Editorial: A COVID-19 Support Platform for Long Term Care Facilities

Who Helped Long-Term Care Facilities and Who Did Not During COVID-19? A Survey of Administrators in Israel

Long Term Care Facility (LTCF) residents are particularly vulnerable to infection and showed increased mortality during the COVID-19 epidemic. The pandemic presented multiple new challenges for LTCFs including considering and implementing new practices to protect residents and staff, and figuring out how to minimize the adverse effects of such practices. There are, however, very few reports addressing which public and private entities helped LTCFs meet these challenges. We examined the most important needs of Israeli LTCFs as the COVID-19 pandemic developed, the extent to which their needs were addressed, and by whom, using a survey specifically designed for this study, including open- and close-ended questions. Fifty-two LTCFs participated in the study. Shortages of nursing aids and personal protective equipment were often reported, as was the need for augmented budgetary support. Charitable organizations and the Israeli Army's Home Front Command were reported to provide significantly more assistance than the Israel Ministry of Health, the regulator of LTCFs. The most common type of support provided was distribution of personal protective equipment, followed by provision of training materials or training, and help in maintaining visiting policies. Findings highlight the need for a more coordinated, systematic and comprehensive approach to assist facilities.

Inadequate human resources, equipment and training: A qualitative assessment of the objectives of the NUHELP end-of-life care programme in the context of the COVID-19 pandemic

BACKGROUND

The COVID-19 pandemic had a particularly severe impact on nursing homes, exposing numerous pre-existing deficiencies in end-of-life care.

AIM

To describe how the COVID-19 pandemic affected nursing home and primary care professionals' attempts to achieve the objectives of a pre-existing end-of-life programme and to explore their personal experiences of end-of-life care in these facilities.

DESIGN

A qualitative descriptive study using thematic analysis.

SETTING/PARTICIPANTS

Twenty semi-structured interviews were conducted from March to November 2020 with professionals from nursing homes and primary care facilities who participated in the development of the NUHELP programme.

RESULTS

Six main themes were identified: (1) Comprehensive assessments of residents at the homes were not conducted due to excessive workload and high staff turnover. (2) New technologies and changes to professional roles were used to meet relatives' needs for information. Residents only received information when they requested it. (3) Advance care planning was not carried out and was limited to potential hospital transfer. (4) Arrangements were made to allow relatives to spend time with residents during their final moments, but complicated grief among relatives and professionals is anticipated. (5) Management of complexity varied depending on the degree of coordination with primary care facilities. (6) Nursing home professionals felt abandoned, with a lack of human resources, equipment and training.

CONCLUSIONS

The pandemic cast light on existing shortcomings in nursing homes in terms of comprehensive assessments, communication, decision making, grief management and palliative care complexity. Nursing homes need more human, material and training resources, as well as improved coordination with the public healthcare system.

Receptor binding domain-IgG levels correlate with protection in residents facing SARS-CoV-2 B.1.1.7 outbreaks

Background

Limited information exists on nursing home (NH) residents regarding BNT162b2 vaccine efficacy in preventing SARS‐CoV‐2 and severe COVID‐19, and its association with post‐vaccine humoral response.

Methods

396 residents from seven NHs suffering a SARS‐CoV‐2 B.1.1.7 (VOC‐α) outbreak at least 14 days after a vaccine campaign were repeatedly tested using SARS‐CoV‐2 real‐time reverse‐transcriptase polymerase chain reaction on nasopharyngeal swab test (RT‐qPCR). SARS‐CoV‐2 receptor‐binding domain (RBD) of the S1 subunit (RBD‐IgG) was measured in all residents. Nucleocapsid antigenemia (N‐Ag) was measured in RT‐qPCR‐positive residents and serum neutralizing antibodies in vaccinated residents from one NH.

Results

The incidence of positive RT‐qPCR was lower in residents vaccinated by two doses (72/317; 22.7%) vs one dose (10/31; 32.3%) or non‐vaccinated residents (21/48; 43.7%; p < .01). COVID‐19–induced deaths were observed in 5 of the 48 non‐vaccinated residents (10.4%), in 2 of the 31 who had received one dose (6.4%), and in 3 of the 317 (0.9%) who had received two doses (p = .0007). Severe symptoms were more common in infected non‐vaccinated residents (10/21; 47.6%) than in infected vaccinated residents (15/72; 21.0%; p = .002). Higher levels of RBD‐IgG (n = 325) were associated with a lower SARS‐CoV‐2 incidence. No in vitro serum neutralization activity was found for RBD‐IgG levels below 1050 AU/ml. RBD‐IgG levels were inversely associated with N‐Ag levels, found as a risk factor of severe COVID‐19.

Conclusions

Two BNT162b2 doses are associated with a 48% reduction of SARS‐CoV‐2 incidence and a 91.3% reduction of death risk in residents from NHs facing a VOC‐α outbreak. Post‐vaccine RBD‐IgG levels correlate with BNT162b2 protection against SARS‐CoV‐2 B.1.1.7.

Rapport 22-02. Après la crise COVID, quelles solutions pour l’EHPAD de demain ?

Le vieillissement de notre population génère des situations de grande vulnérabilité et de dépendance. Le maintien à domicile demeure habituellement la meilleure réponse pour respecter la volonté de la personne, le souhait de la famille et l’intérêt de la société. Il existe cependant un nombre important de situations où la prise en charge dans un établissement d’hébergement pour personnes âgées dépendantes (EHPAD) s’avère nécessaire. La pandémie de COVID-19 a mis sur le devant de la scène les EHPAD et leurs limites pour assurer des soins de qualité. Pour analyser la place actuelle des EHPAD dans la filière de soin et pour comprendre leurs difficultés de fonctionnement, il paraît indispensable de décrire les mutations accélérées qu’ont connues les EHPAD depuis leur création en 1999, puis, à la lumière de la crise actuelle, d’élaborer des pistes pour développer une vision positive du rôle que ces établissements ont à assurer dans le futur.

Modeling COVID-19 Outbreaks in Long-Term Care Facilities Using an Agent-Based Modeling and Simulation Approach

The elderly, especially those individuals with pre-existing health problems, have been disproportionally at a higher risk during the COVID-19 pandemic. Residents of long-term care facilities have been gravely affected by the pandemic and resident death numbers have been far above those of the general population. To better understand how infectious diseases such as COVID-19 can spread through long-term care facilities, we developed an agent-based simulation tool that uses a contact matrix adapted from previous infection control research in these types of facilities. This matrix accounts for the average distinct daily contacts between seven different agent types that represent the roles of individuals in long-term care facilities. The simulation results were compared to actual COVID-19 outbreaks in some of the long-term care facilities in Ontario, Canada. Our analysis shows that this simulation tool is capable of predicting the number of resident deaths after 50 days with a less than 0.1 variation in death rate. We modeled and predicted the effectiveness of infection control measures by utilizing this simulation tool. We found that to reduce the number of resident deaths, the effectiveness of personal protective equipment must be above 50%. We also found that daily random COVID-19 tests for as low as less than 10% of a long-term care facility’s population will reduce the number of resident deaths by over 75%. The results further show that combining several infection control measures will lead to more effective outcomes.

Impact of vaccination on the spread of SARS-CoV-2 infection in north-east Italy nursing homes. A propensity score and risk analysis

Background

In the Veneto Region, 421,000 coronavirus 2019 disease (COVID-19) cases and 11,000 deaths have been reported since 21 February 2020. The pandemic spread particularly in nursing homes (NH).

Objective

This study estimated the impact of SARS-CoV-2 infection among NH residents, focusing on the risk of hospitalisation and death due to COVID-19 compared with the general older population. It also provided evidence of risk changes over time.

Methods

Older people, resident in Veneto, were enrolled from the regional registry of the population. We collected also information about demographic characteristics, chronic diseases, COVID-19 positivity, NH institutionalization, hospitalisation and date of death. Patients were assigned to NH or non-NH residents groups through a propensity score 1:1 matching. The follow-up period was defined as 21 February 2020 – 3 May 2021 and then divided into three waves. Risk ratios (RRs) and 95% confidence interval were estimated by using Poisson models with robust estimation of variance.

Results

NH residents showed a higher risk of COVID-19 infection (RR = 6.28; 6.03–6.54), hospitalisation for COVID-19 (RR = 2.20; 2.05–2.36) and death with COVID-19 (RR = 6.07; 5.58–6.61).

Conclusion

NH residents shared common spaces with other patients and healthcare professionals and were more exposed to infections. Nonetheless, in Italy from late December 2020 to May 2021, 95% of NH residents and their healthcare professionals received at least one vaccine dose and RRs for all outcomes decreased in NH.

COVID-19 management in nursing homes by outbreak teams (MINUTES) - study description and data characteristics: a qualitative study

OBJECTIVES

Nursing homes are hit relatively hard by the COVID-19 pandemic. Dutch long-term care (LTC) organisations installed outbreak teams (OTs) to coordinate COVID-19 infection prevention and control. LTC organisations and relevant national policy organisations expressed the need to share experiences from these OTs that can be applied directly in COVID-19 policy. The aim of the 'COVID-19 management in nursing homes by outbreak teams' (MINUTES) study is to describe the challenges, responses and the impact of the COVID-19 pandemic in Dutch nursing homes. In this first article, we describe the MINUTES Study and present data characteristics.

DESIGN

This large-scale multicentre study has a qualitative design using manifest content analysis. The participating organisations shared their OT minutes and other meeting documents on a weekly basis. Data from week 16 (April) to week 53 (December) 2020 included the first two waves of COVID-19.

SETTING

National study with 41 large Dutch LTC organisations.

PARTICIPANTS

The LTC organisations represented 563 nursing home locations and almost 43 000 residents.

RESULTS

At least 36 of the 41 organisations had one or more SARS-CoV-2 infections among their residents. Most OTs were composed of management, medical staff, support services staff, policy advisors and communication specialists. Topics that emerged from the documents were: crisis management, isolation of residents, personal protective equipment and hygiene, staff, residents' well-being, visitor policies, testing and vaccination.

CONCLUSIONS

OT meeting minutes are a valuable data source to monitor the impact of and responses to COVID-19 in nursing homes. Depending on the course of the COVID-19 pandemic, data collection and analysis will continue until November 2021. The results are used directly in national and organisational COVID-19 policy.

Atypical symptoms, SARS-CoV-2 test results and immunisation rates in 456 residents from eight nursing homes facing a COVID-19 outbreak

Background

Frail older persons may have an atypical presentation of COVID-19. The value of rRT-PCR testing for identifying SARS-CoV-2 nursing homes (NH) residents is not known.

Objective

To determine whether (i) atypical symptoms may predict rRT-PCR results and (ii) rRT-PCR results may predict immunization against SARS-CoV-2 in NH residents.

Design

A retrospective longitudinal study.

Setting

eight NHs with at least ten rRT-PCR-positive residents.

Subjects

456 residents.

Methods

Typical and atypical symptoms recorded in residents’ files during the 14 days before and after rRT-PCR testing were analyzed. Residents underwent blood testing for IgG-SARS-CoV-2 nucleocapsid protein 6 to 8 weeks after testing. Univariate and multivariate analyses compared symptoms and immunization rates in rRT-PCR-positive and negative residents.

Results

161 residents had a positive rRT-PCR (35.3%), 17.4% of whom were asymptomatic before testing. Temperature > 37.8°C, oxygen saturation < 90%, unexplained anorexia, behavioural change, exhaustion, malaise, and falls before testing were independent predictors of a further positive rRT-PCR. Among the rRT-PCR-positive residents, 95.2% developed SARS-CoV-2 antibodies vs 7.6% in the rRT-PCR-negative residents. Among the residents with a negative rRT-PCR, those who developed SARS-CoV-2 antibodies more often had typical or atypical symptoms (p = 0.02 and < 0.01, respectively).

Conclusion

This study supports a strategy based on (i) testing residents with typical or unexplained atypical symptoms for an early identification of the first SARS-CoV-2 cases, (ii) rT-PCR testing for identifying COVID-19 residents, (iii) repeated wide-facility testing (including asymptomatic cases) as soon as a resident is tested positive for SARS-CoV-2, and (iv) implementing SARS-CoV-2 infection control measures in rRT-PCR-negative residents when they have unexplained typical or atypical symptoms.

The Role of Nutrition in the COVID-19 Pandemic

SARS-CoV-2, the cause of the COVID-19 disease, is posing unprecedent challenges. In the literature, increasing evidence highlights how malnutrition negatively affects the immune system functionality, impairing protection from infections. The current review aims to summarize the complex relationship between SARS-CoV-2 infection and nutritional status and the effects of malnutrition in terms of disease severity, patients' recovery time, incidence of complications and mortality rate. Current studies evaluating the possibility of modulating nutrition and supplementation in combination with pharmacological treatments in the clinical setting to prevent, support, and overcome infection are also described. The discussion of the most recent pertinent literature aims to lay the foundations for making reasonable assumptions and evaluations for a nutritional "best practice" against COVID-19 pandemic and for the definition of sound cost-effective strategies to assist healthcare systems in managing patients and individuals in their recovery from COVID-19.

Meaningful Engagement in the Nursing Home

Throughout her career, Rosalie Kane made a major impact in her efforts to improve quality of life for persons living in nursing homes. Near the end of her career, she suggested that it was time to "re-imagine long term care and to produce livable age-friendly nursing homes." This brief review focuses on the role of meaningful engagement and person-centered care as the next step in enhancing nursing home care. The importance of activities that strengthen cognitive and/or physical function is stressed, as well as improving socialization to reduce loneliness.

August 2020 Interim EuGMS guidance to prepare European Long-Term Care Facilities for COVID-19

PURPOSE

The European Geriatric Medicine Society (EuGMS) is launching a second interim guidance whose aim is to prevent the entrance and spread of COVID-19 into long-term care facilities (LTCFs).

METHODS

The EuGMS gathered experts to propose a guide of measures to prevent COVID-19 outbreaks in LTCFs. It is based on the specific features of SARS-CoV-2 transmission in LTCFs, residents' needs, and on experiences conducted in the field.

RESULTS

Asymptomatic COVID-19 residents and staff members contribute substantially to the dissemination of COVID-19 infection in LTCFs. An infection prevention and control focal point should be set up in every LTCF for (1) supervising infection prevention and control measures aimed at keeping COVID-19 out of LTCFs, (2) RT-PCR testing of residents, staff members, and visitors with COVID-19 symptoms, even atypical, and (3) isolating subjects either infected or in contact with infected subjects. When a first LCTF resident or staff member is infected, a facility-wide RT-PCR test-retest strategy should be implemented for detecting all SARS-CoV-2 carriers. Testing should continue until no new COVID-19 cases are identified. The isolation of residents should be limited as much as possible and associated with measures aiming at limiting its negative effects on their mental and somatic health status.

CONCLUSIONS

An early recognition of symptoms compatible with COVID-19 may help to diagnose COVID-19 residents and staff more promptly. Subsequently, an earlier testing for SARS-CoV-2 symptomatic and asymptomatic LTCF staff and residents will enable the implementation of appropriate infection prevention and control. The negative effects of social isolation in residents should be limited as much as possible.

Acute Care of Older Patients with COVID-19: Clinical Characteristics and Outcomes

(1) Background: COVID-19 has become a global pandemic and older patients present higher mortality rates. However, studies on the characteristics of this population set are limited. The objective of this study is to describe clinical characteristics and outcomes of older patients hospitalized with COVID-19. (2) Methods: This retrospective cohort study was conducted from March to May 2020 and took place in three acute geriatric wards in France. Older patients hospitalized for COVID-19 infections were included. We collected clinical, radiological, and laboratory outcomes. (3) Results: Ninety-four patients were hospitalized and included in the final analysis. Mean age was 85.5 years and 55% were female. Sixty-four (68%) patients were confirmed COVID-19 cases and 30 (32%) were probable. A majority of patients were dependent (77%), 45% were malnourished, and the mean number of comorbidities was high in accordance with the CIRS-G score (12.3 ± 25.6). The leading causes of hospitalization were fever (30%), dyspnea (28%), and geriatric syndromes (falls, delirium, malaise) (18%). Upon follow-up, 32% presented acute respiratory failure and 30% a geriatric complication. Frailty and geriatric characteristics were not correlated with mortality. Acute respiratory failure (p = 0.03) and lymphopenia (p = 0.02) were significantly associated with mortality. (4) Conclusions: Among older patients hospitalized with COVID-19, clinical presentations were frequently atypical and complications occurred frequently. Frailty and geriatric characteristics were not correlated with mortality.

COVID-19 highlights the need for universal adoption of standards of medical care for physicians in nursing homes in Europe

The nursing home sector has seen a disproportionately high number of deaths as part of the COVID-19 pandemic. This reflects, in part, the frailty and vulnerability of older people living in care homes but has also, in part, been a consequence of the failure to include care homes in the systematic planning of a response to COVID, as well as a measure of neglect of standards and quality improvement in the sector. In response, the EUGMS published a set of medical standards of care developed in consultation with experts across its member national societies in 2015. The standards consisted of seven core principles of medical care for physicians working in nursing homes as a first step in developing a programme of clinical, academic and policy engagement in improving medical care for older people who are living and frequently also dying as residents in nursing homes. The gravity of the concerns arising for nursing home care from the COVID-19 pandemic, as well as emerging insights on care improvement in nursing homes indicate that an update of these medical standards is timely. This was performed by the writing group from the original 2015 guidelines and is intended as an interim measure pending a more formal review incorporating a systematic review of emerging literature and a Delphi process.

COVIDApp as an Innovative Strategy for the Management and Follow-Up of COVID-19 Cases in Long-Term Care Facilities in Catalonia: Implementation Study

Background

The coronavirus disease (COVID-19) pandemic has caused an unprecedented worldwide public health crisis that requires new management approaches. COVIDApp is a mobile app that was adapted for the management of institutionalized individuals in long-term care facilities.

Objective

The aim of this paper is to report the implementation of this innovative tool for the management of long-term care facility residents as a high-risk population, specifically for early identification and self-isolation of suspected cases, remote monitoring of mild cases, and real-time monitoring of the progression of the infection.

Methods

COVIDApp was implemented in 196 care centers in collaboration with 64 primary care teams. The following parameters of COVID-19 were reported daily: signs/symptoms; diagnosis by reverse transcriptase–polymerase chain reaction; absence of symptoms for ≥14 days; total deaths; and number of health care workers isolated with suspected COVID-19. The number of at-risk centers was also described.

Results

Data were recorded from 10,347 institutionalized individuals and up to 4000 health care workers between April 1 and 30, 2020. A rapid increase in suspected cases was seen until day 6 but decreased during the last two weeks (from 1084 to 282 cases). The number of confirmed cases increased from 419 (day 6) to 1293 (day 22) and remained stable during the last week. Of the 10,347 institutionalized individuals, 5,090 (49,2%) remained asymptomatic for ≥14 days. A total of 854/10,347 deaths (8.3%) were reported; 383 of these deaths (44.8%) were suspected/confirmed cases. The number of isolated health care workers remained high over the 30 days, while the number of suspected cases decreased during the last 2 weeks. The number of high-risk long-term care facilities decreased from 19/196 (9.5%) to 3/196 (1.5%).

Conclusions

COVIDApp can help clinicians rapidly detect and remotely monitor suspected and confirmed cases of COVID-19 among institutionalized individuals, thus limiting the risk of spreading the virus. The platform shows the progression of infection in real time and can aid in designing new monitoring strategies.

Guidance for the Prevention of the COVID-19 Epidemic in Long-Term Care Facilities: A Short-Term Prospective Study

BACKGROUND

Guidance aiming at limiting the entry and spread of the COVID-19 have been widely communicated to Long-term Care Facilities (LTCFs). However, no clinical research has investigated their relevance.

OBJECTIVE

Our objective was to compare the guidance applied for the prevention of the COVID-19 epidemic between the LTCFs having been contaminated by COVID-19 and LTCFs having not been contaminated.

METHODS

A questionnaire was sent and systematically accompanied by phone call to the 132 LTCFs of Haute-Garonne (Occitania region, South-West of France). The questionnaire focused on the preventive measures implemented before March 23, 2020 (first LTCFs contaminated in this area). The questionnaire focused on physician support, implementation of usual guidance (eg, masks, hydro-alcoholic solute used), training on hygiene, containment in residents' rooms and other distancing measures, use of temporary workers, compartmentalization within zones of residents and staff and a self-assessment analogic scale on the quality of the application of the preventive measures. We compared implementation of the guidance between the LTCFs with at least one case of COVID-19 among residents and/or health care professionals and LTCFs without COVID-19 case (between March 23rd and May 6th).

RESULTS

124 LTCFs participated (93.9%). 30 LTCFs (24.19%) were contaminated with COVID-19. Large heterogeneity of the application of the guidance was observed. Public LTCFs (OR= 0.39 (0.20-0.73), LTCFs which organized staff compartmentalization within zones (OR= 0.19 (0.07-0.48)), and LTCF with a staff who self-assessed a higher quality implementation of the preventive measures (OR= 0.65 (0.43-0.98)) were significantly more likely to avoid contamination by the COVID-19 outbreak.

CONCLUSION

Our study supports the relevance of guidance to prevent the entry of COVID-19, in particular the staff compartmentalization within zones, as well as the perception of the staff regarding the quality of implementation of those measures in LTCFs.

COVID-19 and Intrinsic Capacity

The SARS-CoV-2 infection is particularly associated with negative outcomes (i.e., serious disease, death) in frail older people, independently of where they live. Furthermore, the period of pandemic (with its lockdowns, social distancing, fragmentation of care…) has significantly changed the environment in which older people live. It is likely that, when the pandemic will be over, an acceleration of the aging process will be observed for many persons, independently of whether they have been infected or not by the SARS-CoV-2. The World report on ageing and health, published by the World Health Organization, proposes the concept of intrinsic capacity (i.e., the composite of all the physical and mental capacities of the individual) as central for healthy ageing. The routine assessment of biological age through constructs such as intrinsic capacity might have allowed a better understanding of the functional trajectories and vulnerabilities of the individual, even during a catastrophic event as the one we are currently living. In the present article, we describe how COVID-19 has affected the persons' intrinsic capacity, and how the wide adoption of the intrinsic capacity model may support the modernization of our systems and bring them closer to the individual.