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1.
J Am Med Dir Assoc ; 23(8): 1279-1282, 2022 08.
Article in English | MEDLINE | ID: covidwho-1895135

ABSTRACT

OBJECTIVES: Reverse transcription polymerase chain reaction (PCR) and antigen tests for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) are sometimes discordant. We evaluated the discordance between antigen and PCR tests sampled in skilled nursing facilities (SNFs) to assess the relationship of symptom presence, timing between tests, and the presence of a facility outbreak. DESIGN: Observational study using electronic health record data. SETTING AND PARTICIPANTS: Residents of 306 SNFs in 23 states, operated by 1 company. METHODS: We identified all rapid antigen and PCR tests conducted in study SNFs as of January 10, 2021, and classified whether symptoms were present and whether the facility was in outbreak at time of testing. We calculated the proportions of antigen tests with discordant follow-up PCR results conducted no more than 2 days after the antigen test. RESULTS: Of the 171,280 antigen tests in 34,437 SNF residents, 20,991 (12.3%) were followed by a PCR test within 2 days. A total of 1324 negative antigen tests were followed by a positive PCR result, representing 0.8% of all antigen tests and 6.3% of repeated antigen tests; while 337 positive antigen tests were followed by a negative PCR result, representing 0.2% of all antigen tests and 1.6% of repeated antigen tests. Discordance more often occurred when residents were symptomatic at time of antigen testing, during known facility outbreaks, and when the antigen test was compared with a PCR test done within 2 days vs 1 day. CONCLUSIONS AND IMPLICATIONS: Overall, discordance between SARS-CoV-2 antigen and PCR tests was low. Discordance was more common when the individual was symptomatic at time of antigen testing and during facility outbreaks. This suggests that a testing strategy which couples widespread use of antigen tests with clinical thresholds to conduct follow-up confirmatory PCR testing appears to perform well in SNFs, where timely and accurate SARS-CoV-2 case identification are critical.


Subject(s)
COVID-19 , SARS-CoV-2 , COVID-19/diagnosis , COVID-19/epidemiology , COVID-19 Testing , Disease Outbreaks , Humans , Skilled Nursing Facilities
2.
J Am Med Dir Assoc ; 23(8): 1269-1273, 2022 08.
Article in English | MEDLINE | ID: covidwho-1867310

ABSTRACT

OBJECTIVES: To examine the risk of contracting SARS-CoV-2 during a post-acute skilled nursing facility (SNF) stay and the associated risk of death. DESIGN: Cohort study using Minimum Data Set and electronic health record data from a large multistate long-term care provider. Primary outcomes included testing positive for SARS-CoV-2 during the post-acute SNF stay, and death among those who tested positive. SETTING AND PARTICIPANTS: The sample included all new admissions to the provider's 286 SNFs between January 1 and December 31, 2020. Patients known to be infected with SARS-CoV-2 at the time of admission were excluded. METHODS: SARS-CoV-2 infection and mortality rates were measured in time intervals by month of admission. A parametric survival model with SNF random effects was used to measure the association of patient demographic factors, clinical characteristics, and month of admission, with testing positive for SARS-CoV-2. RESULTS: The sample included 45,094 post-acute SNF admissions. Overall, 5.7% of patients tested positive for SARS-CoV-2 within 100 days of admission, with 1.0% testing positive within 1-14 days, 1.4% within 15-30 days, and 3.4% within 31-100 days. Of all newly admitted patients, 0.8% contracted SARS-CoV-2 and died, whereas 6.7% died without known infection. Infection rates and subsequent risk of death were highest for patients admitted during the first and third US pandemic waves. Patients with greater cognitive and functional impairment had a 1.45 to 1.92 times higher risk of contracting SARS-CoV-2 than patients with less impairment. CONCLUSIONS AND IMPLICATIONS: The absolute risk of SARS-CoV-2 infection and death during a post-acute SNF admission was 0.8%. Those who did contract SARS-CoV-2 during their SNF stay had nearly double the rate of death as those who were not infected. Findings from this study provide context for people requiring post-acute care, and their support systems, in navigating decisions around SNF admission during the SARS-CoV-2 pandemic.


Subject(s)
COVID-19 , Skilled Nursing Facilities , COVID-19/epidemiology , Cohort Studies , Humans , Incidence , SARS-CoV-2 , Subacute Care
3.
J Am Geriatr Soc ; 70(6): 1642-1647, 2022 06.
Article in English | MEDLINE | ID: covidwho-1807166

ABSTRACT

BACKGROUND: We sought to compare rates of adverse events among nursing home residents who received an mRNA COVID-19 vaccine booster dose with those who had not yet received their booster. METHODS: We assessed a prospective cohort of 11,200 nursing home residents who received a primary COVID-19 mRNA vaccine series at least 6 months prior to September 22, 2021 and received a third "booster dose" between September 22, 2021 and February 2, 2022. Residents lived in 239 nursing homes operated by Genesis HealthCare, spanning 21 U.S. states. We screened electronic health records for 20 serious vaccine-related adverse events that are monitored following receipt of COVID-19 vaccination by the CDC's Vaccine Safety Datalink. We matched boosted and yet-to-be boosted residents during the same time period, comparing rates of events occurring 14 days after booster administration with those occurring 14 days prior to booster administration. To supplement previously reported background rates of adverse events, we report background rates of medical conditions among nursing home residents during 2020, before COVID-19 vaccines were administered in nursing homes. Events occurring in 2021-2022 were confirmed by physician chart review. We report unadjusted rates of adverse events and used a false discovery rate procedure to adjust for multiplicity of events tested. RESULTS: No adverse events were reported during the 14 days post-booster. A few adverse events occurred prior to booster (ischemic stroke: 49.4 per 100,000 residents, 95% CI: 21.2, 115.7; venous thromboembolism: 9.9 per 100,000 residents, 95% CI: 1.7, 56.0), though differences in event rates pre- versus post-booster were not statistically significant (p < 0.05) after adjusting for multiple comparisons. No significant differences were detected between post-booster vaccination rates and prior year 14-day background rates of medical conditions. CONCLUSIONS: No safety signals were detected following a COVID-19 mRNA vaccine booster dose in this large multi-state sample of nursing home residents.


Subject(s)
COVID-19 Vaccines , COVID-19 , COVID-19/epidemiology , COVID-19/prevention & control , COVID-19 Vaccines/adverse effects , Humans , Immunization, Secondary , Nursing Homes , Prospective Studies , RNA, Messenger , SARS-CoV-2 , Vaccination , Vaccines, Synthetic , mRNA Vaccines
4.
J Am Geriatr Soc ; 70(2): 429-438, 2022 02.
Article in English | MEDLINE | ID: covidwho-1483908

ABSTRACT

BACKGROUND: At the height of the COVID-19 pandemic, a large nursing home chain implemented a policy to temporarily hold potentially unnecessary medications. We describe rates of held and discontinued medications after a temporary hold policy of potentially unnecessary or nonessential medications. METHODS: This retrospective cohort study uses electronic health record (EHR) data on 3247 residents of 64 nursing homes operated by a multistate long-term care provider. Medications were documented in the electronic medication administration record. Overall medication held and discontinued incidences are reported. Hierarchical Bayesian modeling is used to determine individual probabilities for medication discontinuation within each facility. RESULTS: In total, 3247 residents had 5297 nonessential medications held. Multivitamins were most likely to be held, followed by histamine-2 receptor antagonists, antihistamines, and statins. At the end of the hold policy, 2897 of 5297 (54%) were permanently discontinued, including probiotics (73%), histamine-2 receptor antagonists (66%), antihistamines (64%), and statins (45%). Demographics, cognitive and functional impairment were similar between residents with medications who were discontinued versus continued. For most medications, more than 50% of the variance in whether medications were discontinued was explained by facility rather than resident-level factors. CONCLUSION: A temporary medication hold policy implemented during the CoVID-19 pandemic led to the deprescribing of a plurality of 'nonessential' medications. This type of organization-wide initiative may be an effective mechanism for altering future prescribing behaviors to reduce the use of unnecessary medications.


Subject(s)
COVID-19 , Deprescriptions , Nursing Homes , Aged , Female , Health Policy , Humans , Long-Term Care , Male , Nursing Homes/trends , Potentially Inappropriate Medication List/statistics & numerical data , Retrospective Studies , United States
7.
J Am Med Dir Assoc ; 22(11): 2228-2232, 2021 11.
Article in English | MEDLINE | ID: covidwho-1373104

ABSTRACT

OBJECTIVES: To compare rates of adverse events following Coronavirus Disease 2019 (COVID-19) vaccination among nursing home residents with and without previous severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. DESIGN: Prospective cohort. SETTING AND PARTICIPANTS: A total of 20,918 nursing home residents who received the first dose of messenger RNA COVID-19 vaccine from December 18, 2020, through February 14, 2021, in 284 facilities within Genesis Healthcare, a large nursing home provider spanning 24 US states. METHODS: We screened the electronic health record for adverse events, classified by the Brighton Collaboration, occurring within 15 days of a resident's first COVID-19 vaccine dose. All events were confirmed by physician chart review. To obtain risk ratios, multilevel logistic regression model that accounted for clustering (variability) across nursing homes was implemented. To balance the probability of prior SARS-CoV-2 infection (previous positive test or diagnosis by the International Classification of Diseases, 10th Revision, Clinical Modification) more than 20 days before vaccination, we used inverse probability weighting. To adjust for multiplicity of adverse events tested, we used a false discovery rate procedure. RESULTS: Statistically significant differences existed between those without (n = 13,163) and with previous SARS-CoV-2 infection [symptomatic (n = 5617) and asymptomatic (n = 2138)] for all baseline characteristics assessed. Only 1 adverse event was reported among those with previous SARS-CoV-2 infection (asymptomatic), venous thromboembolism [46.8 per 100,000 residents 95% confidence interval (CI) 8.3-264.5], which was not significantly different from the rate reported for those without previous infection (30.4 per 100,000 95% CI 11.8-78.1). Several other adverse events were observed for those with no previous infection, but were not statistically significantly higher than those reported with previous infection after adjustments for multiple comparisons. CONCLUSIONS AND IMPLICATIONS: Although reactogenicity increases with preexisting immunity, we did not find that vaccination among those with previous SARS-CoV-2 infection resulted in higher rates of adverse events than those without previous infection. This study stresses the importance of monitoring novel vaccines for adverse events in this vulnerable population.


Subject(s)
COVID-19 Vaccines , COVID-19 , Humans , Nursing Homes , Prospective Studies , RNA, Messenger , SARS-CoV-2 , Vaccination
9.
J Am Med Dir Assoc ; 22(9): 1853-1855.e1, 2021 09.
Article in English | MEDLINE | ID: covidwho-1322175

ABSTRACT

Vaccines are critical to protect both nursing home residents and staff from COVID-19, but some staff have expressed reservations about being vaccinated. In this brief report, we describe interventions that Genesis HealthCare-one of the largest US long-term care providers-implemented after recognizing midway through vaccinations that racial and ethnic disparities existed in vaccine uptake among employees, with black and Hispanic employees having significantly lower rates of vaccination than their peers. Specifically, Genesis engaged its Diversity, Equity, and Inclusion (DEI) Committee to identify ways to augment its already comprehensive vaccine education campaign in order to build confidence among employees from minority communities. Interventions implemented beginning in late January 2021 included adding DEI representatives to information sessions to facilitate culturally sensitive discussions; holding information sessions at all times of day and night, and inviting employees' family members to join; increasing availability of multilingual educational materials; and featuring DEI representatives in social media campaigns. Between the end of January and beginning of March 2021, we observed statistically significant improvements in the likelihood of black and Hispanic employees being vaccinated relative to white employees, calculated as the relative risk of vaccination, suggesting a reduction in vaccination disparity. Whether these trends are directly related to the organization's efforts, or rather reflect individuals needing longer to become comfortable with the vaccines, is difficult to discern in the absence of a formal pragmatic trial. Still, these findings support the continuation of targeted educational and engagement efforts to improve vaccine uptake among staff, and the critical need to ensure that nursing homes have ongoing access to vaccine supply to continue their vaccination programs.


Subject(s)
COVID-19 Vaccines , COVID-19 , Humans , Nursing Homes , SARS-CoV-2 , Trust , United States , Vaccination
10.
Vaccine ; 39(29): 3844-3851, 2021 06 29.
Article in English | MEDLINE | ID: covidwho-1253724

ABSTRACT

BACKGROUND: The devastating impact of the SARS-CoV-2 pandemic prompted the development and emergency use authorization of two mRNA vaccines in early 2020. Vaccine trials excluded nursing home (NH) residents, limiting adverse event data that directly apply to this population. METHODS: To prospectively monitor for potential adverse events associated with vaccination, we used Electronic Health Record (EHR) data from Genesis HealthCare, the largest NH provider in the United States. EHR data on vaccinations and pre-specified adverse events were updated daily and monitored for signal detection among residents of 147 facilities who received the first dose of vaccine between December 18, 2020 and January 3, 2021. For comparison, unvaccinated residents during the same time period were included from 137 facilities that started vaccinating at least 15 days after the vaccinating-facilities. RESULTS: As of January 3, 2021, 8553 NH residents had received one dose of SARS-CoV-2 vaccine and by February 20, 2021, 8371 residents had received their second dose of vaccine; 11,072 were included in the unvaccinated comparator group. No significant associations were noted for neurologic outcomes, anaphylaxis, or cardiac events. CONCLUSIONS: No major safety problems were detected following the first or second dose of the vaccine to prevent COVID-19 in the study cohort from December 18, 2020 through March 7, 2021.


Subject(s)
COVID-19 Vaccines , COVID-19 , Humans , Nursing Homes , RNA, Messenger , SARS-CoV-2 , United States , Vaccination
11.
J Am Geriatr Soc ; 69(8): 2063-2069, 2021 08.
Article in English | MEDLINE | ID: covidwho-1189734

ABSTRACT

OBJECTIVE: To compare rates of incident SARS-CoV-2 infection and 30-day hospitalization or death among residents with confirmed infection in nursing homes with earlier versus later SARS-CoV-2 vaccine clinics. DESIGN: Matched pairs analysis of nursing homes that had their initial vaccine clinics between December 18, 2020, and January 2, 2021, versus between January 3, 2021, and January 18, 2021. Matched facilities had their initial vaccine clinics between 12 and 16 days apart. SETTING AND PARTICIPANTS: Two hundred and eighty nursing homes in 21 states owned and operated by the largest long-term care provider in the United States. MEASUREMENTS: Incident SARS-CoV-2 infections per 100 at-risk residents per week; hospital transfers and/or deaths per 100 residents with confirmed SARS-CoV-2 infection per day, averaged over a week. RESULTS: The early vaccinated group included 136 facilities with 12,157 residents; the late vaccinated group included 144 facilities with 13,221 residents. After 1 week, early vaccinated facilities had a predicted 2.5 fewer incident SARS-CoV-2 infections per 100 at-risk residents per week (95% CI: 1.2-4.0) compared with what would have been expected based on the experience of the late vaccinated facilities. The rates remained significantly lower for several weeks. Cumulatively over 5 weeks, the predicted reduction in new infections was 5.2 cases per 100 at-risk residents (95% CI: 3.2-7.3). By 5 to 8 weeks post-vaccine clinic, early vaccinated facilities had a predicted 1.1 to 3.8 fewer hospitalizations and/or deaths per 100 infected residents per day, averaged by week than expected based on late vaccinated facilities' experience for a cumulative on average difference of 5 events per 100 infected residents per day. CONCLUSIONS: The SARS-CoV-2 vaccines seem to have accelerated the rate of decline of incident infections, morbidity, and mortality in this large multi-state nursing home population.


Subject(s)
COVID-19 Vaccines/administration & dosage , COVID-19 , Hospitalization/statistics & numerical data , Nursing Homes/statistics & numerical data , Aged , COVID-19/epidemiology , COVID-19/mortality , Female , Humans , Male , SARS-CoV-2 , Time Factors , United States/epidemiology , Vaccination
12.
Health Affairs ; 40(4):655-663, 2021.
Article in English | Academic Search Complete | ID: covidwho-1167123

ABSTRACT

Improved therapeutics and supportive care in hospitals have helped reduce mortality from COVID-19. However, there is limited evidence as to whether nursing home residents, who account for a disproportionate share of COVID-19 deaths and are often managed conservatively in the nursing home instead of being admitted to the hospital, have experienced similar mortality reductions. In this study we examined changes in thirty-day mortality rates between March and November 2020 among 12,271 nursing home residents with COVID-19. We found that adjusted mortality rates significantly declined from a high of 20.9 percent in early April to 11.2 percent in early November. Mortality risk declined for residents with both symptomatic and asymptomatic infections and for residents with both high and low clinical complexity. The mechanisms driving these trends are not entirely understood, but they may include improved clinical management within nursing homes, improved personal protective equipment supply and use, and genetic changes in the virus. [ABSTRACT FROM AUTHOR] Copyright of Health Affairs is the property of Project HOPE/HEALTH AFFAIRS and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

13.
Health Aff (Millwood) ; 40(4): 655-663, 2021 04.
Article in English | MEDLINE | ID: covidwho-1127805

ABSTRACT

Improved therapeutics and supportive care in hospitals have helped reduce mortality from COVID-19. However, there is limited evidence as to whether nursing home residents, who account for a disproportionate share of COVID-19 deaths and are often managed conservatively in the nursing home instead of being admitted to the hospital, have experienced similar mortality reductions. In this study we examined changes in thirty-day mortality rates between March and November 2020 among 12,271 nursing home residents with COVID-19. We found that adjusted mortality rates significantly declined from a high of 20.9 percent in early April to 11.2 percent in early November. Mortality risk declined for residents with both symptomatic and asymptomatic infections and for residents with both high and low clinical complexity. The mechanisms driving these trends are not entirely understood, but they may include improved clinical management within nursing homes, improved personal protective equipment supply and use, and genetic changes in the virus.


Subject(s)
COVID-19/mortality , Nursing Homes , Humans , Personal Protective Equipment , Skilled Nursing Facilities
14.
J Am Geriatr Soc ; 69(7): 1722-1728, 2021 07.
Article in English | MEDLINE | ID: covidwho-1066719

ABSTRACT

OBJECTIVE: To describe the frequency and timing of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) antibody detection in a convenience sample of skilled nursing facility (SNF) residents with and without confirmed SARS-CoV-2 infection. DESIGN: Retrospective analysis of SNF electronic health records. SETTING: Qualitative SARS-CoV-2 antibody test results were available from 81 SNFs in 16 states. PARTICIPANTS: Six hundred and sixty nine SNF residents who underwent both polymerase chain reaction (PCR) and antibody testing for SARS-CoV-2. MEASUREMENTS: Presence of SARS-CoV-2 antibodies following the first positive PCR test for confirmed cases, or first PCR test for non-cases. RESULTS: Among 397 residents with PCR-confirmed infection, antibodies were detected in 4 of 7 (57.1%) tested within 7-14 days of their first positive PCR test; in 44 of 47 (93.6%) tested within 15-30 days; in 182 of 219 (83.1%) tested within 31-60 days; and in 110 of 124 (88.7%) tested after 60 days. Among 272 PCR negative residents, antibodies were detected in 2 of 9 (22.2%) tested within 7-14 days of their first PCR test; in 41 of 81 (50.6%) tested within 15-30 days; in 65 of 148 (43.9%) tested within 31-60 days; and in 9 of 34 (26.5%) tested after 60 days. No significant differences in baseline resident characteristics or symptoms were observed between those with versus without antibodies. CONCLUSIONS: These findings suggest that vulnerable older adults can mount an antibody response to SARS-CoV-2, and that antibodies are most likely to be detected within 15-30 days of diagnosis. That antibodies were detected in a large proportion of residents with no confirmed SARS-CoV-2 infection highlights the complexity of identifying who is infected in real time. Frequent surveillance and diagnostic testing based on low thresholds of clinical suspicion for symptoms and/or exposure will remain critical to inform strategies designed to mitigate outbreaks in SNFs while community SARS-CoV-2 prevalence remains high.


Subject(s)
COVID-19 Serological Testing/methods , COVID-19 , SARS-CoV-2 , Skilled Nursing Facilities , Aged , Aged, 80 and over , Asymptomatic Infections/epidemiology , COVID-19/blood , COVID-19/diagnosis , COVID-19/epidemiology , COVID-19/prevention & control , COVID-19 Nucleic Acid Testing/statistics & numerical data , Early Diagnosis , Electronic Health Records/statistics & numerical data , Female , Health Services Needs and Demand , Humans , Male , Prevalence , SARS-CoV-2/immunology , SARS-CoV-2/isolation & purification , Skilled Nursing Facilities/standards , Skilled Nursing Facilities/statistics & numerical data , Symptom Assessment/methods , Symptom Assessment/statistics & numerical data , United States/epidemiology
15.
JAMA Intern Med ; 181(4): 439-448, 2021 04 01.
Article in English | MEDLINE | ID: covidwho-1006405

ABSTRACT

Importance: The coronavirus disease 2019 (COVID-19) pandemic has severely affected nursing homes. Vulnerable nursing home residents are at high risk for adverse outcomes, but improved understanding is needed to identify risk factors for mortality among nursing home residents. Objective: To identify risk factors for 30-day all-cause mortality among US nursing home residents with COVID-19. Design, Setting, and Participants: This cohort study was conducted at 351 US nursing homes among 5256 nursing home residents with COVID-19-related symptoms who had severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection confirmed by polymerase chain reaction testing between March 16 and September 15, 2020. Exposures: Resident-level characteristics, including age, sex, race/ethnicity, symptoms, chronic conditions, and physical and cognitive function. Main Outcomes and Measures: Death due to any cause within 30 days of the first positive SARS-CoV-2 test result. Results: The study included 5256 nursing home residents (3185 women [61%]; median age, 79 years [interquartile range, 69-88 years]; and 3741 White residents [71%], 909 Black residents [17%], and 586 individuals of other races/ethnicities [11%]) with COVID-19. Compared with residents aged 75 to 79 years, the odds of death were 1.46 (95% CI, 1.14-1.86) times higher for residents aged 80 to 84 years, 1.59 (95% CI, 1.25-2.03) times higher for residents aged 85 to 89 years, and 2.14 (95% CI, 1.70-2.69) times higher for residents aged 90 years or older. Women had lower risk for 30-day mortality than men (odds ratio [OR], 0.69 [95% CI, 0.60-0.80]). Two comorbidities were associated with mortality: diabetes (OR, 1.21 [95% CI, 1.05-1.40]) and chronic kidney disease (OR, 1.33 [95%, 1.11-1.61]). Fever (OR, 1.66 [95% CI, 1.41-1.96]), shortness of breath (OR, 2.52 [95% CI, 2.00-3.16]), tachycardia (OR, 1.31 [95% CI, 1.04-1.64]), and hypoxia (OR, 2.05 [95% CI, 1.68-2.50]) were also associated with increased risk of 30-day mortality. Compared with cognitively intact residents, the odds of death among residents with moderate cognitive impairment were 2.09 (95% CI, 1.68-2.59) times higher, and the odds of death among residents with severe cognitive impairment were 2.79 (95% CI, 2.14-3.66) times higher. Compared with residents with no or limited impairment in physical function, the odds of death among residents with moderate impairment were 1.49 (95% CI, 1.18-1.88) times higher, and the odds of death among residents with severe impairment were 1.64 (95% CI, 1.30-2.08) times higher. Conclusions and Relevance: In this cohort study of US nursing home residents with COVID-19, increased age, male sex, and impaired cognitive and physical function were independently associated with mortality. Understanding these risk factors can aid in the development of clinical prediction models of mortality in this population.


Subject(s)
COVID-19/mortality , Nursing Homes , Age Factors , Aged , Aged, 80 and over , COVID-19/complications , COVID-19/diagnosis , Cohort Studies , Female , Health Status , Humans , Male , Middle Aged , Risk Factors , Sensitivity and Specificity , Sex Factors , Survival Rate , United States
17.
J Am Geriatr Soc ; 68(12): 2716-2720, 2020 12.
Article in English | MEDLINE | ID: covidwho-840738

ABSTRACT

BACKGROUND/OBJECTIVES: Infection screening tools classically define fever as 38.0°C (100.4°F). Frail older adults may not mount the same febrile response to systemic infection as younger or healthier individuals. We evaluate temperature trends among nursing home (NH) residents undergoing diagnostic SARS-CoV-2 testing and describe the diagnostic accuracy of temperature measurements for predicting test-confirmed SARS-CoV-2 infection. DESIGN: Retrospective cohort study evaluating diagnostic accuracy of pre-SARS-CoV-2 testing temperature changes. SETTING: Two separate NH cohorts tested diagnostically (e.g., for symptoms) for SARS-CoV-2. PARTICIPANTS Veterans residing in Veterans Affairs (VA) managed NHs and residents in a private national chain of community NHs. MEASUREMENTS: For both cohorts, we determined the sensitivity, specificity, and Youden's index with different temperature cutoffs for SARS-CoV-2 polymerase chain reaction results. RESULTS: The VA cohort consisted of 1,301 residents in 134 facilities from March 1, 2020, to May 14, 2020, with 25% confirmed for SARS-CoV-2. The community cohort included 3,368 residents spread across 282 facilities from February 18, 2020, to June 9, 2020, and 42% were confirmed for SARS-CoV-2. The VA cohort was younger, less White, and mostly male. A temperature testing threshold of 37.2°C has better sensitivity for SARS-CoV-2, 76% and 34% in the VA and community NH, respectively, versus 38.0°C with 43% and 12% sensitivity, respectively. CONCLUSION: A definition of 38.0°C for fever in NH screening tools should be lowered to improve predictive accuracy for SARS-CoV-2 infection. Stakeholders should carefully consider the impact of adopting lower testing thresholds on testing availability, cost, and burden on staff and residents. Temperatures alone have relatively low sensitivity/specificity, and we advocate any threshold be used as part of a screening tool, along with other signs and symptoms of infection.


Subject(s)
Aging/physiology , Body Temperature/physiology , COVID-19 , Nursing Homes/statistics & numerical data , Thermography , Veterans Health Services/statistics & numerical data , Aged, 80 and over , COVID-19/diagnosis , COVID-19/epidemiology , COVID-19/physiopathology , COVID-19 Testing/methods , Dimensional Measurement Accuracy , Female , Homes for the Aged/statistics & numerical data , Humans , Male , Mass Screening/methods , Mass Screening/standards , SARS-CoV-2 , Sensitivity and Specificity , Thermography/methods , Thermography/standards , Thermography/statistics & numerical data , United States/epidemiology
18.
J Am Geriatr Soc ; 68(10): 2167-2173, 2020 10.
Article in English | MEDLINE | ID: covidwho-648533

ABSTRACT

OBJECTIVE: To identify county and facility factors associated with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) outbreaks in skilled nursing facilities (SNFs). DESIGN: Cross-sectional study linking county SARS-CoV-2 prevalence data, administrative data, state reports of SNF outbreaks, and data from Genesis HealthCare, a large multistate provider of post-acute and long-term care. State data are reported as of April 21, 2020; Genesis data are reported as of May 4, 2020. SETTING AND PARTICIPANTS: The Genesis sample consisted of 341 SNFs in 25 states, including a subset of 64 SNFs that underwent universal testing of all residents. The non-Genesis sample included all other SNFs (n = 3,016) in the 12 states where Genesis operates that released the names of SNFs with outbreaks. MEASUREMENTS: For Genesis and non-Genesis SNFs: any outbreak (one or more residents testing positive for SARS-CoV-2). For Genesis SNFs only: number of confirmed cases, SNF case fatality rate, and prevalence after universal testing. RESULTS: One hundred eighteen (34.6%) Genesis SNFs and 640 (21.2%) non-Genesis SNFs had outbreaks. A difference in county prevalence of 1,000 cases per 100,000 (1%) was associated with a 33.6 percentage point (95% confidence interval (CI) = 9.6-57.7 percentage point; P = .008) difference in the probability of an outbreak for Genesis and non-Genesis SNFs combined, and a difference of 12.5 cases per facility (95% CI = 4.4-20.8 cases; P = .003) for Genesis SNFs. A 10-bed difference in facility size was associated with a 0.9 percentage point (95% CI = 0.6-1.2 percentage point; P < .001) difference in the probability of outbreak. We found no consistent relationship between Nursing Home Compare Five-Star ratings or past infection control deficiency citations and probability or severity of outbreak. CONCLUSIONS: Larger SNFs and SNFs in areas of high SARS-CoV-2 prevalence are at high risk for outbreaks and must have access to universal testing to detect cases, implement mitigation strategies, and prevent further potentially avoidable cases and related complications. J Am Geriatr Soc 68:2167-2173, 2020.


Subject(s)
COVID-19/epidemiology , Skilled Nursing Facilities/statistics & numerical data , Aged , Aged, 80 and over , COVID-19/transmission , Case-Control Studies , Cross-Sectional Studies , Humans , Infection Control/standards , Nursing Staff/statistics & numerical data , Pandemics , Prevalence , Risk Assessment , SARS-CoV-2 , Skilled Nursing Facilities/organization & administration , United States/epidemiology
19.
J Am Geriatr Soc ; 68(10): 2174-2178, 2020 10.
Article in English | MEDLINE | ID: covidwho-595558

ABSTRACT

OBJECTIVES: To illustrate dissemination and asymptomatic transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) during a skilled nursing facility (SNF) outbreak. DESIGN: Case report. SETTING AND PARTICIPANTS: Residents of a 150-bed SNF. MEASUREMENTS: Heat maps generated by the SNF's infection prevention team to track staff and resident symptoms and SARS-CoV-2 test results to identify infection patterns. RESULTS: The SNF experienced a severe outbreak of SARS-CoV-2 early in the pandemic. The initial cluster of residents with symptoms and the first confirmed case occurred on the SNF's dementia care unit. The insufficient availability and prolonged turnaround time of testing for both residents and staff at the outset of the outbreak prevented timely and accurate identification and cohorting of cases. Despite extensive other infection control measures being in place, SARS-CoV-2 disseminated widely through the facility within 3 weeks of the first confirmed case, resulting in significant morbidity and mortality. CONCLUSION: Early, rapid, universal SARS-CoV-2 testing of both SNF residents and staff at the outset of an outbreak and then repeatedly thereafter is critical to mitigate viral transmission. This will become even more important as states relax stay-at-home orders and SNF staff intermingle with communities that are increasingly mobile. Increased testing will inevitably result in more staff testing positive and having to self-quarantine at home, meaning that states must partner with SNFs and other long-term care providers to coordinate and support strategic staffing reserves that can supplement current frontline staff. J Am Geriatr Soc 68:2174-2178, 2020.


Subject(s)
COVID-19/transmission , Infection Control/methods , Skilled Nursing Facilities/organization & administration , COVID-19/diagnosis , COVID-19/epidemiology , COVID-19 Nucleic Acid Testing/statistics & numerical data , Cluster Analysis , Humans , Mass Screening/statistics & numerical data , Nursing Staff/organization & administration , Organizational Case Studies , Pandemics , SARS-CoV-2/pathogenicity
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