Clinical Outcomes After Admission of Patients With COVID-19 to Skilled Nursing Facilities.

Importance: During the COVID-19 pandemic, stabilized COVID-19-positive patients were discharged to skilled nursing facilities (SNFs) to alleviate hospital crowding. These discharges generated controversy due to fears of seeding outbreaks, but there is little empirical evidence to inform policy. Objective: To assess the association between the admission to SNFs of COVID-19-positive patients and subsequent COVID-19 cases and death rates among residents. Design, Setting, and Participants: This cohort study analyzed survey data from the National Healthcare Safety Network of the Centers for Disease Control and Prevention. The cohort included SNFs in the US from June 2020 to March 2021. Exposed facilities (ie, with initial admission of COVID-19-positive patients) were matched to control facilities (ie, without initial admission of COVID-19-positive patients) in the same county and with similar preadmission case counts. Data were analyzed from June 2023 to February 2024. Exposure: The week of the first observable admission of COVID-19-positive patients (defined as those previously diagnosed with COVID-19 and continued to require transmission-based precautions) during the study period. Main Outcomes and Measures: Weekly counts of new cases of COVID-19, COVID-19-related deaths, and all-cause deaths per 100 residents in the week prior to the initial admission. A stacked difference-in-differences approach was used to compare outcomes for 10 weeks before and 15 weeks after the first admission. Additional analyses examined whether outcomes differed in facilities with staff or personal protective equipment (PPE) shortages. Results: A matched group of 264 exposed facilities and 518 control facilities was identified. Over the 15-week follow-up period, exposed SNFs had a cumulative increase of 6.94 (95% CI, 2.91-10.98) additional COVID-19 cases per 100 residents compared with control SNFs, a 31.3% increase compared with the sample mean (SD) of 22.2 (26.4). Exposed facilities experienced 2.31 (95% CI, 1.39-3.24) additional cumulative COVID-19-related deaths per 100 residents compared with control facilities, representing a 72.4% increase compared with the sample mean (SD) of 3.19 (5.5). Exposed facilities experiencing potential staff shortage and PPE shortage had larger increases in COVID-19 cases per 100 residents (additional 10.97 [95% CI, 2.76-19.19] cases and additional 14.81 [95% CI, 2.38-27.25] cases, respectively) compared with those without such shortages. Conclusion: This cohort study suggests that admission of COVID-19-positive patients into SNFs early in the pandemic was associated with preventable COVID-19 cases and mortality among residents, particularly in facilities with potential staff and PPE shortages. The findings speak to the importance of equipping SNFs to adhere to infection-control best practices as they continue to face COVID-19 strains and other respiratory diseases.

Health Care Staff Turnover and Quality of Care at Nursing Homes.

Importance: Turnover in health care staff may disrupt patient care and create operational and organizational challenges, and nursing home staff turnover rates are particularly high. Empirical evidence on the association between turnover and quality of care is limited and has typically relied on low-quality measures of turnover, small and selected samples of facilities, and comparisons across facilities that are highly susceptible to residual confounding. Objective: To quantify the association between nursing home staff turnover and quality of care using within-facility variation over time in reliable turnover measures available for virtually all US nursing homes. Design, Setting, and Participants: In this cross-sectional study, data from the Centers for Medicare & Medicaid Services on health inspection citations and quality measures at US nursing homes were combined with turnover measures constructed from daily staffing payroll data for quarter 2 of 2017 (April 1 to June 30) to quarter 4 of 2019 (October 1 to December 31), covering 1.06 billion shifts for 7.48 million employment relationships at 15 869 facilities. A 2-way fixed-effects design was used to estimate the association between staff turnover (direct care nursing staff and administrators) and quality-of-care outcomes based on how the same facility performed differently in times of low and high turnover. Data analysis was performed from September 2022 to August 2023. Exposures: Facility turnover, defined as the share of hours worked in a period by staff hired within the last 90 days. Main Outcomes and Measures: Number, type, scope, and severity of health inspection citations, overall health inspection scores, and Nursing Home Compare quality measures. Results: The study sample included 1.45 million facility-weeks between April 1, 2017, and December 31, 2019, corresponding to 13 826 unique facilities. During an average facility-week, 15.0% of nursing staff and 11.6% of administrators were new hires due to recent turnover. After both administrator turnover and the overall staffing level were controlled for, an additional 10 percentage points in nursing staff turnover in the 2 weeks before a health inspection was associated with an additional 0.241 (95% CI, 0.084-0.399) citations in that inspection, compared with a mean of 5.98 citations. An additional 10 percentage points in nursing staff turnover was associated with a mean decrease of 0.035 (95% CI, 0.023-0.047) SDs in assessment-based quality measures and 0.020 (95% CI, 0.001-0.038) SDs in claims-based quality measures, with the strongest associations found for measures related to patient functioning. Conclusions and Relevance: Within-facility variation in staff turnover was associated with decreased quality of care. These findings suggest that efforts to monitor and reduce staff turnover may be able to improve patient outcomes.

Covid-19 Surveillance Testing and Resident Outcomes in Nursing Homes.

BACKGROUND: Despite widespread adoption of surveillance testing for coronavirus disease 2019 (Covid-19) among staff members in skilled nursing facilities, evidence is limited regarding its relationship with outcomes among facility residents. METHODS: Using data obtained from 2020 to 2022, we performed a retrospective cohort study of testing for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) among staff members in 13,424 skilled nursing facilities during three pandemic periods: before vaccine approval, before the B.1.1.529 (omicron) variant wave, and during the omicron wave. We assessed staff testing volumes during weeks without Covid-19 cases relative to other skilled nursing facilities in the same county, along with Covid-19 cases and deaths among residents during potential outbreaks (defined as the occurrence of a case after 2 weeks with no cases). We reported adjusted differences in outcomes between high-testing facilities (90th percentile of test volume) and low-testing facilities (10th percentile). The two primary outcomes were the weekly cumulative number of Covid-19 cases and related deaths among residents during potential outbreaks. RESULTS: During the overall study period, 519.7 cases of Covid-19 per 100 potential outbreaks were reported among residents of high-testing facilities as compared with 591.2 cases among residents of low-testing facilities (adjusted difference, -71.5; 95% confidence interval [CI], -91.3 to -51.6). During the same period, 42.7 deaths per 100 potential outbreaks occurred in high-testing facilities as compared with 49.8 deaths in low-testing facilities (adjusted difference, -7.1; 95% CI, -11.0 to -3.2). Before vaccine availability, high- and low-testing facilities had 759.9 cases and 1060.2 cases, respectively, per 100 potential outbreaks (adjusted difference, -300.3; 95% CI, -377.1 to -223.5), along with 125.2 and 166.8 deaths (adjusted difference, -41.6; 95% CI, -57.8 to -25.5). Before the omicron wave, the numbers of cases and deaths were similar in high- and low-testing facilities; during the omicron wave, high-testing facilities had fewer cases among residents, but deaths were similar in the two groups. CONCLUSIONS: Greater surveillance testing of staff members at skilled nursing facilities was associated with clinically meaningful reductions in Covid-19 cases and deaths among residents, particularly before vaccine availability.

Association of State COVID-19 Vaccine Mandates With Staff Vaccination Coverage and Staffing Shortages in US Nursing Homes.

Importance: Several states implemented COVID-19 vaccine mandates for nursing home employees, which may have improved vaccine coverage but may have had the unintended consequence of staff departures. Objective: To assess whether state vaccine mandates for US nursing home employees are associated with staff vaccination rates and reported staff shortages. Design Setting and Participants: This cohort study performed event study analyses using National Healthcare Safety Network data from June 6, 2021, through November 14, 2021. Changes in weekly staff vaccination rates and reported staffing shortages were evaluated for nursing homes in states with mandates after the mandate announcement compared with changes in facilities in nonmandate states. An interaction between the mandates and county political leaning was considered. Data analysis was performed from February to March 2022. Exposures: Weeks after announcement of a state's COVID-19 vaccine mandate. Main Outcomes and Measures: Weekly percentage of all health care staff at a nursing home who received at least 1 COVID-19 vaccine dose, and a weekly indicator of whether a nursing home reported a staffing shortage. Results: Among 38 study-eligible states, 26 had no COVID-19 vaccine mandate for nursing home employees, 4 had a mandate with a test-out option, and 8 had a mandate with no test-out option. Ten weeks or more after mandate announcement, nursing homes in states with a mandate and no test-out option experienced a 6.9 percentage point (pp) increase in staff vaccination coverage (95% CI, -0.1 to 13.9); nursing homes in mandate states with a test-out option experienced a 3.1 pp increase (95% CI, 0.5 to 5.7) compared with facilities in nonmandate states. No significant increases were detected in the frequency of reported staffing shortages after a mandate announcement in mandate states with or without test-out options. Increases in vaccination rates in states with mandates were larger in Republican-leaning counties (14.3 pp if no test-out option; 4.3 pp with option), and there was no evidence of increased staffing shortages. Conclusions and Relevance: The findings of this cohort study suggest that state-level vaccine mandates were associated with increased staff vaccination coverage without increases in reported staffing shortages. Vaccination increases were largest when mandates had no test-out option and were also larger in Republican-leaning counties, which had lower mean baseline vaccination rates. These findings support the use of state mandates for booster doses for nursing home employees because they may improve vaccine coverage, even in areas with greater vaccine hesitancy.

Staffing Patterns in US Nursing Homes During COVID-19 Outbreaks.

Importance: Staff absences and departures at nursing homes may put residents at risk and present operational challenges. Objective: To quantify changes in nursing home facility staffing during and after a severe COVID-19 outbreak. Design Setting and Participants: In this cohort study, daily staffing payroll data were used to construct weekly measures of facility staffing, absences, departures, and use of overtime and contract staff among US nursing homes experiencing a severe COVID-19 outbreak that started between June 14, 2020, and January 1, 2021. Facility outbreaks were identified using COVID-19 case data. An event-study design with facility and week fixed effects was used to investigate the association of severe outbreaks with staffing measures. Exposures: Weeks since the beginning of a severe COVID-19 outbreak (4 weeks prior to 16 weeks after). Main Outcomes and Measures: Total weekly staffing hours, staff counts, staff absences, departures, new hires, overtime and contract staff hours measured for all nursing staff and separately by staff type (registered nurses, licensed practical nurses, certified nursing assistants), facility self-reported staff shortages, and resident deaths. Results: Of the included 2967 nursing homes experiencing severe COVID-19 outbreaks, severe outbreaks were associated with a statistically significant drop in nursing staffing levels owing to elevated absences and departures. Four weeks after an outbreak's start, around when average new cases peaked, staffing hours were 2.6% (95% CI, 2.1%-3.2%) of the mean below preoutbreak levels, despite facilities taking substantial measures to bolster staffing through increased hiring and the use of contract staff and overtime. Because these measures were mostly temporary, staffing declined further in later weeks; 16 weeks after an outbreak's start, staffing hours were 5.5% (95% CI, 4.5%-6.5%) of the mean below preoutbreak levels. Staffing declines were greatest among certified nursing assistants, primarily owing to smaller increases in new hires of this staff type compared with licensed practical nurses and registered nurses. Conclusions and Relevance: In this cohort study of nursing homes experiencing severe COVID-19 outbreaks, facilities experienced considerable staffing challenges during and after outbreaks. These results suggest the need for policy action to ensure facilities' abilities to maintain adequate staffing levels during and after infectious disease outbreaks.

Larger Nursing Home Staff Size Linked To Higher Number Of COVID-19 Cases In 2020.

Staff in skilled nursing facilities (SNFs) are essential health care workers, yet they can also be a source of COVID-19 transmission. We used detailed staffing data to examine the relationship between a novel measure of staff size (that is, the number of unique employees working daily), conventional measures of staffing quality, and COVID-19 outcomes among SNFs in the United States without confirmed COVID-19 cases by June 2020. By the end of September 2020, sample SNFs in the lowest quartile of staff size had 6.2 resident cases and 0.9 deaths per 100 beds, compared with 11.9 resident cases and 2.1 deaths per 100 beds among facilities in the highest quartile. Staff size, including staff members not involved in resident care, was strongly associated with SNFs' COVID-19 outcomes, even after facility size was accounted for. Conventional staffing quality measures, including direct care staff-to-resident ratios and skill mix, were not significant predictors of COVID-19 cases or deaths. Reducing the number of unique staff members without decreasing direct care hours, such as by relying on full-time rather than part-time staff, could help prevent outbreaks.