key: cord-274043-ifr0oo7u authors: rozzini, renzo title: the covid grim reaper date: 2020-05-08 journal: j am med dir assoc doi: 10.1016/j.jamda.2020.05.001 sha: doc_id: 274043 cord_uid: ifr0oo7u nan this is a pdf file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. this version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. the covid grim reaper author: head, geriatric dept reference 23 covid-19 in italy: ageism and decision making in a pandemic the geriatrician: the frontline specialist in the treatment of 26 covid-19 patients -gemelli against covid-19 geriatrics team key: cord-335131-u33dkgr1 authors: gunawan, joko; aungsuroch, yupin; marzilli, colleen title: ‘new normal’ in covid-19 era: a nursing perspective from thailand date: 2020-07-22 journal: j am med dir assoc doi: 10.1016/j.jamda.2020.07.021 sha: doc_id: 335131 cord_uid: u33dkgr1 nan new normal in covid-19 era. none declared. this study was supported by the c2f fund of chulalongkorn university, bangkok, thailand. in conclusion, covid-19 has brought many new features to life with both positive and 54 negative, or yin and yang effects. human beings should learn from this phenomenon and use 55 creativity to find appropriate ways to adapt to the new reality. like nightingale said, the craving 56 for 'the return of the day', is generally nothing but the desire for a positive outlook. 2 57 58 ministry of public health of thailand. thailand situation on covid-19 wash your hand!': the old message from florence nightingale to battle 64 new concept of health with perspective of chinese medicine current mental health issues in the era of 68 state launchers telemedicine in rural areas what have we learned about nursing from the coronovirus pandemic all authors contributed equally in this work.word counts: 721 key: cord-353621-t5tev985 authors: gallina, pasquale; ricci, marco; pera, marcello title: covid-19: decisions to offer interventions with limited availability should be decided based on chance of recovery. date: 2020-05-21 journal: j am med dir assoc doi: 10.1016/j.jamda.2020.05.024 sha: doc_id: 353621 cord_uid: t5tev985 nan dear editor, 1 we read with interest the paper by cesari and 2 proietti 1 entitled "covid-19 in italy: ageism and decision making in 3 a pandemic", which rejects a priori discrimination of aged people in 4 access to care. the issue is particularly relevant in a time when a large 5 number of elderly subjects, who lived in nursing homes, died england and wales court of appeal considered prevailing the interest 73 of jodie since marie was self-designated for a very early death. 74 we are aware that even the case-by-case criterion cannot 75 ultimately avoid discrimination, for example when dealing with 76 patients with similar chances of recovery. in such case, inevitably the 77 "first come, first served" rule is in force, a seemingly impersonal fact 78 that is not however a value judgment. covid-19 in italy: ageism and decision 89 making in a pandemic nursing homes or besieged castles: 91 covid-19 in northern italy universal 93 do-not-resuscitate orders, social worth, and life-years: opposing 94 discriminatory approaches to the allocation of resources during the 95 covid-19 pandemic and other health system satastrophes fair allocation of scarce 98 medical resources in the time of covid-19 clinical ethics 101 recommendations for the allocation of intensive care treatments in 102 exceptional, resource-limited circumstances: the italian 103 perspective during the covid-19 epidemic. crit care siaarti 106 recommendations for the allocation of intensive care treatments in 107 exceptional, resource-limited circumstances a framework for rationing ventilators and 110 critical care beds during the covid-19 pandemic an introduction to the principles of morals and 113 legislation key: cord-321302-eowo2mt0 authors: spaetgens, bart; brouns, steffie h.; schols, jos m.g.a. title: the post-acute and long-term care crisis in the aftermath of covid-19: a dutch perspective date: 2020-06-29 journal: j am med dir assoc doi: 10.1016/j.jamda.2020.06.045 sha: doc_id: 321302 cord_uid: eowo2mt0 nan to the editor: 1 we read with great interest the article by laxton in the netherlands, the peak of the first wave of the pandemic seems to be behind us 5 and it is now becoming apparent how hard the nursing home population has been hit 6 and how disruptive the pandemic is for dutch nursing homes as well. morbidity and 7 mortality in nursing homes that suffered outbreaks of covid-19 has been high 8 despite the fact that dutch nursing home care benefits from well-developed care 9 infrastructures that are fully integrated in the national health sector. 2 despite this, the 10 nursing home sector was overshadowed by the huge national attention for covid-19 11 in acute hospital care, resulting in evident shortages of personal protective 12 equipment (ppe) and the inability to develop an adequate testing policy due to a too 13 low national test capacity as well. as such, the nursing homes were, through no fault on behalf of amda -the society for post-acute 75 and long-term care medicine. solving the covid-19 crisis in post-acute and 76 long-term care mortality and the use of 79 antithrombotic therapies among nursing home residents with covid-19 ger assoc. 2020, accepted for publication nursing home characteristics 85 associated with covid-19 deaths in connecticut separate and unequal: racial 89 segregation and disparities in quality across us nursing homes. health affairs report of the taskforce 'the right care in the right place place/19005+vw+rapport+eng+web.pdf last accessed on allowing visitors back in the nursing home during the covid-19 crisis -a dutch 97 national study into first experiences and impact on well-being model of nursing home care: synthesis of findings and implications for policy the 103 physical environment of nursing homes for people with dementia: traditional 104 small-scale living facilities, and green care farms. healthcare 105 (basel) report of an 107 outbreak: nursing home architecture and influenza-a attack rates author contributions: all authors contributed equally to this letter.sponsor's role: no funding was received for this work key: cord-259787-2sjnsb7m authors: schlaudecker, jeffrey d. title: essential family caregivers in long-term care during the covid-19 pandemic date: 2020-05-21 journal: j am med dir assoc doi: 10.1016/j.jamda.2020.05.027 sha: doc_id: 259787 cord_uid: 2sjnsb7m brief summary: in the months stretching out ahead of us in the prevention of covid-19, we must keep our residents safe from the risk of circulating virus, but we also must promote person-centered geriatric care allowing family presence as essential care partners. four decades ago, my parents were not permitted to hold their dying infant because they were 4 'visitors' to the icu. i learned from them that our healthcare policies sometimes carry huge 5 human costs. as a geriatrician and medical director of a long-term care facility, i have learned 6 that family members are not merely visitors; family members are critical partners in our care. 7 the practice of social distancing and physical separation is important to keep our residents in 8 long-term care facilities (ltc) safe in the covid-19 pandemic, but the time has come to revise 9 our policies allowing family presence at the bedside of loved ones. our facility has recognized the critical role that family members play as partners in the care of 25 our residents. we continue to limit the number of persons coming into the building through 26 restricted visitors and volunteers; but, we are now designating essential family caregivers 27 (efcs). these efcs are not there for social visits, but instead provide services that otherwise 28 would require a private duty caregiver, such as one-on-one direction or especially time-29 intensive hand feedings. efcs are brought into the building under the same specific protocols 30 used with staff. (see table) 31 32 compassion, as well as optimal geriatrics care, requires family members be allowed at the 33 bedside of their loved ones not only in the final hours of life. in the months stretching out 34 ahead of us in the prevention of covid-19, we must keep our residents safe from the risk of 35 circulating virus. we also must promote person-centered geriatric care allowing family 36 presence as essential caregivers. 37 covid-19 and patient-and family-centered care frequently asked questions the author reports no conflicts of interest acknowledgements: the author wishes to thank keesha goodnow for her support key: cord-325128-r53up0ug authors: diamantis, sylvain; noel, coralie; vignier, nicolas; gallien, sébastien title: sars-cov-2 related deaths in french long-term care facilities: the “confinement disease” is probably more deleterious than the covid-19 itself date: 2020-05-03 journal: j am med dir assoc doi: 10.1016/j.jamda.2020.04.023 sha: doc_id: 325128 cord_uid: r53up0ug nan to date coronavirus sars-cov-2 has infected 2.2 million people and has killed more than 5 150,000. 1 the population groups most susceptible to severe and fatal covid-19 are older 6 adults and those with chronic underlying chronic medical disorders. the residents of long-7 term care facilities (ltcfs) typically combine those two features and are thus particularly at 8 risk. in france, 9.4% of the population is over 75, and nearly 600,000 people currently reside 9 in ltcfs for elderly dependent individuals. to date, more than 60% of the french ltcfs have 10 reported at least one case of covid-19 among their residents. 11 estimated overall mortality among covid-19 patients is 10% in france, but reaches up to 12 30% in ltcfs. there are however substantial differences in mortality rates between the 13 different ltcfs. 2 what explains these differences? 14 we intervened in one ltcf located in the southern île-de-france region that had registered 15 more than 24 deaths related to covid-19 among the 140 residents in 5 days. no acute 16 respiratory distress syndrome were observed and mortality was mainly due to hypovolemic 17 shock. most of the victims had been left alone in their rooms for confinement settings for 18 many days without help, due to the lack of protective masks and the work overload for 19 caregivers, affected by a 40% staff absenteeism rate. the dependent infected residents were 20 confined and no longer received the usual assistance for drinking and eating. in addition, 21 general practitioners stopped their physical examination visits, limiting their interventions to 22 telemedicine which proved unsuitable whenever feasible at all. fatal than covid-19 itself. we did not observe this phenomenon in other lctfs where health 25 care staff and physicians were physically present in full force. 26 a task force team intervened as soon as the fifth death was reported. adapted infusion to 27 restore hydroelectrolytic balance as well as oxygen therapy per who guidelines led to a 28 rapid improvement of this high mortality trend. 3,4 29 disproportionate mortality due to covid-19 in ltcfs is not a fatality. continuous provision 30 of pragmatic medicine and wellness care will limit the devastating impact of this infection in 31 dependent elderly people. 32 the authors declare that there is no conflict of interest regarding the publication of this 34 article. 35 an interactive web-based dashboard to track covid-19 in real 38 time clinical management of severe acute respiratory 43 infection (sari) when covid-19 disease is suspected: interim guidance v key: cord-340701-eeqgtk34 authors: kusmaul, nancy title: covid-19 and nursing home residents’ rights date: 2020-07-29 journal: j am med dir assoc doi: 10.1016/j.jamda.2020.07.035 sha: doc_id: 340701 cord_uid: eeqgtk34 nan act included a bill of rights for residents out of recognition of the steep power imbalance 28 between residents and staff 1 , and the development of learned helplessness by those who live in 29 such settings 2 . born from a time when nursing homes residents were subject to physical 30 restraints and sedation, these rights sought to give residents greater control over daily routines 31 and social interactions 2 . could covid-19 be sending residents rights back to this time? 32 as soon as the story about the kirkland, washington nursing home and covid-19 became 33 national news the centers for medicare and medicaid services (cms) took swift action to 34 protect nursing home residents 3 . their press release on march 13, 2020 characterized their 35 directives as the most aggressive and decisive, and they certainly were. they immediately 36 restricted all visitors, volunteers, and nonessential personnel from entering nursing homes and 37 cancelled group activities and communal dining. 38 while the covid-19 pandemic seemed urgent and the risks to nursing home residents 39 were real, these directives superseded and countered residents' rights. one of the core resident's 40 rights is the right to spend time with visitors of your choosing. "you have the… right: to spend 41 private time with visitors. to have visitors at any time, as long as you wish to see them, as long 42 as the visit does not interfere with the provision of care and privacy rights of other residents." 4 43 the restriction of rights is concerning, even in the face of a global pandemic. nursing 44 homes are required by federal regulations to provide maximal quality of life. as defined in the 45 federal register, §483.24 "quality of life is a fundamental principle that applies to all care and 46 services provided to facility residents. each resident must receive and the facility must provide 47 the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident's comprehensive assessment and plan of 49 care." 5 50 how can residents maintain the highest practicable mental and psychosocial well-being 51 when they are not able to connect with other human beings, including loved ones? cms made 52 exceptions for "compassionate cases" which were left to the nursing homes' discretion. • consider physical barriers. 7 the true meaning of residents' rights empowering the elderly nursing home resident: the resident rights 86 campaign cms announces new measures to 88 protect nursing home residents from covid 19 your rights and protections as a 92 nursing home resident federal register. 42 cfr §483 requirements for states and long term care facilities sid=f6c854ab4333a365da3f797f56f91f53&mc=true&tpl=/ecfrbrowse/title42/42cfr 98 483_main_02.tpl. accessed treatment intervention: learning residents' rights frequently asked questions 102 (faqs) on nursing home visitation west virginia department of health and human resources thoughts on living in a nursing facility during the pandemic key: cord-312394-djjarc0f authors: lynch, richard m.; goring, reginald title: practical steps to improve air flow in long-term care resident rooms to reduce covid-19 infection risk date: 2020-04-10 journal: j am med dir assoc doi: 10.1016/j.jamda.2020.04.001 sha: doc_id: 312394 cord_uid: djjarc0f abstract the potential for spread of covid-19 infections in skilled nursing facilities and other long-term care sites poses new challenges for nursing home administrators to protect patients and staff. it is anticipated that as acute care hospitals reach capacity, nursing homes may retain covid-19 infected residents longer prior to transferring to an acute care hospital. this article outlines 5 pragmatic steps that long-term care facilities can take to manage airflow within resident rooms to reduce the potential for spread of infectious airborne droplets into surrounding areas including hallways and adjacent rooms, using strategies adapted from negative pressure isolation rooms in acute care facilities. practical steps to improve air flow in long-term care resident rooms to reduce covid-19 3 infection risk 4 5 keywords: covid, corona, skilled nursing facilities, airborne infection isolation, respiratory droplets, 6 long term care, hotel 7 8 abstract 9 the potential for spread of covid-19 infections in skilled nursing facilities and other long-term care 10 sites poses new challenges for nursing home administrators to protect patients and staff. it is anticipated 11 that as acute care hospitals reach capacity, nursing homes may retain covid-19 infected residents 12 longer prior to transferring to an acute care hospital. this article outlines 5 pragmatic steps that long-13 term care facilities can take to manage airflow within resident rooms to reduce the potential for spread 14 of infectious airborne droplets into surrounding areas including hallways and adjacent rooms, using 15 strategies adapted from negative pressure isolation rooms in acute care facilities. step #1 -estimate total room volume, ventilation, and differential pressure -as an example, in a 15' 61 by 20' room with 8' ceilings, the total room volume is 2,400 cubic feet. assuming the ashrae 170 62 guideline of 2 ach, the room is receiving approximately 80 cubic feet per minute (cfm) of outdoor air 63 from the rooftop air handler along with some recirculated air. estimate room pressure at the hallway door 64 using a manometer, tissue or plastic to determine air current direction. contact the industrial hygienist to design appropriate safe retrofit options. anticipate higher energy costs 78 and increased noise as conditioned make-up air is drawn from hallways into rooms and discharged 79 outdoors. step #3 -increase efficiency of filtration -aii rooms are typically equipped with merv 7 prefilters and 82 merv 14 final filters which remove up to 98% of airborne particles as small as 0.3 to 1.0 microns in 83 diameter (typical diameter of respiratory droplets). place lower efficiency filters on hvac return 84 registers to reduce airborne droplets entering the return air stream. discuss these options for increasing 85 filter efficiency with your hvac contractor to ensure compatibility with your hvac system. 86 step #4 -keep doors to hallways closed -keep doorways between hallways and resident rooms closed 88 to maintain negative pressure differential. if the bathroom is where the exhaust is being discharged, keep how covd-19 spreads letter to facility managers 113 natural ventilation for infection control in 116 world health organization sars-cov-2 as compared with sars-cov-1 persistence of coronaviruses on inanimate surfaces 122 and their inactivation with biocidal agents american society of heating, 125 refrigeration and air conditioning engineers the authors have no conflicts of interest body word count = 1067 abstract word count 103 key: cord-289018-6rnvwptr authors: wong, serena p.; jacobson, heather n.; massengill, jennifer; white, heidi k.; yanamadala, mamata title: safe inter-organizational health information exchange during the covid-19 pandemic date: 2020-10-22 journal: j am med dir assoc doi: 10.1016/j.jamda.2020.10.022 sha: doc_id: 289018 cord_uid: 6rnvwptr accurate and timely transmission of medical records between skilled nursing facilities and acute care settings has been logistically problematic. often people are sent to the hospital with a packet of paper records, which is easily misplaced. the covid-19 pandemic has further magnified this problem by the possibility of viral transmission via fomites. to protect themselves, staff and providers were donning personal protective equipment to review paper records, which was time-consuming and wasteful. we describe an innovative process developed by a team of hospital leadership, members of a local collaborative of skilled nursing facilities, and leadership of this collaborative group, to address this problem. many possible solutions were suggested and reviewed. we describe the reasons for selecting our final document transfer process and how it was implemented. the critical success factors are also delineated. other health systems and collaborative groups of skilled nursing facilities may benefit from implementing similar processes. in july 2017, our health system's accountable care organization established the health 15 optimization for elders (hope) skilled nursing facility (snf) collaborative, which now includes 16 25 skilled nursing facilities from seven surrounding counties. one focus of the collaborative is to personal protective equipment (ppe) to review paper documents to avoid fomite transmission 22 of . 1 in addition to delaying care, this was burdensome and wasteful, considering the 23 nationwide shortage of ppe. 24 hope leadership took this opportunity to both address the infection control need, and 25 to improve transitions of care between snfs and hospitals. one factor long impacting 26 continuity of care between settings is a lack of interoperable clinical information systems. 2 too 27 often paper documentation is misplaced in emergency departments, which were not designed 28 to maintain paper records. hospital care suffers when source documents including medication 29 administration records, medical and nursing notes, and advance directives are not available to 30 care providers who need to review it in detail. the ideal solution would attain two goals: 1) 31 transfer medical documents safely and efficiently to the hospital team, and 2) integrate data 32 into the medical record for all staff to review. in the nine weeks since implementation, the process has been used 287 times 71 throughout our three-hospital health system, with overall increasing usage as shown in figure 72 1. week 1 usage was high in part due to receipt of requested records for patients already 73 admitted; all other data points were spontaneous file transfers from snfs to the hospital. there aerosol and surface stability of sars-cov-2 as 111 compared with sars-cov-1 the impact of health information technology on collaborative chronic care 113 management a qualitative analysis of 115 ehr clinical document synthesis by clinicians. amia annual symposium proceedings amia 116 symposium collaborative model for an academic hospital and long-term care facilities turnover, staffing, skill mix, and 121 resident outcomes in a national sample of us nursing homes a hospital partnership with a nursing home 123 experiencing a covid-19 outbreak: description of a multiphase emergency key: cord-320104-cgzqwbzs authors: lester, paula e.; holahan, timothy; siskind, david; healy, elaine title: policy recommendations regarding skilled nursing facility management of covid-19: lessons from new york state date: 2020-06-02 journal: j am med dir assoc doi: 10.1016/j.jamda.2020.05.058 sha: doc_id: 320104 cord_uid: cgzqwbzs abstract to provide policy recommendations for managing covid-19 in skilled nursing facilities (snfs), a group of certified medical directors from several facilities in new york state with experience managing the disease used email, phone, and video conferencing to develop consensus recommendations. the resulting document provides recommendations on screening, and protection of staff, screening of residents, management of covid-19 positive and presumed positive cases, communication during an outbreak, management of admissions and readmissions, and providing emotional support for staff. these consensus guidelines have been endorsed by the executive board of the new york medical directors association and the board of the metropolitan area geriatrics society. covid-19 has rapidly affected the health care systems in new york. the impact of this 15 pandemic has been widely recognized in hospital systems but guidelines for care for this 16 disease in the skilled nursing facility (snf) are sorely lacking. 17 one of the biggest challenges we have faced in snfs is the transmission by 18 asymptomatic carriers and patients. as a result, covid-19 can insidiously spread prior to 19 awareness of the first case, which leads to rapid spread within the facility. 1 many older adults 20 manifest covid-19 with low grade temperatures, diarrhea or fatigue, and may not have overt 21 respiratory symptoms -causing rapid spread without detection. 22 we describe expert consensus policies for snfs to prepare for and manage covid-19. 23 methods 24 the consensus statements presented here have been formulated by the authors who 25 had experience with outbreaks of covid-19 as the snf community needed to rapidly adapt to 26 the dynamic changes which occurred in these healthcare facilities during this unprecedented 165 6. consider antibiotics if concern for bacterial pneumonia. can be admitted to a "transition" unit for 14 days while they are monitored for 278 symptoms of covid-19 and tested if indicated (and available). 279 additional supportive measures for staff and residents: 280 • unlike hospital staff who generally care for patients for short periods of time, the snf 281 staff care for snf residents often for many years. this strong connection can make the 282 death of snf residents even more devastating. emotional support should be provided to 283 staff as they grieve loss of residents. 284 • cheerful drawings and messages from the community can be uplifting to snf workers 285 and patients. they can be posted in hallways and distributed to residents. 286 • many hospitals are touting their "success" stories as patients coming off a ventilator or 287 being discharged. "success" in the snf, especially for long term care residents, is 288 different. • "success stories" for the snf which can be acknowledged: presymptomatic sars-cov-2 infections and transmission in a skilled nursing facility. nejm idsa covid-19 antibody testing primer. updated the cytokine release syndrome (crs) of severe covid-19 and interleukin-6 receptor (il-6r) antagonist tocilizumab may be the key to reduce the mortality the procoagulant pattern of patients with covid-19 acute respiratory distress syndrome famotidine trial underway in nyc for covid-19 treatment preparing for covid 19; long term care facilities, nursing homes more than 1,700 previously undisclosed deaths at ny nursing homes covid-19 preparedness in nursing homes in the midst of the pandemic estimates of the severity of coronavirus disease 2019: a model-based analysis key: cord-321606-o0gfukzg authors: unruh, mark aaron; yun, hyunkyung; zhang, yongkang; braun, robert t.; jung, hye-young title: nursing home characteristics associated with covid-19 deaths in connecticut, new jersey, and new york date: 2020-06-15 journal: j am med dir assoc doi: 10.1016/j.jamda.2020.06.019 sha: doc_id: 321606 cord_uid: o0gfukzg nan nursing home patients have been disproportionately affected by covid-19. it has been 4 reported that one-fourth of all covid-19 deaths nationwide occurred in nursing homes and 5 other long-term care facilities. 1 the objective of this study was to compare the characteristics 6 of nursing homes with covid-19 deaths to other nursing homes using data from connecticut, 7 new jersey, and new york. 8 we merged data on nursing home characteristics from the 2017 ltcfocus database 9 (long term care: facts on care in the us) with data on nursing homes with covid-19 deaths 10 provided by the states of connecticut , new jersey, and new york. data from connecticut 11 included deaths as of april 16th, new jersey as of april 20th, and new york as of april 15th. 12 after excluding 28 facilities with incomplete information, our sample included 1,162 nursing 13 homes. 14 data from connecticut and new jersey identified nursing homes with 1 or more covid-15 19 deaths, but data for new york only identified nursing homes with 6 or more covid-19 16 deaths. therefore, we created a binary outcome of whether a nursing home had 6 or more 17 covid-19 deaths. nursing home characteristics included mean age of residents, percent 18 female, percent white, mean resource utilization group case-mix index, mean activities of daily 19 living (adl) score, percent restrained, total number of beds, occupancy rate, for-profit status, 20 multi-facility chain membership, mean direct care hours per patient day, presence of an the distributions of the percent of patients covered by medicaid patients and the percent 23 covered by medicare were also included. 24 predicted probabilities were estimated with logistic regression using the covariates 25 listed above in addition to indicators for states. secondary analyses were conducted (1) with 26 samples for each of the three states and (2) by repeating our primary analysis with the sample 27 limited to nursing homes with 100 or more beds. although an outcome measure reflecting the 28 number of covid-19 deaths per nursing home bed would have been ideal, the data did not 29 permit this. nevertheless, our regression estimates reflect the probability of a nursing home 30 having 6 or more covid-19 deaths, holding the number of beds in the facility constant. 31 among the 1,162 nursing homes in our sample, 184 (15.8%) had 6 or more covid-19 32 deaths. 33 estimates from our primary analysis (table) estimates for these measures were not statistically significant for nursing homes in connecticut 45 or new jersey. the results of our secondary analysis of nursing homes with 100 or more beds 46 (table) were largely consistent with our primary analysis with one key exception; more direct 47 care hours per patient day were associated with a lower probability of covid-19 deaths (-4 fresh data shows heavy coronavirus death toll in nursing 68 driven to tiers: socioeconomic and racial 70 disparities in the quality of nursing home care. the milbank quarterly separate and unequal: racial segregation 73 and disparities in quality across us nursing homes key: cord-345746-6jvqsvy5 authors: resnick, barbara title: what have we learned about nursing from the coronovirus pandemic date: 2020-06-13 journal: j am med dir assoc doi: 10.1016/j.jamda.2020.06.011 sha: doc_id: 345746 cord_uid: 6jvqsvy5 nan what have we learned about nursing from the coronovirus pandemic barbara resnick, phd, crnp during the current coronavirus pandemic, the focus of the accolades has gone to nurses working in the acute care sector, where "real nursing" occurs as portrayed in television or in the movies. over the past few months there has, however, been some increased recognition of the critically important role that nurses play in long-term care. nursing home nurses are present 24 hours a day, providing care and serving as the eyes and ears of all other providers who intermittently evaluate residents in these settings. during coronavirus pandemic quarantine they provide enhanced care, as family are not able to visit. they also facilitate telecommunication with physicians, hospital staff, and families and friends of residents. this care is consistent with the role of nurses over time, which ranges from preventing illness and promoting health to caring for the sick and comforting the dying. their courage, dedication, and resilience is something to be admired. never have i been prouder to be a nurse. there is, however, a price to pay for our work as nurses in this pandemic environment. some have begun to think about retiring; some potential nurses are dropping out of nursing school or deciding not to enroll; some are deciding not to engage in clinical care for fear of their own health or the health of their families; some continue to work despite significant mental and physical health related stress; and some have died or become chronically ill due to covid-19 obtained in the line of duty 1,2 . what do we owe the nurses in long-term care? first and foremost it is the availability of appropriate and sufficient personal protective equipment (ppe) to keep them as safe as possible while they are providing the intimate care necessary for 2 residents within these settings. availability of ppe for nursing staff is critical to residents as well -to prevent the spread of disease as staff move from one resident to the next. further, ready availability to ppe provides an important statement to the staff -that we as a society care about keeping them safe and healthy. in addition to ppe, nurses deserve to be recognized for their knowledge about the residents. while telehealth is a wonderful alternative to face-to-face visits when those are not possible, telehealth visits are not ideal. the input from nurses, and other members of the health care team, is invaluable during or associated with telehealth visits. nurses evaluate the function and behavior of their residents day by day, as opposed to the moment of time that a telehealth visit provides. this is especially important in post-acute and long-term care, where residents may present as lethargic one moment and later in the day blossom and engage in activities. moreover, direct care workers and nurses in long-term care can provide the assessment information needed to diagnose and treat a resident following a more careful and comprehensive work up. lastly, nursing home nurses deserve to be able to work to the full scope of their practice. there are not too many silver linings from the 2020 coronavirus, but one of them has been the release of some regulatory issues that limit scope of practice. for example, on april 9 the centers for medicare and medicaid services (cms) made it easier for providers to practice across state lines 3 . further, advance practice nurses can now order home health care services for patients, and we are all aware of the changes in allowing for telehealth visits across multiple settings. nurses deserve to 3 have these "waivers" remain as recognition of their training, skills and ability as well as increasing access to care for all older adults. in closing, remember to thank the nurses providing care to your residents. they are heroes but they are also human. they are tired and afraid but committed to the pledge they took as a nurse, the nightingale pledge 4 , and they are doing their best with limited staff and resources to provide care for the world's older adults. memoriam: healthcare workers who have died a qualitative study on the psychological experience of caregivers of covid-19 patients trump administration issues second round of sweeping changes to support u.s. healthcare system during for the sick. in detroit courage was the fashion: the contribution of women to the development of detroit from 1701 to 1951 key: cord-274508-nigru1o8 authors: lally, michelle; tsoukas, philip; halladay, christopher; o’neill, emily; gravenstein, stefan; rudolph, james l. title: metformin is associated with decreased 30-day mortality among nursing home residents infected with sars-cov2 date: 2020-10-26 journal: j am med dir assoc doi: 10.1016/j.jamda.2020.10.031 sha: doc_id: 274508 cord_uid: nigru1o8 objectives the covid-19 pandemic presents an urgent need to investigate whether existing drugs can enhance or even worsen prognosis; metformin, a known mammalian target of rapamycin (m-tor) inhibitor, has been identified as a potential agent. we sought to evaluate mortality benefit among older persons infected with sars-cov-2 who were taking metformin as compared to those who were not. design retrospective cohort study setting and participants: 775 nursing home residents infected with sars-cov-2 who resided in one of the 134 community living centers (clc) of the veterans health administration (vha) during march 1, 2020 to may 13, 2020 were included. methods using a window of 14 days prior to sars-cov-2 testing, bar coded medication administration records were examined for dispensing of medications for diabetes. the covid-19 infected residents were divided into groups: 1) residents administered metformin alone or in combination with other medications, 2) residents who used long acting or daily insulin, 3) residents administered other diabetes medications, and 4) residents not administered diabetes medication, including non-diabetics and untreated diabetics. proportional hazard models adjusted for demographics, hemoglobin a1c, body mass index, and renal function. results relative to those not receiving diabetes medications, residents taking metformin were at significantly reduced hazard of death (adjusted hr 0.48, 95%ci 0.28, 0.84) over the subsequent 30 days from covid-19 diagnosis. there was no association with insulin (adjusted hr 0.99, 95% 0.60, 1.64) or other diabetes medications (adjusted hr 0.71, 95% ci 0.38, 1.32). conclusions and implications our data suggests a reduction in 30-day mortality following sars-cov-2 infection in residents who were on metformin-containing diabetes regimens. these findings suggest a relative survival benefit in nursing home residents on metformin, potentially through its mtor inhibition effects. a prospective study should investigate the therapeutic benefits of metformin among persons with covid-19. type ii diabetes mellitus (t2dm) ranks highly among the multiple morbidities that affect 39 older nursing home residents. diabetics typically fare worse with infections than non-diabetics. 40 metformin, among the most common t2dm medications, could play an important role for 41 diabetics infected with sars-cov-2. a recent focus on potential treatment for sars-cov-2 42 infection includes a pathway not usually considered for its "antiviral" property, the mammalian 43 target of rapamycin (mtor) pathway. 5 mtor complexes are critical in many cell functions 44 including senescence and apoptosis, and they also play a role in viral protein production, 45 processing, and assembly. mtor and its protein complexes, mtor complex 1 (mtorc1) and 46 mtor complex 2 (mtorc2), are functionally intertwined with the adenosine monophosphate (amp)-associated protein kinase (ampk) pathway and both biological cascades appear to be 48 plausible targets for covid-19 therapy. 5 metformin's immunomodulatory effects on mtor inhibition have sparked interest as a 50 potential cancer and antiviral therapeutic. in a study by sahra and colleagues, the expression of 51 the protein redd1 (regulated in development and dna damage responses 1), a known negative 52 regulator of mtor, rapidly increased following metformin treatment in prostate, breast, and 53 lung cancer cells. 6 metformin may also boast additional anti-inflammatory benefits via 54 alterations of the gut microbiota through carbohydrate metabolism 7 and/or antiseptic properties. 8 metformin's potential anti-inflammatory and immunomodulatory effects are not thoroughly 56 understood, but increased interest in the utility of metformin in inflammatory diseases outside of 57 t2dm, such as human-immunodeficiency virus, 9 multiple sclerosis, 10 and systemic lupus, 11 is 58 growing. metformin historically has shown a modest benefit in treating influenza. 12 influenza a 59 virus has been shown to exploit host signaling molecules, including mtorc1 and mtorc2 60 protein complexes, to increase viral replication. 13 metformin's potential antiviral mechanism of 61 action could be due to increased redd1 which would lead to subsequent mtor regulation. 6 a recent study demonstrated that diabetics with confirmed covid-19 infection had 63 elevated risk of severe pneumonia, hyperinflammatory state, and hypercoagulability compared to 64 a similar cohort of non-diabetics. 14 in both diabetics and non-diabetics, the potential role for the cohort included all residents of the 134 community living centers (clc) operated 74 by the veterans health administration (vha). clcs are nursing homes that the vha operates 75 directly. we evaluated the subset with laboratory confirmed evidence of sars-cov-2 tested 76 during the interval of march 1, 2020 and may 13, 2020, following the vha directive that all 77 residents be tested. demographic variables collected from va administrative records included age, sex, and 92 race. comorbidities were collected to complete the elixhauser comorbidity index. 16 we collected additional variables which would be related to diabetes and metformin utilization. the proportional hazard assumption was satisfied for each of the outcomes. multivariable 108 regression included variables which were significantly disparate among the groups. characteristics of the 775 residents with sars-cov2 infection are displayed in table 1 variables. our data additionally was unable to shed light on the rationale for their specific 209 diabetic regimen, as well as reason for hospitalization. as a retrospective study that did not include 210 clinical record review, we are unable to determine the appropriateness of metformin utilization. 211 additionally, our study was designed to look at population outcomes rather than the world health organization. disease outbreak news: pneumonia of unknown cause -247 first case of 2019 novel coronavirus in the key: cord-339292-mhbwjwrg authors: aubertin-leheudre, m.; rolland, y. title: the importance of physical activity to care for frail older adults during the covid-19 pandemic date: 2020-04-30 journal: j am med dir assoc doi: 10.1016/j.jamda.2020.04.022 sha: doc_id: 339292 cord_uid: mhbwjwrg summary covid-19 restrictions could decreased physical and mental health. simple, adapted and specific physical activities should be implemented and considered as the best solution to care for frail elderly during the covid-19 pandemic. health. simple, adapted and specific physical activities should be implemented and 28 considered as the best solution to care for frail elderly during the covid-19 pandemic. coronavirus disease 2019 (covid-19) is currently causing devastating impacts globally. as 36 of march 31 st , 2020, 857,165 covid-19 cases were confirmed around the world, and more 37 than 42,100 people have died. the death rate is estimated at 5%, with older adults making up 38 the vast majority of cases (>80%). not surprisingly, studies show a decline in the number of pedometer steps taken per week by 50 adults due to restrictions put in place to mitigate covid-19. european countries showed the 51 most dramatic decline, ranging from a 7% to 38% reduction in steps between march 15 to 22, 52 2020. 1 hence, it is also important to keep in mind that inactivity is the fourth leading cause of 53 mortality according to the world health organization 2 . 54 55 maintaining functional ability and coping with functional limitations for as long as possible are 56 key healthcare challenges for independent living institutionalized and hospitalized older 57 adults. thus, although covid-19 restrictions aim to protect older adults, such social and 58 physical distancing is also likely to negatively impact the physical and mental health of older 59 furthermore, long-term care residents are characterized by high prevalence of multimorbidity, 61 prescription drug use and dependency in activities of daily living. hospitalization of older 62 adults is also problematic as it leads to functional decline, also known as iatrogenic decline 3 . 63 in a 10-day hospitalization, an older patient typically loses 16% of muscle strength and 6% of risk of falls (34% within three months of discharge) 5;6 and disability (33% will report functional 66 decline one-year after discharge) 7;8 . the vicious circle of frailty is accelerated by physical 67 inactivity and further increases the need for healthcare services. 68 the negative consequences of hospitalization or living in long-term care are largely due to low 69 physical activity. older hospitalized patients are often on confined to bed for 17 hours per day 70 according to who, healthy aging is largely determined by the ability to maintain both mental 85 and physical capacities 13 . no medications currently exist that help maintain physical capacity, 86 nor will any be commercialized in the foreseeable future. however, physical capacity can be 87 maintained through physical stimulus via adapted physical activity. it is well-known that 88 physical activity is key for the health and well-being of people over age 85 14 . 89 90 physical activity has been shown to protect against the incidence of activities of daily living 91 disability, but also disability progression or severity 15 each physical activity color program included 2 specific and adapted exercises (e.g.: seated 156 knee extension; sit to stand; step aside; chair forward bend; bipodal or unipodal static 157 balance; wall squat) and a walking time (figure 1 ). all programs have been created to 158 improve or at least maintain balance, strength but also mobility and cardio-pulmonary function 159 (aerobic capacities). all program are realized unsupervised, without materials (except room 160 equipment: chair or wall) between 2 to 3 times per day, in seated or standing position. adapted physical activity programs without specific materials and using notebook, tv-screen, 164 video or internet live video can be implement to avoid bed rest and immobilization effects 165 during the covid-19 pandemic (e.g: sprint; match vivifrail; laterlifetraining; go4life, 166 move etc.; see table 1 ). in conclusion, to our knowledge, daily simple, adapted and specific physical activities 177 including strength, balance and walk exercises (see figure 1 & 2 or vivifrail©) should be 178 considered as the best solution to care for frail older adults during the covid-19 pandemic. 179 the impact of coronavirus on world health organization. global recommendations on physical activity for change in muscle strength and muscle mass in older 191 hospitalized patients: a systematic review and meta-analysis effect of 10 days of bed rest on skeletal muscle in healthy older 194 adults risk of falls after hospital discharge a simple tool predicted probability of falling after aged care 198 inpatient rehabilitation hospitalization, restricted activity, and the development of disability 200 among older persons geriatric conditions in acutely hospitalized older patients: 202 prevalence and one-year survival and functional decline the underrecognized epidemic of low mobility during hospitalization 205 of older adults twenty-four-hour mobility during acute hospitalization in older 207 medical patients how much exercise are older 209 adults living in long-term cares doing in daily life? a cross-sectional study daytime sleeping, sleep disturbance, and 212 circadian rhythms in the nursing home the world report on ageing and health: a 214 policy framework for healthy ageing exercise in people over 85 : advanced age is no 216 barrier to the benefits of tailored exercise effect of physical interventions on physical performance and 222 physical activity in older patients during hospitalization: a systematic review can exergames contribute to improving 226 walking capacity in older adults? a systematic review and meta-analysis program using gerontechnology in assisted living communities for older adults technology enhance social connectedness among older adults? a feasibility study maintenance 235 access / details information type of resource specific, simple and adapted program for older adults key: cord-265830-6shiocwr authors: frost, rachael; nimmons, danielle; davies, nathan title: using remote interventions in promoting the health of frail older persons following the covid-19 lockdown: challenges and solutions date: 2020-05-25 journal: j am med dir assoc doi: 10.1016/j.jamda.2020.05.038 sha: doc_id: 265830 cord_uid: 6shiocwr in light of the covid-19 pandemic, many older people across the world are being asked to self-isolate to protect their health. this has led to a rapid reconfiguration of health promotion services, which are diverse in focus, and may include exercise, dietary interventions or psychosocial interventions, towards remote delivery, for example by phone or using computers. whilst currently they are unable to be safely delivered any other way, there are concerns that these remote interventions may replace face-to-face interventions beyond the end of social restrictions. we advocate caution with taking this forward, particularly for frailer older people. 2 in light of the covid-19 pandemic, many older people across the world are being asked to self-isolate 3 to protect their health. this has led to a rapid reconfiguration of health promotion services, which 4 are diverse in focus, and may include exercise, dietary interventions or psychosocial interventions, 5 towards remote delivery, for example by phone or using computers. whilst currently they are 6 unable to be safely delivered any other way, there are concerns that these remote interventions 7 may replace face-to-face interventions beyond the end of social restrictions. we advocate caution 8 with taking this forward, particularly for frailer older people. 9 evidence of effectiveness for remote interventions for frail older people is promising, but very 10 limited at present. small randomised controlled trials have shown positive impacts upon quality of 11 life from video exercises with weekly phone calls, 1 improved mental functioning from computer-12 based home exercises, 2 improved balance from home exercise with phone calls 3 and reduced 13 depression from problem solving therapy delivered by videoconferencing. 4 similarly, for 14 malnourished older people, phone-based nutrition interventions with dieticians improved protein 15 intake and quality of life but not other outcomes in one systematic review of nine studies. 5 however, 16 despite an increase in research on this topic over the last five years, these interventions are rarely 17 compared to face-to-face delivery and small sample sizes often limits the power and generalisability 18 of these studies. most also included a face-to-face session with a healthcare professional to assess 19 and plan treatment beforehand, 1,3,5 an orientation meeting to ensure the technology works 2 or 20 both. 4 21 use of remote interventions therefore needs to facilitate rather than replace contacts with 22 healthcare professionals. phone-based support may be particularly applicable to a population with 23 less internet and computer access, and may improve adherence to independent exercise therapies also showed comparable effects to face-to-face delivery with similar numbers of people 26 completing sessions (49/56 vs 54/63). 4 one systematic review found that mobile health technologies 27 for older people are more acceptable when they facilitate communication with a healthcare provider 28 rather than disrupt it, 7 and a cohort study found that frail older people using teleassistance at home 29 who took up additional specialist telecounselling were almost twice as likely to complete the study 30 after one year (94% vs 44%%). 8 31 there are also known access issues. a recent population-based finnish study suggested that frail 32 older people are less likely than robust older people to have an internet connection (46% vs 79%), to 33 have used the internet in the last 3 months (34% vs 72%) and have used a computer in the last 12 34 months (30% vs 70%). 9 they also found that frail older people are more likely to hold negative 35 opinions about the usefulness and usability of mobile ict. this risks a large proportion of the 36 population being excluded. whilst there is clear evidence of high acceptability scores for remote 37 interventions in those who complete studies, 2,4,6 these can also suffer from high dropout rates, 38 particularly when unsupervised, 3,6 are evaluated mainly for short term interventions and typically 39 lack generalisability to wider populations. 40 services wishing to use remote delivery must therefore ensure the necessary technology is provided 41 to overcome access barriers, and that its use is supported. studies have indicated that it is possible 42 to provide equipment such as tablets, laptops or devices connected to the tv, 4,5,10 however studies 43 also frequently report technical failures even in pilot studies, which can be associated with 44 dropouts. 6 technical support was frequently utilised in feasibility studies, indicating that providing 45 this is an important part of remote intervention delivery. 46 in conclusion, whilst these interventions are potentially effective and received positively by some frail older people, those evaluating or providing services should ensure that digitally underserved 48 older people are not left behind through facilitating contact with healthcare professionals and 49 providing both the technology and technical support needed for interventions to be successful. 50 the authors state that there are no conflicts of interest. 53 home-based video exercise intervention for 56 community-dwelling frail older women: a randomized controlled trial user experience, 59 actual use, and effectiveness of an information communication technology-supported home 60 exercise program for pre-frail older adults telephone calls make a difference in home balance training 62 outcomes: a randomized trial six-month postintervention 64 depression and disability outcomes of in-home telehealth problem-solving therapy for 65 depressed, low-income homebound older adults teleassistance 75 for frail elderly people: a usability and customer satisfaction study information and communication technologies among older people with and without frailty: 79 a population-based survey fit4surgerytv at-home prehabilitation for frail older patients planned for colorectal cancer 82 surgery: a pilot study key: cord-310961-e1mb7uuh authors: nouvenne, antonio; ticinesi, andrea; parise, alberto; prati, beatrice; esposito, marcello; cocchi, valentina; crisafulli, emanuele; volpi, annalisa; rossi, sandra; bignami, elena giovanna; baciarello, marco; brianti, ettore; fabi, massimo; meschi, tiziana title: point-of-care chest ultrasonography as a diagnostic resource for covid-19 outbreak in nursing homes date: 2020-05-25 journal: j am med dir assoc doi: 10.1016/j.jamda.2020.05.050 sha: doc_id: 310961 cord_uid: e1mb7uuh abstract objective bedside chest ultrasound, when integrated with clinical data, is an accurate tool improving the diagnostic process of many respiratory diseases. this study aims to evaluate the feasibility of a chest ultrasound screening program in nursing homes for detecting coronavirus disease-19 (covid-19)-related pneumonia and improving the appropriateness of hospital referral of residents. design pragmatic, descriptive, feasibility study from april 2nd to april 9th, 2020. setting and participants: a total of 83 older residents (age 85±8) presenting mild to moderate respiratory symptoms and not previously tested for covid-19, residing in five nursing homes in northern italy. methods chest ultrasound was performed at the bedside by a team of hospital specialists with certified expertise in thoracic ultrasonography, following a systematic approach exploring four different areas for each hemithorax, from the anterior and posterior side. presence of ultrasonographic signs of interstitial pneumonia, including comet-tail artifacts (b-lines) with focal or diffuse distribution, subpleural consolidations and pleural line indentation was detected. the specialist team integrated ultrasound data with clinical and anamnestic information, and gave personalized therapeutic advice for each patient, including hospital referral when needed. results the most frequent reasons for ultrasound evaluation were fever (63% of participants) and mild dyspnea (40%). fifty-six patients (67%) had abnormal ultrasound findings. the most common patterns were presence of multiple subpleural consolidations (32 patients) and diffuse b-lines (24 patients), with bilateral involvement. a diagnosis of suspect covid-19 pneumonia was made in 44 patients, and six of them required hospitalization. twelve patients had ultrasound patterns suggesting other respiratory diseases, and two patients with normal ultrasound findings were diagnosed with copd exacerbation. conclusions and implications in nursing home residents, screening of covid-19 pneumonia with bedside chest ultrasonography is feasible and may represent a valid diagnostic aid for an early detection of covid-19 outbreaks and adequate patient management. coronavirus disease 2019 (covid-19) represents a big challenge for geriatric medicine. 1, 2 frail 33 older people are particularly at risk of developing severe acute respiratory syndrome coronavirus 2 34 (sars-cov-2) infection, 3, 4 and their clinical course is often characterized by severe respiratory 35 failure and adverse outcomes. 5 in italy, the covid-19 pandemic has been associated with high 36 mortality rates, particularly in subjects older than 65 with multimorbidity. 6 nursing home residents represent a category of subjects particularly vulnerable to the spread of 38 respiratory viruses, including coronaviruses. 7-9 covid-19 outbreaks are being increasingly 39 described in nursing homes and long-term care facilities, 10 and health systems need to put up rapid 40 and effective responses to prevent or detect such outbreaks at an early stage. 11,12 reverse-transcriptase polymerase-chain reaction (rt-pcr) for sars-cov-2 and high-resolution 42 chest ct are the reference standard tests for diagnosing sars-cov-2 infection and covid-19-43 related pneumonia, respectively. 13 however, the limited accessibility to these diagnostic resources 44 in nursing homes could lead to delayed diagnosis or increased rates of hospital admission. 45 alternative diagnostic tests are thus needed in these healthcare settings, to effectively screen 46 residents that should primarily undergo rt-pcr and chest ct testing. point-of-care chest ultrasound is a rapid, inexpensive and reliable diagnostic tool, available directly 48 at the patient's bedside, assisting the diagnostic process of several respiratory diseases. 14,15 this 49 technique is particularly useful in older patients with mobility-limitations and multimorbidity, when consolidations and, in most severe cases, white lung pattern. 17, 18 although not fully specific of 54 covid-19 pneumonia, in the epidemiological context of a pandemic the detection of one or more 55 of these signs is highly suggestive for the disease. 19 thus, in older multimorbid nursing home 56 residents with mild/moderate respiratory symptoms or fever, chest ultrasound could help clinicians 57 to gain important diagnostic information, prioritize the access to sars-cov-2 testing, and avoid 58 many hospital admissions. the objective of this study was to evaluate the feasibility of a chest ultrasound program for the 60 screening of covid-19 in a group of italian nursing homes located in the same district in northern 61 italy, and to describe its impact on patient management. was included in this pragmatic descriptive feasibility study conducted from april 2 nd to april 9 th , 66 2020. the nursing homes were chosen among those of the district where some cases of covid-19, 67 requiring hospital admission, were detected among residents in march 2020. all participants were 68 isolated in compliance with recommendations of local health authorities. included in the study were 69 residents with respiratory symptoms, including cough and mild dyspnea with oxygen saturation in 70 room air between 90% and 95% and respiratory rate >18, or fever, for which the nursing home each hemithorax was split into anterior-lateral sectors and posterior sectors, and each sector was then divided into upper and lower halves using the third intercostal space as reference, as to obtain 89 four areas for each hemithorax, according to our previously published research. 16 the patient was 90 kept in sitting position during examination whenever possible, with the aid of a second operator in 91 case of severe mobility-limitation. images were saved on the ultrasound software for review. data were expressed as mean ± standard deviation or percentages, as appropriate. comparisons 113 between subjects with normal ultrasound and subjects with ultrasound abnormalities were made 114 using t test and chi-square test. data were analyzed with spss software (ibm, united states). the study protocol was approved by the ethics committee of area vasta emilia nord, emiliaprescribed. an overview of the study findings is depicted in figure 2 . overview of demographic, clinical and ultrasound data of the 83 nursing home residents that were screened for covid-19 by chest ultrasonography. geriatric medicine in italy in the time of covid-19 lung ultrasound for the emergency 278 diagnosis of pneumonia, acute heart failure, and exacerbations of chronic obstructive 279 pulmonary disease/asthma in adults: a systematic review and meta-analysis chest ultrasound in italian geriatric wards: use, 282 applications and clinicians' attitudes the authors wish to thank the management, the doctors and personnel of the five nursing homes of parma province that participated to this study, and the management of azienda unità sanitaria locale di parma for the support in the umm project. the authors also wish to thank dr. angela guerra for assistance in data collection and analysis and dr. nicoletta cerundolo for advice in manuscript revision.financial disclosure: no specific funding must be reported for this research. the study has been entirely supported by institutional funds. key: cord-302180-sgg8pvm8 authors: blain, hubert; rolland, yves; tuaillon, edouard; giacosa, nadia; albrand, mylène; jaussent, audrey; benetos, athanase; miot, stéphanie; bousquet, jean title: efficacy of a test-retest strategy in residents and health care personnel of a nursing home facing a covid-19 outbreak date: 2020-06-11 journal: j am med dir assoc doi: 10.1016/j.jamda.2020.06.013 sha: doc_id: 302180 cord_uid: sgg8pvm8 abstract objective to assess the american testing guidance for nursing homes (nhs) updated may 19, 2020 with a new covid-19 case. design case investigation. setting and subjects: all 79 residents and 34 health care personnel (hcp) of a nh. methods 7 days after identification of a covid-19 resident, all residents and hcp underwent rrt-pcr testing for sars-cov-2 with nasopharyngeal swabs. this was repeated weekly in all previously negative subjects until the testing identified no new cases and in all positive subjects until the testing was negative. covid-19 infection prevention and control (ipc) measures were implemented in all residents and hcp with positive testing or with covid-19 symptoms. standard ipc was also implemented in all hcp. six weeks after initial testing, all residents underwent testing for elisa-based igg antibodies directed against the sars-cov-2. symptoms were serially recorded in residents and hcp. results 36 residents had a positive rt-pcr at baseline and two at day 7. six hcp had a positive rt-pcr at baseline and two at day 7. no new covid-19 cases were diagnosed later. among the sars-cov-2-positive cases, six residents (16%) and three hcp (37%) were asymptomatic during the 14 days before testing. twenty-five residents (92.3%) and all 8 hcp (100%) with a positive rt-pcr developed igg antibodies against sars-cov-2. among the residents and hcp always having tested negative, 2 (5%) and 5 (11.5%) developed igg antibodies against sars-cov-2. these 2 residents had typical covid-19 symptoms before and after testing and 2/5 hcp were asymptomatic before and after testing. conclusions and implications this study shows the validity of the updated american testing guidance for nursing homes (nhs). it suggests implementing covid-19 ipc in both residents and hcp with positive testing or covid-19 symptoms and warns that asymptomatic hcp with repeated negative rt-pcr testing can develop antibodies against sars-cov-2. a wide testing strategy is effective in detecting asymptomatic covid-19 residents and hcp in a nh facing covid-19 outbreak. symptomatic residents and hcp as well as asymptomatic hcp with negative testing may also play a role in the virus spread within the nh. later. among the sars-cov-2-positive cases, six residents (16%) and three hcp (37%) were 20 asymptomatic during the 14 days before testing. twenty-five residents (92.3%) and all 8 hcp 21 (100%) with a positive rt-pcr developed igg antibodies against sars-cov-2. among the 22 residents and hcp always having tested negative, 2 (5%) and 5 (11.5%) developed igg 23 antibodies against sars-cov-2. these 2 residents had typical covid-19 symptoms before 24 and after testing and 2/5 hcp were asymptomatic before and after testing. 25 seroconversion with sars-cov-2 antibodies generally occurs rapidly in adult subjects. 5 the 45 immune response to viruses may be influenced by aging, and seroconversion in frail older 46 subjects is uncertain. it is unclear whether residents and hcp with repeated negative testing 47 may develop antibodies against sars-cov-2. 48 a study was carried out on all residents and hcp of a nh facing a covid-19 outbreak. the 49 aim was to assess clinical and serological parameters for the efficacy of infection prevention 50 and control (ipc) measures adapted to (i) symptoms and (ii) results of repeated testing. 51 participants: from march 3 rd to 6 th , 2020, three nh residents were hospitalized for severe 54 non-respiratory covid-19 symptoms. all three developed respiratory symptoms (cough with 55 fever and dyspnea) 7 to 10 days after admission, and rt-pcr following nasopharyngeal swab 56 test confirmed covid-19. seven days after the first diagnosis, all residents or hcp were 57 enrolled in the study. 58 no ethics committee was required as this is an observational study. 59 followed daily for 6 weeks. 62 nasopharyngeal testing for sars-cov-2 using rrt-pcr was performed in all residents and 63 hcp. it was repeated weekly in all previously negative subjects until no new cases were 64 identified and in all positive subjects until testing was negative. 65 covid-19 ipc measures were applied in all residents and hcp with positive testing or with 66 new covid-19 symptoms, including diarrhoea, delirium, or falls. 67 six weeks after initial testing, all residents and hcp underwent blood testing for igg 68 antibodies directed against the sars-cov-2 nucleocapsid protein using an elisa ce-ivd 69 marked kit (id screen ® sars-cov-2-n igg indirect id. vet, montpellier, france). 5 70 residents 72 among the 79 residents, 38 (48%) had a positive rt-pcr (table 1) . 36 were diagnosed at 73 baseline and two at day 7. the residents who tested positive were distributed throughout the 74 4 floors of the nh (10, 9, 10, 9). 75 the mean age of residents was similar in positive and negative rt-pcr groups. diabetes and 76 renal disease were more common in rt-pcr positive residents. 77 thirteen residents died two to seven days after testing due to respiratory symptoms. twelve 78 (7 men) had a positive rt-pcr. six rt-pcr-positive residents (16%) were asymptomatic 79 before testing. 80 six weeks after initial testing, seven residents still had at least one typical covid-19 81 symptom (particularly fever or cough) or a significant functional impairment. among them, 5 82 (83%) were rt-pcr-positive. 83 the rt-pcr test became negative 14, 21, or 28 days after initial positive testing in 2 (14%), 84 7 (27%), and 12 (46%) residents. in the 5 (19%) who still had positive rt-pcr 28 days after 85 initial testing, one recovered completely and 4 had long-lasting symptoms (fever and 86 hypothermia; shortness of breath; dry cough; impaired health status). all residents and hcp were tested and there was no selection bias. this study was conducted 101 before any other covid-19 cases had been detected in the county. the presence of 102 antibodies in residents and hcp is therefore almost certainly linked with the covid-19 103 outbreak in that nh. 104 in the present study, 16% of residents and one third of hcp with positive rt-pcr were 105 asymptomatic in the 14 days before testing. this confirms that all residents and hcp should 106 be tested if there is a confirmed case of covid-19, whatever the symptoms. 4 two residents 107 and two hcp who tested negative at baseline were tested positive for covid-19 7 days after 108 baseline. this suggests that a repeated weekly testing of all previously negative residents and 109 hcp until no new covid-19 cases are identified is also essential in preventing the sars-110 cov-2 spread. 4 111 positive rt-pcr was associated with a severe prognosis (death in 32%), especially in men 112 (death in 58%), confirming previous studies. 1,2 among the 22 negative rt-pcr residents 113 presenting covid-19 symptoms, one died and the others recovered completely, suggesting 114 that severe covid-19 outcomes could be generally, but not always, predicted by positive 115 testing. one remained positive for 8 weeks, indicating that nhs facing a covid-19 outbreak should 118 be prepared to maintain prolonged protective measures in residents tested positive for sars-119 cov-2. in accordance with our regional guidelines 6 , this nh was considered to be covid-120 19-free when none of the residents and hcp were diagnosed within the 14 days after the last 121 positive result. covid-19 free nhs apply regional recommended measures to prevent any 122 further covid entrance and spread. in our occitanie region, these measures include 6 174 epidemiology of covid-19 in a long-term care facility in king county cov-2 infections and transmission in a skilled nursing facility. 178 interpreting diagnostic tests for sars-cov-2 interim testing guidance in response to suspected 182 or confirmed covid-19 in nursing home residents and healthcare personnel. centers 183 for disease control and prevention. coronavirus disease 2019 (covid-19) cov-2 antibodies using commercial assays and seroconversion patterns in hospitalized 187 patients covid-19 strategy for prevention in older subjects. french occitanie county health 189 agency [covid19. stratégie de prévention des personnes agées. agence régionale de 190 la santé occitanie acknowledgements -the authors thank anna bedbrook for editorial assistance and all residents and health care personnel of the nursing home. key: cord-345725-8ijgmbmr authors: shang, jingjing; chastain, ashley m.; perera, uduwanage gayani e.; quigley, denise d.; fu, caroline j.; dick, andrew w.; pogorzelska-maziarz, monika; stone, patricia w. title: covid-19 preparedness in u.s. home healthcare agencies date: 2020-06-04 journal: j am med dir assoc doi: 10.1016/j.jamda.2020.06.002 sha: doc_id: 345725 cord_uid: 8ijgmbmr abstract objectives in the u.s., home health agencies (hhas) provide essential services for patients recovering from post-acute-care and older adults who are aging in place. during the covid-19 pandemic, hhas may face additional challenges caring for these vulnerable patients. our objective was to explore covid-19 preparedness of u.s. hhas and compare results by urban/rural location. design cross-sectional study. setting/participants using a stratified random sample of 978 hhas, we conducted a 22-item online survey from april 10 to 17, 2020. methods summary statistics were computed; open-ended narrative responses were synthesized using qualitative methods. results similar to national data, most responding hhas (n=121, 12% response rate) were for-profit and located in the south. a majority of hhas had infectious disease outbreaks included in their emergency preparedness plan (76%), a staff member in charge of outbreak/disaster preparedness (84%), and had provided their staff with covid-19 education and training (97%). more urban hhas had cared for confirmed and recovered covid-19 patients than rural hhas, but urban hhas had less capacity to test for covid-19 than rural hhas (9% vs 21%). most (69%) experienced patient census declines and had a current and/or anticipated supply shortage. rural agencies were impacted less than urban agencies. hhas have already rationed (69%) or implemented extended use (55%) or limited reuse (61%) of personal protective equipment (ppe). many hhas reported accessing supplemental ppe from state/local resources, donations, and do-it-yourself efforts; more rural hhas had accessed these additional resources compared to urban hhas. conclusions/implications this survey reveals challenges that hhas are having in responding to the covid-19 pandemic, particularly among urban agencies. of greatest concern are the declines in patient census, which drastically impact agency revenue, and the shortages of ppe and disinfectants. without proper protection, hha clinicians are at risk of self-exposure and viral transmission to patients and vulnerable family members. setting/participants: using a stratified random sample of 978 hhas, we conducted a 22-item 10 online survey from april 10 to 17, 2020. results: similar to national data, most responding hhas (n=121, 12% response rate) were for-14 profit and located in the south. a majority of hhas had infectious disease outbreaks included in 15 their emergency preparedness plan (76%), a staff member in charge of outbreak/disaster 16 preparedness (84%), and had provided their staff with covid-19 education and training (97%). 17 more urban hhas had cared for confirmed and recovered covid-19 patients than rural hhas, 18 but urban hhas had less capacity to test for covid-19 than rural hhas (9% vs 21%). most (69%) experienced patient census declines and had a current and/or anticipated supply 20 shortage. rural agencies were impacted less than urban agencies. hhas have already rationed 21 (69%) or implemented extended use (55%) or limited reuse (61%) of personal protective 22 equipment (ppe). many hhas reported accessing supplemental ppe from state/local resources, 23 donations, and do-it-yourself efforts; more rural hhas had accessed these additional resources 24 compared to urban hhas. 25 conclusions/implications: this survey reveals challenges that hhas are having in responding 26 to the covid-19 pandemic, particularly among urban agencies. of greatest concern are the 27 declines in patient census, which drastically impact agency revenue, and the shortages of ppe in the u.s., home healthcare, defined as care delivered in a patient's home by healthcare 33 professionals, 1 plays an important role for post-acute and chronically ill patients. most home care 34 patients are older adults with multiple chronic conditions. 2 during the covid-19 pandemic, 35 caring for this group of vulnerable patients at home is complicated and issues may differ in urban 36 and rural settings. our objective was to explore the covid-19 preparedness of u.s. home 37 healthcare agencies (hhas) and examine any urban and rural differences. we used a stratified random sample of 978 hhas with available email addresses drawn one hundred twenty-one hhas completed the survey (12% response rate). similar to 56 national medicare-certified hhas, the majority of responding hhas were located in the 57 southern census region and had for-profit ownership (table 1) . our sample had more rural 58 hhas (27% vs 14%) than the nation, given that rural agencies were oversampled in the original 59 sample. approximately 15% of responding agencies were affiliated with a hospital. average homes, which are critical to reducing sars-cov-2 transmission. in a text response, one staff 77 member at an urban for-profit hha in pennsylvania highlighted the importance of early and 78 ongoing education to protect staff: " [ hhas, more than rural hhas, lacked n95 respirators (66% vs. 52%), gloves (23% vs. 15%) and 107 eye protection (50% vs. 33%). more urban hhas anticipated shortages in eye protection in the 108 next 2 weeks, compared to those in rural locations (35% vs. 21%). a staff member from a rural, to moonlight in another snf, hospital, etc. they would be putting people at risk." another staff 138 member at a rural, for-profit agency in ohio indicated: "we actually did not take any steps [to 139 preserve staff]. we had a handful of aides who also worked at dentist and doctors' offices and 140 since they are closed temporarily these aides picked up more shifts. so, we just got lucky." most hhas had an emergency preparedness plan in place, and despite regional 143 differences in covid-19 cases, the majority of responding agencies were caring for (or had the current/anticipated shortages of ppe and other supplies remain the largest concern. 164 during the week of april 10, 2020, most responding hhas were already lacking n95 165 respirators, gowns, and cleaning supplies or disinfectants. the lack of ppe has been reported at 166 length in hospitals and nursing homes 9 , but rarely for home health agencies 10 . as in other totals varied due to missing data --* from february 2020 hhc file: n (total) = 8,412, n (respondents) = 103; † from february 2020 hhc file: n (total) = 5,483, n (respondents) = 68 3(9.1) 10(11.4) notes: ipc = infection prevention and control; other ipc components included influenza, tuberculosis, multidrug resistant staphylococcus aureus; other reasons for staffing shortages included employee fear and competition from other healthcare facilities; totals varied due to missing data or skip patterns --* n = 119, ^n = 117, † n=38, ‡ n= 80 what's home health care alliance for home health quality and innovation. home health 198 chartbook 2019: prepared for the alliance for home health quality and innovation _10.3.2019.pdf covid 19 preparedness in michigan nursing homes fact sheet: quality of patient care 206 star rating instruments/homehealthqualityinits/downloads/qopc-fact-sheet-for the national institute for occupational safety and health (niosh); centers for disease 211 recommended guidance for extended use and limited 212 home health agencies: cms 216 flexibilities to fight covid-19 less red tape: what agencies should know about 219 cms's home health changes. home healthcare news calm before the storm: in-home care providers brace for covid-19 surge preparedness in nursing homes in the midst of the pandemic home health care aides and coronavirus: caring for elderly but unprepared for 230 covid-19 phase ii covid-19 survey: 234 summary of impact on home and community-based entities, staff and patients in new 235 hca-phase-ii-survey-summary-final mln matters® article se19027 home health insiders hearing about agency exits less than 10 days 241 into pdgm. home health care news key: cord-267664-vahd59z8 authors: cesari, matteo; proietti, marco title: covid-19 in italy: ageism and decision-making in a pandemic date: 2020-04-01 journal: j am med dir assoc doi: 10.1016/j.jamda.2020.03.025 sha: doc_id: 267664 cord_uid: vahd59z8 nan the world health organization declared the covid-19 situation as a pandemic on march 11th, 2020. 1 to date, italy is the country after china at having been most severely hit by this humanitarian and public health tsunami. projections are even suggesting that the number of deaths due to sars-cov-2 in italy will continue to increase in the near future, leaving us the sad world record of casualties. what has happened in italy during these last few weeks? on february 22nd, a "red zone" was defined by the government to quarantine a group of several towns in the lombardy region, just a few hours after the diagnosis of the first case in italy. this area, where about 50,000 persons live, included codogno (where patient 1 was identified), castiglione d'adda, and casalpusterlengo. on march 8th, the red zone was extended to the entire region of lombardy (about 10 million people) and several surrounding provinces in a new attempt of preventing the uncontrolled diffusion of the virus to the rest of the country. the following day, the entire country was transformed into a "red zone". on march 21st, a complete lockdown of italy was ordered by the government as a drastic and unprecedented countermeasure against the coronavirus. behind this story of the italian crisis is the drama of a healthcare system close to collapse. the exponential increase of patients admitted to emergency departments with fever and/or respiratory symptoms resembled the mounting wave of a tsunami. it soon became evident how inadequate the availability of beds was to face the continuous flow of patients. the situation was aggravated by the need to isolate covid patients, given the high contagiousness of the virus. at the same time, intensive care units started to saturate, and the number of devices for ventilating patients suddenly appeared insufficient to address the growing demand. furthermore, healthcare professionals started falling sick (sometimes even dying) as consequence of their untiring willingness to serve the community, as well as the infrastructural unpreparedness for the enormity of the outbreak. our world was completely subverted by the emergency. no plans or protocols had the time to be tested and verified, at least on a large scale. the rapidity of the evolving scenario made it necessary to adopt easy and pragmatic solutions even for critical and delicate matters. not surprisingly, the usual, despicable age criterion started to be implicitly adopted in the decisional algorithm for the allocation of scarce resources to the mounting number of patients. it is noteworthy that during the early crisis, the società italiana di anestesia, analgesia, rianimazione e terapia intensiva (siaarti; italian society of anesthesia, analgesia, and intensive care) released clinical ethics recommendations for the allocation of treatment in exceptional resource-limited situations. 2 the document mentions the word "age" twice, in two critical paragraphs. they read as follows: "3. it might be needed to set an age limit for the admission to intensive care. it is not a mere choice related to values, but to spare resources that might be extremely scarce to those who have in primis the highest chance of survival and then to those who may have more years of life saved, in order to maximize benefits for the largest number of persons. 4. the presence of comorbidity and functional status must be carefully evaluated in addition to age. it is possible that a relatively short stay in healthy persons might potentially become longer and thus resource consuming over the healthcare system in case of persons with advanced age, frailty or severe comorbidity." it is important to consider that what the siaarti mentioned as a scenario of "extremely scarce" resources may correspond to the optimistic vision of the saturation that the lombardy region has been experiencing over the past weeks. persons with covid-19 often experience extremely rapid (and often unexpected) clinical changes, with sudden respiratory distress. clinicians often find themselves in the position of having to act quickly to move a patient from the acute care ward to the intensive care unit, to be placed on a ventilator. it is not rare to see that in 20-30 minutes, the patient turns from relatively stable to extremely critical. in this scenario, which is the risk factor for negative outcomes that is easier and quicker to obtain? of course, the patient's age… if we want to fight such an ageistic approach and replace the age criterion for the allocation of resources, we must have and propose a parameter more robust than age but equally easy-to-obtain, that can be used for critical and rapid decision-making. otherwise, geriatricians might be at risk of remaining too theoretical and disengaged from the real world. we must show that we understand why intensive care physicians are prioritizing the life of a 40 year-old person over that of a 90 year-old, and that this is the best decision. they have never been exposed to anything other than this approach. and the critical nature of the situation can further provide ground for justifying such arguable choices. "all is fair in love and war"-and we are indeed in war! the 2013 document referred by the siiarti recommendations was developed without the involvement of geriatricians. it discusses how to choose if a patient should undergo palliative versus intensive care. the criterion that is most frequently used is age. 3 however, the most recent recommendations seem to create some formal openings to geriatric concepts that are traditionally ignored, and therefore, to reconsider basing decisions only on the number of years lived. it is true that age is always at the beginning considerations that drive decisions; everything is still strongly designed to lead toward the exclusion of older persons. at the same time, one should not underestimate the statement that "the presence of comorbidity and functional status must be carefully evaluated in addition to age". the sentence might appear superficial to those who do not understand it, perhaps because this is not typically the case. at the same time, the statement potentially draws a first line in the sand for the future. it is a starting point to help discriminate what should be done and what should not be done, between good clinical practice and pure malpractice. implementation of these principles into decisional algorithms should, we believe, be part of pandemic preparation everywhere. in settings where rationing of resources becomes a necessity and such preparation has not been made, medical staff or oversight organizations should implement ad hoc guidelines that incorporate key prognostic factors beyond age -most notably frailty, comorbidity, and functional status. 4, 5 in this manner, a sentence about function and comorbidities in an ethics document underscores the need to operationalize the meaning of prognosis at advanced age, 6 and acknowledges the critical role that function and comorbidity play in the aging individual. 7 clinicians familiar with principles of geriatrics and gerontology could thus support the development of more contemporary recommendations by identifying valid, efficient ways of measuring comorbidities and function across different settings and specialties. we might suggest the use of simple tests and scales, such as the clinical frailty scale, 8 or the assessment of mobility independence, 9 that might optimally capture the pre-illness health status of the individual, mirroring his/her physiological reserve, and, by incorporating such tools into electronic records for rapid assessment, provide support for better clinical decisionmaking than the all-too-simplistic criterion of chronological age. we realize we might be too optimistic to think that ageism is going to soon be defeated among clinicians. age is still the first criterion mentioned. however, we get some hope reading that, unlike the past, it is not the only criterion being proposed. will comorbidities and functional status start to change how we think and act in times of crisis? it is probably still too early to see major changes. however, while continuing to push towards a less ageistic society and medical practice, we should take advantage of these openings that arise from non-geriatricians. these are indeed opportunities to build constructive exchanges. if the principles of geriatrics had been incorporated into pandemic planning before this crisis, perhaps we would today have more justification to counter the ageistic approach. while ageist attitudes cannot be justified, we who focus on the care of older persons must take some responsibility for what is not happening. we need to realize how much work we still have ahead of us in educating and reframing the thinking among our clinician colleagues and our society, and therefore roll up our sleeves and perhaps leave aside some of our ego. when we hear that the decision of using a ventilator for a person with respiratory distress is based on his/her birth date, we must admit our failure and realize how many problems modern medicine has -in particular, that without our input, modern medicine may be at risk of having lost the meaning and value of the human life. who director-general's opening remarks at the media briefing on covid-19 -11 clinical ethics recommendations for the allocation of intensive care treatments, in exceptional, resource-limited circumstances grandi insufficienze d'organo "end stage": cure intensive o cure palliative? documento condiviso per una pianificazione delle scelte di cura prognostic indices for older adults: a systematic review the central role of prognosis in clinical decision making frailty and multimorbidity: different ways of thinking about geriatrics evidence for the domains supporting the construct of intrinsic capacity a global clinical measure of fitness and frailty in elderly people a diagnosis of dismobility-giving mobility clinical visibility: a mobility working group recommendation a comparison of frailty indexes for the prediction of falls, disability, fractures, and mortality in older men prognostic indices for older adults: a systematic review the central role of prognosis in clinical decision making key: cord-354105-lgkfnmcm authors: office, emma e.; rodenstein, marissa s.; merchant, tazim s.; pendergrast, tricia rae; lindquist, lee a. title: reducing social isolation of seniors during covid-19 through medical student telephone contact date: 2020-06-05 journal: j am med dir assoc doi: 10.1016/j.jamda.2020.06.003 sha: doc_id: 354105 cord_uid: lgkfnmcm abstract social isolation has been associated with many adverse health outcomes in older adults. we describe a phone call outreach program in which health care professional student volunteers phoned older adults, living in long-term care facilities and the community, at risk of social isolation during the covid-19 pandemic. conversation topics were related to coping, including fears/insecurities, isolation, and sources of support; health; and personal topics such as family and friends, hobbies, and life experiences. student volunteers felt the calls were impactful both for the students and for the seniors, and call recipients expressed appreciation for receiving the calls and for the physicians who referred them for a call. this phone outreach strategy is easily generalizable, and can be adopted by medical schools to leverage students to connect to socially-isolated seniors in numerous settings. social isolation has been associated with many adverse health outcomes in older adults. we 2 describe a phone call outreach program in which health care professional student volunteers 3 phoned older adults, living in long-term care facilities and the community, at risk of social 4 isolation during the covid-19 pandemic. conversation topics were related to coping, including 5 fears/insecurities, isolation, and sources of support; health; and personal topics such as family 6 and friends, hobbies, and life experiences. student volunteers felt the calls were impactful both 7 for the students and for the seniors, and call recipients expressed appreciation for receiving the 8 calls and for the physicians who referred them for a call. this phone outreach strategy is easily 9 generalizable, and can be adopted by medical schools to leverage students to connect to 10 socially-isolated seniors in numerous settings. social isolation, a quantitative loss in a person's social relationships, is common in older adults, 27 with 27% of adults over 60 y/o living alone. 1, 2 during the covid-19 pandemic, social distancing 28 has been an essential public health strategy. 3 while many older adults entered independent 29 living communities for activities and socialization, they have been advised to remain in their own 30 apartments or room. meals are delivered to doors, activities have stopped, exercise rooms 31 closed, and visitors are restricted. these necessary stay-at-home measures unfortunately 32 increase social isolation. 33 social isolation has been associated with adverse health outcomes including increased risk of 34 falls, all-cause mortality, hospitalizations, and cognitive decline, as well as unhealthy behaviors 35 like physical inactivity and poor diet. 4,5 additionally, in the previous sars pandemic, isolating 36 infection control practices were associated with increased depression and traumatic stress 37 response symptoms. 6 social isolation has been associated with less infection resistance, more 38 emergency admissions to hospital, and extended length of stay, factors which may lead to 39 worse outcomes during the covid-19 pandemic. 7-10 40 given the effects on the mental and physical health of the elderly, interventions targeting social 41 isolation are necessary to mitigate risk of increased morbidity and of infection from covid-19. social isolation calls during covid-19 -3 we created a phone call outreach program, seniors overcoming social isolation (sos), in 48 which medical and health professions student volunteers (e.g. md, md/phd, neuroscience, 49 genetic counseling) called older adults, living in long-term-care facilities (ltcf) and the 50 community, at risk of social isolation during covid-19. the sos program entailed providers 51 identifying at-risk older adults and then referring the contact information to coordinators who 52 would then pass the info to student volunteers. student volunteers were provided with an 53 introduction script and a series of conversation starters, general social history questions, and 54 well-being questions (e.g. resource needs, groceries) to ask the older adult. students then 55 phoned the older adults when they had available free time. the goals were (1) to provide 56 companionship and resources for unmet needs of older adults, while (2) fostering health 57 professional students' skills in communicating and understanding the needs of older adults in 58 their community. we propose that social phone calls to older adults may reduce social isolation 59 while providing meaningful engagement with the community and a learning experience for 60 students. perspectives and resolving any identified discrepancies through discussion. in no cases were 80 the coders unable to reach consensus. the coders organized the content into relevant themes. 81 descriptive statistics were used to analyze participant surveys. 82 fourteen volunteers made 25 phone calls, averaging a length of 8.3 min (sd 4.0). nearly all 85 volunteers (85.7%) were in medical school (md or md/phd program), and most of those 86 students were in their first year of medical school (75%). there was 2 graduate health program 87 students (e.g. medical geneticist and neuroscientist programs) who heard about program 88 through word-of-mouth. volunteers were predominantly female (92.9%), and identified as asian 89 or white (50% and 43%, respectively). 90 both conversational and covid-19-related themes were discussed during calls (table 1) . 91 topics related to covid-19 included health, fears, isolation, coping, and sources of support, 92 while other prominent topics ranged from family and friends, to hobbies, to the older adult's past. in addition to providing social connection, several students assisted in addressing unmet 94 needs by referring the older adults to sources of support. 95 most students felt that the calls were well-received; recipients expressed appreciation both for 97 the calls/callers and for those who referred them. (table 2 ) some students felt that the call was 98 less impactful, while one felt that they had disrupted the older adult by calling. student 99 volunteers indicated they had plans to contact a little over a third of older adults (36%) again. 100 we do not have data about follow-up phone-calls. 101 after the telephone contact, many students felt positive and empowered; one described feeling 103 inspired by the older adult's story, and several reflected on the senior's appreciation. other 104 students acknowledged challenges, such as needing patience and talking about different topics 105 than normally discussed with younger adults (table 3) . 106 107 during the covid-19 pandemic, requisite social isolation is a critical problem among older 109 adults living in assisted and independent living communities. there is ample evidence that this 110 is an important problem desperately needing intervention. 111 to reduce social isolation, we present a practical intervention leveraging health professions 112 graduate students contacting older adults and residents of independent and assisted living by 113 phone. our results show that it is feasible and has bi-directional benefit to both student callers 114 and older adult residents. students felt empowered and that they were able to make a difference in the lives of socially isolated seniors. results also showed that they were learning 116 how to be patient and slowdown in conversations with hearing-impaired seniors, specifically 117 learning important tenets of geriatrics in the process. older adults appreciated and enjoyed 118 receiving calls, likely as they were interrupting their social isolation. 119 limitations of this study include the small sample size, single location, and referral of older 120 adults by a provider. while conducted in a single location (chicago), covid-19 was widespread 121 and existed in most of the area's long-term-care communities necessitating isolation. several 122 students struggled to contact their assigned older adults, potentially due to illness or 123 hospitalizations. this intervention depends on student volunteerism; as classes resume, fewer 124 students may have time to participate. moreover, this requires coordination of providers in 125 identifying appropriate older adults, student volunteering, and a coordinator assigning seniors to 126 call. while online sign-ups limit some of the workload, a dedicated volunteer student coordinator 127 is necessary. 128 seniors overcoming social isolation calls are easily generalizable and can be adopted by most 129 medical schools to connect students to socially isolated seniors in multiple settings. for further 130 generalization, student volunteer groups do not need to be in the same area as those being 131 contacted. medical schools can partner with rural communities or low income areas who do not 132 have direct academic partnerships to reduce isolation in hard-to-reach areas. during covid-19 133 pandemic, this simple innovation has been shown to be a feasible route of improving the lives of 134 both older adults and students. 135 national academies of sciences, e. and medicine, social isolation and 139 loneliness in older adults: opportunities for the health care system social distancing, quarantine, and isolation a review of social isolation: an important but underassessed 145 condition in older adults. the journal of primary prevention health risks associated with social isolation in general and in young, 147 middle and old age sars control and psychological effects of quarantine social ties and susceptibility to the common cold social disconnectedness, perceived isolation, and 154 health among older adults does lack of social support lead to more ed visits for older 157 adults? reducing social isolation and loneliness in older people: a 159 systematic review protocol covid-19 and the consequences of isolating the 161 elderly. the lancet public health social distancing in covid-19: what are the 163 mental health implications? the effect of information communication 165 technology interventions on reducing social isolation in the elderly: a systematic 166 review the use of telephone befriending in low 168 level support for socially isolated older people -an evaluation. health & social care in 169 the community the authors wish to thank their families and loved ones for support while in medical school and the health care profession. the authors also wish to thank the volunteers who assisted with the telephone contact of the older adults. key: cord-264479-s20oacr9 authors: bern-klug, mercedes; beaulieu, elise title: covid-19 highlights the need for trained social workers in nursing homes date: 2020-05-25 journal: j am med dir assoc doi: 10.1016/j.jamda.2020.05.049 sha: doc_id: 264479 cord_uid: s20oacr9 nan core features of psychosocial care in a crisis include access to information and emotional support 2 . this editorial provides examples of how nursing home social workers are adapting the way they connect with residents and families during the pandemic and concludes with suggestions. some of the information comes from experiences shared by nursing home social workers who have participated in weekly online support sessions initiated in april by the national nursing home social work network https://clas.uiowa.edu/socialwork/nursing-home/national-nursing-home-social-work-network .these weekly support sessions provide an anonymous space for social services staff around the country to share experiences and ideas about coping with covid-19 challenges. the editorial also highlights the needs for trained social workers in nursing homes. one of the first topics to surface during the online support sessions was the shortage of personal protective equipment (ppe). many nursing homes around the country still struggle to get enough ppe for the nursing staff who provide hands-on care. in nursing homes experiencing ppe shortages, the lack of equipment means activities and social services staff cannot safely enter resident rooms. much of the psychosocial care provided to these residents now occurs over the phone, computer, or through direct care staff. in nursing homes where ppe is available, training on how to use it safely may not be. this leaves untrained activities and social service staff with a false sense of security and vulnerable to catching and spreading the virus. in some nursing homes, staff members are expected to re-use the ppe. in others, there is not enough ppe for families who want to visit dying loved ones. some hospice workers are arriving at nursing homes to provide services to residents but lack their own ppe. the ppe shortage endangers the physical health of residents and staff and damages emotional health as well. during our weekly online support sessions, social workers shared they are as deeply concerned about bringing covid-19 home to their families as they are about bringing covid to the nursing home. in part because of the lack of ppe, social workers are spending more time on the phone and on the internet communicating with residents. some of these contacts can happen directly between the social worker and the resident. other contacts must be facilitated by busy nursing staff who have access to ppe. cooperation, coordination and collaboration among staff can improve care provided to residents and enhances communication with concerned family members. while a core function of the social work role has always been to anticipate, assess and address resident psychosocial needs, social workers have also been key liaisons between the family and the facility. during a pandemic, that connection is more important than ever, and often occurs over the phone. engaging in this level of conversation with anxious family members requires skill. not all nursing homes have a staff person skilled in delivering bad news, listening to distraught families, and helping to identify and affirm family resilience. the federal government requires only nursing homes with more than 120 beds to hire one fte social services staff member, and that person does not have to hold a degree or license in social work 3 . the unrealistic staffto-resident ratio and the disregard of professional standards has been a problem for decades. the inadequacy of this lax regulatory stance toward the credentials of the key onsite professional responsible for psychosocial care is even more apparent during a crisis when residents, families and staff are simultaneously and chronically in distress. nursing homes are being inundated with phone calls from families concerned about their loved one contracting covid and about the impact of social isolation. families have a lot of questions. some questions have no answers. families wonder why the nurse hasn't called them back in two days and why no one picks up the phone. suspicion brews. families hold themselves responsible for being there for their loved one 4 . this sense of responsibility is heightened during a crisis. families want their mother/brother/sister to know they are not forgotten and have not been abandoned. the nursing staff to provide resident care. one social worker disclosed that while some families use these phone calls to vent their anger, others ask how they can help; she followed up with "…and then a large box of home-made masks appears later in the week." what else are social workers doing during these phone calls? a social worker engages constructively and compassionately with families by using skills acquired as part of a social work education, including: active listening, crisis management, anger deescalation, situation stabilization, emotion processing, problem solving, decision-making support, boundary setting assistance, advance care planning, transitions of care discussions, validation of family connectiveness, role playing, role affirmation, clarifying, reflecting, interpreting, reassuring, and meaning-making 5, 6 . social workers also advocate on behalf of residents and families, provide information on a wide range of topics including health insurance, resident rights, and how to connect with the local foodbank. social workers with a reasonably sized case load can be expected to provide more frequent and comprehensive support to families compared with social workers with large caseloads. even before the pandemic, the most qualified and these conversations can be difficult when the resident and family member disagree on appropriate goals of care for residents. they can also be difficult when residents are not cognitively capable of participating and family members disagree among themselves. sometimes these conversations are difficult because they reflect the mistrust that is present in the larger social context of racism, ageism, and ableism. for example, during a phone conversation with an african american daughter one social worker was asked, "are you saying the same thing to whites?" these delicate conversations call for expertise and compassion. during our online support sessions, social workers discuss the fine line they walk daily between reassuring family members and not over promising. by keeping family expectations realistic today, disappointment can be diminished tomorrow. for example, many families would like the staff to help them connect daily by phone or computer with their loved one. most nursing homes don't have the staff capacity for that, even if they have a spare laptop or tablet. from the family's perspective it doesn't seem to be asking much for a ten-minute daily face-time session, yet from the staff perspective it requires much more than ten minutes to organize, prepare and safely deliver a phone or internet session. many nursing home policies and procedures developed pre-covid are inadequate during covid, including some end-of-life policies. in most nursing homes, the only family members now allowed to visit are those whose relative is actively dying. even then, the number of family members is limited. some family members tell social workers they are afraid to enter the nursing home for fear they will catch covid and are equally afraid they will never forgive themselves if they don't visit in-person to say goodbye. social workers can help people sort out their feelings, understand ppe options, gain the information they need to weigh the risks, and reach a decision they can live with. in nursing homes with multiple covid deaths, social workers leave work with a pit in their stomach from the phone conversations with family members to discuss what to do with the decedent's body and their belongings. most nursing homes do not have an on-sight morgue and many lack sufficient storage space for decedents' possessions. a strong social work presence has always been necessary in nursing homes; the pandemic underscores the need. after the pandemic, the need will continue. because we are working with people in physically, emotionally and socially vulnerable circumstances, many of whom are approaching the last chapter of their life, we know that psychosocial concerns will be ever-present. if we are serious about improving the quality of care and the quality of life in nursing homes, we must be serious about psychosocial care. we need to be concerned with fractures of bones yes of course, but we also need to address a resident's fractured broken heart. we need to do all we can to prevent wounds on the skin, yes of course and we also need to prevent wounds on the soul 7 . this pandemic has exposed many ways the country can better support nursing homes and nursing homes can better care for residents and families. including degreed and licensed social workers as part of the core team is a basic way to provide psychosocial care in nursing homes and enhance resident quality of life. • securing ppe for staff is necessary but not sufficient. training must be provided to all staff. a good source is: https://www.cdc.gov/coronavirus/2019ncov/hcp/using-ppe.html • develop and communicate a protocol for securing ppe and training for family members who come to visit residents who are approaching the end of life. • let residents and families know what format (social media, newsletters, phone calls) and frequency of communication they can expect from the facility. clear, consistent, truthful information from a trusted source is an important factor to help individuals and organizations adapt. • squash rumors and build a sense of inclusion by keeping all staff updated and informed. encourage questions. • have a mechanism for staff who are in touch with families to relay concerns and compliments back to the whole staff. • consider hosting "drop-in" online support sessions for family members. if staff are not available to coordinate, hire a local mental health provider or enlist a trained volunteer. • regularly recognize the hard work of staff in concrete ways. • maintain a "nurturing environment" which provides the necessary resources, security, and support to facilitate individual and organizational adaptation. adaptation is key to resilience 1 . resilience as effective functional capacity: an ecological-stress model psychosocial crisis management: the unexplored intersection of crisis leadership and psychosocial support. risk, hazards, & crisis in public policy code title 42 section 13951. requirements for, and assuring quality of care in, skilled nursing facilities family members' responsibilities to nursing home residents standards for social work services in long-term care facilities psychosocial assessment of nursing home residents via mds 3.0: recommendations for social service training, staffing, and roles in interdisciplinary care transforming palliative care in nursing homes: the social work role key: cord-294423-3458rek8 authors: boucher, nathan a.; van houtven, courtney h.; dawson, walter d. title: older adults post-incarceration: restructuring long-term services and supports in the time of covid-19 date: 2020-09-29 journal: j am med dir assoc doi: 10.1016/j.jamda.2020.09.030 sha: doc_id: 294423 cord_uid: 3458rek8 objectives to describe long-term care services and supports (ltss) in the us, note their limitations in serving older adults post-incarceration, and offer potential solutions – with special consideration for the covid-19 pandemic. design narrative review setting and participants: long-term care services and supports for older adults post-incarceration methods literature review and policy analysis results skilled nursing facilities, nursing homes, assisted living, adult foster homes, and informal care from family and friends compose ltss for older adults, but their utilization suffers from access and payment complexities, especially for older adults post-incarceration. a combination of public-private partnerships, utilization of health professional trainees, and unique approaches to informal caregiver support, including direct compensation to caregivers, could help older adults reentering our communities following prison. conclusions and implications long-standing gaps in us ltss are revealed by the coronavirus (sars-cov-2) pandemic. older adults entering our communities from prison are particularly vulnerable and need unique solutions to aging care as they face stigma and access challenges not typically encountered by the general population. our review and discussion offer guidance to systems, practitioners, and policy makers on how to improve the care of older adults post-incarceration. the united states (us) imprisons a larger proportion of its population than any other 27 country with 1,291,000 prisoners in state prisons, 631,000 in local jails, and 226,000 in federal prison accelerates aging such that the prison population develops chronic illness 10-15 40 years earlier than community counterparts; incarcerated persons can be considered an 'older 41 adult' by 55. 5, 6 contributing factors -largely predating sentencing in these disenfranchised 42 populations -are substance use, inadequate preventive care, mental illness, and the additional 43 stress of being incarcerated. 7 more than 600,000 individuals are released from state and federal 44 prisons each year and over 60,000 of them will be age 50 or above. these released older adults 45 leave prison in worse health than when they arrived and in worse health than community-46 j o u r n a l p r e -p r o o f dwelling persons of the same age. despite the growing number of older incarcerated individuals 47 and their potential impact on the health of society, little has been done to research optimal 48 approaches to care once they are released. firm data on the full extent of health status disparity is scarce, but one texas study found 50 that incarcerated persons 55 years of age and older used an average of 7.3 prescription 51 medications, which is higher than for non-incarcerated americans of the same age. 8 inmates 52 often have their necessary medications stopped once out of the care of the prison system 53 including 25% of chronically ill state prisoners and over 36% of ill local jail inmates. 9 regarding 54 neurocognitive disease (such as dementia), the alzheimer's association indicates dementia 55 prevalence in the general population will be increasing from 1.7% in 2009 to 1.9% in 2030 and 56 then 2.6% in 2050. 10 based on this, inmates with dementia may increase to approximately 57 127,130 in 2050. 11 furthermore, according to a recent systematic review, re-entry planning for 58 older incarcerated persons is "sparse and the outlook is grim, given that many are released to 59 urban communities characterized by health disparities and inadequate health care resources." 12 60 and yet, there is strong evidence that optimal utilization of health-related services is linked to 61 improved health outcomes, lower recidivism (re-incarceration), and improvements in housing, 62 employability, and support provided through families. 13,14 recently released older adults, given high rates of health problems and chronic 64 conditions, may simultaneously face both a great need for access to routine and acute health care, 65 as well as an accelerated need for long-term services and supports (ltss) for their age. 13 a lack 66 of insurance and potential discrimination may compound their difficulty in obtaining continuity 67 of care and medication upon release. 15 the challenges they face are further exacerbated by the 68 introduction of sars-cov-2 (or covid-19) into prisons and the community alike -with 69 j o u r n a l p r e -p r o o f confined space and limited healthcare in the former, and little community support, stigma, and 70 high-risk due to age in the latter. we explore these emergent challenges and offer early release is another approach to mitigate covid-19 transmission but is controversial 99 due to real and perceived risks to communities such as recidivism or a perception of punishments the affordable care act, 33 but again, processing these applications prior to release is critical for 127 older adults between age 55-65 years of age to allow a seamless transition to the community. with the enhanced access that insurance coverage assures, the released persons should then be newly released individual will obtain ltss. while these individuals may also be medicare 147 eligible due to age or disability status (so-called dual eligibles), medicare coverage of ltss is 148 limited to just 100 days of post-acute care (e.g., following a minimum three-day hospital stay). as such, medicaid is the default option for ongoing ltss. in many states, due to their medicaid better support of caregivers -who report financial, emotional and physical strain related 217 to their caregiving role 58,59 --can lead to improved home care for older adults, an increasing 218 concern for our aging population. better care at home for older adults can avoid unnecessary or there is an interrelation of correctional-system health, public health, and long-term care 286 services and supports for older adults. 76 yet, there is a major knowledge gap about older adults 287 who are decarcerated due to a lack of data --including on rates of informal care and ltss 288 utilization after release. we must first fill this knowledge gap to serve this population better. between these ltss components, and along the continuum from prison to community, there are mass incarceration: the whole pie medical problems of state and federal prisoners and jail 297 inmates aging prison populations drive up costs kaiser family foundation since you asked: how many people aged 55 or older are in 306 prison incarceration nation medication prescribing practices for older 311 prisoners in the texas prison system the health and health care of us prisoners: results of 313 a nationwide survey alzheimer's association. alzheimer's disease facts and figures the looming challenge of dementia in corrections. correct care the health of america's aging 320 prison population health and prisoner reentry: how physical, mental, and substance 322 abuse conditions shape the process of reintegration health coverage and care for the adult criminal justice-involved 325 population. menlo park: the henry j kaiser family foundation. 2014. 326 15. us department of health and human services incarceration & social inequality disparities in the population at risk of severe illness from covid-19 by 331 deliberate indifference: inadequate health care in u.s. prisons. ann intern 333 med are our prisons and jails ready for covid-19? the guidelines on infection control in prisons need revising federal inmates to be confined to cells for two weeks amid coronavirus outbreak infection control in jails and prisons flattening the curve for incarcerated populations -covid-344 19 in jails and prisons flattening the curve for incarcerated populations-covid-19 349 in jails and prisons large scale releases and public safety virus-wracked federal prisons again expand release criteria us congress. covid-19 correctional facility emergency response act bureau of prisons. compassionate release criteria for elderly inmates with medical 359 conditions the marshall project. too old to commit understanding violent-crime recidivism using jail to enroll low-income men in medicaid engaging individuals recently 371 released from prison into primary care: a randomized trial a systematic review of randomized controlled trials 374 of interventions to improve the health of persons during imprisonment and in the year after 375 release medicaid expenditures for long-term services and supports (ltss) in 379 fy 2015. truven health analytics inc;2017. 380 38. medicaid.gov. home & community based services final regulation the place of assisted living in long-term care and related service 384 systems. the gerontologist department of health and human services community-based care resident and community 388 assistant secretary for planning and evaluation, 392 department of health and human services disparities in assisted living: does it meet the hcbs test annual costs of care survey nowhere to go: homelessness among formerly incarcerated people. prison policy 403 initiative securing private housing with a criminal record aging with serious mental illness: one state's response where does adult foster care fit in the long-term care continuum medical foster homes: can the adult foster care model substitute for 412 nursing home care telehealth grew wildly popular amid covid-19. now visits are plunging, forcing providers 414 to recalibrate older adults' acceptance of a 417 community-based telehealth wellness system. informatics for health and social care factors associated with receipt of training among 421 caregivers of older adults informal and formal home care both increased 423 between life interrupted: caregiving of justice-involved older adults center for health care strategies. restoring health and humanity to the recently incarcerated objective burden, resources, and other stressors among 434 informal cancer caregivers: a hidden quality issue? better access, quality, and 436 cost for clinically complex veterans with home-based primary care states leverage medicaid to provide nursing homes a lifeline through covid-19 north carolina department of health and human services medicaid temporarily increasing flexibility and reimbursement rates for primary and specialty 443 america's health care safety net: intact but endangered the necessity of 448 social medicine in medical education the ucsd student-run free clinic project: transdisciplinary health professional 450 education predictors of caregiver and family functioning following 452 traumatic brain injury: social support moderates caregiver distress factors associated with receipt of training among caregivers of 455 older adults using care navigation to address caregiver burden in 457 dementia: a qualitative case study analysis family caregiver use and value of support services 461 in the va program of comprehensive assistance for family caregivers medicaid and chip payment and access commission federal medical assistance percentages and enhanced federal medical assistance percentages 475 by state, fys covid-19 and the correctional environment: 479 the american prison as a focal point for public health key: cord-300620-scauefiv authors: gillespie, suzanne m.; handler, steven m.; bardakh, alex title: innovation through regulation: covid-19 and the evolving utility of telemedicine date: 2020-07-28 journal: j am med dir assoc doi: 10.1016/j.jamda.2020.06.054 sha: doc_id: 300620 cord_uid: scauefiv nan a year ago, a group of amda leaders spent the day on capitol hill advocating for policy changes related to post-acute and long-term care (paltc) telemedicine. a main point of discussion was the need to revise the regulations governing payment for telemedicine visits in a way that would make it more feasible for paltc clinicians working with facilities to use telemedicine tools to care for residents. medicare payment for telemedicine physician visits has largely been to support rural nursing homes and limited to no more frequently than monthly regardless of medical necessity. these restrictions have made it very difficult for paltc clinicians to make the business case to include telemedicine into most clinicians' practice. telemedicine to date had largely been supported directly by nursing homes that arrange for afterhours and weekend coverage to manage changes of condition with the primary goals of reducing potentially avoidable emergency department visits and hospitalizations. telemedicine had also been frequently used for certain subspecialties including behavioral health, wound care diagnosis and management. one year later, as a result of rapid policy changes in response to the covid-19 pandemic, much has changed. rational changes in regulations guiding telemedicine in nursing homes and the need for thoughtful infection prevention have inspired a new opportunity for innovation and vision for how high-quality care can be accessed in nursing homes. many factors combine to make nursing homes an ideal venue for telemedicine. the population of patients in nursing homes has steadily increased in complexity, creating the need for timely and skilled acute and chronic care from clinicians with competency in paltc. in contrast to medical providers working in hospitals, emergency departments, and primary care practices, paltc clinicians may only be onsite in the nursing facility intermittently and rarely during nights and weekends. this translates into challenges around change of condition assessment and can contribute to misdiagnoses, delays in diagnosis, and overuse of emergency departments. paltc clinicians and medical directors have believed for many years that their patients would benefit from telemedicine tools to increase access. 1,2 a growing abundance of feasibility studies exploring the application of telemedicine in nursing homes has also supported the concept. in early 2019, amda's workgroup on telemedicine and technology published a white paper offering guidance to clinicians and facilities on the use of telemedicine to deliver medically necessary evaluation and management of change of condition for nursing home residents. 3 the paper reviewed the many research studies and published case reports that demonstrate the ability of telemedicine interventions to reduce avoidable emergency department visits and hospitalizations. in this issue of jamda, the gericare@north example also demonstrates the feasibility of deploying acute geriatric medicine consultation via telemedicine for a variety of routine and symptom-based concerns to nursing home residents in singapore. 4 the covid-19 pandemic has highlighted the need to provide timely access to high-quality medical care, especially to nursing home residents with new or worsening respiratory symptoms. the benefits of telemedicine allow for actual or suspected covid-19epositive residents to be treated in place when their care plan goals support this (ie, goal-concordant care). this concept, called forward triage, can allow for resident assessment in the nursing home using telemedicine to optimize survival and resources, while reducing the risk of community spread and limiting exposure of other health care personnel to covid-19. 5 in their march 2020 response to covid-19, the us center for medicare & medicaid services (cms) has essentially removed the biggest financial barriers to paltc clinicians providing telemedicine services in the nursing facility. in a sweeping interim final rule issued at the end of march, cms removed the once-a-month limitation for essentially, the agency suspended all face-to-face regulatory visit requirements and allowed them to be completed using telehealth tools. further, the agency announced that these visits will be paid at the same rate as a face-toface visit even if completed via telehealth. 6, 7 other codes that are now reimbursable are listed in table 1 . importantly, also removed was the limitation of telemedicine reimbursement for only rural nursing homes. regulations previously restricted reimbursement to rural nursing homes as originating sites (the location of the patient at the time the service is furnished via a telemedicine). under the public health emergency waiver, clinicians originating care for residents located in either rural or urban nursing homes can bill for eligible encounters delivered via telemedicine tools. paltc practitioners at the distant site who may furnish and receive payment for covered telemedicine services, also referred to as distal site practitioners, complete their billing documents with appropriate e&m codes, place of service where the service took place, and modifier 95 indicating a telemedicine visit. supplemental funding through the federal communications commission was also made available to health care centers seeking to expand their capacity to provide virtual care, further reducing barriers to telemedicine-based care. 8 governmental discretion to not enforce penalties for health insurance portability and accountability act (hipaa) violations on health care providers using telemedicine tools in good faith to deliver care during the covid-19 pandemic has allowed more health care providers to try using telemedicine tools without the burden of complex technology and program initiation costs. however, privacy concerns will likely resurface as we deal with the aftermath of the pandemic. in separate rulemaking just prior to the covid pandemic, the office of the national coordinator (onc) released a long-awaited interoperability final rule dealing with a plethora of issues including cybersecurity. there will be an ongoing need for the onc to address concerns about privacy and security as telehealth use expands. 9 for now, public health emergency waivers have enabled every paltc medical provider and facility to try adding telemedicine to their care delivery toolkit. telemedicine programs are reporting significant growth. health care's relationship with telemedicine has the opportunity to be forever changed as a result of the covid-19 global pandemic. during the pandemic, health systems across the united states have exponentially expanded care via telemedicine to nursing home residents. for example, at the university of rochester, between march and may 2020, telemedicine visits between the medical providers of our regulatory reform allow medicare payments to post-acute and long-term care clinicians for all skilled/nursing facility cpt e&m codes using telehealth allow medical necessity to dictate telemedicine visit frequency for subsequent care visits allow nursing homes to receive facility fees for all telemedicine encounters regardless of physical location expand billable telemedicine services for nursing home residents to include e-consultation and additional remote patient monitoring ensure payment parity between face-to-face and telemedicine care in medicare and third-party payors evaluate the impact of telemedicine on nursing home structure, process, and outcomes develop and assess the impact of paltc workforce competencies for both originating and distal site providers who use telemedicine tools on clinical outcomes refine and assess the use of telemedicine for forward triage on clinical outcomes evaluate how regulatory visits delivered by telemedicine vs face-to-face impact the quality of clinical care and provider or resident satisfaction technology collaborate with telemedicine service providers to develop cost-effective, low-bandwidth, accessible, and easy-to-use telemedicine technology work with cellular service and internet service providers to deliver high-speed, low-cost internet access, to support telemedicine and communication technologies in nursing homes collaborate with electronic medical record vendors to improve access to and documentation within various information systems during telemedicine visits increase the number of easy-to-use, low-cost health insurance portability and accountability act (hipaa) securityecompliant telemedicine tools available to post-acute and long-term care providers. cpt, current procedural terminology; e&m, evaluation and management. editorial / jamda 21 (2020) 1007e1009 geriatrics group that cares for residents of several nursing homes went from being a rare occurrence to the group completing approximately 250 telemedicine visits a week, representing about a third of the practice's nursing home encounters. the veterans health administration, a longstanding leader in adoption of telemedicine in health care, moved to create telemedicine access for nursing home residents in all of their community living centers. as we ride the momentum of change, it is important for us to continue to expand our understanding of how telemedicine tools are best used in care. the interconnected relationship between patient population, the reason for the medical visit, and the modality of telemedicine used needs to be further refined for us to deliver the highest-value care. many have hypothesized that telemedicine should not replace the face-to-face regulatory care visits and medically necessary visits that form the foundation of primary care in the nursing home. our experiences in covid-19 may change our perspective on that question. can we embrace the disruption of the pandemic and use it to drive other programmatic innovations in post-acute long-term care? as we move beyond the initial covid-19 storm to a new, improved way of providing care in nursing homes, strategic action is needed to more permanently resolve the issues that may limit our progress ( table 2 ). the integrated health network of eastern ontario has demonstrated the feasibility of using e-consultation for specialty care such as dermatology and infectious disease and identified perceived value with respect to timeliness, quality of care, and cost. 10 similarly, investigators in the amda telemedicine workgroup conducted a study of the perceived value of subspecialty telemedicine that showed that dermatology, geriatric psychiatry, and infectious disease were the specialties that paltc practitioners would consult the most if available. 11 similarly, many have called for reimbursement models to further expand reimbursement for telemonitoring and other telephonic-based care modalities. now is the time to quantify the cost, quality, and value of these types of clinical services. when we look back, years from now, what will paltc practitioners have learned about effective care delivery using telemedicine technology? hopefully, we will see 2020 as the turning point in our understanding of how to build effective, financially stable medical care models, that leverage telemedicine technology effectively to deliver the right care, at the right time, in the right place, to the right patient. perceived benefits, barriers, and drivers of telemedicine from the perspective of skilled nursing facility administrative staff stakeholders nursing home provider perceptions of telemedicine for reducing potentially avoidable hospitalizations standards for the use of telemedicine for evaluation and management of resident change of condition in the nursing home the nuts and bolts of utilizing telemedicine in nursing homesdthe gericare@north experience virtually perfect? telemedicine for covid-19 physicians and other clinicians: cms flexibilities to fight covid-19 long-term care nursing homes telehealth and telemedicine tool kit united states health and human services department. 21st century cures act: interoperability, information blocking and the onc health it certification program federal communications commission. covid-19 telehealth program the feasibility of using econsult in long-term care homes nursing home provider perceptions of telemedicine for providing specialty consults key: cord-260110-8tud5fao authors: mcarthur, caitlin; saari, margaret; heckman, george a.; wellens, nathalie; weir, julie; hebert, paul; turcotte, luke; jiblou, jalila; hirdes, john p. title: evaluating the effect of covid-19 pandemic lockdown on long-term care residents’ mental health: a data driven approach in new brunswick date: 2020-10-26 journal: j am med dir assoc doi: 10.1016/j.jamda.2020.10.028 sha: doc_id: 260110 cord_uid: 8tud5fao long-term care (ltc) residents, isolated because of the covid-19 pandemic, are at increased risk for negative mental health outcomes. the purpose of our article is to demonstrate how the ltcf can inform clinical care and evaluate the effect of strategies to mitigate worsening mental health outcomes during the covid-19 pandemic. we present a supporting analysis of the effects of lockdown in homes without covid-19 outbreaks on depression, delirium, and behaviour problems in a network of seven ltc homes in new brunswick, canada where mitigative strategies were deployed to minimize poor mental health outcomes (e.g., virtual visits, increased student volunteers). this network meets regularly to review performance on risk-adjusted quality of care indicators from the interrai ltcf and share learning through a community of practice model. we included 4209 assessments from 765 ltc residents between january 2017 to june 2020 and modelled the change within and between residents for depression, delirium, and behavioural problems over time with longitudinal generalized estimating equations. though the number of residents who had in-person visits with family decreased from 73.2% before to 17.9% during lockdown (chi square, p<0.0001), the number of residents experiencing delirium (4.5% to 3.5%, p=0.51) and behavioural problems (35.5% to 30.2%, p=0.19) did not change. the proportion of residents with indications of depression decreased from 19.9% before to 11.5% during lockdown (p<0.002). the final multivariate models indicate that the effect of lockdown was not statistically significant on depression, delirium, or behavioural problems. our analyses demonstrate poor mental health outcomes associated with lockdown can be mitigated with thoughtful intervention and ongoing evaluation with clinical information systems. policy makers can use outputs to guide resource deployment and researchers can examine the data to identify better management strategies for when pandemic strikes again. j o u r n a l p r e -p r o o f demonstrate poor mental health outcomes associated with lockdown can be mitigated with 24 thoughtful intervention and ongoing evaluation with clinical information systems. policy makers 25 can use outputs to guide resource deployment and researchers can examine the data to identify 26 better management strategies for when pandemic strikes again. to be a pandemic. as we put pen to paper, the who is reporting over 30 million cases and over conditions including depression, delirium, and behavioural problems. depression is one of the 39 most common psychiatric condition in ltc, 5 with rates ranging from 11% 6 to 16.9%. 7 delirium, 40 an acute change in attention and cognition that develops rapidly over several hours or days, 8 has 41 been estimated to affect 14% of ltc residents. 9 b across canada, an estimated 26 to 66% of 42 ltc residents exhibit behavioural problems, 10 which can be disruptive, distressing or 43 challenging to persons in the ltc environment including other residents, staff, and family. 11 reduced social interaction associated with lockdown during the covid-19 pandemic could 45 further increase the risk for worsening mental health outcomes. stress among ltc staff could 46 lead to stress among residents, increasing the risk for delirium and behavioural problems. 47 isolation, lack of family contact, and lack of stimulation from social activities within the home 48 could lead to boredom, loneliness, and depression. indeed, in the general population quarantine 49 measures during covid-19 have consistently been associated with negative psychological 50 j o u r n a l p r e -p r o o f outcomes. 12 reports from ltc homes in italy suggest as many of 50% of ltc residents 51 experienced hypokinetic delirium superimposed on dementia (e.g., residents refused food and 52 had difficulty getting out of bed). 13 calls have arisen to overcome limited physical interaction 53 and improve social interaction via virtual strategies (e.g., facetime, zoom) and through creative 54 outlets to overcome workload barriers (e.g., student visitors). 14 however, the implementation of 55 such programs may be limited by access to resources (e.g., tablets or smartphones), and their 56 effect on mental health outcomes is unclear. the purpose of our article is to demonstrate how thoughtful use of mitigating strategies (e.g., 74 window visits, use of technology) and clinical information systems like the interrai ltcf can 75 inform clinical care and prevent worsening mental health outcomes (depression, delirium, and 76 behavioural problems) during the covid-19 pandemic. our discussion will focus on 77 internationally adopted interrai instruments (i.e., interrai ltcf). the interrai ltcf is a standardized assessment tool which is administered by trained registered 106 nurses within new brunswick ltc homes. information to complete the assessment is collected 107 through interaction with residents, their families, and the clinicians who work with them, and 108 chart review if required. in new brunswick, the interrai ltcf is administered within 11 days 109 of admission, and on a quarterly basis thereafter, or if there is a significant change in status. importantly, all new brunswick ltc homes continued to complete scheduled and change of 111 status ltcf assessments throughout the lockdown period. 112 table 1 provides a summary of the outcomes and covariates examined. we described social 113 engagement with family through two items in the ltcf, one capturing in-person visits the other 114 capturing other interaction (e.g., telephone or email) in the last 3 days, and using the revised 115 index of social engagement (rise) scale (table 1) . correlation matrix was deemed to be more suitable for these data because the correlation between 127 responses is expected to decrease over time. age, sex, and lockdown were included in all models 128 regardless of significance. we modelled the ltc home's effect by comparing to a reference 129 home, called 'facility x', which demonstrated differences in univariate analyses. interactions 130 that were hypothesized a priori to influence the outcomes were entered into the multivariate 131 models and quadratic terms were used to test for curvilinearity of the continuous covariates. the 132 final multivariate models were constructed by adding all variables to the model and retaining 133 those significant at p<0.05. we included 4209 assessments from 765 ltc residents. on average, residents had 4.7 (standard 136 deviation, 3.3) assessments between january 2017 and june 2020. table 2 after: 30.2%, p=0.19) and with delirium (before: 4.5%; after:3.5%, p=0.51) was not different. the final multivariate models (table 3) we document an example of how clinical information systems like the interrai ltcf can be 171 used in a community of practice to examine changes in resident outcomes over time and evaluate 172 strategies put in place to mitigate negative outcomes. in particular, the network of seven private, 173 not-for-profit ltc homes in our study who did not experience covid-19 outbreaks but were 174 locked down for three months were able to mitigate the negative effects of social isolation on 175 depression, delirium, and behavioural problems. using depression, delirium, and an aggressive 176 behaviour outcome embedded within the interrai ltcf quantified changes over time including 177 effects of covid-19 policies such as lockdown without requiring additional documentation or 178 data collection. in addition, homes can use these routinely collected data to monitor residents' 179 mood over time and evaluate the effect of home-level strategies (e.g., redeploying activity staff). likewise, policymakers can use these data at a jurisdiction-level to evaluate the effect of 181 strategies (e.g., providing ipads) and plan for additional resources as needed. our data suggest that with thoughtful deployment of strategies to improve ltc residents' social monitoring the individuals' needs and the staffing available will be a marathon of post-outbreak 218 follow up, as the crisis profoundly affects both. however, obtaining data and using it to guide decisions requires ongoing assessments. in our 220 example of the seven homes in new brunswick, assessments continued to be completed 221 throughout lockdown, so it could be used to guide practice and evaluate changes over time. granted, there were no covid-19 outbreaks in the seven homes, but home-level stress and in this study, we were most interested in the temporal effects of lockdown on mental health 244 outcomes, we did not examine fully explanatory models for our outcomes. we were able to 245 determine changes in our study group but did not have contemporaneous controls to ensure the 246 effects were real. in addition, outcomes other than mental health concerns were not fully global measure of cognitive status based on functional parameters rated by severity. scored 0 (intact) to 6 (very severe impairment). revised index of social engagement 33 measures positive features of ltc residents' social behaviour using 6 items. 0 (no engagement) to 6 (high engagement) ltc=long-term care covid-19) in long-term care 274 facilities in ontario, canada covid-19 directive #3 for long-term care homes under the longterm care homes 279 act loneliness and isolation in long-term care and the covid-19 pandemic depression in the elderly the management of depression in older nursing home residents the prevalence and recognition of 287 major depression among low-level aged care residents with and without cognitive impairment 102 diagnostic 290 and statistical manual of mental disorders: dsm-5 $199 (hbck) £45 $69 (pbck) longitudinal patterns of delirium 294 severity scores in long-term care settings beyond the "iron lungs of gerontology": using 297 evidence to shape the future of nursing homes in canada dementia/caring-for-someone/understanding-symptoms/responsive-behaviours quarantine measures during serious coronavirus outbreaks: a rapid review nursing homes or besieged castles: covid-19 in northern italy. the 307 lancet psychiatry competing crises: covid-19 countermeasures and social 309 isolation among older adults in long-term care chronic disease management: a primer for physicians reliability of the interrai suite of assessment 312 instruments: a 12-country study of an integrated health information system sharing clinical information across care settings: the birth of an 316 integrated assessment system measuring depression in nursing home residents with 318 the mds and gds: an observational psychometric study the seniors quality leap initiative (sqli): an 322 international collaborative to improve quality in long-term care the impact of covid-19 measures on well-330 being of older long-term care facility residents in the netherlands delirium in hospitalized older patients: recognition and risk factors risk factors for depression in long-term care: a systematic 335 review factors associated with aggressive behavior between residents 337 and staff in nursing homes nurse aide retention in nursing homes evaluation of a staff training 342 programme to reimplement a comprehensive health assessment interrai clinical assessment protocols (caps) for use with 345 community and long-term care assessment instruments. version 9 the aggressive behavior scale: a new scale to measure aggression based 348 on the minimum data set the mds-chess scale: a new measure to predict mortality in 351 institutionalized older people scaling adls within the mds mds cognitive performance scale a revised index for 360 social engagement for long-term care key: cord-290836-jldfrec9 authors: laosa, olga; pedraza, laura; álvarez-bustos, alejandro; carnicero, jose a.; rodriguez-artalejo, fernando; rodriguez-mañas, leocadio title: rapid assessment at hospital admission of mortality risk from covid-19: the role of functional status date: 2020-10-08 journal: j am med dir assoc doi: 10.1016/j.jamda.2020.10.002 sha: doc_id: 290836 cord_uid: jldfrec9 objective to evaluate the role of functional status along with other used clinical factors on the occurrence of death in patients hospitalized with covid-19. design prospective cohort study setting public university hospital (madrid) participants and methods 375 consecutive patients with covid-19 infection, admitted to a public university hospital (madrid) between march 1 and march 31, 2020, were included in the prospective cohort study. death was the main outcome. the main variable was disability in activities of daily living (adl) assessed with the barthel index. covariates included sex, age, severity index (quick sequential organ failure assessment, qsofa), polypharmacy (>5 drugs in the month before admission), and comorbidity (≥3 diseases). multivariable logistic regression was used to identify risk factors for adverse outcomes. estimated model coefficients served to calculate the expected probability of death for a selected combination of five variables: barthel, sex, age, comorbidities and severity index (qsofa). results mean age was 66 years (sd 15.33), 207 (55%) males. 74 patients died (19.8%). mortality was associated to low barthel index (or per 5-point decrease 1.11; 95ci 1.03-1.20), male sex (0.23, 0.11-0.47), age (1.07, 1.03-1.10) and comorbidity (2.15; 1.08-4.30) but not to qsofa (1.29, 0.87-1.93) or polypharmacy (1.54; 0.77-3.08). calculated mortality risk ranged from 0 to 0.78. conclusions and implications functional status predicts death in hospitalized covid-19 patients. combination of five variables allows to predict individual probability of death. these findings provide useful information for the decision-making process and management of patients. in december 2019, the first case of sars-cov-2 infection was reported in wuhan, 30 china 1 , resulting in an outbreak that was declared a pandemic on 11 march 2020 by 31 the world health organization (who) 2 . covid-19 pandemic has had a major impact in 32 the madrid region, where 27509 cases and 3603 deaths were registered on the same 33 date (31 march 2020, the last date of inclusion in our study) 3 . regarding age 34 distribution, 86% of deaths have occurred in patients over 70 years of age and 95% if 35 we extend to those over 60 years. mortality reaches over 60% for patients over 80 36 years 4 . taking this fact into account, it should be expected that relevant factors 37 associated to mortality in older people, like functional status [5] [6] [7] [8] , had been included in 38 predictive models of coronavirus mortality. however, this has not been the case, with 39 its potential impact on the decision-making process 9 . 40 deterioration of functional status, as a sign of an augmented vulnerability state and a 41 declining of biological reserves, is generally considered a strong predictor of poor 42 outcome mainly, but not exclusively, in older people 7, 10, 11 . often frailty and disability, 43 rather than illness, have significant prognostic value 5 . in fact, frailty predicts mortality 44 in older people independently from other clinical variables [12] [13] [14] [15] . 45 the role of functional status in determining poor outcomes in old patients with covid46 19 has not been yet firmly established. evidence is even smaller regarding the joint 47 therefore, the aim of this study was to evaluate, in patients hospitalized with covid50 19, the role of limitations in activities of daily living along with other habitual clinical 51 factors on death during hospitalization, building a predictive model. we analyzed the data of a cohort comprising all the covid-19 patients admitted to a 55 public university hospital (madrid, spain). we have included patients hospitalized 56 from march 1 to 31, 2020, a time period covering the peak of the pandemics in the 57 madrid region. all cases were selected consecutively according to the date of 58 admission to hospital, due to covid-19 infection confirmed by positive pcr. information on covid-19 and the current disease course was collected from hospital 61 electronic clinical records, while information on drug treatment and comorbidities 62 before admission were obtained from electronic primary health-care records. main outcome included mortality during hospitalization. we followed patients until 65 discharge, death or june 18, 2020, whichever was first. on june 18, 2020, 2 patients 66 were still in-hospital, and were excluded from the analyses. clinical records. this was not possible in 5 patients, who were excluded from the 73 analyses. barthel index score has been split into the following categories: 0-60 (severe 74 disability); 65-85 (moderate disability); 90-95 (mild disability) and 100 (no disability). we collected data about age, sex and comorbidities (hypertension, diabetes mellitus, 77 obesity, hyperlipidemia, ischemic heart disease, heart failure, atrial fibrillation, 78 thromboembolic disease including deep vein thrombosis and pulmonary embolism, 79 stroke, chronic obstructive pulmonary disease (copd), asthma, cancer, and chronic 80 kidney disease). to evaluate the number of diseases needed to characterize significant 81 comorbidity we assessed the number of diseases that were associated with increased 82 mortality (annex , table a1 ). 83 clinical severity was assessed with the qsofa (quick sequential [sepsis-related] organ 84 failure assessment) score which identifies high-risk patients for in-hospital mortality. it 85 includes three clinical criteria, assigning one point for low blood pressure (sbp≤100 86 mmhg), high respiratory rate (≥22 breaths/min), or altered consciousness (glasgow 87 coma scale<15). the score ranges 0-3 point 18 . 88 the number of drug treatments in the month preceding the current hospitalization 89 was also collected. patients were classified in two groups: with (≥ 5 drugs) or without 90 (< 5 drugs) polypharmacy. 104 we performed two sensitivity analysis. we repeated the analysis excluding patients 105 younger than 40 years, among whom deaths were not observed. the second one 106 regarded the calculated expected probability of death, including the severity (i.e., 107 qsofa) of the clinical status of the patient. 108 the level of significance was set at p<.05. the analyses were performed using the 109 statistical package r for windows (version 3.6.1). march 2020) 19 . the study included 375 patients with a mean age of 66 years (sd 15.33), 207 males 116 (55.2%) ( table 1 ). the median number of comorbidities was 2 (interquartile range iqr 117 j o u r n a l p r e -p r o o f [1] [2] [3] [4] . 74 patients died (19.7%), and 299 (79.7%) recovered and were discharged before 118 the end of the follow-up. differences between the two groups were statistically 119 significant for all the morbidities analyzed except for obesity, thromboembolic disease, 120 and asthma. 121 the median number of morbidities in those who died was 4 (iqr 2-5) while in those 122 who survived was 2 (iqr 0-3). differences in the barthel index between groups were 123 statistically significant (p <.001). 124 when we looked at qsofa, 21.67% of patients who died presented at least 2 criteria of 125 severity (median 1) versus 10.45% in the group of patients who recovered (median 0) 126 (p=0.043). 127 in logistic regression analysis, a 5-point lower in the barthel score was associated with 128 a 13% increased risk of death table a2 ). 137 we developed a model to predict the risk of death in males (annex , table a3 ) and (tables 3, 4 ), so we show this "expanded" 142 model. risk of mortality ranged 0% to 78%. the association between disability and risk 143 of death showed a dose-dependent relationship. while mild disability (barthel 90-95) 144 increases the risk moderately, it does in a very significant way when it was moderate 145 or severe, especially in older people. 146 the main results held in the sensitivity analysis excluding patients younger than 40 147 years (annex , table a5 ). in this study we show that, in addition to other variables usually considered, functional 150 status is an independent risk factor for death. barthel index remained associated to 151 the risk of death in all the models developed in our study, with a mean increase of 10-152 15% in the risk of death by each decrease of 5-points. this finding expands those 153 recently reported in a multicenter study about the effect of frailty on mortality 13 . 154 the presence of comorbidity, defined as having ≥3 comorbidities, was associated to an 155 increased risk of mortality, like in many other publications [20] [21] [22] a novel coronavirus from patients with pneumonia in china who declares covid-19 a pandemic a cohort of patients with covid-19 in a major teaching hospital in europe frailty as a major factor in the increased risk of death and disability in older people with diabetes age, frailty, disability, institutionalization, multimorbidity or comorbidity. which are the main targets in older adults? a new functional classification based on frailty and disability stratifies the risk for mortality among older adults: the fradea study impact of physical function impairment and multimorbidity on mortality among community-living older persons with sarcopaenia: results from the ilsirente prospective cohort study outcome of older persons admitted to intensive care unit, mortality, prognosis factors, dependency scores and ability trajectory within 1 year: a prospective cohort study relationship between functional loss before hospital admission and mortality in elderly persons with medical illness validation of the risk analysis index for evaluating frailty in ambulatory patients the contribution of frailty, cognition, activity of daily life and comorbidities on outcome in acutely admitted patients over 80 years in european icus: the vip2 study the effect of frailty on survival in patients with covid-19 (cope): a multicentre, european, observational cohort study frailty index predicts poor outcome in covid-19 patients covid-19: use of the clinical frailty scale for critical care decisions whose life to save? scarce resources allocation in the covid-19 outbreak functional evaluation: the barthel index the third international consensus definitions for sepsis and septic shock (sepsis-3) use of renin-angiotensin-aldosterone system inhibitors and risk of covid-19 requiring admission to hospital: a case-population study 30-day mortality in patients hospitalized with covid-19 during the first wave of the italian epidemic: a prospective cohort study factors associated with hospital admission and critical illness among 5279 people with coronavirus disease predictors of mortality for patients with covid-19 pneumonia caused by sars-cov-2: a prospective cohort study risk factors for death from covid-19 risk factors for mortality in patients with coronavirus disease 2019 (covid-19) infection: a systematic review and meta-analysis of observational studies diabetes and covid-19: a global health challenge association of hypertension with the severity and fatality of sars-cov-2 infection: a meta-analysis clinical characteristics, outcomes, and risk factors for mortality in patients with cancer and covid-19 in hubei, china: a multicentre, retrospective, cohort study kidney disease is associated with inhospital death of patients with covid-19 features of 20 133 uk patients in hospital with covid-19 using the isaric who clinical characterisation protocol: prospective observational cohort study epidemiology, clinical course, and outcomes of critically ill adults with covid-19 in new york city: a prospective cohort study key: cord-277278-lg38l5gh authors: tang, olive; bigelow, benjamin f.; sheikh, fatima; peters, matthew; zenilman, jonathan m.; bennett, richard; katz, morgan j. title: outcomes of nursing home covid-19 patients by initial symptoms and comorbidity: results of universal testing of 1,970 residents date: 2020-10-14 journal: j am med dir assoc doi: 10.1016/j.jamda.2020.10.011 sha: doc_id: 277278 cord_uid: lg38l5gh objective clinical implications of asymptomatic cases of the novel coronavirus disease 2019 (covid-19) in nursing homes remain poorly understood. we assessed the association of symptom status and medical comorbidities on mortality and hospitalization risk associated with covid-19 in residents of a large nursing home system. design retrospective cohort study. setting and participants 1,970 residents from 15 nursing home facilities with universal covid-19 testing in maryland. methods we used descriptive statistics to compare baseline characteristics, logistic regression to assess the association of comorbidities with covid-19, and cox regression to assess the association of asymptomatic and symptomatic covid-19 with mortality and hospitalization. we assessed the association of comorbidities with mortality and hospitalization risk. symptom status was assessed at the time of the first test. maximum follow-up was 94 days. results among the 1,970 residents (mean age 73.8, 57% female, 68% black), 752 (38.2%) were positive on their first test. residents who were positive for covid-19 and had multiple symptoms at the time of testing had the highest risk of mortality (hr 4.44; 95% ci: 2.97, 6.65) and hospitalization (shr 2.38; 95% ci: 1.70, 3.33), even after accounting for comorbidity burden. cases who were asymptomatic at testing had a higher risk of mortality (hr 2.92; 95% ci: 1.95, 4.35), but not hospitalization (hr 1.06; 95% ci: 0.82, 1.38) compared to those who were negative for covid-19. of 52 sars-cov-2 positive residents who were asymptomatic at the time of testing and were closely monitored for 14 days at one facility, only 6 (11.6%) developed symptoms. conclusions and implications asymptomatic infection with sars-cov-2 in the nursing home setting was associated with increased risk of death suggesting a need for closer monitoring of these residents, particularly those with underlying cardiovascular and respiratory comorbidities. setting was associated with increased risk of death suggesting a need for closer monitoring of 24 these residents, particularly those with underlying cardiovascular and respiratory comorbidities. based on case reports of covid-19 submitted to the cdc surveillance network, adults with 56 comorbidities such as diabetes, lung disease, or heart disease had a higher prevalence of covid-57 19 and may develop more severe illness 9-12 . however, comorbidity data was missing for over 58 half of the reported cases. another study looking at hospitalized patients with covid-19 59 showed a relationship between increasing age and number of comorbidities with in-hospital 60 mortality 13 . in particular, a history of chronic kidney disease, lung disease, or cardiovascular 61 disease was associated with higher mortality 13 . literature examining the effect of comorbidities 62 on outcomes has predominantly focused on hospitalized cohorts, or those in middle-age without 63 testing of all individuals regardless of symptoms 5, 14, 15 . 64 on april 29, 2020, the maryland governor mandated that all residents of nursing homes in the 66 state of maryland must undergo testing for sars-cov-2. we assessed outcomes associated 67 with sars-cov-2 infection among residents who were tested for sars-cov-2 rna across one 68 nursing home system with both long-term and post-acute rehabilitation services. signs and 69 symptoms of illness were obtained at the time of testing, and risk of infection, hospitalization, 70 and death was analyzed based on symptoms and underlying comorbidities. 71 study population. all residents (n=1,970) from a large system of skilled nursing facilities who 75 were universally tested for sars-cov-2 and had recorded test results between march 1, 2020 76 and june 12, 2020, were included in our study. data was obtained from respiratory surveillance 77 line list and manual chart review of the skilled nursing facility electronic health record. a 78 cohort of all residents at one facility who were asymptomatic at the time of testing were closely 79 monitored by nursing home staff for development of symptoms over a 14 day period; this was 80 documented in a dedicated line list and included as a sub-analysis. this study protocol was 81 approved by the institutional review board with a waiver of written consent. 82 83 exposure. nasopharyngeal samples were collected at the nursing homes for reverse transcription 84 polymerase chain reaction testing for sars-cov-2 rna. when nasopharyngeal swabs were not 85 available or if the resident would only consent to oropharyngeal swabs, an oropharyngeal sample 86 was collected instead. all residents who consented to testing were tested. residents who did not 87 consent to testing were considered positive and isolated accordingly. symptom status at the time 88 of testing was determined based on review of respiratory surveillance line list documentation 89 maintained by nursing facility in the health system. the respiratory surveillance line list is used 90 to monitor staff and resident symptoms during a respiratory disease outbreak or cluster. 68% black) who were tested at least once for sars-cov-2 rna; of these 752 (38.2%) initially 131 tested positive between march 1, 2020 and june 12, 2020. of the 1,218 residents who initially 132 tested negative, 558 (45.8%) had at least 1 additional test, and 169 (13.9%) eventually tested 133 positive at some point before the end of follow-up. residents who were positive for sars-cov-134 2 on their first test were significantly more likely to be hospitalized and die during follow-up 135 than residents who tested negative (table 1, p<0.001). 136 not at a higher risk of testing positive for sars-cov-2 (or 1.07, 95% ci: 0.80, 1.42). 143 peripheral vascular disease, diabetes, chronic kidney disease, and depression remained 144 significantly associated with increased risk for infection after accounting for age, sex, and 145 facility ( table 2) . 146 after accounting for age, sex, race, and facility (model 1) among those who tested 147 positive for sars-cov-2, coronary artery disease, heart failure, peripheral vascular disease, 148 anemia, diabetes, end-stage kidney disease, and depression were at increased risk of 149 hospitalization ( table 2) . only a history of copd/emphysema was significantly associated with 150 higher mortality from covid-19 after accounting for age, sex, and facility ( table 2) . 151 152 of the 752 residents who tested positive, 56.4% (n=424) had no documented signs or 154 symptoms at the time of testing. of the cases with documented signs or symptoms (n=328), the 155 most common were fever 49.1 % (n=161) and cough 59.5% (n=195 , table 1 ), and 56.4% of 156 residents (n=185) had only 1 documented sign or symptom. among residents with covid-19, 157 those with anemia, cancer, or end-stage renal disease were more likely to have signs and 158 symptoms of illness at the time of testing and those with dementia and peripheral vascular 159 disease were more likely to be asymptomatic ( table 1) . 160 over a maximum of 94 days of follow-up, there were 475 incident hospitalizations 161 observed among the 1,845 residents who consented to hospital transfer from the nursing home 162 system. the 30-day cumulative hospitalization rate was 45% among cases with multiple 163 symptoms at testing, 35% among cases with 1 symptom at testing, 22% among cases 164 asymptomatic at testing, and 21% among those who were negative. after accounting for all 165 confounders, cases who were symptomatic at testing remained at significantly higher risk of 166 hospitalization than those who were asymptomatic or negative (figure 1a) . 167 there were 242 total deaths among the 1,970 residents over the 94 day follow up period; 168 155 (64%) were in those who tested positive for sars-cov-2. mortality rates were highest 169 among residents who tested positive for sars-cov-2 and had covid-19 signs or symptoms 170 (figure 1b) . the 30-day cumulative mortality was 39% among cases with 2 or more signs or 171 symptoms at testing, 27% among cases with 1 sign or symptom at testing, 14% among cases who 172 were asymptomatic at testing, and 7% among those who were negative for sars-cov-2. after 173 accounting for demographics, comorbidities, and resuscitation preference (model 2), cases who 174 were symptomatic at testing remained at highest risk of mortality, and cases asymptomatic at 175 testing were at intermediate risk (hr 2.92; 95% ci: 1.95, 4.35) compared to those who were 176 negative (table 3) . those with multiple signs or symptoms also had a higher risk of mortality 177 compared to those with a single sign or symptom (model 1 hr 1.52, 95% ci: 1.01, 2.99; model 178 2 hr 1.52, 95% ci: 0.99, 2.35). 179 one facility had 52 cases who were asymptomatic at the time of testing and were closely 180 monitored for 14 days for development of signs or symptoms. of these, only 6 (11.5%) 181 developed any documented symptoms over the 14 day follow up from point prevalence testing. 182 of the 6 residents that became symptomatic, one developed a non-productive cough at day 9 post 183 diagnosis and remained stable in the facility. three residents were hospitalized: one developed 184 malaise and shortness of breath at day 12 and was transferred to the hospital, then returned 5 185 days later; one developed an elevated temperature (99 o f) on day 10-he was transferred to the 186 hospital on day 12 when his oxygen saturation reached 91% and expired the next day. one 187 resident developed chills, shortness of breath, and diminished lung sounds on day 12 and expired during transfer to the hospital. the remaining two residents passed away abruptly in the facility-189 both were noted to rapidly develop restlessness and shortness of breath and expired shortly 190 thereafter (one on day 6 post diagnosis and one on day 11). state reporting data have all demonstrated that mortality from covid-19 is higher in 206 underrepresented minority groups. our findings suggest that this mortality differential among 207 blacks is predominantly due to increased prevalence, and possibly severity of underlying 208 diseases, rather than a covid-19-specific cause. 209 the clinical implications of covid-19 detection among asymptomatic people remains 210 poorly understood 17 . the published prevalence of asymptomatic cases varies greatly from 211 population to population, ranging from 1.6% in china 18 to 88% in a boston homeless shelter 19 . 212 in our study population of residents of long-term care facilities undergoing point prevalence 213 testing, over half of the cases detected were asymptomatic at testing, which is consistent with 214 other early reports in this setting 10,20,21 . 215 despite a lack of documented symptoms at the time of testing, our data shows that 216 residents who are asymptomatic at testing have up to two times the mortality risk of residents 217 who test negative for sars-cov-2. however, there was no difference in risk of hospitalization 218 between residents who tested negative and asymptomatic residents who tested positive. this may 219 suggest that staff are unable to accurately elicit symptoms, or that infected individuals are 220 decompensating so rapidly that nursing home staff are not able to identify a clinical decline and 221 transfer them to a higher level of care prior to death. indeed, residents with dementia or 222 cerebrovascular disease or history of stroke were more likely to be deemed asymptomatic than 223 others, suggesting that assessing symptom status in this population is particularly challenging infections with sars-cov-2 detected on asymptomatic screening in the nursing home 273 setting are not benign, underscoring the importance of universal testing, especially in high-risk 274 subgroups. reliance on signs and symptoms for sars-cov-2 risk assessment alone may not be 275 sufficient, as residents living with dementia may be at a higher risk of infection but less likely to 276 report or exhibit signs and symptoms, and the natural history of this disease remains to be fully 277 established, particularly in the setting of hypoxia without dyspnea. in addition to the obvious 278 benefits of case identification to assist with infection control practices, our data suggest that 279 asymptomatic residents are at higher risk of death than residents who tested negative and may 280 benefit from close monitoring, such as regular pulse oximetry, as well as any future treatments. hospitalization and 334 mortality among black patients and white patients with covid-19 prevalence of asymptomatic sars-cov-2 infection the novel coronavirus pneumonia emergency response epidemiology team. the 339 epidemiological characteristics of an outbreak of 2019 novel coronavirus diseases 340 (covid-19) -china prevalence of sars-cov-2 infection in residents of a large homeless asymptomatic sars-cov-2 infection and 346 covid-19 mortality during an outbreak investigation in a skilled nursing facility. clin 347 infect dis couzin-frankel j. the mystery of the pandemic's 'happy hypoxia.' science (80-) why covid-19 silent hypoxemia is baffling to 358 opinion | the infection that's silently killing coronavirus patients -the new 361 detection of sars-cov-2 in different types of clinical 363 kidney disease chronic kidney disease key: cord-331520-o9e4qqn4 authors: kistler, christine e.; jump, robin l.p.; sloane, philip d.; zimmerman, sheryl title: the winter respiratory viral season during the covid-19 pandemic date: 2020-10-26 journal: j am med dir assoc doi: 10.1016/j.jamda.2020.10.030 sha: doc_id: 331520 cord_uid: o9e4qqn4 the winter respiratory virus season always poses challenges for long-term care settings; this winter, sars-cov-2 will compound the usual viral infection challenges. this special article discusses unique considerations that covid-19 brings to the health and well-being of residents and staff in nursing homes and other long-term care settings this winter. specific topics include preventing the spread of respiratory viruses, promoting immunization, and the diagnosis and treatment of suspected respiratory infection. policy-relevant issues are discussed, including whether to mandate influenza immunization for staff, the availability and use of personal protective equipment, supporting staff if they become ill, and the distribution of a covid-19 vaccine when it becomes available. research is applicable in all of these areas, including regarding the use of emerging electronic decision support tools. if there is a positive side to this year’s winter respiratory virus season, it is that staff, residents, family members, and clinicians will be especially vigilant about potential infection. spread farther and linger longer as the temperature falls, cooler weather brings a seasonal rise of several communicable respiratory infections; in addition, heated indoor spaces encourage closer physical contact and dry mucosal surfaces, leaving individuals more susceptible to 20 increased air particles. 1 until this year, influenza has been the most feared seasonal virus, as it 21 causes 12,000 to 56,000 deaths in the u.s. each year. 2 this winter will be different, of course, due to the pandemic caused by the sars-cov-2 virus, which has already claimed the lives of 23 over 1 million people worldwide. in the u.s., more than 75% of those deaths are in people 65 24 years of age and older. 3 before the covid-19 pandemic, influenza was the most concerning viral respiratory infection 27 for nursing home (nh) residents, with outbreaks requiring both treatment and prophylaxis, and 28 even causing some buildings to close to outsiders for brief periods of time. 4 however, influenza 29 is not the only respiratory virus that abounds in the community and frequents nhs in winter. others, such as parainfluenza, rhinovirus, adenovirus, metapneumovirus, other coronaviruses, 31 and especially respiratory syncytial virus (rsv), may also cause outbreaks. 5 other than 32 influenza, there are not yet vaccines or effective antiviral therapies for these infections. making 33 matters worse, in addition to these viral infections as a cause of pneumonia, they contribute to 34 exacerbations of chronic obstructive pulmonary disease, and, in the case of influenza, may 35 predispose individuals to secondary bacterial infections and cardiac morbidity. 6 ,7 36 37 the winter respiratory virus season always poses challenges for nhs and assisted living 38 communities. overlaying the usual viral infection challenges this winter will be sars-cov-2. in 39 this special article, we discuss unique challenges that covid-19 will bring to the health and 40 well-being of residents and staff in long-term care settings this winter. specific topics include 41 preventing the spread of respiratory viruses, promoting immunization, and the diagnosis and 42 treatment of suspected respiratory infection. we also address several issues related to staff, 43 including whether or not to mandate influenza immunization, availability and use of personal 44 protective equipment (ppe), absenteeism, presenteeism (coming to work despite illness), work 45 release for illness, and paid leave. in addition, we discuss strategies to help mitigate these 46 challenges, some important differences between nhs and assisted living relevant to infection and covid-19, and conclude with a brief consideration of a future sars-cov-2 vaccine. preventing the spread of respiratory viruses 50 51 fortunately, we know more about covid-19 than we did last spring when it first appeared. we 52 know that it spreads primarily via droplets, and less commonly through fomite transmission and 53 aerosolization. 8 however, the influence of heating systems that recirculate air on increasing the 54 aerosol spread of sars-cov-2 is not yet clear. we know that masks and other ppe prevent the 55 spread of sars-cov-2, 9 and because inadequate ppe has demonstrably increased the death 56 toll in nhs, it will be critical to have access to ample supplies this winter. 10 it also will be 57 necessary to have protocols for universal screening; to require that all persons wear face 58 coverings and practice physical distancing; to test staff and residents for purposes of screening 59 and when an outbreak is identified; and to isolate persons with a viral exposure or positive test. if other respiratory viruses circulate widely as is typical in winter, nhs and assisted living 62 communities will need to have a workable plan for addressing new symptoms among residents, in addition to influenza and pneumococcal vaccines for residents, the advisory committee on 101 immunization practices recommends that all nh employees receive an annual influenza 102 vaccination, including those who do not have direct patient care responsibilities. 16 however, whereas hospitals have mandatory vaccination policies, most nhs do not. 17 consequently, only 104 two-thirds of nh staff were vaccinated in 2017-2018. mandatory vaccination policies increase 105 influenza vaccination rates to nearly 100%, 18 and amda's infection advisory committee 106 recommends that all nhs adopt a similar mandatory vaccination policy. 16 the success of these 107 policies relies on staff education, incentives, and making the vaccine readily accessible. in 108 relation to education, the centers for disease control and prevention (cdc) provide numerous 109 resources, as do state and local health departments. in terms of incentives, nh leadership 110 might consider paid leave or other benefits to workers who receive a vaccination. regarding 111 accessibility, nh leadership may need to work with their local health department and health care 112 system to provide free access to the vaccine, preferably on site and across all shifts, to promote begins with recognizing symptoms of an acute infection, followed by recognition of respiratory tract involvement. then, clinicians are alerted to a change in condition; they conduct a diagnostic evaluation, initiate supportive care, and consider whether bacterial pathogens are pneumonia. 21 further complicating matters, a study of adults with community-acquired 127 pneumonia suggested that viruses may be responsible for 23% of cases, with bacteria identified 128 in only 11% of cases; no pathogen was identified in the majority of cases. 22 among nh 129 residents, pneumonia carries with it a case fatality rate of at least 25%, 23 the specific test used to diagnose covid-19 infections may vary depending on the types of 163 tests available, the time required to obtain the results, and the sensitivity and specificity of the 164 results. 30 in general, polymerase chain reaction (pcr) based tests, which detect viral 165 ribonucleic acid from a nasopharyngeal swab, are the most sensitive and specific. test results the results. antigen-based tests are largely point-of-care tests with samples collected from the purposes, a negative antigen test should be confirmed with a negative pcr test. as nhs continue to grapple with the covid-19 pandemic, these diagnostic tests are also being tested for covid-19 at least weekly until there a two week period transpires without screening tests, whereas the frequency of staff screening depends on whether there are cases in addition to diagnostic testing for respiratory viral pathogens, several cutting-edge health 192 information technology and testing strategies may improve the diagnosis and management of 193 winter respiratory illnesses in nh residents. • for pneumonia, evidence strongly suggests that electronic decision support may improve 195 clinician decision making. 33 integrating clinical decision support in the electronic health 196 record improves evidence-based infection-related decisions. 34 the reduce trial 197 demonstrated that incorporating a pneumonia evaluation decision tool into the electronic 198 health record reduced antibiotic use for adults in outpatient care. 35 our research also found that nh residents receive an average of one prescription every three 229 months. 43 at any one time, over 10% of nh residents are taking antibiotics, and up to 75% of 230 these antibiotics are inappropriately prescribed. [44] [45] [46] because constitutional symptoms often 231 promote inappropriate antibiotic prescribing, they present an opportunity for quality of care 232 assessment. 47 consistent with cms' focus on antibiotic stewardship over the last years, 48 available; and continually monitoring the ppe supply. 60 earlier in the pandemic, approximately 20% of nhs reported having less than a one week supply of masks and gowns, and over 15% 266 reported staffing shortages; 61 recent data suggest that nhs have not closed the ppe gap. 62 shortages, as reports indicate that staff shortages persist as well. 51 plans must include preparing for potential loss of staff due to illness or exposure to covid-19. based on cdc employees or more, and provided broad exemptions to employers of emergency responders and health care workers. although the house has passed revisions of the act to remove these being mindful of challenges and implementing mitigation efforts for both residents and staff may 286 lessen the toll the winter respiratory viral season will take on long-term care residents. indeed, 287 many experts are predicting that social distancing for covid-19 will result in a mild influenza 288 season. it is unknown whether a sars-cov-2 vaccine will become available this winter. if so, important 291 questions include adverse effects of the vaccine and whether it will have immunogenicity for 292 chronically ill older adults. current evidence suggests that mrna vaccines appear safe and 293 immunogenic in older populations, 64 but whether such is the case remains a significant concern. 294 the question about cost was recently answered, as the u.s. government announced plans to 295 provide and administer covid-19 vaccines to long-term care residents across the country with 296 no out-of-pocket costs. 65 although specific plans for distribution of vaccines is unknown, nh and 297 assisted living residents should receive priority. immunizing staff will further protect this 298 vulnerable population but must affordable and accessible. due to public concerns about vaccine 299 safety and anti-vaccination resistance, public health efforts to promote the widespread uptake of 300 an effective vaccine should start in each nh and long-term care community as soon as a 301 vaccine appears imminent, to prepare staff and residents for the coming vaccination drives in 302 the spring and summer. 66 implications for practice, policy, and research the winter respiratory virus season always poses challenges for long-term care settings, and 307 those challenges will be exacerbated with the second wave of covid-19; as such, they present 308 numerous implications for practice, policy, and research. as summarized in this paper, practice 309 must focus on preventing the spread of respiratory viruses, promoting immunization, and the seasonality of respiratory viral infections centers for disease control and prevention. flu & people 65 years and older influenza in long-term care facilities. influenza other respir viruses respiratory syncytial virus and other noninfluenza respiratory viruses in older adults secondary bacterial infections associated with influenza pandemics seasonal influenza infections and cardiovascular disease mortality covid-19: transmission, prevention, and potential therapeutic opportunities physical distancing, face masks, and eye protection to prevent person-to-person transmission of sars-cov-2 and covid-19: a systematic review and meta-analysis abandoned" nursing homes continue to face critical supply and staff shortages as covid-19 toll has mounted medicare state operations manual, appendix pp: interpretive guidelines for long-term care facilities nursing home resident and facility characteristics associated with pneumococcal vaccination: national nursing home survey, 1995-1999 centers for disease control and prevention. different types of flu vaccines use of 13-valent pneumococcal conjugate vaccine and 23-valent pneumococcal polysaccharide vaccine among adults aged ≥65 years: updated recommendations of the advisory committee on immunization practices pneumococcal vaccination guidance for post-acute and long-term care settings: recommendations from amda's infection advisory committee recommendations for mandatory influenza vaccinations for health care personnel from amda's infection advisory subcommittee influenza vaccination coverage among health care personnel -united states, 2017-18 influenza season changes in influenza vaccination requirements for health care personnel in us hospitals barriers to timely care of acute infections in nursing homes: a preliminary qualitative study nursing home-associated pneumonia, part i: diagnosis defining characteristics and risk indicators for diagnosing nursing home-acquired pneumonia and aspiration pneumonia in nursing home residents, using the electronically-modified delphi method community-acquired pneumonia requiring hospitalization among u.s. adults predictors of mortality for nursing home-acquired pneumonia: a systematic review viral respiratory infections in a nursing home: a sixmonth prospective study unprecedented solutions for extraordinary times: helping long-term care settings deal with the covid-19 pandemic role of body temperature in diagnosing bacterial infection in nursing home residents temperature in nursing home residents systematically tested for sars-cov-2 clinical practice guideline for the evaluation of fever and infection in older adult residents of long-term care facilities: 2008 update by the infectious diseases society of america does universal testing for covid-19 work for everyone? centers for disease control and prevention. managing investigations during an outbreak cms-3401-ifc, updating requirements for reporting of sars-cov-2 test results by (clia) additional policy and regulatory revisions in response to the covid-19 public health emergency thinking fast and slow in pneumonia computerized clinical decision support systems and antibiotic prescribing: a systematic review and meta-analysis effectiveness and safety of electronically delivered prescribing feedback and decision support on antibiotic use for respiratory illness in primary care: reduce cluster randomised trial evaluation of viruses associated with acute respiratory infections in long-term care facilities using a novel method: wisconsin, 2016-2019 covidapp as an innovative strategy for the management and follow-up of covid-19 cases in long-term care facilities in catalonia: implementation study prognostic value of lung ultrasonography in older nursing home residents affected by covid-19 combining procalcitonin and rapid multiplex respiratory virus testing for antibiotic stewardship in older adult patients with severe acute respiratory infection efficacy of a test-retest strategy in residents and health care personnel of a nursing home facing a covid-19 outbreak bacterial and fungal co-infection in individuals with coronavirus: a rapid review to support covid-19 antimicrobial prescribing does adherence to the loeb minimum criteria reduce antibiotic prescribing rates in nursing homes? successfully reducing antibiotic prescribing in nursing homes antibiotic use in the nursing home. physician practice patterns development of minimum criteria for the initiation of antibiotics in residents of long-term-care facilities: results of a consensus conference the urine-culturing cascade: variation in nursing home urine culturing and association with antibiotic use and clostridiodes difficile infection constitutional symptoms trigger diagnostic testing before antibiotic prescribing in high-risk nursing home residents nursing home action plan: action plan for further improvement of nursing home quality infectious diseases in older adults of long-term care facilities: update on approach to diagnosis and management prioritizing prevention to combat multidrug resistance in nursing homes: a call to zction infection preventionist staffing in nursing homes long-term care providers and services users in the united states national survey of long-term care providers. long-term care providers and services users in the united states-state estimates supplement: national study of long-term care providers residential care/assisted living staff may detect undiagnosed dementia using the minimum data set cognition scale dementia prevalence and care in assisted living families filling the gap: comparing family involvement for assisted living and nursing home residents with dementia the role of physicians practicing in assisted living: time for change variability in state regulations pertaining to infection control and pandemic response in us assisted living communities the need to include assisted living in responding to the covid-19 pandemic department of labor issues alert to keep nursing home and long-term care facility workers safe during coronavirus pandemic shortages of staff in nursing homes during the covid-19 pandemic: what are the driving factors? severe staffing and personal protective equipment shortages faced by nursing homes during the covid-19 pandemic gaps in the emergency paid sick leave law for health care workers safety and immunogenicity of sars-cov-2 mrna-1273 vaccine in older adults trump administration partners with cvs and walgreens to provide covid-19 vaccine to protect vulnerable americans in long-term care facilities nationwide influences on attitudes regarding potential covid-19 vaccination in the united states. vaccines (basel) key: cord-355256-7ksbvisv authors: sloane, philip d. title: cruise ships, nursing homes and prisons as covid-19 epicenters: a ‘wicked problem” with breakthrough solutions? date: 2020-04-30 journal: j am med dir assoc doi: 10.1016/j.jamda.2020.04.020 sha: doc_id: 355256 cord_uid: 7ksbvisv nan i was not surprised that some of the earliest signs of covid-19 outside of china were outbreaks on cruise ships. several years ago, during a month on a 500-passenger cruise ship, i learned firsthand how rapidly viral infections can travel through those floating communities. i was the trip physician; the month was december; respiratory virus season had arrived early that year; and we unknowingly welcomed several unwanted guests when our passengers boarded in nassau. within two weeks over half the passengers were actively coughing and the clinic was inundated. on just one typical clinic day, i diagnosed three cases of influenza a; eight patients with viral bronchitis; one case of pneumonia, and three cases of gastroenteritis. and this was a "small" voyage; more common are passenger lists at least five times larger! news headlines soon shifted from cruise ships to nursing homes. the canary in the coal mine was a five-star-rated home in kirkland, washington, 1 whose staff had the misfortune of being blindsided because they had no forewarning that covid-19 was in the area when a cluster of febrile respiratory infections hit the facility, leading within two weeks to 23 deaths. 2 after that, the floodgates opened, such that as of mid-april over 7,000 deaths -a fifth of all u.s. covid-19 mortality -were linked to skilled nursing facilities. 3 in new york, 72 long-term care facilities had five or more deaths each; in new jersey, almost two-thirds of nursing homes had recorded covid-19 infections; 3 and in pennsylvania 55% of covid-19 deaths were reported to have been among residents of nursing homes or personal care homes. 4 next, we began to hear similar reports from prison complexes. cook county (illinois) jail, one of the country's largest, reported that over 500 inmates and staff tested positive for covid-19, with inmates constituting two-thirds of the cases and all three of the deaths. 5 closer to my own home, the neuse correctional institution in goldsboro nc, a state prison, reported that 259 inmates tested positive for the coronavirus, and that the vast majority were asymptomatic; 6 and practically in my backyard, the federal prison in butner, nc reported that 91 inmates had tested positive for the virus, at least five of whom died of the infection. 7 while at first glance cruise ships, prisons, and nursing homes are very different institutions, in fact they share many commonalities. each is a densely-population congregate setting with cramped housing units that do not lend themselves well to sheltering in place. each prepares meals in a central kitchen and serves them to large gatherings. each sponsors activities that bring large groups together on a regular basis. each has relatively large numbers of staff who have extensive contact with the residents and work under demanding conditions for modest pay. each has medical resources that compete with other, non-medical priorities. each has health care regulations that, while extensive, could not possibly have fully prepared them for covid-19; instead, in the face of an impending outbreak, rapid, nimble responses were needed, and these have proven hard to initiate and coordinate in all three settings. thus, each setting can be considered high risk for amplifying infectious diseases such as covid-19, because the conditions that prevent disease dissemination are nearly impossible to achieve. indeed, so daunting are the prospects for avoiding the spread of covid-19 in these settings that a case can be made for getting as many people out as soon and safely as possible. for the cruise ship industry, the short-term solution was to suspend all operations for 30 days, with a longer furlough likely. 8 the challenge, of course, will be whether and if so when and how operations can be safely resumed. reducing the prison population is a more challenging proposition and requires legal action. nonetheless, many states have acted to reduce bookings and/or to release persons who are older, have chronic disease, or have been jailed for nonviolent crimes. 9, 10 in california, noting that older inmates are at particularly high risk if they acquire the infection, a motion was filed to allow older inmates to be released even if they had been incarcerated for violent crimes. 11 no similar movement has taken place around discharging nursing home residents, despite significant family concerns and some recommendations that families look for alternatives. 12 instead, most experts, including the u.s. centers for disease control and prevention (cdc), do not recommend contemplating such moves, because acceptable living arrangements are not readily apparent. 13 a few families have taken independent action, particularly to bring post-acute patients home earlier than anticipated, but this has been infrequent. more common is the opposite situation -hospitals looking to discharge covid-19 patients to nursing homes for post-acute care, and in response some nursing home units and entire nursing homes devoting themselves to covid-19 care. these transitions, as well as outbreaks in the nursing homes themselves, place tremendous pressure on the nursing home industry to in short order develop the policies and procedures, provide the requisite staffing, and acquire the protective equipment and testing capacity that are necessary to safely manage covid-19 patients. during my "viral" december as a cruise ship doctor, i had several advantages in comparison to nursing home or prison health care. my population was relatively healthy, educated, and health-conscious; the average age was 52. i had numerous opportunities to provide public health messages about basic hygiene, which were understood and occasionally followed. the crew -largely minorities from the developing world who worked long hours -had minimal turnover and were meticulous in their work. furthermore, cruise ships that visit u.s. ports are required to follow cdc policy recommendations and have their infection control processes inspected twice annually and the results posted publicly. 14,15 on the ship i held clinic twice a day; access was on an as-needed basis; and the ship provided nurses to support the medical clinic and conduct a wide variety of prevention and surveillance activities. the clinic's on-site testing included an influenza kit, a cbc, and an x-ray machine; so, while resources were limited, our diagnoses were immediate, and positive flu cases could be isolated within minutes after presenting to the clinic. on the other hand, the unavailability of many tests and the lack of ready access to referral resources came into sharp focus when, 48 hours away from the next port, a passenger in his 80's presented with incipient sepsis, having spent the previous 72 hours alone in his cabin awaiting spontaneous resolution of what proved to be bacterial pneumonia. furthermore, even on that short trip i had to deal with outbreaks of acute gastroenteritis and, aware that norovirus can spread like wildfire on cruise ships, struggled to decide whether or not to isolate patients. still, these issues were minor compared with what i would have experienced had we encountered a more deadly outbreak such as covid-19. in contrast, nursing home care is far more challenging. the average patient is in their low 80's, has multiple chronic illness and disabilities, needs hand-on care with activities of daily living, and has some degree of cognitive impairment. post-hospitalization admissions come daily, often bringing with them such subacute problems as delirium, gastrointestinal upset, pressure ulcers, and atelectasis. shortages and rapid turnover of nursing and personal care staff create care challenges almost daily. medical care providers are off-site most of the time and have competing responsibilities; 16 in consequence, decisions are often made over the telephone, with nursing staff assuming far more responsibility than they do in other health care settings. laboratory specimens are collected on site but transported to outside laboratories for processing, resulting in diagnostic delays. covid-19 magnifies the challenges of providing medical care in the nursing home. it brings into sharp focus the fact that infection control leadership tends to be assigned to a parttime nurse whose position turns over more than 50% per year, 17 meaning that institutional knowledge and the ability to provide leadership in the face of an infection outbreak is often compromised. and, while many staff show tremendous loyalty and perseverance in the face of a coronavirus outbreak, a covid-19 outbreak leads to increased staff absenteeism due to the need for isolation among persons who become ill or from fear of contracting the disease, thereby worsening an already difficult staffing situation. 18 shortages of personal protective equipment occur rapidly, without a clear avenue to obtain more, and access to testing is limited, with results often not returning for four or more days. prison medicine is in many ways similar, with the exception that the average patient is younger, has fewer chronic illnesses, and rarely has cognitive impairment. perhaps even more than nursing homes, prisons have difficulty keeping and retaining physicians and nurses -in my home state of north carolina, for example, it is the norm to have as many as a quarter of prison healthcare staff positions unfilled. 19 furthermore, as with nursing homes, lack of access to rapid testing is a major problem, with covid-19 results typically taking four or more days to be reported. 20 a world health organization guide to preparedness, prevention and control of covid-19 in prisons advocates ready access to testing, routine hand washing, hand sanitizer access, physical distancing, availability and use of disposable tissues when coughing or sneezing, admonition to avoid touching the face if hands are not clean, use of masks for any person with respiratory symptoms, environmental cleaning measures capable of killing viruses, restriction of movement when cases present, and use of personal protective equipment for staff attending to persons with suspected covid-19 disease. unfortunately, these are no more than a pipe dream in many settings. 21 given the many risks in and limitations of these settings, working in health care at this time has come to be considered a heroic act. 22 efforts to recognize and support health care workers have ranged from audible displays such as howling, screaming, applauding, and beating pots and pans, 23 to fundraising and volunteer efforts to provide needed personal protective gear and mental health support. 24,25 i can only hope that the public's applause, approbation, and vocal support for hospital staff and emergency medical providers extends all the way to the staff of nursing homes and prisons, where the resources are usually far less available, the workload especially massive, and the remuneration lower. unfortunately, a common first reaction from the media, policy makers, and regulators to a covid-19 tragedy has been to look for someone to blame. a perfect example of such blame was the levying of a $611,000 fine on life care center of kirkland, washington, for failing to report the outbreak, for giving inadequate care, and for failing to provide 24-hour emergency physician services. 26 i can understand the regulators' point of view. nursing homes have been known for years to be an especially hazardous component of the health care system, with high rates of multidrug resistance and multiple problems around infectious disease prevention. 27 infection control issues have chronically been and continue to be the most common single reason for deficiency citations. 28 to help improve infection control practices, the u.s. centers for medicare & medicaid services in 2016 released new requirements for long-term care facilities, all components of which were to have been initiated by november 2019. 29 so, levying a punitive fine to a nursing home that had been previously cited for infection control violations would seem a reasonable reaction. but the covid-19 pandemic is too unprecedented an event to expect any residential care setting to have been adequately prepared to handle an outbreak. instead of blaming, a much more helpful approach would be to pull together as rapidly as possible to identify and address the problems and needs, and to support rather than to blame. after all, it appears that covid-19 is going to be with us for years, and that the current short period of intense scrambling and tight isolation is going to give way to a long, arduous "dance" in which we seek to keep the disease at bay while trying to maximize restitution of our pre-covid-19 lives and routines. 30 in planning and policy, the term "wicked problem" is used to describe issues that are complex, intractable, and open-ended. 31 solutions to wicked problems are neither easy nor apparent, do not lie within existing decision-making pathways, require imagination and transdisciplinary thinking, call for changes in society, are the best that can be done at the time, and need to be continually re-examined. 32 the covid-19 pandemic has exposed a wicked problem for the cruise ship industry, the prison system, and the nursing home industry. since the pandemic will persist for at least a few more years and, if the virus mutates as does influenza, perhaps permanently, changes in all three industries are needed beyond the stopgap measures that are currently being pursued. i don't know enough about the cruise ship industry or the prison system to hazard a guess about which directions the ultimate problem-solving should take. however, by virtue of having worked in post-acute and long-term care for over 40 years, i feel prepared to highlight a few issues that need priority attention: physical plant limitations, chronic staffing problems, poor infection control, and limited health care capacity. together they embody the wicked problem of how to best care for older persons who have numerous morbidities and functional limitations, many of whom are near the end of life. of course, these issues have already been pervasive in the nursing home industry; all that covid-19 has done is to shine a spotlight on them. will the tragedy of covid-19 for long-term care settings mobilize positive change, through out-of-the-box, interdisciplinary problem-solving? will it lead policy makers to eliminate multi-person rooms, shared bathrooms, and large wards, and possibly large buildings, because they increase infection risk? 33 will it lead to real solutions to the staffing problems that have existed in long-term care for decades? will it truly integrate the long-term care, acute care, and primary care systems in a manner that is not only seamless but in which acute care settings no longer receive most of the resources? given the societal ageism that has been exposed by the covid-19 pandemic, 34 and the persistent economic problems that will follow the pandemic for the foreseeable future, i would not bet money on major changes occurring in the long-term care system in the near future. but i would be thrilled to lose that wager. covid-19 in a long-term care facility they're death pits': virus claims at least 7,000 lives in u.s. nursing homes cruise industry suspends operations in response to coronavirus prison policy initiative. responses to the covid-19 pandemic prosecutors, defense attorneys press to release inmates, drop charges and thin jail population in response to the coronavirus epidemiologist says covid-19 may be more infectious than thought. the harvard gazette families anxious over loved ones in nursing homes, assisted living centers for disease control and prevention. guidance for cruise ships on influenzalike illness (ili) management physician practice in the nursing home: missing in action or misunderstood a 2-year pragmatic trial of antibiotic stewardship in 27 community nursing homes world health organization. preparedness, prevention and control of covid-19 in prisons and other places of detention. interim guidance supporting the health care workforce during the covid-19 global epidemic washingon nursing home faces $611,000 fine over lapses during fatal coronavirus outbreak prioritizing prevention to combat multidrug resistance in nursing homes: a call to action nursing home infection control program characteristics, cms citations, and implementation of antibiotic stewardship policies: a national study reform of requirements for long-term care facilities programs-reform-of-requirements-for-long-term-care-facilities the hammer and the dance. medium wicked problems in public policy tackling wicked problems through transdisciplinary imagination detection of sars-cov-2 among residents and staff members of an independent and assisted living community for older adults covid-19 in italy: ageism and decision-making in a pandemic key: cord-310123-h7i49pdb authors: de smet, robert; mellaerts, bea; vandewinckele, hannelore; lybeert, peter; frans, eric; ombelet, sara; lemahieu, wim; symons, rolf; ho, erwin; frans, johan; smismans, annick; laurent, michaël r. title: frailty and mortality in hospitalized older adults with covid-19: retrospective observational study date: 2020-06-09 journal: j am med dir assoc doi: 10.1016/j.jamda.2020.06.008 sha: doc_id: 310123 cord_uid: h7i49pdb abstract objectives to determine the association between frailty and short-term mortality in older adults hospitalized for coronavirus disease 2019 (covid-19). design retrospective single-center observational study. setting and participants: n = 81 patients with covid-19 confirmed by reverse-transcriptase polymerase chain reaction (rt-pcr), at the geriatrics department of a general hospital in belgium. measure ments: frailty was graded according to the rockwood clinical frailty scale (cfs). demographic, biochemical and radiological variables, co-morbidities, symptoms and treatment were extracted from electronic medical records. results participants (n = 48 women, 59%) had a median age of 85 years (range 65 – 97 years), median cfs score of 7 (range 2 – 9), and 42 (52%) were long-term care residents. within six weeks, eighteen patients died. mortality was significantly but weakly associated with age (spearman r = 0.241, p = 0.03) and cfs score (r = 0.282, p = 0.011), baseline lactate dehydrogenase (ldh) (r = 0.301, p = 0.009), lymphocyte count (r = -0.262, p = 0.02) and rt-pcr cycle threshold (ct, r = -0.285, p = 0.015). mortality was not associated with long-term care residence, dementia, delirium or polypharmacy. in multivariable logistic regression analyses, cfs, ldh and rt-pcr ct (but not age) remained independently associated with mortality. both age and frailty had poor specificity to predict survival. a multivariable model combining age, cfs, ldh and viral load significantly predicted survival. conclusions and implications although their prognosis is worse, even the oldest and most severely frail patients may benefit from hospitalization for covid-19, if sufficient resources are available. results: participants (n = 48 women, 59%) had a median age of 85 years (range 65 -97 years), 12 median cfs score of 7 (range 2 -9), and 42 (52%) were long-term care residents. within six weeks, 13 eighteen patients died. mortality was significantly but weakly associated with age (spearman r = 14 0.241, p = 0.03) and cfs score (r = 0.282, p = 0.011), baseline lactate dehydrogenase (ldh) (r = 0.301, 15 p = 0.009), lymphocyte count (r = -0.262, p = 0.02) and rt-pcr cycle threshold (ct, r = -0.285, p = 16 0.015). mortality was not associated with long-term care residence, dementia, delirium or 17 polypharmacy. in multivariable logistic regression analyses, cfs, ldh and rt-pcr ct (but not age) 18 remained independently associated with mortality. both age and frailty had poor specificity to 19 predict survival. a multivariable model combining age, cfs, ldh and viral load significantly predicted 20 survival. 21 although their prognosis is worse, even the oldest and most severely 22 frail patients may benefit from hospitalization for covid-19, if sufficient resources are available. 23 coronavirus disease 2019 is a global pandemic caused by severe acute respiratory 28 syndrome coronavirus 2 (sars-cov-2). 1 older adults are at increased risk of hospitalization and 29 mortality due to different ethical guidelines deal with triage in case a surge in hospital admissions due to overwhelms scarce hospital resources. 6-8 likelihood of benefit, age and frailty are among the most 32 commonly used triage criteria. 9, 10 in the u.k. and in belgium (among other countries), intensive care 33 unit (icu) admission is not recommended for frail older adults aged 65 years and older. 11, 12 these 34 guidelines rely on frailty assessment according to the rockwood clinical frailty scale (cfs). patients 35 can be classified on the cfs as not frail (scores 1-4), mildly frail (score 5), moderately frail (score 6) or 36 severely frail (score 7-9). 13 icu admission is discouraged for frail older adults i.e. those with a cfs 37 score of 5 or higher in the u.k. and belgium. 11, 12 hospital admission is discouraged for nursing home 38 residents with suspected or confirmed covid-19 and a cfs score of 7 or higher. 12 39 previous studies have shown that frailty is associated with worse outcomes in hospitalized older 40 adults. 13, 14 however, little is known about the outcomes in frail older adults or long-term care 41 residents hospitalized for covid-19. therefore, the aim of this retrospective observational study was 42 to describe outcomes in hospitalized geriatric covid-19 patients according to their age, degree of 43 frailty and place of residence. 44 a retrospective, single-center observational study was performed among covid-19 patients at the 47 geriatrics department of our general hospital in belgium, admitted between march 12 th and april 48 30 th , 2020. demographic, clinical, laboratory and radiographic parameters were extracted from 49 electronic health records. laboratory values included c-reactive protein (crp, reference values < 5 50 mg/l), ferritin, d-dimers, lactate dehydrogenase (ldh), 25-hydroxyvitamin d levels and white blood 51 cell, platelet and lymphocyte counts. polypharmacy was defined as the use of five or more 52 ethics 54 the ethical committee approved the research protocol and waived the need for informed consent, 55 since it did not constitute a clinical study according to national and european regulations. 56 clinical procedures 57 covid-19 was confirmed by reverse transcriptase polymerase chain reaction (rt-pcr) testing on 58 nasopharyngeal swabs, using protocols validated within our national sars-cov-2 reference 59 network. 15 all patients admitted through the emergency department were screened for covid-19 by 60 low-dose chest computed tomography (ct). findings on covid-19 likelihood and extent of 61 pulmonary involvement (ct-score ranging 0 -25) were reported using a standardized radiological 62 protocol as described previously. 15 63 all covid-19 patients in our hospital were hospitalized on dedicated wards under the care of a staff 64 pulmonologist, nephrologist, infectious disease specialist or geriatrician, depending on their usual 65 care team (e.g. nephrology in dialysis patients). additional local criteria to admit patients under 66 geriatric care were age 85 years or older, long-term care residence or equivalent home care (i.e. 67 complete dependency on assistance for activities of daily living), patients with dementia or delirium, 68 or patients aged 75 years and older with multiple co-morbidities and polypharmacy. 69 on admission, an experienced geriatrician scored premorbid frailty according to the cfs based on 70 information from patients, their families, caregivers, primary care referral letters or long-term care 71 records. 72 statistics 73 examined using mann-whitney u-test and chi-square test for continuous and categorical variables, 76 respectively. association of age, frailty and other baseline characteristics with mortality were 77 evaluated by spearman r and multiple logistic regression. survival according to frailty status was 78 examined using odds ratios, survival analyses (log-rank mantel-cox test) and receiver-operator curve 79 (roc) analysis. two-tailed p values < 0.05 were considered significant. all analyses were performed 80 using graphpad prism v8.4.2. 81 baseline characteristics of our cohort are shown in table 1 . median age was 85 years (minimum 65, 83 maximum 97 years), and 48 were women (59%). median cfs score was 7 (range 2-9). dementia had 84 been diagnosed in 36 patients (44%), and 42 (52%) were long-term care residents. polypharmacy was 85 present in 52 (64%) subjects. 86 sex, place of residence, dementia, polypharmacy, extent of affected lung tissue on ct or crp values 87 at baseline did not differ between survivors and non-survivors. however, compared to survivors of 88 covid-19, non-survivors were significantly older (88.5 vs. 85 years, median age) and frailer (median 89 cfs 7 vs. 6). their rt-pcr cycling threshold (ct) values were also significantly lower (indicating higher 90 viral load). baseline ldh was significantly higher and baseline lymphocyte count lower in non-91 survivors. baseline crp, ferritin, d-dimer, white blood cell, platelet or 25-hydroxyvitamin d levels 92 were not different (latter data not shown). lymphopenia was present on admission in 48 patients 93 (60%) and occurred during admission in 60 of 80 patients (75%; one patient was excluded due to 94 chronic lymphocytic leukemia). the peak crp and lymphocyte nadir reached during admission was 95 higher among non-survivors, and these differences were highly significant. length of stay tended to 96 be shorter in those who died (p = 0.05). 97 among these variables, the cfs score was associated with dementia (p < 0.0001, r = 0.602), long-98 term care residence (p < 0.0001, r = 0.465), and weakly with sex (lower frailty in males, p = 0.007, r = 6 -0.296) and incident delirium (p = 0.043, r = 0.230). there was no significant association between cfs 100 and older age in our cohort. 101 one out of seventeen patients died in the non-frail group (cfs score 1-4), compared to eighteen 102 deaths among 64 frail patients, however this difference did not reach significance (p = 0.054). 103 supplementary fig. 1a shows survivors and non-survivors according to their age and cfs. most 104 deaths occurred in older, frailer patients. however, this group overlapped considerably with many 105 surviving frail older patients. kaplan-meier curves also showed only a trend towards higher mortality 106 in frail vs. non-frail subjects (mantel-cox log-rank p = 0.06, supplementary fig. 1b) . 107 next, we examined the clinical diagnostic utility of the individual variables that were significantly 108 associated with mortality, in multiple logistic regression analyses. again, age, cfs, rt-pcr ct values 109 and ldh were significantly associated with higher odds of mortality ( table 2 and supplementary fig. 110 1c-f), whereas baseline lymphocyte count was no longer significant. in a bivariate model with age 111 and cfs score combined, only the cfs remained significantly associated with mortality. the area 112 under the roc curve (auroc) was 0.7443 (95% ci 0.6213 -0.8673) for this model (figure 1a) , with a 113 positive and negative predictive value of 57% and 80%, respectively. when age and cfs were 114 combined with rt-pcr ct values and ldh the latter three variables remained significantly associated 115 with mortality. the four-factor model predicted probability of mortalilty (range 0-1) as follows 116 (intercept + β1*age + β2*cfs + β3*rt-pcr ct value + β4*ldh): -13.89 + 0.126*years + 0.561*cfs-117 score + (-0.1623)*ct + 0.5275*[u/l]/100 (supplementary table 1) . the auroc for this model was 118 0.8824 (0.7384 -1.000, p < 0.0001, figure 1b) , with a negative predictive power of 89.5% and a 119 positive predictive power of 78%, sensitivity of 54% and specificity of 78%. 120 seven patients were treated with hydroxychloroquine, 60 (74%) with antibiotics, 46 (57%) with i.v. 121 fluid support and 25 with glucocorticoids (31%). seven patients were admitted to icu, five of whom 122 died. the odds ratio for mortality was significantly higher in patients requiring icu admission (p = admission, incubation time and a local outbreak in one of our non-covid-19 wards into account). 126 four of these patients died. there was no significantly higher or lower mortality between presumed 127 hospital-acquired or community-acquired covid-19 cases. 128 the current covid-19 pandemic particularly strikes frail older adults and/or long-term care residents, 130 posing considerable medical and ethical challenges for overwhelmed healthcare systems. different 131 guidelines have been released to assist triage in this population. 9, 11,16 belgian and u.k. guidelines 132 recommend the cfs to inform decision making regarding hospital referral of nursing homes residents 133 with suspected or confirmed covid-19. however, empirical evidence supporting the use of frailty 134 instruments to predict treatment outcomes and thus apply triage restrictions, has remained 135 lacking. 17 136 the short-term mortality (~23%) in this case series is similar to mortality rates reported for 137 hospitalized older adults in wuhan or california, 3, 4 but lower than reported by sun et al. 18 or than in 138 the new york city area. 2 this may be considered unexpected, given the greater frailty and older age 139 of our patients compared to previous cohorts. similar or higher mortality rates have been reported in 140 long-term care residents 19 or in younger icu populations. 20 these findings support the notion that it 141 may be discriminatory and unethical to restrict hospital care based on age or frailty status alone. 10, 21 142 still, mortality was higher in patients requiring icu transfer in our cohort, suggesting that intensive 143 care is of unclear clinical benefit in this population. 22 144 older age was significantly but weakly associated with increased risk of mortality, confirming recent 145 studies. 1-4 anecdotally, nonagenarians or centenarians have survived our main finding 146 was that frailty was also significantly but weakly associated with higher risk of mortality in covid-19 147 patients (multivariate odds ratio for mortality with each higher cfs point: 1.75.) still, many severely 148 frail patients survived (72%), and the cfs by itself had poor specificity and no useful cut-off for mortality prediction. a recent study from italy showed that in n=105 covid-19 patients, frailty as 150 assessed by the fraity index was associated with in-hospital mortality or icu admission, independent 151 of age and sex. 24 152 apart from age and frailty, ldh was the only circulating biomarker significantly associated with 153 mortality in our cohort. this confirms prior studies. 25, 26, 27 however, only few patients met this 154 criterion in our cohort, making it practically useless. maximal crp and nadir lymphocyte count during 155 admission was significantly associated with mortality, but these parameters are not available at 156 baseline. interestingly, we observed a significant association between rt-pcr ct values and 157 mortality. viral load peaks longer in patients with more severe covid-19 and in older adults, as 158 shown by zheng et al. 28 we speculate that higher viral load may also be a marker for increased risk of 159 mortality, although sampling bias needs to be excluded before we can support this conclusion. of 160 note, our rt-pcr method was semi-quantitative rather than quantitative, precluding extrapolation to 161 other settings. the four-factor model combining clinical, host and viral parameters showed the most 162 promising characteristics, but still remained inadequate from a clinical perspective. sun et al. 163 reported a similar logistic regression model based on older age and lymphocyte count. 18 further 164 work is needed to establish optimal clinical, viral and host immune system characteristics to predict 165 mortality among covid-19 patients. 26 166 our study provides the geriatric community with several novel insights into the outcomes of frail 167 older covid-19 patients. however, we recognize several limitations, mainly due to our retrospective 168 study design. since data were obtained retrospectively from electronic health records, missing data 169 (e.g. for ct-scan or biochemical parameters) may have introduced bias, and follow-up was limited. 170 however, selection bias is unlikely, since we included consecutive cases in a country with universal 171 health coverage. caution should be applied to extrapolate findings from this single-center study to 172 other healthcare settings. the associations we observed may not be causally related. despite our 9 underpowered. a larger sample size would have helped reduce the size of our parameter estimate 175 confidence intervals and increase the validity of our model; however the first covid-19 wave ended 176 in our hospital and no more deaths have accumulated. we chose not to include patients with so-177 called "radiographically confirmed" covid-19 i.e. with typical clinical features and radiographic 178 evidence on chest ct, but with repeatedly negative sars-cov-2 rt-pcr. however, only three such 179 patients were excluded, which is unlikely to have influenced the results. 180 many instruments to determine frailty are available. 29 we applied the cfs, which has been adopted 181 in several national covid-19 triage policies, most notably by u.k. nice guidelines. 11 previous 182 research has shown that cfs scores can reliably be obtained in critically ill patients based on chart 183 review, patient interview and/or family interview. 30 however, we recommend further research to 184 ascertain the reproducibility and reliability before widespread implementation of the cfs during 185 covid-19 outbreaks. importantly, we were unable to include younger, non-frail patients, since frailty 186 was not assessed in non-geriatric patients. the association between frailty and mortality would likely 187 have been stronger if we included younger, less frail patients. 188 in summary, we showed that age and frailty were significantly but weakly associated with mortality 190 among hospitalized older adults affected by covid-19. however, both frailty and age alone have 191 poor specificity to predict mortality, and many severely frail patients survived covid-19. we 192 recommend clinicians, ethicists and policy makers to consider these empirical findings. covid-19 and older adults: what we 196 presenting characteristics, comorbidities, and 198 outcomes among 5700 patients hospitalized with covid-19 in the new york city area characteristics of hospitalized adults with covid-201 19 in an integrated health care system in california clinical course and risk factors for mortality of adult inpatients 203 with covid-19 in wuhan, china: a retrospective cohort study coronavirus disease 2019 in geriatrics and long-206 term care: the abcds of covid-19 ags position statement: resource allocation 208 strategies and age-related considerations in the covid-19 era and beyond rationing limited health care resources in the covid-211 ethical considerations regarding older adults covid-19 in italy: ageism and decision making in a pandemic ventilator triage policies during the 215 covid-19 pandemic at u.s. hospitals associated with members of the association of 216 universal do-not-resuscitate orders opposing discriminatory approaches to the allocation of resources during 11. national institute for health and care excellence (nice). nice guideline [ng159]: covid-19 221 rapid guideline: critical care in adults flowchart for decision making on hospital admission of possibly 224 covid-19 infected nursing home residents complementing chronic frailty assessment at hospital 226 admission with an electronic frailty index (fi-laboratory) comprising routine blood test 227 results the impact of frailty on intensive care unit 229 outcomes: a systematic review and meta-analysis accuracy and reproducibility of low-dose 232 submillisievert chest ct for the diagnosis of covid-19 covid-19: use of the clinical frailty scale for critical care 235 frailty in the face of covid-19 risk factors for mortality in 244 older adults with covid-19 in 238 china: a retrospective study epidemiology of covid-19 in a long-term care 240 facility in king county, washington baseline characteristics and outcomes of 1591 patients infected with sars-cov-2 admitted to icus of the lombardy region, italy a framework for rationing ventilators and critical care beds during the 22 israel ad hoc covid 19 committee. guidelines for 247 care of older persons during a pandemic china's oldest coronavirus survivors frailty index predicts poor outcome risk factors of severe disease and efficacy of treatment in 253 patients infected with covid-19: a systematic review prediction for progression risk in patients with covid-19 256 pneumonia: the call score hematologic, biochemical and immune 258 biomarker abnormalities associated with severe illness and mortality in coronavirus disease 259 2019 (covid-19): a meta-analysis viral load dynamics and disease severity in patients infected with 261 sars-cov-2 in zhejiang province, china instruments for the detection of frailty syndrome 264 in older adults: a systematic review assessing frailty in the intensive care unit: a 266 reliability and validity study conflict of interest: mrl has received consultancy and lecture fees from alexion, amgen, kyowa kirin, menarini, sandoz, takeda, ucb and will-pharma, none of which are related to this work. all other authors have no conflicts.author contributions: rds and mrl designed the study, collected the data, analyzed the results and wrote the first draft. all authors contributed to the care of our covid-19 patients, assisted in the data collection and analysis of the results, the writing of the manuscript and approved the final version. key: cord-325953-yvtyh27k authors: shea, yat-fung; lam, ho yeung; yuen, jacqueline kwan yuk; adrian cheng, ka chun; chan, tuen ching; mok, wing yee winnie; chiu, ka chun patrick; luk, ka hay james; chan, hon wai felix title: maintaining zero covid-19 infection among long term care facility residents in hong kong date: 2020-05-29 journal: j am med dir assoc doi: 10.1016/j.jamda.2020.05.042 sha: doc_id: 325953 cord_uid: yvtyh27k nan letter to the editor 1 2 maintaining zero covid-19 infections among long term care facility residents in hong kong 3 4 introduction: during the novel coronavirus disease 2019 (covid-19) pandemic, older adults are a 5 particularly vulnerable group with higher mortality. 1 in long-term care facilities (ltcfs), the risk of 6 serious outbreaks is great given a higher prevalence of dementia and potential poor resident 7 compliance with infection control measures such as hand hygiene and wearing of surgical masks. 2, 3 8 transmission from infected health care workers in lctfs have led to disastrous outbreaks. 2 hong 9 kong recorded its first confirmed case of covid-19 on january 23, 2010. up to the point of writing 10 (16 th may 2020), there has been no ltcf resident (~74000 in 940 ltcf) infected with covid-19 in 11 hong kong. we believe that the following measures have contributed to this favorable outcome. reported to the chp and cgat link nurses. all staff (n=60) and most residents (n=102) in the involved 55 facilities were instructed to save deep throat secretions or throat swab for sars-cov-2 by real-time 56 reverse transcriptase polymerase chain reaction (rrt-pcr) and the tests were repeated 8-9 days apart 57 during the quarantine period. they all turned out negative. four residents under surveillance were 58 admitted with fever and respiratory symptoms but respiratory specimens for sars-cov-2 rrt-pcr 59 were again negative. workflow to alert the appropriate personnel including the hospital infection team and staff in emergency department were set-up so as to ensure smooth transfer of 61 residents to the acute hospital conclusions and implication: we achieved a zero covid-19 infection rate among ltcf residents 64 because of strict hand hygiene, near 100% compliance among staff in wearing of surgical masks, 65 prohibition of visitors and reducing the frequency of on-site physician visits. however, it remains our 66 concern how the restriction of visitors may affect the general wellbeing of residents clinical course and risk factors for mortality of adult inpatients 74 with covid-19 in wuhan, china: a retrospective cohort study asymptomatic and presymptomatic sars-cov-2 77 infections in residents of a long-term care skilled nursing facility -king county institution type-dependent high prevalence of dementia in 80 long-term care units efficacy of trivalent seasonal influenza 82 vaccination in reducing mortality and hospitalization in chinese nursing home older adults guidelines for residential care homes for the elderly or persons 85 with disabilities for the prevention of coronavirus disease (covid-19) (interim) temporal profiles of viral load in posterior 89 oropharyngeal saliva samples and serum antibody responses during infection by sars-cov-2: 90 an observational cohort study authors declared there are no conflict of interest. 70 71 72 key: cord-353136-z5yo6wji authors: sepulveda, edgardo r.; stall, nathan m.; sinha, samir k. title: a comparison of covid-19 mortality rates among long-term care residents in 12 oecd countries date: 2020-09-12 journal: j am med dir assoc doi: 10.1016/j.jamda.2020.08.039 sha: doc_id: 353136 cord_uid: z5yo6wji nan an early and persistent trend of the coronavirus disease 2019 (covid-19) pandemic has been the large number of deaths occurring among older adults and those living in long-term care (ltc) homes. 1 residents of ltc homes are at a disproportionately high risk of contracting severe acute respiratory syndrome coronavirus 2 (sars-cov-2) due to their congregant living environments, greater likelihood of being exposed to asymptomatic and pre-symptomatic care providers, and difficulty in effectively implementing infection prevention and control practices. 2, 3 the majority of ltc home residents are also older adults, for whom advanced age represents a strong risk factor for covid-19 morbidity and mortality due to the higher prevalence of immunosenescence and chronic illnesses. 4 while the proportion of deaths occurring in ltc homes at an international level has been explored, population-specific mortality rates for ltc home residents and their comparison to rates for community-dwelling older and younger persons have neither been calculated nor analyzed. 5 using publicly reported data on covid-19 deaths for 12 organization for economic cooperation and development (oecd) member-countries (belgium, canada, denmark, france, germany, ireland, italy, netherlands, spain, sweden, united kingdom, and the united states), we calculated and compared the population-specific mortality rates and ratios for ltc home residents and community-dwelling older (age ≥65 years) and younger (age <65 years) persons. covid-19 deaths data were collected directly from publicly available national health and epidemiological reports and were current as of july 24, 2020 (see appendix 1 for methodology and data sources). covid-19 deaths included both those reported as confirmed and probable, and those that occurred in ltc home and acute hospital settings. we report a total of 361,161 covid-19 deaths for the 12 countries, which accounted for ireland). (figure 1 ). here we confirm a very high concentration of mortality of ltc home residents and report substantial variation between 12 oecd countries. our results suggest that the level of community transmission, as reflected in the mortality rate for community-dwelling persons, and the level of policy response related to infection prevention and control practices in ltc homes and at the broader community level were important factors driving ltc home resident mortality rates. 5 countries, such as denmark and germany, that maintained relatively low levels of community transmission and acted early and aggressively to prevent the introduction and spread of covid-19 into their ltc homes had the lowest ltc home resident mortality rates. 7 these policy actions included the early restriction of non-essential visitors, enacting universal masking j o u r n a l p r e -p r o o f policies, improving ltc staffing levels, preventing care providers from working across multiple sites, implementing enhanced ltc infection control training and audit procedures, and widespread testing and isolation protocols for infected residents and asymptomatic contacts. 1, 8, 9 in contrast, countries such as spain and the uk, that had relatively high levels of community transmission and less robust ltc home-related policy responses, had the highest ltc home resident mortality rates. other countries had mixed responses with uneven results. for instance, canada promoted relatively forceful measures that were effective in limiting community transmission, but its ltc home-related responses were uneven and less robust for a system already characterized as being poorly staffed and funded at its baseline. 10 as some countries are still grappling with their first-waves of covid-19 infections and others are starting to combat their second waves, understanding the factors that led to substantial mortality rates for ltc home residents in certain jurisdictions could help allow for the implementation of key policies and practices that could prevent introduction, transmission, and death from covid-19 across all jurisdictions. all authors received no support from any organization for the submitted work, have not entered into an agreement with any organization that has limited their ability to complete the research as planned and publish the results, have no financial relationships with any organizations that might j o u r n a l p r e -p r o o f have an interest in the submitted work, and have no other relationships or activities that could appear to have influenced the submitted work. covid-19 in nursing homes: calming the perfect storm epidemiology of covid-19 in a long-term care facility in king county, washington asymptomatic spread of covid-19 in 97 patients at a skilled nursing facility coronavirus disease 2019 in geriatrics and long-term care: the abcds of covid-19 pandemic experience in the long-term care sector: how does canada compare with other countries? germany and the covid-19 long-term care situation. international long term care policy network. ltc responses to covid-19 web site policy recommendations regarding skilled nursing facility management of coronavirus 19 (covid-19): lessons from new york state the nia's 'iron ring' guidance for protecting older canadians in long-term care and congregate living settings understanding the impact of covid-19 on residents of canada's long-term care homes -ongoing challenges and policy responses key: cord-336467-w528t92h authors: anderson, diana c.; grey, thomas; kennelly, sean; o'neill, desmond title: nursing home design and covid-19: balancing infection control, quality of life, and resilience date: 2020-10-31 journal: j am med dir assoc doi: 10.1016/j.jamda.2020.09.005 sha: doc_id: 336467 cord_uid: w528t92h many nursing home design models can have a negative impact on older people and these flaws have been compounded by coronavirus disease 2019 and related infection control failures. this article proposes that there is now an urgent need to examine these architectural design models and provide alternative and holistic models that balance infection control and quality of life at multiple spatial scales in existing and proposed settings. moreover, this article argues that there is a convergence on many fronts between these issues and that certain design models and approaches that improve quality of life, will also benefit infection control, support greater resilience, and in turn improve overall pandemic preparedness. residential care settings for older people are known variously as "nursing homes," "long-term care facilities," or "care homes." 1 in general, it is argued that the design of many of these facilities do not adequately support quality of life for older people, 2,3 and now this is compounded by the covid-19 pandemic which illustrates how they are ill-designed for infection control and the protection of older people who are most at risk in our society. 4 furthermore, this pandemic has illustrated the importance of space and spatial practices such as social distancing, isolation, or quarantine, 5 all of which have immediate and long-term implications for the built environment in terms of planning, urban design, and architecture. 6, 7 this article identifies the urgent need to examine these design models and provide alternative and holistic models that balance infection control and quality of life at multiple spatial scales in existing and proposed settings. the convergence on many fronts between these issues alongside certain design models and approaches that improve quality of life can also benefit infection control, support greater resilience, and in turn improve overall pandemic preparedness. built environment issues are of considerable importance in longterm care settings where older residents live in close quarters and often have high levels of impairment and chronic illness, all of which can lead to a greater infection rates and mortality. 8e10 in addition to physical health issues, the built environment of long-term care exacerbates psychosocial and mental health challenges of covid-19 as a result of quarantine, constrained social interaction, restricted visits from family and friends, the cancellation of shared activities, or the wearing of personal protective equipment by staff. 11, 12 these interventions are particularly difficult for people with a cognitive impairment or a person that walks with purpose, formerly termed "wandering." 4 finding a balance and convergence among infection control, quality of life, and overall resilience although the covid-19 pandemic has made it apparent that the design or retrofit of long-term care settings will have to tackle many difficult infection control challenges, additional recognition that the convergence between design for infection control and design for improved quality of life can yield an overall resilience is needed. in the following sections we explore these concepts further. in a series of studies, nursing home residents describe a range of issues important to their well-being, consistently identifying space and the built environment as factors. barney 13 argues that community involvement and interaction is critical to quality of life in nursing homes. at the community scale, rijnaard et al. 14 highlight the importance of proximity to a person's home community, contact with a familiar neighborhood, and access to local services or shops for small purchases. other major themes identified as important to nursing home residents include generativity, spiritual well-being, homelike environment, and privacy. 15 aspects contributing to thriving in nursing homes challenge the traditional passive perspective of residents and instead emphasize more active aspects. 16 these include positive relationships with other residents including visiting each other's rooms, participation in meaningful activities, and opportunities to go outside the residence, including visiting family, organized tours, attending church, or experiencing nature. qualities of the physical environment includes bright, spacious and private rooms with private bathrooms. qualities of the environment are also connected to the wellbeing of older adults in institutions, linked to 2 main categories including "well-being in public and private spaces" and "lack of well-being in public and private spaces." experiences of being together and forming friendships is important for public spaces such as a lounge, whereas peacefulness is fundamental to relaxation and sleep in a resident's private room. conversely, being excluded from the group in lounge settings can be a source of negative feelings, whereas feelings of incompetence in private spaces such as not being able to use the bathroom can undermine well-being. 17 the sense of home experienced by residents is influenced by a number of jointly identified factors, including the building and interior design. residents and relatives stress the importance of having a connection with nature and the outdoors. 18 important themes contributing to a sense of home include the physical view; mobility and accessibility; and space, place, and the social environment. a holistic understanding of which features of the built environment are appreciated by the residents can lead to the design and retrofitting of nursing homes that are more in line with personal wishes and can impact positively on the quality of life and the sense of home of nursing home residents. 19 the term "resilience" is gaining momentum within design professions given increasing environmental uncertainty and the current pandemic events. hildon et al. 20 define resilience as "flourishing despite adversity" and examine the connection between resilience and quality of life for older people. for people with dementia, christie et al. 21 argue that resilience or "adaptation in the face of adversity" is influenced by a person's "protective factors," including "a sense of connectedness with others," a "sense of mastery and control," and "meaning making opportunities." in this context, the quality of life issues discussed in the previous section have implications for resilience, yet very little attention has been paid to these issues in relation to nursing home design. 22 although current design strategies have been primarily reactive to the context of covid-19, a prospective approach to improving quality of life through architectural design, which includes maintaining connection to others and an overall focus on health, is a critical part of pandemic preparedness as it strengthens resilience. quality of life and care issues pertain to all aspects of the nursing home built environment (ie, from nursing home location and interaction with the community, down to building details, components, and technology), therefore we adopt a spatial framework spanning macro (overall urban setting), meso (neighborhoods and districts), and micro-scale level issues (site/building design). this multi-scalar approach (figure 1 ) draws on both urban design 23 and geographical gerontology 24 and is used to briefly investigate examples of convergence/divergence among quality of life, infection control or pandemic preparedness, and overall resilience of nursing homes. furthermore, this spatial framework helps understand the issues around the lived experience of older people, community integration, and quality of life in nursing homes; issues that are also critical for resilience. proximity to a person's home community place attachment and a sense of home are complex issues tied not only to a particular dwelling, but also to the broader community, familiarity, and sense of belonging. 25 for instance, a nursing home within a person's community has been shown to have pragmatic benefits (proximity to family), but also a factor in maintaining a sense of self through continuity with a place or community. 26 these factors are rarely taken into account, reflected in comments from advocacy groups 27 that state that the practice of locating nursing homes outside towns and villages "cuts residents off from community life and social interaction, and isolates those residing in them, thereby lessening their quality of life." given the importance that christie et al. 21 ascribe to a "sense of connectedness" for resilience, proximity to a person's home community may be a critical factor in supporting and helping them adapt to adversity. although access by family and friends during a pandemic may be an infection risk and has resulted in restricted visiting has been enforced during covid-19, 11,12 this cannot be sustained due to the loneliness, anxiety, and sense of loss and besiegement that this creates. 28 integration with health and social care, and emergency services mapping local resources and creating service and care pathways among acute care, long-term care, health services, and the local community are critical to the implementation of integrated care for older persons. 29 this integration is vital during certain emergency situations, first for evacuating residents of nursing homes to hospitals if required, and second for bringing emergency and medical aid to residents where evacuation is not safe or appropriate. 22 fig. 1 . nursing home design and the macro, meso, and micro spatial scales. many of the overall neighborhood issues that support quality of life and resilience (eg, public transportation, access to amenities, access and size of open and green spaces 23 ), will also benefit the residents and staff of nursing homes, and family members. for older people in particular, a well-designed public realm with safe, accessible, and attractive pedestrian space is linked to walkability and improved social outcomes. 30 furthermore, if nursing homes are to be more integrated with communities as promoted by certain nursing home models such as the green house model, 31 then the neighborhoods in which they are embedded must be of a certain quality. indeed, walkable and activity friendly neighborhoods have been shown to have benefits for noncommunicable and infectious diseases by supporting walking and cycling, and by providing local amenity spaces for safe exercise and socialization. 32 urban design that unites quality of life and pandemic resilience is vital. for instance, accessibility for wheelchairs and mobility devices is crucial for many older people and this requires wide footpaths, 33 a feature that also supports covid-19erelated social distancing. 34 air quality issues at local community level research shows that older people are more vulnerable to both short-term and long-term air pollution. 35 emerging research is also linking poor air quality to higher rates of covid-19, 36 making air quality at a neighborhood scale both a quality of life and resilience issue. care model and overall building configuration some of the environmental issues that make nursing homes prone to infection may include the number and density of residents, the numbers of staff and visitors accessing a single building, staff movement between multiple residents rooms, and singular high-traffic communal areas such as dining rooms or living spaces. 8, 9 early research has suggested small settings with fixed staff that minimized entry/re-entry lower covid-19 infection rates. 37, 38 these studies found that staff were a key source of outbreaks, suggesting that smaller, more autonomous residences with dedicated staff may improve infection control. in this regard, small-scale, homelike settings, known variously as "household" or "green care" models, 39,40 may prove beneficial. the "green house" 31 model is an example of these households and typically have 10 to 12 residents with private bedrooms and bathrooms and small number of fixed staff (figure 2) . the bedrooms surround a central living area and open kitchen and have access to a protected outdoor space. household models are linked to improved outcomes for residents, staff, and visitors, 41 at the same time some aging advocates have promoted household models as a they allow covid-19 outbreaks to be managed in one household without affecting adjacent or colocated settings. 42 the small number of people in a typical "household" setting reduces the amount of human traffic that may consequently reduce infection spread. 43 signage at entrances and on key internal routes instructing people not to enter if they have certain symptoms, advising them about social distancing and hygiene, along with the provision of hand sanitizing facilities is advised. 44 hand sanitizers should also be place in all resident rooms (ideally inside and outside door) and at other key spaces such as common rooms. 44 although not specifically aimed at nursing homes, the american institute of architect's (aia) re-occupancy assessment tool 45 contains useful advice, such as the use of one-way traffic flow systems in circulation areas; removing clutter from corridors to increase space for social distancing; the use of separate entrances and exits; or separate staff, resident, and visitor entrances. they also suggest contactless, motion sensor, or automatic operating doors. private rooms with bathrooms are linked to quality of life in nursing homes, 16 improved infection control, and can be used to isolate confirmed or suspected cases of covid-19 46 and to facilitate visitors. the quality of these rooms is important and therefore size, good natural light, and ideally access to a private outdoor space or balcony would improve the experience for the resident, visitor, and staff. restricted access to common areas or shared living areas can be isolating for residents and a balance must be struck among social engagement, communal activities, and infection control. this issue pre-dates covid-19, with stone et al. 47 arguing that "maximizing quality of life for the resident while minimizing transmission of infections is a known challenge facing nh staff." although more research is required in this area, it is useful to consider the advice set out by the aia 45 to change layouts in shared spaces to facilitate social distancing or provide outdoor seating and exterior social areas for occupants and visitors. although some nursing homes may need to zone or cohort patients, it is still important to ensure there is safe walking space, especially for residents with a cognitive impairment who may "walk with purpose." 48 in addition to the resident room and communal shared spaces, the integration of "intermediate spaces" (ie, porches, alcoves in corridors, and seating placed strategically to allow viewing of the streetscape) supports the activities of viewing, watching, and observing, which have been noted as critical components of nursing home life. 49 in an analysis of these transitional spaces, granger 49 notes that they provide visual stimulus through purposeful design, critical for physical and mental health "even in old age. there is joy, companionship, and spontaneity which, i would add, is facilitated by the material contextdthe places and porchesdthat allow the elderly to touch the world beyond." although covid-19 has challenged architects and nursing homes to consider design strategies for minimizing outbreaks in these congregate living facilities, "it is imperative that the social needs of institutionalized seniors are accounted for, both in physical form and in programmatic strategy." space to exercise, access to nature, exposure to sun, and fresh air are some of the proven benefits of outdoor spaces in nursing homes. 50 the outdoors can boost beneficial vitamin d 51 for residents and provide an environment that is inhospitable to pathogens through reduced moisture, uv light, and the diluting effects of fresh air and air movement. early research from chinese hospitals treating covid-19 found outdoor hospital spaces had undetectable or very low concentrations of the virus. 52 although more research is required in this area, reviews of previous pandemics argue for the benefits of spending time outdoors. 53 although there has been a focus on dedicated staff entrances in the context of this current pandemic, staff must also be provided with adequate changing and hygiene facilities, with the flexibility to segregate these areas further in the setting of pandemic preparedness. space that can be converted to accommodate staff testing, in addition to a central command center, which might be needed to oversee facilities operations in this context, can also be considered. in addition, we advocate for respite areas for staff members that include access to natural light and nature, given the challenges posed by covid-19 in the context of mental health. 54, 55 ventilation and air quality at the building level ventilation and air quality are critical to the well-being of older people in nursing homes 56, 57 and are an important infection control issues. 58 increasing air flow through natural and mechanical ventilation within buildings may help dilute and remove the virus, whereas higher relative humidity can be detrimental to viruses. 59 although many heating, ventilation, and air conditioning systems (hvac) will not have built-in air humidification equipment, these systems may be appropriate in high-risk settings or low humidity regions. although most nursing homes may not have airborne infection isolation rooms, lynch and goring 60 outline a number of steps to adapt a resident rooms with existing hvac to create a slightly negative-pressure room to reduce the spread of infected airborne droplets to the main facility. this involves installing supplemental exhaust ventilation, upgrading filters, and keeping doors closed to maintain the negative pressure. the macro, meso, and micro issues identify examples of the overlaps between design for quality of life, infection control/pandemic preparedness, and overall resilience. examining any new approaches to nursing home design through the lens of quality of life and resilience will help reduce fragility of long-term care and protect against ongoing infectious threats such as influenza or covid-19, or future pandemics. table 1 provides an overview of each spatial scale with proposed design solutions for consideration. although current gaps exist in the research for residential buildings for older adults and health outcomes, we propose a convergence between design for infection control and design for improved quality of life in order to yield resilience and subsequently, pandemic preparedness. although we recognize that issues around cost in the context of retrofitting existing facilities in addition to new construction are an important part of the necessary changes in nursing home living, monetary analysis is outside the scope of this paper. although costeffectiveness of using evidence-based design strategies in the acute care setting is well documented, 61 further exploration is needed in the area of nursing home design and health outcomes. the future of residential design for older adults should promote quality of life, social interaction, and engagement, but more importantly foster choice and collaboration with older adults. this culture of resilience and care must occur at various spatial scales and include individual buildings in addition to a broader integration within communities. resilient nursing home building design needs to respond to potential vulnerabilities and allow the built environment certain flexibility in the face of changing conditions. given the impending consequences of infectious outbreaks, it is imperative that health care leaders collaborate with architects and designers to invest in long-term care facility designs for maximum resiliency. collaboration between the health and design professions can yield design solutions that promote quality of life alongside pandemic preparedness and resiliency. overall neighborhood factors, public realm disconnection from, or location within poor-quality neighborhood or public realm. age-attuned urbanism that creates walkable, safe, accessible, and attractive neighbors as the nursing home context. air quality poor community or neighborhood air quality. local policies to reduced traffic emissions, or improve air quality, the presence/planting of urban trees. micro (site/building design) care model and overall building configuration large institutional settings that undermine quality of life and increase potential ingress of virus. small-scale homelike models that enhance wellbeing and reduce potential ingress of virus. access and internal circulation large settings with high-traffic levels, singular entrances/exits with high usage and contamination risk, lack of signage or information, lack of social distancing space in corridors. smaller settings with dedicated resident/visitor and staff access, contact free doors, generous circulation space and controlled traffic flow. key resident spaces shared rooms and bathrooms, poor-quality rooms, and lack of direct access to outside, infectionrelated restricted access to shared spaces and isolation. high-quality single rooms with outdoor spaces, carefully managed shared spaces, provision for transitional spaces, safe walking areas, and access and views to outside. staff space consolidated spaces currently provided (ie, central locker room, centralized care stations). decentralized care stations, ability to subdivide staff spaces and provision for respite areas to support mental health. outdoor areas and spaces to exercise lack of access to outdoors and nature, and lack of outdoor exercise areas. provision of safe, secure, and easily observed/ monitored outdoor space within easy access for all residents. air quality/ventilation poor ventilation and air quality. provision of high-quality natural and mechanical ventilation as required, carefully designed/ maintained hvac. an international definition for "nursing home living well in care homes: a systematic review of qualitative studies nursing home design: a misguided architectural model covid-19 in nursing homes smart lifts, lonely workers, no towers or tourists: architecture after coronavirus. the guardian how the covid-19 pandemic will change the built environment nursing homes are ground zero for covid-19 pandemic long-term care facilities and the coronavirus epidemic: practical guidelines for a population at highest risk coronavirus disease 2019 in geriatrics and long-term care: the abcds of covid-19 world health organization. mental health and psychosocial considerations during the covid-19 outbreak 2020 infection prevention and control guidance for long-term care facilities in the context of covid-19: interim guidance community presence as a key to quality of life in nursing homes the factors influencing the sense of home in nursing homes: a systematic review from the perspective of residents quality of life in nursing homes thriving in nursing homes in norway: contributing aspects described by residents well-being and lack of well-being among nursing home residents a three perspective study of the sense of home of nursing home residents: the views of residents, care professionals and relatives picture your nursing home: exploring the sense of home of older residents through photography examining resilience of quality of life in the face of health-related and psychosocial adversity at older ages: what is "right" about the way we age promoting resilience in dementia care: a person-centred framework for assessment and support planning disaster preparedness for seniors: a comprehensive guide for healthcare professionals resilient urban form: a conceptual framework geographical gerontology: perspectives, concepts, approaches the meaning of "aging in place" to older people the importance of place for older people moving into care homes housing-choicesfor-older-people-in-ireland-time-for-action-1.pdf nursing homes or besieged castles: covid-19 in northern italy a 10 step framework to implement integrated care for older persons talking while walking: an investigation of perceived neighbourhood walkability and its implications for the social life of older people the green house model of nursing home care in design and implementation activity-friendly neighbourhoods can benefit noncommunicable and infectious diseases planning and designing for pedestrians using mobility equipment covid-19: keeping things moving adverse effects of outdoor pollution in the elderly association between short-term exposure to air pollution and covid-19 infection: evidence from china characteristics of u.s. nursing homes with covid-19 cases how can pandemic spreads be contained in care homes? post-occupancy evaluation of a transformed nursing home: the first four green houseã� settings effect of design interventions on a dementia care setting small-scale homelike care in nursing homes sage advocacy submission to covid-19 nursing home expert panel sage advocacy how can pandemic spreads be contained in care homes guidelines for preventing respiratory illness in older adults aged 60 years and above living in long-term care: a rapid review of clinical practice guidelines. medrxiv occupancy assessment tool v3.0. available at european centre for disease prevention and control. infection prevention and control for covid-19 in healthcare settings e fourth update understanding infection prevention and control in nursing homes: a qualitative study managing the covid-19 pandemic in care homes for older people home/viewing-watching-observing-aging-and-the-architecture-of-intermediatespace outdoor environments at three nursing homes optimisation of vitamin d status for enhanced immunoprotection against covid-19 aerodynamic characteristics and rna concentration of sars-cov-2 aerosol in wuhan hospitals during covid-19 outbreak. biorxiv the open-air treatment of pandemic influenza mental health care for medical staff in china during the covid-19 outbreak uncovering the devaluation of nursing home staff during covid-19: are we fueling the next health care crisis? indoor air quality and thermal comfort in elderly care centers indoor air quality, ventilation and respiratory health in elderly residents living in nursing homes in europe a review of the research literature on evidence-based healthcare design novel coronavirus (covid-19) pandemic: built environment considerations to reduce transmission practical steps to improve air flow in long-term care resident rooms to reduce covid-19 infection risk fable hospital 2.0: the business case for building better health care facilities key: cord-333153-hjgf3ay8 authors: griffith, matthew f.; levy, cari r.; parikh, toral j.; stevens-lapsley, jennifer e.; eber, leslie b.; palat, sing-i t.; gozalo, pedro l.; teno, joan m. title: nursing home residents face severe functional limitation or death after hospitalization for pneumonia date: 2020-10-21 journal: j am med dir assoc doi: 10.1016/j.jamda.2020.09.010 sha: doc_id: 333153 cord_uid: hjgf3ay8 objectives: pneumonia is a common cause of hospitalization for nursing home residents and has increased as a cause for hospitalization during the covid-19 pandemic. risks of hospitalization, including significant functional decline, are important considerations when deciding whether to treat a resident in the nursing home or transfer to a hospital. little is known about postdischarge functional status, relative to baseline, of nursing home residents hospitalized for pneumonia. we sought to determine the risk of severe functional limitation or death for nursing home residents following hospitalization for treatment of pneumonia. design: retrospective cohort study. setting and participants: participants included medicare enrollees aged ≥65 years, hospitalized from a nursing home in the united states between 2013 and 2014 for pneumonia. methods: activities of daily living (adl), patient sociodemographics, and comorbidities were obtained from the minimum data set (mds), an assessment tool completed for all nursing home residents. mds assessments from prior to and following hospitalization were compared to assess for functional decline. following hospital discharge, all patients were evaluated for a composite outcome of severe disability (≥4 adl limitations) following hospitalization or death prior to completion of a postdischarge mds. results: in 2013 and 2014, a total of 241,804 nursing home residents were hospitalized for pneumonia, of whom 89.9% (192,736) experienced the composite outcome of severe disability or death following hospitalization for pneumonia. although we found that prehospitalization functional and cognitive status were associated with developing the composite outcome, 53% of residents with no prehospitalization adl limitation, and 82% with no cognitive limitation experienced the outcome. conclusions and implications: hospitalization for treatment of pneumonia is associated with significant risk of functional decline and death among nursing home residents, even those with minimal deficits prior to hospitalization. nursing homes need to prepare for these outcomes in both advance care planning and in rehabilitation efforts. pneumonia is a common cause of illness among nursing home residents, with approximately 1 case occurring for every 1000 days of nursing home care provided, prior to the current covid-19 global pandemic. 1 pneumonia was also the leading cause of hospitalization and death among nursing home residents, accounting for 40% of hospitalizations and 25% to 33% of deaths prior to the current pandemic. 2e7 the current global covid-19 pandemic has disproportionately affected american nursing home residents, with at least 1 in 11 nursing home residents suffering a confirmed sars-cov-2 infection, and has led to an increase in hospitalizations for pneumonia. 8 approximately 1 in 3 nursing home residents with covid-19 has been hospitalized, primarily because of pneumonia symptoms (cough, fever, and shortness of breath) and more than 1 in 4 (27%) has died. 9, 10 advance care planning for episodes of pneumonia was already challenging for residents and facilities; however, the uncertainty surrounding short and long-term effects of hospitalization for pneumonia during the current pandemic has amplified the difficulty of advance care planning. at the same time, centers for medicare & medicaid services (cms) considers pneumonia the leading cause of potentially avoidable hospitalizations among nursing home residents and penalizes nursing homes and hospitals for avoidable pneumonia readmissions. 11 the conflicting recommendation by triage tools and health care organizations makes it challenging for nursing home residents, their caregivers, and providers to make informed decisions about the most appropriate treatment decision. to reach informed decisions around hospitalization for pneumonia (including covid19) , residents, families, and caregivers must understand patient preferences, potential benefits, and potential harms. 12 functional decline is a potential harm of inpatient pneumonia care that must be factored into shared decision making regarding hospitalization for pneumonia. prior studies have found that functional decline is a potential outcome of hospitalization, particularly among patients with cognitive impairment. 13, 14 loss of a single activities of daily living (adl) is associated with a decline in health-related quality of life and an increased likelihood of requiring long-term nursing home care. 15 among patients with mild to moderate functional limitation at baseline, loss of 1 adl could have a profound effect on a patient's health-related quality of life and lead to the perception that such a loss would be "worse than death." 16, 17 although patients and their surrogates may be familiar with the risks of hospitalization for exacerbations of chronic diseases that they have suffered for many years (eg, chronic obstructive pulmonary disease or congestive heart failure), providing them with an estimate of functional outcomes following hospitalization for an unplanned acute illness like pneumonia allows for shared decision making through scenario planning. 18, 19 every nursing home resident whose care is paid for by medicare, medicaid, or the veterans health administration is evaluated using the minimum data set (mds), a federally mandated, validated instrument that assesses health conditions, disease diagnoses, treatments, and functional and cognitive status. 20 mds evaluations are completed on admission to the nursing home and quarterly thereafter, as well as at the time of acute changes in clinical status and readmission from a hospital. information from mds assessments submitted to cms. the mds assessment includes an evaluation of adl independence available prior to and following hospitalization to quantify functional decline in the perihospitalization period for nursing home residents. this study was designed to assist nursing home residents, surrogates, providers, and facilities conduct appropriate scenario planning to prepare for unplanned acute care hospitalizations, by describing functional decline among nursing home residents hospitalized for pneumonia and evaluating patient and hospitalization characteristics associated with severe functional decline and death. these findings will aid patients, families, and caregivers in advance care planning and decisions regarding hospitalization during the current pandemic. this study evaluated cms data for patients hospitalized with pneumonia identified using medicare part a claims submitted between january 1, 2013, and discharge by october 31, 2014. this was a retrospective cohort analysis of nursing home residents, receiving either post-acute or long-term care, hospitalized for pneumonia during their nursing home stay. after initially identifying all fee-for-service medicare beneficiaries with a claim submitted for hospitalization during the study period, patients were identified as nursing home residents based on the completion of a mds assessment during the 120 days prior to the index hospital admission. hospitalized nursing home residents were included if they had (1) a primary discharge diagnosis of pneumonia or a primary diagnosis of septicemia and secondary diagnosis of pneumonia associated with the hospitalization, (2) age 66 years; and (3) resided in united states (excluding puerto rico). we included patients with a primary diagnosis of sepsis and secondary diagnosis of pneumonia as there has been a substantial increase in coding patients with clinical signs and symptoms of pneumonia as having sepsis over the 10 years prior to the study. 21 nursing home residents were excluded if they were (1) discharged to another hospital following the index admission, as we sought to collect information for only 1 episode of inpatient care per patient, or (2) lacked an mds assessment submitted within 60 days following the index admission. the first claim submitted during the study period was considered the index hospitalization. this study was reviewed and approved by our institutional review board, who waived the requirement for patient consent. the primary outcome was a composite of severe functional limitation or death following hospitalization. severe functional limitation was defined as 4 or more adl impairments documented in the mds-adl long form scale completed posthospitalization. adl assessed bed mobility, transfer, locomotion, dressing, eating, toilet use, and personal hygiene. 22 most individuals with 4 or more adl limitations on this scale are functionally bed bound; therefore, we set this cutoff for our definition of severe functional limitation. 23 failure to perform an adl without assistance was considered an adl deficiency. death was defined as dying during the hospitalization or within 60 days of discharge. in order to identify whether hypothesized patient characteristics and comorbidities would be associated with functional decline following hospitalization, specific comorbidities and patient characteristics of interest were included in an a priori model. sociodemographic characteristics including age, race and ethnicity, sex, and state of residence were identified from the medicare beneficiary enrollment file. patient cognitive status, baseline adl limitations, active medical comorbidities contributing to the risk of functional limitation (dementia, cancer, aphasia, congestive heart failure, diabetes, stroke, paraplegia, hip fracture, renal failure, schizophrenia, and chronic lung disease) 24e26 and significant patient conditions, including weight loss (loss of 5% or more in last month or 10% or more in last 6 months), difficulty eating, and dependency on a feeding tube, were identified from the mds completed 120 days or less before the index hospitalization. the model included receipt of invasive mechanical ventilation using procedure codes (current procedural terminology [cpt]). bivariate analyses were performed to describe differences in baseline characteristics and characteristics of hospitalization between patients who did and did not experience the outcome. a multivariable logistic regression model was created to evaluate the association between covariates defined in our a priori model and our composite outcome of severe disability and death, adjusted for receipt of mechanical ventilation. analyses allowed for robust variance estimates to account for clustering of persons within hospitals. all data analysis was conducted in stata, version 15.0 (stata corp, college station, tx)). between january 1, 2013, and october 31, 2014, a total of 256,012 medicare beneficiaries were hospitalized for pneumonia with an mds completed within 120 days prior to hospitalization. among those patients, 41,505 (16.2%) did not have an mds completed within 60 days following discharge and did not die during that period, so they were excluded. among excluded patients, 13,822 (33.3%) were discharged to home, an assisted living facility, or an adult family home, 5356 (12.9%) were discharged to hospice care, and 7361 (17.7%) were readmitted to the hospital before their next mds assessment. the remaining 14,966 (36.1%) patients excluded from the cohort lacked an mds assessment submitted within 60 days but were discharged from the hospital alive and did not go to any of the previously listed locations. likely they were discharged to a nursing home but an mds was not submitted in a timely fashion. the resulting cohort consisted of 214,507 patients. among patients in this cohort, 56.0% (n ¼ 135,438) were female, 85.1% white (n ¼ 182,298), and 10.2% black (n ¼ 21,774), and had a mean age of 83.1 years (standard deviation 8.1) (table 1) . overall, the cohort had a high prevalence of cognitive impairment (cognitive performance score >2, 60.1%, n ¼ 129,005), and 10.1% (n ¼ 19,816) had a feeding tube. nearly half of patients (47.4%, n ¼ 101,791) had severe disability before hospitalization (table 2) . among the members of the cohort, 79,558 (37.1%) died during or within 60 days of hospitalization and 113,228 (52.8%) had severe disability following admission, for a total of 192,736 (89.9%) with the primary composite outcome. among patients without severe disability prior to hospitalization (<4 adl limitations, n ¼ 46,702), 66.3% (n ¼ 30,982) experienced the primary outcome of severe disability or death. the majority of patients with no prehospitalization adl limitations (52.5%) experienced the composite outcome, as did the majority of patients with all levels of prehospitalization functional limitation. among patients with severe disability prior to hospitalization, 96.4% (n ¼ 161,754) experienced the primary outcome and 39.3% (n ¼ 66,014) of these patients died during or within 60 days of hospitalization. severe functional limitation and dementia prior to hospitalization were associated with severe functional limitation or death following hospitalization for pneumonia (table 3) . adjusting for prehospitalization functional and cognitive status, male gender, race (black non-hispanic, asian, and hispanic), certain pre-existing medical comorbidities [congestive heart failure (adjusted odds ratio 1.07, 95% confidence interval 1.03-1. patients with pre-existing feeding tubes were not at increased risk of the outcome (0.98, 0.87-1.10). patients who received mechanical ventilation during the hospitalization were at increased risk of the outcome (1.24, 1.19-1.29). being admitted from a stay in long-term care (admissions not following a prior hospitalization) was associated with increased risk of the primary outcome (1.14, 1.10-1. 19 ). in the largest study to date of functional decline following hospitalization for nursing home residents, we found that most residents hospitalized for pneumonia developed severe disability or died. notably, among those with no prehospitalization functional limitation, the majority developed significant disability or experienced death by 60 days following hospitalization. individuals with severe cognitive, physical or neurologic dysfunction prior to hospitalization were at the greatest risk of severe disability or death. these findings suggest that, during the current pandemic, nursing homes must plan for the influx of a high proportion of nursing home residents returning with severe functional limitation requiring a higher level of care. additionally, during this time, when admitting new residents or readmitting former residents, providers should discuss likely outcomes following hospitalization for pneumonia to inform advance care planning. our findings build on prior studies demonstrating persistent functional decline following hospitalization for infectious and noninfectious acute care admissions among community-dwelling older adults, particularly for those with cognitive and functional impairment assessed on admission. 13,14,27e32 these studies have demonstrated that almost every group of older adults is at risk for a perceptible decline in function following hospitalization that can last for months after discharge or become permanent. however, because community dwelling adults do not undergo detailed functional assessments as performed as part of the mds, these studies relied on patient or caregiver report of functional status at the time of hospitalization or most recent primary care assessment of functional status. use of mds data ensured that we had an accurate assessment of function as close to the time of admission as possible, and a similarly accurate assessment following hospitalization. the few prior studies of functional decline among nursing home patients following pneumonia have relied on assessments performed up to 6 months prior to admission or performed assessments of functional status at the time of discharge, which may have over-or underestimated the severity of function in the days to weeks following discharge. 33, 34 this study is the first to use mds data to characterize functional decline following hospitalization for pneumonia for the entire spectrum of patients in nursing homes, including patients with few functional and cognitive limitations receiving post-acute care and those with more severe baseline limitations residing in long-term care. engaging nursing home residents and their families in advance care planning reduces bothersome or burdensome care received at the end of life and improves family member and caregiver satisfaction with care at the end of life. 35e38 however, approximately 4 of 10 nursing home residents fail to have any advance care plan documented. 39, 40 a major barrier to advance care planning is choosing the correct time to initiate it. discussions occurring too early may not accurately reflect patient preferences over time and discussions that occur too late fail to protect patients from receiving care that was not consistent with their wishes. 41 when informed about the high likelihood of a poor outcome, nursing home residents, their families, and their providers are more likely to engage in advance care planning. 42 our study demonstrates that nursing home admission, particularly with individuals suffering from cognitive and physical limitations who are admitted for long-term care, is likely the right time to initiate advance care planning around the decision to hospitalize for covid or other pneumonias, as we found that residents are more likely to experience functional decline or death at 60 days following hospitalization than individuals diagnosed with metastatic nonesmall cell lung cancer. 43 presently, only 6% to 7% of nursing home residents have documented do-not-hospitalize orders, with the proportion ranging from 4% among those with mild cognitive impairment to 8% to 9% among those with severe impairment. 39,44e46 we anticipate that once aware of how poor prognosis is after hospitalization, nursing home residents, their families, and their providersdwho are already concerned about visitation limitations once hospitalized for coviddwill be more likely to engage in advance care planning and the decision not to hospitalize, rather than delay these discussions. do-not-hospitalize orders can be effective in preventing hospitalization and burdensome treatment for covid or other causes of pneumonia, particularly given the stresses of relocation to the hospital and the limited contact family members and caregivers may have with their loved one once hospitalized; however, many patients and families change their minds during episodes of acute illness and agree to hospitalization regardless of documented preferences. 39,47e50 we believe that, in many cases, this is the result of a lack of appropriate scenario planning between patients, their families or caregivers, and nursing home providers. as our findings suggest that the risk of severe functional limitation and death varies among patient populations, there are specific populations of patients that are at greater risk for severe functional limitation and death following hospitalization for pneumonia, suggesting that scenario planning during advance care planning conversations could include discussion of these risk factors when making decisions about covid hospitalization and do-nothospitalize orders. there are limitations to this study. first, all patients in our study were hospitalized for pneumonia. most nursing home residents who develop pneumonia (w65%) are treated in their facility rather than in the hospital. 45, 51, 52 despite this, septicemia and pneumonia remain the most common reasons for hospitalization of nursing home residents. 53 we were unable to reliably identify individuals treated for pneumonia in the nursing home; however, prior observational studies have demonstrated that individuals hospitalized for pneumonia are no more likely to survive than those treated in facilities and likely experience a reduction in quality of life after hospitalization. 45, 54 additionally, fewer than 1 in 10 residents with critical illness due to pneumonia are hospitalized, suggesting that our cohort of patients may not have had more severe disease than those treated in facilities. 52 therefore, it is plausible that we would not find a difference in mortality between the cohort of patients included in this study and those who were treated in the facility. 55 second, few if any individuals were hospitalized for viral pneumonia due to coronaviruses such as covid-19, sars, or mers. despite this, we can generalize that the severity of disease and prognosis among those included in our study was similar to those hospitalized with covid pneumonia, as we found an overall mortality of 37%, higher than the overall mortality for nursing home residents with covid (27%). at this time, there are no estimates of inpatient mortality for nursing home residents with covid to provide a direct comparison. third, we may not have captured all hospitalizations during which pneumonia was treated, as we only looked for individuals with a primary diagnosis of pneumonia or septicemia. patients with hospital-acquired pneumonia or ventilator-associated pneumonia likely were not included in our study; however, our primary interest was to identify patients who would benefit from scenario planning in the event of pneumonia and not to identify those who acquired pneumonia during a hospital transfer for another indication (eg, stroke, myocardial infarction, or hip fracture). because of the high prevalence of comorbid medical conditions, functional limitations, and dementia, nursing home residents are at risk for severe complications resulting from covid-19. therefore, it is crucial to discuss possible outcomes of seemingly routine care with patients and their families well in advance so that appropriate decisions can be made in times of acute illness. the results of this study should inform patient and family decisions regarding hospitalization for covid-19 and other causes of pneumonia at the time of admission to the nursing home as well as inform planning for a high proportion of hospitalized patients returning with new or significantly worsened functional limitations. further research evaluating severity and duration of decline caused by covid-19erelated pneumonia from other etiologies is warranted as there are additional comorbidities associated with covid-19 such as thrombosis and myocarditis that may exacerbate functional loss. 56, 57 additionally the social isolation resulting from covid-related closures of nursing homes to outside visitors, leading to functional and cognitive decline among individuals without acute illnesses, warrants further study as well. pneumonia in residents of long-term care facilities: epidemiology, etiology, management, and prevention potentially avoidable hospitalizations for elderly long-stay residents in nursing homes potentially avoidable hospitalizations of dually eligible 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residents: results from the incur study changes in physical function after hospitalization in patients with nursing and healthcare-associated pneumonia end-of-life transitions among nursing home residents with cognitive issues satisfaction with end-of-life care for nursing home residents with advanced dementia improving the end-of-life for people with dementia living in a care home: an intervention study systematic implementation of an advance directive program in nursing homes: a randomized controlled trial are hospital/ed transfers less likely among nursing home residents with do-not-hospitalize orders? advance directives among nursing home residents with mild, moderate, and advanced dementia strategic targeting of advance care planning interventions: the goldilocks phenomenon improving end-of-life outcomes in nursing homes by targeting residents at high-risk of mortality for palliative care: program description and evaluation survival by histologic subtype in stage iv nonsmall cell lung cancer based on data from the surveillance, epidemiology and end results program racial differences in hospitalizations of dying medicare-medicaid dually eligible nursing home residents the cost-effectiveness of the decision to hospitalize nursing home residents with advanced dementia advance directives in nursing home residents aged > or ¼65 years: united states interventions associated with the management of suspected infections in advanced dementia changes in care goals and treatment orders around the occurrence of health problems and hospital transfers in dementia: a prospective study call the family instead of calling the ambulance do-not-hospitalize orders for individuals with advanced dementia: healthcare proxies' perspectives effects of nursing home ownership type and resident payer source on hospitalization for suspected pneumonia a multifaceted intervention to implement guidelines did not affect hospitalization rates for nursing home-acquired pneumonia transitions between nursing homes and hospitals in the elderly population does hospitalization impact survival after lower respiratory infection in nursing home residents? pneumonia management in nursing homes: findings from a cms demonstration project thrombosis in hospitalized patients with covid-19 in a new york city health system clinical predictors of mortality due to covid-19 based on an analysis of data of 150 patients from wuhan, china key: cord-270254-dp7z1kla authors: inzitari, marco; udina, cristina; len, oscar; ars, joan; arnal, cristina; badani, hugo; davey, vanessa; risco, ester; ayats, pere; de andrés, ana m.; mayordomo, cristina; ros, francisco j.; morandi, alessandro; cesari, matteo title: how a barcelona post-acute facility became a referral center for comprehensive management of subacute patients with covid-19 date: 2020-06-11 journal: j am med dir assoc doi: 10.1016/j.jamda.2020.06.015 sha: doc_id: 270254 cord_uid: dp7z1kla abstract the covid-19 pandemic’s greatest impact is among older adults. management of the situation requires a systemic response, and post-acute care (pac) can provide an adequate mix of active treatment, management of associated geriatric syndromes and palliative care, both in the acute phase, and in post-covid-19 recovery. in the region of catalonia, spain, selected pac centers have become a site to treat covid-19 older patients. referrals come from the emergency department (ed) or covid-19 wards of the acute reference hospitals, nursing homes or private homes. we critically review the actions taken by parc sanitari pere virgili, a pac facility in barcelona, to manage the pandemic, including its administration, healthcare, communication, psychological support and ethical frameworks. we believe that the strategies we employed and the lessons we learned can be useful for other sites and countries where similar adaptation of existing facilities may be implemented. brief summary: the paper describes how a large post-acute care facility in 23 barcelona, was adapted at the outbreak of the covid 19 pandemic to become 24 a polyvalent reference center for older covid-19 patients assessed as not 25 requiring intensive care. 26 key word: covid-19, post-acute care, older adults, geriatrics, geriatric 27 syndromes, palliative care 28 funding source: this research did not receive any funding from agencies in 29 the public, commercial, or not-for-profit sectors. 30 acknowledgements: we acknowledge the staff working at parc sanitari pere 31 virgili during the covid-19 pandemic, including healthcare professionals as 32 well as support staff and central services from this and external institutions. table 1) . the facility receives around 75% of admissions 99 directly from the ed or wards of two major acute university hospitals (vall 100 d'hebron and clinic hospitals, serving around 900.000 inhabitants), and 25% 101 from primary care. pspv was adapted to admit acutely ill patients in response to the pandemic. from pspv with other specialists (infectious diseases, oncology) from vall d'hebron university hospital. nursing staff ratios were increased through 106 internal reorganization ( table 1) severe outcomes among patients with coronavirus disease 2019 (covid-19) -united states articles estimates of the severity of coronavirus disease 2019: a model-based analysis covid-19 and older adults: what we know the geriatrician: the frontline specialist in the treatment of covid-19 patients cross-country comparison of case fatality rates of covid-19/sars-cov-2. osong public heal res perspect coronavirus disease 2019 in geriatrics and long-term care: the abcds of covid-19 editorial: covid-19 and older adults covid-19 in older adults atypical covid 19 presentations in frail older adults the course of geriatric syndromes in acutely hospitalized older adults: the hospital-adl study dementia care during covid-19 risk factors and outcomes of delirium in older patients admitted to postacute care with and without dementia age, complexity, and crisis -a prescription for progress in pandemic epidemiology of covid-19 in a long-term care facility in king county, washington postacute care preparedness for covid-19 frailty, severity, progression and shared decision-making: a pragmatic framework for the challenge of clinical complexity at the end of life proof of concept: nursing home specialist in action. the impact of full-time physician services in postacute care geriatric screening tools to select older adults susceptible for direct transfer from the emergency department to subacute intermediate-care hospitalization rehabilitation profiles of older adult stroke survivors admitted to intermediate care units: a multi-centre study hospital-athome integrated care programme for the management of disabling health crises in older patients: comparison with bed-based intermediate care the catalonia who demonstration project of palliative care: results at 25 years (1990-2015) asymptomatic and presymptomatic sars-cov-2 infections in residents of a long-term care skilled nursing facility comprehensive geriatric assessment for older adults admitted to hospital a global clinical measure of fitness and frailty in elderly people management of avoidable acute transfers from an intermediate care geriatric facility to acute hospitals: critical aspects of an intervention protocol good care of dying patients: the alternative to physician-assisted suicide and euthanasia covid-19 in italy: ageism and decision making in a pandemic the emotional impact of coronavirus 2019-ncov (new coronavirus disease) effect of exercise intervention on functional decline in very elderly patients during acute hospitalization: a randomized clinical trial consideracions sobre la limitació de recursos i decisions clíniques en la pandèmia covid19.; 2020 asymptomatic spread of covid'19 in 97 patients at a skilled nursing facility. jamda 2020. in press presymptomatic sars-cov-2 infections and transmission in a policy recommendations regarding skilled nursing facility management of covid-19: lessons from new york state key: cord-272772-zqmychmr authors: stall, nathan m.; johnstone, jennie; mcgeer, allison j.; dhuper, misha; dunning, julie; sinha, samir k. title: finding the right balance: an evidence-informed guidance document to support the re-opening of canadian nursing homes to family caregivers and visitors during the covid-19 pandemic date: 2020-08-03 journal: j am med dir assoc doi: 10.1016/j.jamda.2020.07.038 sha: doc_id: 272772 cord_uid: zqmychmr abstract during the first few months of the covid-19 pandemic, canadian nursing homes implemented strict no-visitor policies to reduce the risk of introducing covid-19 in these settings. there are now growing concerns that the risks associated with restricted access to family caregivers and visitors have started to outweigh the potential benefits associated with preventing covid-19 infections. many residents have sustained severe and potentially irreversible physical, functional, cognitive, and mental health declines. as canada emerges from its first wave of the pandemic, nursing homes across the country have cautiously started to reopen these settings, yet there is broad criticism that emerging visitor policies are overly restrictive, inequitable and potentially harmful. we reviewed the nursing home visitor policies for canada’s ten provinces and three territories as well as international policies and reports on the topic to develop evidence-informed, data-driven and expert-reviewed guidance for the re-opening of canadian nursing homes to family caregivers and visitors. for nursing homes. 2, 3 as the community prevalence of covid-19 continues to decrease in 23 canada, and regions across the country begin phased re-openings, experts and advocates have 24 grown increasingly concerned that subsequent visiting policies and family caregiver access to 25 nursing home settings remain overly restrictive, causing substantial and potentially irreversible 26 harm to the health and wellbeing of residents. 4 a more balanced approach is needed that both 27 prevents the introduction of covid-19 into nursing homes, but also allows family caregivers 28 and visitors to provide much needed contact, support and care to residents, to maintain their 29 overall health and wellbeing. 30 we reviewed the emerging nursing home visitor policies issued by canada's ten provincial and 32 three territorial governments (see appendix 1) as well as international policies and guidance on 33 the topic in order to recommend, evidence-informed and data driven guidance to support a 34 balanced, risk-mitigated re-opening of canadian nursing homes to family caregivers and 35 visitors. 5 while this guidance is specific to nursing homes, many of the guiding principles and 36 planning assumptions presented in this document could be applied to other congregate settings 37 such as retirement homes and group homes. 38 39 these efforts should be executed with the support and input of family caregivers, existing 40 resident and family councils as well as from nursing home medical directors, administrators, 41 involved primary care and specialist providers, and local ipac and public health leadership. we 42 also recognize that reopening nursing homes will require additional resources including 43 government funding for personal protective equipment (ppe), covid-19 testing, and addressing 44 chronic staffing shortages to support visitor protocols. importantly, homes must ensure that 45 existing care resources are not reduced to support this implementation, which could negatively 46 impact resident care, especially for those residents who do not have family caregivers or visitors. 47 48 family caregiver: is any person whom the resident and/or substitute decision-maker identifies 51 and designates as their family caregiver. as essential partners in care, they can support feeding, 52 mobility, personal hygiene, cognitive stimulation, communication, meaningful connection, 53 relational continuity, and assistance in decision-making. 4 54 55 essential support worker: is a person performing essential support services (e.g., food delivery, 56 inspector, maintenance, or personal care or health care services such as phlebotomy or medical 57 imaging). 6 general visitor: is neither a family caregiver nor an essential support worker and is "visiting" 60 primarily for social reasons. 6 in reviewing the literature, consulting with national and international experts (see 65 acknowledgements), and hearing from both residents, and their family caregivers and visitors 66 through various forums, we have identified six core principles and planning assumptions as 67 foundational and fundamental to any current and future guidelines. these recommendations 68 focus on family caregivers and general visitors rather than essential support workers and nursing 69 home staff, and are made with the acknowledgement that the approach to visiting may need to be 70 dynamic based on the community prevalence of covid-19. 71 72 1. policies must differentiate between "family caregivers" and "general visitors". residents, 73 determine who is essential to support them in their care. 75 it is imperative that visitor policies identify and distinguish "family caregivers" from "general 77 visitors" who are visiting primarily for social reasons. while socialization is certainly important, 78 family caregivers as partners in care should be prioritized to support resident health and 79 wellbeing. family caregivers are those individuals who assume essential caregiving 80 responsibilities for a spouse, family member, or friend who needs help because of limitations in 81 their physical, mental, or cognitive functioning, and are essential to meeting the needs of 82 residents especially in the face of chronic staffing shortages. [8] [9] [10] [11] [12] [13] family caregivers also help 83 ensure that all residents receive culturally safe and appropriate care, especially for lgbtq2s+ 84 and indigenous residents and/or those with language barriers. importantly, while the term family 85 caregiver is widely used, it is important to recognize that approximately 15% of all caregivers are 86 not related to their care recipients, including some who may be privately hired. 8 the importance 87 of identifying family caregivers is that they are not accessing the nursing home primarily for 88 social reasons, but rather to provide services and care such as assistance with feeding, medical 89 decision-making, and management of responsive behaviours among residents living with 90 dementia. 14 91 while the definition of family caregiver has been operationalized in various ways, in a resident-93 centred and caregiver-partnered long-term care system, residents must have the sole authority 94 and autonomy to determine who is essential to support them in their care; substitute decision 95 makers should make this determination for incapable residents. 4 this differs from approaches 96 such as those used in australia that have relied on identifying family caregivers as those 97 individuals with a clearly established and regular pattern of involvement in contributing to the 98 care and support of residents prior to the covid-19 pandemic. 15 this definition fails to 99 recognize that some individuals may be willing and able-or need to-assume caregiving 100 responsibilities to assist with special care needs and staffing shortages that have been further 101 aggravated during the covid-19 pandemic, or provide care which they may not have been able 102 to previously. it also fails to recognize that as conditions change during a pandemic, so too might 103 a resident's desire or need for support change, and their ability to designate family caregivers 104 must be flexible, consistent with their ongoing right to choose. it also fails to address that 105 limiting or eliminating congregate dining and recreational activities during the covid-19 106 pandemic may now necessitate that those who were once "general visitors" become "family 107 caregivers" to better address unmet resident needs. 108 other definitions being proposed also violate the principles of resident-centred and caregiver-110 partnered care, including those that identify family caregivers as those individuals providing 111 services that would otherwise require a private duty caregiver; this definition could be open to 112 interpretation and a source of disagreement between nursing homes, residents and their 113 families. 14,16 114 115 given there are both diverging definitions and interpretations of who constitutes a family 116 caregiver, residents, substitute decision makers and their families must retain the authority and 117 autonomy to designate their own family caregivers and this should be clearly documented in the 118 resident's care plan and record. 4 initially, each resident should be supported in allowing the 119 reintroduction of at least two family caregivers, and these individuals should receive a caregiver 120 identification card or badge. 17,18 121 125 strict blanket 'no visitor' policies were enacted early on during the pandemic with the 126 recognition that visitors were potential vectors for the introduction of covid-19 infection into 127 nursing homes and transmission back into the wider community. 19 when these policies were 128 implemented, nursing homes were more vulnerable to covid-19 outbreaks for several reasons: 129 1) the extent of asymptomatic transmission and atypical presentations of covid-19 were not 130 fully appreciated, 2) access to timely and comprehensive covid-19 testing was limited, 131 impairing homes ability to identify outbreaks, and determine scale and scope, including 132 symptomatic and asymptomatic cases, 3) many homes had not fully adopted robust ipac 133 approaches including universal masking of staff and enabling them to work at only one 134 healthcare setting, and 4) access to ppe was more limited. 20-22 135 136 now that many homes are working to address these deficiencies, it is essential that we also focus 137 on the considerable detrimental effects of the ongoing lockdown of nursing homes and restricted 138 access to family caregivers and general visitors. 23, 24 many residents have experienced severe and 139 potentially irreversible functional and cognitive declines, deteriorations in physical and mental 140 health, severe loneliness and social isolation, worsening of responsive behaviours and increased 141 use of psychotropic medications and physical restraints. [24] [25] [26] [27] worse, many residents have died 142 alone without family present to support end-of-life needs. while virtual visiting was 143 implemented to try and meet the psychosocial needs of residents, it is no substitute for family 144 caregivers who prior to the lockdown were providing substantial care and support for many 145 residents. 146 147 these negative outcomes have raised concerns that the risks associated with ongoing blanket 148 visitor restrictions outweigh the benefits associated with preventing covid-19 outbreaks in 149 nursing homes, particularly in canadians jurisdictions with low rates of community 150 transmission. 2 additionally, these restrictions may be violating the autonomy of residents and 151 their right to make informed and risk-based decisions which prioritize their access to visitors 152 over the risks of them contracting covid-19. in ontario, the long-term care homes act 153 recognizes the right of every resident to "receive visitors of his or her choice…without 154 interference", which is legally required and enforceable under contract as set out in the act. 28 155 there are also several active legal challenges across the country arguing that fundamental 156 resident and human rights are being violated. 29 visitor policies must prioritize equity over equality, recognizing that a "one size fits all" 170 approach is neither optimal nor practical. whereas equality would mean giving all nursing home 171 residents the same access to visitors, equity means giving nursing home residents the right 172 amount of access they need to maintain their health and wellbeing. 7 importantly, visitor policies 173 must not prioritize the convenience of the nursing homes over the best interests of their residents 174 in receiving the care and support of family caregivers and visitors. 175 176 nursing homes must reserve the right to create and implement visitor screening protocols 177 consistent with local public health guidance and procedures for visits that maintain the safety and 178 wellbeing of all residents and staff members. however, blanket implementation of policies must 179 be avoided, and instead policies uniquely supporting family caregivers and general visitors must 180 be both flexible and compassionate, recognizing that some of the new conditions and procedures 181 surrounding visiting may not work for all residents, family caregivers and visitors. 15, 31, 32 this 182 includes providing flexibility around the timing of visits (e.g., some visitors may have work and 183 other caregiving duties), the location of visits (e.g., some residents and/or visitors may not be 184 able to tolerate outdoor visits because of inclement weather and/or bedbound status), the length 185 or frequency of visits (e.g., as some visitors may be traveling long distances, longer visits should 186 be considered), absolute restrictions on physical contact (e.g., some residents with cognitive 187 impairment and/or behavioural issues may neither be able to understand nor comply with 188 physical distancing). 15 it is imperative that individual homes, with the support of local health authorities and public 215 health units, collect and report data on covid-19 cases as it relates to reopening. in canada, the 216 national institute on ageing long-term care covid-19 tracker could support this (https://ltc-217 covid19-tracker.ca). 33 it is recognized that many decisions about balancing different risks to 218 residents, staff, family caregivers and visitors to nursing homes are difficult. however, it is also 219 true that it is less difficult to impose restrictions than it is to remove them. public health and 220 governmental authorities should also be actively working to use modelling and evidence to 221 remove visitor restrictions as quickly as possible as regional community prevalence declines. in order to find the right balance between infection prevention and supporting resident health and 257 wellbeing, the six core principles and planning assumptions described in this guidance document 258 were used to create recommended, evidence-informed, and expert-reviewed visitor policies for 259 family caregivers (table 1 ) and general visitors ( table 2 ) to nursing homes. 260 all authors meet the international committee of medical journal editors (icmje) criteria for authorship and have no competing interests, financial or otherwise. recommended policy 1. defining an "family caregiver" • residents, substitute decision makers and their families must retain the authority and autonomy to determine who is essential to support them in their care and designate their own family caregivers. 4 • governments, public health authorities and homes must not define who is a family caregiver, especially on the basis of either an individual's caregiving involvement and role prior to the pandemic or by identifying those individuals providing services that would otherwise require a private duty caregiver. • a resident may designate at least two family caregivers. • similar to guidance from alberta health services, a resident may identify a temporary replacement family caregiver if the primary designated family caregivers are unable to perform their roles for a period of time; the intent is not for designates to change regularly or multiple times but to enable a replacement, when required. 36 3. allowable number of family caregivers in the nursing home at one time • one family caregiver per resident should be allowed in the home at a time. • under extenuating circumstances (i.e., end-of-life), this allowable number should be flexible. • as essential partners in care, family caregivers should have access to areas both outside and inside the home (similar to staff members) but must maintain physical distancing from other residents and staff. they should be provided with an individualized caregiver identification and/or badge, and must abide by all ipac and ppe requirements and procedures concerning staff members of the home. 17,18 • in order to promote relational continuity and meet the ongoing needs of residents, family caregivers should still have access to the home during a covid-19 outbreak, as long as the following conditions are met: -the family caregiver attests that they understand and appreciate they are entering a home under outbreak and that they may be at increased risk of covid-19 infection -they must be trained in ipac procedures and the proper use of ppe and abide by all outbreak-related policies that apply to staff members of the home. • no restrictions as long as it does not negatively impact the care of other residents or the ability of other family caregivers to provide care and support. • as partners in care, family caregivers should be subjected to the same covid-19 screening requirements as nursing home staff. if asymptomatic covid-19 testing is recommended, family caregivers should be provided with the same access to testing as staff members of the home. • as partners in care, family caregivers should receive an orientation and be educated and trained to follow the same ipac and ppe requirements and procedures as staff members of the home, including remaining masked at all times. 3 the ottawa hospital has designed a ppe training video specifically for family caregivers: www.youtube.com/watch?v=gkayc5wcn0c&feature=youtu.be • homes must maintain ample ppe supply to enable family caregivers' participation in care. • failure of family caregivers to comply with these procedures could be grounds for loss of their rights to participate in care as family caregivers, which should be appealable. • outdoors: similar to guidance from the saskatchewan health authority, outdoor visits can include more than one visitor at a time, provided that physical distancing can be maintained. additionally, family members from the same household and/or bubble should not have to physically distance from one another. • indoors: one visitor per resident in the home at a time. similar to guidance from the british columbia centre for disease control, a visitor who is a child may be accompanied by one parent, guardian or family member. 37 • outdoor visits should be prioritized, when possible and feasible, to both minimize the risk of covid-19 transmission and to maximize the number of possible visitors. provinces like manitoba plan to construct outdoor, all-season visiting shelters. 38 • when outdoor visits are not feasible for either the resident or the visitor (e.g. for cognitive, psychiatric or physical reasons), the home must provide an indoor alternative which provides ample open space for physical distancing and adequate ventilation. • exceptional circumstances may sometimes necessitate the visitor meeting the resident in their room, but this should be a last resort if none of the previously noted alternative options are deemed feasible. • if the home goes into covid-19 outbreak status, general visits may need to be temporarily suspended (if advised by the local public health authority), but if the outbreak does not involve the entire home, consideration should be given to suspending visits only on the floor or unit under outbreak. virtual visits must be upscaled during suspensions of in-persons visits. • as per the ontario ministry of long-term care, visits should be at least 60 minutes/visit and residents should have access to visitors at a minimum of once per week. 39 • visitors must pass an active screening questionnaire (which may include an on-site temperature check) but there should be no requirement for covid-19 testing for outdoor and physically distanced visits. if exceptional circumstances necessitate a visitor entering the resident's room, they should be subject to the same screening and testing requirements as family caregivers. • visitors must remain masked (cloth or surgical/procedure for outdoor visits and surgical/procedure for indoor visits) at all times and maintain at least 2 metres of physical distance from the resident they are visiting. visitors should be encouraged to bring their own cloth masks for outdoor visits, but appearing without a mask should not be a barrier to visiting. • if masking of visitors causes distress to the resident (e.g. for cognitive or mental health reasons) or poses difficulties with either recognizing (e.g. cognitive impairment) or understanding the resident (e.g. hearing-impaired residents who rely on lipreading) a face shield which wraps around the chin or a transparent mask can be considered as alternatives. • consideration may be given to allowing brief hugs and handholding while maintaining as much distance as possible between the faces of the resident and visitor, and ensuring the availability of alcohol-based hand sanitizer for prompt and effective hand hygiene both immediately before and after these encounters. 40 • homes must maintain ample ppe supply to enable resident visits. • failure of visitors to comply with procedures could be grounds for a loss of visiting rights, which should be appealable. • visitors must have access to bathrooms (an accessible outdoor sheltered bathroom or designated indoor bathroom). • outdoor visiting must occur in weather protected settings (e.g. a shaded area with hydration for hot weather, a sheltered area for rain, or a heated area for colder weather). • residents designated as being "critically ill" or at "end-of-life" (<14-day life expectancy) should be provided with the same level of access that would be rendered to a family caregiver. if visitors need to enter the home under these circumstances, they should be subject to the same conditions and procedures as "family caregivers". ipac guidance will be provided. 7. end-of-life considerations: -designated essential visitor is permitted to visit "as much as required". -there is no limit on the number of different individuals who can visit overall, but visits must be coordinated with the care team and the site. -up to two designated family/ support persons at a time are allowed to visit as long as physical distancing can be maintained between the family/support persons. *may leave the home for medically necessary care or treatment. yes, defined as: -visits considered paramount to resident care and well being, such as assistance with feeding, communication, personal care, emotional support or mobility. -existing registered volunteers providing services as described above only. yes, defined as: -"caregivers who provide or would like to provide significant assistance and support to a loved one to meet their needs and contribute to their integrity and well-being. assistance and support may include: helping with meals; supervising and being attentive to the person's overall condition; providing support with various daily or recreational activities; assistance with walking; providing moral support or comfort". -a significant caregiver…residents must have received support from the person before visiting restrictions were put in place due to covid 19. -visitors are only allowed in chslds, intermediate or family-type resources (sapa program) or private seniors' homes without a covid-19 outbreak. a visitor is anyone who wants to visit the person in the home and who does not meet the criteria to be identified as a caregiver. 1. may designate more than one essential family caregiver. 2. a maximum of two essential family caregivers from the same household can be in the home at a time. 3. yes, as of june 18, 2020. 4. no limit on frequency or on length of time. 5. self-monitoring of symptoms. no testing requirement. most sign a consent form stating that "their decision was informed and voluntary, with full knowledge of the associated risks and knowing that they could become infected during their visits or even infect their loved one." 6. must remain continuously masked and wear ppe as required. will be given a face shield. training of visitors and procedural masks must be available in sufficient quantity for visits to be allowed. 7. compassionate visits will be permitted when death is imminent (24-48 hours). a maximum of two visitors are allowed at one time. pandemic experience in the long-term care sector: how does canada compare with other countries? family presence in older adult care: a statement regarding family caregivers and the provision of essential care infection prevention and control for covid-19: interim guidance for long term care homes better together: re-integration of family caregivers as essential partners in care in a time of covid-19 easing lockdowns in care homes during covid-19: risks and risk reduction. ltccovid, international long-term care policy network ontario ministries of health and long-term care. covid-19 directive #3 for long-term care homes under the long-term care homes act challenges, solutions and future directions in the evaluation of service innovations in health care and public health words matter: the language of family caregiving families caring for an aging america nothing informal about family caregiving we should care more about caregivers considerations on caring for caregivers in an aging society why canada needs to better care for its working caregivers essential family caregivers in long-term care during the covid-19 pandemic registered nurses' association of ontario. person-and family-centred care the change foundation. the caregiver identification (id) program and family presence policy the ontario caregiver organization. partners in care: a resource for welcoming back caregivers to hospitals and long-term care epidemiology of covid-19 in a long-term care facility in king county, washington presymptomatic sars-cov-2 infections and transmission in a skilled nursing facility typically atypical: covid-19 presenting as a fall in an older adult a hospital partnership with a nursing home experiencing a covid-19 outbreak: description of a multiphase emergency response in toronto groupe de recherche et d'etude des maladies infectieuses -paris s-e. severe acute respiratory syndrome coronavirus 2 (sars-cov-2)-related deaths in french long-term care facilities: the "confinement disease" is probably more deleterious than the coronavirus disease-2019 (covid-19) itself detrimental effects of confinement and isolation on the cognitive and psychological health of people living with dementia during covid-19: emerging evidence international long-term care policy network loneliness and isolation in long-term care and the covid-19 pandemic nursing homes or besieged castles: covid-19 in northern italy loneliness and social isolation during the covid-19 pandemic ontario government warned that isolating seniors is elder abuse and violates the charter legal warnings issued to long-term care homes who continue to isolate seniors one person per resident. 3. not specified. 4. not specified. 5. must be screened upon entry and includes temperature checks must be supported by staff in appropriately using ppe maximum of two visitors at a time outdoor visits only in designated areas on the grounds must wear a non-medical mask and maintain physical distancing. must follow ipac guidelines. may remove mask once at the designated visiting area if physical distancing can be maintained and if needed for effective communication documents/covid-19-management-in-long-term-care-facilities-directive.pdf 3 indoors and outdoors self-monitoring of symptoms must remain continuously masked in the home and wear ppe as required. training of visitors and procedural masks must be available in sufficient quantity for visits to be allowed we gratefully acknowledge the numerous experts who reviewed and commented on this guidance -their names are listed below. none of them received compensation for their contributions. *residents allowed outside as long as they are physically distancing.yes, defined as:-where the resident's quality of life and/or care needs cannot be met without the assistance of the "designated essential visitor".-may be a family member, friend, religious and spiritual advisor or paid caregiver. appendix 1: nursing home visitor policies for canada's ten provinces and three territories (as of july 14, 2020) 6 . creative solutions:-some homes to set up large, 3-sided plexiglass cube that will shield residents from their visitors to allow for enhanced communication; -plans to add disposable gloves that would 'poke through' the plexiglass allowing families to hug; -large, marquis-style tents that will be put up in the gardens and available in the rain or shine. key: cord-345864-87b5qdjx authors: rudolph, james l.; halladay, christopher w.; barber, malisa; mccongehy, kevin; mor, vince; nanda, aman; gravenstein, stefan title: temperature in nursing home residents systematically tested for sars-cov-2 date: 2020-06-09 journal: j am med dir assoc doi: 10.1016/j.jamda.2020.06.009 sha: doc_id: 345864 cord_uid: 87b5qdjx abstract objectives many nursing home residents infected with sars-cov-2 fail to be identified with standard screening for the associated covid-19 syndrome. current nursing home covid-19 screening guidance includes assessment for fever defined as a temperature of at least 38.0°c. the objective of this study is to describe the temperature changes before and after universal testing for sars-cov-2 in nursing home residents. design cohort study setting and participants: the veterans administration (va) operates 134 community living centers (clc), similar to nursing homes, that house residents who cannot live independently. va guidance to clcs directed daily clinical screening for covid-19 that included temperature assessment. measures all clc residents (n=7325) underwent sars-cov-2 testing. we report the temperature in window of the 14 days before and after universal sars-cov-2 testing among clc residents. baseline temperature was calculated for 5 days prior to the study window. results sars-cov-2 was identified in 443 (6.0%) residents. the average maximum temperature in sars-cov-2 positive residents was 37.66 (0.69) compared to 37.11 (0.36) (p=0.001) in sars-cov-2 negative residents. temperatures in those with sars-cov-2 began rising 7 days prior to testing and remained elevated during the 14-day follow up. among sars-cov-2 positive residents, only 26.6% (n=118) met the fever threshold of 38.0°c during the survey period. most residents (62.5%, n=277) with confirmed sars-cov-2 did experience two or more 0.5°c elevations above their baseline values. one cohort of sars-cov-2 residents’ (20.3%, n=90) temperatures never deviated >0.5°c from baseline. conclusions and implications a single screening for temperature is unlikely to detect nursing home residents with sars-cov-2. repeated temperature measurement with a patient-derived baseline can increase sensitivity. the current fever threshold as a screening criteria for sars-cov-2 infection should be reconsidered. conclusions and implications: a single screening for temperature is unlikely to detect nursing 24 home residents with sars-cov-2. repeated temperature measurement with a patient-derived 25 baseline can increase sensitivity. the current fever threshold as a screening criteria for sars-26 cov-2 infection should be reconsidered. 27 28 29 introduction: 30 older people with chronic illness are at greatest risk for severe covid-19 outcomes. in early 31 march 2020, 34 of 101 (33.7%) sars-cov-2 infected residents died in a 130-bed washington 32 state king county nursing home facility; overall mortality was 18%. a total of 50 of 170 33 healthcare personnel were infected along with 16 visitors. 1 these findings led to aggressive 34 monitoring to detect disease, and to efforts to reduce transmission by keeping visitors and 35 symptomatic staff out of the building, while isolating residents in whom covid-19 was 36 suspected or confirmed. however, when 76 residents with sars-cov-2 laboratory confirmed 37 infection, 57% were asymptomatic, 2 suggesting that symptomatic monitoring will fail to provide 38 timely disease detection and undermine effective outbreak control. 39 40 because threshold symptoms and signs, such as a temperature of at least 38°c, have been used to 41 determine who is tested, their frequency may underestimate sars-cov-2 population 42 prevalence. standard screening processes now routinely screen for covid-19 by assessing for 43 temperature >38.0°c. from the king county experience 1,3 , "fever" is limited as a screening 44 criterion for covid-19 in nursing facilities. 4 while the utility of fever as an indicator has been 45 debated for older adults, 5,6 studies have reported that nursing home residents with pneumonia 46 often present without fever 7,8 and have a lower basal temperature than community dwelling older 47 adults. 9 the 'older and colder' adage for nursing home residents may have statistical validity but 48 poses challenges in guiding nursing facilities about fever during a pandemic. 49 50 while covid and pneumonia can elevate temperature from within an individual's usual range, 51 an absolute, universal cut-off for fever may miss potentially important temperature perturbations. 52 with infection control practices presently dependent on a threshold temperature criterion to 53 determine fever, we need to better understand the value and limitations such a threshold adds to 54 identifying people infected with sars-cov-2 or appropriate actions for additional screening, 55 especially in a nursing home context. we hypothesized that most residents of veterans 56 administration community life centers (clcs) infected with sars-cov-2 do have 57 temperature elevations well ahead of a confirmatory test, but also that peak temperatures will not 58 typically meet the current screening criterion threshold of 38°c that follows the centers for 59 disease control's (cdc) guidance. 10 testing of all clc residents and staff. the purpose of this analysis is to compare temperature 73 trends and identify maximum temperatures in nursing home residents fourteen days prior to and 74 following systematic testing for sars-cov-2 throughout vha clcs. 75 cohort 76 using vha electronic records, we identified veterans residing in clcs during the period of 77 march 1, 2020 until may 4, 2020. veterans who were not tested for covid-19 were excluded 78 as were those tested prior to admission to the clc. in addition, we excluded those who were 79 symptomatically tested because of symptoms prior to universal testing. demographic descriptors 80 were collected from the electronic medical records. 81 each clc uses standard equipment to measure temperature, and enters the reading into the 83 electronic medical record. in most clcs temperature is uploaded directly to the electronic 84 medical record from the vital signs machine. based on cdc guidance, the fever threshold was 85 established at 38.0° c. 10, 11 for this analysis, we selected the first temperature after 4am for 86 analysis. we assessed temperatures in the two weeks before and after sars-cov-2 testing. to 87 establish a baseline temperature for each resident, we calculated the mean of 5 temperatures prior 88 to our window of interest. 89 we identified sars-cov-2 pcr testing results from the va's electronic medical records. the funder had no role in the design, data collection, analysis, interpretation, or writing. 101 the cohort consisted of veterans (n=7325) residing in clcs. a total of 453 (6.0%) veterans 7 maximum temperature (37.7 vs. 37.1°c, p<.001). in both cohorts, the baseline temperature was 107 36.6°c (sd ±0.2) and a temperature deviation of 2 sd is approximately 0.5°c. 108 109 figure 1 illustrates the first daily temperatures of those with and without sars-cov-2 infection. table 1 lists single timepoint temperature screening thresholds. 123 124 measurement of temperature deviation from baseline has been proposed as a mechanism to 125 detect underlying infectious disease in nursing home residents. the majority of residents (79.7%, 126 n=353) with confirmed sars-cov-2 did experience a 0.5°c elevation of their baseline values, 127 and this elevation was noted at least twice in 62.5% (n=277) ( table 2 ). figure 3 examines 128 potential temperature change from baseline values (0°c to 2.5°c) occurring more than once 8 ( figure 3 , panel a) and more than twice (figure 3, panel b) . using a threshold increase from 130 baseline occurring in multiple readings offers a favorable balance of sensitivity and specificity 131 relative to a single reading. 132 we describe peak and daily morning temperature variation two weeks before and after covid-134 19 testing among va clc residents and the tmax occuring during that interval. the morning 135 temperatures in clc residents with sars-cov-2 typically began rising a week or more before 136 reaching tmax. most residents (74%) did not reach a peak temperature over 38°c. the 137 temperature for those with sars-cov-2 whose tmax was at least 0. table 1: temperature cutoffs and sars-cov-2 213 214 sars-cov-2 -sars-cov-2 + n epidemiology of covid-19 in a long-term care facility 219 in king county, washington residents of a long-term care skilled nursing facility -king county presymptomatic sars-cov-2 infections and 226 transmission in a skilled nursing facility spread of sars-cov-2 in the icelandic 228 clinical 230 practice guideline for the evaluation of fever and infection in older adult residents of long-term 231 care facilities: 2008 update by the infectious diseases society of america vital signs in older patients: age-related changes the significance of pneumonia in the elderly role of body temperature in diagnosing bacterial 238 infection in nursing home residents fever response in elderly nursing home residents: are the 10. centers for disease control. evaluating and testing persons for coronavirus disease department of health and human services sars−cov2 + (tmax >= 38.0) sars−cov2 + (tmax low 25%) key: cord-254753-viz37rzv authors: archbald-pannone, laurie r.; harris, drew a.; albero, kimberly; steele, rebecca l.; pannone, aaron f.; mutter, justin b. title: covid-19 collaborative model for an academic hospital and long-term care facilities date: 2020-05-25 journal: j am med dir assoc doi: 10.1016/j.jamda.2020.05.044 sha: doc_id: 254753 cord_uid: viz37rzv abstract the covid-19 pandemic is devastating post-acute and long-term care (pa/ltc). as geriatricians practicing in pa/ltc and a regional academic medical center, we created this program for collaboration between academic medical centers and regional pa/ltc facilities. the mission of the geriatric engagement and resource integration in post-acute and long-term care facilities (geri-pal) program is to support optimal care of residents in pa/ltc facilities during the covid-19 pandemic. there are 5 main components of our program: (1) project echo; (2) nursing liaisons; (3) infection advisory consultation; (4) telemedicine consultation; and (5) resident social contact remote connections. implementation of this program has had positive response from our local pa/ltc facilities. a key component of our program is our inter-professional team, which includes physicians, nursing, emergency response, and public health experts. with diverse professional backgrounds, our team have created a new model for academic medical centers to collaborate with local pa/ltc facilities. the geri-pal arms are detailed in the figure. the prevention arm cultivates dialogue among an inter-23 professional academic clinical team (geriatrics, pulmonary, and nursing), local government agencies 24 including our local health department and emergency management, and local organizations related to 25 prevention and treatment of covid-19 in patients in pa/tlc facilities. the program includes the 26 following components: a daily community collaborative rounds ("project echo covid-19 in nursing 27 homes"); nursing liaisons; infection advisory consultation; telemedicine consultation; and resident 28 phone calls to provide social contact remote connections (table 1 ). 9 29 the response arm includes all components of prevention, as well as targeted rapid response as detailed 30 in table 2 . these include an expansion of nursing liaisons and rapid implementation of telemedicine 31 consult service with daily clinical rounds and team huddle. the response arm is activated for facilities 32 experiencing an outbreak, in need of point-prevalence survey, or deemed high-risk (through self-33 identification or determined by local health department). the response team assesses facility needs to 34 determine the best path for collaboration within 24 hours. the geri-pal team is available to assist the 35 facility care team with daily discussions with stakeholders including facility clinical staff, facility 36 administration, and corporate leadership, and to provide clinical consultative care. in these daily 37 huddles, the team also assesses staffing and personal protective equipment (ppe) to ensure appropriate 38 staffing to facilitate hospital transfers, on-site care, and can connect facility with local ppe resources as 39 implementation 41 geri-pal began on march 13, 2020 with facility-based infection advisory consultation meetings. these 42 meetings were quickly transitioned to web-based teleconferencing as the pandemic threat emerged. we 43 met individually with 8 local facilities-to provide general guidance on infection control policies, as 44 recommended by amda, cdc, and cms. 10-12 the geri-pal team listened to facility-specific infection 45 control concerns, staffing concerns, cohorting concerns, and challenges with ordering ppe from their control practitioner, medical director, and all facility licensed independent practitioner (lip), while other 48 meetings were attended by only a facility medical director or lip. 49 parallel to these meetings, on march 16th 2020, a "telementoring" series was rapidly instituted using 50 the project echo model which leverages learning, training, and practice support to build a 51 collaborations for health professionals. 13, 14 the project echo team included a nurse practitioner, 52 geriatrician, pulmonologist, clinical nurse leader, and nurse educator. the goal of the virtual meetings 53 was to connect long-term care facility administrators and directors of nursing to assess facility needs for 54 covid-19 preparedness. in the response arm, we provided updated covid-19 information, testing and 55 treatment guidelines, and best practices in infection control. participants in project echo sessions 56 shared their experiences and sought input from a network of peers and insight from experts on 57 managing covid-19 positive patients in the pa/ltc setting. other frequent community participants 58 include local county fire and rescue representation and regional long-term care ombudsman. these 59 sessions were daily focused discussions and needs assessments regarding clinical information, ppe 60 preparedness and infection control, as well as education based discussions. four days a week this 61 program was driven by facility needs (in a question and answer format similar to academic office hours). 62 one session each week the program was a more formal didactic session given by an academic content 63 expert on a topic of interest determined by the group. 64 from the relationships established via project echo, academic nursing educators actively cultivated 65 relationships with local pa/ltc nursing leaders to determine facility needs for assistance with ppe, 66 improve care coordination between inpatient medical teams and facilities, and provide support to 67 optimize telemedicine consultation processes. 68 in addition, a facility telemedicine consult service was established to provide academic pulmonary/ 69 critical care clinical support and recommendations for testing/monitoring/treatment-in-place and to 70 communicates with a hospital medical communications center to directly admit acute patients, as well 72 as to ensure key aspects of care coordination, such as transfer of accurate medication lists, code status 73 documentation, and demographic information faxed to centralized number for ease of facility-based 74 staff. an allied geriatric consultation service, including geriatric and palliative care specialists, provides a 75 parallel telemedicine consult service that supports complex medical conditions, goals of care 76 discussions, and assistance with comfort care treatment when needed. 77 through this program, our academic medical center is providing support for local facilities and staff and 78 increasing collaboration and communication with local health departments and other agencies. we also 79 paired local medical student volunteers with facility residents for phone calls to connect socially and 80 help combat social isolation. 81 evaluation 82 for our project echo daily discussions, our nurse liaison invited all 28 of our local facilities, as well as an 83 additional 49 regional facilities. we connected with up to 25 facilities each week for needs assessment 84 and education. table 1 provides outcomes information and lessons learned for each of the prevention 85 components as related to feasibility and adoption. due to our collaboration with local emergency 86 management and health department, we focused these discussion based on these localities instead of 87 the large catchment area of our hospital. of the local facilities with initial covid-19 infection, 2 of the 3 88 facilities had participated in our prevention program and none of these facilities had sustained 89 transmission or outbreak. the response outcomes and feasibility are listed in table 2 severe outcomes among patients with coronavirus disease 2019 (covid-19) -united states covid-19 in a long-term care facility -king county doi infections in residents of a long-term care skilled nursing facility doi they're death pits': virus claims at least 7,000 lives the new york times epidemiology of covid-19 in a long-term care facility in king county long-term care facilities and the coronavirus epidemic: practical guidelines 131 for a population at highest risk state reporting of cases and deaths due to covid-19 in long-term care key: cord-270935-t9pym9k0 authors: dumyati, ghinwa; gaur, swati; nace, david a.; jump, robin l.p. title: does universal testing for covid-19 work for everyone? date: 2020-08-15 journal: j am med dir assoc doi: 10.1016/j.jamda.2020.08.013 sha: doc_id: 270935 cord_uid: t9pym9k0 abstract the covid-19 pandemic has been especially devastating among nursing home residents, with both the health circumstances of individual residents as well as communal living settings contributing to increased morbidity and mortality. preventing the spread of covid-19 infection requires a multipronged approach that includes early identification of infected residents and healthcare personnel, compliance with infection prevention and control measures, cohorting infected residents, and furlough of infected staff. strategies to address covid-19 infections among nursing home residents vary based on the availability for sars-cov-2 tests, the incorporation of tests into broader surveillance efforts, and using results to help mitigate the spread of covid-19 by identifying asymptomatic and presymptomatic infections. we review the tests available to diagnose covid-19 infections, the implications of universal testing for nursing home staff and residents, interpretation of test results, issues around repeat testing, and incorporation of test results as part of a long-term response to the covid-19 pandemic. we propose a structured approach for facility-wide testing of resident and staff and provide alternatives if testing capacity is limited, emphasizing contact tracing. nursing homes with strong screening protocols for residents and staff, that engage in contact tracing for new cases, and that continue to remain vigilant about infection prevent and control practices, may better serve their residents and staff by thoughtful use of symptomand risk-based testing strategies. dr. jump reports support for this work in part through the cleveland geriatric research 50 while there is general agreement that increased access to testing is important for personal and 23 public health, the selection and use of diagnostic tests to mitigate covid-19 infections in post-24 acute and long-term care settings is complex and should be tailored to individual sites. he responded to antibiotics and his fever resolved within 12 hours. because he met the nursing 36 home's enhanced screening criteria for covid-19 (table 1) , 1 he was placed on transmission-37 based precautions and a laboratory test for sars-cov-2 was ordered. 38 39 the food and drug administration (fda) has authorized several diagnostic and serologic 41 (blood-based) tests as part of the emergency use authorization (eua) process ( table 2) . reported that rt-pcr was 70% sensitive when compared to a computed tomography (ct) scan 54 of the chest. 4 this study was conducted in the early stages of the pandemic on 1014 patients. 55 since then, the number of rt-pcr-based tests and availability of those tests, as well as the 56 prevalence and clinical recognition of signs and symptoms of covid-19 infection, has changed 57 dramatically. all of these factors influence the sensitivity and specificity of diagnostic rt-pcr 58 tests. even if the sensitivity of rt-pcr based testing has increased to an optimistic 90% to 95%, 59 it still means that 1 out of every 10 to 20 negative results will be a false negative and miss a 60 covid-19 infection. a lower level of sensitivity may not be an issue in settings or regions 61 where the disease prevalence is low. where the disease is prevalent however, such as during a 62 facility outbreak, negative results must be viewed with caution. the sensitivity of the test also depends on when testing is done during the course of illness, with 65 the peak of viral shedding occurring around the time of symptom onset. 5 a bayesian hierarchical 66 model, fit to previously published studies describing the performance of sars-cov-2 rt-pcr 67 tests, reported the probability of a false negative rt-pcr test over time. 6 from exposure (day 0) 68 to the typical time of symptom manifestation (day 5), the probability of a false negative results 69 changes from 100% on day 1, to 67% on day 4, reaching a nadir of 20% three days after 70 symptom onset on day 8. in some individuals, rt-pcr tests will remain positive for weeks after 71 symptom resolution. 10 staff, particularly in areas with mandates for serial testing of healthcare workers. this also offers 97 the possibility that staff may effectively collect their own samples. self-collected samples have 98 the advantage of decreasing staff exposure and their use of ppe. 10 99 100 antigen tests on may 9 th , 2020, the fda provided the first eua for a test designed to detect 101 an antigen specific to sars-cov-2; a second antigen-based test received an eua on july 2 nd , 102 2020. 11,12 antigen tests target markers on the outer surface of the viral capsule and do not 103 require extraction of rna. viral structures that represent good candidates for antigen-based 104 testing include nucleocapsid phosphoproteins and spike glycopeptide proteins. 13 advantages to 105 antigen-based tests are the relatively lower cost compared to rt-pcr tests, the ease of collection 106 samples from the anterior nares, the potential to scale the number of tests, and the rapid turn-107 around-time, providing answers within minutes. 12 a disadvantage to antigen-based tests, 108 however, is lower sensitivity, which can lead to false negative results. this is a particular issue 109 in the setting of outbreaks or in regions with increased prevalence rates of sars-cov-2. the 110 j o u r n a l p r e -p r o o f fda recommends that a second pcr-based test should be used to confirm negative results for 111 individuals likely to have covid19. 11 given that only 2 of the 164 diagnostic tests given euas 112 are antigen-based, 12 the role for these tests is still evolving and may be best suited for diagnosing 113 symptomatic individuals seeking medical care, rather than screening asymptomatic individuals 114 or healthcare workers. . regardless, cms recently announced a plan to deploy the two available 115 antigen test kits to all u.s. nursing homes to assist in universal screening efforts, 14 though noting 116 caution in interpreting negative results. 15 facilities using antigen tests need to make sure they 117 have obtained the required federal and/or state clinical laboratory improvement amendments 118 (clia) waivers, competency trained staff, a recording system to document and track results, and 119 are able to report results to state and/or federal agencies as required. 15 unfortunately, many nursing homes may not be able to implement universal testing for a 169 multitude of reasons, including lack of access to testing, inadequate supplies of ppe, limited 170 personnel, and insufficient resources to pay for testing. 27-30 as they attempt to respond to 171 federal 31 and state 32 recommendations and requirements, many nursing homes will need to 172 consider other approaches to testing such as unit-based testing and/or risk-based testing. 173 regardless of how they proceed, it is essential that nursing homes work with their laboratory 174 provider to prioritize residents and staff tests and ensure rapid turnaround times (48 hours or 175 less). 33 176 177 unit-based strategies, while not desirable, would be most suitable for situations in which testing 178 capacity is limited. for this approach, the building focuses testing on residents and staff members 179 who had close contact with the index case. testing can also be extended to include high risk 180 individuals such as those leaving the facility frequently (e.g., for hemodialysis, radiation therapy, 181 or off-site chemotherapy) and those recently admitted. determination of whom to test first is 182 inherently complex and may be best approached by a multi-disciplinary team that includes the 183 infection preventionist, medical director, director of nursing, and administrator. the need and frequency of staff and resident testing in that particular facility. as mentioned 277 above, however, insufficient access to rapid diagnostic testing, ppe, staff, and resources may 278 render seemingly insurmountable challenges. even under these dire circumstances, nursing 279 homes will continue to strive to provide the best care they can offer for residents entrusted to 280 their care ( table 3) . the prospect of reopening nursing homes, which includes permitting visitors, presents additional 297 complexities. efforts by states to relax stay-at-home orders, reopen businesses, and even 298 encourage tourism 38 contribute to increased spread of sars-cov-2 in the community which in 299 turn means increased risk for nursing home staff to acquire and transmit the virus to their 300 residents. as part of plans to reopen nursing homes, cms recommended "baseline" testing for 301 all nursing residents and staff, along with the capacity to continue weekly tests for staff. 31 after 302 the initial response to the cms recommendation, most, if not all, nursing homes should continue 303 surveillance testing. older adults often manifest atypical signs and symptoms of infection. while 304 it may be tempting to attribute a change in condition to exacerbation of known heart failure or 305 sinus congestion to allergies or a "summer cold", the severity of the illness experienced by some if testing many residents, consider using two teams with staff not assigned to frontline care -one to prepare each resident and room, and one to obtain the specimen. identify the ordering provider for the laboratory requisition, which can be the medical director. ensure that ppe is available for the staff obtaining np swab. ideally, ppe worn during sample collection includes a respirator, eye protection, a gown, and gloves. in settings without respirators, a surgical mask and face shield may be used instead. testing of staff identify the list of staff that will need to be tested. decide on the source of the sars-cov-2 specimen (np, nasal, oropharyngeal, oral). if using pcr, identify and train staff to perform testing including need to change ppe between staff members. chose a room for testing and ensure that staff are able to social distance while waiting for testing. if testing is done in the facility, identify the ordering provider, which might be the medical director or an employee health provider. if testing is done outside the facility, evaluate the process of obtaining the results. identify and communicate with the laboratory to ensure that the testing supplies are available and the laboratory can run the some states do not need a provider order for the staff testing but this is requested by the laboratory. some insurance providers are not covering testing of asymptomatic nursing home staff. when possible, sample collection should be in a well-ventilated area, which includes outdoors and, weather permitting, may be feasible to accomplish with staff members. j o u r n a l p r e -p r o o f 5 large number of tests and provide the results within 24-48 hours. dealing with sars-cov-2 testing results from residents create a process to communicate the test results with residents and their families or responsible party. identify how information is shared with the local or state health department. ensure that a cohorting plan is in place before testing. assess the availability of personal protective equipment (ppe). ensure that shared equipment is available to dedicate to the covid-19 cohort develop a policy for when covid-19 positive residents should be transferred to an outside covid-19 facility, another nursing home or hospital. one option is to communicate with resident's family that they will only be informed of positive test results. plan for use of multiple means of communication to residents, family members, and/or responsible parties. this may include use of recorded phone systems, email, website updates, town-hall updates, and direct phone communication. communication about resident results should ensure individual privacy. prepare for the additional works of moving residents and their belongings to a covid-19 cohorting area. dealing with sars-cov-2 results from staff create a process to communicate the test results with staff, respecting employee privacy. create a process to communicate with residents and their families or responsible party that the facility has staff that tested positive. identify a process to communicate results with the local or state health department, including plans for monitoring of isolation, return to work and contact tracing for quarantine. for staff that test positive and work at multiple facilities, inform the health department so the information can be communicated to other facilities. assign a staff member the role of monitoring staff furloughs and review of criteria to return to work. they also should monitor adverse effects such as hospitalization and death establish a process to deal with staff shortages: 1) train non-medical staff at your facility to assist with resident related tasks, 2) establish relationship with nursing agencies, 3) collaborate with hospital systems and evaluate if they can assist with staffing needs, 4) evaluate other staffing options such as reaching out to nursing schools. unprecedented solutions for extraordinary times: 343 helping long-term care settings deal with the covid-19 pandemic the food and drug administration comparison of four molecular in vitro diagnostic 350 assays for the detection of sars-cov-2 in nasopharyngeal specimens correlation of chest ct and rt-pcr testing in coronavirus disease 353 2019 (covid-19) in china: a report of 1014 cases interpreting diagnostic tests for sars-cov-2 variation in false-negative rate of 358 reverse transcriptase polymerase chain reaction-based sars-cov-2 tests by time since 359 annals of internal medicine duration of isolation and precautions for adults with covid-19. centers for disease 362 control and prevention detection of sars-cov-2 in different types of clinical 365 specimens a combined 367 oropharyngeal/nares swab is a suitable alternative to nasopharyngeal swabs for the 368 detection of sars-cov-2 swabs collected by patients or health care workers for 370 sars-cov-2 testing the food and drug administration. coronavirus (covid-19) update: fda authorizes first 373 antigen test to help in the rapid detection of the virus that causes covid-19 in patients commissioner o of the. coronavirus (covid-19) update: daily roundup molecular targets for the testing of covid-19 trump administration announces initiative for more and faster 385 more-faster-covid-19-testing-nursing-homes.html 386 15. centers for medicare and medicaid services. frequently asked questions: covid-19 testing 387 at skilled nursing facilities/ nursing homes american health care association. point-of-care antigen test devices -ahca information for laboratories about coronavirus (covid-19). centers for disease 396 control and prevention the food and drug administration duration of antibody responses after severe acute 402 respiratory syndrome persistence of antibodies against middle east respiratory 405 syndrome coronavirus performing facility-wide sars-cov-2 testing in nursing homes. centers for disease 408 control and prevention covid-19): interim clinical guidance for management of 411 patients with confirmed coronavirus disease (covid-19). centers for disease control and 412 prevention the incubation period of coronavirus disease from publicly reported confirmed cases: estimation and application asymptomatic and presymptomatic sars-cov-2 419 infections in residents of a long-term care skilled nursing facility -king county evidence supporting transmission of severe acute 425 respiratory syndrome coronavirus 2 while presymptomatic or asymptomatic nursing homes continue to face critical supply and staff shortages 429 as covid-19 toll has mounted nursing home care in crisis in the wake of covid-19 centers for medicare & medicaid services. toolkit on state actions to mitigate covid-19 434 prevalence in nursing homes new state by state breakdown: covid-19 testing for nursing homes and assisted living 441 american health care association/national center for assisted living 442 the centers for medicare & medicaid services. nursing home reopening 448 recommendations for state and local officials | cms 30 continuing temporary suspension and modification of laws relating to the 453 disaster emergency guidance for infection control and prevention of coronavirus disease 2019 (covid-460 19) in nursing homes (revised) | cms discontinuation of transmission-based precautions and disposition of patients with 468 covid-19 in healthcare settings (interim guidance). centers for disease control and 469 prevention guidance for use of certain industrial respirators by health care personnel | cms how not to wear a mask. the new york times taking action to protect america's nursing home residents against 479 covid-19. your valley medicare administrative contractor (mac) 482 covid-19 test pricing 41. r14som.pdf. accessed key: cord-333960-pkpbts7s authors: genet, bastien; vidal, jean-sébastien; cohen, adrien; boully, clémence; beunardeau, maelle; harlé, louise; goncalves, anna; boudali, yasmina; hernandorena, intza; bailly, henri; lenoir, hermine; piccoli, matthieu; chahwakilian, anne; kermanach, léna; de jong, laura; duron, emmanuelle; girerd, xavier; hanon, olivier title: covid-19 in-hospital mortality and use of renin-angiotensin system blockers in geriatrics patients. date: 2020-09-09 journal: j am med dir assoc doi: 10.1016/j.jamda.2020.09.004 sha: doc_id: 333960 cord_uid: pkpbts7s objective the role of treatment with renin-angiotensin-aldosterone system blockers at the onset of covid-19 infection is not known in geriatric population. the aim of this study was to assess the relationship between angiotensin receptor blockers (arb) and an ace inhibitor (acei) use and in-hospital mortality in geriatric patients hospitalized for covid-19. design this observational retrospective study was conducted in a french geriatric department. patients were included between march 17 and april 18, 2020. setting and participants: all consecutive 201 patients hospitalized for covid-19 (confirmed by rt-pcr methods) were included. all non-deceased patients had 30 days of follow-up and no patient was lost to follow-up. methods demographic, clinical, biological data and medications were collected. in-hospital mortality of patients treated or not by acei/arb was analyzed using multivariate cox models. results mean age of the population was 86.3 (8.0) years old, 62.7% of patients were institutionalized, 88.6% had dementia and 53.5% had severe disability (adl score < 2). sixty-three patients were treated with acei/arb and 138 were not. mean follow-up was 23.4 (10.0) days, 66 (33.8%) patients died after an average of 10.0 days (6.0). lower mortality rate was observed in patients treated with acei/arb compared with patients not treated with arb nor acei (22.2% (14) vs. 37.7% (52), hr = 0.54 (95% ci = 0.30-0.97), p=0.03). in a multivariate cox regression model including age, sex, adl score, charlson index, renal function, dyspnea, crp and white blood cells count, use of acei/arb was significantly associated with lower in-hospital mortality (hr = 0.52 (0.27−0.99), p=0.048). conclusion and implications in very old subjects hospitalized in geriatric settings for covid-19, mortality was significantly lower in subjects treated with arb or acei prior to the onset of infection. the continuation of acei/arb therapy should be encouraged during periods of coronavirus outbreak in older subjects. worldwide, as of june 15, 2020, according to john hopkins university, more than 8 million people 31 have been affected by coronavirus disease 2019 (covid-19) caused by sars-cov-2, and more than 32 400 thousands died of covid-19 since december 31, 2019. 1 in france according to santé publique 33 france, the french health agency, more than 141 thousand people have been contaminated and 34 more than 29 thousands died of covid-19. 2 35 covid-19 predominantly affects elderly people. subjects aged 75 years and older accounted 36 for 75% of all deaths related to covid-19 in france 2 and mortality rate is 31.1% in italy among 37 people > 80 years old. 3 sars-cov-2 virus belongs to the family of orthocoronavirinae, and shares 38 some similarities with the mers-cov (75% identical genome sequence) and the sars-cov (85 % of 39 identical genome sequence respectively) that were responsible for severe pneumonia. 4 their s 40 protein (of their capsize) are 99% similar and they have the same binding site: the angiotensin 2 41 conversion enzyme. 4 angiotensin 2 converting enzyme has a role in the entry of sars-cov-2 into 42 target cells and animal experimental data indicate an increase in enzyme expression after 43 administration of renin-angiotensin-aldosterone system blockers (i.e., angiotensin-converting-44 enzyme inhibitors (acei) and receptors blockers (arb)). 5 thus the question has arisen as to whether 45 acei/arb treatment could increase severity and mortality of covid-19. 6 in observational studies, subjects with cardiovascular diseases and hypertension are often 47 treated with acei or arb, and have an increased risk of in-hospital mortality related to covid-19. 5, 7 48 meanwhile some studies have found no effect 7, 8 or even a beneficial effect of acei/arb on covid-19 49 mortality. 5, 9, -11 older people are frequently treated with acei/arb, however few data are available 50 on their use in geriatric population affected by covid-19. the aim of this study was to assess the 51 relationship between acei/arb and in-hospital mortality among geriatric patients hospitalized for 52 covid-19. 12 53 this retrospective study included all symptomatic patients admitted in acute geriatric units 56 dedicated to treating covid-19, between march 17 and april 18, 2020, in a geriatric department with 57 a positive reverse-transcription polymerase chain reaction (rt-pcr) for sars-cov-2 on nasal swabs. 58 patients were followed-up until may 18, 2020. before admittance in the acute geriatric units, 59 patients with positive rt-pcr for sars-cov-2 were first examined in emergency room and had a 60 geriatric evaluation. only patients who were assessed as not fit enough or had too severe 61 comorbidities for intensive care unit were admitted acute geriatric units and included in the study. 62 as available, four different pcr tests were performed by the hospital's virology department (abbott 63 real time sras cov-2, xpert xpress sras cov-2, simplexa covid 19 direct and allplex 2019-ncov 64 assay). 65 the study was conducted in accordance with the ethical standards set forth in the declaration of 66 helsinki. the study protocol was approved by local ethics committee and the study complied with the 67 strengthening the reporting of observational studies in epidemiology statement guidelines 13 all 68 patients' data were anonymized prior to analysis. no consent to participate was sought for the 69 participants in accordance with the french law because the study was observational in nature (as 70 part of usual care), and no nominative data were collected. 14 71 72 all data were collected as part of usual care. in-hospital mortality was assessed during a follow up of 73 30 days after rt-pcr confirmation. all patients included in the study were hospitalized at least 30 74 days in the geriatric department (acute unit and then rehabilitation unit if needed). thus all non-75 deceased patients had a full 30-day follow-up. 76 ethnicity was not recorded but the sample was overwhelmingly white caucasian (> 90%). 77 cancer (localized or metastatic), heart failure, coronary heart disease, atrial fibrillation, hypertension 79 (defined as systolic blood pressure ≥ 140 mm hg or diastolic blood pressure ≥ 90 mm hg or use of 80 antihypertensive medications or history of hypertension), diabetes mellitus (defined as self-report or 81 use of oral hypoglycemic medication or insulin or a history of diabetes), chronic respiratory disease 82 (chronic obstructive pulmonary disease or asthma), stroke or transient ischemic attacks, dementia 83 (based on the diagnostic and statistical manual of mental disorders, 5 th edition), 15 chronic kidney 84 disease and major depression. nutritional status was assessed by body mass index (bmi) and serum 85 albumin level and malnutrition was defined as bmi <21 kg/m 2 or albumin < 35 g/l as defined in a best 86 practice guideline by the french health authority. 16 comorbidity was evaluated with the charlson 87 comorbidity index (cci). 17 functional status was assessed with activities of daily living (adl). 18 adl 88 was regrouped in 3 classes, no disability to mild disability (adl ≥4 to 6), moderate disability (adl ≥ 2 89 to < 4) and severe disability (adl 0 to < 2). 90 symptoms that led to the covid-19 diagnosis or occurred in the first 72 hours before or after 91 the rt-pcr confirmation, such as fever (defined as t° > 37.8°c), dyspnea, coughing, severe 92 hypotension (sbp < 95 mmhg), digestive disorders (diarrhea and nausea or vomiting) or falls were 93 also collected. 94 ongoing treatments defined as treatment taken for at least 1 week before inclusion and 95 taken the day of the inclusion were recorded: acei, arb, diuretics, beta-blockers, calcium channel 96 blockers, antiplatelet therapy, oral anticoagulants, benzodiazepines, neuroleptics, antidepressant 97 therapy and proton pump inhibitors. 98 biological data were also collected at admission including hemoglobin level, white blood cell 99 count (wbc), lymphocyte and platelet count, c-reactive protein (crp), serum creatinine, ldl and 100 albumin. estimated glomerular filtration (egfr) rate was calculated with ckd-epi formula 19 and 101 categorized in 3 classes, egfr ≥ 50 ml/min, 50 ml/min > egfr ≥ 30 ml/min and egfr < 30 ml/min. 102 baseline characteristics of the participants were analyzed in the whole sample and according to death 105 at 30 days using descriptive statistics: means and standard deviations for continuous variables, and 106 percentages and counts for categorical variables and compare with t-tests and χ 2 respectively. 107 variables were also compared with univariate cox model to take into account the different follow-up 108 durations. 109 baseline characteristics of the participants were also analyzed according to the use of acei/arb and 110 comorbidity index were standardized in order to obtain hr for an increase of 1 sd of each of those 118 variables. hr for age was calculated for an increase of 10 years. 119 another multivariate regression cox model was built with 30-day in-hospital mortality as dependent 120 variable and use of arb and acei taken separately as independent variable and with the same 121 adjustment as the first cox regression model. 122 ldh was not included in this model because it was missing in 50 subjects. proportional hazard 123 assumption was checked graphically for all covariates and using schoenfeld residuals. 124 all analyses were two-sided and a p-value < 0.05 was considered statistically significant. data analysis 125 was performed using r software version 3. table 2) . 148 among patients with hypertension, 46% (58/125) were treated with acei/arb. patients 149 receiving acei or arb had more often hypertension and coronary artery disease and less often 150 dementia and lower level of hemoglobin. overall they had a higher charlson comorbidity index than 151 j o u r n a l p r e -p r o o f patients not treated with acei or arb. they were more often treated with calcium channel blockers, 152 diuretics, and antiplatelet (table 3) . 153 in a multivariate cox regression model including age, sex, adl, cci, renal function, dyspnea, 154 crp and wbc, use of acei or arb was significantly associated with lower in-hospital mortality (hr = 155 0.52 (0.27−0.99), p=0.048) (figure 2) . severe disability (adl < 2), (hr = 2.54 (1.13-5.72)), high white 156 blood cells count (hr= 1.45 (1.16-1.81)) and high crp (hr= 1.37 (1.11-1.69)) were significantly 157 associated with death (figure 2) . 158 in the multivariate cox regression model analyzing arb and acei separately, hr was 0.40 159 (0.14-1.15), p=0.09 for arb and 0.60 (0.28-1.31), p=0.20 for acei (figure 2) . in this cohort of very old patients affected by covid-19, a high rate of in-hospital mortality was 164 observed. the main factor associated with mortality was severe disability. in-hospital mortality 165 among patients treated with acei or arb was significantly lower compared with patients without 166 acei or arb therapy. 167 in our study, 33% of the patients died within 30 days of covid-19 rp pcr confirmation. this 168 mortality is much higher than that of younger population and of other respiratory virus diseases like 169 influenza -and respiratory syncytial virus in elderly people. 20 older age has already been found a 170 major risk factor for mortality from covid-19 ranging from 14% to 30 % in patients aged > 80 years 171 old. 3, 21, 22 as of may 28, 2020 among the 59,134 peoples aged > 80 years old affected by covid-19 in 172 italy the mortality was 31.1% 3 . the relation of age and covid-19 mortality is probably related to 173 immunosenescence that has been identified as a major risk factor for respiratory diseases and its 174 related mortality. 23 175 as already published, we also found that crp and leukocytes increase were associated with 176 death. 8, 24, 25 however in our geriatric population, the main factor associated with mortality was 177 severe disability and not factors usually associated with higher mortality in covid-19 like, 178 cardiovascular diseases, diabetes mellitus, obesity and chronic obstructive pulmonary disease. 26-28 . 179 disability through adl is an already known factor of all-cause mortality in the elderly. 29, 30 180 interestingly, poor functional status was a most relevant factor associated with mortality than 181 respiratory symptoms like dyspnea that are major prognostic factors in younger population. 31-33 182 conversely to other studies, age was not associated with in-hospital mortality in our study probably 183 because of the specificity of our population that was very old with a somewhat narrow age range. in our geriatric population no patient were managed in intensive care unit because of high 213 level of comorbidity, dementia and low physiologic reserves that make prolonged intensive care 214 unreasonable. indeed, among critically ill elderly geriatric patients, icu admission do not reduce 6-215 month mortality. 38 in this frail population at high risk of mortality, the need of effective treatment 216 before critical stage of covid-19 is of paramount importance. 217 the high prevalence of dementia could be explained by the fact that only patients who were 218 assessed too debilitated or had too severe comorbidities for intensive care unit after a geriatric 219 evaluation were transferred in the acute geriatric units and because 60% of our patients came from 220 nursing homes. 221 this study has several strengths. very few data existed on geriatric population affected by 222 covid-19, characterized by high risk of mortality and no access to intensive care unit. 38 prevalence of 223 dementia was very high (89%) and few data exist on such population. there was no loss to follow-up 224 and all non-deceased patients were followed-up for 30 days enabling the estimate of the actual 30-225 day mortality. our results were adjusted on confounding factors including symptoms, comorbidity, 226 disability and biological factors and suggest that in this population the acei/arb therapy could be 227 associated with better prognosis and ought to be confirm in other geriatric populations. randomized 228 controlled trials are much needed to assess the benefit on mortality associated with acei/arb 229 treatment in elderly patients with this study has also some limitations, this cohort was monocentric and retrospective, so 231 causality between acei or arb use and mortality cannot be ascertained. epidemia covid-19. aggiornamento nazionale receptor recognition by the novel coronavirus from wuhan: an analysis based on decade-long structural studies of sars coronavirus cardiovascular disease, drug therapy, and mortality 264 in covid-19 hypertension, the renin-angiotensin 266 system, and the risk of lower respiratory tract infections and lung injury: implications for covid-267 19 renin-angiotensin-aldosterone system blockers and the risk of covid-19 association of renin-angiotensin system inhibitors with 271 severity or risk of death in patients with hypertension hospitalized for coronavirus disease 272 2019 (covid-19) infection in wuhan, china enzyme inhibitor or angiotensin receptor blocker use with covid-19 diagnosis and mortality association of inpatient use of angiotensin-converting enzyme 278 inhibitors and angiotensin ii receptor blockers with mortality among patients with 279 hypertension hospitalized with covid-19 angiotensin-converting enzyme) inhibitors on virus infection, inflammatory status, and clinical we wish to thank the team of health-care workers from the broca's hospital who collected the data and completed the study.j o u r n a l p r e -p r o o f ii receptor blocker; 378 acei, angiotensin-converting-enzyme inhibitors; bmi, body mass index; tia, transient ischemic 379 attack; copd, chronic obstructive pulmonary disease; ppi, proton-pump inhibitor; wbc, white blood 380 cells; egfr, glomerular filtration rate estimated with cpk-epi formula; crp, c-reactive protein. key: cord-306421-r8wzvpn5 authors: sizoo, eefje m.; monnier, annelie a.; bloemen, maryam; hertogh, cees m.p.m.; smalbrugge, martin title: dilemmas with restrictive visiting policies in dutch nursing homes during the covid-19 pandemic: a qualitative analysis of an open-ended questionnaire with elderly care physicians date: 2020-10-23 journal: j am med dir assoc doi: 10.1016/j.jamda.2020.10.024 sha: doc_id: 306421 cord_uid: r8wzvpn5 objectives to mitigate the spread of covid-19, a nationwide restriction for all visitors of residents of long-term care facilities including nursing homes (nhs) was established in the netherlands. the aim of this study was an exploration of dilemmas experienced by elderly care physicians (ecps) as a result of the covid-19 driven restrictive visiting policy. setting and participants ecps working in dutch nhs. methods a qualitative exploratory study was performed using an open-ended questionnaire. a thematic analysis was applied. data was collected between april 17 and may 10, 2020. results seventy-six ecps answered the questionnaire describing a total of 114 cases in which they experienced a dilemma. thematic analysis revealed four major themes: (1) the need for balancing safety for all through infection prevention measures versus quality of life of the individual residents and their loved ones; (2) the challenge of assessing the dying phase and how the allowed exception to the strict visitor restriction in the dying phase could be implemented; (3) the profound emotional impact on ecps; (4) many alternatives for visits highlight the wish to compensate for the absence of face to face contact opportunities. however, given the diversity of nh residents, alternatives were often only suitable for some of them. conclusions and implications ecps reported that the restrictive visitor policy deeply impacts nhs residents, their loved ones and care professionals. the dilemmas encountered as a result of the policy highlight the wish by ecps to offer solutions tailored to the individual residents. we identified an overview of aspects to consider when drafting future visiting policies for nhs during the covid-19 pandemic. in the netherlands, the first covid-19 confirmed case in a nursing home (nh) was reported 24 on march 12, 2020, 1 and by the first week of april, about 40% of dutch nhs reported covid-25 19 infections (figure 1 ). 2 about 115000 people reside in one of the estimated 1000 nhs or 26 care homes across the netherlands, 3 for whom medical care is provided by physicians with 27 an elderly care medicine specialty (i.e., elderly care physicians). 4 to mitigate the spread of 28 covid-19, strict social distancing policies were implemented by the dutch government as of 29 march 12, 2020. by march 19, a nationwide restriction for all visitors of residents of long 30 term care facilities (ltcfs) including nhs was established ( figure 1 ). 5 this decision was made 31 in view of a lack of alternatives as the netherlands was facing shortages of personal 32 protection equipment (ppe) and a lack of diagnostic capacities. the only exception of this 33 restrictive policy included residents in the dying phase to allow a farewell moment for family 34 members (i.e., maximum two visitors per 24 hours). 6 it is inevitable this policy has consequences for the residents, their families and their formal 36 caregivers. involvement of the resident's family through visits to the nh has previously been 37 described to be beneficial for the quality of life of residents. 7, 8 indeed, family has been 38 reported to promote social engagement and to strengthen identity and dignity of residents. 9 39 family visits to the nh allow for the monitoring of the provided formal care as well as for 40 additional care tasks for the institutionalized older adults. 7 while the rationale for the restrictive visiting policy imposed to the nhs in the netherlands 42 the data. 15 the analysis included the following steps: (1) familiarizing with the data, (2) 68 inductive thematic coding, (3) searching for themes, (4) reviewing of themes and (5) 69 finalization of themes. 15 an iterative approach (i.e., the process of going back and forth 70 between the data, the codes and themes) was followed across the different steps to ensure 71 a systematic analysis. 72 the coding of the first 14 cases was performed independently by two researchers trained in 73 qualitative research methods (es and am). the results of the two independent codings were 74 then merged into a single codebook. the codebook was used to code the remaining 75 questionnaire data. the cases collected within the first two weeks were coded by one of the 76 two researchers (es and am). changes to the codebook (e.g., renaming of codes and 77 addition of codes) were made in consensus between the two researchers during research 78 meetings (es and am). a third researcher (mb) validated the coding by checking for 79 inconsistencies to make sure no relevant information was missed and coded the last 20 80 cases. doubts were discussed with two other researchers (es and am). regular meetings 81 between the researchers involved with the coding allowed for frequent reflections on the 82 data analysis including the collation of codes into themes and the evolution of the identified 83 themes. the questionnaire data were analyzed using microsoft word and microsoft excel. 84 all participants were informed about the aim of the study and the purpose of data 85 collection. formal ethical approval from a medical ethical committee was not required for 86 this research in the netherlands since it did not subject participants to any medical 87 treatment or impose any specific rules of conduct on participants. 88 the questionnaire was sent to 103 ecps-in-training and 92 ecps and anonymously returned 89 by 76 physicians (ecps or ecps-in-training). these 76 physicians, further referred to as 'ecps', 90 described a total of 114 cases in which they experienced a dilemmas. 91 thematic analysis of open-ended questions revealed four major themes related to the 92 restrictive visiting policy. quotes illustrating the four themes are shown in table 1 . 93 furthermore, we identified dilemmas related to other covid-19 measures in nursing homes 94 (appendix 2). 95 the core dilemma experienced was that on the one hand, ecps wanted to protect residents 96 against covid-19 infections -implying adherence to the strict visitor restrictions -but on 97 the other hand, as a consequence quality of life of most residents seriously decreased (quote 98 1 and 2). 99 ecps encountered serious suffering as a result of covid-19. hence, they wanted to 100 minimalize the risk of contamination (quote 3). according to ecps, for some residents, the 101 risk of contamination was acceptable but it was not just about the individual resident (quote 102 4). ecps emphasized infection prevention concerned safety of all residents (quote 5) and 103 health care professionals (quote 6). 104 the visitor restriction policy contributed to limiting the further spread of covid-19. most 105 ecps encountered understanding of the dilemmas they were facing among family members 106 (quote 7 and 8), although not in all cases (quote 9). 107 j o u r n a l p r e -p r o o f ecps used the words 'loved ones', 'partner', 'family members' and 'next-of-kin' instead of 108 'visitors'. ecps considered the presence of these 'visitors' as essential to quality of life. as the 109 majority of residents of nhs has limited life-expectancy, ecps estimated quality of life was 110 often considered more important than life duration (quote 10 -12). furthermore, according 111 to ecps, next of kin could have provided company and support in uncertain times (quote 13). 112 moreover, ecps described cases where they missed additional care otherwise provided by 113 next-of-kin (quote 14) . 114 ecps described cases where the visitor restriction had profound impact on residents. ecps 115 observed loneliness, depressive symptoms (quote 15), decreased intake (quote 16), increase 116 in somatic symptoms (i.e. pain) (quote 17), physical deterioration and in psychogeriatric 117 residents rapid cognitive decline (quote 18, 19) and changes in neuropsychiatric symptoms 118 including agitation and aggression (quote 20). the latter was even reported to result in 119 increased psychotropic drug prescriptions for some of the residents. on the other hand, 120 ecps observed visitor restrictions brought peace for some of the psychogeriatric residents 121 (quote 21). in addition, the restrictions impacted next-of-kin and nursing staff (appendix 3). 122 ecps noted that although protection against contamination was irrelevant for a resident in 123 the dying phase, protection of other residents in the institution, health care providers, next-124 of-kin and society remained notwithstanding important (quote 22). ecps described the 125 presence of visitors in the dying phase implies being surrounded with loved ones and being 126 j o u r n a l p r e -p r o o f able to say farewell (quote 23 and 24). we distinguished two types of issues raised by ecps: 127 assessing the dying phase and implementing of the exception. 128 ecps struggle with the timing to diagnose 'dying'. the beginning of the dying phase is not 129 always clear (quote 25). ecps describe a grey area classified as 'preterminal phase': life 130 expectancy is short, but the resident is not yet in the dying phase (quote 26). in these 131 scenario's, ecps observed residents whose last days, weeks or months were lonely (quote 132 27) and residents with a rapid course of the dying phase, thereby not being able to say 133 farewell to their loved ones (quote 25). ecps described that next-of-kin were missing the 134 process of decline and feared this might impact their mourning process (quote 28). ecps 135 remarked that concluding too early that the resident was in a dying phase implies more 136 visitors (i.e., higher risk of infection) and may set a precedent for others (quote 29). 137 furthermore, in practice several requirements for visits were pointed out by ecps. first, ecps 142 were aware that ppe was scarce, increasing the urgency to limit the exceptions (quote 32). the exception allowing for visitors in the dying phase caused struggles with the assessment 202 of dying phase. dutch guidelines for palliative care define dying phase as last days of life. 23 it 203 is well-known that diagnosing dying is a highly complex process. 24 the examples of alternatives for visits (technical and at distance) underscore the urgency to 227 compensate for the absence of visits and in the dutch media was parallel reported on 228 various creative solutions to allow contact at distance (e.g., using a cherry picker, 229 'coronatainers'). 27, 28 however, alternative solutions are only suitable for some residents as 230 j o u r n a l p r e -p r o o f many have cognitive impairments, visual or hearing disabilities and/or speech disorders. in 231 addition, the effect of technical solutions in decreasing social isolation in nh is limited. 29 30 in 232 the dying phase these alternatives could not replace the presence of close loved ones who 233 wanted to say goodbye. consequently, ecps deliberately weighed, whether or not a tailored 234 exception could be made in individual cases. ecps find it reassuring to take these decisions 235 with a group of colleagues. 236 after a significant peak in the number of deaths in early april, the number of covid-19 cases 237 and deaths in nhs has been declining in the netherlands. 31 on may 11th, a pilot in 26 nhs 238 allowed for one fixed visitor, which as of may 26 applied to all covid-free nhs; restrictions 239 were further relaxed june 15 to allow for more than one fixed visitor and more frequent 240 visits under certain conditions (figure 1 ). 12 in our study ecps struggled with on the one hand 241 the pressure to adhere to the national visiting policy and on the other hand their wish for 242 tailoring for the individual. at first, they experienced largely understanding for the situation. 243 however, since may families have increasingly been expressing resistance against the visitor 244 policies. 13, 14 although there is no 'one size fits all' solution for the complex dilemmas faced 245 here, our analysis provides several insights worth considering in assessing and reviewing 246 current and future visiting policies. we observed that the nationwide 'top-down' restrictive 247 visitor policy resulted in resistance and a need for more regional and local tailored visiting 248 policies. important aspects emerging from our study to be considered by policy makers 249 when issuing visiting policies are the regional and local covid-19 prevalence, the availability 250 of sufficient ppe, the possibility to streamline visits (e.g., separate visiting areas, schedules 251 for visitors), and the possibility to isolate residents. nevertheless, even with visiting policies 252 tailored to the regional and to the local nh organization context, dilemmas may still occur on 253 j o u r n a l p r e -p r o o f an individual level. health care professionals may still have to weigh whether or not the local 254 visiting policy is proportional to the specific circumstances of the resident and his or her 255 visitors. relevant aspects emerging from our analysis to take into account when decisions 256 have to made for those dilemmas are summarized in table 2 . we believe explicitly 257 considering these aspects by health care professionals should contribute to cautious • "covid negative client, displays no symptoms, has to stay in his room because the care unit is closed due to a covid positive client, family member wants to put on ppe and pick up client in ppe, to take them outside so they are no longer in a sad mood and will eat and drink again" • "yes, that too, it would be more pleasant to be able to go outside with a few people to keep the situation on the care unit bearable. in many cases, this prevents agitation and behavioral problems among clients with dementia." isolation and psychotropic drugs • "sedating patients who are infected and don't remain in their rooms. isolating and sedating 'walkers', with as a result: an unpleasant end of life." • "severe agitation with a pg-resident who can be calmed by family and requires more sedating medication out of necessity." • "psychiatric drugs became necessary to improve the quality of life, with drowsiness and decreased mobility as a result." • "sir now receives an increase of clozapine-medication, while it is unclear whether a non-medicated visit of family could be more effective." • the residents' world was already small, now it is even more limited because they can no longer receive family and friends, and are also locked inside the nursing home. the fact that residents cannot go outside themselves is very restrictive and increases psychological complaints. freedom restriction and tailoring to residents • "it would be nice if national policy would be that those to whom it relates, and to whom sitting in the courtyard is not enough, could go for a daily walk around the house or (duo)cycling accompanied by a member of staff." • "i find it difficult that they are not allowed to go outside under the condition that they have no social contact, don't go to the supermarket etc. a stroll around the block of a client with dementia accompanied by a member of staff, without any other form of social contact, should be possible." • "the client with the spinal cord injury has complete autonomy over his life, despite the dependence on care. he would be capable of adhering to social rules. however, he is in a total lockdown and i am in an intelligent lockdown". • "it feels unethical to restrict someone in their freedom, if your expectation is that he would act responsibly." • "in my opinion, riding around on empty parking lots or visiting quiet parks barely increases the risk of infection, but increases the feeling of freedom." • "taking away the option of going out for fresh air from a cognitively competent person on an uninfected care unit, even j o u r n a l p r e -p r o o f when they adhere well to regulations, is something i consider a strong intervention of their right to lead their own life. the risk of spreading corona verses the restriction of freedom is, in my opinion, disproportional. " • "what is difficult is that most of the contact is through telephone, there is no face-to-face contact. it makes communicating different, and more difficult." • "immediate incident with a resident, rectal blood loss. considering the stage of dementia, we will wait and see, and temporarily stop using anticoagulants scared wife on the phone, fears cancer, cries. reassured with difficulty. a personal conversation would have been better." • "there is little deployment of volunteers, spiritual care or psychologists possible, because they are also required to work from a distance as much as possible. this has caused the deployment of help with her mood to be slowed down." alternatives for therapies and care • "she currently does receive a psychologist and spiritual caretaker in her room because of the urgency, but visitors are still not allowed. an attempt will be made to improve that through videocalling or standing on the blacony with a baby monitor." j o u r n a l p r e -p r o o f impact on next-of-kin • "family also found it very hard to hear her speech was declining as a result of als and they could not come to see her, to talk to her about it." • "family is losing autonomy: i can see this is painful for them." • "the powerlessness and frustration of partner and the major worries this caused." impact on nursing staff • "informing families more often and better, many extra reports by nursing staff, use of video calls etcetera. nursing staff experience this impotence too and are not always able to provide extra care." • "the team is more at ease as there is no traffic of various people and professionals across the care units • . therefore, they have more time for residents. " • "this took a lot of effort by phone from my side to maintain a good doctor-patient relationship. " • "guidance of care-teams and explaining decisions take a lot of time. " nos. van dissel: 'corona in minstens 40 procent van de verpleeghuizen aantal bewoners van verzorgings-en verpleeghuizen the dutch move beyond the concept of nursing home physician specialists op advies van verenso scherpt kabinet bezoekregeling verpleeghuizen aan afscheid in de stervensfase en na overlijden family involvement in residential long-term care: a synthesis and critical review quality of life of institutionalized older adults by dementia severity dutch government. new measures to stop the spread of coronavirus in the netherlands handreiking voor bezoekbeleid verpleeghuizen in corona-tijd versie 4 juni 2020 using thematic analysis in psychology ethical issues experienced by healthcare workers in nursing homes: literature review amid the covid-19 pandemic, meaningful communication between family caregivers and residents of long-term care facilities is imperative prolonged social isolation of the elderly during covid-19: between benefit and damage loneliness and isolation in long-term care and the covid-19 the coronavirus and the risks to the elderly in long-term care covid-19 in older adults: clinical, psychosocial, and public health considerations de impact van sociale isolatie onder bewoners van verpleeg-en verzorgingshuizen ten tijde van het nieuwe coronavirus richtlijn zorg in de stervensfase care of the dying patient: the last hours or days of life white paper defining optimal palliative care in older people with dementia: a delphi study and recommendations from the european association for palliative care video calls for reducing social isolation and loneliness in older people: a rapid review nursing homes or besieged castles: covid-19 in northern italy the impact of covid-19 on long-term care in the netherlands ethisch verantwoorde zorg in tijden van corona -een handreiking voor zorginstellingen verruiming van de bezoekregeling in verpleeghuizen: bevindingen van de diepte-monitoring na 3 weken what affected you most in this situation? could you describe what impact it had on you? 3. did considerations relating to the resident play a role? if yes, which ones? 4. did considerations relating to the resident's family play a role? if yes, which ones? 5. did considerations relating to the nursing staff play a role? if yes, which ones? 6. did considerations relating to the care unit play a role? if yes, which ones? 7. did considerations relating to the organization play a role? if yes, which ones? 8. did any other considerations play a role? 9. what was decided upon regarding the dilemma and who was involved in the decision? 10. are there any other in my nursing home, i observe how much suffering corona causes and how many people fall victim to it. the risk of spreading should really not be taken measures also protect the professionals in particular: they are very vulnerable to be infected or to spread the coronavirus patient was terminal and visitors were allowed, a maximum of 2 people per day. except, these two would walk in and out throughout the day (…) this made me realise that the policy of 'two people a day in the terminal phase' is not specific enough. are they allowed to walk in and out? how long are they allowed to stay?" 34 for example: • loneliness • depressive symptoms, depression • decreased intake • neuropsychiatric symptoms (increased or decreased) • physical complaints (for example pain) proportional? visitor covid-19 confirmed? covid-19 related symptoms? connotation of visiting the resident for specific visitor: • being able to say goodbye to loved one • being involved in resident's disease process/ process of decline • being involved in resident's care process • being involved in resident first confirmed covid-19 case in national nursing home registry social distancing policies implemented by the dutch government 2020: nationwide restriction for all visitors of residents of ltcfs including nhs start of data collection/questionnaire sent to ecps end of data collection/questionnaire closed start of a pilot with eased visiting policies (i.e., allowing for one fixed visitor) in a selection of 26 dutch nhs eased visiting policies (i.e., allowing for one fixed visitor) in all nhs free from first monitoring results of the pilot published by the collaboration of academic university networks for older adult care in the netherlands stepwise lifting of restrictive visiting policy (i.e., allowing for more than one fixed visitor and more frequent visits) for all nhs under certain conditions including covid epidemiology and organizational factors researchers from two academic university networks for older adult care commissioned by the dutch ministry of health advise against a nationwide visitor restriction and argue that nhs should implement tailored visitor policies upon a second wave of covid-19 key: cord-264059-jf4j00bp authors: lee, chien-chang; chang, julia chia-yu; mao, xiao-wei; hsu, wan-ting; chen, shey-ying; chen, yee-chun; how, chorng-kuang title: combining procalcitonin and rapid multiplex respiratory virus testing for antibiotic stewardship in older adult patients with severe acute respiratory infection date: 2019-11-30 journal: j am med dir assoc doi: 10.1016/j.jamda.2019.09.020 sha: doc_id: 264059 cord_uid: jf4j00bp objectives: virus infection is underevaluated in older adults with severe acute respiratory infections (saris). we aimed to evaluate the clinical impact of combining point-of-care molecular viral test and serum procalcitonin (pct) level for antibiotic stewardship in the emergency department (ed). design: a prospective twin-center cohort study was conducted between january 2017 and march 2018. setting and participants: older adult patients who presented to the ed with saris received a rapid molecular test for 17 respiratory viruses and a pct test. measures: to evaluate the clinical impact, we compared the outcomes of sari patients between the experimental cohort and a propensity score–matched historical cohort. the primary outcome was the proportion of antibiotics discontinuation or de-escalation in the ed. the secondary outcomes included duration of intravenous antibiotics, length of hospital stay, and mortality. results: a total of 676 patients were included, of which 169 patients were in the experimental group and 507 patients were in the control group. more than one-fourth (27.9%) of the patients in the experimental group tested positive for virus. compared with controls, the experimental group had a significantly higher proportion of antibiotics discontinuation or de-escalation in the ed (26.0% vs 16.1%, p = .007), neuraminidase inhibitor uses (8.9% vs 0.6%, p < .001), and shorter duration of intravenous antibiotics (10.0 vs 14.5 days, p < .001). conclusions and implications: combining rapid viral surveillance and pct test is a useful strategy for early detection of potential viral epidemics and antibiotic stewardship. clustered viral respiratory infections in a nursing home is common. patients transferred from nursing homes to ed may benefit from this approach. objectives: virus infection is underevaluated in older adults with severe acute respiratory infections (saris). we aimed to evaluate the clinical impact of combining point-of-care molecular viral test and serum procalcitonin (pct) level for antibiotic stewardship in the emergency department (ed). design: a prospective twin-center cohort study was conducted between january 2017 and march 2018. setting and participants: older adult patients who presented to the ed with saris received a rapid molecular test for 17 respiratory viruses and a pct test. measures: to evaluate the clinical impact, we compared the outcomes of sari patients between the experimental cohort and a propensity scoreematched historical cohort. the primary outcome was the proportion of antibiotics discontinuation or de-escalation in the ed. the secondary outcomes included duration of intravenous antibiotics, length of hospital stay, and mortality. results: a total of 676 patients were included, of which 169 patients were in the experimental group and 507 patients were in the control group. more than one-fourth (27.9%) of the patients in the experimental group tested positive for virus. compared with controls, the experimental group had a significantly higher proportion of antibiotics discontinuation or de-escalation in the ed (26.0% vs 16.1%, p ¼ .007), neuraminidase inhibitor uses (8.9% vs 0.6%, p < .001), and shorter duration of intravenous antibiotics (10.0 vs 14.5 days, p < .001). conclusions and implications: combining rapid viral surveillance and pct test is a useful strategy for early detection of potential viral epidemics and antibiotic stewardship. clustered viral respiratory infections in a nursing home is common. patients transferred from nursing homes to ed may benefit from this approach. ó 2019 amda e the society for post-acute and long-term care medicine. community-acquired respiratory tract infections are among the most common reasons for emergency department (ed) visits and can be caused by both viral and bacterial pathogens. identification of the pathogen causing symptoms is critical for rapid institution of adequate antiviral or antibiotic therapy. because of the challenges in differentiating between viral and bacterial pathogens, patients with viral respiratory infections are usually underdetected, and unnecessary antibacterial agents are more likely to be administered. therefore, laboratory tests providing accurate and timely determination of the infectious agents associated with viral respiratory diseases are important. a broad array of tests is available to detect viral respiratory agents. rapid antigen tests are available for influenza a and b and respiratory syncytial virus (rsv), but these tests have low sensitivity and specificity. 1, 2 the authors declare no conflicts of interest. molecular diagnostic tests using the polymerase chain reaction (pcr) method to detect the rna or dna of the infectious agents show high sensitivity and specificity, but they are technically challenging and time consuming. the advent of sensitive point-of-care (poc) molecular detection methods has made rapid diagnosis of respiratory virus infections possible. the filmarray system (biofire diagnostics, inc, salt lake city, ut) is a desktop automated real-time pcr system that integrates sample preparation, amplification, detection, and analysis into 1 complete process that delivers results in 1 hour. the respiratory panel can detect 17 respiratory viruses and 3 bacterial targets in a single reaction. 3 initial studies demonstrated that such poc multiplex pcr systems identified previously under-evaluated viral or atypical infections in ed dyspneic patients, and the additional information on rapid respiratory infection testing may also change the physician's antibiotic-prescribing behavior, enabling more timely and appropriate treatment. 4e6 the hospital length of stay and direct medical cost for patients with the identified respiratory pathogens decreased. 7e16 despite the availability of highly accurate viral testing results, the discontinuation or the de-escalation of antibiotics still raises concerns because mixed virus-bacteria coinfection, especially influenza with pneumococcus, is common in older adults. 17 in this study, we proposed a diagnostic approach that combines the multiplex pcr respiratory panel with procalcitonin (pct) tests to better guide the antibiotic treatment. pct is a precursor of calcitonin that is constitutively secreted by c cells of the thyroid gland and k cells of the lungs. in healthy individuals, pct is normally undetectable (<0.01 ng/ml). when stimulated by endotoxin, pct is rapidly produced by parenchymal tissue throughout the body. unlike c-reactive protein, pct does not respond to sterile inflammation or viral infection. 18 this distinctive characteristic makes pct a valuable diagnostic marker. multiple randomized controlled trials have demonstrated that pct levels of <0.25 mg/l can guide the decision to withhold antibiotics or stop therapy early. 19, 20 since the approval of filmarray respiratory panel tests, only a few studies have evaluated the clinical impact after implementation of the multiplex pcr respiratory panel on patients with less severe acute reparatory illness. 8,13e15 to date, no study has focused on older adults with severe acute respiratory illness. older adults are more vulnerable to respiratory virus infection. because of undifferentiated clinical manifestation between bacterial and viral infection, antibiotic overuse in this population is common. in this study, we aimed to assess the impact of implementing a diagnostic algorithm that combines rapid respiratory viral surveillance and pct tests on older patients presenting to the ed with severe acute respiratory illness. we conducted a prospective cohort study in the ed of 2 urban medical centers. clinical impact was evaluated through a comparison of the experimental cohort with a propensity score (ps)ematched historical cohort. we conducted a prospective, multicenter, observational study of a sample of ed patients presenting with acute severe respiratory illness. the eds of 2 urban medical centers participated in this project. the annual ed census is around 100,000 for one medical center and 80,000 for the other. the study period included january 2017 through march 2018. we defined the preerespiratory panel system implementation period as january 2016 through december 2016 (12 months) and the posterespiratory panel system implementation period as january 2017 through march 2018. we had 200 multiplex pcr kits, of which 22 were used for rapid pcr respiratory panel system calibration; the remaining 178 kits were aimed for use among the study patients. however, at the planned end date of the study, we could not reach the target sample size. therefore, a 3-month extension in the experimental group was made to collect sufficient samples. the trial was approved by the institutional review board for human research at each participating center. patients aged 65 years or older presenting to the ed with acute severe respiratory illness were eligible for inclusion. we defined a case of severe acute respiratory illness according to the world health organization's case definition. we defined severe acute respiratory illness in adults as physician-diagnosed lower respiratory tract infection with a pulse oxygen saturation (spo 2 ) on presentation of less than 90% or a respiratory rate >20 breaths/min or the requirement of intubation and mechanical ventilation. basic demographic and clinical information and specimens were collected on the day of admission. an episode of lower respiratory tract infection was defined as acute pulmonary disease with or without acute respiratory failure, including pneumonia, influenza-like illness, or an acute exacerbation of a chronic respiratory illness (including an exacerbation of chronic obstructive pulmonary disease, asthma, or bronchiectasis). the exclusion criteria included if the patient was receiving palliative care or declined nasopharyngeal swabbing. all participants provided written informed consent. the filmarray respiratory panel (biofire diagnostics, inc) detects 17 viruses (rsv, influenza a h1, h1-2009, h3, influenza b, adenovirus, parainfluenza virus 1e4, rhinovirus/enterovirus, human metapneumovirus, human coronavirus oc43, 229e, nl63, and hku1), and 3 atypical bacteria (bordetella pertussis, mycoplasma pneumoniae, and chlamydia pneumoniae). we collected a nasopharyngeal swab using a nylon flocked swab that was immediately placed in universal transport media (utm). the study nurse collected all samples and specimens in utm, and they were tested according to the manufacturer's instructions. blood samples were collected within 24 hours of admission. pct concentrations were measured using an immunoluminometric assay with a detection limit of 0.06 ng/ml (brahms pctsensitive kryptor, thermo fisher scientific, brahms gmbh). respiratory swab and blood samples were tested as soon as they were received in the laboratory. during the study period, the study nurse identified eligible patients and explained the study protocol to the treating physicians and patients. eligible patients received a rapid molecular test with 17 respiratory viruses and a pct test. the results of the respiratory panel or pct tests were communicated to the treating physicians directly by the study nurse as soon as they were available and were kept in the medical records. the study nurse reminded the treating physician of the recommendation of antibiotic treatment based on different viral and pct testing results. the detection of influenza initiates isolation or neuraminidase inhibitor use. the detection of a virus with an elevated serum pct level (!0.25 ng/ml) may indicate the possibility of a superimposed bacterial infection and justify the continual use of antibacterial treatment in patients with noneinfluenza virus infection and combined antiviral and antibacterial treatment in patients with influenza infection. a positive result for respiratory virus with a low serum pct level and stable clinical manifestation may allow early discontinuation or de-escalation of empiric antibiotics. de-escalation was defined as changing to a narrower-spectrum antibiotic or shifting the intravenous antibiotics to oral form. a negative respiratory virus test result with a low serum level of pct (<0.25 ng/ml) would prompt clinicians to consider noninfectious causes of respiratory distress, such as acute exacerbation of obstructive airway disease, acute decompensated heart failure, or fluid overload. information regarding laboratory tests, antibiotic or antiviral therapy administration, duration of intravenous antibiotic treatment, length of intensive care unit stays, length of hospital stay, and 30-day mortality was obtained from electronic health records. we compared the outcome and duration of intravenous antibiotic use with a historical cohort with similar baseline characteristics and clinical presentations. the clinical impact was measured via the proportion of stopping or de-escalating antibiotics, neuraminidase inhibitor uses in the ed, duration of intravenous antibiotics treatment, length of hospital stay, length of intensive care unit stays, 30-day mortality, and overall all-cause mortality. to evaluate the clinical impact of combining the respiratory panel and pct testing on the outcomes of patients with severe acute respiratory illness, we established a historical cohort, including all patients presenting to the ed with severe acute respiratory illness from january 1, 2016 to december 31, 2016. the database included the following: demographics, clinical presentations, presenting viral signs, laboratory data, image results, ed and admission, medications used in the ed and hospitalization course, and discharge status. we then used a ps-matching technique to select a group of patients with similar demographics, comorbidities, diagnoses, vital signs, and laboratory results to the experimental cohort that received the respiratory panel and pct test. to increase the statistical power for analysis, we performed a 1-to-3 matching. the final cohort includes 169 older adult severe acute respiratory illness patients who received the respiratory panel and pct test and 507 ps-matched control patients. this composite cohort was used to assess the clinical impact of the rapid respiratory viral surveillance and pct tests. baseline characteristics were summarized using appropriate descriptive statistics. the categorical variables were presented as frequency and percentage and compared using the chi-squared test. the continuous variables were presented by median with interquartile range and compared by nonparametric mann-whitney u tests. the numbers of different respiratory viral isolates and mean serum level of pct for different viral infections were shown by bar graph. to select control patients, we built a ps for matching. ps was defined as the conditional probability of being tested with respiratory panel and pct, which was derived from the logistic regression model that included the following potential predictors: demographics, comorbidity, presenting vital signs, laboratory results, and admission diagnoses. to verify the balancing of baseline covariates after ps matching, we made a standardized difference plot to ensure minimum differences in the baseline covariates between 2 groups of patients (supplementary figure 1 ). in the ps-matched cohort, we compared the outcome between the current cohort and the ps-matched historical cohort using the logistic regression model, adjusting for the residual difference in the baseline covariates. all statistical analyses were performed by sas 9.4 (sas inc, cary, nc), and a p value of < .05 was deemed significant. a total of 178 patients enrolled in the study, of which 9 were excluded because of missing data or loss of follow-up. finally, 169 older adult patients with severe acute respiratory illness were included in the study analysis, of which 36 (21.3%) patients tested positive for respiratory virus. these patients were sick, so they were all hospitalized. the demographics, presenting vital signs, laboratory test results, and underlying comorbidity of the experimental and control cohorts are shown in table 1 . in the experimental cohort, the mean age was 81.2 years and 69.8% were males. diabetes, cancer, and chronic pulmonary disease were the leading 3 comorbidities, and pneumonia, chronic obstructive pulmonary disease with acute exacerbation, and acute respiratory failure were the most prevalent diagnoses. the control cohort had a comparable distribution on the aforementioned characteristics, except for including fewer patients with dementia or chronic liver disease. in the experimental group, 36 patients tested positive for respiratory virus, including 13 influenza a or b virus (7.7%), 9 rsv (5.3%), 9 human rhinovirus/enterovirus (5.3%), 2 coronavirus (1.2%), 2 parainfluenza virus type 3 (1.2%), and 1 human metapneumovirus (0.6%). in the control group, 20 patients (3.3%) were diagnosed with influenza, which was significantly lower than in the experimental group (p ¼ .049) ( table 2) . of the 36 patients who tested positive for virus, 14 (38.9%) had a pct level lower than 0.25 ng/ml. coronavirus, influenza a, and human rhinovirus/enterovirus infections had higher serum levels of pct (figure 1 ). compared with the control group, the patients in the experimental group had more antibiotics de-escalation (21.9% vs 13.2%, p ¼ .007), received more neuraminidase inhibitor in the ed (8.9% vs 0.6%, p < .001), had a shorter duration of intravenous antibiotics use (mealthough the patients in the experimental group had a trend of more antibiotic discontinuation, the small number of patients prevents meaningful comparison. neither 30-day nor in-hospital mortality was significantly different between the 2 groups. to further account for the residual covariate difference after ps matching, we performed logistic or linear regression adjusting for age, temperature, chronic liver disease, and dementia. the results revealed that rapid pcr respiratory panel and pct testing were associated with increased odds of discontinuing or de-escalating antibiotics [odds ratio (or) 1.97, 95% confidence interval (ci) 1.28, 3.02], increased odds of neuraminidase inhibitor prescription (or 17.9, 95% ci 5.02, 63.98), and shorter duration of intravenous antibiotics (-e4.44, 95% ci e2.08, à2.79). there was no difference in length of hospital stay and 30-day mortality (table 3) . this prospective cohort study reports the clinical impact of rapid molecular diagnosis of respiratory pathogens in conjunction with pct testing on older adult patients presenting to the ed with severe acute respiratory illness. the results showed 21.3% of older adult severe acute respiratory illness patients to be having respiratory virus infection, with influenza, rsv, and human rhinovirus/enterovirus being the 3 leading pathogens. we demonstrated that the new diagnostic approach was associated with increased discontinuation or deescalation of antibiotics, reduced length of intravenous antibiotics treatment, and improved influenza detection and antiviral use. these findings are consistent with those of previous studies. brendish et al 8 showed that patients receiving respiratory panel testing were more likely to undergo single doses or brief courses of antibiotics treatment. respiratory panel testing was also associated with a reduced length of stay and improved influenza detection and antiviral use. however, they did not find that routine use of respiratory panel testing could reduce the proportion of patients treated with antibiotics, which they ascribed to the initiation of antibiotics before the results of pct in many patients. a pre-post study showed that the use of the respiratory panel decreased the time to diagnosis of respiratory viruses, hospital admission rate, length of stay, number of chest radiographs, and duration of antimicrobial use. 13 gelfer et al 21 combined the respiratory panel and pct tests, but found no significant differences in overall antibiotic exposure between the experimental and standard-of-care groups. nevertheless, they found significantly fewer patients discharged on antibiotics and a shorter duration of therapy in a subgroup of patients with positive viral and negative pct testing results. they stressed the importance of proactive communication between the antibiotics stewardship team and physicians. our results showed that the proposed diagnostic approach could reduce intravenous antibiotics treatment duration by 4.44 days without compromising patient outcomes. historically, it has been advised to complete the course of intravenous antibiotics treatment despite the resolution of clinical symptoms. however, there is little evidence to support this practice. 22, 23 overuse of antibiotics was associated with increased risk of clostridioides difficile infection, and a prolonged course of intravenous antibiotics may increase the risk of adverse drug events, organ dysfunction, or mortality. 24 it is noteworthy that the identification of respiratory virus alone may not be sufficient to reduce antibiotic use because of the concerns regarding mixed virus-bacteria coinfection, especially influenza with pneumococcus infection. 25 low serum level of pct may help alleviate the concerns of mixed infection. in addition, communicating the results to the treating physicians is important. 13, 16 although we did not have a formal antibiotic stewardship team, the study nurse communicated the results to the treating physicians and promoted antibiotics stewardship. another finding is the underdiagnosis of influenza in older adult patients. older adult patients were less likely to undergo a provider-ordered influenza test. they usually lack the typical presentation of influenza-like illness and may present with respiratory distress or confusion. 26 a recent study showed that the diagnosis of influenza based on clinical grounds alone was associated with a suboptimal sensitivity of 36% and a specificity of 78%. 27 effect estimates for dichotomous outcomes were calculated by logistic regression whereas those for continuous outcomes were calculated using quantile regression. both models were adjusted for covariates not balanced after ps matching, including age, temperature, chronic liver disease, dementia, and chronic obstructive pulmonary disease with acute exacerbation. the proposed algorithm for respiratory virus infection diagnosis and antibiotic stewardship may also have implications for nursing home (nh) residents. acute respiratory virus infection outbreaks are a common problem in nhs. 28, 29 a recent systematic review reported a 1.21% to 85.2% annual incidence of influenza or rsv infection in long-term care facilities. 28 other than influenza and rsv, human metapneumovirus is the third most common causative pathogen for nh respiratory infection outbreaks. 30 nhs often do not have on-site equipment to evaluate suspected infection; therefore, a lower threshold for antibiotic prescription is common. it is estimated that approximately two-thirds of nh residents received antibiotics each year, and up to 75% of the treatment is inappropriate. nhs become the reservoirs for resistant bacteria within a community. 31 although the present protocol cannot be implemented in nhs, it can be used among severe nh patients who are transferred to the ed. in a less severe outbreak, the nasopharyngeal samples of nh residents can be collected and sent to contracted laboratories for respiratory panel testing. the early detection of acute respiratory infection enables early isolation of infected patients and early antiviral drug administration, which can prevent or contain a respiratory virus infection outbreak. cost is an important consideration for the large-scale clinical implementation of rapid multiplex pcr testing. previous analyses showed that rapid multiplex pcr testing was the most cost-effective testing strategy for the detection of influenza in children. 12, 32 the cost-effectiveness of respiratory panel testing is highly influenced by the prevalence of influenza and the proportion of patients treated with antivirals. the significant improvement in influenza diagnosis and antiviral treatment in our study suggests that a combination of respiratory panel and pct testing may be cost-effective in our study setting. such speculation, however, requires future validation. our results have to be interpreted in light of several limitations. first, pct tests were not used in the comparison cohort. we cannot determine the impact of the viral panel and pct tests separately. second, the study nurse only enrolled patients during working hours of weekdays. selection or spectrum bias is less likely because we did not find significant difference in the outcomes of patients presenting to the ed on different time shifts. third, the postdischarge follow-up data of the historical comparison cohort cannot be retrieved. we therefore could not compare the duration of oral antibiotics between the 2 cohorts. the reduction of intravenous antibiotic duration alone is important because it has been shown to be a strong risk factor for the development of resistant bacteria strains. fourth, the generalization of the results to other settings should be taken into consideration. the long hospitalization duration in our study was due to old age, severe illness, and low hospitalization cost. 33, 34 lastly, the incidence of various respiratory viruses may have varied across the 2 seasons of the study period. the strengths of our study include the older adult population, the twin-center prospective cohort design, the simple antibiotic stewardship algorithm, and the comparison to a ps-matched cohort. the findings of our study support the use of rapid multiplex pcr respiratory panels in conjunction with the pct test for early diagnosis of respiratory viral infection and to inform optimizing antibiotic use in older adult patients presenting to the ed with severe acute respiratory illness. respiratory viral infection outbreak is common in nursing homes. performing the proposed diagnostic approach on patients transferred from nhs may enable early detection of the causative pathogens and early isolation of infected patients. as the cost per test is still high, institutions should develop a protocol to prevent indiscriminate testing with multiplex pcr and provide proactive real-time feedback to treating physicians for antimicrobial stewardship. further studies are needed to assess the incremental value of multiplex pcr viral testing compared with pct testing alone in the management of patients with severe acute respiratory infection in the ed. diagnostic accuracy of rapid antigen detection tests for respiratory syncytial virus infection: systematic review and meta-analysis diagnostic accuracy of novel and traditional rapid tests for influenza infection compared with reverse transcriptase polymerase chain reaction: a systematic review and meta-analysis the filmarray(r) respiratory panel: an automated, broadly multiplexed molecular test for the rapid and accurate detection of respiratory pathogens the clinical significance of filmarray respiratory panel in diagnosing community-acquired pneumonia multiplex pcr system for the rapid diagnosis of respiratory virus infection: systematic review and meta-analysis multicenter evaluation of biofire filmarray respiratory panel 2 for detection of viruses and bacteria in nasopharyngeal swab samples the influence of rapid influenza diagnostic testing on antibiotic prescribing patterns in rural thailand routine molecular point-of-care testing for respiratory viruses in adults presenting to hospital with acute respiratory illness (respoc): a pragmatic, open-label, randomised controlled trial effect of the influenza virus rapid antigen test on a physician's decision to prescribe antibiotics and on patient length of stay in the emergency department the rapid diagnosis of viral respiratory tract infections and its impact on antimicrobial stewardship programs the use of a multiplex real-time pcr assay for diagnosing acute respiratory viral infections in children attending an emergency unit randomised controlled trial and health economic evaluation of the impact of diagnostic testing for influenza, respiratory syncytial virus and streptococcus pneumoniae infection on the management of acute admissions in the elderly and high-risk 18-to 64-yearolds impact of early detection of respiratory viruses by multiplex pcr assay on clinical outcomes in adult patients impact of rapid molecular respiratory virus testing on real-time decision making in a pediatric emergency department impact of a rapid respiratory panel test on patient outcomes multiplex respiratory virus testing for antimicrobial stewardship: a prospective assessment of antimicrobial use and clinical outcomes among hospitalized adults viral infection in community-acquired pneumonia: a systematic review and meta-analysis diagnostic accuracy of c-reactive protein and procalcitonin in suspected community-acquired pneumonia adults visiting emergency department and having a systematic thoracic ct scan using procalcitonin to guide antibiotic therapy overview of procalcitonin assays and procalcitonin-guided protocols for the management of patients with infections and sepsis the clinical impact of the detection of potential etiologic pathogens of community-acquired pneumonia should we abandon "finishing the course" of antimicrobials? the antibiotic course has had its day hospital ward antibiotic prescribing and the risks of clostridium difficile infection viral-bacterial coinfection affects the presentation and alters the prognosis of severe community-acquired pneumonia underdiagnosis of influenza virus infection in hospitalized older adults clinical diagnosis of influenza in the ed the burden of respiratory infections among older adults in long-term care: a systematic review influenza in long-term care facilities outbreak of human metapneumovirus in a nursing home: a clinical perspective comparing appropriateness of antibiotics for nursing home residents by setting of prescription initiation: a cross-sectional analysis economic analysis of rapid and sensitive polymerase chain reaction testing in the emergency department for influenza infections in children effect of a modified hospital elder life program on delirium and length of hospital stay in patients undergoing abdominal surgery: a cluster randomized clinical trial predicting the length of hospital stay of postacute care patients in taiwan using the chinese version of the continuity assessment record and evaluation item set biofire diagnostics, llc, salt lake city, ut sponsored the filmarray rp kits for this study. biofire has no role in the interpretation of the results and writing of the manuscript. key: cord-276621-9exp8e7h authors: jacobs, jeremy m.; marcus, esther-lee; stessman, jochanan title: prolonged mechanical ventilation: symptomatology, well-being, and attitudes to life date: 2020-09-06 journal: j am med dir assoc doi: 10.1016/j.jamda.2020.07.037 sha: doc_id: 276621 cord_uid: 9exp8e7h objective: although prolonged mechanical ventilation (pmv) is increasingly common, little is known concerning patient symptom burden or attitudes toward pmv. this study aims to describe the mood, well-being, distressing symptoms, and attitudes toward prolonged ventilation among pmv patients treated either at home or long-term acute care (ltac). design: an observational study. setting and participants: 62 communicative participants treated with pmv, aged ≥18 years, insurees of a single hmo, treated at home hospital or ltac specializing in ventilation in jerusalem. measures: sociodemographic characteristics; chronic conditions; functional status; symptom burden measured by revised edmonton symptomatic assessment system (r-esas); attitudes toward pvm. results: participants were aged 61.7 ± 20.7 years, commonly suffered progressive neuromuscular disease (43.5%) or chronic lung disease (29%), were functionally dependent, treated at home (64.5%) or ltac (35.5%), and had a mean pmv duration of 36.6 months (interquartile range 10.8-114.1). the 5-item, short geriatric depression scale identified depression among 38% of participants, and was less at home vs ltac (34% vs 44%, p < .001). mean revised edmonton symptom assessment system score was 24.5 ± 14.8 (maximum severity = 100), and participants reported severe or distressing symptoms for tiredness (27%/20%), pain (10%/25%), anxiety (16%/14%), depression (9%/21%), drowsiness (12%/17%), shortness of breath (9%/15%), poor appetite (7%/9%), and nausea (0%/10%). impaired general well-being was reported as severe, moderate, mild, or none among 15%, 40%, 30%, and 15%, respectively. only 1 patient had advance directives concerning ventilation prior to intubation, and when asked if they had to choose again today, 85% of patients would again opt for ventilation. conclusions and implications: few pmv patients reported distressing symptoms, and 85% would choose ventilation if asked again. these findings might be useful in clinical practice to assist in decision making concerning prolonged ventilation. those who fail to wean from ventilator following an acute event such as acute respiratory failure, acute brain injury, and cardiopulmonary resuscitation, alongside survivors of intensive care units suffering from chronic critical care illness. 13, 14 in addition, there is a growing population of pmv patients with progressive neuromuscular diseases and chronic lung diseases who opt for semielective ventilation when faced with encroaching respiratory failure. research into pmv has primarily focused on objective measures and outcomes of care including long-term survival, rates of long-term liberation from ventilation, and economic ramifications of care. 2,4,15e17 despite the importance of the increasing population of pmv patients as a public health care challenge, far less is known about the patient's perspective toward pmv. although limited research does exist concerning overall quality of life, 18e22 little is known about the range and severity of symptomatology, and only rarely has research addressed the attitudes of pmv patients themselves toward prolonged ventilation, and their decisional regret. in light of the recent increase in the number of people receiving invasive ventilation due to covid-19, often for a prolonged period of time, this area is of particular relevance. this observational study among pmv patients aims to describe the range and severity of common symptoms, their mood and well-being, as well as their attitudes concerning ventilation. the current study focuses on a subset of 62 participants treated with pmv and able to communicate, who were enrolled in a larger observational study of 120 invasive pmv patients (defined as ventilation via tracheostomy !21 days), treated either at home or in longterm acute care (ltac) between may 1, 2016, and april 31, 2018. a comprehensive description of the study methodology and patient characteristics has been recently published. 23 setting study participants were all insurees of the clalit health services, the largest hmo in israel, which provides mandatory comprehensive health coverage to all citizens. pmv care in jerusalem is provided either in a single specialized ltac (chronic ventilator-dependent division, herzog medical center, jerusalem), or at home, cared for by the jerusalem home hospital. 24e28 the decision concerning site of care depends on the patient's and/or custodian's agreement, sufficient informal/formal home care, and medical condition. at the time of the study, there were 120 beds in the ltac available for adult pmv patients, of which 76 beds were occupied by pmv patients of the clalit health fund. during the study period, there were 47 adult pmv patients cared for at home by the jerusalem home hospital. both settings provide comprehensive multidisciplinary team, with 24/7 on-call medical and respiratory backup at home, and on-site medical, nursing, and respiratory care in ltac. 23 all adult invasive pmv participants (aged !18 years, clalit health services insurees) treated either at home or in ltac during the study period in jerusalem were eligible for inclusion in the study and all were approached to enroll. those participants already being treated with pmv at the start of the study were approached to enroll, as were subsequent participants who were admitted to ltac or home hospital during the study period. informed consent was given by cognitively intact participants or legal custodians where appropriate. we identified a total of 123 potential participants (47 at home and 76 in ltac), among whom 1 communicative patient (at home) and 2 legal custodians of noncommunicative patients (at ltac) declined to enroll. among the 120 enrolled participants, there were a total of 62 participants who were able to communicate (40 at home, 22 at ltac), all of whom gave their consent to enroll. the current study focuses exclusively on this subset of 62 communicative pmv participants. the local ethics committee approved the study proposal. data were collected from review of medical records and structured patient interview by the study assistant. medical records were available for all participants, and all participants were interviewed. data were confidentially coded with a unique identifier and uploaded to the secure research database. standardized questionnaire included sociodemographic characteristics, primary indication for pmv, current comorbidities and medications, functional status before and after pmv according to the barthel index 29, 30 (measuring dependence in eating, bathing, personal hygiene, and dressing, continence of bladder and bowel, toileting, transfer from bed to chair; mobility, and stair climbing, with total independence maximum score ¼ 100), daily hours, and duration of ventilation. assessment of patient symptoms was performed using the revised edmonton symptom assessment system (r-esas) (a 10-item set of patient-reported outcomes assessing the current feeling of tiredness, lack of appetite, pain, drowsiness, nausea, shortness of breath, overall well-being, depression, anxiety, and other problems). each symptom is graded by patient from 0 (no problem) to 10 (most severe), with the total score ranging from 0 to 100 (100 most severe). 31, 32 as regards the definition of well-being, the participants were instructed to rate their overall feeling of health in general, from 0 (best) to 10 as the worst possible feeling. the r-esas has been validated in 20 languages including hebrew. 33 the 5-item, short geriatric depression scale (gds) 34 was used to determine depression, with each question scored as 0 or 1 for a maximum score of 5, with depression defined as !2/5. participants answered the following question: "if you had to decide today concerning advance directives for long term ventilation, how would you choose?", the possible answers being "yes, i would choose to be ventilated," "no, i would choose not to be ventilated," or "unsure." for continuous variables, we determined means and standard deviations or median and interquartile range, as appropriate. the total r-esas score and attitude toward ventilation were analyzed by site of care and age of patient (cutoff chosen by age median). comparisons were performed using chi-square, t test, or wilcoxon rank-sum test. multivariate analysis, using a linear regression, examined the relationship between r-esas score and independent variables, including age, gender, marital status, financial difficulty, site of care, cause of pmv (chronic lung disease, degenerative neuromuscular disease, acute cause), and functional status. multivariate analysis using logistic regression examined the relationship between depression (measured by the 5-item gds) and these variables. demographic, medical, and functional variables were tested. the multivariate model included variables with p < .2 in univariate testing. baseline characteristics are shown in table 1 for the 62 pmv study participants. mean age was 61.7 ae 20.8 years, 34% were single, 21% had >12 years' education, 52% had no legal custodian, and participants were more frequently cared for at home (64.5%) vs in ltac (35.5%). the most common indication for pmv was progressive degenerative neuromuscular disease (43.5%) followed by chronic lung disease (29%). prior to pmv, the mean barthel index score was 60.4 ae 34.2, with a mean decline in score of 41 ae 30.3 following pmv. most participants were ventilated >18 hours daily, and the mean duration of pmv was 36.6 months [interquartile range (iqr) 10. .1] at the study end. the scores for each of the 10 items of the r-esas are shown in table 2 . the total mean r-esas score was 24.5 ae 14.8 (maximum score 100), and both the mean and median score for all individual subitems was <4 (maximum score 10), apart from the subitem for general wellbeing (mean 3.8 ae 2.6, median 4, iqr 2-6). the distribution of severity of symptoms is shown in figure 1 , using cutoff points to define each subitem as asymptomatic (score 0), mild (score 1-3), moderate (score 4-6), and severe (score 7-10). participants reported severe or distressing symptoms for tiredness (27%/20%), pain (10%/25%), anxiety (16%/14%), depression (9%/21%), drowsiness (12%/17%), shortness of breath (9%/15%), poor appetite (7%/9%), and nausea (0%/10%). accordingly, many participants were asymptomatic or mildly symptomatic for nausea (90%), poor appetite (84%), shortness of breath (76%), drowsiness (71%), depression (70%), anxiety (70%), pain (65%), and tiredness (53%). impaired general well-being was reported as severe, moderate, mild, or none among 15%, 40%, 30%, and 15%, respectively. in addition to the single item for depression in the r-esas, the short-form 5-item gds revealed a mean score of 1.32 ae 1.36, with 38% of participants screening positive for depressive symptomatology, scoring !2/5. interestingly 33% of participants were receiving antidepressant medication, whereas the use of analgesics and sedatives was 27% and 34%, respectively. despite a trend toward less symptom burden among younger participants, there were no significant differences in the total r-esas score among participants aged <65 years vs those aged !65 years, with a mean score of 21.2 (sd 12.5) vs 27.9 (sd 16.2) (p ¼ .08), and a median score of 19 (iqr 14-31) vs 28 (iqr 20-33) (p ¼ .10). several multivariate analyses were performed to examine the possible association between baseline independent variables and either depression or the total sum r-esas score. no significant association was observed with depression in several logistic regression analyses; however, a significant association between chronic lung disease and increased r-esas score was observed in linear regression analyses (beta coefficient 14, p < .01). we re-examined the data according to site of care, comparing participants treated at home (40/62) to those in ltac (22/62). the symptom burden of pmv patients was similar irrespective of site of care, with a mean r-esas score of 24.9 ae 16.7 vs 23.7 ae 10.0 (p ¼ .74) at home and ltac, respectively. although no significant differences were observed in the severity of the 10 r-esas subitem symptoms between home and ltac, nonetheless, well-being was reported as asymptomatic or mildly impaired by 54% of home pmv patients compared with 26% among long-term care, with similar rates of severely impaired well-being reported by 10% and 11% of patients, respectively. depressive symptomatology, as measured using the 5-item short gds, was less frequent at home compared with ltac (34% vs 44%, p ¼ .049). planned ventilation was more common among participants at home hospital, and the initiation of ventilation (prior to intubation) was discussed with the patient or family members and/or custodians among 74% vs 43% (p ¼ .001) of home vs ltac pmv patients, respectively. no other significant differences were observed. as shown in table 3 , only 85.5% (53/62) of participants were initially intubated within a hospital setting, and among 30.6% (19/62) the intubation was elective. prior discussion with either patient, family, or custodian concerning intubation was reported to have taken place among 67.2% of study participants. only 1 of the 62 study participants had formal advance directives concerning ventilation prior to the initiation of ventilation. in answer to the question "if you had to number of chronic diseases from the following: diabetes mellitus, ischemic heart disease, chronic heart failure, hypertension, chronic lung disease, chronic renal failure, dementia, past history of cancer, past history of stroke. x barthel index score: 0 ¼ maximum independence, 100 ¼ maximum dependence. decide today concerning advance directives for ventilation, how would you choose?" 7 of 61 participants (11.5%) answered that they would choose not to be ventilated, compared to 52/61 (85.2%) who would choose again to be ventilated, and 2 participants who were undecided. among the 19 elective pmv participants, discussion concerning ventilation prior to intubation was reported by 15 participants, no discussion reported by 1, and 3 failed to answer the question. among these 15 participants who discussed pmv prior to elective intubation, 13/15 (86.7%) answered that they would choose again today in favor of ventilation. there were no significant differences observed concerning choices around ventilation when subdividing the study sample according to age <65 years vs those aged !65 years old, with 85.7% (24/29) vs 84.8% (28/33) in favor of pmv (p ¼ .8), respectively. similarly, no significant differences were observed when subdividing participants according to home vs ltac, with 82.2% (32/40) vs 90.9% (20/22) in favor of pmv (p ¼ .9), respectively. this study describes the mood, symptoms, well-being, and attitudes toward ventilation, among study participants treated with prolonged mechanical ventilation via tracheostomy both at home and in ltac. progressive neuromuscular diseases, chronic lung disease and chronic critical illness where the most common causes for pmv, and participants were typically highly functionally dependent, ventilated >18 hours daily, with a mean duration of pmv of around 3 years. few participants reported moderate or severe distress across a wide range of symptoms, both physical (nausea, poor appetite, shortness of breath, drowsiness, tiredness, and pain) and emotional (depression and anxiety), whereas the global measure of general well-being was reported as either normal or mild impairment among 45%, moderately impaired among 40%, and severely impaired among 15% of participants. half of those cared for at home reported their overall well-being as normal or only mildly impaired, compared with only a quarter of ltac, and, similarly, depression was significantly less common at home vs ltac (34% vs 44%). whereas advance directives were completely lacking prior to initiation of ventilation, an interesting finding to emerge was the observation that if faced again with the decision to choose pmv, then 85% of patients would opt for pmv. research into the health-related quality of life among patients receiving pmv has commonly focused on patients treated with noninvasive ventilation, with assessment based on either single-item questions or tools such as the eq-5d (euroqol-5 dimensions) 35 or more recently the severe respiratory insufficiency questionnaire. 36 this 49-item test has typically been used among patients with advanced lung disease, as well as those treated with noninvasive ventilation, 37 and evaluates the impact of respiratory insufficiency on several aspects of health-related quality of life including respiratory complaints, physical function, attendant symptoms, social the r-esas consists of 10 items, each graded 0-10, with 0 ¼ no symptoms and 10 ¼ maximum distress. the total score thus ranges from 0 (completely symptom free) to 100 (most severe). *n ¼ 50 for the 5-item gds scoring. y depression defined as a score !2/5 using the 5-item short gds. relationships, anxiety, psychological well-being, and social functioning. findings have varied considerably depending on the patient population, with more severe symptoms described among older patients with chronic lung disease as compared to younger patient population with progressive neuromuscular disease. the r-esas scale used in the present study has been widely used in both clinical practice and research for more than 25 years and repeatedly shown to be a robust and validated tool in the measurement of patient-reported outcome measures. 33 originally designed to assess the palliative needs of oncology patients, it has seen widespread use among numerous other patient groups, including, for example, nephrology, cardiac, hepatic diseases, multiple chronic comorbidities, and pulmonary diseases, 33, 38 in both inpatient and outpatient ambulatory and home care settings. extensive research and comparative studies have validated meaningful cutoff points to define asymptomatic, mild, moderate, or severe symptomatology, and which we used in this study. 32, 39, 40 accordingly, a score greater than !7/10 on any individual subitem has been defined by some researchers as a high symptom burden, and suggested to serve as a "trigger" in clinical practice to highlight the need for reassessment of palliative care needs. our data help quantify the severe distress experienced by pmv patients in the study sample, among whom severe (!7/10) anxiety, drowsiness, tiredness, and impaired well-being were reported by 16%, 12%, 27%, and 15%, with the remaining symptoms reported as severe by 10% of patients. similarly, frequency of depression was 38%, which is considerably higher than the estimates of 20% baseline rate among the local jerusalem population aged 70 years 41 and 25% among a national sample aged !65 years. 42 indeed, the depression rates of our sample are similar to residents of long-term care facilities. 43 a prerequisite first step toward relieving this distress is the need to increase awareness among health care workers and provide skills to proactively identify distressing symptoms shown here to affect pmv patients. although few patients suffered severe levels of distressing symptoms, the range of symptom severity observed among our sample was very similar to a study of 506 community-based patients (nonventilated) enrolled into a home care unit. 40 among patients in our study, the severity of most symptoms was unaffected by the site of care (whether at home or in long-term care). a similar finding was also reported in a study of 32 invasive pmv patients treated either at home or nursing facility, among whom the reported health-related quality of life ranged from very good (primarily among the 14 neuromuscular disease patients) to poor (among older chronic lung disease) irrespective of place. 18 interestingly, the only significant association to emerge from several multivariate analysis of our data was the association between chronic lung disease and an increase in the total r-esas score, mediated by the r-esas subitem of increased severity of the shortness of breath. among the few studies that have addressed this point, this would appear to be a recurrent finding for both invasive and noninvasive pmv patients. 18, 19 qualitative research into the impact of invasive pmv among young men with duchenne muscular dystrophy in denmark, 20 and patients aged between 18 and 75 years with various neuromuscular diseases from norway 21 emphasized the recurrent themes of "empowerment" and the "positive contribution to a purposeful meaningful life" expressed by patients. of note, in answer to one of the items in the short gds, 80% of the patients in our study answered that "overall they were satisfied with their life," which is in accordance with the assessment of overall well-being among the patients in our study. the positive perspective on overall health and well-being has also been noted in several studies of home pmv patients, 22 and although it may reflect high quality of care, it highlights the dissonance between good subjective patient-reported outcomes, on the one hand, and their extremely complex medical needs, functional impairment, and high technological dependence, on the other. the decision-making process surrounding pmv is complex. it is noteworthy that many study participants suffered from progressive diseases for which respiratory failure was a foreseeable event, often a long time in advance. nonetheless, all but 1 study participant were without advance directives at the time of intubation. the observation that 85% of our study participants would, if necessary, again choose ventilation, is in keeping with the few studies that have also addressed this sensitive issue. despite different patient populations, different place of care, and different treatment models, the percentages of patients stating they would again choose ventilation were similar: 84.7% among 315 pmv patients in ltac in the united states (of whom 54% were successfully weaned at 1 year, and the total 1-year survival rate was 66.9%); 44 90% among 77 patients with both lung and neuromuscular diseases treated with home pmv via tracheostomy in italy, median survival 49 months; 45 85% of 19 patients with neuromuscular diseases treated at home in the united states, median survival 54 months; 46 8/14 (57.1%) of copd patients and 9/11 (81.8%) of progressive neuromuscular disease patients with invasive pmv at home in the united states. 19 the consistency of this finding attests to its validity and affirms that the findings of our study are reproducible and thus representative of other similar patient populations. similarly, comparisons of data describing similar patient populations from other countries, treated either in long-term care or at home, suggest that our findings can be extrapolated to other populations of pmv patients. 9, 11, 12, 16, 44 recent work 5 that aimed to introduce algorithms to aid the informed decision-making process concerning pmv have largely failed to change the pattern of decisions, and a frequent finding to emerge has been the "overoptimistic" outlook of the health proxy. a possible source of bias may have been introduced, because all patients were treated by a single center, and therefore local standards and practices may have influenced the findings. our research is limited by its inclusion of only patients who were able to communicate. the patients who declined ventilation, and those who did not survive long enough to reach prolonged ventilation, as well pmv patients unable to communicatedthe opinion and voice of these "nonsurvivors" and silent patients remain unheard. however, as suggested elsewhere, the survivors of prolonged ventilation are the closest witnesses of the "struggle endured," and as such may speak by proxy in the light of their own experience. 47, 48 conclusions and implications few patients with pmv reported distressing symptoms, depression, or impaired well-being. most patients did not regret their decision to undergo pmv. these findings deserve consideration and may assist decision making concerning prolonged ventilation. management of patients requiring prolonged mechanical ventilation: report of a namdrc consensus conference prolonged acute mechanical ventilation, hospital resource utilization, and mortality in the united states accuracy of previous estimates for adult prolonged acute mechanical ventilation volume in 2020: update using 2000-2008 data prolonged mechanical ventilation in 540 seriously ill older adults: effects of increasing age on clinical outcomes and survival effects of a personalized web-based decision aid for surrogate decision makers of patients with prolonged mechanical ventilation patterns of home mechanical ventilation use in europe: results from the eurovent survey who benefits from home mechanical ventilation provision of home mechanical ventilation and sleep services for england survey home mechanical ventilation in australia and new zealand home mechanical ventilation: an overview home mechanical ventilation in canada: a national survey attitudes and preferences of home mechanical ventilation users from four european countries: an ers/elf survey chronic critical illness long-term acute care hospital utilization after critical illness long-term survival of critically ill patients treated with prolonged mechanical ventilation: a systematic review and metaanalysis one-year trajectories of care and resource utilization for recipients of prolonged mechanical ventilation: a cohort study chronic comorbid illnesses predict the clinical course of 866 patients requiring prolonged mechanical ventilation in a long-term, acute-care hospital invasive home mechanical ventilation: living conditions and health-related quality of life quality of life and life satisfaction are severely impaired in patients with long-term invasive ventilation following icu treatment and unsuccessful weaning life with home mechanical ventilation for young men with duchenne muscular dystrophy clients' experiences of living at home with a mechanical ventilator clinical outcomes associated with home mechanical ventilation: a systematic review prolonged mechanical ventilation: a comparison of patients treated at home compared to hospital long-term-care. jamda decreased hospital utilization by older adults attributable to a home hospitalization program home hospital care home hospitalization home hospitalization: 15 years of experience closure of a home hospital program: impact on hospitalization rates the barthel index: a reliability study establishing cutoff values for the simplified barthel index in elderly adults in residential care homes edmonton guidelines for using the revised edmonton symptom assessment system (esas-r) a multicenter study comparing two numerical versions of the edmonton symptom assessment system in palliative care patients the edmonton symptom assessment system 25 years later: past, present, and future developments development and testing of a five-item version of the geriatric depression scale measurement of quality of life using eq-5d in patients on prolonged mechanical ventilation: comparison of patients, family caregivers, and nurses the severe respiratory insufficiency (sri) questionnaire. a specific measure of health-related quality of life in patients receiving home mechanical ventilation health-related quality of life as predictor for mortality in patients treated with long-term mechanical ventilation the burden of symptoms among community-dwelling older persons with advanced chronic disease the optimal cutoff point for expressing revised edmonton symptom assessment system scores as binary data indicating the presence or absence of symptoms pilot testing of triage coding system in home-based palliative care using edmonton symptom assessment scale. indian the changing profile of health and function from age 70-85 depressive symptoms and use of health services among older adults in israel depression in late life: review and commentary long-term outcome after prolonged mechanical ventilation. along-term acute-care hospital study outcome and attitudes toward home tracheostomy ventilation of consecutive patients: a 10-year experience long-term tracheostomy ventilation in neuromuscular diseases: patient acceptance and quality of life long-term outcomes after prolonged mechanical ventilation: what of those cast away? reply to law and walkey: long-term outcomes after prolonged mechanical ventilation: what of those cast away? we acknowledge ruth steiner (rn) for the many hours spent collecting data and interviewing the patients and their caregivers both in the ltac and at home. we also acknowledge aliza hammerman-rozenberg (ma) for her statistical consultation. key: cord-272995-yvj2pqh1 authors: bergman, christian; stall, nathan m.; haimowitz, daniel; aronson, louise; lynn, joanne; steinberg, karl; wasserman, michael title: recommendations for welcoming back nursing home visitors during the covid-19 pandemic: results of a delphi panel date: 2020-10-07 journal: j am med dir assoc doi: 10.1016/j.jamda.2020.09.036 sha: doc_id: 272995 cord_uid: yvj2pqh1 objectives nursing homes became epicenters of covid-19 in the spring of 2020. due to the substantial case fatality rates within congregate settings, federal agencies recommended restrictions to family visits. six months into the covid-19 pandemic, these largely remain in place. the objective of this study was to generate consensus guidance statements focusing on essential family caregivers and visitors. design a modified two-step delphi process was used to generate consensus statements. setting and participants the delphi panel consisted of 21 us and canadian post-acute and long-term care experts in clinical medicine, administration, and patient care advocacy. methods state and federal reopening statements were collected in june 2020 and the panel voted on these using a three-point likert scale with consensus defined as ≥80% of panel members voting “agree.” the consensus statements then informed development of the visitor guidance statements. results the delphi process yielded 77 consensus statements. regarding visitor guidance, the panel made five strong recommendations: 1) maintain strong infection prevention and control precautions, 2) facilitate indoor and outdoor visits, 3) allow limited physical contact with appropriate precautions, 4) assess individual residents' care preferences and level of risk tolerance, and 5) dedicate an essential caregiver and extend the definition of compassionate care visits to include care that promotes psychosocial wellbeing of residents. conclusions and implications the covid-19 pandemic has seen substantial regulatory changes without strong consideration of the impact on residents. in the absence of timely and rigorous research, the involvement of clinicians and patient care advocates is important to help create the balance between individual resident preferences and the health of the collective. the results of this evidence-based delphi process will help guide policy decisions as well as inform future research. visitor guidance for america's nursing homes regarding the abrogation of self-determination and clinical concerns that ongoing restrictions 24 have begun to outweigh any potential benefits. 15, 20-22 25 cms released phased reopening guidelines on may 18, 2020, instructing nursing homes 26 to reopen only when the facility had no new covid-19 cases for a 28 day period and no 27 shortages in ppe, staffing, or testing capacity. 23, 24 three months after release of these guidelines, 28 many facilities are still far from meeting these criteria. 11 residents, families, clinicians, and 29 advocates are calling for a more immediately actionable, sustainable, balanced, nuanced, and 30 resident-centered approach to reopening nursing homes that respects residents' rights to 31 autonomy, informed risk taking, access to essential family caregivers, and other face-to-face 32 interactions. a group of experts convened to develop a set of evidence-informed guidance 33 statements to welcome back visitors and essential family caregivers to america's nursing homes. in round one, participants voted on the statements, using a three-point likert scale 74 ("agree," "neutral," or "disagree") with an option to offer "absent" due to a lack of perceived 75 expertise. consensus was defined as ≥80% of participants voting "agree" (green statements). 76 we grouped non-consensus statements into ≤50% (red statements) and 51-79% (yellow 77 statements) for purposes of facilitating discussion after each round. the whole panel discussed 78 statements not reaching consensus in a videoconference, starting with statements that had the 79 highest degree of uncertainty (red statements). in preparation for round two of voting, 80 participants also suggested additional statements for consideration. following the second round 81 of voting, a final videoconference discussion collected comments on the non-consensus 82 statements to help inform the final document. we report the final count of consensus and non-83 consensus statements. descriptive statistics and tables illuminated differences in responses 84 among the expert panel. 85 86 although the present reopening statements cover a wide range of topics, we focused on the 88 statements specific to visitors in order to communicate immediately actionable recommendations 89 to policymakers. those statements reaching consensus shaped our visitor guidance document. 90 we edited the final guidance statements for clarity, aiming to capture the consensus of the delphi aspects of the following topics (see table 1 ): testing of asymptomatic staff and residents, 111 surveillance testing, visitor guidance, immunity from prior covid-19 infection and associated 112 risk of infecting others. the panel generally agreed on the need for testing of asymptomatic staff 113 (79%); but the panel discussion reflected the importance of understanding community prevalence 114 as a key factor in deciding to test asymptomatic individuals. while the panel mostly agreed 115 j o u r n a l p r e -p r o o f visitor guidance for america's nursing homes (68%) that residents should be allowed to opt out of testing for sole purposes of surveillance, 116 fewer agreed that testing of asymptomatic residents should not be done (53%). most members 117 agreed that an asymptomatic resident who has recovered from the disease need not be tested 118 within 8 weeks from the onset of symptoms (74%) but fewer agreed to extend that to 90 days 119 (58%) or to never test again (11%). this general uncertainty about the time was again reflected 120 when the panel commented on whether an asymptomatic covid-19 resident who has recovered 121 could be contagious 8 weeks after recovery (65% agreement that they are not contagious), or 122 after 90 days (53% agreement that they are not contagious). a minority of the panel members 123 (35%) agreed that a recovered covid-19 who remains asymptomatic is not contagious. 124 the delphi process reached consensus on 12 of 14 statements related to visitors. these 127 statements were then merged and expanded into guidance statements (see table 2 guidance that begins to balance the well-being and self-determination of residents and their 141 families with the very real public health concern of preventing nursing home outbreaks. 142 our panel was able to review 119 guideline statements and develop consensus around 77 143 general statements to help inform a set of suggested visitor guidance statements. the panel 144 strongly agreed on some preconditions that would be essential prior to welcoming back visitors, 145 such as universal masking for staff, sufficient disinfecting supplies, ppe, and written plans 146 around isolation, cohorting, screening, testing, and outbreak investigations. furthermore, our 147 panel had wide consensus on testing of symptomatic residents and staff, the importance of 148 contact tracing, and barring communal and group activities for symptomatic residents. a key 149 finding reinforced by the panel was the future need to assess individual residents' care 150 preferences and level of risk tolerance, something that has been missing in many of the existing 151 reopening guidelines, in part due to cohorting challenges. this was envisioned by the panel as 152 allowing some residents to participate in a risk-accepting group that could be cohorted together 153 for increased social interactions and dining. 154 however, as illustrated in table 1 j o u r n a l p r e -p r o o f agreed that limited physical contact between visitors and residents should be allowed with 185 meticulous hand hygiene before and after resident contact, and the use of masks, gowns and 186 gloves. a lack of visitor access to ppe should not preclude a visit, so nursing homes must be 187 able to provide masks, gloves and gowns when required. 188 the panel had less accord, however, regarding infection prevention strategies during a 189 visit encounter. for example, universal masking for staff was supported but the group did not 190 reach consensus on which type of mask (e.g. surgical vs. cloth) or whether all visitors had to 191 wear a mask all of the time during a visit. similarly, it was agreed that physical distancing be 192 required in public, common spaces such as the lobby, hallways, or nursing stations, but perhaps 193 not applicable during a visit encounter with an asymptomatic resident. 194 regarding visitor guidance logistics, the panel strongly recommended the use of an 195 electronic process to schedule visits and a sign-in log with contact information to aid in potential 196 contact tracing. additionally, the panel recommended allowing the designation of one or two 197 essential family caregivers by the resident or surrogate decision maker. the essential family 198 caregiver(s) and the surrogate decision maker would have priority to visit the resident. these 199 visitors, for example, might provide complex care, such as assistance with feeding or support for 200 responsive behaviors commonly encountered in residents with dementia. all visitors and 201 essential family caregivers must be provided entry during serious illness, including at the end-of-202 life, irrespective of covid-19 status of the resident, provided that the visitor dons appropriate 203 lastly, regarding visitor guidance and risk tolerance, the panel acknowledged that 205 essential family caregivers may wish to visit a resident who may be contagious such as 1) a 206 symptomatic resident with a positive covid-19 test, 2) a symptomatic resident with an 207 j o u r n a l p r e -p r o o f unknown or pending covid-19 test, or 3) an asymptomatic resident who has tested positive for 208 covid-19. after discussion, the authors recommend three steps be followed. first, a shared 209 informed consent discussion between essential caregivers and nursing leadership that would regarding immunity and cohorting, our panel agreed (83%) that cohorting asymptomatic 216 residents who have all recovered for covid-19 can be safely done and that a resident who has 217 recovered from covid-19, remains asymptomatic, and is at least 3 weeks post onset of 218 symptoms is likely not infectious (88% consensus). regarding the role of antibody testing, a 219 modest majority agreed (69%) that antibody testing could be a surrogate marker of individual 220 immunity; but all agreed that a positive immunity test does not currently inform clinical practice 221 and instead one has to rely upon recovery from prior infection. it should be noted that the delphi 222 process occurred before the cdc guidance that recovered covid-19 residents do not require re-223 testing or precautions for 90 days had been released 27 . 224 the areas of congruence leading to the suggested visitor guidance statements stem from 225 thoughtful resident-centered debates among a panel of delphi experts. the fact that there are 226 many areas with substantial variation certainly arises from the state of the science but might also 227 be a result of the interaction of certain statements with each other, difficulties with precise 228 wording or statements, or the persistent inability of guidelines to accommodate the wealth of 229 variations in clinical situations. one limitation of this study was that a rapid two-step modified 230 j o u r n a l p r e -p r o o f delphi process may not have allowed enough time for the panel to develop consensus around 231 some of the challenging language or the more controversial topics, but the panel felt the urgency 232 to produce high-quality guidance statements promptly. 233 the use of a modified delphi process to standardize the process, provide iterative 234 feedback, and consensus-gathering strengthens the findings of this study. the delphi process 235 itself limits bias but could be influenced by how panelists were selected 29 . there was some 236 degree of self-selection in the organization of this panel as the group shared a common concern 237 regarding the health and wellbeing of the vulnerable older adults living in nursing homes during 238 the covid-19 pandemic. additionally, the panel had substantial diversity but did not include all 239 important stakeholders, such as nurse leaders, direct care workers, or residents. nevertheless, the 240 panelists were chosen for their expertise in the field of geriatrics and long-term care medicine, 241 and have all been listed in the acknowledgement section. 242 243 the objective of this study was to develop a set of visitor guidance statements that could 245 be used to welcome back visitors and essential family caregivers to us nursing homes. even 246 after a structured delphi process, experts in nursing home care still had substantial discord on 247 important elements. however, through rigorous and evidence-informed discussions, a concise 248 and practical set of guidance statements was developed (table 2) in order for a nursing home to proceed with phased reopening, there should be no new nh-onset cases for 28 days. 14 (74) 1 4 testing a proportion of randomly selected asymptomatic hcp (staff) who have not previously tested positive should be done for surveillance efforts. the frequency and sample size of staff should be guided by size of the nursing home and level of local community spread. in facilities without any positive covid-19 cases, test 100% of asymptomatic hcp (staff) who have previously not tested positive weekly for 4 weeks; if no new positives may test 25% of asymptomatic hcp (staff) every 7 days such that 100% of the nursing home staff are tested each month. 10 (53) 3 6 testing a proportion of randomly selected asymptomatic residents who have not previously tested positive should not be done for surveillance efforts. instead, residents who are asymptomatic should only be tested during outbreak investigations of close contacts of a known covid-19 positive resident or staff member. residents who are asymptomatic should be allowed to opt out of testing for sole purposes of surveillance. this statement would not be applicable for contact tracing with a known exposure to a covid-19 resident or staff member. an asymptomatic resident who has previously tested positive for covid-19 and recovered does not need to be 14 (74) 2 3 tested again within an 8 week window of prior onset of symptoms. an asymptomatic resident who has previously tested positive for covid-19 and recovered does not need to be tested again within a 90 day window of prior onset of symptoms. an asymptomatic resident who has previously tested positive for covid-19 and recovered does not need to be tested again. a new or returning asymptomatic nursing home resident without a prior diagnosis of covid-19 and who has remained under isolation in a private room for 14 days since admission tests positive during nursing home testing of asymptomatic residents. not during an outbreak investigation and there has been no exposure to a covid-19 positive resident or staff. in this situation, re-test the resident only. if subsequently negative and no further suspicion of covid-19 in the building, this scenario would not warrant nursing home-wide testing or phase regression. 14 (74) 1 4 a negative covid-19 test is not a requirement prior to visiting a nursing home. 14 (70) 1 5 visitors who wish to visit a nursing home resident who is actively symptomatic but for whom covid-19 testing is pending or unknown should have an informed consent discussion with nursing leadership, demonstrate appropriate donning/doffing of ppe and agree to wear appropriate ppe during the visit. allow entry of all essential and non-essential healthcare personnel, contractors, and vendors with appropriate screening, physical distancing, hand hygiene, and face coverings. they would be subject to the same testing and surveillance requirements as the rest of the hcp (staff) cohort. visitors including non-employed caregivers and surrogate-decision makers would be subject to the visitor the nursing home should consider a designated care giver (or dedicated support person, surrogate decision-maker) an essential member of the healthcare team who would not be subject to visitor guidelines if resources (ppe, training, monitoring) are available at the time and the person is directly engaged in compassionate care to alleviate a residents psycho-social stress as a result of isolation. 15 (79) 0 4 a resident who engages in a visit with family or friends beyond the nursing home grounds, remains outside, and the visit does not involve close contact with covid+ individuals or symptomatic individuals would not be subject to isolation upon re-entry to the nursing home. after a resident returns from an outside trip beyond the nursing home grounds and prior to the resident resuming activities within a shared space, the resident should be bathed according to accepted practice with soap and have the clothes they were wearing laundered in a standard fashion. immunity a currently asymptomatic individual who has recovered from covid-19 and is post 8 weeks from onset of symptoms is not considered infectious and should not be tested. if tested and the test returns positive, as long as the resident remains asymptomatic, it would not be considered a re-infection and the resident is not contagious. a currently asymptomatic individual who has recovered from covid-19 and is post 90 days from onset of symptoms is not considered infectious and should not be tested. if tested and the test returns positive, as long as the resident remains asymptomatic, it would not be considered a re-infection and the resident is not contagious. a currently asymptomatic individual who has recovered from covid-19 is not considered infectious and should not be tested. if tested and the test returns positive, as long as the resident remains asymptomatic, it would not be considered a re-infection and the resident is not contagious. antibody testing can be a surrogate marker of individual immunity but does not currently inform clinical practice; recovery from prior infection does. color scheme represents level of consensus among panel. yellow represents statements in which 51-79% of members voted "agree" and red represents statements in which <50% of members voted "agree." j o u r n a l p r e -p r o o f all staff, residents, and visitors engage in basic hand hygiene and physical distancing in public, shared spaces. all staff wear a medical-grade mask while in the nursing home. all residents and visitors wear a face covering when in shared, public spaces. if a resident or visitor does not own a face covering, one must be provided by the nursing home. the facility has sufficient disinfecting supplies (hand sanitizers, soap, detergent, etc.) and adequate personal protective equipment (gloves, gowns, masks, face shields/goggles). a written isolation and cohorting plan is in place. a written screening and testing plan with adequate capacity for implementation is in place. a written contact tracing and outbreak investigation plan is in place. all persons entering the nursing home (staff, visitors, volunteers, and vendors) undergo the same entrance screening process, including a temperature check and answering an exposure and symptom questionnaire by a trained entrance screener. visitors that do not comply with the screening procedure are not allowed to enter. visitors and volunteers can sign up to visit a resident for a defined time period using an electronic process. the nursing home maintains a sign-in log that includes contact information (name, phone number, email address) of visitors and volunteers to help with contact tracing in the event of an exposure. a nursing home may need to limit the number of indoor visitors to no more than 2 visitors at one time to allow physical distancing between visitor groups. visit frequency and the number of visitors a nursing home is able to accommodate would depend on the physical space, availability to visit outdoors, and ppe availability. visitors must be guided to the designated visit area to limit interactions with patient-care areas, staff, or other residents. gloves and a gown with associated hand hygiene are required if visitors wish to engage in limited physical contact with a resident, such as hugging, hand holding, or direct resident care such as assistance with meals. the nursing home must provide gloves and gowns for this purpose. the nursing home should designate areas for indoor and outdoor visits. ideally the visits would occur outside, conditions permitting. indoor areas should be accessible without walking through a resident care area, must be disinfected between scheduled visits, and should be large enough to facilitate physical distancing between visit groups. a nursing home should allow each resident or surrogate decision maker to choose essential family caregivers who, along with the surrogate decision maker, would have priority to frequently visit a resident, e.g. to provide complex care, aid in feeding, or redirect and reassure those residents living with dementia who have responsive behaviors. visiting a resident with or without symptoms who has a positive, unknown, or pending covid-19 test result requires the following steps: 1. the visitor must participate in an informed consent discussion with leadership regarding the risks of potential exposure to covid-19 and whether they outweigh the benefits of a visit. additionally, visitors should be counseled to understand the covid-19 test status and encouraged to wait for a pending test result to return prior to a scheduled visit. 2. the nursing home must provide education and training so that the visitor can demonstrate appropriate donning/doffing of ppe, including a mask, gowns, gloves, and possibly a face shield. 3. the visitor must agree to wear the recommended ppe during the visit and follow all infection prevention and control procedures within the nursing home. the nursing home should make every attempt possible to work with visitors of residents who are seriously ill, receiving care focused on comfort, and approaching end-of-life. specifically, facilities may waive the visitor limits, offer extended hours, and offer an in-person room visit to help facilitate the psycho-social well-being of the resident and family members. j o u r n a l p r e -p r o o f  social distancing, hand washing, and disinfection practices need to continue in directpatient care areas.  residents, visitors, and volunteers wear cloth face coverings or a facemask when in a shared-space.  all persons entering the facility (including staff, visitors, volunteers, and vendors) should undergo screening to include: temperature check, exposure questionnaire, and symptom questionnaire.  entry screening is performed by a screener who has received training in basic infection control, appropriate education on questionnaires and hands-on practice with thermometer.  all persons attempting to enter the facility who have either recorded a temperature >99.5 f or report having taken a medication to treat fever (anti-pyretic such as acetaminophen) should not be permitted to enter.  all residents should undergo a daily symptom screening and have temperature monitored.  symptomatic residents/staff o test all symptomatic residents and staff but allow individual residents autonomy with an appropriate plan on how to isolate and cohort a resident who is symptomatic but does not wish to be tested. o a symptomatic staff member who does not wish to be tested would be excluded from work until they meet the return to work criteria of a presumed positive individual. o treat a symptomatic resident who does not wish to be tested as a presumed positive. isolate and cohort accordingly. o  asymptomatic residents/staff o all residents, staff should have undergone baseline testing as part of phase 1 and phase 2. o have a plan for ongoing surveillance testing of asymptomatic staff and residents.  testing a proportion of randomly selected asymptomatic hcp (staff) who have not previously tested positive should be done for surveillance efforts. the frequency and sample size of staff should be guided by size of facility and level of local community spread. -79% agreement  in facilities without any positive covid-19 cases, test 100% of asymptomatic hcp (staff) who have previously not tested positive weekly for 4 weeks; if no new positives may test 25% of asymptomatic hcp (staff) every 7 days such that 100% of facility staff are tested each month. 53% agreement  testing a proportion of randomly selected asymptomatic resident who have not previously tested positive should not be done for surveillance efforts. instead, residents who are asymptomatic should only be tested during outbreak investigations of close contacts of a known covid-19 positive resident or staff member. 53% agreement  residents who are asymptomatic should be allowed to opt out of testing for sole purposes of surveillance. this statement would not be applicable for contact tracing with a known exposure to a covid-19 patient or staff member. -68% agreement o triggers to increase testing:  a trigger to increase testing of asymptomatic individuals would be based on response to an outbreak investigation and contact tracing results.  one covid-19 + case in staff or residents should trigger the execution of a comprehensive plan addressing contact tracing, isolation/cohorting, and testing within 24 hours of positive test result.  during an outbreak investigation, there should be a low threshold to extend testing of all staff and residents to entire units, floors, buildings if the situation deems it necessary.  asymptomatic residents and staff who have previously tested positive would not be subject to repeat testing.  once one nh-onset case (case definition from cdc) has been identified within a facility, facilities should resume testing of asymptomatic hcp (staff) who have not previously tested positive o the facility should make every effort possible to secure a collection method that is least invasive and uncomfortable if testing residents and staff with a low pretest probability of covid-19 disease (asymptomatic without known exposure), such as saliva testing or nasal/oral swabs instead of a nasopharyngeal swab. o asymptomatic covid-19 recovered resident  an asymptomatic resident who has previously tested positive for covid-19 and recovered does not need to be tested again within an 8 week window of prior onset of symptoms. 74% agreement  an asymptomatic resident who has previously tested positive for covid-19 and recovered does not need to be tested again within a 90 day window of prior onset of symptoms. 58% agreement  an asymptomatic resident who has previously tested positive for covid-19 and recovered does not need to be tested again. 11% agreement  a process should be identified for how facilities will actively track staff/ resident and visitor interactions to help facilitate appropriate contact tracing in the event of an outbreak investigation.  in the event of a pui or covid-19 positive staff or resident, a list of individuals with possible exposures should be able to be generated for the prior 3 days (preferably 5 days) within 24 hours.  facilities should be aware and document individual resident and/or surrogate decisionmakers' care preferences regarding testing, cohorting, and isolation. it may be possible to cohort a certain group of individuals (ie recovered covid-19 positive patients who are asymptomatic) as long as the risks for other residents is not substantially increased.  new admissions should be placed in a dedicated area of the facility where appropriate isolation and contact precautions are maintained.  there should be a written cohorting and isolation plan for the facility. group activities  do not allow symptomatic residents with an unknown covid-19 status to participate in group activities in which proper infection control practices cannot be maintained.  make every effort possible to maintain social distancing, practice hand hygiene, and wear a mask during group activities.  try to facilitate indoor group activities in a well-ventilated space that allows for appropriate social distancing.  make an effort to offer residents the ability to join a risk-accepting group that could be cohorted together for activities, provided that the facility can manage them separately. non-medically necessary trips outside facility  residents must adhere to face coverings, hand hygiene, and social distancing during trips outside of the facility.  isolation o a resident who engages in a supervised outside visit with family or friends within the nursing home grounds, remains outside, and the visit does not involve close contact with covid+ individuals or symptomatic individuals would not be subject to isolation upon re-entry to the facility. o a resident that makes a trip outside the facility and is exposed to a covid+ individual, symptomatic individual or otherwise fails the screening questionnaire upon re-entry to the building would be subject to 14 days of isolation. o a resident who engages in a visit with family or friends beyond the nursing home grounds, remains outside, and the visit does not involve close contact with covid+ individuals or symptomatic individuals would not be subject to isolation upon re-entry to the facility. 17% agreement  infection control o after a resident returns from an outside trip beyond the nursing facility grounds and prior to the resident resuming activities within a shared space, the resident should practice hand hygiene and have their wheelchair and belongings disinfected. o after a resident returns from an outside trip beyond the nursing facility grounds and prior to the resident resuming activities within a shared space, the resident should be bathed according to accepted practice with soap and have the clothes they were wearing laundered in a standard fashion. 47% agreement  leave of absence o the facility should have a discussion regarding risks/benefits with every resident and family who requests a leave of absence with a bed hold. this would include a discussion on hand hygiene, social distancing, and mask covering as well as subsequent isolation upon return to the facility if deemed necessary at the time of the visit based on level of community spread.  phase regression and facility wide restrictions should not be imposed after one isolated covid-19 case. rather, a prompt outbreak investigation should occur with further results triggering appropriate restrictions.  response to positive resident o once one nursing home resident tests positive for covid-19, an outbreak investigation should include baseline testing of close contacts (to include roommate, neighboring rooms, and staff) o once one nh-onset case (case definition from cdc) has been identified within a facility, facilities should resume testing of asymptomatic hcp (staff) who have not previously tested positive. o during an outbreak investigation of a single case it is determined that there is 1 nh-onset case on an isolated wing with isolated staff. this scenario would warrant testing of the entire wing staff and residents but not warrant facility wide testing or phase regression. o a new snf admission who has remained under isolation in a private room becomes symptomatic within 14 days of admission and tests positive. in this situation, i would re-test and extend testing to close contacts. if no further positive cases, this situation would not warrant facility wide testing or phase regression. o a new or returning asymptomatic nursing home resident without a prior diagnosis of covid-19 and who has remained under isolation in a private room for 14 days since admission tests positive during facility testing of asymptomatic residents. not during an outbreak investigation and there has been no exposure to a covid-19 positive patient or staff. in this situation, i would re-test the resident only. if subsequently negative and no further suspicion of covid-19 in the building, this scenario would not warrant facility-wide testing or phase regression. 74% agreement  response to positive hcp o an asymptomatic hcp tests positive on routine surveillance testing and is appropriately following work-restrictions. this scenario should prompt an outbreak investigation of close contacts but should not automatically warrant a phase regression as long as the outbreak investigation does not identify new cases among staff or residents who have not previously tested positive. o a symptomatic hcp tests positive. this would warrant testing of close contacts (staff and residents) of the immediate patient care area. o once one nursing home staff member tests positive for covid-19, an outbreak investigation should include baseline testing of close contacts (to include roomate, neighboring rooms, and staff)  phase regression o during an outbreak investigation, it is determined that there is >2 nhonset cases in a building within a short time period (<14 days). there is concern for wide spread disease in the building. this scenario would warrant testing of the entire facility and phase regression with subsequent restrictions on visitors, communal dining, and group activities. immunity  a patient who has recovered from covid-19 disease and is 3 weeks post onset of symptoms is likely not infectious to another individual as long as they have not developed new symptoms.  a cohort of asymptomatic individuals who have all recovered from covid-19 can safely be cohorted together.  antibody testing can be a surrogate marker of individual immunity but does not currently inform clinical practice; recovery from prior infection does. 69% agreement  covid-19 recovered individual o a currently asymptomatic individual who has recovered from covid-19 and is post 8 weeks from onset of symptoms is not considered infectious and should not be tested. if tested and the test returns positive, as long as the resident remains asymptomatic, it would not be considered a re-infection and the patient is not contagious. 65% agreement o a currently asymptomatic individual who has recovered from covid-19 and is post 90 days from onset of symptoms is not considered infectious and should not be tested. if tested and the test returns positive, as long as the resident remains asymptomatic, it would not be considered a re-infection and the patient is not contagious. 53% agreement o a currently asymptomatic individual who has recovered from covid-19 is not considered infectious and should not be tested. if tested and the test returns positive, as long as the resident remains asymptomatic, it would not be considered a re-infection and the patient is not contagious. 35% agreement  hairdressers, beauticians, hospice staff and other staff members who work within a nursing home should be included in the cdc definition of healthcare personnel (hcp) and follow the same guidelines regarding screening and testing.  hairdressers and stylists should be considered direct patient care staff and be subject to the same screening and work restrictions as other healthcare facility staff.  patients that are unable to adhere to social distancing or face coverings should be allowed to visit with family in a private isolated area as long as visitors were full ppe.  dialysis patients who leave the facility regularly for hemodialysis will remain under appropriate isolation and contact precautions and not mix with covid-, asymptomatic individuals. j o u r n a l p r e -p r o o f definitions i agree with the following modification of the formal cdc definition of healthcare personnel (hcp). "hcp include, but are not limited to, emergency medical service personnel, nurses, nursing assistants, physicians, technicians, therapists, phlebotomists, pharmacists, feeding assistants, students and trainees, contractual hcp not employed by the healthcare facility, and persons not directly involved in patient care but who could be exposed to infectious agents that can be transmitted in the healthcare setting (e.g., clerical, dietary, environmental services, laundry, security, beauticians and hairdressers, engineering and facilities management, administrative, billing, and volunteer personnel)". (added beauticians to cdc definition of hcp) nursing homes are ground zero for covid-19 covid-19 nursing home data covid-19 in nursing homes: calming the perfect storm coronavirus disease 2019 in geriatrics and long-term care: the abcds of covid-19 presymptomatic sars-cov-2 infections and transmission in a skilled nursing facility asymptomatic sars-cov-2 infection in belgian long-term care facilities presymptomatic transmission of sars-cov-2 amongst residents and staff at a skilled nursing facility: results of real-time pcr and serologic testing epidemiology of covid-19 in a long-term care facility in king county, washington cms announces new measures to protect nursing home residents from covid-19 centers for disease control and prevention. preparing for covid-19 in nursing homes html?cdc_aa_refval=https%3a%2f%2fwww.cdc.gov%2fcoronavirus%2f2019-ncov%2fhealthcare-facilities%2fprevent-spread-in-long-term-care-facilities continued bans on nursing home visitors are unhealthy and unethical. the washington post amid the covid-19 pandemic, meaningful communication between family caregivers and residents of long-term care facilities is imperative families caring for an aging america essential family caregivers in long-term care during the covid-19 pandemic detrimental effects of confinement and isolation on the cognitive and psychological health of people living with dementia during covid-19: emerging evidence. ltccovid, international long-term care policy network: care policy and evaluation centre (cpec) finding the right balance: an evidence-informed guidance document to support the re-opening of canadian nursing homes to family caregivers and visitors during the covid-19 pandemic we gratefully acknowledge the time and dedication of our delphi panel experts and other experts who have participated in this process, provided guidance, or critically appraised our manuscript. their names are listed below in alphabetical order. none received compensation, financial or otherwise, for their contributions. j o u r n a l p r e -p r o o f the facility should make every effort possible to secure a collection method that is least invasive and uncomfortbale if testing residents and staff with a low pretest probability of covid-19 disease (asymptomatic without known exposure), such as saliva testing or nasal/oral swabs instead of a nasopharyngeal swab. immunity q86 a currently asymptomatic individual who has recovered from covid-19 and is post 8 weeks from onset of symptoms is not considered infectious and should not be tested. if tested and the test returns positive, as long as the resident remains asymptomatic, it would not be considered a re-infection and the patient is not contagious. immunity a currently asymptomatic individual who has recovered from covid-19 and is post 90 days from onset of symptoms is not considered infectious and should not be tested. if tested and the test returns positive, as long as the resident remains asymptomatic, it would not be considered a re-infection and the patient is not contagious. 9 1 7 17 53% immunity a currently asymptomatic individual who has recovered from covid-19 is not considered infectious and should not be tested. if tested and the test returns positive, as long as the resident remains asymptomatic, it would not be considered a re-infection and the patient is not contagious. immunity q85 antibody testing can be a surrogate marker of individual immunity but does not currently inform clinical practice; recovery from prior infection does. 