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Long-term care and COVID-19: An equitable recovery

Published:November 17, 2021DOI:https://doi.org/10.1016/j.ajic.2021.11.010
      The impact of the COVID-19 pandemic on nursing home (NH) residents has highlighted the long-standing systemic deficiencies in and need for effective infection prevention and control (IPC) practices. Residents typically have multiple conditions that increase their risk of infection, including chronic diseases, incontinence, fragile skin, malnutrition, dehydration, and depressed immune systems.
      • Montoya A
      • Mody L.
      Common infections in nursing homes: a review of current issues and challenges.
      As of October 17, 2021, there have been a total of 138,587 nursing home resident deaths,

      Centers for Disease Control and Prevention. COVID-19 nursing home data. Accessed November 1, 2021. https://data.cms.gov/covid-19/covid-19-nursing-home-data.

      with some 16,000 deaths likely having gone unreported in the early stages of the pandemic.
      • Shen K
      • Loomer L
      • Abrams H
      • Grabowski D
      • Ganshi A.
      Estimates of COVID-19 cases and deaths among nursing home residents not reported in federal data.
      Despite high rates of vaccination (86% of NH residents, nationally

      Centers for Disease Control and Prevention. COVID-19 nursing home data. Accessed November 1, 2021. https://data.cms.gov/covid-19/covid-19-nursing-home-data.

      ), NHs continue to experience higher mortality rates compared to deaths in the community. From July to August 2021, influenced by the Delta variant, the mortality rate in NHs quadrupled while the rate in the general community doubled.

      Chidambaram P, Garfield R. Nursing homes experienced steeper increase in COVID-19 cases and deaths in August 2021 than the rest of the country. Kaiser Family Foundation. 2021. Accessed November 1, 2021.https://www.kff.org/coronavirus-covid-19/issue-brief/nursing-homes-experienced-steeper-increase-in-covid-19-cases-and-deaths-in-august-2021-than-the-rest-of-the-country/

      While the devastating impact of the pandemic on older adults in LTC settings may reflect society's deeply rooted ageism, the added dimension of race appears to compound these age-based inequities. An analysis of 13,312 NHs found that facilities with the highest proportions of non-White residents experienced over 3 times the number of deaths than those facilities with the highest proportion of White residents.
      • Gorges R
      • Konetzka T.
      Factors associated with racial differences in deaths among nursing home residents with COVID-19 infection in the US.
      Efforts to maintain a safe environment free of the spread of infectious disease are also complicated by the inherently conflicted nature of these institutions – they are expected to be both the primary residence and the primary provider of medical care for large numbers of older adults. While the high numbers of fully vaccinated residents are to be celebrated, the problem of IPC compliance among direct care workers (DCWs) persists. One study demonstrated a significant “bump” in acute care IPC compliance in the early stages of the pandemic that then trended downwards by the end of the 5-month study period.
      • Moore L
      • Robbins G
      • Quinn J
      • Arbogast J.
      The impact of COVID-19 pandemic on hand hygiene performance in hospitals.
      All this places considerable responsibility on the DCWs that provide life-sustaining interventions as well as the critical social and emotional connections during a time of restricted visitations. The neologism “COVID fatigue” is relatable to all of us who have experienced the pandemic, but the outsized burden borne by NH staff is unique among health care professionals. Even before the pandemic, nurses in NHs had been shown to experience higher rates of burnout than nurses in any other setting.
      • McHugh M
      • Kutney-Lee A
      • Cimiotti J
      • Sloane D
      • Aiken L.
      Nurses’ widespread job dissatisfaction, burnout, and frustration with health benefits signal problems for patient care.
      Feelings of overwhelm and exhaustion can impact the quality of care that is provided. A survey of NH nurses found that 95% of nurses experiencing burnout reported at least one missed care event during their most recent shift.
      • White E
      • Aiken L
      • McHugh M.
      Registered nurse burnout, job dissatisfaction, and missed care in nursing homes.
      In the context of COVID-19 and its variants, a single missed care event (such as neglecting to follow proper hand hygiene protocol, poorly surveilling the early symptoms of COVID-19, or neglecting to use/misusing personal protective equipment) could result in an outbreak within a unit and trigger the loss of morale that accompanies a sudden return to strict unit lockdown procedures.
      • Dykgraaf S
      • Matenge S
      • Desborough J
      • et al.
      Protecting nursing homes and long-term care facilities from COVID-19: a rapid review of international evidence.
      Systemic and organizational changes must be implemented to support and protect the residents and staff that live and work in these communities. A focus on building a “just culture” within a NH organization can help to eliminate the many communication failures that occur between DCWs and unit managers and administrators. Frontline staff who fear punishment or penalty for reporting their own or a colleague's error will be less inclined to share this information with managers or supervisors,
      • Vogelsmeier A
      • Scott-Cawiezell J.
      A just culture: the role of nursing leadership.
      yet knowledge of these events is critical for maintaining an effective IPC program. Systems of shared accountability, along with a pivot away from purely punitive policies, can encourage an organization to “learn together” and facilitate the building of more effective solutions that are unique to the needs of each community. It may also communicate from leadership an awareness of and sensitivity to the stress under which NH DCWs are working.
      Research into these trends within NHs lags behind other health care settings and will likely continue to lag as the field of nursing research navigates the obstacles that have stalled, or stopped entirely, many ongoing studies.
      • Im E
      • Sakashita R
      • Oh E
      • et al.
      COVID-19 and nursing research across five countries/regions: commonalities and recommendations.
      If we are to see an equitable recovery to the pandemic, it is crucial that researchers prioritize projects that can help us to better understand the ongoing IPC needs of NHs.

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