Staffing and protective equipment access mitigated COVID-19 Penetration and Spread in US nursing homes during the Third Surge

Simoni-Wastila, Linda; Wallem, Alexandra; Fleming, Sean; Le, Tham; Kepczynska, Paulina; Yang, Jeanne; Qato, Danya M.

Objectives During the last quarter of 2020—despite improved distribution of personal protective equipment(PPE) and knowledge of COVID-19 management—nursing homes experienced the greatest increases in cases and deaths since the pandemic’s beginning. We sought to update COVID-19 estimates of cases, hospitalization, and mortality, and to evaluate the association of potentially modifiable facility-level infection control factors on odds and magnitude of COVID-19 cases, hospitalizations, and deaths in nursing homes during the third surge of the pandemic. Design Cross-sectional analysis Setting and Participants Facility-level data from 13,156 United States nursing home facilities Methods Two series of multivariable logistic regression and generalized linear models to examine the association of infection control factors (personal protective equipment and staffing) on incidence and magnitude, respectively, of confirmed COVID-19 cases, hospitalizations, and deaths in nursing home residents reported in the last quarter of 2020. Results Nursing homes experienced steep increases in COVID-19 cases, hospitalizations, and deaths during the final quarter of 2020. Four-fifths (80.51%;n=10,592) of facilities reported at least one COVID-19 case, 49.44%(n=6,504) reported at least one hospitalization, and 49.76% (n=6,546) reported at least one death during this third surge. N95 mask shortages were associated with increased odds of at least one COVID-19 case (OR: 1.21[95% Confidence Interval(CI), 1.05-1.40]) and hospitalization (OR: 1.26 [95%CI, 1.13-1.40]), as well as larger numbers of hospitalizations (OR: 1.11 [95%CI, 1.02-1.20]). Nursing aide shortages were associated with lower odds of at least one COVID-19 death (OR: 1.22 [95%CI, 1.12-1.34]) and higher hospitalizations (OR:1.09 [95%CI, 1.01-1.17]). The number of nursing hours per resident per day was largely insignificant across all outcomes. Of note, smaller (<50 beds) and mid-sized (50-150 beds) facilities had lower odds yet higher magnitude of all COVID outcomes. Bed occupancy rates > 75% increased odds of experiencing a COVID-19 case (OR:1.48 [95%CI, 1.35-1.62]) or death (OR: 1.25 [95%CI, 1.17-1.34]). Conclusions and Implications Adequate staffing and PPE—along with reduced occupancy and smaller facilities—mitigate incidence and magnitude of COVID-19 cases and sequellae. Addressing shortcomings in these factors is critical to the prevention of infections and adverse health consequences of a next surge among vulnerable nursing home residents.