key: cord-0834871-2b0ea7bo
authors: Bharmal, Aamir; Ng, Carmen; Vijh, Rohit
title: COVID-19 prevention assessments: A promising tool for preventing outbreaks in long-term care homes
date: 2021-08-18
journal: J Am Med Dir Assoc
DOI: 10.1016/j.jamda.2021.08.008
sha: 085719e400486330311f9990c58a07972aaf3b81
doc_id: 834871
cord_uid: 2b0ea7bo

nan

assessed 48 unique homes, which included 5,481 residents, approximately 7,600 staff and 1,151 COVID-23 19 cases (681 resident and 470 staff cases). 24

We used negative binomial regression to compare the assessment tool score (i.e. total number of unmet 25 items) to home outbreak severity (calculated as the COVID-19 facility attack rate). We controlled for 26 confounding variables at the resident-level and facility-level known to contribute to larger outbreaks. 27

Confounding variables included facility age, whether the index case was a staff member or resident, the 28 percentage of private single-bed rooms, community COVID-19 case rate, and the month of outbreak. 29

When all of these factors were controlled for, we found the tool score was still significantly associated 30 with increasing outbreak severity. For every item not met in our assessment tool during facility 31 assessment, we observed an increase of 22% in the COVID-19 attack rate. Noting the median number of 32 unmet items on the assessment tool was three items (IQR = 4), these facilities had a 66% higher risk of a 33 severe outbreak compared to homes with no unmet items. 34

Of interest, while a higher number of unmet items on the assessment tool was significantly associated 35 with outbreak severity, we found most items on the tool individually did not vary by severity. However, 36 some item categories in the tool were associated with higher outbreak severity. When facilities had at 37 least one unmet item in the hallway, dining area, housekeeping or PPE categories, facilities were more 38 likely to have larger outbreaks compared to facilities that were fully adherent to items in these 39 categories. Dining area unmet items were most strongly associated with larger outbreaks. In fact, 40 facilities with unmet dining measures were six times more likely to have larger outbreaks than facilities 41 who were fully compliant with dining measures. 42

Several analyses have suggested LTCH factors contributing to outbreaks. 2, 5, 6 Often, these are less 43 modifiable facility-level factors (e.g., public vs. private ownership, facility age) or highly resident-specific 44 (e.g., residents who wander). Our results indicate that assessment tools assessing LTCH IPC measures 45 J o u r n a l P r e -p r o o f and pandemic preparedness may play an important role in preventing large outbreaks from occurring 46 independent of these other risk factors. Such tools appear to be most effective when incorporated into 47 a program including education, regular monitoring, and feedback. 2,3 48 Assessment tools need to be adaptable. We modified our tool in both December 2020 and June 2021 to 49 ensure we flagged items in our analysis associated with severe outbreaks. Similarly, our pre-December 50 2020 tool was modified to include a medium risk category to capture items that were important to 51 address but less urgent. 52

Widespread vaccination will likely reduce the impact of COVID-19 outbreaks; however, there are 53 opportunities to capitalize on the current renewed interest in IPC within LTCH. Tools such as ours are 54 most impactful when used regularly and embedded into LTCH culture, infrastructure decisions, 55 education, and staff evaluation so that staff and leadership are encouraged to build protective practices 56 into their everyday work. 2 

Site Name (if floors have a significantly different population audit all floors):

Site Contact (e.g. Residential Care Coordinator/Director of Care/Manager):

Auditor's Comments (please be as descriptive as possible )

10 VO Active Screening 2 x per shift: Beginning and during shift for all staff. Screen staff for: symptoms (i.e. fever, new or worsening cough, new or worsening shortness of breath, sore throat, and nausea /vomiting and diarrhea); travel outside of Canada, and/or; contact with confirmed COVID-19 case.

ACTIVE SCREENING of all staff: follow BC CDC guidelines for screening at beginning of shift and during shift . Staff screening of each other must occur and it must be documented during their shift. FH Screeners can be deployed in an outbreak situation and screening will occur 2 x shift beginning and during shift.

11 VO All staff have been provided with information on how to self-monitor for symptoms.

Poster for staff monitoring in locations that are visible to staff ( eg: entrance to building, staff lounge) , staff have been educated on self monitoring and it is reviewed regularly by site leadership with their teams 12 VO Documentation of findings of self report and checklists are kept in a binder or folder by site leaders.

If staff are symptomatic, they are aware of process, to report to the supervisor immediately, remove themselves from work, refer to testing assessment center and self-isolate pending results.

Ensure any staff member with even mild symptoms has access to a supervisor who can quickly reassign the work and release the employee to go home. Check there are posters for staff monitoring in locations that are visible to staff ( eg: entrance to building, staff lounge).

Active Screening' twice a day ( Refer to BCCDC website. Home testing for AL IL, private sites will receive training on how to obtain NP swabs ( back up is home testing until trained) . See KYI for TDGstaff must be certified in how to package the swab.

Staff prefill their screening forms prior to reporting to work and present them to the screener who checks their temperature. The staff member then takes the form to their unit for the mid shift screen. Hands free is optimal and best practice but not mandatory. 43 V There is a process for cleaning residents/tenants hands before/after meal time.

Ensure wipes ( ABHR type) eg: Sani /Wet ones are used as needed in LTC and assistance is provided or ABHR is available in both LTC and AL. 44 O There is signage indicating step-by-step guide to proper hand hygiene (HH).

Poster reminders " steps to perform HH" . 

Site 

Site Name (if floors have a significantly different population audit all floors):

Site Contact (e.g. Residential Care Coordinator/Director of Care/Manager):

Auditor's Comments (please be as descriptive as possible )

Site Category:

Cleaning instructions ( work) are available for all shared equipment and recreational equipment (e.g. lifts, walkers, wheelchairs, slings both sit to stand and ceiling lifts, shower chair, tub; recreation tools such as bowling equipment, instruments) Ensure work/cleaning instructions are visible and are being cleaned appropriately. Sit to stand slings cannot be used for more than one resident if soiled-they must be laundered between use. They cannot just be wiped off and sprayed with disinfectant if fabric sections-must be laundered. If wipeable no fabric sections, CAVI WIPES are suitable. Encourage disposable slings particularly if in outbreak. * Action planning may entail purchasing more slings. Ceiling lifts are resident specific. There is a policy and procedure ( link to policy and procedure) for cleaning and disinfection of environmental surfaces and shared equipment (e.g., commodes, wheelchairs,)

There is no sharing of equipment , wash basins or supplies between residents/persons without appropriate cleaning and disinfection between use.

Basins must be dedicated. 

Site The 4 moments HH practice before resident/environment contact; before aseptic procedure; after blood and body fluid exposure risk; after resident/environment/client/tenant contact. Observe hand hygiene practices. In AL placing of posters must be on the wall outside of the suites.

Hand Hygiene (HH) audits are completed at a minimum monthly (NOTE: Hand hygiene audit frequency will increase to three times a week during outbreaks or daily if a complex outbreak.) . Observe staff hand hygiene practices Sites must show documentation and auditor observe what their compliance results are and they need to be 80% or higher. If sites are under 80% increase audit frequency to weekly until compliant. AL/IL sites may not meet this requirement however they must ensure they are aware of audits and importance and may see that sites are using a non FH tool. Non FH tool must include 4 moments HH 61 V/O Ensure staff have been orientated via FH education sessions on HH & its been recorded e.g.: learning hub registration. Staff have completed the Learning Hub Hand hygiene module (minimum annually) . Ensure refresh education is completed if HH audit results are under 80%

If sites do not have learning hub access ensure documention of HH education has been recorded .There is a written hand hygiene policy and procedure that is readily available to staff.

Hand hygiene results are publicly posted on each unit and in public places; results are also being shared with staff.

Please check how they are being shared with staff e.g.: weekly meetings, visible in staff areas. AL/IL may not be aware of this requirement -ensure awareness of importance of hand hygiene practices are available in public places. 

The infection control audit: the standardized audit as a tool for change

Effectiveness and core components of infection prevention and control programmes in long-term care facilities: a systematic review

World Health Organization. Prevention of hospital-acquired infections: a practical guide

COVID-19 Resources for Long-Term Care, Assisted Living, and Independent Living Sites

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

COVID-19 Infection Prevention and Control Adherence in Long Term Care Facilities

We would like to thank the Fraser Health Long-Term and Assisted Living Coordinating Centre, Licensing Team, and the Infection Prevention and Control team for their support and assistance with this project.

Single control access point is recommended for screening and access to building * sites may have a variety of stand alone buildings so there will be more than one staff access point e.g.: campus of care.5 VO Ensure PPE availability eg: masks & protective eye wear are available at the entrance.[NO] COUNT / PERCENT 0% 6 VO 1 essential visitor during outbreak (e.g. compassionate visits only , actively dying), visitors must be asymptomatic.[NO] COUNT / PERCENT 0% 7 V O Family/social visits require a written plan and screening process, vistors are wearing a mask ( can be personal cloth or surgical procedural mask* ) , must be asymptomatic 11 VO All staff have been provided with information on how to self-monitor for symptoms.12 VO Documentation of findings of self report and checklists are kept in a binder or folder by site leaders.

If staff are symptomatic, they are aware of process, to report to the supervisor immediately, remove themselves from work, refer to testing assessment center and self-isolate pending results. 

Site