Government Abstract
The COVID-19 pandemic has disproportionately affected residents and employees in nursing properties and different long-term care amenities (LTCFs). Whereas this group is within the high precedence group for vaccine distribution in all states, some could stay in danger because the pandemic continues to unfold throughout the nation, significantly LTCF employees for whom vaccination charges have been low. As well as, the pandemic could have uncovered vulnerabilities in LTCFs that may inform future efforts to deal with infectious illness outbreaks.
This transient summarizes the findings of 30 research between April 2020 and January 2021 that examined potential components related to COVID-19 circumstances and/or deaths in LTCFs. Key takeaways embody:
- The prevalence of COVID-19 circumstances locally is constantly related to COVID-19 circumstances and/or deaths in long-term care amenities.
- Workers infections look like a hyperlink between circumstances locally and long-term care amenities, though it’s unclear if the employees infections have been the results of neighborhood unfold or pre-existing circumstances in LTCFs.
- Lengthy-term care amenities which might be for-profit or have greater shares of residents who’re folks of colour (or are situated in communities with a big share of individuals from communities of colour) have been extra more likely to have COVID-19 circumstances and deaths. City location and huge mattress dimension are additionally related to circumstances and deaths, which can replicate different components akin to neighborhood unfold or affiliation between mattress aspect and case rely.
- Amongst research that look at the affiliation between CMS general high quality rankings and an infection management deficiencies in nursing amenities, most discover no clear affiliation with COVID-19 circumstances or deaths, however a small variety of research do.
- Nursing properties with greater staffing ranges, together with these with greater CMS 5-star high quality rankings for staffing are related to fewer circumstances or deaths within the facility.
It needs to be famous that many of those research have been carried out in actual time, because the pandemic was gaining drive and shifting geographically; it’s potential that outcomes from research carried out within the earlier months could not replicate modifications which have occurred over the course of the yr. Additional, we didn’t determine analysis that examines the position of PPE shortages, employees shortages, or state or facility coverage on circumstances or deaths in LTCFs. Whereas a profitable vaccination effort ought to mitigate the long run threat of significant sickness and deaths on account of COVID-19, this evaluation identifies components that will make residents and employees of nursing properties and different LTCFs susceptible if adequate numbers will not be vaccinated, or if they’re uncovered to different extremely contagious and harmful infections sooner or later.
Introduction
The COVID-19 pandemic has disproportionately affected residents and employees in nursing properties and different long-term care amenities (LTCFs), accounting for six% of all circumstances and 38% of all COVID-19 deaths nationwide. In response, the Facilities for Illness Management (CDC) really helpful that LTCFs have the best precedence with regards to vaccinations. Because the preliminary high-profile outbreak of the virus on the Life Care Heart of Kirkland, Washington, many amenities have carried out measures to include the unfold of coronavirus in LTCFs, together with common testing, widespread use of private protecting gear (PPE), and customer restrictions. The federal authorities additionally responded to pandemic by refocusing early routine nursing house inspections on an infection management and convening a panel of consultants to supply evidence-based suggestions on easy methods to tackle the pandemic in nursing properties (Coronavirus Fee for Security and High quality in Nursing Properties). Moreover, federal laws allotted some funds to assist cowl the expense of PPE and testing.
Regardless of these measures, deaths and infections amongst long-term care facility residents and employees have continued to extend all through the pandemic, largely following the nationwide development, underscoring the necessity to higher perceive components which might be related to elevated COVID-19 circumstances and deaths in LTCFs. Early knowledge additionally means that preliminary vaccine distribution has been slower than anticipated, and that employees vaccination charges are comparatively low on account of issues about vaccine security, which may result in the continued unfold of the virus in LTCFs. In accordance with a current survey carried out by KFF, almost three in ten (29%) individuals who work in well being care settings mentioned they might positively or most likely not get vaccinated. Moreover, 35% of Black adults (a gaggle that has borne a disproportionate burden of the pandemic and makes up over 1 / 4 of the long-term care work drive) say they positively or most likely wouldn’t get vaccinated. This assessment of research informs ongoing efforts to restrict preventable infections and deaths in long-term care settings, and will assist to determine traits of amenities most in danger that could possibly be prioritized for vaccine distribution, employees schooling and oversight.
This subject transient summarizes the findings of 30 research which have examined potential components related to COVID-19 circumstances and/or deaths in LTCFs. We group these components into classes of neighborhood unfold, together with staff-to-patient transmission and affected person transfers; facility high quality and an infection management; staffing ranges; and different facility-level traits, akin to possession, location, payer combine, and the racial/ethnic composition of residents. An summary of the strategies utilized in figuring out research included is supplied within the Strategies field on the finish of the transient.
Key Findings
Neighborhood Unfold
The prevalence of COVID-19 locally is constantly related to COVID-19 circumstances and/or deaths in long-term care amenities. In whole, all 9 research that checked out neighborhood transmission discovered an affiliation between neighborhood (sometimes county) case charges and probability or severity of outbreaks or deaths in LTCFs. All research discovered that communities with excessive coronavirus case charges had extra circumstances and deaths in its long-term care amenities than communities with low case charges. These research used knowledge from time durations starting from early within the pandemic (finish of Could) to mid-September 2020, however most have been utilizing knowledge from late Spring by Summer season 2020. Solely two used nationwide or 50-state knowledge, whereas 4 research used state-reported knowledge for a subset of states,,,, and three used different samples or a single state.,, Solely one in all these research adjusted for the potential endogeneity between neighborhood circumstances and LTCF circumstances (that’s, excessive circumstances or deaths in LTCFs contributing to excessive COVID-19 charges inside the county), although it nonetheless discovered a big relationship between neighborhood charges and circumstances and deaths in LTCFs.
Some research determine employees infections as a possible hyperlink between neighborhood circumstances and circumstances in long-term care amenities. Three research explicitly appeared on the position of employees in LTCF outbreaks, and all discovered a relationship between neighborhood unfold, employees infections, and resident infections. In a NY state report from summer time 2020, researchers discovered that employees infections correlated with the timing of peak nursing house resident mortality throughout the state and have been sometimes centralized in communities with excessive case charges. One other evaluation utilizing geolocation knowledge from 50 million smartphones and knowledge from 22 states discovered that overlapping employees networks between nursing properties have been considerably related to coronavirus infections. The third research, utilizing knowledge from one giant tutorial LTCF, discovered that amenities with a excessive burden of illness have been extra more likely to have employees members that lived in communities with excessive charges of COVID-19 an infection. It’s unclear from current analysis whether or not these findings are generalizable nationwide or whether or not employees infections themselves have been a results of neighborhood transmission or pre-existing circumstances inside the facility.
The proof is combined on the impact of affected person transfers on COVID-19 circumstances and deaths in long-term care amenities. Following studies within the media about transfers from hospitals and different well being care settings resulting in new infections in LTCFs, three state-based analyses (from New York, Michigan, and Maryland) examined the potential position of affected person transfers to different well being care amenities in COVID-19 outbreaks in LTCFs. Neither the New York nor Michigan state report discovered a constant relationship between hospital transfers and elevated COVID-19 case load or deaths amongst nursing house residents, although each relied on descriptive evaluation of timing and variety of circumstances., In distinction, a 3rd research from Maryland discovered that nursing house residents that have been transferred to obtain dialysis therapy have been extra more likely to contract the virus than those that weren’t transferred. The generalizability of findings from the three state-based research might not be generalizable nationwide. As well as, we didn’t determine analysis evaluating outcomes of residents that have been transferred inside long-term care amenities.
High quality and An infection Management
Among the many twelve research that analyzed whether or not decrease high quality rankings below the CMS 5-Star High quality Score System have been related to COVID-19 circumstances or deaths, the proof is combined: eight research discovered that general high quality rankings weren’t related to the probability of a COVID-19 circumstances and deaths whereas 4 states recognized a hyperlink between high quality rankings and circumstances or deaths. The CMS star-rating system is among the most cited measures of nursing house high quality and accounts for a nursing house’s efficiency within the following domains: well being inspection rankings, high quality measure rankings, and staffing rankings. Early within the pandemic, there was hypothesis that nursing house high quality was related to virus outbreaks. This principle gained extra traction when early evaluation by CMS discovered that nursing properties with a one-star high quality star ranking have been extra more likely to have extra COVID-19 circumstances than amenities with a five-star high quality ranking. Since that report, 12 research have investigated star rankings and COVID-19 amongst expert nursing amenities, utilizing knowledge from time durations starting from early within the pandemic (finish of Could) to the summer time (June-July). Just one research used nationwide or 50-state knowledge, whereas 5 research used state-reported knowledge for a subset of states and 6 used single state knowledge.
Amongst these 12 research, eight research, together with 1 nationwide research, 5 research primarily based on a subset of states, and a couple of single-state research, discovered that CMS general high quality rankings weren’t related to the probability of getting a reported COVID-19 case,, the variety of COVID-19 circumstances,,,,, or mortality charges . Among the many remaining 4 research, which have been all primarily based on single-state knowledge, all discovered some hyperlink between general star ranking and both probability of getting COVID-19 circumstances or deaths, or severity of outbreaks amongst amenities with circumstances., Extra research have examined star rankings on staffing and COVID-19 and located vital associations between these rankings and circumstances or deaths, as summarized within the staffing part under.
Many of the restricted variety of research that look at nursing house an infection management and COVID-19 discover no affiliation between nursing house an infection management deficiencies and COVID-19 circumstances and deaths. Current evaluation by the Authorities Accountability Workplace discovered that the majority nursing properties had an infection management deficiencies even previous to the COVID-19 pandemic. In the course of the pandemic, amenities, states, and the federal authorities have undertaken a number of measures to strengthen an infection management practices in nursing properties, together with by CMS’ Nationwide Coaching Program.
4 out of 5 research which have evaluated whether or not an infection management practices or deficiencies, individually from general well being deficiencies and/or CMS general star ranking, are related to COVID-19 outcomes in nursing properties, discovered no affiliation with COVID-19 burden. Among the many 4 research that discovered no affiliation, one research used nationwide knowledge and located no relationship between the variety of deficiencies associated to an infection management and COVID-19 outbreak, two used knowledge from a subset of states and discovered no affiliation between prior an infection violations and chance of getting not less than one COVID-19 case,, and one carried out the identical an infection management procedures throughout all long-term care facility items in a single long-term care facility in Boston however nonetheless discovered that the prevalence of COVID-19 circumstances and deaths various broadly. In distinction, one of many 5 research discovered that 91% of nursing properties that reported not less than one COVID-19 case had a previous an infection management violation in comparison with 81% of nursing properties with none reported circumstances. Different research checked out broader measures of deficiencies not restricted to an infection management and located that nursing properties with greater well being charges of deficiencies have been extra more likely to report not less than COVID-19, however nursing properties that obtained a fantastic for deficiencies had decrease case charges than people who didn’t.
Staffing Ranges
Findings recommend that greater staffing ranges could play a protecting position in containing COVID-19 circumstances and deaths in nursing properties, significantly in containing outbreaks as soon as they enter the ability, although some analysis finds a hyperlink between LPN hours and circumstances or deaths. Previous to the pandemic, analysis urged that majority of nursing properties didn’t have enough staffing ranges, elevating questions as as to if decrease staffing ranges are linked to COVID-19 circumstances and deaths in LTCFs. Seven research examined the connection between staffing ranges and COVID-19 outcomes in nursing properties, with some variation in conclusions:
- High quality rankings on staffing: 4 research examined whether or not nursing properties’ star ranking on nurse staffing have been related to COVID-19 circumstances or deaths, together with one which used nationwide knowledge, one which used knowledge from a subset of states, and two that used knowledge from a single state. Three of the 4 research discovered that nursing properties with prime quality rankings on nurse staffing have been much less more likely to have greater than 30 COVID-19 circumstances or deaths (controlling for mattress dimension and different components), had fewer circumstances and deaths per mattress, and decrease chance of getting a resident with COVID-19. Nevertheless, the remaining research, primarily based on nationwide knowledge, didn’t discover a statistically vital affiliation between decrease staffing rankings and COVID-19 circumstances.
- Nursing and aide hours: 5 research examined whether or not staffing ranges, separate from staffing high quality rankings, are related to COVID-19 circumstances and/or deaths, together with two nationwide research and three state- primarily based analyses. Three research discovered an affiliation between greater staffing and fewer circumstances, deaths, and/or decrease probability of experiencing an outbreak. Particularly, the primary research, primarily based on nationwide knowledge, discovered that whereas nursing properties with a greater variety of registered nurse (RN) hours per resident per day have been extra more likely to expertise not less than one COVID-19 case, greater nurse aide hours and whole nursing hours have been related to fewer deaths and decrease probability of an outbreak amongst amenities with not less than one COVID-19 case. The second research, additionally primarily based on nationwide knowledge, discovered that greater whole staffing was related to no COVID-19 circumstances. The third research primarily based on California knowledge, discovered that early within the pandemic, nursing properties with decrease whole nurse staffing (RN, LVN, and CNA) had greater case charges, however because the pandemic progressed to August, nursing properties with greater RN staffing had decrease case charges. Of notice, these three research included each employees and resident circumstances of their analyses, with two research discovering that county-level charges of COVID-19 have been related to COVID-19 transmission in nursing properties.,
- The remaining two research, primarily based on single-state knowledge of circumstances amongst residents solely, discovered both an inverse relationship between staffing and circumstances, the place low RN hours per resident have been related to greater odds of a nursing house having COVID-19 circumstances, or discovered no affiliation between RN staffing and probability of getting a number of COVID-19 circumstances or deaths however somewhat, amongst amenities with not less than one case or loss of life, a rise in RN staffing was related to fewer circumstances and deaths.
- Moreover, among the many 5 research, two nationwide research examined the position of licensed sensible nurses (LPNs) and located a optimistic affiliation between LPN hours and COVID-19 circumstances and/or deaths. The primary research discovered that low LPN hours have been related to fewer deaths however not the chance of an outbreak, and the second research discovered that greater LPN staffing charges have been related to extra COVID-19 circumstances, a distinction that could possibly be partially attributed to the truth that LPNs, not like RNs, are likely to work together with extra residents whereas finishing duties akin to wound care or dressing modifications.
Extra analysis has examined components related to staffing shortages in the course of the pandemic and located that shortages are related to components which might be additionally related to COVID-19 circumstances and deaths. Knowledge from the federal authorities exhibits that roughly one in 5 nursing properties have reported a staffing scarcity sooner or later in time in the course of the pandemic. Nevertheless, we have been unable to determine analyses that examined whether or not and to what extent these shortages contributed to outbreaks or severity of outbreaks in LTCFs. Not surprisingly, staffing shortages as an final result measure in analysis are linked to the identical components related to circumstances and deaths, akin to neighborhood unfold, since shortages are logically associated to COVID-19 outbreaks amongst employees.
5 research evaluated the most certainly components related to staffing shortages in nursing properties in the course of the pandemic, discovering that greater COVID-19 circumstances within the surrounding neighborhood or inside the facility,,, decrease CMS star ranking,,, authorities possession,, and the next share of residents lined by Medicaid, have been related to employees shortages. One research discovered that top concentrations of Black residents and facility location in a much less city county have been related to reported staffing shortages. One research recognized a number of components related to a decrease probability of reporting a staffing scarcity, together with having not less than a one week provide of PPE, greater occupancy charges, or the next share of Medicare residents. Once more, it’s unclear from current analysis if these staffing shortages in flip contribute to greater COVID-19 circumstances or deaths.
Different Facility-Degree Traits
Lengthy-term care amenities which might be for-profit, have the next share of residents who’re folks of colour, situated in city areas, and have extra beds usually tend to have COVID-19 circumstances and deaths. Seventeen research analyzed a variety of facility-level traits related to COVID-19 circumstances and/or deaths in long-term care amenities, together with traits akin to location, facility dimension (as measured by variety of beds), share of residents with Medicaid as their main payer, racial composition of residents, possession, and labor union presence.,,,,,,,,,,,,,,,, These research used knowledge from numerous time durations, together with eleven research with knowledge collected early within the pandemic (finish of Could), 4 research as of June and July, and one research as of October. One research collected knowledge from two time durations: Could and August 2020. Amongst these seventeen research, solely 4 research used nationwide or 50-state knowledge, whereas seven research used state-reported knowledge for a subset of states and 6 used single state knowledge.
- For-profit nursing amenities are at greater threat for COVID-19 circumstances and deaths, whereas nursing amenities with labor unions are much less more likely to have COVID-19 deaths: Six research evaluated whether or not for-profit versus non-profit standing was related to COVID-19 outcomes.,,,,, Three research collected knowledge as of early within the pandemic (finish of Could), two research had research assortment durations in the course of the summer time, and one research used knowledge from each Could and August. 4 research obtained knowledge from a subset of states whereas two research obtained knowledge from single states. All six research discovered that for-profit nursing properties have been related to greater COVID-19 case and/or loss of life counts.
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One research that centered extra particularly on private-equity owned nursing properties, utilizing nationwide knowledge from early summer time, discovered that personal equity-owned nursing properties didn’t have greater COVID-19 case charges or loss of life charges than non-profit or for-profit nursing properties, although they did have greater case charges than government-owned amenities. Two examined chain standing, with combined outcomes: a Connecticut research discovered that nursing amenities that have been a part of a sequence have been extra more likely to have not less than one COVID-19 case, whereas the second research, primarily based on a subset of states, discovered that non-chain standing was related to the probability of getting not less than one COVID-19 case., .
One research utilizing knowledge as of Could discovered that nursing amenities in New York with labor unions have been related to decrease COVID-19 loss of life charges in comparison with amenities with out these unions.
- Lengthy-term care amenities with greater shares of residents who’re folks of colour usually tend to expertise COVID-19 circumstances and/or deaths: Ten research examined racial/ethnic composition of LTCF residents as potential components related to COVID-19 circumstances and/or deaths. Amongst these 10 research, 9 research discovered that LTCFs with greater shares of individuals of colour, particularly Black or Hispanic residents, have been extra more likely to have a better probability of getting not less than one COVID-19 case, , or not less than one COVID-19 loss of life, the next variety of new COVID-19 circumstances and deaths, the next variety of circumstances,, greater case charges, and better case and loss of life counts. The remaining research discovered that the focus of residents who’re folks of colour was not related to the probability of getting a number of COVID-19 case or deaths within the facility; nonetheless, amongst amenities with not less than one case, nursing properties with a better share of individuals of colour had greater counts of COVID-19 circumstances. One research examined whether or not the focus of African-Individuals on the county-level was related to circumstances in nursing properties. This research discovered that county-level inhabitants of African-Individuals was related to COVID-19 circumstances in nursing properties.
- City location could also be related to circumstances in long-term care amenities: Two research examined the position of location utilizing knowledge collected in Could from a subset of states., Each research discovered that nursing amenities situated in city places have been related to an elevated chance of getting not less than one COVID-19 case or the next probability of extra COVID-19 circumstances. Because the pandemic has unfold throughout the nation and affected extra rural areas, it’s potential that distinctions in location are not related to LTCF outbreaks.
- Services with extra beds and better occupancy charges usually tend to have COVID-19 circumstances and/or deaths: 9 research evaluated the connection between COVID-19 burden and the dimensions of long-term care amenities, as measured by the variety of beds, amongst a subset of states or from single states utilizing knowledge starting from early within the pandemic (finish of Could) to August.,,,,,,,, These 9 research discovered that long-term care amenities with extra beds have been related to elevated chance of getting not less than one COVID-19 case , greater case counts, greater mortality charges, greater case and loss of life counts, ,, and severity of outbreak. Two extra research additionally discovered that LTCFs with greater occupancy charges have been related to elevated probability of experiencing not less than one COVID-19 case however not essentially the next rely of circumstances, and the next rely of COVID-19 circumstances and deaths. The connection between COVID-19 circumstances and facility dimension seemingly displays the truth that bigger amenities settle for extra residents and have extra employees, doubtlessly rising the danger of neighborhood unfold by actions of residents and employees to and from the ability.
- There may be some affiliation between the share of residents lined by Medicaid as a main payer and COVID-19 burden: 5 research evaluated whether or not nursing properties with a better share of residents for whom Medicaid was main payer had extra COVID-19 circumstances and deaths, with combined outcomes.,,,, Two research, one multi-state research utilizing knowledge from Spring 2020 and one primarily based on Spring 2020 knowledge from Connecticut, discovered that amenities with a comparatively excessive share of residents lined by Medicaid didn’t have greater probability of a number of circumstances or deaths; nonetheless, the Connecticut-based research discovered that amongst amenities with not less than one case, nursing properties with comparatively excessive share of Medicaid-insured residents had extra COVID-19 circumstances (controlling for different facility traits together with dimension and resident race/ethnicity). Two multi-state research discovered that amenities with the next share of residents on Medicaid have been related to extra COVID-19 circumstances or deaths. Moreover, one research discovered that amenities that reported not less than one COVID-19 case had a better share of Medicaid-insured residents than amenities that didn’t report any circumstances.
- Few research have examined the affiliation between COVID-19 circumstances and deaths and facility-level traits in Assisted Residing Services individually from nursing amenities: One research, utilizing knowledge from a subset of seven states, examined the affiliation between assisted residing traits and COVID-19 circumstances and deaths within the facility. In step with different research on nursing properties, this research discovered that assisted residing amenities with a excessive share of residents who’re folks of colour have excessive case charges. Moreover, this research discovered that bigger ALFs usually tend to expertise not less than one COVID-19 case. We have been unable to seek out different research that analyzed the connection between assisted residing traits and COVID-19 outcomes.
Dialogue
The coronavirus pandemic has had an outsized affect on older adults typically and long-term care facility residents and employees extra particularly, prompting a wave of research which have checked out components related to COVID-19 circumstances and deaths. Our evaluation of the research printed 9 months into the pandemic finds that neighborhood transmission was discovered to be constantly related to circumstances and deaths. As well as, the information point out that sure facility traits are related to COVID-19 circumstances and deaths, together with having a comparatively giant share of Black or Hispanic residents, for-profit standing, a comparatively giant variety of beds, and being situated in city areas. There additionally seems to be proof that nursing properties with greater staffing ranges, together with greater CMS 5-star high quality rankings for staffing, have a decrease probability of circumstances or deaths.
Nevertheless, there are different areas the place the proof to this point is much less clear. Research have combined outcomes on the connection between general nursing house high quality rankings and COVID-19 circumstances and deaths. Outcomes are additionally much less clear on necessary questions of transmission patterns, akin to whether or not affected person transfers contribute to the unfold of the virus. As well as, we may discover no research that have a look at whether or not shortages of PPE, testing and employees are related to circumstances or deaths, nor whether or not sure practices (e.g., establishing separate COVID-19 amenities) or insurance policies (e.g., stress-free or proscribing visitation) straight affected the unfold of an infection throughout LTCFs. Additional, we have been capable of determine just one pertaining to assisted residing, group properties, and different residential amenities, separate from nursing facility research, that are house to almost a million people who find themselves unable to dwell independently.
Whereas the pandemic took maintain in March of 2020, nursing amenities weren’t required to start reporting coronavirus circumstances and deaths to the federal authorities till Could 8, 2020, which implies that most of the research have been restricted to state-reported knowledge, if accessible, or lacking the early months when nursing properties in some states have been hit exhausting by infections. Even with the federal reporting necessities imposed by CMS, there are gaps in knowledge that will assist additional pinpoint which residents, employees and amenities have been most in danger. For instance, present necessities don’t embody circumstances or deaths from long-term care amenities that aren’t licensed by Medicare or Medicaid, which excludes nearly all assisted residing and residential care amenities. Additional, nursing amenities will not be required to report the race or ethnicity, age, or comorbidities of the employees and residents who’ve change into critically sick or died on account of COVID-19.
As the brand new Administration takes the helm in managing the pandemic and setting up safeguards to guard residents and employees from future outbreaks, this evaluation informs efforts which may be used to assist strengthen security and high quality protections in long-term care settings and inform efforts to maximise resident and employees vaccinations.
This literature assessment summarizes findings from 30 research printed by January 2021 that look at components related to COVID-19 circumstances and deaths in long-term care amenities. It consists of analyses and studies printed by authorities, analysis, and coverage organizations utilizing knowledge from April 2020 or later. We additionally included sure research accomplished by media organizations (The New York Occasions and Kaiser Well being Information) that embody authentic knowledge evaluation on this matter. Most research included on this literature assessment are journal articles from peer-reviewed journals, however we additionally included research printed by impartial coverage and analysis teams in addition to authorities studies. We excluded studies from advocacy or business teams.
The important thing final result of curiosity was COVID-19 circumstances and deaths. We have been unable to seek out research that examined the consequences of PPE, testing, and staffing shortages on the outcomes of curiosity, however integrated the research that examined components related to staffing shortages as a result of they have been components additionally related to COVID-19 circumstances and deaths. We included research that checked out LTCFs particularly however didn’t restrict our inclusion standards to solely nursing properties or different kind; that mentioned, the overwhelming majority of research we recognized have been for nursing facility settings. To gather related research, we carried out key phrase searches of PubMed and Google Scholar, in addition to web sites of long-term care policy-specific journals. We additionally recognized research utilizing a snowball approach primarily based on bibliographies of beforehand pulled research. Whereas we tried to be as complete as potential in our inclusion of research and findings that meet our standards, it’s potential that we missed some related research or findings. For every research, we learn the ultimate publication and summarized the information sources, strategies, and findings. We broke findings out into key components of curiosity – neighborhood unfold, high quality/an infection management, staffing ranges, and different facility traits. Research could also be cited in a number of of those classes or in a number of locations inside a class. The Appendix Desk on the finish of the transient supplies an inventory of citations for every of the included research, grouped by the 4 classes of findings. |