key: cord-0943594-v1rm2fta
authors: Shi, Sandra M.; Bakaev, Innokentiy; Chen, Helen; Travison, Thomas G.; Berry, Sarah D.
title: Risk Factors, Presentation, and Course of COVID-19 in a Large, Academic Long-term Care Facility
date: 2020-08-25
journal: J Am Med Dir Assoc
DOI: 10.1016/j.jamda.2020.08.027
sha: 3aed058e6cfdc9bd38bf2307fb5d4f15a7ca798e
doc_id: 943594
cord_uid: v1rm2fta

Abstract Objective To describe clinical characteristics, and risk factors associated with COVID-19 in long-stay nursing home residents. Design and Participants Retrospective cohort study (3/16/2020-5/8/2020). Setting Academic long-term chronic care facility (Boston, MA) Participants Long-term care residents Methods Patient characteristics and clinical symptoms were obtained via electronic medical records and Minimum Data Set. Staff residence was inferred by zip codes. COVID-19 infection was confirmed by polymerase chain reaction testing using nasopharyngeal swabs. Residents were followed until discharge from facility, death, or up to 21 days. Risk of COVID-19 infection were modeled by generalized estimating equation to estimate the relative risk and 95% confidence intervals of patient characteristics and staff community of residence. Results Overall 146 of 389 (37.5%) long-stay residents tested positive for COVID-19. At the time of positive test, 66 of 146 (45.5%) residents were asymptomatic. In the subsequent illness course the most common symptom was anorexia (70.8%), followed by delirium (57.6%). During follow-up 44 (30.1%) of residents with COVID-19 died. Mortality increased with frailty (16.7% in pre-frail, 22.2% in moderately frail, and 50.0% in frail; p<0.001). The proportion of residents infected with COVID-19 varied across the long-term care units (range: 0-90.5%). In adjusted models male sex (RR: 1.80, 95% CI, 1.07, 3.05), bowel incontinence (RR: 1.97, 95% CI 1.10, 3.52), and staff residence remained significant predictors of COVID-19. For every 10% increase in the proportion of staff living in a high prevalence community, the risk of testing positive increased by 6% (95% CI, 1.04, 1.08). Conclusions and Implications Among long-term care residents diagnosed with COVID-19, nearly half were asymptomatic at the time of diagnosis. Predictors of COVID-19 infection included male sex, bowel incontinence and staff residence in a community with a high burden of COVID-19. Universal testing of patients and staff in communities with high COVID-19 rates is essential to mitigating outbreaks.

The COVID-19 pandemic caused by a novel coronavirus (SARS-Cov-2) has had a marked 33 impact on every sector of society, with long-term care facilities and nursing homes bearing a Factors related to transmission of COVID-19 within long-term care facilities are also not well 54 understood. Media attention has suggested that COVID-19 transmission in NHs may be related 55 to poor quality of care, 8 but patient and staff characteristics are likely to affect disease burden.

For example, behavioral symptoms of dementia, such as wandering, could increase the risk of 57 transmission. Also, residents with advanced dementia typically require assistance with toileting 58 and feeding, demanding close personal contact with direct care staff. Staff who live in a 59 neighborhood more severely affected by COVID-19 may then inadvertently increase the risk of 60 transmission among these residents.

The objective of this study was to describe the presenting clinical characteristics and outcomes of 63 long-term care residents affected by COVID-19 in a large, academic long-term care facility. licensed as a long-term chronic care hospital (LTCH). In addition, the facility housed one 74 medically complex acute care unit, and a sub-acute rehabilitation unit which are excluded from 75 J o u r n a l P r e -p r o o f the first positive test was ordered and the three preceding days, including of cough, anorexia, 98 vomiting, or diarrhea. Delirium, either documented by a geriatrician or reported as an acute 99 change in mental status or lethargy, was noted. Fever, defined as any recorded temperature of 100 greater than or equal to 100 o Fahrenheit, was documented from the vital sign reports.

We obtained information on clinical symptoms and outcomes following a positive test, including 103 vomiting, diarrhea, delirium, and anorexia. The total number of calendar days with fever, the 104 need for supplemental oxygen, hospitalization, and falls (during the three days before testing or 

During the study period, 389 residents received 620 tests for COVID-19 (mean 1.6, range 1-6 156 tests). The mean (Standard Deviation; SD) age of the study population was 86.8 (9.0) years. 253 moderately frail, and 50.0% in frail; p<0.001). Results were similar when we restricted our 184 analysis to residents with the opportunity for 21 days of follow-up (Appendix 2).

The proportion of residents infected with COVID-19 varied across the long-term care units 187 (range: 0-90.5%, Table 3 ) Units with a high burden of disease had more residents of younger 188 age, severe cognitive impairment, and behavioral symptoms. Units with a high burden of disease 189 were more likely to have staff members that lived in a community with a high rate of infection.

In unadjusted models, eight resident characteristics were significant predictors of COVID-19 193 disease including younger age and wandering (Table 4 ). The proportion of staff living in a 194 community with a high rate of COVID-19 was also a significant predictor of testing positive 195 (RR: 1.06, 95% CI 1.05, 1.08). In the adjusted model, two clinical characteristics were associated 196 with an increased risk of testing positive for COVID-19: male sex (RR: 1.80, 95% CI, 1.07, 3.05) 197 and bowel incontinence (RR: 1.97, 95% CI 1.10, 3.52). Staff residence was a significant 198 predictor of disease: for every 10% increase in the number of staff who live in a high prevalence 199 community, the risk of testing positive for COVID-19 increased by 6% (95% CI, 1.04, 1.08). Our results demonstrate that even in a frail, long-term care population, the prevalence of 213 asymptomatic carriers of COVID-19 is substantial (45.5%). In a study of 89 nursing home 214 residents in Washington State, 56% of residents who tested positive for COVID-19 were 215 asymptomatic at diagnosis, but only 3/27 residents (11.1%) remained asymptomatic one week 216 after diagnosis using a prospective symptom survey. 6 We found a slightly greater proportion of 217 residents remained asymptomatic over 3 weeks: 15.0% were asymptomatic and an additional 218 8.8% experienced only transient anorexia. Without universal testing, asymptomatic residents 219 would go undiagnosed and may continue to spread the disease. It is challenging to prevent 220 spread of the virus in LTC given the high prevalence of moderate to severe cognitive 221 impairment. Often, these patients are unable to adhere to infection control guidelines (e.g. 222 frequent handwashing, mask wearing), or safely isolate themselves. Ideally, residents with care staff must have close, prolonged contact to assist patients with bowel incontinence, which 247 may place these residents at greatest risk.

The community where staff lived was also a significant predictor of disease. A recent study of in the communities where staff resided reflect a broad prevalence comparable to Massachusetts 259 state data (Appendix 1), and it is unlikely that single zip code outliers were responsible for our 260 results. Together, these findings suggest that community prevalence of COVID-19 remains a 261 major risk factor for nursing home outbreaks, and thus efforts directed toward mitigating 262 outbreaks in nursing homes must additionally consider the broader community which they 263 belong to.

There are weaknesses of our study. First, data on clinical characteristics was collected from 266 retrospective chart review, and we suspect underreporting of some symptoms. Second, we did residence. This should bias our results to the null, so the true association between staff residence 277 and COVID-19 infection may be higher. Finally, our results are from a single, academic facility.

Our patient population is older and has a greater burden of comorbidities than most community 279 nursing homes. The overall census of our facility is equivalent to several nursing homes. 

First, given the large number of asymptomatic carriers, universal testing of long-term care 288 residents is strongly recommended. Second, standardized quick assessments for delirium may be 289 useful in identifying early cases of COVID-19. Third, special attention should be given to 290 residents with bowel incontinence, as the close, direct contact required to care for these residents may confer particularly high risk for the virus. Finally, because the community where staff live 292 was a significant predictor of COVID-19 disease, early testing of direct patient care staff is 293 recommended. As part of early response to the pandemic some cities and health systems offered 294 alternative housing for health care workers. Allowing nursing home care workers to take 295 advantage of such opportunities may be a strategy to reduce community exposure and potential 296 introduction into the facility. Lastly, many states are now recommending universal testing of all 297 nursing home workers, who provide direct patient care. Facilities with limited resources could 298 consider prioritizing testing for staff in neighborhoods where COVID-19 is most prevalent.

In summary, despite the abundant precautionary measures initiated in a well-resourced LTC 301 facility, COVID-19 disease was prevalent in many of the LTC units. More than 40% of infected 302 residents were asymptomatic at the time of diagnosis, and many never developed symptoms.

Male sex, bowel incontinence, and the community where staff lived were predictors of COVID-304 19 infection. Improved strategies to detect and mitigate spread of COVID-19 within long-term 305 care facilities are urgently needed. We hope that our findings and implications will be 306 informative as these strategies are being developed. 

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