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M. Tandan


Corresponding author: Meera Tandan, PhD, Cecil G Sheps Centers for Health Service Research, University of North Carolina, USA, Email -meerat@email.unc.edu,
ORCID = orcid.org/0000-0002-7742-7980

Jour Nursing Home Res 2021;7:65-70
Published online September 30 2021, http://dx.doi.org/10.14283/jnhrs.2021.11



The rapid increase in antimicrobial resistance is a great concern in safeguarding the nursing home population. Improving inappropriate prescribing is the main agenda of antimicrobial stewardship. It is complicated to articulate the appropriateness of antimicrobial prescribed in nursing home residents, especially the prophylaxis. It is tricky because most of the residents are often on multiple medications, and there are no guidelines available for prescribers to decide on the appropriateness. Except for urinary tract infections, prescribing instructions rarely exists for other infections in nursing homes. Very few studies discuss prophylactic prescribing, and most of them are prevalence studies. These studies showed the urinary tract, respiratory tract, and skin-related problem as the most common cause of antimicrobial prophylaxis. However, this information is presented as total proportion without disaggregated analysis of conditions and types of the urinary and respiratory tract and skin-related infections. Further, the definition used is vague, and significant risk factors of antimicrobial prophylaxis and precision about the use remain unanswered. Lack of appropriate definition and unanswered questions are potentially challenging for stewardship in nursing homes. This review summarizes the current situation of antimicrobial prophylaxis and discusses gaps in the literature and pertinent areas for moving forward for antimicrobial stewardship in nursing home settings.

Key words: Prophylactic, antimicrobials, review, stewardship, nursing homes, urinary tract infection, respiratory tract infection, skin infections.



Antimicrobial resistance (AMR) is a global issue. In the United States (US), more than 2.8 million antimicrobial-resistant infections occur each year, and above 35,000 people die due to AMR (1). One of the critical causes of AMR is inappropriate prescribing. It could be either prescribing for no reasons or preventing infection, choosing wrong antimicrobials or prescribing correct antimicrobials but incorrect dose or duration, or prescribing against the guidelines (2, 3). None can avoid antimicrobials and the risk of getting resistant bacteria in their lifetime. Though, the older people living in nursing homes (NHs-also known as long-term care facilities) are more likely to get infections and AMR (4). Every year, 1.6 to 3 million infections occur in NHs and between 40-75% of the prescribed antimicrobials are inappropriate (5). In the US, 11% of NH residents receive antimicrobials in a single day. Nearly 40% lack prescription information (6). Similarly, 9% antimicrobials are prescribed in Australian NHs, of which 40% do not meet bacterial infection criteria (7). In Europe, antimicrobial use in NH varies across countries (range 1-12%), and 27% are prophylaxis (8).
Antimicrobial prophylaxis (AP) is an effective intervention in preventing infections; yet, it has become an inappropriate practice in NH. For example, 80% of prophylactic antimicrobials are without termination or end date, and many of them are broad-spectrum in nature, such as fluoroquinolones (2, 9). Such prescribing behavior indicates that AP becomes an essential reason for irrational prescribing and might be the leading cause of AMR in NH. Addressing prophylactic prescribing is central to attain the motto of antimicrobial stewardship. While much attention has not been given to this area, and very few literatures published. This study aims to provide the extent to which antimicrobials are prescribed prophylactically, including challenges in attaining stewardship in NH settings.


Prophylactic Antimicrobial Prescribing

The term prophylaxis means the prevention of infections. Prophylaxis is not only limited to preventing disease occurrence, but it can also prevent the disease’s worsening and minimize the severity. For example, preoperative prophylaxis used to avoid initial infection as well as to reduce the severity. Sometimes, prophylaxis measures are applied to prevent recurrence or reactivation of diseases (e.g., prevention of recurrent urinary tract infections (UTI) (5).
AP varies across countries and regions (8, 10). In NHs, overall prevalence lies between 4 -53% in European countries (8), 26% in Australia (7), and 23% in the US (6). In some countries such as Denmark, Finland, Norway, and UK-Northern Ireland, prophylactic use is higher than the therapeutic (10). A study in Michigan reported that 17% of the antimicrobial prescriptions were without clinical or laboratory evidence of infections (11), potentially the indication was for prevention. Antimicrobials are often prescribed to prevent most common infections -mainly related to urinary and respiratory tract and skin. A comparative study in Irish NHs reported 70-75% of AP for urinary tract, 16-26% for respiratory tract and 8-9% for skin or wound-related conditions in NH (9). Likewise, a similar trend reported from other European countries (10, 12) and Australia (13).

Prophylaxis related to urinary tract

A vital issue in the management of UTI in NH is inappropriate antimicrobial use, where prophylaxis accounted for 22% of antimicrobials prescribed (8). The prevalence is above 30% in Belgium, Denmark, Finland, Ireland, Norway, Sweden, and the UK (8), and 25% in the US (14). Prescribing in NH resident are misguided by the positive urine culture results and mild pyuria, and are almost treated with antimicrobials. As asymptomatic bacteriuria increases with age and practically all NH residents (asymptomatic) tests positive bacteriuria (15). Antimicrobial either therapeutic or prophylactic for asymptomatic bacteriuria is not recommended (16). A previous study demonstrated no benefits of antimicrobials in reducing symptomatic UTI (17). Still, there is a practice of antimicrobial prescribing for such conditions. But, the exact prophylactic contribution of asymptomatic bacteria is unknown, an auspicious area for exploration.
A urinary catheter is another cause of AP. About 7-9% of the residents in NH had a urinary catheter (18, 19). Urinary catheter increases the risk of asymptomatic bacteriuria, subsequently increase antimicrobial use as described above. UTI guidelines do not emphasize AP for a resident with a urinary catheter (20). Nevertheless, a urinary catheter viewed as a straightforward indication for antimicrobial prescribing and, more often, prophylaxis in the NH. A study reported that a resident with a urinary catheter is nearly two times more likely to be on AP than those without catheter (9). A Cochrane review indicated weak evidence of AP in reducing bacteriuria (symptomatic and symptomatic) in adult patients with a urinary catheter. However, there remains a higher heterogeneity among the included studies (21). Moreover, few studies describe the use of prophylactic antimicrobials during insertion and removal of a catheter for UTI (22). But, the outcome of the study describe was not strong enough to support prophylaxis and did not include the patients from NH. Additionally, guidelines from the US and Europe do not advocate AP for either of the cases or the patients undergoing urological procedure unless it is essential because of AMR issues (20, 23, 24).
Recurrent UTI (at least three UTI per year or two in the last six months) is another apparent reason for AP. In older people, both UTI or recurrent UTI are over diagnosed and over treated (25). In NHs, 12-14% of older adults with recurrent UTI receive AP.26 Guidelines recommendation for recurrent UTI prophylaxis varies– American Urological Association moderately recommends UTI prophylaxis to those with recurrent UTI and emphasize that prescriber should always outweigh benefit than the risk (27). While the UK guidelines commend a daily use of low dose prophylaxis for recurrent UTI if initial single-dose prophylaxis fails to prevent UTI’s re-occurrence (28). Nevertheless, these guidelines are silent about recurrent UTI prophylaxis in NH residents about when to start and for how long. A study of a large cohort of older people in UK indicated that prophylaxis for recurrent UTI significantly reduces the risk of clinical recurrence of UTI and UTI related hospitalization in men (26). The study has the limitation of exclusion of microbiological data in the analysis. Hence, it is unclear if the AP genuinely meets the definition of recurrent UTI. The current increasing trend of AMR and adverse events associated with antimicrobials suggests further investigation of the usefulness and practicality of recurrent UTI prophylaxis in NHs.
The common prophylactic antimicrobials include trimethoprim (30%), nitrofurantoin (27%), methenamine (12%), cefalexin (6%), and fosfomycin (6%) for urinary infections. These antimicrobials cover 81% of all prophylactic antimicrobials prescribed in NHs (8). The proportion of use and antimicrobials types differ between countries. For example, nitrofurantoin and trimethoprim more often used in Irish NHs (9), and methenamine in Norwegian (29). These are the approved first-line treatment option for UTI. Moreover, for recurrent UTI, the preventive use of these antimicrobials did not show significant clinical and microbiological cure rates in adult women (30). Consequently, the use of these antimicrobials is associated with increased risk of bacterial resistance and side effects, encouraging for limited use in older people. Trimethoprim is frequently associated with a higher risk of acute kidney injury and hyperkalemia (31), and its resistance to uropathogens is above 35% in NH population (32, 33). In contrast, nitrofurantoin did not show resistance to uropathogens (33) and has proven useful for acute and severe UTI, including the catheter-associated if prescribed prophylactically (either shorter or longer duration) (34). Meanwhile, nitrofurantoin cause pulmonary fibrosis, hepatoxicity, and symptoms specific to gastrointestinal in older adults (30, 34). So far, methenamine prophylaxis has proven effective in reducing symptomatic UTI in older adults without resistance to uropathogens and low adverse events (35). Its use is sometimes problematic in residents without adequate renal function and with renal tract abnormalities, and these conditions are rarely not present in NH residents. Therefore, in total, the AP, if necessary, should be based on clinical judgment balancing the risk and benefit without excluding the local resistance profile of antimicrobials prescribed.

Prophylaxis related to respiratory tract

Overall, prophylaxis related to respiratory tract shares 6% of the total antimicrobials used in NHs (8). The highest prescribed in Netherland (27%), Portugal (23%), Italy (9%), Ireland (9%), Sweden (8%), and UK (6%) (8, 36). These prophylactic prescribing includes both the infection of the upper and lower respiratory tract (10). A separate analysis, specific to different types of respiratory infection, is not reported. In the US, AP is 38% for aspiration pneumonia (37). In sum, the prescription for acute bronchitis could be a more prominent contributor to prophylaxis related to respiratory infections in NHs. Most of the acute bronchitis is viral in etiology. Overprescribing more often connected to acute bronchitis, compromising 40% of all prescriptions (38). Guidelines do not suggest antimicrobials for acute bronchitis, except confirmed by a diagnostic test or suspected for pertussis or unless the risk of a severe complication due to comorbidity (39). Also, no clinical benefits of antimicrobials in the treatment of acute bronchitis reported for patients above 60 years. Alternatively, AP may have suggested in acute cough for patients with a history of hospitalization, diabetes mellitus, congestive heart failure, or patients on steroids; but, not for long-term use in stable patients.
The other reason of AP for respiratory problems could be chronic obstructive pulmonary disease (COPD) and pneumonia. It is mainly because 20% of hospitalizations of NH residents are from these infections where most of the antimicrobials initiated (40). A study demonstrated that AP substantially reduces the number of exacerbations and improves the quality of life of older people with COPD (41). Moreover, the routine AP is not suggested for acute exacerbation of COPD as the prophylaxis duration is quite lengthy (12 to 36 months) (39). Concerning pneumonia, AP significantly reduces the incidence and mortality in the intensive care unit (42), but no clinical benefits for older people in outpatient settings (37). The finding implies benefits of AP to some extent. Nevertheless, long term use for more than a year in older adults in outpatients subsequently escalate frequent use leaving no antimicrobial free days. Such a situation is more likely to provide a conducive environment for AMR, hence these prescribing issues with NH required further research attention.
For respiratory infections, macrolides, cephalosporin, and tetracycline are the conventional AP.8 Of the total prophylaxis, macrolides represent 47-69%, tetracycline 11-16% (most importantly, the doxycycline), and cephalosporin 3-11%.9 Macrolides prophylactics could be associated with COPD, as 27% of NH residents had COPD.40 In this study, the prophylactic use of these antimicrobials is not subject to either COPD or pneumonia. Macrolide causes adverse drug events if used long-term in patients under medication that prolonged QT interval. For example, an antipsychotic medication. Nearly a quarter of the NH residents receive one or more antipsychotic drugs (43). Therefore, understanding the appropriateness of prophylactic antimicrobials in this population is imperative. Further, desegregation analysis of AP by types of respiratory problems and appropriateness of prophylaxis merits advantages in reducing adverse drug events and AMR in NH residents.

Prophylaxis related to skin problem

Skin infection is the third most common problem, accounting for 20% of all infections in NH (8). AP for skin-related problems ranges from 10-12% (9, 36). The skin infection includes cellulitis, soft tissue, and wound infection, while a discrete analysis of AP is not available for specific skin conditions. In NH, cellulitis (mostly non-purulent) is a common skin problem often confused with non-bacterial chronic inflammation, dermatitis occurring in the lower extremities (38). Therefore, these problems are misdiagnosed, misinterpreted in many residents, and subsequently mistreated and prescribed inappropriately, which may include AP. Of the total misdiagnosed cellulitis cases, 92% receive inappropriate antimicrobials (44). AP is moderately recommended for recurrent cellulitis (3-4 episodes per year) for 4-52 weeks (45); however, no clear indication exists specific to NH resident. As AP may reduce future recurrent cellulitis, prescribing for a longer duration may likely to develop AMR and associated adverse events. Therefore, a detailed study on skin-related AP in NH is vital to curb the increase AMR issue and accomplish stewardship. Similarly, due to a lack of standardized guidelines, there is a significant dilemma in both diagnosis and antimicrobial use for pressure ulcers and abscess. Meanwhile, antimicrobials have shown no clinical benefit, and prophylaxis is not suggestive for wound infection (45).
On a similar note, studies on types of antimicrobials (either therapeutic or prophylactic) used for skin infections for NH are very less. In the US, oral beta-lactam (cephalexin, amoxicillin/clavulanate), tetracycline (doxycycline), and fluoroquinolones are common therapeutics for skin infections (46). Whilst, this study did not discuss prophylactic. An Irish study showed that of the skin-related AP, 65-68% are tetracycline, 8-26% penicillin, and 3-6% macrolides in NH (9). Tetracycline, particularly doxycycline, was reported from intellectual disability facilities. These are the facilities where residents are young, and prolonged use of doxycycline is an advised option for acne vulgaris in Ireland. Every country has its definition of NH and guidelines for antimicrobials, so the prescribed antimicrobials’ local AMR profile should be considered. At the same time, further detailed exploration is required to understand the issue and suppress the unwanted skin-related AP problems in NH.


Literature-related to Antimicrobial Prophylaxis

Very few pieces of literature are available on AP in NH (Figure 1). With the introduction of a stewardship concept in the infection control in NH, the number of scientific studies substantially increased for antimicrobial stewardship. But then, the literature on AP is scarce. There are 41 published papers available till May 27, 2020, in the PubMed database. The main objective of most of the published papers was not prophylactic prescribing. Of the 41 studies, 18 studies from Europe, 15 the US, 4 UK, and 2 Canada. About 25% of the studies are related to the microbiological aspect, but with a little information on AP. If included, AP either mentioned in the discussion or conclusion sections. The majority of the European studies are related to AP for any cause/infections (11 studies) and UTI (4 studies), while from the US are related to UTI (6 studies) and pneumonia and Invasive Group A Streptococcal Disease (iGAS-4 studies) (Figure 2). Compared to the US, studies conducted in Europe are explicit about AP, but the data presented are just limited to prevalence. The higher number of studies in Europe is the effect of a few AP data collected as a part of point prevalence surveys. In Europe surveillance study on healthcare-associated infections in long-term care facilities (HALT) began in 2008 and has already completed three consecutive studies.8,10 The definition used for collecting AP data was vague and differed across countries. The analysis was mainly presented descriptively as a proportion. Except for a study published in 2019 in Eurosurveillance,9 none of the studies had performed an in-depth analysis of prophylactic prescribing. This study compares the result of two surveys and identified the risk factors of AP in NH.

Growth of literature related to antimicrobials use, prophylactic antimicrobial use, and antimicrobial stewardship in NHs or in LTCFs (till May 27, 2020)

Figure 2
Prophylactic papers and the disease conditions studied in the literature by countries


Similarly, in 2009, the Center for Disease Prevention and Control (CDC) launched a pilot point prevalence survey in 9 NH in the 4 Emerging Infection Program (EIP) states and collected information on prophylactic antimicrobial prescribing (47). A paper from this pilot study mostly focuses on UTI prophylaxis.48 Following the pilot study, a full-scale survey was conducted in 161 NHs in 2017 in the 10 EIP states. Recently, a paper has been published as an outcome of this study; however, is UTI centered.49
Besides, studies from Canada were a prevalence 50 and a review on AP (51). The review study included a little argument on the prophylactic prescribing and indwelling urethral catheter in NH residents.51 A study in Puerto Rico discussed antimicrobials’ use, isoniazid as a preventive therapy for tuberculin positive test for the prevention of active tuberculosis in the NH residents (52).


Antimicrobial Prophylaxis and Stewardship

Antimicrobial stewardship is directly proportional to rational prescribing, meaning prescribed only when required in appropriate quantity and duration. In the current situation of AMR tragedy, antimicrobial stewardship practice is critical in NH settings. A study showed that antimicrobial stewardship practices reduce the prevalence of antimicrobial consumption by 20% in NH (18). In the US, all NH required to implement antimicrobial stewardship programs since 2017 (33). According to a recent report, 33% of NH had a comprehensive antimicrobial stewardship policy (53). Additionally, antimicrobial stewardship guidelines do not explicitly discuss prophylactic prescribing in NH, except asymptomatic bacteriuria (54). Considerable insight has been developed regarding inappropriate antimicrobial prescribing for successful stewardship in NH (14, 21, 30). The prophylactic prescribing remains broad and neglected. Guidelines specifically addressing the antimicrobial prescribing for NH are few, and most of them are silent about the prophylactic prescribing in particular that elucidate duration, and indications (16, 45, 55, 56). If mentioned, they are developed based on little evidence and have little association with definite practice and outcome. UTI is highly focused, but stewardship cannot be attained by only focusing on AP related to UTI only because RTI and skin infections are equally important infections contributing in the development of AMR in NH.
Likewise, NH residents are older people with long-term physical and cognitive impairments, chronic illness, multiple morbidities, and often exposed to indwelling devices and invasive procedures (5). These multiple and complicated problems could be the reasons providers baffle decision making and identify prophylactic prescribing as a natural option or to be on the safe side. Antimicrobials use directly linked to AMR, and studies have shown that antimicrobial stewardship can reduce antimicrobial prescribing and resistance (33, 57). Therefore, developing further understanding of AP should be an essential agenda for effective antimicrobial stewardship in NH. The scope of AP use includes identifying the cause and appropriateness of prophylaxis and their amendment in the NH guidelines to improve prescribing and subsequently reduce the AMR.



Antimicrobial prophylaxis is a critical prescribing issue in NHs. More than two-thirds of the total prophylaxis are urinary tract-related, one-fourth respiratory tract, and one in ten skin-related problems. In the current literature, factors of UTI prophylaxis are unexplored except recurrent UTI. Similarly, there is a lack of disaggregated data on AP precisely by respiratory and skin problems for NHs. Guidelines are not clear about when and under which condition to prescribe or not to prescribe for common infections in NHs, specifically AP. Likewise, evidence supporting how appropriate AP practices in NHs is lacking, which necessitates future exploration of this area for effective antimicrobial stewardship implementation. In the absence of evidence of infection prevention and gravity limitation of prevalent infections, it is necessary to limit the prophylactic prescribing in NHs. Further studies are needed to clarify their efficacy and indication for appropriate antimicrobial stewardship in NHs.


Conflict of Interest: Author declare no conflict of interest.
Funding: None.



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52. Vega RA, Conde JG, Díaz M. Prevalence of tuberculin reactivity and prevalence of risk factors for the development of active tuberculosis in a nursing home in Puerto Rico. P R Health Sci J. 1996.
53. Fu CJ, Mantell E, Stone PW, Agarwal M. Characteristics of nursing homes with comprehensive antibiotic stewardship programs: Results of a national survey. Am J Infect Control. 2020;48(1):13-18. doi:10.1016/j.ajic.2019.07.015
54. CDC. The core elements of antibiotic stewardship for nursing homes. Center for Disease prevention and Control (CDC). https://www.cdc.gov/longtermcare/prevention/antibiotic-stewardship.html. Published 2020.
55. Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019;200(7):E45-E67. doi:10.1164/rccm.201908-1581st
56. Sloane PD, Tandan M, Zimmerman S. Preventive antibiotic use in nursing homes: A not uncommon reason for antibiotic overprescribing. Journal of the American Medical Directors Association. 2020 Sep 1;21(9):1181-5.
57. Sloane PD, Zimmerman S, Ward K, et al. A 2-Year Pragmatic Trial of Antibiotic Stewardship in 27 Community Nursing Homes. J Am Geriatr Soc. 2020. doi:10.1111/jgs.16059




M.M.T.J. Broekman1, J. de Vos2, L. de Vijlder1, M. Brundel1


1. Elderly care physician, Beweging 3.0, Amersfoort, The Netherlands; 2. Department of primary and community care, Radboud University Medical Center, Nijmegen, The Netherlands. Corresponding author: Mark M.T.J. Broekman, Elderly care physician, Beweging 3.0, Beweging 3.0, Postbus 1599, 3800 BN Amersfoort, The Netherlands. E-mail: broekmanmark@gmail.com, ORCID: 0000-0001-5523-2771

Jour Nursing Home Res 2021;7:62-64
Published online September 23, 2021, http://dx.doi.org/10.14283/jnhrs.2021.10



Purpose: In very frail nursing home residents transport to the hospital for diagnostics in case of a suspected hip fracture might be considered too burdensome or not desirable. We aimed to elucidate the prognosis and disease course for this group. Methods: We performed a retrospective cohort study between 2017 and 2020 in a nursing home in the Netherlands. All patients with a suspected hip fracture were eligible. The main exclusion criteria was transport to the hospital for diagnostics. Our primary outcome is survival after one month. Results: 23 patients fulfilled the inclusion criteria. Median age was 84 years. Almost all patients had severe dementia. After one month 20 patients (87%) had died. Median survival was 5 days (interquartile range 3-8). Conclusion: In the most frail nursing home residents with a suspected hip fracture the prognosis is very poor with a median survival of only 5 days.

Key words: Non-operative, conservative, hip fracture, long term care facility, nursing home, frailty, elderly.



For residents of long term care facilities mortality rates after a hip fracture with surgical treatment vary between 20-55% after 6 months (1, 2). The high mortality rate follows from significant physical and cognitive comorbidity leading to an increased risk of complications after surgery (3, 4). Moreover, there is a significant decline in mobility and quality of life after a hip fracture (5).
Surgery is considered the treatment of choice. It is associated with a better prognosis and pain relief (6, 7). However, because of the poor prognosis and high complication rate of surgery, a conservative treatment is increasingly considered in frail patients with extensive comorbidity, including dementia (8). Historically, conservative treatment of a hip fracture included traction therapy, however nowadays it merely comprises the administration of sufficient painkillers and early mobilization when feasible. A large study showed a mortality of 53,8 % after six months in nursing home residents with advanced dementia and a radiological conformed hip fracture treated conservatively (9).
In daily practice, there is a significant group of very frail nursing home residents for whom even transport to the hospital for diagnostics is considered too burdensome. This group is not included in previous studies exploring mortality with conservative treatment. It would be of great value to gain more insight in their prognosis. Though not radiological confirmed, we aimed to elucidate the disease course of nursing home residents with a clinical suspicion of a hip fracture with a conservative treatment.




We performed a single center retrospective cohort study in the long term care facility Beweging 3.0 in the region of Amersfoort, the Netherlands.

Patient identification

All patients with a clinical suspicion of a hip fracture as diagnosed by the treating physician for whom a conservative treatment was initiated were eligible. Patients were identified by screening the daily reports. Daily reports were screened from end 2017 till March 2020 (because from March 2020 the covid pandemic might have influenced the decision to admit a patient to the hospital.) A clinical suspected hip fracture is typically characterized by severe pain or swelling in the groin, the leg is held in external rotation and the leg appears shortened. Exclusion criteria were transport to the hospital for diagnostics with or without subsequent surgery, transfer to another care organization after the suspected hip fracture, and a fast functional recovery, which makes a fracture unlikely.

Data collection and statistics

One author (JV) extracted patient and clinical characteristics from the medical charts. In case of doubt findings were discussed with MB. Variables identified included age, sex, comorbidity, type of dementia. Data about mobility before as well as the best achieved mobility after the suspected hip fracture were retrieved. Drugs administered in the period after the suspected hip fracture (pain medication and sedative drugs) were verified, even as day of death. Our primary outcome is mortality within one month. Secondary outcomes are median time to death, death within two weeks, three months and six months. Descriptive analyses were performed. A survival curve was plotted to illustrate disease course. Statistical analyses were performed with SPSS version (SPSS Inc.,Chicago, IL, USA). The study was approved by the Medical Ethics Review Committee of VU University Medical Center (Registration number 2020.448).



Patient characteristics

Twenty-three patients were identified with a clinical suspicion of a hip fracture treated conservatively without diagnostics in the hospital. Table 1 shows the patient characteristics. The majority of patients (three out of four) was female. All patients lived in psychogeriatric homes, because of advanced dementia (22/23) or Korsakov (1/23). One patient was recently diagnosed with metastatic lung cancer.

Table 1
Characteristics of patients with a clinical suspected hip fracture treated conservatively

Mobility and clinical symptoms of the hip fracture

Three patients used no walking aid, while 19/23 used a walking aid before the incident. From 21 of 23 information about typical symptoms could be retrieved. Two out of three patients had all three typical symptoms of a hip fracture (pain, external rotation, decreased length), while one out of ten had 2 out of 3 symptoms and one out of five had one typical symptom. Most patients (19/23) became fully bedridden after the hip fracture. All patients received opioids and 14/23 received sedative drugs, during the disease course. Nine patients received a urinary catheter.


One-month mortality rate was 87% . Figure 1 shows the survival curve. Median survival after the suspected hip fracture was 5 days [IQR 3-8]. Mortality after two weeks and three months was 19/23 and 22/23, respectively. In patients who became bedridden (n=19) mortality was 100% after 10 days. More typical symptoms of a hip fracture was related to a worse prognosis.

Figure 1
Survival in days after the suspected hip fracture



We showed a very poor prognosis for the most frail nursing home residents with a suspected hip fracture for whom even transport to the hospital for diagnostics is considered not desirable or too burdensome. With a median survival of 5 days and a mortality rate of 87% after one month the prognosis of this group is very poor, especially in those patients who become bedridden with a 100% mortality after 10 days.
Our findings are in contrast with recent literature evaluating the prognosis of the conservative treatment of a hip fracture.(2, 6). In a comparable patient population, patients with advan ed dementia living in a nursing home, Berry et al. showed a mortality rate of 30% after one month after a hip fracture with a conservative treatment.(9) Other studies showed an one-month mortality between 25% and 64% (10, 11). In contrast to our study, all patients were sent to the hospital for diagnostics in these studies. Therefore, an explanation for the large difference is that patients in our study were more frail, either because of more advanced dementia or more severe comorbidity, compared to those patients who are considered fit enough for transport to the hospital. Another reason might be that in those studies a conservative treatment in the hospital was preferably initiated when there was an anatomically favorable fracture, which positively influences the prognosis. This is supported by the fact that all patients who became bedridden, suggesting an evident displaced fracture, deceased within 10 days. Interestingly, a recent study, evaluating the effect of a comprehensive geriatric assessment on the number of patients being treated conservatively, also showed a median survival of five days in case a conservative treatment was preferred (12). An explanation for the very poor prognosis might be that food and fluid administration is suppressed due to a combination of an already very poor functional status in combination with the administration of opioids or sedative drugs, resulting in a rapid deterioration.
Our study is unique, because we only included patients who have not been admitted in the hospital for diagnostics or surgery. Currently, there is no literature evaluating the prognosis of this group. Some limitations are inherent to our study design. No definite diagnoses can be provided and small fractures with a better prognosis might have been missed. Approximately, 15% of hip fractures are undisplaced, which fades typical symptoms (13). As nondisplaced fractures might have been missed, our population especially consisted of patients with a displaced hip fracture with a worse prognosis. In conclusion, in nursing home residents with a suspected hip fracture who are considered as very frail the prognosis is very poor, especially when patients become bedridden.


Acknowledgements: None

Funding: No funds, grants, or other support was received

Conflicts of interest: The authors have no relevant financial or non-financial interests to disclose.

Ethical standards: ??????.



1. van de Ree CL, Gosens T, van der Veen AH, Oosterbos CJ, Heymans MW, de Jongh MA. Development and validation of the Brabant Hip Fracture Score for 30-day and 1-year mortality. Hip Int. 2020;30(3):354-62.
2. Loggers SAI, Van Lieshout EMM, Joosse P, Verhofstad MHJ, Willems HC. Prognosis of nonoperative treatment in elderly patients with a hip fracture: A systematic review and meta-analysis. Injury. 2020;51(11):2407-13.
3. Smith T, Pelpola K, Ball M, Ong A, Myint PK. Pre-operative indicators for mortality following hip fracture surgery: a systematic review and meta-analysis. Age Ageing. 2014;43(4):464-71.
4. Berry SD, Samelson EJ, Bordes M, Broe K, Kiel DP. Survival of aged nursing home residents with hip fracture. J Gerontol A Biol Sci Med Sci. 2009;64(7):771-7.
5. Hannan EL, Magaziner J, Wang JJ, Eastwood EA, Silberzweig SB, Gilbert M, et al. Mortality and locomotion 6 months after hospitalization for hip fracture: risk factors and risk-adjusted hospital outcomes. JAMA. 2001;285(21):2736-42.
6. van de Ree CLP, De Jongh MAC, Peeters CMM, de Munter L, Roukema JA, Gosens T. Hip Fractures in Elderly People: Surgery or No Surgery? A Systematic Review and Meta-Analysis. Geriatr Orthop Surg Rehabil. 2017;8(3):173-80.
7. Neuman MD, Silber JH, Magaziner JS, Passarella MA, Mehta S, Werner RM. Survival and functional outcomes after hip fracture among nursing home residents. JAMA Intern Med. 2014;174(8):1273-80.
8. Meijer-Schafrat EC, Janssens JF, van Delden JJ, Achterberg WP. [Hip fracture in patients with dementia: surgery is not always the best alternative]. Ned Tijdschr Geneeskd. 2012;156(45):A5237.
9. Berry SD, Rothbaum RR, Kiel DP, Lee Y, Mitchell SL. Association of Clinical Outcomes With Surgical Repair of Hip Fracture vs Nonsurgical Management in Nursing Home Residents With Advanced Dementia. JAMA Intern Med. 2018;178(6):774-80.
10. Frenkel Rutenberg T, Assaly A, Vitenberg M, Shemesh S, Burg A, Haviv B, et al. Outcome of non-surgical treatment of proximal femur fractures in the fragile elderly population. Injury. 2019;50(7):1347-52.
11. Chlebeck JD, Birch CE, Blankstein M, Kristiansen T, Bartlett CS, Schottel PC. Nonoperative Geriatric Hip Fracture Treatment Is Associated With Increased Mortality: A Matched Cohort Study. J Orthop Trauma. 2019;33(7):346-50.
12. van der Zwaard BC, Stein CE, Bootsma JEM, van Geffen H, Douw CM, Keijsers C. Fewer patients undergo surgery when adding a comprehensive geriatric assessment in older patients with a hip fracture. Arch Orthop Trauma Surg. 2020;140(4):487-92.
13. Parker M, Johansen A. Hip fracture. BMJ. 2006;333(7557):27-30.



P. Nambisan1, M. Abahussain1,6, E.H. Duthie2, C. Galambos3, B. Zhang4, E. Bukowy5


1. Department of Health Informatics & Administration, College of Health Sciences, University of Wisconsin – Milwaukee, Milwaukee, USA; 2. Medical College of Wisconsin Division of Geriatric and Palliative Medicine, Milwaukee, USA; 3. Helen Bader School of Social Welfare, University of Wisconsin Milwaukee, Medical College of Wisconsin, Milwaukee, Wisconsin, USA; 4. Educational Measurement, Department of Educational Psychology, University of Wisconsin-Milwaukee, Milwaukee, Wisconsin, USA; 5. Division of Geriatric and Palliative Medicine, MCW & Froedtert Hospital, Medical Director for the Lutheran Home and Clement Manor Nursing Home, Milwaukee, Wisconsin, USA; 6. Department of Ambulance Services, Prince Sultan Bin Abdulaziz College for Emergency Medical Services, King Saud University, Riyadh, Saudi Arabia. Corresponding author: Priya Nambisan, Department of Health Informatics & Administration, College of Health Sciences, University of Wisconsin – Milwaukee, Northwest Quadrant Building B, Rm #6410, 2025 East Newport Avenue, Milwaukee, WI 53201-0413, Phone: (414) 251-0421, Office Ph: (414) 251-5217; Email: nambisap@uwm.edu

Jour Nursing Home Res 2021;7:55-61
Published online September 17, 2021, http://dx.doi.org/10.14283/jnhrs.2021.9



Background: The COVID-19 pandemic disproportionately affected the older adult population, especially those in nursing homes (NHs). However, there is also evidence that some NHs fared better than others. Objectives: This study examines a set of nursing home related factors to understand whether these factors are associated with the number of COVID-19 cases. Design: We combined three datasets from the Centers for Medicare & Medicaid Services (CMS) – the Star Rating Dataset, the Provider Information Dataset, and the COVID-19 Nursing Home Dataset. Setting and Participants: 4390 NHs that responded to the CMS survey. Methods: Data used is from the period of Jan 1–Dec 27, 2020 for all 12 Midwestern states. The measures used were self-reported information on ratings, staff shortages, PPE shortage, number of beds, Registered Nurse (RN), Licensed Practical Nurses (LPN), Certified Nursing Assistants (CNA) hours per resident, star rating and ownership. Results: Of the 4390 NHs in 12 Midwestern states, high performing NHs were less likely to have more than 30 COVID-19 cases versus low-performing facilities for two of the CMS domains (health inspections, 520 NHs [27.6%] vs 1363 NHs [72.4%]; and staffing 773 NHs [41.1%] vs 1110 NHs [58.9%]). There was also a statistically significant association COVID-19 cases and star rating, NH ownership, NH size, RN, LPN, and CNA staffing in NHs (all p ≤ 0.01). NH ownership status persisted as a predictor of COVID 19 cases when controlled for NH size. Conclusions: Our study highlights two interesting findings. A) a statistically significant association between NH ownership structure and COVID-19 cases among residents – for-profit NHs had higher number of COVID-19 cases B) a statistically significant negative association between RN and CNA staffing and COVID-19 cases (i.e., more staffing hours of RNs and CNA correlated with a smaller number of COVID-19 cases) and a statistically significant positive association between LPN staffing and COVID-19 cases. We discuss ensuing policy implications for NHs.

Key words: COVID-19, Nursing homes, staffing hours, for-profit nursing homes.



The COVID-19 pandemic disproportionally affected the older adult population, especially those in nursing homes (NHs). According to a recent AARP report, an estimated 174,000 residents and staff of nursing homes and other long-term care facilities across the country died due to COVID-19 (1). Further complicating the situation, there are reports of under-reporting of nursing home deaths due to COVID-19 from many states (2). While many NHs were reporting COVID-19 cases to state and local public health departments, it was not until April 2020 that they started reporting to the CDC in a standardized format, which may have led to under or inaccurate reporting (3).
To understand how older adults can be protected in nursing homes, it is important to consider the characteristics that make some nursing homes more susceptible to the spread of COVID-19. In many ways, the COVID-19 pandemic has exposed the existing weaknesses of the nursing home system which provides care to some of the frailest and most vulnerable individuals in our society. Some researchers have called this pandemic a ‘case study of infection control’ (4) and studies delving into the factors that contributed to devastating outbreaks can provide critical insights into how this can be prevented in the future.
Nursing homes are prone to infectious outbreaks (e.g., seasonal influenza, norovirus) and there are several factors that make nursing homes highly vulnerable. These factors could range from high number of residents causing crowding, shared bathroom facilities, gathering/common areas to staffing shortages, frequent staff turnover, high resident-to-staff ratios, shortage of PPE, inadequate quality control and poor management (4, 5). In addition, NH residents are typically older adults with multiple chronic conditions such as diabetes, heart disease, pulmonary disease and other functional and cognitive disabilities including frailty (6, 7). Individuals with underlying chronic conditions were particularly vulnerable to contracting COVID-19 (8). Additionally, staff and caregivers in NHs are underpaid, do not get sick leave and move from resident to resident without adequate sanitation control or PPE (4, 9). Given that staff turnover rates are very high in nursing homes, training and maintaining sanitary protocols can also be challenging in this environment (4).
Using datasets available from CMS, which consists of self-reported data from NHs around the country on various factors, many studies (10–14) have reported findings on the factors associated with nursing homes and COVID-19 cases for various time periods in 2020. There have also been several single-state studies e.g. California (15), Connecticut (16) and West Virginia (17), that considered various factors such as star ratings, staffing, CMS quality indicators and PPE shortage. While data from CMS have been analyzed for NHs in Northeastern states (18) and for 30 States (11, 12), no studies have yet focused on NHs in the Midwestern states. Analyzing data from different regions is important as climate, COVID-19 prevalence, COVID-19 related policies and attitude of the population vary from region to region. Further, most existing studies have considered only a narrow time frame (few months in 2020), which may miss valuable information on recurrent NH outbreaks.
This study examines a number of factors such as nursing home ratings, quality of care, staff shortage, PPE shortage, and NH ownership structure (for-profit vs non-profit vs government) to understand whether these factors are associated with COVID-19 cases in NHs in Midwestern states for the entire year of 2020 (Jan 1 2020 – Dec 27 2020). More specifically, the research question that guided this study is: What are the factors that shape the incidence of COVID-19 cases in NHs in Midwestern states?



Three datasets were combined from the Centers for Medicare & Medicaid Services (CMS): 1. Star rating; 2. Provider information and 3. COVID-19 nursing home reported cases. The period examined is from Jan 1 – Dec 27, 2020, for the 12 Midwestern states in the population set (Illinois, Indiana, Iowa, Kansas, Michigan, Missouri, Minnesota, Nebraska, North Dakota, Ohio, South Dakota, and Wisconsin). This time period includes one year of data for the analysis, providing a more longitudinal picture of what occurred in nursing homes during the COVID-19 pandemic. Our sample size consisted of 4390 free-standing NHs, after removing cases with missing values.
We combined COVID-19 NH cases data with CMS and provider information. The provider information includes star ratings in three domains (health inspection rating, quality measure rating, staffing rating) and the star ratings range from one(low) to five (high). The health inspection domains are based on the three most recent standard surveys for each nursing home that result from any complaint investigation during the recent three years. The quality measure rating is based on indicators to describe the quality of care given in each nursing home. These measures address a wide range of functioning and health status in multiple care areas. The staffing domain is based on self-reported data from the nursing homes on the number of hours worked by their nursing staff, including Registered Nurse (RN) + Licensed Practical Nurse (LPN) + Certified Nursing Assistants (CNA) hours and the number of residents in the facility.
Drawing on a recent study, we grouped nursing homes into three categories (19) based on the number of COVID-19 cases: those with (a) 10 cases or fewer, (b) 11 to 30 cases, and (c) more than 30 cases. Other measures used were self-reported information on ratings, overall star rating (1 to 5-star facilities), staff shortages, PPE shortage, number of beds, occupancy rate, and ownership status (profit, non-profit, government), and nursing staffing level hours per resident per day (RN, LPN, CNA). Ordinal logistic regression was used to examine the association between nursing home characteristics and incidence of COVID-19 cases.
Descriptive analyses in Table 1 show COVID-19 cases, Midwestern states, and NH characteristics. Three separate ordinal logistic regressions were conducted to examine the three domains associated with COVID-19 cases and assess the odds of high-performing facilities (4- or 5-star facilities) having more than 30 cases vs 11 to 30 cases vs 10 or fewer cases relative to low-performing facilities (1- to 3-star facilities). These factors were compared with reported resident COVID-19 cases and the statistical significance was tested between NHs having more than 30 cases vs 11 to 30 cases vs. 10 or fewer cases of COVID-19. Statistical measures used were ANOVA for nominal variables, Spearman r for ordinal variables, and Pearson correlation tests for continuous variables.
Further analysis to understand the impact and effect of NH ownership structure on COVID-19 cases was done using the ANCOVA analysis to control for NH size.
All statistical analyses were performed by SPSS V. 27, and two-sided p values were considered significant at p<0.01.



Of the 4390 NHs in 12 Midwestern states, when we compared the low-performing facilities and high performing NHs, the high performers were less likely to have more than 30 COVID-19 cases for two of the CMS performance domains (health inspections, 520 [27.6%] high performers vs 1363 [72.4%] low performers; and staffing 773 (41.1%) vs 1110 (58.9%) (see Tables 1 & 2). Table 1 shows the number of nursing homes in each Midwestern state for each CMS domain, classified into high-performing and low-performing.

Table 1
Characteristics of High-Performing vs Low-Performing Nursing Homes Across 3 CMS Performance Domains in the Order of Number of Nursing Homes in Each State

Table 2
Association Between Nursing Home Ratings of Health Inspections, Quality Measures, and Nurse Staffing Domains with COVID-19 Cases


Table 3 provides the distribution of NH COVID-19 cases in each of the Midwestern States, with Ohio having the biggest share of NH COVID -19 cases and South Dakota having the lowest.
Illinois by far and away had the most large sized NHs. Ohio had the most NHs overall and was the state with the most medium sized facilities. Interestingly, as a percent of total beds, Missouri had the highest percent of middle sized NHs.

Table 3
State wide Distribution of Nursing Homes with COVID-19 Cases in Descending Order Based on the “All COVID-19 NH Cases”

* n = 4334; Data not available for 56 NH


NHs with high ratings on health inspection and nurse staffing were less likely to have more than 30 COVID-19 cases vs facilities with 11 to 30 and vs facilities with 10 or fewer cases than were low-performing NHs (OR, 0.68; 95% CI(.567-.823; P = <.01), (OR, 0.48; 95% CI(.418-.557; P = <.01). There was no significant association between high- vs low-performing NHs in the quality measures domains with COVID-19 cases.
While PPE shortages was a major concern in the early part of 2020, this study did not find any statistically significant impact of PPE on the incidence of COVID-19 cases (Table 4). There was no statistically significant association between self-reported staff shortages and COVID-19 cases.

Table 4
Nursing Home Characteristics, Covid-19 Factors, and Star rating

** p<0.01, * p<0.05, ***p<.001; *. Correlation is significant at the 0.05 level (2-tailed); **. Correlation is significant at the 0.01 level (2-tailed); CV-Corona Virus; P values measures whether nursing homes of residents with COVID-19 cases using ANOVA for nominal variables, spearman r for ordinal variables, and Pearson correlation tests for continues variables; Ownership P value = ANOVA; Overall star rating P value = spearman r


Ownership of NHs (for-profit vs. not-for-profit vs. government) also showed a statistically significant (p<.001) association with incidence of COVID-19 cases (See Table 4). The data shows that for-profit NHs had more COVID-19 cases than not-for-profit and government owned. In this dataset, 60.4% were for-profit, 7.8% were government owned and 31.8% were not-for-profit nursing homes. In the category of NHs with less than 10 cases 53.2% were for-profit, 9.7% were government and 37.1% were not-for- profit. Whereas in NHs with over 30 cases of COVID-19, 67.9% were for-profit, 6.6% were government owned and 25.4% were not-for-profit. This could be because there are more for-profit nursing homes than government owned and non-profit.
To further understand the ownership effect, an ANCOVA analysis was performed to control for NH size measured by number of beds. The results of ANCOVA (see Table 5) clearly show a statistically significant (F=20.1** p<0.01) association between ownership and COVID-19 cases after controlling for number of beds. We did a post hoc analysis (Bonferroni comparison) for NH ownership and found that there is statistically significant difference between for-profit vs government (mean difference 6.82** p< 0.01) and statistically significant difference between for-profit and non-profit (mean difference 3.77** p< 0.01) and there was no significant difference between not-for-profit and government ownership (mean difference -3.05 p=.09). This additional analysis indicates that for-profit NHs were significantly different from both government-owned and non-profit NHs, when it came to the number of COVID-19 cases.
COVID-19 cases also increased with the number of beds in the nursing homes. NHs with over 30 COVID-19 cases had an average of 114.8 beds, whereas NHs with less than 10 COVID-19 cases had only 70.9 beds on average. This association is statistically significant (p<.01) (See Table 4). However, there was a statistically significant but small negative correlation between occupancy rate and COVID-19 cases, NHs with less than 10 COVID-19 cases had slightly higher occupancy than NHs with over 30 cases of COVID-19. The average occupancy rate was 65.8% and there was not much variance in this when compared based on COVID-19 cases. There was also a low negative correlation between number of beds and occupancy rate r=-0.155 p<0.01(data not shown).
There was also a statistically significant (p<.01) association between star ratings of NHs and the incidence of COVID-19 cases (Table 4). The data shows there were fewer nursing homes with 5-star rating in the over 30 COVID-19 cases. Of the NHs that had 1-star rating 57.6% had more than 30 COVID-19 cases, whereas only 29.5% of NHs that had 5-star rating had more than 30 COVID-19 cases. Similarly, only 19.4% NHs with 1-star rating had less than 10 cases of COVID-19 while 39.1% of NHs with 5-star rating had less than 10 cases of COVID-19.
While there was no significant association between self-reported staff shortages and COVID-19 cases, staff hours per resident of RN and CNA, had a statistically significant (p<.001) negative association. i.e., the more RN and CNA hours per resident, the lower the number of COVID-19 cases. In NHs with less than 10 COVID-19 cases, the staffing hours per resident was on average .96 RN hours and 1.69 CNA hours where it was only .61 RN hours and 1.46 CNA hours in NHs with more than 30 COVID-19 cases (see Table 4). However, in the case of LPN hours, there was positive association with COVID-19 cases, i.e., as the number of LPN hours increased, so did the incidence of COVID-19 cases. In NHs that had less than 10 COVID-19 cases, LPN hours per resident was on average .72 hours, but in NHs that had more than 30 cases, there were .77 LPN hours on average. The difference is small, but it was statistically significant with p<.001. On further analysis, we also found that while there is a positive correlation for RN and CNA hours with star rating (RN .432** & CNA .307** p<.01), there was a statistically significant negative correlation between LPN hours and star rating (LPN -.073** p<.01). In addition, RN and CNA hours were negatively correlated with number of beds (RN -206**, CNA -.118**, p<.01), LPN hours were positively correlated with number of beds (LPN .116**, p<.01).

Table 5
Association between Ownership and COVID-19 cases after controlling for number of beds

**p < 0.01



The distribution of NH COVID-19 cases among the Midwestern states seems to be highly correlated with size and population density of these states. However, Illinois was leading in the number of COVID-19 cases until October 2020 (21). The metropolitan city of Chicago (in Illinois) with high population density could have been the reason for Illinois to be leading in COVID-19 cases until Oct 2020. Chicago and Illinois were also one of the first cities and states to experience more COVID-19 cases early on in the pandemic (22). When data from Nov and Dec 2020 were included in the analysis, Ohio led in number of cases. In all Midwestern states, COVID-19 cases doubled when the Nov and Dec 2020 data were added to the data from Jan-Oct 2020 (21).
From National Organization of State Offices of Rural Health (NOSORH) data, Ohio is the only Midwestern state with no frontier population, while S. Dakota and N. Dakota had more than 30% frontier population (23). Frontier areas have very low population density. State-by-state differences in NH COVID-19 rates could also be due to differences in state-level policies on social distancing, mask wearing, level of community spread, and variation in testing and reporting. Variations in reporting format, case definitions and update frequency were also indicated as barrier in another study (11).
The number of beds was positively associated with higher COVID-19 cases, consistent with prior studies (in other States) (11, 13, 18). There have been some studies that have found that smaller NHs, especially greenhouse NHs fared better in the COVID-19 pandemic (13). The stated reasons were that smaller NHs’ residents have better psychosocial well-being, such NHs are usually not-for-profit, and that the resident case mix usually have less minority population (that are often at higher mortality risk) (13). It could also be that larger nursing homes have higher number of staff; spread of COVID-19 through staff is another aspect that some studies have indicated (24), where surges where highly correlated with increase in staff and resident cases. Staff testing was also not fully implemented in around 12% of facilities according to another study (25). This finding is consistent with other studies that indicate smaller sized nursing homes are associated with better quality care (5, 26). Since, COVID-19 is highly contagious in crowded areas, the analysis checked for associations with overcrowding i.e. occupancy in these NHs. However, our findings show that NH COVID-19 cases are negatively correlated with occupancy rate. One possible explanation for this negative relationship is larger NHs tend to have lower occupancy rates.
This study also found a correlation between NH ownership status and COVID-19 cases. From our analysis, for-profit NHs were more likely to have higher rates of COVID-19 cases. Other studies have reported similar findings (14, 18) and a news report (27) also noted that for-profit nursing homes are not faring well in controlling COVID-19. While other studies report a correlation between NH ownership and COVID-19, our analysis included multiple tests to confirm the statistically significant relationship between ownership and COVID-19. Potential explanations for this finding include the tendency for there to be more beds in for-profit facilities, the facilities being larger in general and also usually located in urban areas that has larger proportion of minority population (28). Our study further indicated that for-profit NHs had more cases even after controlling for NH size. In this study, there was a negative correlation between for-profit ownership and 5-star rating and with RN and CNA staffing hours. Poor star rating is associated with lower RN staffing hours and high staff turnover rates (29). Also, for-profit status is associated with higher LPN staffing hours, which could indicate that for-profits are utilizing LPNs (to reduce costs), instead of RNs.
A limitation of the current study is that other factors such as health and functional status of the resident at admission, rate of resident admissions from the community or from the hospital and the population density of the city or town in which the NH is located, could also affect the COVID-19 cases in NHs. However, these factors could not be part of the analysis as CMS database does not have these measures.
Across the 12 Midwestern states, high-performing NHs, especially in terms of health inspection ratings and nurse staffing, had fewer COVID-19 cases than low-performing NHs. This is consistent with prior studies that have focused on other states (19). These findings do indicate that such performance measures are important and they do indicate poor staffing and poor health standards needs to be addressed (10). Poor health standards and nurse staffing shortages can make an NH more vulnerable to future pandemics.
Our study findings also reveal another nursing staff -related insight; specifically, higher RN and CNA hours correlated with lower COVID-19 cases, whereas LPN staff hours lead to higher COVID-19 cases. These findings are consistent with other nursing home studies that link quality care with higher and more qualified staffing (30). However, more research is needed that examines whether it is the reduction of RNs or something specific to LPN training that impacted the COVID-19 cases. We also found from further analysis that LPN hours were negatively correlated with star ratings, indicating a link to quality care. LPN hours was also positively correlated with number of beds, indicating that larger NHs tend to hire more LPNs and from this study and others, we know that the size of the NH is positively associated with higher COVID-19 cases.


Conclusion and Implications

While vaccination campaigns are well underway and will limit the spread of COVID-19, nursing homes are still vulnerable to mutations of the virus and other endemics. The frailty, age and multiple chronic conditions of this population make them especially vulnerable and the safety of older adults in NHs should remain top priority. This study of NHs in Midwestern states indicate that the NH factors that are most associated with a higher prevalence of COVID-19 cases are size of the nursing home/number of beds, for-profit ownership, star ratings, and RN and CNA hours per resident per day. We depart from prior studies on this topic by examining self-reported NH data for the entire year of 2020 (Jan 1 2020 – Dec 27 2020) and by specifically focusing on all the Midwestern states. Our analysis findings imply the potential to use a minimal set of indicators to predict the future incidence of COVID-19 pandemic (and other endemics) among NH residents and inform on appropriate policy considerations to reduce NH vulnerabilities in this context. Future studies could consider state-wide policies to limit community spread and impact on COVID-19 cases in NHs. In addition, studies could also evaluate the impact of the adoption of COVID-19 related policies within NHs such as visitation and staff testing on the incidence of COVID-19 cases and evaluate the impact of providing more resources in terms of qualified staffing and care practices that promote strong infection control on the spread of diseases such as COVID-19. Future studies could consider integrating external data, such as government policy changes, magnitude of the COVID-19 outbreak and attitudes of the population in that region towards the pandemic and the restrictions imposed, with the CMS data to understand how that impacted COVID-19 cases in NHs in that region.


Conflict of Interest: Priya Nambisan: No conflict of Interest to report. Mohammed Abahussain: No conflict of Interest to report. Colleen Galambos: No conflict of Interest to report. Bo Zhang: No conflict of Interest to report. Elizabeth Bukowy: No conflict of Interest to report; Edmund Duthie: . No conflict of Interest to report.

Funding sources: This research did not receive any funding from agencies in the public, commercial, or not-for-profit sectors. All authors meet criteria for authorship as stated in the Uniform Requirements for Manuscripts Submitted to Biomedical Journals. All authors contributed to the analysis of the data, interpretation of the results and writing of the paper.



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A.K. Gergen1, P. Hosokawa2, C. Irwin1, M.J. Cohen1, F.L. Wright1, C.G. Velopulos1, E.J. Kovacs1, R.C. McIntyre Jr1, J.-P. Idrovo1


1. University of Colorado School of Medicine, Department of Surgery, Division of GI, Trauma, and Endocrine Surgery, Aurora, USA; 2. Adult and Child Consortium for Health Outcomes Research (ACCORDS), Aurora, USA. Corresponding author: Anna K. Gergen, University of Colorado School of Medicine, Department of Surgery, Division of GI, Trauma, and Endocrine Surgery, 12631 E. 17th Avenue, MS C-302, Aurora, CO 80045, USA, Telephone: 206-384-7837, Fax: 303-724-2806, Email: anna.gergen@cuanschutz.edu

Jour Nursing Home Res 2021;7:47-54
Published online September 10, 2021, http://dx.doi.org/10.14283/jnhrs.2021.8



Objectives: Elderly patients requiring emergency general surgery (EGS) are at high risk for complications due to preexisting malnutrition. Thus, correcting nutritional deficits perioperatively is essential to improve outcomes. However, even in patients unable to tolerate enteral nutrition, initiation of parenteral nutrition (PN) is often delayed due to concerns of associated complications. In this study, we hypothesized that in elderly EGS patients with relative short-term contraindications to enteral nutrition, early administration of PN is as safe as delayed administration. Furthermore, early PN may improve outcomes by enhancing caloric intake and combatting malnutrition in the immediate perioperative period. Design and Setting: A single-institution, retrospective review was performed at a quaternary academic medical center. Participants: Participants consisted of 58 elderly patients >65 years of age admitted to the EGS service who required PN between July 2017 and July 2020. Measurements: Postoperative outcomes of patients started on PN on hospital day 0-3 (early initiation) were compared to patients started on PN on hospital day 4 or later (late initiation). Bivariate analysis was conducted using the Chi-square or Fisher’s exact test for categorical variables and the Wilcoxon-Mann-Whitney test and F-test for continuous variables. Results: Fifty-eight patients met inclusion criteria, with 27 (46.6%) patients receiving early PN and 31 (53.4%) receiving late PN. Both groups shared similar baseline characteristics, including degree of frailty, body mass index, and nutritional status at time of admission. Complications associated with PN administration were negligible, with no instances of central venous catheter insertion-related complications, catheter-associated bloodstream infection, or factors leading to early termination of PN therapy. A significantly higher proportion of patients in the early administration group met 60% of their caloric goal within 72 hours of admission (62.9% versus 19.5%, p=0.0007). Patients receiving late PN demonstrated a significantly higher rate of unplanned admission to the intensive care unit (38.7% versus 14.8%, p=0.04). Moreover, there was a 21.5% reduction in mortality among patients in the early initiation group compared to patients in the late initiation group (33.3% versus 54.8%, p=0.10). Conclusions: Early initiation of PN in hospitalized elderly EGS patients was not associated with increased adverse events compared to patients undergoing delayed PN administration. Furthermore, patients receiving early PN demonstrated a 2.6-fold decrease in the rate of unplanned admission to the intensive care unit and trended toward improved mortality. Based on these results, further prospective studies are warranted to further explore the safety and potential benefits of early PN administration in elderly surgical patients unable to receive enteral nutrition.

Key words: Elderly, geriatric, emergency general surgery, surgery, parenteral nutrition.


Following emergent surgery, adequate nutritional status is fundamental to a patient’s successful recovery. The added stress of the perioperative period and critical illness increase caloric demands and subsequent risks for malnutrition, immune system dysfunction, and poor healing (1). Moreover, due to the nature of their disease process, most patients requiring emergency general surgery (EGS) frequently present at admission with a recent history of inadequate food intake, thus increasing their risk of prolonged undernutrition and concomitant surgical complications.
Although enteral nutrition (EN) remains the preferred route of dietary support in hospitalized patients, EGS patients frequently exhibit relative contraindications or poor tolerance to EN in the perioperative period. In the postoperative adult patient unable to receive EN, current guidelines by the American Society of Parental and Enteral Nutrition (ASPEN) favor waiting 5-7 days prior to the initiation of parenteral nutrition (PN), and only if the duration of therapy is anticipated to exceed at least 7 days (2). Even in critically ill patients with contraindications to enteral feeding for the indeterminate future, administration of PN is commonly delayed due to historical concerns over accompanying complications, such as infections, metabolic derangements, and liver dysfunction (3). While an average, previously healthy adult may tolerate delayed nutritional supplementation, the elderly population represents a unique cohort at high risk for poor postoperative outcomes due to increased rates of preexisting malnutrition, decreased baseline functional status, and diminished ability to adapt to metabolic stress (4). Consequently, these patients may exhibit a more difficult recovery in the setting of inadequate nutritional intake.
Compared to younger age groups, elderly patients account for a disproportionate burden of admissions and health care spending, presenting with a greater number of comorbid conditions, more frequent hospitalizations, and longer durations of stay (5). Furthermore, with an increasingly aging population, the percentage of people 65 years and older is expected to nearly double worldwide over the next three decades, signifying an anticipated parallel increase in health care needs (6). The need for emergency surgery increases with age, with numerous EGS diagnoses occurring at a higher incidence among older age groups (7-9). Notably, nutritional derangements in elderly patients have been associated with a broad range of unfavorable outcomes, including longer hospital stay, pressure ulcers, higher infection rates, increased falls, and death (10-12). Furthermore, malnutrition is a well-established but often underreported risk factor for poor surgical outcomes, with surgical stress creating a catabolic state that further compounds protein and energy depletion (13). Studies indicate that nearly 50% of elderly hospitalized patients are undernourished or malnourished on admission, with current guidelines recommending initiation of PN as soon as possible in critically ill patients unable to receive EN who are at high nutrition risk or severely malnourished (14, 15). However, despite the wide availability of validated nutrition assessment tools, routine screening of hospitalized patients is broadly underutilized in clinical practice (16). In addition, energy goals are frequently not met among inpatients (16, 17). Therefore, given the high incidence of preoperative malnutrition in elderly adults in conjunction with the added physical stress of surgery, it is likely that patients at high nutritional risk with indications for early PN remain grossly underestimated. This ultimately leads to delays in nutrition delivery and the inability to achieve nutritional intake goals.
Current recommendations guiding the use of PN in hospitalized patients are based on studies that include a wide range of ages and may be less pertinent to high-risk age groups, such as geriatric patients. Furthermore, while modern therapeutic guidelines, advanced monitoring, and improvements in medications have significantly decreased the overall incidence of complications associated with PN use, hesitancy regarding its initiation continues to exist among inpatient providers (18-21). Based on these observations, we hypothesized that in elderly EGS patients with relative short-term contraindications to EN, early administration of PN is as safe as delayed administration. Moreover, early administration of PN may be beneficial in elderly surgical patients by enhancing caloric intake in the early perioperative period.


Patient population and outcomes

This study was submitted to the Colorado Multiple Institutional Review Board (COMIRB) who deemed it exempt. A single-institution, retrospective review of elderly adult patients admitted to the EGS service at a quaternary academic medical center between July 2017 and July 2020 was conducted. Patients >65 years of age who required initiation of PN during admission were included. Early initiation of PN was defined as within the first 0-3 days of admission, while late initiation of PN was defined as day 4 or later. Patient data, including demographics, medical comorbidities, Charlson Comorbidity Index, protein-calorie malnutrition present on admission, body mass index, admitting diagnosis, surgical interventions, hospital length of stay, PN-related complications, 30-day postoperative complications, and 90-day mortality, were collected from patient medical records. The Charlson Comorbidity Index predicts 10-year survival based on the presence of various predefined comorbidities (22). Each comorbidity category has an associated weight based on the severity of disease and adjusted risk of mortality, with the sum of all weights resulting in a single comorbidity score. The Charlson Comorbidity index was used as an objective measure to help risk stratify patients and compare severity of illness across groups. A diagnosis of protein-calorie malnutrition was established by the consulting dietitian based on criteria provided in Supplemental Material 1. All data were stored in a REDCap database.
The primary outcome of the study was adverse events associated with PN administration, including central venous catheter insertion-related complications (pneumothorax, hemothorax, arterial injury, or nerve injury), catheter-associated bloodstream infection, catheter-associated deep venous thrombosis, and early termination of PN therapy due to associated laboratory derangements or other related complication. Secondary outcomes included hospital length of stay, days of mechanical ventilation, infection (pulmonary, non-catheter-associated bloodstream, urinary tract, wound, or other), wound dehiscence, non-catheter-associated deep venous thrombosis, pulmonary embolism, renal failure requiring renal replacement therapy, unplanned intubation, unplanned admission to the intensive care unit (ICU), unplanned reoperation, readmission within 30 days of discharge, and 90-day mortality.

Frailty Index

Frailty is a multifactorial syndrome prevalent among elderly adults and associated with various poor health outcomes, including death (23). There are many definitions and methods for measuring frailty, including a clinical phenotypic framework or calculation of a Frailty Index (FI) (24, 25). The FI is based upon the accumulation of age-related conditions and calculated by dividing the number of deficits present by the number of total deficits considered in that particular scale. The optimal approach to characterizing frailty in the geriatric acute care surgery population has been inadequately studied. We pooled deficits from multiple studies to create a list of variables that were biologically sensible, related to the process of aging, impactful in the setting of acute illness or emergent surgical intervention, and relatively easy to glean from the medical record (26, 27). A FI was calculated for each patient using the variables provided in Table 1. Vitals and laboratory variables were documented based on the first available values within 48 hours of presentation to the hospital. Based on prior reports, patients with a FI >0.25 were considered to be frail, while patients with a score of <0.08 were deemed to be non-frail (26, 27).

Table 1
Clinical and laboratory data used to calculate a patient’s Frailty Index

Modified from Cheung A, Haas B, Ringer TJ, McFarlan A, Wong CL. Canadian Study of Health and Aging Clinical Frailty Scale: Does It Predict Adverse Outcomes among Geriatric Trauma Patients? J Am Coll Surg. 2017;225(5):658-65.e3

Statistical Analysis

Bivariate analysis was conducted using the Chi-square or Fisher’s exact test for categorical variables and the Wilcoxon-Mann-Whitney test and F-test for continuous variables. Composite morbidity was defined as the presence of one or more of the following: infection, wound dehiscence, renal failure requiring renal replacement therapy, unplanned intubation, and unplanned admission to the ICU. Multivariable logistic regression analysis was used to determine variables independently associated with 90-day mortality or composite morbidity, with candidate variables including early versus late initiation of PN, age, gender, FI, body mass index, Charlson Comorbidity Index, and the number of operations.
Descriptive statistics are presented as absolute numbers and percentages for categorical variables and median and interquartile range (IQR) for continuous variables. A two-sided p-value of <0.05 was considered statistically significant. All analyses were performed using Stata version 15.1 (StatCorp, College Station, TX) and SAS version 9.4 (SAS Institute Inc, Cary, NC).


Patient characteristics

A total of 58 elderly patients were admitted to the EGS service at a quaternary academic medical center and required PN initiation during the study period. Admitting diagnoses are summarized in Table 2. Intestinal obstruction (36.2%), perforated viscus (19.0%), and mesenteric ischemia (17.2%) were the three most common reasons for admission, accounting for over 70% of all diagnoses. During hospitalization, 27 (46.6%) patients received early PN, and 31 (53.4%) received late PN. Baseline characteristics of patients in the early versus late initiation groups are summarized in Table 3. Bivariate analysis revealed no significant differences between groups. The median age of the entire cohort was 71.7 years, with a relatively equal distribution of males (53.4%) and females (46.6%). The median Charlson Comorbidity Index of the entire cohort was 4, correlating to a 10-year survival of approximately 53%. Additionally, the median FI score was 0.27, suggesting a significant degree of frailty among all patients studied.

Table 2
Summary of admitting diagnoses

Values are presented as N (%)

Table 3
Baseline patient characteristics of elderly patients receiving early versus late parenteral nutrition

Values are presented as N (%) or median (IQR).


At the time of admission, a consulting dietitian screened patients for the presence of protein-calorie malnutrition. Screening was completed in 67.2% of the study cohort, with the remaining patients unable to be adequately assessed. Of those screened, 46.2% of patients met criteria for moderate or severe malnutrition. There were no significant differences in malnutrition rates (44.4% versus 47.6%, p=0.84) or median body mass index (27.9 kg/m2 versus 23.4 kg/m2, p=0.08) between early and late administration groups.
Most patients (91.4%) required 1 or more operations, while the remaining 8.6% of patients were admitted to the EGS service for observation and non-operative management. Of those undergoing surgery, 64.2% required a small and/or large bowel resection, and 41.5% were left with an open abdomen after the initial operation with return to the operating room at a later date for abdominal closure.

Outcomes following early versus late initiation of parenteral nutrition

The incidence of adverse events explicitly associated with PN administration was overall rare. There were no instances of central venous catheter insertion-related complications, including pneumothorax, hemothorax, arterial injury, or nerve injury, or catheter-associated bloodstream infections in either the early or late initiation groups. In addition, there were no cases requiring early termination of PN therapy for any reason. The rate of catheter-associated deep venous thrombosis was similar between early and late initiation groups (14.8% versus 9.7%, p=0.69). Notably, a significantly higher proportion of patients in the early administration group met 60% of their caloric goal within 72 hours of admission (62.9% versus 19.5%, p=0.0007).
Other postoperative complications, including infection (40.7% versus 48.4%, p=0.56), wound dehiscence (11.1% versus 12.9%, p=1.0), renal failure (11.1% versus 6.5%, p=0.66), unplanned intubation (18.5% versus 12.9%, p=0.72), unplanned reoperation (14.8% versus 16.1%, p=1.0), and 30-day readmission (3.7% versus 3.2%, p=1.0) were similar between early and late initiation groups (Table 4). Likewise, length of stay (18 days versus 19 days, p=0.28) and days of mechanical ventilation (1 day versus 1 day, p=0.62) did not significantly differ. The early initiation group demonstrated a significant decrease in critical care needs, with a 23.9% reduction in the rate of unplanned admission to the ICU (14.8% versus 38.7%, p=0.04). Moreover, there was a 21.5% reduction in mortality rate among patients in the early initiation group compared to patients in the late initiation group (33.3% versus 54.8%, p=0.10).

Table 4
Outcomes of patients receiving early versus late parenteral nutrition

Values are presented as N (%) or median (IQR).


In a multivariable logistic regression model, timing of initiation of PN was not a significant predictor of 90-day mortality (Table 5). Charlson Comorbidity Index and number of operations were the only factors independently predictive of mortality. Specifically, for each 1-point increase in Charlson Comorbidity Index, a patient’s chance of death doubled (OR 2.09, 95% CI 1.24-3.51, p=0.006). Likewise, for each additional operation endured, a patient’s chance of death increased 2.5 times (OR 2.56, 95% CI 1.28-5.15, p=0.001). A multivariable logistic model for overall morbidity, including aggregated events of any infection, wound dehiscence, renal failure, unplanned intubation, or unplanned admission to the ICU, revealed no significant predictors.

Table 5
Multivariable logistic regression model of variables independently associated with 90-day mortality

OR: odds ratio; CI: confidence interval.


EGS patients frequently demonstrate relative contraindications to EN in the perioperative period, and thus, administration of PN is often a consideration. However, controversy and variation in clinical practice persist regarding the optimal timing of initiation of PN in the postoperative patient. Elderly surgical patients represent a particularly vulnerable cohort of patients at increased risk for malnutrition and postoperative outcomes. PN is frequently delayed due to concerns regarding PN-associated complications. The goal of this study was to evaluate whether early administration of PN in hospitalized elderly EGS patients was associated with increased adverse events compared to patients receiving delayed PN. Our results indicate that early initiation of PN is as safe as delayed initiation in elderly surgical patients with short-term contraindications to enteral feeding. Furthermore, patients receiving early PN demonstrated a 2.6-fold decrease in the rate of unplanned admission to the ICU and trended toward improved mortality, indicating decreased critical care needs and potentially reduced severity of illness.

While the timing of initiation of PN in adult patients has been frequently debated in the literature, there is continued controversy over optimal administration practices and a lack of data specifically addressing PN use in the elderly. Consequently, this scarcity of evidence and assortment of opinions amongst practitioners has resulted in a wide variance in practice patterns and general discomfort surrounding PN administration and timing of initiation. Two randomized controlled trials, the EPaNIC trial and the Early PN Trial, evaluated the timing of PN administration in critically ill patients admitted to the ICU, with adults >18 years of age eligible for inclusion (28, 29). Neither study found a reduction in mortality or infection rates with early PN. In the EPaNIC trial, late initiation of PN was associated with several benefits, including shorter duration of mechanical ventilation, shorter duration of renal replacement therapy, shorter ICU stay, shorter hospital stay, and reduced health care costs (28). Importantly, this trial enrolled critically ill adults to begin PN regardless of the adequacy of enteral intake, with the dose of PN targeted to meet 100% of a patient’s caloric goal through combined PN and EN. In contrast, our study primarily focused on patients with contraindications or intolerance to EN, with only 3 of the 58 patients receiving EN simultaneously with PN. The Early PN Trial also focused on this subset of patients unlikely to receive any early EN. Both medical and surgical patients were included, with 65% of patients requiring surgery. Results demonstrated that early administration of PN was protective against both muscle wasting and fat loss, although this did not translate into improvements in physical function or mortality at 60 days (29).
EGS patients frequently present with complex intraabdominal processes that prevent the immediate use of the gastrointestinal tract. Therefore, PN is often the only option for many EGS patients presenting with intestinal obstruction, perforation, or other pathology that prohibits adequate oral or enteral intake (30). Historically, concerns regarding PN-associated complications were commonly cited reasons for delaying PN initiation or avoiding its use altogether. However, much of the data outlining these risks are derived from dated studies conducted in the 1980s to early 2000s (21). Studies performed within the most recent decade have failed to demonstrate the same rates of infection, potentially due to improved glycemic control as well as improved sterile technique and central line care (18, 20). Likewise, increasing access to inpatient nutrition consult services and better education amongst healthcare providers have assisted in proper management and avoidance of PN-related metabolic disturbances and nutritional derangements. Furthermore, some of the more feared risks, such as metabolic bone disease, liver failure, and central venous access complications, are more frequently associated with long-term, chronic use of PN and less likely to occur in inpatients requiring short-term therapy (31). In the present study, complications related to PN were negligible following a median duration of use of 10 days. Additionally, no patients in this cohort demonstrated metabolic or electrolyte derangements that necessitated premature cessation of PN therapy. Therefore, in the setting of short-term, in-hospital use, PN-associated complications may be less of a concern than initially suggested.
In addition to demonstrating a nominal rate of PN-related complications, this study also revealed a potential benefit of early PN use in this particular population. Morbidity and mortality outcomes for patients requiring emergent general surgery are an estimated 7-fold higher compared to elective surgery (32). These rates are further amplified in the elderly population, with mortality increasing every decade beyond age 50 years, reaching nearly 40-50% in patients 80 years and older (9). Our cohort demonstrated a similar trend, with an overall mortality rate of 45% for the entire group. Additionally, similar to our findings, a study by Joseph et al evaluating geriatric EGS patients demonstrated that, on average, nearly half of a patient’s hospital stay was spent in the ICU, indicating a high degree of acuity and critical care needs among this population (33). Importantly, our results revealed an impressive decrease in ICU admissions by 23.9% as well as a reduction in mortality by 21.5% in patients receiving early PN. A larger sample size will be necessary to assess whether this mortality difference is in fact significant. Additionally, patients in the early administration group were 3.2 times more likely to reach 60% of their target caloric goal within the first 72 hours of admission, indicating a positive trajectory to meeting their overall nutritional needs earlier in their hospital stay. In a study by Kim et al, critically ill surgical patients who approached their target calorie intake demonstrated significantly improved clinical outcomes (34). Harmandar et al confirmed similar results, with a lower mortality rate and improved nutritional status in those who achieved their target caloric goal compared to non-achievers (35). Therefore, given the potential for improved outcomes with earlier initiation of PN in this inherently high-risk operative group, future research in this area is a necessity.
There are several limitations to this study. First, the small case number and single-institution design limit the generalizability of our results. Additionally, the findings must be interpreted with caution due to the methodological limitations associated with the retrospective, observational design. While the cohorts were well matched, thus suggesting minimal selection bias, we recognize that it is impossible to eliminate residual confounding without prospective randomization. In regard to the use of the Frailty Index, while we based the development of this index on several validated studies in other ageing populations, there is little evidence evaluating the Frailty Index specifically in the EGS population. For the purposes of this study, the Frailty Index was intended to provide an objective measure of health and functional status among an elderly study cohort. Therefore, while we acknowledge the limitations of its use and need for further validation in the acute care setting, we utilized the index as one potential helpful method to globally compare and risk stratify patients across the two study groups. Additionally, it is important to note that despite an increased rate of ICU admissions among the late PN group, we observed no difference in specific postoperative outcomes, likely secondary to the small sample size, a wide assortment of complications necessitating ICU admission, or complications that were not captured by our defined outcome variables. Ultimately, a larger sample size is needed to distinguish differences in these individual outcomes. We also recognize that information regarding functional status post-hospitalization is an essential adjunct for assessing long-term morbidity. However, this was difficult to consistently ascertain from the medical chart and, therefore, was not included as an outcome variable. Although underpowered due to the small sample size, this initial study suggests that the timing of nutritional support in elderly surgical patients is an important area for future research and provides critical groundwork to inform and power future prospective analyses. Ultimately, large-scale, randomized studies are needed to validate the theoretical advantages of early PN in elderly surgical patients to expedite healing and potentially improve postoperative outcomes.
Elderly patients undergoing emergent general surgery are at high risk for malnourishment and functional decline, resulting in substantial morbidity and mortality rates (9, 32). Current guidelines fail to address PN use specifically in this high-risk age group, resulting in potentially avoidable delays in proper nutritional support in elderly surgical patients unable to receive EN. We have demonstrated that early initiation of PN in hospitalized elderly EGS patients is safe and not associated with increased adverse events compared to patients receiving delayed PN. Furthermore, our findings demonstrate a significant decrease in critical care utilization and a trend toward improved mortality among patients receiving early PN. Based on these findings, and with the lack of existing recommendations guiding the use of PN in this age group, larger prospective studies are warranted to further explore the safety and potential benefits of early PN administration in elderly surgical patients unable to receive EN.


Disclosures: None.

Sources of Funding: This research was supported by K08GM134185 (JPI) and R01AG018859 (EJK). The content in this report is the responsibility of the authors and does not represent the formal National Institutes of Health opinion.

Conflict of Interest: There are no conflicts of interest to report.

Ethical standards: All procedures performed involving human participants were in accordance with the ethical standards of the Colorado Multiple Institutional Review Board and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.





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B.M. Jesdale1, C.A. Bova2, A.K. Mbrah1, K.L. Lapane1


1. Division of Epidemiology, Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA; 2. Graduate School of Nursing, University of Massachusetts Medical School, Worcester, MA, USA. Corresponding author: Kate Lapane, PhD, University of Massachusetts Medical School, 55 Lake Avenue North, Worcester, MA 01605, USA, Telephone number: 508-856-8798, Fax: 508-856-8993, Email: Kate.lapane@umassmed.edu

Jour Nursing Home Res 2021;7:38-46
Published online August 31, 2021, http://dx.doi.org/10.14283/jnhrs.2021.7



Background: Residents of nursing homes frequently report loneliness and isolation, despite being in an environment shared with other residents and staff. Objective: To describe, among long-stay US nursing home residents living with Alzheimer’s disease and/or related dementias (ADRD), group activity participation in relation to contextual isolation: living in a nursing home where fewer than 20% of residents share socially salient characteristic(s). Design: A cross-sectional evaluation of group activity participation in relation to contextual isolation across 20 characteristics based on demographic characteristics, habits and interests, and clinical and care dimensions. Setting: US nursing homes. Participants: We included 335,421 residents with ADRD aged ≥50 years with a Minimum Data Set 3.0 annual assessment in 2016 reporting their preference for group activity participation, and 94,735 with participation observed by staff. Measurements: We identified 827,823 annual (any anniversary) assessments performed on nursing home residents in 2016, selecting one at random for each resident, after prioritizing the assessment with the least missing data (n=795,038). MDS 3.0 item F0500e assesses resident interest in group activities. Results: When considering all potential sources of contextual isolation considered, 30.7% were contextually isolated on the basis of a single characteristic and 13.7% were contextually isolated on the basis of two or more characteristics. Among residents reporting importance of group activity, 81% of those not contextually isolated reported that group activity participation was important, as did 78% of those isolated on one characteristic, and 75% of those isolated on multiple characteristics. Among residents with staff-observed group activity participation, 64% of those not contextually isolated reported were observed participating in group activities, as were 59% of those isolated on one characteristic, and 52% of those isolated on multiple characteristics. Conclusion: Residents with ADRD facing contextual isolation placed less importance on group activity than residents who were not contextually isolated.

Key words: Nursing homes, social isolation, Alzheimer’s disease, dementia.

Abbreviations: ADRD: Alzheimer’s Disease and related dementias; HIV: Human immunodeficiency viru; MDS: Minimum Data Set.



Residents of nursing homes frequently report loneliness and isolation, despite being in an environment shared with other residents and staff. Adjusting to life in both a home and care setting can be an isolating experience (12, 21). In addition to being unpleasant in its own right, isolation has long been understood to contribute to worsening health conditions and accelerated time to death (9, 10, 15, 16).
Residents with Alzheimer’s Disease and related dementias (ADRD) may be particularly likely to experience social isolation in nursing homes due to the nature of cognitive impairment, along with other factors (24). They often spend prolonged periods in a nursing home, with half living in this setting for more than two years, and many living out the remainder of their lives there (27, 29).
The great majority of nursing homes offer group activities, including weekend activities (98% of nursing homes), evening activities (95%), outdoor activities (95%), and intergenerational activities (85%) (20). Although cognitively impaired residents with dementia are more likely to decline to participate in group activities, those who do engage in longer stretches of activity (7). Activity therapists can play a large role in the degree to which residents feel welcomed and included in group activities, perhaps especially for residents at risk of exclusion due to being in a minority of residents (3). Techniques such as modeling activities and small group settings can improve participation in group activities, particularly for residents with severe cognitive impairment (8, 25). Group activities are particularly important tools for reducing loneliness and boredom of residents with dementia (1, 5), and social stimuli decrease behavioral symptoms and improve affect in these residents (6).
In this study, we first introduce the concept of “contextual isolation” in nursing homes – namely, the condition of 1) possessing a socially salient characteristic, and 2) being in a context where few other residents share that characteristic. We consider residents in a situation where they are contextually isolated on one or more characteristics to be at risk of the experience of isolation, although not determinative of an individual’s experience of isolation. For example, being the only Spanish speaking resident in a setting where the residents and staff speak only English may place them at risk of social isolation. We propose potential measures of contextual isolation, based on demographic characteristics (young age, gender, marital status, race/ethnicity, staff needs translator services to communicate with resident, heavy-bodied), habits and interests (tobacco use, importance of religious practice, importance of music, importance of pets, importance of keeping up with the news), and clinical diagnoses and care dimensions (active cancer, human immunodeficiency virus (HIV) infection, intellectual disability, sensory deprivation, disfiguring conditions (amputation, paralysis, burns), stroke, and physician-documented limited life expectancy). Second, we sought to validate the concept against measures of resident group activity participation. We hypothesized that contextual isolation would be a common phenomenon experienced by nursing home residents with ADRD; and that contextually isolated residents would express less interest in engaging in group activities than residents who are not contextually isolated, even among residents sharing the same socially salient characteristics who are not contextually isolated.



The University of Massachusetts Medical School Institutional Review Board approved this study. The nurse expert survey was work conducted preparatory to research.

Data Source

We used resident-level and facility-level aggregated data from resident assessments completed using the Minimum Data Set 3.0 (MDS) instrument (4). MDS assessments are required of all residents of Medicare and Medicaid supported nursing homes in the US and US territories, at admission, quarterly thereafter, and when there is a significant change in clinical status. The Minimum Data Set 3.0 assessment is a collaborative document: residents are interviewed for substantial portions of the assessment, and multiple direct care staff contribute to the assessment. Completion of the document is typically overseen by a nurse coordinator responsible for ensuring that all relevant assessments are conducted according to detailed guidance documents (4). All measures to develop contextual isolation measures were derived from standard MDS 3.0 items.

Long-Stay Population

We identified 827,823 annual (any anniversary) assessments performed on nursing home residents in 2016. For each resident, we selected one at random, after prioritizing the assessment with the least missing data (n=795,038) (Figure 1). Among these long-stay residents, 456,771 had a diagnosis of Alzheimer’s disease (MDS item I4200) and/or other dementia (I4800). We excluded residents who were aged less than 50 years (or had unknown age) (n=467), were comatose (or unknown) at the time of assessment (n=308), had missing information on any variable needed to assess contextual isolation (described in detail below) (n=25,149), lived in a nursing home with fewer than 10 residents (n=17), or did not have a valid assessment of group activity participation (n=674), resulting in a final sample of 430,156 residents.

Figure 1
Sample Construction

Contextual Isolation

We developed an expansive list of socially salient characteristics that we felt could potentially be the basis for contextual isolation in the nursing home setting, regardless of whether these characteristics could be readily measured in our dataset (see Supplemental Table 1). We then solicited feedback from seven experts (selected by C.A.B) in nursing home care on three aspects we conceived of as most relevant to the concept of contextual isolation: 1) how often is this characteristic a source of shared experiences / solidarity with other residents; 2) how often is this characteristic a basis for potential exclusion / ostracism by other residents; and 3) how often this characteristic contributes to a sense of identity within the nursing home. We offered four response options (for all or almost all residents with this characteristic (score=4), for most residents with this characteristic (score=3), for some residents with this characteristic(score=2), for no or very few residents with this characteristic (score=1). Scores for each characteristic were averaged. We also solicited written comments and narratives to further characterize these nurse experts’ opinions. Supplemental Table 2 summarizes the expert opinions. We applied the following criteria to each characteristic to be further considered in our development of contextual isolation: 1) readily measurable using MDS 3.0 data; 2) average score of >=2 on the “shared experience” item; 3) average score of >=2 on the “sense of identity” item. We did not rely on the “social exclusion” item after review of nurse expert opinions and comments, because this item did not conceptually fit with the narratives that our nurse experts described. Because the narratives and comments of our nurse experts described advanced age as a source of reverence by out-group members, as opposed to in-group solidarity, we did not include this among the contextual isolation measures. Shaded rows in Supplemental Table 2 indicate the social characteristics not considered further. The characteristics excluded because the MDS 3.0 lacked measures were: being lesbian, gay or bisexual, having children, veteran status, and shared political orientation. We excluded being transgender (based on Section I diagnosis codes) because fewer than 10 residents in our long-stay sample with ADRD met this criterion.
Operational details of the included social characteristics are provided in Supplemental Table 3. We created quarter-specific (1/1-3/31, 4/1-6/30, 7/1-9/30, 10/1-12/31) tabulations of residents within each nursing home for the above characteristics, drawing on both short-stay and long-term residents, regardless of eligibility for our long-stay analytic sample described above. For residents with multiple assessments in a given quarter, we selected one assessment at random, after prioritizing the assessments with the most complete data. Additionally, because some items are not included in quarterly assessments, we carried the most recent non-missing value forward (no more than 300 days to capture the most recent comprehensive assessment) to substitute for missing values to more accurately characterize the pool of residents in each nursing home residence. Among nursing homes with at least 10 residents, we calculated the proportion of residents sharing each of the selected social characteristics.
To identify which residents in our long-term cohort living in nursing homes were contextually isolated, we identified those with a given social characteristic also living in a nursing home with fewer than 20% of residents possessing the same social characteristic. We also created summary measures that categorized residents as contextually isolated on no, one, or two or more of these characteristics. In sensitivity analyses, we conducted a parallel analysis using different thresholds based on expert opinions.

Participation in Group Activities

MDS 3.0 item F0500e assesses resident interest in group activities by soliciting from the resident and/or a relative or close friend involved in their care: “While you are in this facility…how important is it to you to do things with groups of people?”, with possible responses of “Very important”, “Somewhat important”, “Not very important”, “Not at all important”, and “Important, but can’t do or no choice”. Test-retest reliability of this item was found to be high (17), as is agreement between residents and family proxies (14). For residents who had been judged to be unable to communicate and for whom no family was available to interview, or who were otherwise unable to answer this item, staff reported whether the resident had been observed engaging in group activities (yes/no) (F0800p).

Analytic Approach

In this descriptive paper, we did not employ modeling techniques. Rather, we focused on describing the proportion of residents with ADRD who experienced contextual isolation in relation to each of the social characteristics considered, the proportion experiencing contextual isolation in relation to any one of the social characteristics, and the proportion experiencing contextual isolation in relation to more than one of the included social characteristics. As a first step to validate the concept of contextual isolation as measured, we estimated the proportion of nursing home residents with ADRD who expressed different levels of interest in group activity participation across levels of contextual isolation. Because the self- and staff- reported group activity participation variables measure somewhat different concepts (importance of versus observed engagement in group activities), are reported from different sources (residents and/or family vs. staff), and are not concurrently reported for the same residents, we analyzed these populations separately throughout. There were 335,421 residents with an assessment of the importance of group activity participation as reported by the resident themselves or a proxy, and 94,735 with a valid staff report of being observed as participating in group activities or not.
Finally, because residents possessing a given socially salient characteristic may, as a population, have different levels of engagement in group activities, we also examined each of the socially salient characteristics used to define contextual isolation, and their complements. For example, although only “young age” was used to construct contextual isolation, we also examined additional age groups (65-74, 75 to 84, 85 to 94, and ≥95 years). In large samples, p-values are uninformative because trivial differences are often statistically significant; we a priori decided to treat absolute percentage differences of 5% or more to be notable, where the numerator of both percentages is greater than 50.

Suppression of Data Reporting

While the Centers for Medicare and Medicaid Services requires the suppression of reporting any cell with fewer than 10 residents, we elected to suppress the display of proportions with a numerator of 50 or smaller, to avoid drawing inferences based on imprecise estimates.



Among 335,421 long-stay residents with ADRD who were asked directly (or via family proxy) about the importance they place on participation in group activities, Table 1 describes the proportion with each of the social characteristics considered, and the proportion of residents contextually isolated on that basis. For example, 29.3% of the eligible long-stay residents with ADRD were male, and 1.6% of male residents lived in a nursing home where fewer than 20% of all residents (short-stay and long-stay, with or without ADRD) were also male, while 70.7% of eligible residents were female, of whom 0.2% lived in a nursing home where fewer than 20% of residents were also female. Among the most contextually isolated residents among the groups we considered were those who were young (35.2%), Hispanic (42.2%), American Indian / Alaska Native (66.2%), Asian (45.3%), Pacific islander (78.2%), multiracial (100%), staff required a translator to communicate with the resident (44.4%), current tobacco users (64.6%), residents with an intellectual disability (88.9%), a sensory impairment (59.8%), a disfiguring condition (84.7%), stroke (61.2%), cancer (95.6%), HIV infection (78.4%), and those in end-of-life care (94.3%). Conversely, contextual isolation was infrequent (under 5% of residents) on the basis of sex, being widowed, being White, not being a current tobacco user, engaging in religious practices, listening to music, engaging with animals, or keeping up with current events. Supplemental Table 4 describes comparable information for the 94,735 residents with no reported importance of group participation, but whose participation in group activities was observed by staff.

Table 1
Contextual Isolation on the Basis of Individual Characteristics among Long-Stay US Nursing Home Residents in 2016 with Alzheimer’s Disease and Related Dementias and Reported Importance of Group Activity Participation

When considering all potential sources of contextual isolation, 30.7% were contextually isolated on the basis of a single characteristic, and 13.7% were contextually isolated on the basis of two or more characteristics (Table 2). Furthermore, the degree of contextual isolation on any basis (cumulative contextual isolation) varied substantially across resident strata. For example, although only 1.6% of men lived in a nursing home where fewer than 20% of co-residents were also men, more than half lived in a nursing home where they were contextually isolated with respect to at least one of the social characteristics we investigated, and nearly 1 in 5 were contextually isolated with respect to multiple social characteristics; at the same time, only 11.2% of women lived in nursing homes where they were contextually isolated with respect to multiple social characteristics. Supplemental Table 5 describes comparable information for the residents whose group activity participation was observed by staff.

Table 2
Cumulative Contextual Isolation among Long-Stay US Nursing Home Residents in 2016 with Alzheimer’s Disease and Related Dementias and Reported Importance of Group Activity Participation, Stratified by Social Characteristic (n=335,421)

*Percentages may not total 100% due to rounding.


Table 3 shows, among long-stay residents with ADRD, that men who lived in a nursing home with at least 20% male residents, 73.2% rated participation in group activities as important, while among men who were contextually isolated in relation to other male residents, 74.9% rated participation in group activities as important. Likewise, differences between residents who were or were not contextually isolated were small (under 5%) for most characteristics, with the exception of residents who were Asian (85.5% vs. 81.1%), residents for whom staff required a translator to communicate (86.0% vs. 80.6%), residents for whom participation in religious activities is important (85.0% vs. 74.1%), residents for whom keeping up with the news is important (82.0% vs. 73.3%), and residents living with HIV infection (88.2% vs. 82.9%). Supplemental Table 6 describes comparable information for the residents whose group activity participation was observed by staff.

Table 3
Importance of Group Activity Participation in Relation to Contextual Isolation on the Basis of Individual Characteristics among Long-Stay Residents in 2016 with Alzheimer’s Disease and Related Dementias and Reported Importance of Group Activity Participation

a. Proportions based on a numerator under 50 not reported to avoid imprecise estimates.


Table 4 demonstrates that 80.6% of residents not contextually isolated on any basis rated participation in group activities as important, while 77.6% of residents contextually isolated on the basis of a single characteristic did, and 75.2% of residents experiencing contextual isolation on the basis of multiple characteristics did. Rating participation in group activities as important varied dramatically across resident strata. For example, among residents who were not contextually isolated on any social characteristics, 85.6% of residents who engage in religious practices rated group participation as important, while 55.7% of comparably situated residents who do not engage in religious practice did. Despite often large differences in the importance of group participation across strata, in most strata, residents who were contextually isolated on the basis of multiple characteristics were at least 5% less likely to report participation in group activities as important (in absolute terms). For example, among White residents, 80.8% of those who were not contextually isolated rated group activity participation as important, while 72.6% of those experiencing contextual isolation across multiple characteristics did.

Table 4
Importance of Group Activity Participation by Cumulative Contextual Isolation among Long-Stay Residents in 2016 with Alzheimer’s Disease and Related Dementias Living in a Nursing Home and Reported Importance of Group Activity Participation, Stratified by Social Characteristic

a. Proportions based on a numerator under 50 not reported to avoid imprecise estimates.


Among 94,735 residents unable to complete the resident assessment of the importance of group activity participation, 63.6% of those not contextually isolated were observed by staff to have participated in group activities, while 58.7% of those contextually isolated on the basis of a single characteristic were observed participating in group activities, and 52.5% of residents contextually isolated on the basis of multiple characteristics were observed participating in group activities. These data, as well as stratum-specific data comparable to Table 4 can be found in Supplemental Table 7.
Supplemental Table 8 shows the proportion of residents considered contextually isolated when defined as sharing a nursing home with fewer than 10%, and fewer than 15% of residents with the same social characteristic. By definition, fewer residents are considered contextually isolated when using a lower threshold for defining contextual isolation. Supplemental Table 9, in turn, shows the proportion of residents considered contextually isolated with respect to any single characteristic, and with respect to multiple characteristics, when the threshold for contextual isolation is lowered to 10%. Following the results in Supplemental Table 8, these proportions are lower than those shown in Table 3.



The concept of contextual isolation encourages understanding the potential for isolation of each resident in context, rather than as the sum of individual risk factors, and reframes efforts to address isolation and loneliness from an individualized process of risk assessment and intervention to one focused on systematic and relational approaches that validate–even cherish–the diverse views, experiences, and strengths that residents have to offer.
These analyses demonstrate that not only is contextual isolation in nursing home residents with ADRD a common experience, but that it is related to diminished participation in group activities. Residents sharing a socially salient characteristic often place less importance on group activity participation when they are in settings where they are contextually isolated with respect to multiple characteristics. One plausible interpretation of these findings is that residents with ADRD who live in a context where a socially salient characteristic puts them in a minority have greater difficulty developing a sense of solidarity and inclusion. Alternately, these residents may be at risk of exclusion or ostracism from the larger population of residents, diminishing their interest in participating in group activities. The finding that staff observation of participation in group activities often showed an even stronger association with contextual isolation than the expression of resident interest bolsters this interpretation.
Being contextually isolated is far from determinative of group activity participation. The majority of residents we examined either rated participation in group activities as important or had staff observe group activity participation. Taking the findings based on importance of group participation and observed group activity participation reported by staff together points to the need for nuance in interpreting this overall narrative. For instance, both residents who live in a setting where staff need translation services to communicate with them and those who don’t demonstrated a stronger gradient from no contextual isolation to multiple contextual isolation than the population as a whole. This may suggest there is negative confounding when looking at the whole population. Additionally, some of the groups who were least likely to experience contextual isolation nonetheless saw a notable (>5%) decrease in placing high importance on group activity participation when they were contextually isolated. These included non-Hispanic White residents, female residents, and those whose weight for height was lower than 30 kg/m2. These findings may suggest that residents coming from a socially dominant position in the larger society may be more likely to avoid group activities when confronted with the possibility of being in the minority, while residents with a lifetime of experience negotiating as a minority in one way or another are better prepared to handle group interactions in a diverse setting.
Alternate explanations include the possibility that residents in a minority position may feel some degree of exclusion in dyadic interactions, and thus express an even greater preference for group activities, which may involve more oversight and structure provided by staff to facilitate healthy and supportive interactions. Qualitative analyses of the individual, dyadic, small, and large group interactions of residents with ADRD in nursing home settings will be required to assess these potential explanations, as well as to add dimensionality to the quantitative findings of this analysis.

Strengths and Limitations

This analysis was performed on a census of residents in 2016 living in US nursing homes for at least one year with ADRD, aside from exclusions for missing data. The MDS item assessing the importance the resident places on participation in group activities is not, to our knowledge, incorporated into any quality indicators, nor does it serve as the basis for determining differences in reimbursement rates. As a result, it may be perceived as a low salience item and be filled in without great attention to detail. Direct assessment of the importance a resident places on participation in group activities is not conducted when a) the resident is judged unable to communicate and a family member is not present to serve as a proxy, or b) previous items designed to assess resident preferences and activity patterns were not answered. It is plausible that staff may be more likely to code a resident as non-responsive or non-communicative in ways that are causally related to the very contextual isolation these residents face. Although the inclusion of the resident’s voice in the MDS assessment instrument is a welcome improvement over previous assessment techniques (28), in this case, the resident’s expression of the importance of group activity participation may not closely reflect the degree to which contextually isolated residents are invited and welcomed to participate fully and authentically in these activities.
Our measure of contextual isolation is based on measures incorporated into MDS 3.0 that have sufficiently low missingness to be reliably incorporated into these measures for a wide range of populations. There are many other dimensions of identity and socialization that may have a large influence on contextual isolation in the nursing home setting, including prior occupation and social class (13, 23), sexual and gender minority status (2, 11, 26), and even musical preferences (18). Thus, our measure of contextual isolation is incomplete, and in addition, does not reflect the potential for greater degrees of isolation associated with different socially salient characteristics.
Our main hypothesis that residents experiencing contextual isolation would be less fully included in group activities ignores several important additional contextual factors that may have a large influence on the experience of contextually isolated residents. For instance, contextual isolation in a nursing home dominated by a single majority group is likely to be a distinct experience from being contextually isolated in a diverse setting where multiple groups interact frequently, although these scenarios are treated interchangeably in our formulation. Similarly, contextual isolation in relation to other residents may not reflect isolation when staff are incorporated into the picture. For example, a Filipina resident who is in a relatively small minority with respect to other residents may feel common bonds and solidarity with Filipino/a staff that could compensate for what might be an isolating experience when only other residents are considered. Furthermore, in a nursing home culture where diverse experiences and backgrounds are cherished and revered, rather than serving as the basis for exclusion (as our hypothesis implicitly assumes), the experience of being contextually isolated may have little to no bearing on the experience of feeling isolated or lonely as an individual resident. Likewise, staff engagement impacts resident participation in group activities (19), suggesting a large role for staff in proactively addressing contextual isolation by being solicitous of residents who might otherwise be at risk of social isolation (3). In addition, observations in Veterans Affairs nursing homes have demonstrated that residents have much more frequent interactions with staff and the environment than with other residents (22), potentially limiting the proposed mechanism we explore here that group activity participation is inflected by social interactions based on resident composition in the nursing home setting.



Residents with ADRD who are contextually isolated, that is, who share socially salient characteristic(s) with fewer than 20% of their co-residents, often put less importance on participation in group activities than residents who are not contextually isolated. Contextually isolated residents are also less likely to be observed participating in group activities by staff. This overall trend is somewhat more pronounced in groups of residents sharing racial/ethnic identities, in nursing homes where staff require translation services to communicate with them, residents living with HIV, and residents with lower weight for height. Nursing homes should consider, at the level of a residential community, means to encourage group activities that incorporate the full richness and diversity of their residential population.


Acknowledgements: We thank Lynn Botelho for her insights into social interactions in nursing homes, seven anonymous experts in nursing home care for insights on further refining the concept of contextual isolation, and Divya Shridharmurthy for coding the nursing expert survey into RedCap.
Funding: This work was funded by the National Institutes of Health (NR016977, TR001454, and AG071692 to Dr. Lapane). The sponsors had no role in the design and conduct of the study; in the collection, analysis, and interpretation of data; in the preparation of the manuscript; or in the review or approval of the manuscript.

Declaration of Interest: Bill M. Jesdale has no conflicts of interest to declare; Carol A. Bova has no conflicts of interest to declare; Attah K. Mbrah has no conflicts of interest to declare; Kate L. Lapane has no conflicts of interest to declare.

Ethical Approval for Study: This study was approved by the University of Massachusetts Institutional Review Board.





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V. Guion1, L. He1, H. Blain2, H. Villars1,3, G. Durel4, P. De Souto Barreto1,3, Y. Rolland1,3


1. Gerontopole of Toulouse, Institute on Aging, Toulouse University Hospital (CHU Toulouse), Toulouse, France; 2. Department of Geriatrics, Montpellier University Hospital, Montpellier, France; 3. CERPOP Centre d’Epidémiologie et de Recherche en santé des POPulations UPS/INSERM UMR 1295, Toulouse, France; 4. MCoor Association nationale des médecins coordonnateurs et du secteur médico-social, Paris, France. Corresponding author: Vincent GUION, Gerontopole, 20 rue du Pont Saint-Pierre, Cité de la Santé, CHU de Toulouse, 31059 Toulouse – France, Phone: (+33) 561 145 664, Fax: (+33) 561 145 640, e-mail: vincent.guion@gmail.com

Jour Nursing Home Res 2021;7:32-37
Published online June 23, 2021, http://dx.doi.org/10.14283/jnhrs.2021.6



Background/Objectives: To identify which infection prevention and control (IPC) precautions in long-term care facilities (LTCF) were associated with reduced COVID-19 incidence and mortality among residents and reduced COVID-19 incidence in health care professionals (HCP). Design: Retrospective data on self-assessment of adherence to 101 IPC measures collected via an online questionnaire sent to 825 nursing homes in France in December 2020. Setting and participants: Medical and administrative staff jointly reported data on IPC measures, characteristics of LTCF, counts of residents’ COVID-19 deaths and cases, and counts of HCP cases. Measurements: Random forest models were used to identify the most important IPC measures associated with reduced number of COVID-19 deaths and cases in residents and cases in HCP. The identified variables were then included in linear regression models to estimate the association between levels of adherence to each selected IPC measure and COVID-19 deaths and cases. No data on time of IPC measures implementation were collected. Results: Data from 307 LTCF (37.2%) were collected, accounting for 22,214 residents. A higher number of COVID-19 deaths in residents was associated with a better adherence to physical distancing in group activity rooms. A better adherence by HCP to physical distancing during their mealtimes and break times was associated with fewer COVID-19 cases among residents and HCP. Other IPC measures were not significantly associated with COVID-19 cases or deaths. Conclusion: Physical distancing between residents was more implemented when LTCF had been confronted with COVID-19 deaths. Physical distancing between HCP was associated with fewer COVID-19 cases in residents and HCP, suggesting it may prevent significantly COVID-19 spreading in LTCF. HCP should particularly adhere to physical distancing measures during their mealtimes and break times. A higher adherence to such preventive measures does not require extra material or human resources and may be easily achievable.

Key words: Nursing home, COVID-19, health professional, infection prevention and control measure, random forest model.



The prevalence of COVID-19 is considerably larger in long-term care facilities (LTCF) than in the community (1-4) despite progressive implementation of measures of infection prevention and control (IPC) since first outbreaks (5). In January 2021, the World Health Organization (WHO) issued update advice on IPC precautions to be implemented in LTCF in the context of COVID-19 (6), comprising nine critical IPC policies and procedures, four critical measures to ensure early detection of cases, and five immediate precautions to implement when a resident is identified as a suspected or confirmed case.
The adherence to these IPC measures in the long run by health care professionals (HCP), residents, and their relatives is yet challenging (7-9) since IPC measures can impair residents’ and their relatives’ psychosocial well-being (8, 10, 11), and HCP’s work satisfaction (12).
Qualitative and quantitative reduction in the implementation of recommended IPC precautions in LTCF may be better accepted by HCP and residents but may in turn be less effective in limiting COVID-19 incidence and mortality.
The objectives of this study were to identify which IPC measures in LTCF were associated with reduced COVID-19 incidence and mortality among residents and COVID-19 incidence in HCP.



Design, data collection and study population

All 825 LTCF in the Occitania Region of France were sent a questionnaire to self-assess their adherence to 101 IPC measures. Descriptive LTCF-level data which could be associated with COVID-19 spreading were retrieved, including the number of residents (13-17), ownership (17-20), and presence of a laundry service on-site (6, 21, 22). No resident-level data were collected. LTCF administrative and medical staff jointly collected data on number of COVID-19 cases among HCP and residents, and number of COVID-19 deaths over up to four possible outbreaks before December 2020. IPC measures could have been implemented at any time before data collection, either before or after COVID-19 cases were diagnosed in the facility, and no data on time of implementation were collected.

Outcome measures

The main outcome measure was the number of COVID-19 residents’ deaths, used as a proportion of the total number of beds in the facility. Secondary outcomes were the number of COVID-19 residents’ cases and HCP cases, used as proportions of the total number of beds. Each outcome was calculated as follows:
Outcome = 100 x Number of COVID-19 cases (or deaths) / Number of beds
In France, the number of HCP related to the number of residents, whatever public or private institution, is defined by the regional health agency (RHA) and is globally identical from one LTCF to another.


All explored IPC measures were described in Supplemental Figure 1. For each measure, the four possible answers, defining the level of implementation of the IPC measures in the LTCF, were “never”, “insufficiently”, “regularly” and “always”. In practice, all LTCFs in Occitania were invited by email by the RHA and the investigating Hospital to provide a questionnaire to judge the quality of the preventive measures against COVID-19 currently engaged in the institution. The LTCF leadership team (i.e., the medical coordinator, the nurse coordinator, and the principal) had to answer the questions. In order to ensure that the answers given were objective and without fear of criticism or derogatory judgment, the results of the survey were not returned by name to the RHA. The questionnaire was directly fulfilled online and validated by the LTCF’s team in a way that no missing data on adherence to IPC measures was possible.
Ownership was defined as public, private non-profit and private for-profit. The size of the LTCF was defined as the number of permanent authorized beds.

Statistical analyses

Random forest (RF) models were used to analyze the importance of each variable (the 101 IPC measures) in predicting the dependent variables (COVID-19 mortality or incidence in residents and COVID-19 incidence in HCP). A 10-fold cross-validation was used for RF model hypertuning over a tree number from 200 to 2000 and an entry number of independent variables from 3 to 13. Root mean square error (RMSE) was used for hypertuning evaluation and the hypertuning parameters (i.e., tree number and independent variable entry number) yielding the smallest RMSE value were selected as optimal parameters. With the optimal parameters, a final RF model was built for each dependent variable. The importance of each independent variable in the RF model was evaluated using the percentage increase in mean square error (%IncMSE), which shows the percentage increase in MSE when corresponding independent variable is permuted. A higher %IncMSE indicates a greater importance of the variable to predict the outcome.
The most important independent variables were finally included in multivariate linear models to obtain regression coefficients, while keeping the number of observations per degree of freedom of each model over ten. Independent variables were used as categorical, with the category “never” being the reference.
RF models were performed in R (version 4.0.3). Regression models were performed in Stata (version 16.1).



A total of 307 LTCF filled out the questionnaire between November 30th, 2020 and December 16th, 2020, describing IPC precautions and practices applied to 22,214 residents. LTCF’s characteristics were presented in Table 1.

Table 1
Characteristics of participating long term care facilities (n=307)


Table 2
Final regression models on number of COVID deaths among residents, and number of COVID cases among residents and among healthcare professionals (HCP)

The three final regression models were presented in Table 2.
The ten most important variables as identified by the RF model on the number of residents’ deaths were presented in Supplemental Figure 2. The seven most important IPC measures were used in the regression model on the number of residents’ deaths, with %IncMSE ranging from 4.40 to 7.35. A higher number of COVID-19 deaths in residents was associated with a better adherence to physical distancing between residents in activity rooms: compared to “never”, coefficients for “regularly” and “always” were significantly positive. The number of COVID-19 residents’ deaths was also significantly higher in LTCF that implemented reception area disinfection “regularly” rather than “always” (coefficient 3.80 [1.64, 5.96]). None of the five other variables were significantly associated with the number of residents’ deaths.
The ten most important variables as identified by the RF model on the number of residents’ cases were presented in Supplemental Figure 3. The seven most important IPC measures were used in the regression model on the number of residents’ cases, with %IncMSE ranging from 2.34 to 3.73. A better adherence by HCP to physical distancing of at least one-meter during their mealtimes and break times was associated with fewer COVID-19 cases among residents: compared to “never”, coefficients for “insufficiently”, “regularly” and “always” were significantly positive. None of the six other variables were significantly associated with the number of residents’ cases.
The ten most important variables as identified by the RF model on the number of HCP cases presented in Supplemental Figure 4. The six most important IPC measures were used in the regression model on the number of HCP cases, with %IncMSE ranging from 2.27 to 3.37. A better adherence by HCP to physical distancing of at least one-meter during their mealtimes and break times was also associated with fewer COVID-19 cases among HCP: compared to “never”, coefficients for “insufficiently”, “regularly” and “always” were significantly positive. None of the five other variables were significantly associated with the number of HCP cases.



This study highlights the importance of physical distancing in preventing the spread of COVID-19 in LTCF, especially among HCP during critical moments of the day at work like mealtimes and break times. WHO has widely recommended physical distancing, including between HCP during their breaks (6), suggesting that it prevents transmission of COVID-19 between HCP. The recommended distance was increased from one to two meters in general population in France after the emergence of new variants of SARS-CoV2 (23). Our results confirm that physical distancing of HCP during their breaks is also associated with the prevention of transmission to residents. The applicability and acceptability of such IPC measures seem high, as they do not require extra staffing nor expensive material, and could be implemented despite shortages of HCP (24).
The level of adherence to certain IPC measures may increase as the number of cases and deaths increases in the LTCF, demonstrating the adaptation of HCP during an epidemic by strengthening precautions. This was illustrated in our study by the association between a fairly abstract measure (the area of activity rooms being at least 4m² per resident) and a higher number of resident deaths. We explain this association by considering that the measure was all the more implemented when the institution had been confronted with deaths related to COVID-19.
The use of random forest models was a novel approach and allowed to investigate a high number of IPC measures and levels of adherence. This method was particularly appropriate as the number of participating LTCF was limited, even though it reached almost 40% of the target sample.
Yet, this study shows several limitations in its methods. The most important limitation must be the absence of resident-level data, excluding the possibility to consider individual outcomes rather than facility-level outcomes. Individual data may also have brought insight into risk factors for lower adherence of residents to some IPC measures, like dementia that could limit the ability of residents to develop new hand hygiene habits. The declarative nature of LTCF’s level of adherence may have introduced a selection bias, with the most performing LTCF being more prone to answer, thus introducing a ceiling effect in adherence levels to IPC measures. Ownership is known to play a role in the spread of COVID-19 in LTCF, especially in private for-profit facilities (18, 20), and these were surprisingly under-represented in our sample. This may have introduced an underestimation of COVID-19 number of cases and deaths. The nature of the outcomes (the number of cases and deaths) may have been too sensitive for a declarative method of data collection, even though the WHO proposed self-assessment “to help identify, prioritize and address any gaps in IPC capacity” (6). LTCF may have felt responsible for COVID-19 cases or deaths if IPC measures were not sufficiently implemented. This may have introduced a methodological bias as about one LTCF in three did not report cases or deaths counts and were consequently excluded from analyses.
Physical distancing between HCP members was associated with a lower rate of COVID-19, suggesting this IPC measure might prevent COVID-19 spreading in LTCF. HCP should be particularly precautious during their mealtimes and break times, as a lower adherence to physical distancing measures seem to be associated with a higher number of cases among HCP, and among residents. A higher adherence to such preventive measures seems to be easily achievable in all settings, as it does not rely on extra material or human resources.


Conflict of interest: All authors have completed the ICMJE uniform disclosure form (available on request from the corresponding author) and declare: no support from any organization for the submitted work; no financial relationships with any organizations that might have an interest in the submitted work in the previous three years, no other relationships or activities that could appear to have influenced the submitted work; no spouses, partners, or children have financial relationship that may be relevant to the submitted work; and no nonfinancial interests that may be relevant to the submitted work.

Author Contributions: • Study concept and design: Yves Rolland, Hubert Blain, Gaël Durel, Hélène Villars; • Acquisition of data: Yves Rolland, Hubert Blain, Hélène Villars; • Analysis and interpretation of data: Vincent Guion, Lingxiao He, Hubert Blain, Hélène Villars, Gaël Durel, Philipe de Souto Barreto, Yves Rolland; • Drafting of the manuscript: Vincent Guion; • Critical revision of the manuscript for important intellectual content: Vincent Guion, Lingxiao He, Hubert Blain, Hélène Villars, Gaël Durel, Philipe de Souto Barreto, Yves Rolland. All authors had full access to all of the data in the study and first author can take responsibility for the integrity of the data and the accuracy of the data analysis. The corresponding author attests that all listed authors meet authorship criteria and that no others meeting the criteria have been omitted.

Acknowledgements: We would like to thank Christelle Voisin and Cendrine Blazy (Agence Régionale de Santé- Occitania) for their valuable contribution in the study design and data collection.

Sponsor’s role: Funding was supported by the CHU Toulouse.

Impact statement: We certify that this work is novel. This research adds to the literature an insight on infection prevention and control measures associated with COVID-19 cases and death in long-term care facilities’ residents and healthcare professionals. Physical distancing between health care professionals may prevent COVID-19 spreading in long-term care facilities, and professionals should be particularly precautious during their mealtimes and break times.

Ethical standards: Ethics statement: Participants were long term care facilities whose medical and administrative staff reported organizational data. No data was collected at the resident level or at the health care professional level. No consent from participants was therefore required.





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L. Bavelaar1, H.T.A. van der Steen2,3, H. de Jong1, G. Carter4, K. Brazil4, W.P. Achterberg1, J.T. van der Steen1,5


1. Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, the Netherlands; 2. Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands; 3. Faculty of Science, University of Amsterdam, Amsterdam, the Netherlands; 4. School of Nursing and Midwifery, Queen’s University Belfast, Belfast, Northern Ireland, United Kingdom; 5. Department of Primary and Community Care, Radboud university medical center, Nijmegen, the Netherlands. Corresponding author: Jenny T. van der Steen, Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, the Netherlands, jtvandersteen@lumc.nl

Jour Nursing Home Res 2021;7:23-31
Published online June 18, 2021, http://dx.doi.org/10.14283/jnhrs.2021.5



Background: The literature indicates that palliative care for people with dementia needs to be enhanced. Objectives: To assess barriers to providing high-quality palliative dementia care and potential solutions to overcome these barriers, as perceived by physicians responsible for end-of-life care with dementia. Design: Cross-sectional study. Setting: The Netherlands. Participants: A representative sample of 311 elderly care physicians of whom 67% (n=207) responded. Measurements: A postal survey in 2013 containing open-ended items probing for barriers in the elderly care physicians’ practices and possible solutions. Answers were coded and grouped using qualitative content analysis and presented to expert physicians in 2021. Results: Barriers to palliative care in dementia were (1) beliefs held by family, healthcare professionals or the public that are not in line with a palliative care approach, (2) obstacles in recognizing and addressing care needs, (3) poor interdisciplinary team approach and consensus, (4) limited use or availability of resources, and (5) poor family support and involvement. Suggested solutions were improving communication and information transfer, and educating healthcare staff, families and the public about palliative care in dementia. Timely and frequent communication with the family, including advance care planning, and more highly skilled nursing staff were also proposed as solutions. Conclusions: The results suggest a strong need for ongoing education for healthcare professionals about palliative dementia care. Strengthening interprofessional collaboration and shared responsibility for advance care planning is also key. Increasing public awareness of the dementia trajectory and the need for a proactive approach call for a broader societal agenda setting.

Key words: Dementia, geriatrics, nursing homes, palliative care.



As the number of people living and dying with dementia increases, dementia has been declared a public health priority (1). Because dementia is a terminal disease, a palliative care approach is appropriate in principle. In 2014, the European Association for Palliative Care (EAPC) published a white paper (2) that provided evidence- and expert consensus-based recommendations to guide clinical practice and policy in shaping palliative care in dementia. However, palliative and end-of-life care in dementia are still perceived to be suboptimal according to family and healthcare professionals because the recommendations are not always implemented (3-5). Improving care and services for people with dementia and their families is thus necessary.
The majority of people with dementia in the Netherlands die in nursing homes, estimates vary by setting of sampling between 70% (6) and 93% (7). Nursing home teams in the Netherlands are multidisciplinary teams, supervised by elderly care physicians who carry the primary responsibility for the care of nursing home residents (8, 9). The Netherlands is unique in having these care (instead of cure) oriented physicians as staff who have received specialist education in geriatrics, dementia and palliative care (8). Compared to, for example, the United States, it is more common in the Netherlands that physicians decide, together with the family, to withhold curative treatment and focus on achieving a goal of comfort for nursing home residents with dementia (10). Specialized palliative care teams are mostly serving hospital and hospice settings and are rarely called upon for nursing home residents with dementia (11).
Due to their significant role and expertise in providing end-of-life care for people with dementia, elderly care physicians are key informants as to why implementation of palliative care in dementia is still suboptimal and how to address these barriers. The main question we address in this study is: What are the barriers to providing high-quality palliative care in dementia in the Netherlands according to elderly care physicians, and what solutions do they propose to address these barriers?



Participants and procedure

This study was part of a larger cross-sectional survey in the Netherlands and Northern Ireland (12-14) from which we present the Dutch qualitative data. A representative sample of elderly care physicians in the Netherlands participated in a postal survey in 2013. We used systematic random sampling by e-mailing a self-administered postal survey to every fourth elderly care physician from an alphabetical list of the 1248 members of the Dutch Association of Elderly Care Physicians and Social Geriatricians (Verenso). This member list includes more than 80% of Dutch registered elderly care physicians. The inclusion criteria were: (i) experience with end-of-life care for people living with dementia and (ii) practicing at Autumn 2012. Two reminders and a prize draw to win a 100-euro gift card were used to maximize responses.
The survey contained a quantitative evaluation of the priorities of elderly care physicians in the end-of-life care for people with dementia (see Additional file 1). Its components were based on the EAPC white paper recommendations domains (Box 2 in (2)). Additionally, the survey included an open-ended item, asking:
“Finally, in your opinion, what are the three most significant barriers to providing good quality palliative care in dementia in your practice, and importantly, how would you suggest these barriers are best addressed?”.
In February 2021, we presented the most frequent pairs of barriers and solutions that emerged from this survey to expert elderly care physicians with a minimum of three years of experience in caring for people living with dementia, and who were affiliated with an academic center in the role of teacher, supervisor or researcher. They were asked to indicate whether the results were still relevant and up-to-date, soliciting for additional comments.

Data management and analysis

The responses were analysed using conventional content analysis (15, 16) in Atlas.ti (version 7.5.10, 2015) and Excel. First, all responses were read and reread to gain familiarization with the barriers and solutions mentioned by the respondents. Next, codes were created from the data based on the specific barriers and solutions identified. Because there was no one-to-one relation, proposed solutions were coded separately from the barriers to maintain meaningful differentiation between the categories and codes for both solutions and barriers. To ensure validity and rigor (17), codes developed by LB (PhD student trained in quantitative and qualitative methods) were peer checked by HJ (elderly care physician) and HS (BSc student trained in quantitative and qualitative methods). Finally, codes were reviewed and grouped into larger categories inspired by the literature (14, 18) and based on discussions between the researchers (LB; HS; JS, associate professor in end-of-life care). Codes were quantified to describe the frequency of their occurrence.
Codes were developed in the original language (Dutch) and translated to English for reporting. Quotations used to support findings were translated to English by a professional translator as recommended (19).

Ethical procedure

The Medical Ethics Review Committee of the VU University Medical Center approved the survey as part of series of studies on end of life in nursing homes (2010/157; 14 June 2010). Consent was implied with receiving a completed questionnaire. Returned surveys were pseudonymized with a numbering system. The expert physicians were informed of the purpose of the study and consented to use their evaluation and relevant demographics (gender and experience) for publication while not personally identifiable in the report.



Characteristics of respondents

A response rate of 67% was achieved with 207 out of 311 self-complete postal surveys returned. Nineteen were excluded from analysis because the physicians did not meet the inclusion criteria of experience with end-of-life care (n = 13) or currently practicing (n = 6). Of the included 188 respondents, 171 mentioned one to four barriers and associated solutions. The majority of the elderly care physicians was female, visited their residents daily and had lost more than one resident with dementia in the past year (Table 1). The demographics of the respondents correspond with the entire population of elderly care physicians in the Netherlands (mean age: 48.4, percentage women: 64%; (20)) and we assume that the respondents are geographically representative of the entire population, as this was the case in a study conducted at the same time using the same sampling approach (21).

Table 1
Characteristics of the 2013 survey respondents


The barriers to providing good quality palliative care in dementia were clustered into five categories (cf. (14)) and are listed in Table 2 in order of frequency together with the underlying codes and example quotes.
1. Beliefs and lack of knowledge, awareness or understanding. A perceived lack of knowledge about dementia and palliative care appeared to be the most prominent barrier according to the elderly care physicians. Consequently, families, hospital doctors, nursing staff, and the public did not see the need for a palliative approach for people with dementia.
2. Obstacles in recognizing and addressing care needs. The respondents mentioned difficulties in identifying and managing decline, discomfort, and diagnosing and managing dementia in general. The start of the palliative phase was often recognized late. Additionally, care goals or treatment plans were not documented or vague.
3. Poor interdisciplinary team approach and consensus. The elderly care physicians indicated that care was not continuous because of high staff turnover, poor information transfer, and poor collaboration between healthcare professionals. This could delay starting palliative care. Moreover, the respondents stated that palliative care terminology was used inconsistently, and uncertainty remained about what a palliative care approach entailed.
4. Limited use or availability or resources. The next most frequently mentioned barrier was limited staff resources. Elderly care physicians often mentioned a lack of time and poor staffing to negatively impact the care provided.
5. Poor family support and involvement. The respondents indicated that frequently family did not feel ready to part with their relative-hence resisting palliative care. Underlying this resistance was insufficient support for families, as elderly care physicians and the nursing staff were not able to timely discuss the end of life. Further, family and nursing home staff sometimes disagreed about the quality of life of the person with dementia.

Table 2
Barriers: categories, codes and illustrative examples


Proposed solutions

Table 3 shows five clusters of solutions that the respondents proposed for various barriers. First, we discuss three clusters in chronological order of patient transitions across care settings. Next, we present two clusters that address barriers at a broader, societal level.

Table 3
Solutions: categories, codes and illustrative examples across settings



Improving healthcare professional – patient or family interaction

Starting in community practice, the elderly care physicians proposed a stronger involvement of general practitioners (GPs) in palliative or dementia care. The respondents called for an early start of patient support, dementia diagnosis and advance care planning (ACP), to prevent emergency actions in nursing homes. This was most frequently mentioned as a solution for a lack of continuity of care, palliative care or dementia knowledge, and resources.
Transitioning to nursing home practice, the respondents stated that improved communication and family support could be a solution to the suggested barriers. Nursing home staff needed to increase the frequency of their conversations with family and provide counseling (“psychoeducation”). Together with timely conversations about end of life and an early start of ACP, this could assist families in accepting or understanding their relative’s prognosis, and to recognize palliative care as an appropriate approach. Potentially, this would ameliorate disagreements between family and nursing home staff.
Further, nursing home staff should focus more on person and family-centered care. This includes attention for spiritual care and providing compassionate care, with an emphasis on social and emotional bonding, and less on a medical approach. It was suggested that nursing home staff should engage family in daily care tasks and improve their interaction with other cultures. This was highlighted in case of limited resources, obstacles in recognizing and addressing care needs and poor family involvement. Finally, respondents proposed to expand facilities, activities or services for patients and families to facilitate family support and involvement.

Improving the quality of care provided

In nursing home practice, barriers to palliative dementia care could by countered by nursing staff receiving specific training in palliative care. Many respondents suggested that multidisciplinary training could enhance palliative care knowledge and overcome several barriers related to limited staff resources and a lack of consensus about palliative care terminology.
Another important solution proposed by many elderly care physicians was to train nursing staff in symptom recognition and in using standardized instruments, such as pain observation scales and the Liverpool Care Pathway (22). If correctly used as a supportive tool and not as a ‘protocol’, the respondents believed that this could help improve recognizing and addressing care needs, and increase staff knowledge about dementia and palliative care.
Both barriers could also be countered if nursing staff were able to consult a specialist, and if elderly care physicians consulted peers. The respondents further suggested that consulting a specialist or specializing staff could improve continuity in practice, although some, both in the survey and expert consultation, regarded themselves palliative care specialists.

Improving the continuity of care provided

To improve the continuity of care in the nursing homes, many elderly care physicians suggested to increase staff resources. More staff and decreased (administrative) workload would reduce lack of time. Additionally, investing in having the same healthcare professional attending the same patient and family would facilitate relationships and improve acceptance of dementia diagnosis or prognosis.
Another proposed solution to increase continuity was to provide further training for nursing home staff in communication to facilitate initiating or conducting end-of-life conversations and ACP. This would also help connect with family and enhance the quality of information transfer between healthcare professionals. Specifically, a clear use of terminology was needed. This could improve families’ and staff’s knowledge and acceptance of appropriateness of palliative care in dementia.
Many respondents proposed improved collaboration, coordination and information transfer, both within nursing home practice and in transfers to and from secondary care. This could address barriers related to lack of continuity in care or personnel, misunderstandings between healthcare professionals, and to obstacles in recognizing and addressing care needs. In particular, multidisciplinary meetings and collaboration were considered key, also to support ACP. Respondents also suggested to specifically improve collaboration between nursing home staff and medical specialists. Hospital doctors (and GPs) were suggested to benefit from nursing home staff’s expertise in providing good care for people living with dementia. This could foster continuity in care and ameliorate problems with overtreatment.
In relation to the latter, the elderly care physicians proposed to have more discussions about futile treatment and focus on care rather than cure. This could also help overcome disagreements about care goals between healthcare professionals, within the nursing home and in the interaction with hospital doctors.


In addition to specific changes of healthcare, the elderly care physicians proposed more general solutions to address barriers for palliative dementia care at a broader, societal level.

Improving policy to support palliative care provision

The respondents suggested that an increase and reallocation of government funding for palliative care could address barriers such as poor staffing and a lack of time, and support the enhanced education of nursing staff to increase their knowledge in palliative and dementia care. Funding could support the provision of palliative care in practice by enabling more facilities, activities or services for the patient or family.
Another policy improvement was clarification of law and regulation. This was proposed to help resolve perceived ambiguity in legislation regarding (foregoing) treatment.

Improving public perception

The elderly care physicians expressed a need for public education on palliative care and end of life. This could help address barriers to providing high-quality palliative care in dementia such as the perceived unrealistic public image of prolonging or ending life, the denial of dementia diagnosis or prognosis by some families, and the difficulties in recognizing and addressing care needs.
The respondents also proposed that public education to increase awareness around the medical futility of life-prolonging treatment in people with advanced dementia could solve a variety of barriers related to overtreatment and a lack of knowledge and acceptance. It could also diminish the stigma around dementia and myths around prolonging or ending life. Finally, public education on ACP or advance directives could be a solution for the lack of clear guidance for their practice.

Expert checking

These results from the 2013 survey were presented to 26 expert physicians in 2021, ten of whom were men and the average years of experience in caring for people living with dementia was 19.6 years. All barriers and solutions were indicated to still be relevant by at least 12 physicians (range: 12-25 confirmations per barrier and solution). The barriers and solutions related to the availability of resources, information transfer, and symptom recognition and control were endorsed by the lowest numbers of physicians (13, 16 and 12, respectively). Nearly all physicians endorsed the barriers and solutions related to palliative dementia care knowledge (n = 25) and family support (n = 22).



Dutch elderly care physicians see most people living with dementia in the last phase of their life as they are responsible for providing nursing home care and most people with dementia in the Netherlands die in a nursing home. Specialist training supports their competency; the Netherlands is a country where withholding curative treatment based on quality-of-life care goals is more common than elsewhere (10). Therefore, we expected this particular setting to be promotive of palliative and end-of-life care provision to person with dementia. Yet, this representative sample of elderly care physicians raised a variety of barriers to providing high-quality palliative care in dementia.
Interestingly, the barriers perceived by the elderly care physicians mirror the barriers reported in international literature (e.g. (18)). Apparently, having a skilled elderly care physician on the staff of nursing homes is not enough to overcome these barriers to high-quality palliative care. Families having insufficient awareness of the terminal nature of dementia and a poor understanding of palliative care (23-25) still remain as barriers, causing families to resist a palliative approach and insisting on curative treatment. Also continuity of care is not assured. A strong upstream orientation to palliative care that addresses palliative care early on is missing (26). GPs would not usually discuss palliative care and ACP when their patients with dementia were still able to contribute. Living wills that elderly care physicians can use to guide treatment and thus provide continuity in care remain uncommon. In addition, the extended palliative phase in dementia is not being recognized by all healthcare professionals (27). The elderly care physicians reported that hospital doctors did not consider the dementia of their patients in the treatment plans. Continuity of palliative care was therefore disrupted upon hospitalization.
A broader support base for palliative care is thus required and this refers to all involved in caring for people living with dementia: families, GPs, hospital doctors and nurses. Figure 1 visualizes the solutions that the elderly care physicians proposed to overcome these barriers. To improve the quality and continuity of palliative care in dementia (overall aims), increased understanding of palliative care and dementia and improved communication is needed (objectives). The means necessary to achieve increased understanding and improved communication are ACP, education and communication training. With their expertise, elderly care physicians function as the key consultants to facilitate this process, supported by palliative care specialists. Rather than have healthcare professionals refer cases to the elderly care physician or palliative care specialists, this means that elderly care physicians and palliative care specialists need to support GPs, hospital doctors and nursing staff in providing palliative dementia care themselves. It is thus important that consulting a specialist in palliative dementia care does not reinforce the lack of support for palliative dementia care in certain healthcare settings.

Figure 1
Schematic of process to overcome barriers to high-quality palliative care in dementia


Public education on palliative care has been labeled a key priority by international experts to support integrated palliative care (28) and several studies found a positive effect on palliative care delivery (29-31). The effectiveness of education on dementia, however, remains unclear (32). This is why improving communication that was frequently proposed is an important solution. Families want more information about dementia, preferably provided by healthcare professionals that follow-up on this information (33). Communication between healthcare providers and families is thus important to educate families. In addition, ACP, if perceived as an ongoing dialogue, can serve as a means to support education and communication. This ongoing dialogue is further important as families need repeated information about their relative’s condition and palliative care options to foster acceptance (34). Timely discussions of death and dying are important in orienting families to palliative care (35). To support an early start of ACP, the physicians called for public education on ACP or advance directives, end of life and the lack of added value of curative medical treatments in advanced dementia. Moreover, families, nurses and physicians should use consistent language in ACP.
In addition to pointing to complexities around families not being on the same page, many solutions targeted nursing staff. Nurses are especially important to address barriers to providing high-quality palliative care that are specific to dementia: difficulties in assessing discomfort and the start of the dying phase (36). Having an elderly care physician on the staff does not suffice, as proper assessment involves continuous monitoring. Nursing staff are in a better position to perform this. Continuous monitoring requires time, training and communication with team members. However, the elderly care physicians stated that there was a lack of time and poor staffing levels, as frequently observed before (18), causing high workload. In addition, they expressed a lack of trust in nursing staff being sufficiently equipped to deliver high-quality palliative care. Nurses indeed express difficulties in recognizing and addressing care needs (37). Training in using tools is therefore necessary (38) and was often suggested by the elderly care physicians. This training should underline the use of the tools as supportive instruments and not as standardized protocols or as a tick box approach, to retain a person-centered approach. This specific issue was also raised by one of the respondents.
There are some limitations of this study. Brief answers to the open-ended survey items complicated interpretation and elaboration could not be sought. Another limitation is the time between data collection (2013) and reporting. This could affect the relevance of the results. However, the findings were considered to be relevant-and the interpretation of answers appropriate-as the perceived barriers and proposed solutions were confirmed by expert physicians in 2021. Additionally, developments in nursing home care in the years following data collection (39) lead us to believe that the barriers were stable or even increasing. For example, nursing home staff was found to feel less competent. A strength of this study is the inclusion of a large and representative sample of elderly care physicians and the two-stage approach, adding expert views. The representative sample led to the inclusion of more women than men in this study, as the proportion of women working in nursing home care in the Netherlands is higher than in medical specialist care (40). Future research could investigate if men and women in healthcare experience different barriers to palliative dementia care.
In conclusion, elderly care physicians in the Netherlands experience several barriers to providing high-quality palliative care in dementia. The current study suggests a strong need for specialist training of nursing staff, stronger networks between healthcare professionals to ensure continuity of care, and raising public awareness in the domains of dementia, palliative care, ACP and end of life. Palliative dementia care is shared care as families, nurses and physicians all have a role to play. Better education could overcome barriers in several contexts: both in nursing homes and in society.


Funding: The study in the Netherlands was supported by the Aspasia supplement to a career award for JS provided by the Netherlands Organization for Scientific Research (NWO; Innovational Research Incentives Scheme) Vidi grant number 91711339. Analyses were part of an EU Joint Programme – Neurodegenerative Disease Research (JPND) project. This project is supported in the Netherlands through the Netherlands Organisation for Health Research and Development (ZonMw) program Memorabel grant number 733051084 under the aegis of the EU Joint Programme – Neurodegenerative Disease Research (JPND) – www.jpnd.eu. The sponsors had no role in the design and conduct of the study; in the collection, analysis, and interpretation of data; in the preparation of the manuscript; or in the review or approval of the manuscript.

Acknowledgements: Special thanks to the elderly care physicians who completed the surveys and the expert physicians who checked the results. The authors would like to thank Dr. Tamara Sussman for reviewing an earlier version of the manuscript.

Conflict of interest: The authors declare that they have no competing interests.





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21. Gijsberts, M-HJE, van der Steen, J.T., Hertogh, C.M.P.M., et al. Spiritual care provided by nursing home physicians: a nationwide survey. BMJ Support Palliat Care 2019; 0: 1-9.
22. Klapwijk, M. S., Dekker, N. L., Caljouw, M. A., et al. Experiences with the Liverpool care pathway for the dying patient in nursing home residents: a mixed-method study to assess physicians’ and nurse practitioners’ perceptions. BMC Palliat Care 2020; 19: 1-11.
23. Gabbard, J., Johnson, D., Russell, G. et al. Prognostic awareness, disease and palliative understanding among caregivers of patients with dementia. Am J Hosp Palliat Care 2020; 37: 683-691.
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M.D. Simon1, S.D. Meshkat1, N. Raja1,2


1. Office of Population Health and Accountable Care, UCLA Health System, Los Angeles, California. USA; 2. Division of Medicine, UCLA Health System, Los Angeles, California, USA. Corresponding author: Megan D. Simon, 10960 Wilshire Blvd. Suite 1410, Los Angeles, CA 90024, mdsimon@mednet.ucla.edu

Jour Nursing Home Res 2021;7:17-22
Published online April 30, 2021, http://dx.doi.org/10.14283/jnhrs.2021.4



Objectives: As COVID-19 spread across the United States, and most rapidly in skilled nursing homes, public health departments developed policies to mitigate the spread. Concerns grew over whether this spread linked to nursing home quality. Design: We collected data on nursing home quality, staffing, and COVID-19 cases from the Centers of Medicare and Medicaid Services. Demographic data was sourced from Long Term Care Focus. Settings and Participants: The analysis used cross-sectional data from 1,025 California skilled nursing homes including quality ratings and confirmed COVID-19 cases between May 17, 2020 and August 23, 2020. Methods: The dependent variable was confirmed COVID-19 cases among residents. The primary independent variables were Overall Rating and Health Inspection Rating, while also including nursing home beds, patient race composition, ownership and geographic classification. Results: 5-Star Overall Rating, 5-Star Health Inspection Rating, and a lower count of health inspection deficiencies each predicted a lower likelihood of having a confirmed COVID resident case (p<.05). Conclusions and Implications: Skilled nursing homes with higher quality ratings and fewer health inspection deficiencies were less likely to have a confirmed case of COVID-19 among residents.

Key words: COVID-19, nursing home, healthcare quality.



A Center for Disease Control investigation in early March revealed how quickly SARs-CoV-2 spread in one Washington nursing home in King’s County. After just a few weeks, the nursing home’s index case infected an additional 167 employees, residents and visitors (1). Tracers found that this outbreak spread to eight more facilities and continued spreading across the county and beyond. This King’s County nursing home had the highest possible CMS Star Rating for its region, and its outcome posed the question of how to prepare skilled nursing homes(NH) for the spread of a new, unknown virus.

Links Between CMS Scores and Quality Outcomes

Center for Medicare and Medicaid Services (CMS) Star Ratings come from a step-wise mix of scores on health inspections, quality, and staffing, before weighing the final score relative to performance in the state (2). The overall score is limited first by the health inspection rating, with the scores from the other components added thereafter. NHs with the top 10% of overall scores in each state receive a 5-star rating. High CMS Star Ratings significantly associate with improved quality outcomes including lower rates of emergency department visits, 30-day and 90-day readmissions, and mortality (3-5).
The components of the CMS Star Rating also demonstrate significant effects. Higher health inspection scores associate with a lower risk of 30-day readmissions and mortality (3, 6). Higher quality star ratings associate with a 20% reduction in ED visits (5). A meta-analysis of 150 studies determined that a higher ratio of nursing staff to patients is also linked to fewer health inspection deficiencies, lower readmissions and improved CMS clinical quality metrics (7).

Previous Factors Attributed to the Spread of COVID-19 in Skilled Nursing Homes

Key factors determined to influence the spread of COVID-19 include a difficulty identifying individuals infected with COVID-19 based on signs and symptoms alone, industry trends in nursing home staff working at more than one facility, and location of a facility in a region with high community prevalence of the virus (8, 9).
Metropolitan regions have found that individuals of Black and Latinx race or ethnicity disproportionally make up more confirmed COVID-19 cases and deaths. A project within the San Francisco Mission District discovered that when testing was offered to all residents in the community, individuals identifying as Latinx represented 40% of those tested but 95% of confirmed cases (10). Risk factors listed include inability to shelter in place and maintain income, frontline service work, unemployment, and household income <$50,000 a year. In May, a multi-state analysis revealed that NHs with a lower percentage of white residents, and a greater percentage of Black residents, are significantly more likely to have COVID-19 outbreaks (9).
While some studies found an inconsistent association between Overall CMS Star Rating and COVID-19 cases (8, 9), others found a significant link, including a study in California that analyzed cases reported between May 17th through June 2nd (11, 12). Since then, California Department of Public Health announced a new mandate for proactive facility-wide testing which had the effect of accelerating the identification of one or more cases. By looking at a longer time period, this study seeks to further understand the relationship between COVID-19 resident cases and quality ratings in California NHs. It also aims to determine whether health inspection findings associate with confirmed cases, while adjusting for NH size, ownership status and a higher percentage of white residents compared to California average.



Cross-sectional data was collected for 1,101 skilled nursing homes in California through CMS publicly-reported data and the Shaping Long Term Care in America Project. NHs were then selected for analysis based on availability of data for each of the variables.

Data Collection

COVID-19 case volume was reported by NHs from May 17 to August 23, 2020 to the CDC National Healthcare Safety Network and shared via the CMS Nursing Home COVID-19 Public File (13). Reporting of cases prior to May 17th, 2020 was deemed optional. NHs were categorized by those with one or more reported resident cases or no reported resident cases.
Patient demographic data was collected from the Shaping Long Term Care in America Project, supported by the National Institute on Aging and Brown University (14). Though the dataset’s creation was several years ago, recent studies have used it to demonstrate significant association between skilled nursing home composition of race/ethnicity and presence of confirmed COVID-19 cases (9, 11, 12). NHs were categorized into either above the California average percentage of white residents (59.5%), or not above average.
NH metrics were extracted from the Centers of Disease Control to measure urban-rural classification, and from CMS Nursing Home Compare to measure bed count and ownership status (15). While previous studies found significance with occupancy rate (12), CMS data on NH occupancy showed declines each week reported, potentially confounding more SNFs reporting suspected or confirmed cases. To avoid selecting a confounding variable, we used CMS bed count.
CMS Nursing Home Compare also provided measures of quality, including Overall Star Rating, Staffing Star Rating, and Health Inspection Star Rating. To understand these measures more deeply, we also looked at count of health deficiencies by CMS-defined category, as well as average licensed practice nursing (LPN) hours per resident per day, which uses mandated payroll reporting and total residents at the NH to estimate the average. Since NHs are required to have a minimum of one registered nurse staffed at all hours, LPN staffing is more likely to vary independent of bed count (2). We used the Health Inspection rating as the primary independent variable as it has the greatest potential to impact a NH’s overall rating (2).

Statistical Analyses

We measured significant relationships between the independent variables and confirmed COVID-19 cases using univariate logistic regressions. We then used multivariate logistic regressions to estimate the impact of the independent variables on cases while adjusting for size, ownership, above average white resident percentage and rural classification. Analyses were performed using R v 3.6.3. (R Core Team, 2020)
After analyzing the effect of Overall Star Rating, we looked at the rating components including Health Inspection Star Rating, and Staffing Star Rating. In order to understand the effect of specific deficiencies on cases, we used the three most common categories of Health Inspection deficiencies as defined by CMS: Quality of Life, Resident Rights and Resident Assessment and Care Planning deficiencies.



We analyzed the results of 1,025 skilled nursing homes in California. Table I shows characteristics of NH by COVID-19 confirmed resident case volume and the resulting significance of independent logistic analyses. Each CMS quality or demographic variable showed a significant relationship to COVID-19 cases reported, with the exception of staffed LPN hours per patient per day.

Table 1
Characteristics of Skilled Nursing Homes with COVID-19 Cases (n=1025)

Count(percentage) are presented for overall and health inspection ratings, white resident percentage, ownership, and geographic classification. Mean(standard deviation) are presented for health inspection deficiency categories, beds and LPN staffing hours. P Value measures the significance of independent logistic regressions with the variable and presence of a confirmed COVID-19 case; Sources: CMS Nursing Home COVID-19 Public File, CMS Minimum Data Set, LTC Focus, CDC


To understand the relationship between Health Inspection Ratings and COVID-19 cases, we used a multivariate logistic regression. Table II summarizes the results of the first model which used Health Inspection Rating as the key independent variable. Health Inspection Rating showed a significant association to cases, while adjusting for beds, white resident percentage, ownership, and rural classification. The Odds Ratio of a 5-Star Rated NH having a case reported compared to a 1-Star NH was 0.45, suggesting these nursing homes are 45% less likely to have a confirmed case (95% CI 0.25 – 0.80). For each additional bed, the odds of a confirmed case increased by 1.5% (OR 1.015, 95% CI 1.01 – 1.02). NHs with above average percentage of white residents had a 57% lower likelihood of a confirmed case (OR 0.565, 95% CI 0.42 – 0.75). For-profit ownership associated with a 70% greater likelihood (OR 1.704, 95% CI 1.13 – 2.58). Lastly, nursing homes in rural areas had a 16% lower likelihood of a confirmed case (OR 0.162, 95% CI 0.06 – 0.46). Using these variables, Figure I plots the model’s predicted probability of each indexed nursing home to have a confirmed case. If the facility did have a case during the time period, they are marked in red while those without are marked in green.

Table 2
Regression Results of Health Inspection Rating and COVID-19 Cases among California Skilled Nursing Homes

*p<.001, †p<.01, ‡p<.05; 1025 cases


Individual deficiencies also have a significant relationship with COVID-19 cases. Table III summarizes the results in this second model. Each quality deficiency associated with a 6.7% greater likelihood of a confirmed case (OR 1.067, 95% CI 1.04 – 1.10) and each resident rights deficiency associated with an 8.1% greater likelihood (OR 1.081, 95% CI 1.04 – 1.12). Among the categories, care plan deficiencies had the largest effect size where each additional deficiency increased the likelihood of a confirmed case by 11.3% (OR 1.113, 95% CI 1.07 – 1.16).

Figure 1
Graph of 1,025 Skilled Nursing Homes’ Predicted Probability of a Confirmed Case of COVID-19 Among Residents

This graph plots each of the 1,025 nursing facilities against the model’s prediction of a confirmed case. Facilities are marked with a red “X” if the facility had 0 resident cases during the time period and a green “X” if the facility and 1 or more resident cases.

Table 3
Regression Results of Health Inspection Deficiency Category and COVID-19 Cases among California Skilled Nursing Homes

*p<.001, †p<.01, ‡p<.05; 1025 cases



This study shows a significant association between a number of important skilled nursing home quality metrics and the likelihood of a confirmed COVID-19 case. The association remained after adjusting for influential NH demographics, including bed count, white resident percentage, ownership and rural classification. Figure I plots the model’s success in predicting if a facility has a confirmed case. The model is relatively more accurate when a facility has a very low or very high probability predicted based on these variables.
Fewer quality, residents’ rights or care plan deficiencies each associate with a lower likelihood of COVID-19 cases. These findings may answer current questions about the importance of CMS Health Inspections and also impact future policies and practices to support quality of care. Experts recommend increased oversight and regulation of nursing homes which contrasts with the CMS announcement in June 2020 to reduce frequency of inspections (16, 17). Further research and transparency is needed to understand the effect of these changes on patient care as well as how CMS identifies and categorizes health inspection deficiencies. In September 2020, CMS launched a new website, CareCompare, with less information about nursing home quality (17). Experts called for increased transparency on this website of quality ratings and enforcement of accurate ownership and financial information, which have proven ties to repeat quality issues (17). Our research shows that quality ratings and inspection findings have a meaningful association to the likelihood of an outbreak and are important data to share.
Because CMS Health Inspection Ratings may be weighted by the amount of time to respond to deficiencies and the relative performance of a nursing home compared to others in its state, a direct count of deficiency types may be more indicative of infection risk than ratings themselves (2). This study found significance with the three most common deficiency types. Future analyses should seek to understand the effect of other deficiency types on infection control.
While Staffing Rating demonstrated a significant association with the likelihood of a confirmed case (p<.001), other factors may limit this significance. These include recent changes in minimum staffing waivers and the relative movement of asymptomatic carriers (8). The intersection of quantity of staffing, quality of training and percentage of shared part-time staff with other NHs is of considerable interest for future studies.
Other factors beyond the scope of this study may contribute to the size of the outbreak, including amount of traffic in and out of NHs, air exchange rate and amount of physical space per resident (1, 8, 10).
Additionally, education and supplies for infection prevention continue to be of importance in preventing the spread (1, 9, 15). Patient-level factors, such as socioeconomic status, comorbidities or age, may also impact prevalence and presentation of the virus in NHs. More research is needed to capture and understand the relative effect of these factors in addition to quality ratings.
This study design is limited to NHs in only one state, California. This state was selected in part because of its mandate for weekly facility testing and relative accuracy of mandated reporting. Still, the study is limited by the ability and willingness of NHs to test residents, and the true frequency of such tests. Due to this, the effect size may be underrepresented in this analysis.
This analysis does not suggest a causal link between health deficiencies and COVID-19 outbreak size. It looks to define the significance of quality ratings in relation to COVID-19 cases, which can highlight areas of opportunity for future outbreak management.
Skilled nursing homes with higher quality ratings and fewer health inspection deficiencies were less likely to have a confirmed case of COVID-19 among residents. By working to excel in these measures, while also following current COVID-19 public health guidelines, skilled nursing homes may impact their performance on outbreak management of COVID-19 or other viruses.
Public policies to support ample staffing and adherence to infection prevention may also provide significant benefit. Some experts call for the reinstatement and expansion of a previous requirement for nursing homes to employ a part-time infection preventionist. CMS reduced this requirement in 2019 from infection preventionists employed “part-time” to “sufficient time” (19). Beginning January 1, 2021, California requires a full-time infection preventionist at all skilled nursing homes (20). Further research should evaluate the effect of this intervention and others on type and frequency of health inspection findings, quality of patient care, and overall prevention of the spread of infectious diseases.


Acknowledgements: We would like to thank the public health workers at the California Department of Public Health, Centers for Medicare and Medicaid Services, and LTCFocus for collecting this information and making it available to patients, family members and researchers.

Funding: The authors have declared no funding related to this article.

Conflict of Interest: The authors have declared no conflicts of interest.

Ethical standards: This study used data freely available in the public domain. Therefore, the authors did not seek approval from an ethics body.



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R.M. Buchanan1,2, K. Ibrahim1,2, H.C. Roberts1,2, B. Stuart3, F. Webley3, Z. Eminton3, D. Ball3, F. Chinnery3, J. Parkes1,2, J. Wyatt1, T. Daniels4


1. Faculty of Medicine, University of Southampton, Southampton, Hampshire, United Kingdom; 2. NIHR Applied Research Collaboration Wessex, University of Southampton, Hampshire, United Kingdom; 3. Southampton Clinical Trials Unit, University of Southampton, Southampton, Hampshire, United Kingdom; 4. Respiratory Department, University Hospital Southampton, Southampton, Hampshire, United Kingdom & University of Southampton Respiratory Biomedical Research Centre, United Kingdom. Corresponding author: Ryan M Buchanan, University of Southampton, Room AC22, C level, South Academic Block, University Hospital Southampton, Tremona Road, Southampton, Hampshire SO16 6YD, ryan.buchanan@soton.ac.uk

Jour Nursing Home Res 2021;7:13-16
Published online April 30, 2021, http://dx.doi.org/10.14283/jnhrs.2021.3



Hypertonic saline nasal irrigation and gargling (HSNIG) has the potential to reduce COVID 19 transmission. We present a pilot cluster randomised controlled trial to assess the feasibility and acceptability of a future trial to test the effectiveness of HSNIG in care homes (CHs). Staff in the intervention CHs were invited to perform HSNIG whereas control CHs carried on with their routine protection procedures. The acceptability of HSNIG was explored via interviews and online surveys. Seven (21%) of contacted CHs participated but following randomisation three (43%) dropped out leaving two intervention CHs and two control CHs. Facilitators to uptake of HSNIG included motivated ‘champions’ and integration into routines. Barriers included a lack of ownership and perceptions of reduced risk from COVID-19. Recruiting and retaining CHs in this study was challenging. Although HSNIG was reported to be safe and acceptable by staff, further work is required to quantify and optimise its acceptability.

Key words: COVID-19, nasal irrigation, gargling, hypertonic saline, care home, Sars-CoV-2; HSNIG.



COVID-19 has a high mortality rate in older people (1). There have been many devastating outbreaks in care homes (CHs) (2). In England there were over 12000 deaths in CHs in the 1st wave of the pandemic and CH associated fatalities accounted for over a third of total deaths in the USA in the same time-frame (3, 4).
It is recognised that COVID-19 is carried in the nasal passages of asymptomatic individuals (5–8). Nasal irrigation with salty water is already used as a simple and cheap treatment for sinusitis and hypertonic saline and has been shown to have anti-microbial (8) and anti-viral properties (9). A trial of regular hypertonic saline nasal irrigation rinse and mouth gargle (HSNIG) for viral upper respiratory tract infections has shown a reduction in transmission of symptoms to close contacts (8). Importantly, this study also recorded a decline in the viral load of corona viruses indicating the potential utility of HSNIG in reducing COVID-19 transmission (10).
The effectiveness of HSNIG by CH staff at preventing COVID-19 in residents has not been investigated. However, before designing an effectiveness trial of HSNIG by CH staff to prevent COVID-19 in residents it is necessary to pilot the study design and the HSNIG intervention. Therefore the aim of this study was to assess the feasibility of recruiting and randomising CHs and the acceptability of HSING by CH staff.



Study design and setting

The study was a pilot cluster-RCT of daily HSNIG for CH staff. Whole CHs were randomised 1:1 to either HSNIG by staff, or usual infection control/hygiene practice. To meet our study objectives we aimed to recruit eight CHs.
All CHs in Hampshire (United Kingdom) were potentially eligible to participate in the study. Exclusion criteria included CHs where HSNIG was already part of hygiene policy or those with ≥50% of agency staff. CH managers were contacted by phone; those who expressed interest were emailed an information sheet and contacted to ask if they wanted to participate. The Southampton Clinical Trials Unit (CTU) randomised CHs to intervention or control immediately after recruitment. The study had ethical approval from a UK National Research Ethics Committee (20/WA/0162). The study protocol was registered online: http://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=379905&isReview=true.


Staff were asked to perform HSNIG at the beginning of each shift and up to twice more mid-shift for 12 weeks. The CH manager was asked to nominate an enthusiastic champion to lead training and implementation. A video produced by the research team was sent to the managers and the nominated champions (see link-https://www.youtube.com/watch?v=__-QSLlGWps) that demonstrated how to perform HSNIG. The HSNIG equipment was a plastic 60ml galley pot, 1.5g of sea salt in two sachets and a plastic stirrer (cost 0.16 GBP). Staff members had to make up the solution themselves and could opt out of performing HSNIG at any time.

Control care homes

All CHs were asked to continue with existing infection control precautions including hand washing and protection equipment as per CH policy. Control CHs were not asked to perform HSNIG or given the training videos.

Data collection and analysis

HSNIG champions were asked about engagement with HSNIG training and the number of staff rinsing during shifts via weekly online surveys. A purposive sample of staff, managers and champions in the intervention CHs (including those which withdrew and continued) were also invited for a telephone interview to explore their views and experiences with the study. Interviews transcripts were anonymised and analysed using thematic analysis with constant comparison (11).



Recruitment and randomisation

Thirty-three CHs were approached and seven agreed to participate (Figure 1). Twenty-six CHs declined to participate in the study: six (23%) declined by ‘head office’ without further explanation, three (12%) declined because of an active outbreak of COVID-19, three (12%) declined because they were ‘too busy’ and one (4%) declined to participate because the idea of HSNIG was unacceptable to staff members.

Seven CHs were randomised. One dropped out immediately after allocation to ‘control’ because the manager found this unacceptable and wanted to use HSNIG. Two of the four CHs in the intervention arm never implemented HSNIG because one was overwhelmed and the other felt the pandemic had passed (Figure 1). Therefore, four CHs completed the study (dropout rate= 43%): two in the control arm and two in the intervention arm.

Acceptabilty of the HSNIG

The online ‘champions’ weekly survey from the two intervention CHs that implemented HSNIG were received for four weeks (weeks 1 to 4) of the intended 12-week study period. The champions reported that the proportion of staff administering HSNIG 2-3 times per shift varied from 40% to 100% during these weeks. We received no survey returns after week 4. However, the qualitative interviews indicated that staff carried on performing the procedure until the end of 12 weeks.
Six telephone interviews were conducted with two managers, two champions and two staff members from three out of the four CHs that were randomised to the intervention. These included two CHs that implemented HSNIG and one that withdrew. Interviews took place 6-12 weeks following randomisation and were on average 20minutes long.

Figure 1
CONSORT diagram showing care home recruitment and retention in the study


Barriers and facilitators for HSNIG implementation in CHs are summarised with direct quotes from participants in Table 1. A number of facilitators to uptake of the HSNIG were reported including enthusiastic champions and motivated staff. Strong leadership and a shared commitment from managers and champions as well as the integration of HSNIG into daily routines also facilitated implementation. Easily accessible information and training materials as well as the simplicity of the intervention were additional facilitators. All interviewees were satisfied with the training materials and found them understandable. Participants reported that group training with champions was preferable as it promoted a shared commitment by staff and that having someone to watch them was reassuring. No staff members reported adverse events from HSNIG and most participants found the intervention easy, quick and non-invasive. Some described finding it easier the more they did it.

Table 1
Quotes from qualitative interviews highlighting important barriers and facilitators for the uptake of hypertonic saline nasal irrigation and gargling by care home staff


A number of barriers were reported including a lack of staff motivation. This was due to staff already feeling that COVID-19 was less a threat, or due to negative test results and feeling they were doing enough to prevent the virus from coming to their home. Perceived lack of proven benefits from the HSNIG and the view that nothing can stop COVID-19 from spreading contributed to staff lack of motivation. Lack of ownership by managers and champions was also a reported barrier that influenced staff motivation to implement HSNIG. Interviewees also mentioned how time constraints and workload during the pandemic and the fact that they had to implement other infection control procedures hindered them from trying the intervention. Some interviewees also reported that HSNIG was an unpleasant experience that made some feel sick and unwilling to carry on with it.



We have shown two important positive findings. Firstly, it is feasible to recruit CHs for a cluster RCT of HSNIG by CH staff and secondly, whilst some staff members can willingly and safely perform HSNIG, its widespread implementation is challenging. Specifically, randomisation to standard care was unacceptable for one CH and retention of CHs in the intervention group proved challenging. Furthermore, we highlight significant difficulties with remote data collection to ascertain the acceptability of HSNIG in CHs during a pandemic.
Other teams have described some of the challenges we have encountered in CH research. Gaining necessary regulatory approvals takes time – particularly for clinical trials (13), recruitment can be problematic (14), and taking consent from participants is challenging (15). Based on our experience in this study we would argue that research in the ‘COVID-era’ with limited access to the CHs by any visitors, including researchers, is a new obstacle.
Limitations of this study affect the reliability of our findings. Our sample of interview participants was small and the majority were from CHs that had successfully implemented HSNIG for a period. This may have led to an overly positive assessment of the HSNIG procedure. Even within these CHs we were reliant on participants contacting us for an interview and it is likely these willing individuals were more engaged with the study.
Despite these limitations, our findings are worthy of consideration when designing a future effectiveness trial. An alternative design such as a stepped-wedge (12) trial should be considered, and whilst managerial support and the use of champions are likely to help, it is likely that researchers need to be physically present in the CH setting to support implementation of HSNIG and collect clinical outcome data collection.
HSNIG has the potential to reduce transmission of COVID-19 to CH residents and other respiratory viruses. However, the acceptability of HSNIG by CH staff needs further investigation and acceptable, reliable and safe approaches to collect quantitative data from CHs during the COVID pandemic need to be considered.


Acknowledgements: The research team are very grateful to the care homes and staff members who participated in the study. We are also grateful to our patient and public involvement representatives who gave up their time to support the design and implementation of the study. The study was sponsored by the University of Southampton. The opinions expressed in this document are those of the authors. The sponsor had no role in the design, methods, data collection, analysis and preparation of this paper.

Funding Source: This research is funded as part of a block grant by the National Institute for Health Research (NIHR) Applied Research Collaboration Wessex. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR, or the Department of Health. RB is supported by the NIHR Academic Clinical Lecturer scheme. KI, HCR and JP receive support from the NIHR Applied Research Collaboration (ARC) Wessex. HCR receives support from the NIHR Southampton Biomedical Research Centre.

Conflict of Interest: All authors declare no conflicts of interest.

Ethical standards: All aspects of the study was approved by the National Health Service for England Research Ethics Committee (Reference number 20/WA/0162) and the University of Southampton ethics committee. Care home workers were invited to conduct the hypertonic saline nasal irrigation and gargling (HSNIG) procedure by care home managers and champions. They were free to opt out at any time. Care home staff who participated in the telephone interviews gave verbal consent. Written consent was not taken to minimise physical contact between researchers and the care home environment – care homes were in ‘lock down’ during the study. A record of the verbal consent procedure was recorded on the trust file on the secure University of Southampton server.



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M. Nagae1, T. Mitsutake2, M. Sakamoto3


1. Department of Agro-Environmental Sciences, Faculty of Agriculture, Graduate School of Kyushu University, Laboratory of Systematic Forest and Forest Products Sciences, Fukuoka, Japan; 2. Department of Physical Therapy, Fukuoka International University of Health and Welfare, Fukuoka, Japan; 3. Division of Medical Education Development, Research & Education Center for Community Medicine, Faculty of Medicine, Saga University, Saga, Japan. Corresponding author: Masumi Nagae,: Department of Agro-Environmental Sciences, Faculty of Agriculture, Graduate School of Kyushu University 744, Motooka, Nishi-ku, Fukuoka 819-0395, Japan, Phone/Fax: +81-92-802-4673, nagae.masumi.258@kyushu-u.ac.jp

Jour Nursing Home Res 2021;7:9-12
Published online February 24, 2021, http://dx.doi.org/10.14283/jnhrs.2021.2



This study aimed to clarify the practices of skincare such as bathing, face-washing, and using of skincare products, among older adults living in nursing homes in Japan. From July to August 2017, questionnaire surveys were mailed to 343 long-term care facilities in one prefecture in Japan, and 105 facilities returned the survey. Management policies on the use of facial skincare products was significantly associated with the number of resident/caregiver ratio. Meanwhile, residents in nursing homes with higher numbers of caregivers washed their faces and bathed at lower rates. There were no correlations between the number of resident/caregiver ratio, face-washing, and bathing times. When older residents could not independently perform their skin cleansing and care, that care is likely to happen less often. Sufficient manpower for the support of older residents’ skincare will improve the quality of life in long-term nursing facilities.

Key words: Activities of daily living (ADL), nursing home, skin cleansing, skincare, quality of life.



Japan is a country with one of the fastest aging populations. In 2017, the older population (65 years old or older) was 3.52 million (1).
Quality of life (QOL) among older populations has become an important outcome measure because it can give a more comprehensive “view of health care in the country and the specific growing population” (2).
Skincare in late adulthood has come to be recognized as one of the cornerstone nursing practices (3). However, given the limited number of studies, it is unclear how skincare has been practiced in public health worldwide. Moreover, it is also unclear how the basic ADLs with regard to skincare for older residents in nursing homes are currently being provided. This study aimed to collect practical data in Japanese nursing homes on the basic ADLs regarding skincare such as bathing, face-washing and the use of skincare products, and deduced the surroundings of those practices.



Study setting and participants

A questionnaire survey was conducted at 343 long-term care facilities that were registered in a prefecture in Japan, from July to August 2017. Once facilities agreed to voluntarily participate in this study and provided their consent, respective administrators answered the questionnaires. We referred to the research protocol from a previous study which had carried out in Germany (4). Meanwhile, we referred to the response rates from another previous study regarding Japanese nursing homes, which reported that those rates of domestic surveys were usually around 30% (5). The study protocol was in keeping with the ethical standards laid down in the Declaration of Helsinki and was approved by the Faculty of Medicine, Saga University Sciences Committee on Ethics (29-26, 2017). All participants provided informed consent before participating in the study.


To gain an overview of the facilities, data regarding the type of facility and the number of employees working in each job type at the facilities were also collected.
The variables of residents’ skin cleansing and care were assessed from questions which were re-formulated based on a previous study (6). We inquired about how often the residents washed their face per day and bathed per week, with or without help. We also asked about the facilities’ policies regarding their use of skin cleansing and application products on residents’ faces and bodies (See appendix for more information).

Statistical analyses

First, types and numbers of facilities in this sample were compared descriptively with those from the prefecture and Japan (7-9). Second, the basic information on nursing homes that were surveyed in this study descriptively. In the present study, 94-96% of facilities provided older residents with cleansing-products of hair and skin on their own responsibility. On the other hand, skincare products were provided according to each facility’s management policy. Therefore, we categorized the facilities based on the use of face-application products. Facilities where residents individually provided their own face-application products or they did not use any product were defined as Individual management; facilities where a face-application product was provided for the residents were defined as Nursing home management. Third, the Mann-Whitney U-test was performed to compare basic characteristics of nursing homes and characteristics of nursing homes’ skincare, by two categories based on the use of face-application products. Finally, Spearman’s rank correlation analysis was performed between number of caregivers, number of resident/caregiver ratio, and each item of characteristics of nursing homes’ skincare to analyse each association. A p-value of less than 0.05 was considered as a statistically significant difference. The analyses were performed using SPSS 25.0 J for Windows (SPSS, Chicago).




Of the 343 long-term care facilities contacted, 105 facilities (31%) agreed to participate in this study and provided informed consent. Table1 shows the number of nursing homes in a prefecture in Japan, and those which took part in the present study, and basic information and characteristics of nursing homes’ skincare in this sample and by two categories based on types of management of face-application products usage.
The proportions of different types of facilities, such as nursing home, special nursing home, long-term care health facility, and medical long-term care facility were as follows: the sample survey 2017 (53.4%, 26.2 %, 13.6%, 6.8 %, respectively), Statistics A Prefecture 2017 (65.3 %, 16.6 %, 12.0%, 6.1%, respectively) (Table 1), and Japanese national statistics from 2017 (50.2%, 29.3%, 16.1%, 4.4%, respectively).

Table 1
Nursing home characteristics

All nursing homes registered on Welfare and Medical Service Agency of a prefecture in Japan, during the research (in 2017); † Each p value is the level of significance of comparison between Individual skincare management versus Nursing home skincare management; ‡ Each value is expressed as n (%) or median (0.25–0.75). P values were determined by Mann–Whitney U test. § Two of 105 facilities did not fit any of these four care home types, and four of 105 facilities did not show either one of two management types.


Analyses between individual-management-type and nursing-home-management-type facilities regarding the use of face-application products and manpower

There was no significant difference between characteristics of nursing homes’ skincare by two categories based on the use of face-application products (Table 1). However, there was a significantly higher older residents/caregiver ratio in individual-management facilities [2.2 (1.8-3.1)] compared to nursing-home-management facilities [1.8 (1.4-2.2)] (p = 0.031).

Relationship between face-washing and bathing frequency and manpower environment in facilities

Table 2 shows the result of correlations between number of caregivers, number of older residents/caregiver ratio, and each item of the characteristics of nursing homes’ skincare. There was a significant negative correlation between number of caregivers and the number of older residents/caregiver ratio (correlation coefficient [R] = -0.319, p = 0.002). Number of caregivers had a significant negative correlation with both residents with need for help (R = -0.283, p =0.005) and without need for help (R = -0.230, p = 0.042) to perform daily face-washing. Similarly, number of caregivers had a significant negative correlation with both residents with need for help (R = -0.461, p < 0.001) and without need for help (R = -0.485, p<0.001) to take their weekly bath.
Contrastingly, there was no significant correlation between number of resident/caregiver ratio and daily face-washing frequency for both residents with need for help (R = 0.003, p = 0.980) and without need for help (R = 0.124, p = 0.294). Similarly, there was no significant correlation between number of resident/caregiver ratio and weekly bath frequency for both residents who needed for help (-0.043, p = 0.685) or those who did not need for help (R = 0.031, p=0.790).

Table 2
Spearman’s rank correlation coefficients between manpower at facilities and face-washing and bathing frequencies

* statistically significant (p<0.05) correlation coefficients.



Residents in facilities bathed and washed their faces fewer times than other people performed those activities at their homes (10). Japan is aging ever faster, and understaffing of welfare work has been a serious problem (11). However, no significant correlation was found between the resident/caregiver ratio and the frequency of face-washing or bathing. Thus, lack of manpower may not be a direct factor related to the limited number of opportunities for face-washing or bathing. In contrast, there was a significant difference of the number of taking care of older residents between two categories based on types of management of face-application products usage.
Since the late 1990s, nursing care in Japan has been developed in terms of individual and unit care, which has created a homelike environment (12). However, the government recommendation for bathing merely states, “at least twice a week using an appropriate method”, and there are no guidelines for the quality of bathing.
Even if facilities observe minimum standard rules, the quality of bathing practices differs from that in regular homes. Most facilities tend to have less frequency of daily face-washing and weekly bath. Their face-washing or bathing policies might have been developed to observe the guidelines on the minimum number of bathing times (13), even if there are enough staff members to support older residents. In contrast, management policy on the use of facial skincare products was significantly associated with the number of the resident/caregiver ratio. Individual-management-type facilities showed a 2.2 resident/caregiver ratio, on the other hand, Nursing-home-management-type facilities showed 1.8 resident/caregiver ratio. This small difference affected residents’ opportunities to use skincare products. Enhancing QOL is an important part of older adults’ healthcare (3), and it has gained more attention in recent years (8). Moreover, policies around older residents’ care have been designed to support personal dignity (14). Additionally, it has reported that maintaining healthy skin was associated with better mental and emotional wellbeing (15). However, if facilities always leave older adults to their own skincare without looking at the personal environment, the policy is not consistent with supporting personal dignity and wellbeing.


This study has a few limitations. First, the present study was conducted at long-term care facilities in only one prefecture in Japan, and the facilities participated voluntarily. We cannot completely remove the possibility of selection bias. Secondly, this study was a cross-sectional survey that focused on the lifestyles of nursing home residents, so these results should be cautiously applied to clinical practice.



Regardless of these limitations, to the best of our knowledge, this was the first study to collect practical data on skin cleansing and care in Japanese nursing homes. As for the support for activities of daily living in long term care, facilities do not only obey guidelines, but also should examine how best to support residents from the viewpoint of personal dignity and the individual care.


Study design: MN, TM, MS; data collection and analysis: MN and manuscript preparation: MN, MS.

Conflict of Interest: The authors have no potential conflicts of interest to disclose.
Funding: This work was supported by JSPS KAKENHI under Grant number JP17K09218.

Ethical standards: The study protocol was approved by the Faculty of Medecine, Saga University Sciences Committee on Ethics (29-26, 2017).



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