic. As well, many factors 323 that place facilities at-risk for any COVID-19 case, hospitalization, or death may differ from 324 those that contribute to increased magnitude of these outcomes. What remains apparent is that 325 more than half a year into the pandemic-as knowledge of social distancing practices, infection 326 prevention and treatment became established, and availability of PPE increased-nursing 327 facilities experienced the highest rates of infection, morbidity, and mortality, which were largely 328 preventable through relatively simple interventions. Adequate high-quality interventions provide 329 significant returns to nursing home resident health; their lack of availability and adoption late in 330 the pandemic provides cause for alarm for future outbreaks. 

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Abbreviations COVID-19, coronavirus disease 2019; NH, nursing homes; RUGS NCMI, Resource Utilization Groups Nursing Case Mix Index

The authors declare no relevant conflicts of interest or financial relationships 335 336 337