Connectivity between long-term care homes and subsequent SARS-CoV-2 outbreaks

Long-term care (LTC) homes have been the epicentre of the coronavirus disease 2019 (COVID-19) pandemic in Canada to date. Previous research shows that for-profit LTC homes deliver inferior care across a variety of outcome and process measures, raising the question of whether for-profit homes have had worse COVID-19 outcomes than nonprofit homes. We conducted a retrospective cohort study of all LTC homes in Ontario, Canada, from Mar. 29 to May 20, 2020, using a COVID-19 outbreak database maintained by the Ontario Ministry of Long-Term Care. We used hierarchical logistic and count-based methods to model the associations between profit status of LTC homes (for-profit, nonprofit or municipal) and COVID-19 outbreaks in LTC homes, the extent of COVID-19 outbreaks (number of residents infected), and deaths of residents from COVID-19. The analysis included all 623 Ontario LTC homes, comprising 75 676 residents; 360 LTC homes (57.7%) were for profit, 162 (26.0%) were nonprofit, and 101 (16.2%) were municipal homes. There were 190 (30.5%) outbreaks of COVID-19 in LTC homes, involving 5218 residents and resulting in 1452 deaths, with an overall case fatality rate of 27.8%. The odds of a COVID-19 outbreak were associated with the incidence of COVID-19 in the public health unit region surrounding an LTC home (adjusted odds ratio [OR] 1.91, 95% confidence interval [CI] 1.19-3.05), the number of residents (adjusted OR 1.38, 95% CI 1.18-1.61), and older design standards of the home (adjusted OR 1.55, 95% CI 1.01-2.38), but not profit status. For-profit status was associated with both the extent of an outbreak in an LTC home (adjusted risk ratio [RR] 1.96, 95% CI 1.26-3.05) and the number of resident deaths (adjusted RR 1.78, 95% CI 1.03-3.07), compared with nonprofit homes. These associations were mediated by a higher prevalence of older design standards in for-profit LTC homes and chain ownership. For-profit status is associated with the extent of an outbreak of COVID-19 in LTC homes and the number of resident deaths, but not the likelihood of outbreaks. Differences between for-profit and nonprofit homes are largely explained by older design standards and chain ownership, which should be a focus of infection control efforts and future policy.

The objective of this review was to chart the literature on assistive technologies (excluding robots) that support social interaction of older adults in long-term care homes, and to advance a definition of socially assistive technologies. Loneliness and social isolation have adverse effects on the health and well-being of older adults. Many long-term care homes provide recreational programming intended to entertain or distract residents, yet the evidence of their effectiveness is limited. Absent from the literature are comprehensive reviews of assistive technologies (other than robots) that are used to support social interaction in long-term care homes. The review considered research studies as well as gray literature that included older adults (≥65 years) living in long-term care homes. The concept of interest was the use of assistive technologies (excluding robots) that support social interaction in long-term care homes. The databases were searched on June 26, 2019, and included CINAHL Full Text (EBSCO), MEDLINE (Ovid), PsycINFO (EBSCO), Sociological Abstracts (ProQuest), Embase (Elsevier), and Web of Science (Clarivate). The search for gray literature was conducted in ProQuest Dissertations and Theses Databases and across 11 websites during September and October 2019. The recommended JBI approach to study selection, data extraction, and data synthesis was used. Twenty-five articles were included in this review, with comparable numbers of quantitative (n = 6), qualitative (n = 9), and mixed methods (n = 7) studies, with the remaining articles employing non-empirical designs (n = 3). Technologies were categorized as low (easily recognizable to everyone), medium (more electronics), or high (involves internet). Two studies reported on low-assistive technologies, including videotapes and the telephone. Medium-assistive technologies were identified in nine studies and included videophones; Nintendo Wii; tablet-based games; picture- and video-viewing tools; and CRDL (pronounced "cradle"), a special instrument that translates touch into sound. More than half (n = 14) of the included articles utilized high-assistive technologies, such as computer labs/kiosks, tablet-based applications, social media (eg, Facebook), videoconferencing, and multi-functional systems. Five studies measured whether assistive technologies had an impact on the quantity of long-term care residents' social interaction levels. Qualitative themes were related to residents' social connections and experiences after using various technologies. Four studies systematically incorporated a framework/model, and Social Structuration Theory was considered the most comprehensive. In the absence of a definition of socially assistive technologies, the definition advanced from this review is as follows: Socially assistive technologies are user-appropriate devices and tools that enable real-time connectivity to enhance social interaction. Included literature reported the benefits of technology use, with considerable variability in engagement and no cost estimates. We recommend that future research continue to advance our definition of socially assistive technologies, make promising assistive technologies available in long-term care homes after studies are completed, report the costs of assistive technologies, and include participants with dementia and culturally and linguistically diverse backgrounds.

To identify and examine the structures and processes that support the director of nursing role in long-term care homes. The director of nursing in long-term care homes is central to overseeing and supporting the workforce and delivery of safe, quality resident care. With ongoing health human resource challenges and an aging population requiring care from long-term care homes, it is important to understand what individual and organizational factors support the director of nursing leadership in these settings. Evaluation. This review was guided by Cooper's five stages of the integrative review process. Donabedian's structure-process-outcome framework was applied to synthesize the literature. Key Issue(s). Five individual-level structures (years of experience, level of education, demonstrated leadership capabilities, completed certification and/or established linkages with a professional association, and completed continuing education); three organizational-level structures (physical presence of leadership across the organization, a clear job description, and salary); and four processes (nursing home administrators and the director of nursing relationship, availability of onsite continuing education opportunities targeting directors of nursing and support for continuing education, cultivating relationships and enhancing networks beyond the long-term care home, and orientation to the role) were identified across 11 articles to support the director of nursing role in long-term care homes. Conclusion(s). The findings indicate that there are individual characteristics that support the director of nursing in their role. Notably, there are organizational structures and processes that can be modified at the practice and policy level to better recruit, retain, and support the performance of directors of nursing. Implications for Nursing Management. There are actionable steps that leaders and decision-makers can take to support nursing leadership across long-term care homes and directly address health human resource challenges.

BackgroundResidents living in long-term care homes (LTCH) have complex care needs, multiple chronic conditions, increasing frailty and cognitive impairment. A palliative approach that incorporates advance care planning (ACP) should be integrated with chronic disease management, yet it is not a norm in most LTCHs. Despite its growing need, there remains a lack of staff engagement in the ACP process.ObjectivesThe aim of this study was to explore the perceptions and experiences of interdisciplinary staff related to the practice of ACP in LTCHs.MethodsThis study is part of a larger Canadian project, iCAN ACP, that aims to increase uptake, and access to ACP for older Canadians living with frailty. An exploratory qualitative design using an interpretive descriptive approach was employed utilizing focus groups and semi-structured interviews with staff from four LTCHs in Ontario, Canada.FindingsThere were 98 participants, including nurses (n = 36), physicians (n = 4), personal support workers (n = 34), support staff (n = 23), and a public guardian (n = 1). Three common themes and nine subthemes were derived: a) ongoing nature of ACP; b) complexities around ACP conversations; and c) aspirations for ACP becoming a standard of care in LTCHs.DiscussionThe findings of this study provide important contributions to our understanding of the complexities surrounding ACP implementation as a standard of practice in LTCHs. One of the critical findings relates to a lack of ACP conversations prior to admission in the LTCHs, by which time many residents may have already lost cognitive abilities to engage in these discussions. The hierarchical nature of LTCH staffing also serves as a barrier to the interdisciplinary collaboration required for a successful implementation of ACP initiatives. Participants within our study expressed support for ACP communication and the need for open lines of formal and informal interdisciplinary communication. There is a need for revitalizing care in LTCHs through interdisciplinary care practices, clarification of role descriptions, optimized staffing, capacity building of each category of staff and commitment from the LTCH leadership for such care.ConclusionThe findings build on a growing body of research illustrating the need to improve staff engagement in ACP communication in LTCHs.

Diagnostic Testing in Long-Term Care and Resident Emergency Department Visits: A Retrospective Cohort Study

Background: During the COVID-19 pandemic, new processes and policies were implemented to limit the spread of COVID-19 in long-term care homes (LTCH).Technology use within LTCH changed significantly. Research Aim:The purpose of this literature review was to examine the breath of evidence in the use of technology in LTCHs in North America during the COVID-19 pandemic.Methods: Guided by Arksey and O'Malley's scoping review framework, five databases were searched to identify peer-reviewed articles using key words and subject headings related to Long Term Care, COVID-19, and Technology.Results: Research articles that described the investigation of, or the analysis of reported data on, the use of any kind of technology in LTCHs in North America during the COVID-19 pandemic were included for analysis.There were 121 articles retrieved, of which 32 articles met the inclusion and exclusion criteria and were included for analysis.Technology was deployed in support of the quality of life of LTCH residents in the context of social isolation, telehealth, virtual services, multidisciplinary collaborations, continuing education and training, infection prevention and control services, and activities, computer-based modelling for the LTCH setting.Technologies described included robots, web-based websites and games, and computer-based models that predict COVID-19 transmission in LTCHs, though most described the use of information and communication technologies to connect people within the LTCH to those outside the LTCH.Researchers also noted technology challenges in LTCH such as poor technological infrastructure, unstable Wi-Fi connectivity and inadequate number of devices to support virtual visits, other online recreation activities in LTCH, as well as the provision of telehealth services.Conclusion: Findings emphasize the need to examine the impacts of technology use in LTCH in rural and remote areas, to inform actionable insights to the promote accessible, inclusive, and sustainable adoption of new technologies across all LTCH settings.

Background Antibiotics are frequently prescribed for long-term care residents with asymptomatic bacteriuria, for which there is no indication. In order to help reduce unnecessary urine culturing and concomitant antibiotic use, C. difficile infection, and antibiotic resistance, Public Health Ontario (PHO) developed a multi-component organizational change program. The program focuses on five practice changes, recommends nine implementation strategies that have been linked to barriers, and includes an implementation planning process. Methods A purposive sampling strategy was used to recruit 12 long-term care homes (LTCHs) in the province of Ontario, Canada. LTCHs worked with PHO staff to implement the program over a 4-month period in mid-2016. The outcome evaluation compared rates of urine cultures sent, total antibiotics, and urinary antibiotics (ciprofloxacin, nitrofurantoin, TMP/SMX, and fosfomycin) per 1,000 resident days before and after the implementation phase. A Poisson regression model adjusting for time-trends, seasonality and controlling for autocorrelation, was used. Results Of the 12 LTCHs recruited, as of May 2017, 9 LTCHs provided data, totaling 106 facility-months. During the pre-implementation phase, inter-facility variation in urine culturing rates (mean = 2.4, inter-decile range [IDR] = 4.3), total antibiotic use (median = 3.2, IDR = 5.5), and urinary antibiotic use (median = 1.2, IDR = 2.2), were large (Figure 1). Comparing the post-implementation period to the pre-implementation period, we observed a 31% adjusted decline in urine culturing (incidence rate ration [IRR] = 0.69, 95% CI: 0.51 to 0.94, Figure 2), a 65% adjusted decline in total antibiotic use (IRR = 0.35, 95% CI: 0.13 to 0.92), and a 38% adjusted decline in urinary antibiotic use (IRR = 0.62, 95% CI: 0.23 to 1.68) across the participating facilities. Conclusion While there was variation in baseline urine culturing rates and antibiotic use across LTCHs, preliminary data indicate that these outcomes declined in a relatively short time period following implementation of an organizational change program. Plans to expand the program to the provinces 600 LTCHs could prioritize facilities with high baseline urine culturing rates. Disclosures All authors: No reported disclosures.

BackgroundThe COVID-19 pandemic has profoundly affected the health and care of older adults, with particularly negative consequences for those residing in long-term care homes (LTCH) and retirement homes (RH). To inform the implementation of interventions with the most potential for impact, Healthcare Excellence Canada identified six promising practices and policy options that can be introduced to ensure that LTCH and RH are better prepared for potential future outbreaks. A total of 22 implementation science teams (ISTs) were funded to support LTCH and RH across Canada in their implementation of these practices. This study aims to identify the enablers and barriers to the successful implementation of evidence-based practices and the impact of intervention in LTCH and RH across Canada.MethodsA survey-based longitudinal correlational design will be used. The Organizational Readiness for Knowledge Translation (OR4KT) tool will be used to assess the readiness of LTCH and RH to implement the selected practice. The OR4KT includes 59 questions and takes about 15 min to complete. Five to ten respondents per organization, holding different job positions, will be invited by the ISTs to complete the OR4KT in 91 LTCH or RH across Canada at the beginning of the project (T1) and 6 months after the first measurement (T2).DiscussionThe study will provide a benchmark for assessing the readiness of LTCH and RH to implement evidence-based practices. It will also inform decision-makers about barriers and facilitators that influence the integration of promising practices in these organizations.

IntroductionAdvance care planning can improve the quality of life for residents in long-term care homes and reduce stress for families. However, care home staff and families often lack knowledge about advance care planning, making it especially difficult for residents with dementia to communicate their care plan wishes. A Conversation Starter Kit may increase advance care planning awareness among staff and families.ObjectivesThis study evaluated an advance care planning intervention, the Conversation Starter Kit booklet, for use in long term care homes.MethodsData were collected at three long-term care homes in southern Ontario. We collected data from 55 residents who were able to make decisions on their own paired with 11 family members of these residents. We also collected data from 24 family members of residents who were unable to make decisions on their own. This study used a quasi-experimental, one group pre/post design. Quantitative surveys were administered before and after a three-month advance care planning intervention. An additional structured interview was completed at the end of the intervention period, which included both closed and open-ended questions to assess perceptions about the booklet's use or non-use.ResultsResidents reported more engagement in advance care planning after completing the Conversation Starter Kit booklet, particularly related to asking questions to health care providers about health care decisions. Family members reported feeling very certain that they would be able to make decisions on behalf of the resident but felt less certain after completing the booklet, implying the booklet raised their awareness of the types of decisions they might need to make, hopefully prompting them to be more prepared for decisions in the future.ConclusionsAn advance care planning intervention – The Conversation Starter Kit booklet - appears acceptable and easy to use for residents and family members/friends in long-term care and can improve resident engagement in advance care planning. Although using the booklet may decrease efficacy for decision making among family members of long-term care residents, it may highlight the importance of more actionable engagement in advance care planning among residents, their families/friends, and staff.

Pain is the most common medical issue that older people face in a long-term care facility. Registered nurses have a critical role in helping residents manage their pain. This research looked at measures to improve pain management practices in long-term care facilities in Ontario. The site for this research was a chosen long-term care facility in Ontario, Canada, a 160-bed nursing home for the elderly that provides various nursing and medical care services. Semi-structured focus group interviews lasting about an hour were done. This study's population consisted of 45 nurses. The researcher chose a sample of 25 registered nurses using a purposive sampling strategy. The data was reviewed using qualitative data analysis to detect recurring concerns. This research revealed the necessity of identifying measures to improve pain management and reinforcing good practices in long-term care homes; better pain management practices are necessary to manage pain in a long-term care home. This study demonstrated the importance of recognizing and overcoming measures to improve pain management and reinforce good practices in long-term care homes. Therefore, improved measures to improve pain management practices are required to manage pain in a long-term care home effectively. Education about safe pain management will help to prevent the undertreatment of pain and its negative consequences. The overall benefits of measures to improve pain management practices in long-term care homes expand nurses' clinical knowledge in the care of residents living in nursing homes.

ObjectivesNew models for the workforce are required in long-term care (LTC) homes, as was made evident during the Coronavirus Disease 2019 (COVID-19) pandemic. Nurse Practitioner (NP)-led models of care represent an effective solution. This study explored NPs’ roles in supporting LTC homes as changes in directives, policies, and recommendations related to COVID-19 were introduced.DesignQualitative exploratory study.ContextThirteen NPs working in LTC homes in Ontario, Canada.MethodsSemi-structured interviews were conducted in March/April 2021. A five-step inductive thematic analysis was applied.FindingsAnalysis generated four themes: leading the COVID-19 vaccine rollout; promoting staff wellbeing related to COVID-19 fatigue; addressing complexities of new admissions; and negotiating evolving collaborative relationships.ConclusionsNurse practitioners were instrumental in supporting LTC homes through COVID-19 regulatory changes producing unintended consequences. The NPs’ leadership in transforming care is equally essential in LTC homes as in other established healthcare settings, such as primary and acute care.

To determine the proportion of older people moving to care homes with a recent stroke, incidence of stroke after moving to a care home, mortality following stroke, and secondary stroke prevention management in older care home residents. Retrospective cohort study using population-scale individual-level linked data sources between 2003 and 2018 in the Secure Anonymized Information Linkage (SAIL) Databank. People aged ≥65years residing in long-term care homes in Wales. Competing risk models and logistic regression models were used to examine the association between prior stroke, incident stroke, and mortality following stroke. Of 86,602 individuals, 7.0% (n= 6055) experienced a stroke in the 12months prior to care home entry. The incidence of stroke within 12months after entry to a care home was 26.2 per 1000 person-years [95% confidence interval (CI) 25.0, 27.5]. Previous stroke was associated with higher risk of incident stroke after moving to a care home (subdistribution hazard ratio 1.83, 95% CI 1.57, 2.13) and 30-day mortality following stroke (odds ratio 2.18, 95% CI 1.59, 2.98). Severe frailty was not significantly associated with risk of stroke or 30-day mortality following stroke. Secondary stroke prevention included statins (51.0%), antiplatelets (61.2%), anticoagulants (52.4% of those with atrial fibrillation), and antihypertensives (92.1% of those with hypertension). At the time of care home entry, individuals with history of stroke in the previous 12months are at a higher risk of incident stroke and mortality following an incident stroke. These individuals are frequently not prescribed medications for secondary stroke prevention. Further evidence is needed to determine the optimal care pathways for older people living in long-term care homes with history of stroke.

Objectives:People working in long-term care homes (LTCH) face ethical dilemmas about how to minimize the risk of spread of COVID-19, while also minimizing psychological hardship and other harms of infection control measures on residents. The Dementia Isolation Toolkit (www.dementiaisolationtoolkit.com; DIT) was developed to address the gap in ethical guidance for LTCH on how to safely and effectively isolate people with dementia while supporting the personhood and well-being of residents. In this presentation, we will present the DIT and report on the results of a survey of LTCH staff in Ontario, Canada on their experiences isolating residents in LTCH and the use of the DIT in supporting person-centred isolation care.Methods:A link to an online survey was distributed to LTCH staff through provincial organizations and agencies as well as through social media and the DIT website. Inclusion criteria were LTCH staff working on-site at a LTCH since March 1, 2020, who had direct or indirect experience with the isolation/quarantine of LTCH residents. Results were summarized descriptively.Results:A broad sample of LTCH staff (n=207) participated in the survey, most of whom had experienced an outbreak in their LTCH. Dementia (96%) was the most important barrier to implementation of infection control measures in LTCH, followed by staff distress about the effects of isolation on residents (61%). Important facilitators for isolation included delivery of 1:1 activities in the resident’s room (81%) and designating essential caregivers to provide support (67%), while inadequate staffing levels were reported as a barrier (55%). 65% of respondents indicated some familiarity with the DIT, and of those who had used the toolkit, 62% found it helpful in supporting isolation care, particularly in developing care plans and making and communicating decisions. Of those who had used the DIT, 48% found it fairly or very helpful at reducing their level of distress.Conclusions:Isolation as an infection control and prevention (ICP) measure in LTCH environments can be harmful to residents and create moral distress in staff. ICP guidance and support of LTCH needs to address how to minimize these harms by providing dementia-specific guidance such as in the DIT.

Multiple jobholding and part-time work among nurses in long-term care homes compared to other healthcare sectors: Evidence from Ontario

We aim to assess how COVID-19 infection and mortality varied according to facility size in 965 long-term care homes (LTCHs) in Catalonia during March and April 2020. We measured LTCH size by the number of authorised beds. Outcomes were COVID-19 infection (at least one COVID-19 case in an LTCH) and COVID-19 mortality. Risks of these were estimated with logistic regression and hurdle models. Models were adjusted for county COVID-19 incidence and population, and LTCH types. Sixty-five per cent of the LTCHs were infected by COVID-19. We found a strong association between COVID-19 infection and LTCH size in the adjusted analysis (from 45% in 10-bed homes to 97.5% in those with over 150 places). The average COVID-19 mortality in all LTCHs was 6.8% (3887 deaths) and 9.2% among the COVID-19-infected LTCHs. Very small and large homes had higher COVID-19 mortality, whereas LTCHs with 30 to 70 places had the lowest level. COVID-19 mortality sharply increased with LTCH size in counties with a cumulative incidence of COVID-19 which was higher than 250/100,000, except for very small homes, but slightly decreased with LTCH size when the cumulative incidence of COVID-19 was lower. To prevent infection and preserve life, the optimal size of an LTCH should be between 30 and 70 places.