LTCcovid Country Profiles

Responses to 3.07.02. Approach to isolation of people with confirmed or suspected Covid-19 infections in care homes

The LTCcovid International Living report is a “wiki-style” report addressing 68 questions on characteristics of Long-Term Care (LTC) systems, impacts of COVID-19 on LTC, measures adopted to mitigate these impacts and new reforms countries are adopting to address structural problems in LTC systems and to improved preparedness for future events. It was compiled and updated voluntarily by experts on LTC all over the world. Members of the Social Care COVID-19 Resilience and Recovery project moderated the entries and edited as needed. It was updated regularly until the end of 2022.

The report can be read by question/topic (below) or by country: COVID-19 and Long-Term Care country profiles.

To cite this report (please note the date in which it was consulted as the contents changes over time):

Comas-Herrera A, Marczak J, Byrd W, Lorenz-Dant K, Patel D, Pharoah D (eds.) and LTCcovid contributors.  (2022) LTCcovid International living report on COVID-19 and Long-Term Care. LTCcovid, Care Policy & Evaluation Centre, London School of Economics and Political Science. https://doi.org/10.21953/lse.mlre15e0u6s6

Copyright is with the LTCCovid and Care Policy and Evaluation Centre, LSE.

 

About this question

With thanks to Andrea Iaboni

Overview

Key findings so far:

– There are different approaches to the isolation of people living in care homes who test positive with COVID-19 or who are potentially infected. These range from isolating people in their bedrooms, to cohorting them in separate sections of a facility, to being transferred to another care setting.

– There is relatively little evidence on this, with most of the published research so far being case studies and outbreak reports that do not establish whether one approach is better than the others.

– There is evidence that suggests that care homes with difficulties implementing isolation measures have had worse outcomes in terms of infections.

– There is concern about the well-being, physical, and mental health impacts of isolation measures (in particular confinement to a bedroom), especially for people living with dementia and other forms of cognitive impairment.

– Concerns about the impact on residents may result in staff not implementing isolation measures, and so it is important to develop compassionate approaches to isolation that take into account these concerns.

Introduction

Once there is a confirmed or suspected case of COVID-19 among residents in a care home, they are usually isolated from other residents in order to limit the risk of transmission. There is relatively little evidence on which approaches to isolation work best. This overview builds on the Cochrane rapid review of non-pharmacological measures in long-term care facilities by Stratil et al. (2021), complemented with articles identified as part of an update of an ongoing literature mapping review (see Byrd et al., 2021). Most of the evidence in this overview is from outbreak reports or case studies, which describe interventions undertaken, but are unable to provide an assessment of how effective these were in comparison to if no action had been taken.

Main approaches to isolation:

Sometimes, isolation has been combined with universal testing through point prevalence surveys, so that asymptomatic cases can also be identified and isolated (McBee et al., 2020; Shimotsu et al., 2020). However, as illustrated by Kim (2020), cohorting can occur in the absence of universal testing, where residents are divided into smaller units to try and limit the contacts between residents and therefore reduce the spread. In other cases, isolation has occurred in negative isolation spaces, either in individual rooms (Alawi, 2021), or in specific units (Miller et al., 2021).

More comprehensive strategies include cohorting, where the internal organisation of a care home is rearranged so that different groups of residents can be spatially isolated from each other. Sometimes, this cohorting separated positive and negative residents in different units (Shrader et al., 2020; Dora et al., 2021; Escobar et al., 2021). In addition, three-tiered cohorting was undertaken to separate positive, negative-exposed, and negative-unexposed residents, with the idea that negative-exposed residents may convert to positive, highlighting the importance of separating them from negative-unexposed (Collison et al., 2020; Eckardt et al., 2020). Cohorting often relied heavily on the availability of PCR testing to universally categorise residents for cohorting. Gonzalez de Villaumbrosia et al. (2020) suggested serology can be used to develop a three-tiered cohort when PCR testing is unavailable.

In some countries, for example Singapore, all residents who tested positive for COVID-19 were transferred to acute hospitals, as it was considered too risky to attempt isolation in nursing homes.

There have been some examples where care home staff have moved into care homes to avoid bringing in infections, in some countries this was voluntary and in others it was mandated. A study in France showed that the 17 care homes that implemented voluntary self-confinement of staff (in combination with other infection-control measures) had significantly lower levels of infection (Belmin et al., 2020).

These studies and examples are summarised below, by country.

Evidence on what works in relation to isolation in care homes:

Two studies that compared COVID-19 related outcomes in care homes with different abilities to isolate infected residents found that care homes that reported having difficulties with or were unable to isolate effectively had higher rates of outbreaks and larger outbreaks (Lombardo et al., 2021, Shallcross et al., 2021).

There are concerns about potential negative outcomes of isolation measures (impacts on physical and mental health) on the mental and physical health of care home residents, and in particular people who have cognitive impairment or dementia (see section 2.05. in this report for an overview of evidence). This has led, for example, to the development of a toolkit to support compassionate and effective isolation for people with dementia (Dementia Isolation Toolkit).

Concerns about the impacts of isolation may lead to staff feeling conflicted in implementing these measures. There are also significant constraints in the ability of care homes to implement isolation effectively, given physical and staffing constraints.

Iaboni et al (2022) found that most homes were not able to implement IPC measures effectively, with residents leaving isolation to circulate in common areas and not following hand hygiene or masking requests. Staff found it difficult to mitigate the impact on resident well-being, with mental health impacts, physical decline, and safety issues all reported.  Staff experienced high level of distress due to having to apply these measures. Around 1/3 respondents had used tools from the Dementia Isolation Toolkit, and of those, about half found the toolkit helpful at reducing their level of distress.

As illustrated by Collison et al. (2020), specific memory-care units within care homes can create their own isolation protocols, because off-unit isolation has the potential to do more harm than good for dementia patients. In Iceland a home-like isolation ward was used for older people with care needs with COVID-19 who did not require hospitalisation.

In the section below there are examples of isolation policies in different countries, as well as summaries of the studies identified in this overview.

References:

Alawi, M. M. S. (2021). Successful management of COVID-19 outbreak in a long-term care facility in Jeddah, Saudi Arabia: Epidemiology, challenges for prevention and adaptive management strategies. Journal of Infection and Public Health, 14(4), 521–526. https://doi.org/https://dx.doi.org/10.1016/j.jiph.2020.12.036

Belmin J, Um-Din N, Donadio C, et al. Coronavirus Disease 2019 Outcomes in French Nursing Homes That Implemented Staff Confinement With Residents. JAMA Netw Open. 2020;3(8):e2017533. doi:10.1001/jamanetworkopen.2020.17533

Byrd, W., Salcher-Konrad, M., Smith, S., & Comas-Herrera, A. (2021). What Long-Term Care Interventions and Policy Measures Have Been Studied During the Covid-19 Pandemic? Findings from a Rapid Mapping Review of the Scientific Evidence Published During 2020. Journal of Long-term Care, (2021), 423–437. DOI: http://doi.org/10.31389/jltc.97

Collison, M., Beiting, K. J., Walker, J., et al. (2020). Three-Tiered COVID-19 Cohorting Strategy and Implications for Memory-Care. Journal of the American Medical Directors Association, 21(11), 1560–1562. https://doi.org/10.1016/j.jamda.2020.09.001

Dora  V, A., Winnett, A., Fulcher, J. A., et al. (2021). Using Serologic Testing to Assess the Effectiveness of Outbreak Control Efforts, Serial Polymerase Chain Reaction Testing, and Cohorting of Positive Severe Acute Respiratory Syndrome Coronavirus 2 Patients in a Skilled Nursing Facility. CLINICAL INFECTIOUS DISEASES, 73(3), 545–548. https://doi.org/10.1093/cid/ciaa1286

Eckardt, P., Guran, R., Hennemyre, J., et al. (2020). Hospital affiliated long term care facility COVID-19 containment strategy by using prevalence testing and infection control best practices. American Journal of Infection Control. https://doi.org/10.1016/j.ajic.2020.06.215

Escobar, D. J., Lanzi, M., Saberi, P., et al. (2021). Mitigation of a Coronavirus Disease 2019 Outbreak in a Nursing Home Through Serial Testing of Residents and Staff. Clinical Infectious Diseases, 72(9), E394–E396. https://doi.org/10.1093/cid/ciaa1021

Gonzalez de Villaumbrosia, C., Martinez Peromingo, J., Ortiz Imedio, J. et al. (2020). Implementation of an Algorithm of Cohort Classification to Prevent the Spread of COVID-19 in Nursing Homes. Journal of the American Medical Directors Association, 21(12), 1811–1814. https://doi.org/10.1016/j.jamda.2020.10.023

Iaboni, A., Quirt, H., Engell, K. et al. Barriers and facilitators to person-centred infection prevention and control: results of a survey about the Dementia Isolation Toolkit. BMC Geriatr 22, 74 (2022). https://doi.org/10.1186/s12877-022-02759-4

Kim, T. (2020). Improving Preparedness for and Response to Coronavirus Disease 19 (COVID-19) in Long-Term Care Hospitals in the Korea. Infect Chemother.

Lombardo FL, Bacigalupo I, Salvi E, et al. The Italian national survey on coronavirus disease 2019 epidemic spread in nursing homes. International Journal of Geriatric Psychiatry 2021;36(6):873-82. https://doi.org/10.1002/gps.5487

McBee, S. M., Thomasson, E. D., Scott, M. A., Reed, C. L., Epstein, L., Atkins, A., & Slemp, C. C. (2020). Notes from the Field: Universal Statewide Laboratory Testing for SARS-CoV-2 in Nursing Homes – West Virginia, April 21-May 8, 2020. MMWR. Morbidity and Mortality Weekly Report, 69(34), 1177–1179. https://doi.org/10.15585/mmwr.mm6934a4

Miller, S. L., Mukherjee, D., Wilson, J., Clements, N., & Steiner, C. (2021). Implementing a negative pressure isolation space within a skilled nursing facility to control SARS-CoV-2 transmission. American Journal of Infection Control, 49(4), 438–446. https://doi.org/10.1016/j.ajic.2020.09.014

Shallcross L, Burke D, Abbott O, Donaldson A, Hallatt G, Hayward A, et al. Risk factors associated with SARS-CoV-2 infection and outbreaks in long term care facilities in England: a national survey. Lancet Healthy Longevity 2021;2(3):e129-e142. https://doi.org/10.1016/S2666-7568(20)30065-9

Shimotsu, S. T., Johnson, A. R. L., Berke, E. M., & Griffin, D. O. (2020). COVID-19 Infection Control Measures in Long-Term Care Facility, Pennsylvania, USA. Emerging Infectious Diseases, 27(2). https://doi.org/10.3201/eid2702.204265

Shrader, C. D., Assadzandi, S., Pilkerton, C. S., & Ashcraft, A. M. (2020). Responding to a COVID-19 Outbreak at a Long-Term Care Facility. Journal of Applied Gerontology?: The Official Journal of the Southern Gerontological Society, 733464820959163. https://doi.org/10.1177/0733464820959163

Stratil JM, Biallas RL, Burns J, et al. (2021). Non-pharmacological measures implemented in the setting of long-term care facilities to prevent SARS-CoV-2 infections and their consequences: a rapid review. Cochrane Database of Systematic Reviews 2021, Issue 9. Art. No.: CD015085. DOI: 10.1002/14651858.CD015085.pub2. Accessed 09 January 2022.

International reports and sources

Systematic review of non-pharmacologocial measures to prevent COVID infections in Long-Term Care facilities:

Stratil JM, Biallas RL, Burns J, et al. Non-pharmacological measures implemented in the setting of long-term care facilities to prevent SARS-CoV-2 infections and their consequences: a rapid review. Cochrane Database of Systematic Reviews 2021, Issue 9. Art. No.: CD015085. DOI: 10.1002/14651858.CD015085.pub2. Accessed 09 January 2022.

Guidance

If the COVID-19 positive person is a staff member, they must apply a surgical mask and leave the aged care facility by isolating at home. If the COVID-19 positive person is a resident, they must be moved to a single room, preferably with an en-suite, to isolate. The residential home may also be placed under lockdown for further testing. The local public health unit is responsible for contact tracing and the monitoring of residents (source: health.gov).

Dementia Support Australia provided guidance to support people with dementia during COVID-19. They suggested 1:1 residential support as the ideal way to help a resident isolate (source: Dementia Support Australia).

Last updated: January 12th, 2022

Implementation considerations

In care homes, isolation was used frequently, however, this was problematic in situation where more people shared rooms. (https://journal.ilpnetwork.org/articles/10.31389/jltc.54/)

Last updated: January 12th, 2022

Guidance

If a positive case is found in a LTC facility, the operator must close the affected floor/unit/ward or facility/residence to new admissions, re-admissions, or transfers, unless medically necessary and/or approved by a Medical Health Officer. COVID positive residents are not transferred to an external quarantine facility and are only transferred to acute medical care for COVID if necessary (http://www.bccdc.ca/Health-Info-Site/Documents/COVID19_LongTermCareAssistedLiving.pdf).

Last updated: January 12th, 2022

Evidence on barriers to implementing isolation

Iaboni et al (2022) surveyed staff working in care homes in Ontario, Canada, asking about their experiences with implementing infection control measures (IPC) in the first two waves, in the context of a preliminary evaluation of a toolkit to support compassionate and effective isolation for people with dementia (the Dementia Isolation Toolkit).  Their study found that most homes were not able to implement IPC measures effectively, with residents leaving isolation to circulate in common areas and not following hand hygiene or masking requests. Staff found it difficult to mitigate the impact on resident well-being, with mental health impacts, physical decline, and safety issues all reported.

Staff identified many barriers to isolating residents effectively- in particular, staff distress about the impact of isolation on residents’ quality of life (61%), and their fear about the reaction of residents when enforcing these measures (59%) were reported as important barriers to the effectiveness of isolation.  Moral distress around the implementation of these measures was high- one-third (33%) had large to extreme amounts of moral distress, 84% had an increase in moral distress since the start of the pandemic, and 40% reported a large impact of moral distress on their job satisfaction.  Around one third of respondents had used tools from the Dementia Isolation Toolkit, and of those, about half found the toolkit helpful at reducing their level of distress.

References:

Iaboni, A., Quirt, H., Engell, K. et al. Barriers and facilitators to person-centred infection prevention and control: results of a survey about the Dementia Isolation Toolkit. BMC Geriatr 22, 74 (2022). https://doi.org/10.1186/s12877-022-02759-4

Last updated: February 6th, 2022   Contributors: Andrea Iaboni  |  

On April 8, 2020, an extensive guidelines were issued by the Board of Health, outlining how nursing homes and other institutions could prevent the spreading of COVID-19, in the wake of the so-called controlled re-opening of the country which was planned to take place after Easter (April 14th 2020). It was intended to supplement the procedures that the municipalities had already put in place, and provided guidelines on how to organize this. It specifically addressed the handling of the disease as a responsibility of the local management. The managers were encouraged to plan the daily activities so that residents gathered in smaller groups than normally, preferably no more than two (https://ltccovid.org/2020/05/28/new-country-report-the-covid-19-long-term-care-situation-in-denmark/).

In the current guidelines (Sept 2022), it is still recommended to isolate residents in nursing homes if they have tested positive. If more than one resident is positive, it is recommended to establish a separate unit for these residents. In this way, the residents can have some mobility outside their own dwelling and staff do not need to change PPE in between visiting the residents. The nursing home can also choose to separate the home into zones, so that specific units are isolated. In the case where a resident does not understand the necessity for isolation, due to cognitive impairment or dementia, the guidelines emphasize the need for trying to motivate the resident to stay in their own dwelling by using pedagogical methods and means. version-5_6-Vejledning-om-forebyggelse-af-smitte-paa-plejecentre-mv_-september-2022.ashx (sst.dk)

 

Last updated: May 25th, 2023   Contributors: Tine Rostgaard  |  

National government guidelines to isolation have included LTC unit visiting bans, the provision of single rooms within LTC homes for symptomatic or exposed residents, restricted use of common areas in LTC units, and limited visitation of at-home care users. Some municipalities were quick to adhere to these policies, while others delayed implementation until the end of April (https://ltccovid.org/wp-content/uploads/2020/06/ltccovid-country-reports_Finland_120620.pdf).

Last updated: September 9th, 2021

Implementation experiences:

Many care homes had to individually isolate service users, especially at the beginning of the pandemic, due to lack of adequate PPE. The guidance published in April 2020 around testing would test the first symptomatic resident, who would then be taken care of either in strict isolation or in single rooms. If one care worker tested positive, all workers were required to be tested and isolate. This was noted as a struggle by the Assembly Commission as many care homes had shared rooms for residents (https://www2.assemblee-nationale.fr/static/15/pdf/rapport/i3633.pdf). This was linked to severe health impacts (https://ltccovid.org/2020/05/05/summary-sars-cov-2-related-deaths-in-french-long-term-care-facilities-the-confinement-disease-is-probably-more-deleterious-than-the-covid-19-itself/).

Evidence: 

A study from France comparing mortality in nursing homes with staff confining with residents compared to national average showed that staff confining with residents was effective in preventing infection and reducing mortality (Belmin et al., 2020).

References:

Belmin J, Um-Din N, Donadio C, et al. Coronavirus Disease 2019 Outcomes in French Nursing Homes That Implemented Staff Confinement With Residents. JAMA Netw Open. 2020;3(8):e2017533. doi:10.1001/jamanetworkopen.2020.17533

Last updated: January 12th, 2022

Guidance:

Guidance to support people living in care homes stress the importance of human dignity and focus on the need to ensure social participation and quality of life of residents (https://www.awmf.org/uploads/tx_szleitlinien/184-001l_S1_Soz_Teilhabe_Lebensqualitaet_stat_Altenhilfe_Covid-19_2020-10_1.pdf). Guidance on approaches to isolation of confirmed/suspected cases in care homes are provided (and regularly updated following the latest evidence) by the Robert Koch Institute.

In some federal states (e.g. Bavaria) relevant ministries can also issue guidelines (https://www.stmgp.bayern.de/wp-content/uploads/2020/08/20200818_handlungsanweisungen.pdf).

Last updated: February 12th, 2022   Contributors: Klara Lorenz-Dant  |  

Several LTC homes set up COVID wards and/or isolation areas within their institutions to limit the number of people in need of ambulatory transfer to hospitals. Medical geriatric centres were also asked to open at least one ward dedicated to mild or moderate COVID-19 cases; if cases became severe, patients were transferred to a general hospital. Due to lack of post-hospital geriatric support, many older people with COVID-19 remained in isolated recovery in hospital (Tsadok-Brosenbluth et al., 2021).

References:

Tsadok-Rosenbluth, S., Hovav, B., Horowitz, G. and Brammli-Greenberg, S., 2021. Centralized Management of the Covid-19 Pandemic in Long-Term Care Facilities in Israel. Journal of Long-Term Care, (2021), pp.92–99. DOI: http://doi.org/10.31389/jltc.75

Last updated: January 12th, 2022   Contributors: Shoshana Lauter  |  

Guidelines have been issued by the Ministry of Health through the Italian Institute for Health (ISS), defining standards and procedures for isolation in nursing homes.

Last updated: December 4th, 2021   Contributors: Eleonora Perobelli  |  Elisabetta Notarnicola  |  

LTCFs used well-established infection control procedures and swiftly isolated affected residents and suspended visits and social events (as they are used to do in the case of influenza/TB outbreaks). Mask-wearing was also already common practice in the event of these outbreaks. Data suggests most cases were contained with few large outbreaks within facilities (https://programs.wcfia.harvard.edu/files/us-japan/files/margarita_estevez-abe_covid19_and_japanese_ltcfs.pdf).

Last updated: September 9th, 2021

The association of geriatricians has issued guidelines for infection control in care homes (Verenso). The ability to control infection has increased substantially between the first and second wave. The publicly financed programme “Dignity and Pride on Location” has developed a “roadmap” to help providers to prepare for a new pandemic (https://ltccovid.org/wp-content/uploads/2020/11/COVID-19-Long-Term-Care-situation-in-the-Netherlands-_-the-second-wave-25-November-2020-2.pdf).

Last updated: September 9th, 2021

Evidence on experiences of cohorting to separate groups of residents (starting March 2020)

A study describes an emergency response to a COVID-19 outbreak in a long-term care hospital (LTCH) spread over floors 2 through 5 in a five-storey building in Bucheon, South Korea. As of March 12, 2020, there were 142 patients, with six to ten patients assigned to each room, and bed distance of less than one metre apart.

In response to an index case, all patients were considered contact persons. Patients in a dischargeable condition were isolated at home. Of the other patients, 73 were transferred to public hospitals and nearby private acute care hospitals. The remaining patients were in isolation cohorts after the beds were repositioned to maintain a bed distance of 2 metres or more. There were no more infected persons (Kim, 2020).

References:

Kim, T. (2020). Improving Preparedness for and Response to Coronavirus Disease 19 (COVID-19) in Long-Term Care Hospitals in the Korea. Infect Chemother. https://doi.org/10.3947/ic.2020.52.2.133

Last updated: January 14th, 2022   Contributors: William Byrd  |  

Evidence from a case study on isolation of new admissions in a negative pressure room

A study describes the experience and outcomes of a COVID-19 outbreak in a long-term care facility in Jeddah, Saudi Arabia. This private long-term nursing centre (LTNC) comprised a 100-bed nursing home and a 6-bed intensive care and cardiovascular unit (ICVU).

On April 9, 2020, a new patient was admitted to the institution for long-term care. They were placed in an isolation room with negative air pressure and managed as a suspected case. On April 14, their test result came back positive. However, following a contact tracing investigation, no patient screened positive in the building. Tracing and screening were continued for more than 2 weeks following the identification of the index case, and yet no additional case has been detected so far (Alawi, 2021).

References:

Alawi, M. M. S. (2021). Successful management of COVID-19 outbreak in a long-term care facility in Jeddah, Saudi Arabia: Epidemiology, challenges for prevention and adaptive management strategies. Journal of Infection and Public Health, 14(4), 521–526. https://doi.org/https://dx.doi.org/10.1016/j.jiph.2020.12.036

Last updated: January 12th, 2022   Contributors: William Byrd  |  

In comparison to other countries, there were only very few cases in nursing homes in Singapore. All of the residents with COVID-19 were transferred to acute hospitals.

Nursing homes introduced mandatory split zones to reduce the number of contacts for residents and staff. The zones cannot house more than 100 residents, a fixed set of staff and need to have dedicated entry and exist points. Communication between staff in different zones should take place remotely via text messages, phone or video conference. Shared spaces, such as pantries and lifts should have staggered access that allows for cleaning between the use from different zones. Medical staff needing to move across split zones are recorded for contact tracing and have to adhere to increased infection prevention and control measures (https://ltccovid.org/wp-content/uploads/2020/08/The-COVID-19-Long-Term-Care-situation-in-Singapore-27July-2020.pdf).

Last updated: September 9th, 2021

Evidence on using a cohorting algorithm to separate infected, exposed, and unexposed residents

This study describes the implementation of a cohort classification algorithm to prevent the spread of COVID-19 in nursing homes in Spain. This algorithm helps to classify residents in order to separate them into three different areas. The approach was designed in the surge of the COVID-19 outbreak when PCR tests could not be performed for all nursing home residents.

The first step is to perform a chromatographic immunoassay to detect antibodies in all residents in the nursing home using rapid point-of-care test. Residents with a positive result would be placed in the ‘red zone’. Residents with a negative result would initially be located in the ‘green zone’. Early detection of cases of COVID-19 in this area must be performed either by identification of close contact to confirmed cases or through daily surveillance of symptoms. Residents considered suspicious of being infected should be immediately transferred to the ‘yellow zone’, where further study must be undertaken. The intervention was implemented on April 24, 2020, and it has been held in 17 nursing homes. The study reports that, after the intervention, 94% of nursing homes had made an improvement in sectorisation (Gonzalez de Villaumbrosia et al. 2020).

References:

Gonzalez de Villaumbrosia, C., Martinez Peromingo, J., Ortiz Imedio, J., Alvarez de Espejo Montiel, T., Garcia-Puente Suarez, L., Navas Clemente, I., Morales Cubo, S., Cotano Abad, L. E., Suarez Sanchez, Y., Torras Cortada, S., Onoro Algar, C., Palicio Martinez, C., Plaza Nohales, C., & Barba Martin, R. (2020). Implementation of an Algorithm of Cohort Classification to Prevent the Spread of COVID-19 in Nursing Homes. Journal of the American Medical Directors Association, 21(12), 1811–1814. https://doi.org/10.1016/j.jamda.2020.10.023

Last updated: January 12th, 2022   Contributors: William Byrd  |  

Cohort care i.e. separating infected from non-infected care home residents within a care setting, was introduced; while some municipalities have used separate places for the care of people who have previously been hospitalized and infected with COVID-19. In many care homes new cleaning routines   organized, i.e. staff dedicated solely to care for people with suspected or established infection who live at home. In some care homes, COVID-19 teams have been combined with cohort care (https://aldrecentrum.se/wp-content/uploads/2021/02/Johansson-L.-Sch%C3%B6n-P.-2021.-Governmental-response-to-the-COVID-19-pandemic-in-Long-Term-Care-residences.pdf).

Last updated: November 2nd, 2021

Case Study of a Care Home in Istanbul (Özten et al, 2021)

A report describes successful pandemic response measures in a nursing home in Istanbul. This nursing home, which is one of the biggest in the country, managed to avoid COVID-19 cases for residents and staff altogether, as a result of strictly adhered-to regulations and implementation of preventative measures. This included the use of an assigned quarantine ward for any residents with suspicious symptoms. Residents sent to this ward were isolated, evaluated clinically, and followed up on by doctors and nurses. If indicated, they were transferred to hospital (Özten et al, 2021).

References:

Özten O, Aytekin Akta? T, Süer H, Do?an H, Üner A, Özp?nar S, Ayy?ld?z Y, Bekta? H, Saka B. 2021. A 15-day Working Shift Prevent the Cross-contamination of Coronavirus Disease-2019 in a Nursing Home in Turkey. Eur J Geriatr Gerontol 2021;3(3):131-133

Last updated: January 26th, 2022   Contributors: Daisy Pharoah  |  

Guidance

There have been two major difficulties in identifying and isolating infected individuals effectively in care homes in England. First, guidance issued to care homes focused only on people who were displaying symptoms (initial guidance only mentioned a persistent cough and fever as symptoms). It took a long time for official guidance to consistently recognize the potential for pre-symptomatic or asymptomatic transmission. Guidance on identifying residents and staff who may have been in contact with persons who had the virus and subsequent preventive isolation became available on April 2, 2020.

Ahead of the second wave, the government set up a scheme to prepare ‘designated settings’ that could provide safe isolation for people who were discharged from hospital while positive for COVID-19 and who needed to move to a care home. The settings had a to meet a set of standards to deliver safe care for COVID-19 positive residents.

Evidence on implementation difficulties

The ability of care homes to implement existing IPC guidance was hampered by a lack of access to testing (tests for asymptomatic residents and staff only started to be available after April 28, 2020) and PPE, staff shortages, and facilities that were not suitable for effective isolation or cohorting (Rajan et al., 2020). Where care homes are not able to implement adequate isolation or cohort policies, it is the responsibility of the local authority to secure alternative accommodation for the isolation period, drawing on the £1.3 billion discharge funding.

References:

Rajan, S., Comas-Herrera, A., and Mckee, M. (2020). Did the UK Government Really Throw a Protective Ring Around Care Homes in the COVID-19 Pandemic?. Journal of Long-term Care, (2020), 185–195. DOI: http://doi.org/10.31389/jltc.53

House, S., Fewster, E. (2020). Asymptomatic and pre-symptomatic transmission in UK care homes – and infection, prevention and control (IPC) guidance – an update. Retrieved from:https://ltccovid.org/2020/06/12/

 

Last updated: March 24th, 2022   Contributors: William Byrd  |  

Guidance:

The Centers for Disease Control guidelines encourage suspected and confirmed cases amongst new and returning residents of LTCFs to be placed in a designated, in-house COVID-care unit.

Evidence on isolation approaches:

Tiered cohorting to separate positive, exposed, and unexposed residents 

This study describes a rapidly deployed point-prevalence testing and 3-tiered cohorting in an urban skilled nursing facility (SNF) in Chicago with over 200 beds spread over 4 floors, including a memory-care unit floor. Three resident cohorts were created: positive (red), negative-cleared (green), and negative exposed (yellow).

On COVID-19 positive floors, sharing rooms was permitted, whereas on COVID-19 negative-exposed floors, residents were placed in their own rooms. The memory floor was separated into positive and negative cohorts, because off-floor relocation was believed to potentially cause more harm than benefit given the care needs of residents with dementia. Initial testing (n=120) identified 43 negative-exposed residents and 77 positive residents. Of those residents who were negative, testing performed 1 week later revealed 12 residents had converted to positive. Ten of the 12 who converted were on the memory-care unity (Collison et al., 2020)

Cohorting positive or exposed residents in specific units

A study by Dora et al. (2021) reported on the serology results following an outbreak in a skilled nursing facility (SNF) at the Veterans Affairs Greater Los Angeles Healthcare System West Los Angeles (WLA) campus where residents were serially tested and positive residents were cohorted.

From 28 to 30 March 2020, symptom based testing identified 3 COVID-19 cases. In response, all remaining patients (n=96) underwent testing. Between 29 March and 6 April, 16 additional cases were identified. These 16 and the original 3 patients were transferred to the acute care hospital for treatment or a designated COVID-19 recovery unit (CRU) located within the SNF. No further cases were identified upon additional testing. An additional 9 patients from the community who were diagnosed with COVID-19 were transferred to the CRU by 5 June. When tested 46-76 days later, 24 of 26 positive residents available for testing were seropositive. None of the 124 negative residents had confirmed seropositivity.

Another study describes the interruption of a potential outbreak of COVID-19 in a 120 bed hospital affiliated long-term care facility in Florida using a point prevalence testing containment strategy. Universal prevalence testing was undertaken every 14 days for 6 weeks, starting on April 8, 2020. A cohort unit was established to avoid placing unexposed residents into a shared space with exposed residents. This included private rooms with a private bathroom. All positive confirmed cases were transferred to the hospital for complete medical evaluation and airborne isolation. The cohort unit did not see any conversions to positive. Over 6 weeks the spread of the disease was contained shown by the prevalence decreasing from 5.4% to 3.6% to 0.4%. From April 7 – May 6, a total of 9 patients were positive at the facility (Eckardt et al., 2020).

A case study on the response to an outbreak of COVID-19 in a long-term care facility (LTCF) in West Virginia. The facility is a free-standing structure with a 100-bed capacity, providing long-term care, skilled nursing, and hospice care. On March 22, 2020, an index case was identified. Within 36 hours, 21 of 98 residents initially tested were identified as positive. The facility has six separate units with four nursing stations. The designated isolation unit was chosen due to no shared common space with other units and a private nursing station. Each resident room had its own ventilation, recirculating air. As of August 20, 2020, the facility has had 52 residents test positive. The resident rate of infection (53%) and mortality (5%) are better than reported world averages for LTCFs (Shrader et al., 2020).

Isolation of positive residents in private rooms

A study conducted in 123 West Virginia in nursing homes in April 21 through May 8, 2020 reported on a universal testing strategy and isolation in private rooms. In nursing homes with active outbreaks, all persons received testing who had previously tested negative or had not been tested. All patients with positive test results were isolated in private rooms. Following universal testing, nursing homes screened residents daily and tested anyone with signs or symptoms of COVID-19. If additional cases were identified, testing was performed for close contacts. In total, 42 COVID-19 cases were identified in 28 nursing homes. Of these cases, 11 were residents. The 42 cases represented 20 single cases from 20 facilities and 22 outbreak associated cases, representing new outbreaks in eight facilities. In six of the eight nursing homes with newly identified outbreaks where cohorting of residents with positive test results was implemeneted, daily symptom screening of all residents and staff members for 28 days found that further transmission did not occur (McBee et al., 2020).

Isolation in negative pressure isolation spaces

A case study reports on the design, implementation, and validation of an isolation space at a skilled nursing facility (SNF) in Lancaster, Pennsylvania, with 114 beds. One hall was the subject of this study which consisted of 6 double occupancy rooms and one single occupancy room, all with single bathrooms.

The negative pressure isolation space was created on April 6, 2020, by modifying an existing HVAC system of the SNF. These modifications were not resource intensive and were rapidly established. As of June 23, 14 confirmed positive residents had been treated in the negative isolation space and the facility had utilised the isolation space for a total of 21 individuals. No transmission between residents isolated to the space occurred, not did any transmission to other residents occur (Miller et al., 2021).

References:

Collison, M., Beiting, K. J., Walker, J., Huisingh-Scheetz, M., Pisano, J., Chia, S., Marrs, R., Landon, E., Levine, S., & Gleason, L. J. (2020). Three-Tiered COVID-19 Cohorting Strategy and Implications for Memory-Care. Journal of the American Medical Directors Association, 21(11), 1560–1562. https://doi.org/10.1016/j.jamda.2020.09.001

Dora  V, A., Winnett, A., Fulcher, J. A., Sohn, L., Calub, F., Lee-Chang, I., Ghadishah, E., Schwartzman, W. A., Beenhouwer, D. O., Vallone, J., Graber, C. J., Goetz, M. B., & Bhattacharya, D. (2021). Using Serologic Testing to Assess the Effectiveness of Outbreak Control Efforts, Serial Polymerase Chain Reaction Testing, and Cohorting of Positive Severe Acute Respiratory Syndrome Coronavirus 2 Patients in a Skilled Nursing Facility. CLINICAL INFECTIOUS DISEASES, 73(3), 545–548. https://doi.org/10.1093/cid/ciaa1286

Eckardt, P., Guran, R., Hennemyre, J., Arikupurathu, R., Poveda, J., Miller, N., Katz, R., & Frum, J. (2020). Hospital affiliated long term care facility COVID-19 containment strategy by using prevalence testing and infection control best practices. American Journal of Infection Control. https://doi.org/10.1016/j.ajic.2020.06.215

McBee, S. M., Thomasson, E. D., Scott, M. A., Reed, C. L., Epstein, L., Atkins, A., & Slemp, C. C. (2020). Notes from the Field: Universal Statewide Laboratory Testing for SARS-CoV-2 in Nursing Homes – West Virginia, April 21-May 8, 2020. MMWR. Morbidity and Mortality Weekly Report, 69(34), 1177–1179. https://doi.org/10.15585/mmwr.mm6934a4

Miller, S. L., Mukherjee, D., Wilson, J., Clements, N., & Steiner, C. (2021). Implementing a negative pressure isolation space within a skilled nursing facility to control SARS-CoV-2 transmission. American Journal of Infection Control, 49(4), 438–446. https://doi.org/10.1016/j.ajic.2020.09.014

Shrader, C. D., Assadzandi, S., Pilkerton, C. S., & Ashcraft, A. M. (2020). Responding to a COVID-19 Outbreak at a Long-Term Care Facility. Journal of Applied Gerontology?: The Official Journal of the Southern Gerontological Society, 733464820959163. https://doi.org/10.1177/0733464820959163

Last updated: January 13th, 2022   Contributors: William Byrd  |  

Contributors to the LTCcovid Living International Report, so far:

Elisa Aguzzoli, Liat Ayalon, David Bell, Shuli Brammli-Greenberg, Erica Breuer, Jorge Browne Salas, Jenni Burton, William Byrd, Sara Charlesworth, Adelina Comas-Herrera, Natasha Curry, Gemma Drou, Stefanie Ettelt, Maria-Aurora Fenech, Thomas Fischer, Nerina Girasol, Chris Hatton, Kerstin Hämel, Nina Hemmings, David Henderson, Kathryn Hinsliff-Smith, Iva Holmerova, Stefania Ilinca, Hongsoo Kim, Margrieta Langins, Shoshana Lauter, Kai Leichsenring, Elizabeth Lemmon, Klara Lorenz-Dant, Lee-Fay Low, Joanna Marczak, Elisabetta Notarnicola, Cian O’Donovan, Camille Oung, Disha Patel, Martina Paulikova, Eleonora Perobelli, Daisy Pharoah, Stacey Rand, Tine Rostgaard, Olafur H. Samuelsson, Maximilien Salcher-Konrad, Benjamin Schlaepfer, Cheng Shi, Cassandra Simmons, Andrea E. Schmidt, Agnieszka Sowa-Kofta, Wendy Taylor, Thordis Hulda Tomasdottir, Sharona Tsadok-Rosenbluth, Sara Ulla Diez, Lisa van Tol, Patrick Alexander Wachholz, Jae Yoon Yi, Jessica J. Yu

This report has built on previous LTCcovid country reports and is supported by the Social Care COVID-19 Resilience and Recovery project, which is funded by the National Institute for Health Research (NIHR) Policy Research Programme (NIHR202333) and by the International Long-Term Care Policy Network and the Care Policy and Evaluation Centre at the London School of Economics and Political Science. The views expressed in this publication are those of the author(s) and not necessarily those of the funders.