Staffing Levels and COVID‐19 Cases and Outbreaks in U.S. Nursing Homes

Abstract

BACKGROUND/OBJECTIVES: Nursing homes have experienced a disproportionate share of COVID-19 cases and deaths. Early analyses indicated that baseline quality was not predictive of nursing home cases, but a more nuanced study of the role of nurse staffing is needed to target resources and better respond to future outbreaks. We sought to understand whether baseline nurse staffing is associated with the presence of COVID-19 in nursing homes and whether staffing impacts outbreak severity. DESIGN: We analyzed Centers for Medicare & Medicaid Services (CMS) facility-level data on COVID-19 cases and deaths merged with nursing home and county characteristics. We used logistic regressions to examine the associations of staffing levels from Nursing Home Compare with the outcomes of any COVID-19 cases and, conditional on at least one case, an outbreak. Among facilities with at least one case, we modeled count of deaths using hurdle negative binomial-2 regressions. SETTING: All nursing homes in the CMS COVID-19 Nursing Home Dataset with reports that passed the CMS Quality Assurance Check as of June 25, 2020. PARTICIPANTS: Residents of nursing homes that met COVID-19 reporting requirements. MEASUREMENTS: A nursing home is defined as having at least one case is if one or more confirmed or suspected COVID-19 case among residents or staff is reported. Conditional on at least one case, we examine two outcomes: an outbreak, defined as confirmed cases/certified beds >10% or total confirmed and suspected cases/beds >20% or >10 deaths, and the total number of deaths attributed to COVID-19 among residents and staff. RESULTS: A total of 71% of the 13,167 nursing homes that reported COVID-19 data as of June 14 had at least one case among residents and/or staff. Of those, 27% experienced an outbreak. Higher registered nurse-hours are associated with a higher probability of experiencing any cases. However, among facilities with at least one case, higher nurse aide (NA) hours and total nursing hours are associated with a lower probability of experiencing an outbreak and with fewer deaths. The strongest predictor of cases and outbreaks in nursing homes is per capita cases in the county. CONCLUSION: The prevalence of COVID-19 in the community remains the strongest predictor of COVID-19 cases and deaths in nursing homes, but higher NA hours and total nursing hours may help contain the number of cases and deaths.

COVID-19 in long-term care homes in Ontario and British Columbia

“…[18][19][20][21] Recent studies have also shown an association between low staffing levels and COVID-19 infections within LTC homes. [22][23][24] Many LTC staff, in particular care aides or personal support workers, are underpaid and less likely to secure fulltime positions relative to their counterparts in other sectors of the health care system. 25,26 As such, staff frequently take on several part-time or casual roles at different LTC homes, which increases the risk of transmission among facilities.…”

Nontraditional Small House Nursing Homes Have Fewer COVID-19 Cases and Deaths

“…All operating Green House homes that held a skilled nursing license and received Medicaid or Medicare payment were invited to participate, as was one additional small house organization (with 10 NHs) that may be joining the Green House network because its operation mirrors that of Green House homes. Given that COVID-19 rates vary by location and relate to community prevalence, 5 analyses compared rates of Green House/small NHs to other NHs that were selected through matching each Green House/small NH to up to the 5 nearest traditional NHs in the Centers for Medicare and Medicaid Services (CMS) database with <50 beds and with ≥50 beds and that were located within 100 miles. Because some Green House and other small NHs are colocated/colicensed with a larger NH, all such organizations were omitted from the CMS data.…”

“…Short-term remedies related to the congregate nature of long-term care include using personal protective equipment, restricting visitors, and instituting screening. 3 Longer-term remedies may ward off threats when the next pandemic arises, centered on nursing home (NH) quality, 4 staffing, 5 and physical design. 6 , 7 Presumably, smaller NHs reduce risk because there are fewer residents (including new admissions), staff, and visitors who may spread infection.…”

The Effect of National Weekly COVID-19 Screening Testing of All Workers in Long-Term Care Facilities: A Decrease in Mortality

“…During the COVID-19 pandemic, LTCFs have been a major source of devastating outbreaks in many countries accompanied by high mortality and morbidity, causing a consequential load on national health systems [1,2]. Root-cause analysis of LTCF outbreaks identi ed that COVID-19 prevalence in the community is the main factor that is directly associated with the likelihood of COVID-19 entering the facility [11,[18][19][20][21][22]. Accordingly, this program involves primary prevention of outbreak events by identifying asymptomatic HCWs and potentially preventing the outbreak entirely.…”