Risk factors for outbreaks of COVID-19 in care homes following hospital discharge: a national cohort analysis

Abstract Background Adult residential and nursing care homes are settings in which older and often vulnerable people live in close proximity. This population experiences a higher proportion of respiratory and gastrointestinal illnesses than the general population and has been shown to have a high morbidity and mortality in relation to COVID-19. Methods We examined the number of hospital discharges to all Welsh adult care homes and the subsequent outbreaks of COVID-19 occurring over an 18 week period 22 February and 27 June 2020. A Cox proportional hazards regression model was used to assess the impact of time-dependent exposure to hospital discharge on the incidence of the first known outbreak, over a window of 7-21 days after discharge, and adjusted for care home characteristics (including size, type of provision and health board). Results A total of 1068 care homes were monitored; 330 homes experienced an outbreak of COVID-19, and 511 homes received a discharge from hospital over the study period. The exposure to discharge from hospital was not associated with a significant increase in the risk of a new outbreak (hazard ratio 1.15, 95% CI 0.89, 1.49, p = 0.28), after adjusting for care home size, which was by far the most significant predictor. Hazard ratios (95% CI) in comparison to homes of <10 residents were: 3.4 (2.0, 5.8) for 10-24 residents; 8.3 (5.0, 13.8) for 25-49 residents; and 17.3 (9.6, 31.1) for homes of 50+ residents. When stratified for care home size, the outbreak rates were very similar for periods when homes were exposed to a hospital discharge, in comparison to periods when homes were unexposed. Conclusion Our analyses showed that large homes were at considerably greater risk of outbreaks throughout the epidemic, and after adjusting for care home size, a discharge from hospital was not associated with a significant increase in risk. Keywords: COVID-19, care homes, hospital discharge, outbreak, time dependent Cox regression

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OP9 Perch – preliminary exploration of the role of paramedics in care homes

Emergency Medicine Journal ◽

10.1136/emermed-2020-999abs.9 ◽

2020 ◽

Vol 37 (10) ◽

pp. e5.2-e6

Author(s):

Mark Kingston ◽

Leigh Keen ◽

Stephanie Green ◽

Lesley Griffiths

Keyword(s):

Primary Care ◽

Care Home ◽

Care Homes ◽

Health Board ◽

List Type ◽

Role Clarity ◽

England And Wales ◽

Fact Finding ◽

The Impact

BackgroundHalf a million people live in UK care homes. General practices struggle to deliver primary care for residents due to high demand and staff shortages. Meanwhile, ambulance services are seeing an increase in 999 calls from care homes. In response, some areas are involving paramedics in proactive support to care homes, part of a shift towards paramedics undertaking non-emergency community care. Yet such workforce changes require urgent evaluation to understand implications for residents, staff and health services. We aimed to explore the role of non-emergency paramedics in care homes to support the design of portfolio research.MethodsWe convened a Research Development Group of care home, ambulance service, health board, primary care, public and academic representatives. We:Conducted fact-finding visits to sitesAnalysed 999 call data from care homesSurveyed ENRICH (Enabling Research in Care Homes) care home managers in England and WalesHeld a stakeholder workshop to explore the issuesResultsWe identified sites in England and Wales where paramedics provide non-emergency care in care homes. Operating models varied with paramedics employed by ambulance services, health boards and practices. Monthly 999 data from 300 homes confirmed high call and hospital conveyance rates. Survey respondents thought paramedics were well suited to assessing residents, identifying issues, improving care and avoiding admissions. They foresaw benefits to inter-professional working, clinical support and person-centred care, but raised concerns over professional boundaries and role clarity. These messages were reinforced in our workshop, where the value of timely assessment was highlighted, alongside challenges of funding and governance.ConclusionsThe role of paramedics is shifting into dedicated primary and community work, including care homes. It is imperative that research is aligned and informs evidence based practice. We are developing PERCH2, a feasibility study evaluating the impact of paramedics working in this way.

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The impact of statin therapy after surgical or endovascular treatment of cerebral aneurysms

Journal of Neurosurgery ◽

10.3171/2019.3.jns183500 ◽

2020 ◽

Vol 133 (1) ◽

pp. 182-189

Author(s):

Tae-Jin Song ◽

Seung-Hun Oh ◽

Jinkwon Kim

Keyword(s):

Statin Therapy ◽

Coil Embolization ◽

Primary Outcome ◽

Cox Regression ◽

Cerebral Aneurysms ◽

Time Dependent ◽

Lipid Lowering ◽

Surgical Clipping ◽

The Impact

OBJECTIVECerebral aneurysms represent the most common cause of spontaneous subarachnoid hemorrhage. Statins are lipid-lowering agents that may expert multiple pleiotropic vascular protective effects. The authors hypothesized that statin therapy after coil embolization or surgical clipping of cerebral aneurysms might improve clinical outcomes.METHODSThis was a retrospective cohort study using the National Health Insurance Service–National Sample Cohort Database in Korea. Patients who underwent coil embolization or surgical clipping for cerebral aneurysm between 2002 and 2013 were included. Based on prescription claims, the authors calculated the proportion of days covered (PDC) by statins during follow-up as a marker of statin therapy. The primary outcome was a composite of the development of stroke, myocardial infarction, and all-cause death. Multivariate time-dependent Cox regression analyses were performed.RESULTSA total of 1381 patients who underwent coil embolization (n = 542) or surgical clipping (n = 839) of cerebral aneurysms were included in this study. During the mean (± SD) follow-up period of 3.83 ± 3.35 years, 335 (24.3%) patients experienced the primary outcome. Adjustments were performed for sex, age (as a continuous variable), treatment modality, aneurysm rupture status (ruptured or unruptured aneurysm), hypertension, diabetes mellitus, household income level, and prior history of ischemic stroke or intracerebral hemorrhage as time-independent variables and statin therapy during follow-up as a time-dependent variable. Consistent statin therapy (PDC > 80%) was significantly associated with a lower risk of the primary outcome (adjusted hazard ratio 0.34, 95% CI 0.14–0.85).CONCLUSIONSConsistent statin therapy was significantly associated with better prognosis after coil embolization or surgical clipping of cerebral aneurysms.

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Survival and community care use by care home residents in England: does mental health matter?

Ageing and Society ◽

10.1017/s0144686x21001148 ◽

2021 ◽

pp. 1-15

Author(s):

Apostolos Tsiachristas ◽

Antoinette Broad ◽

Alice Coates ◽

Surya Singh ◽

Jane Fossey

Keyword(s):

Mental Health ◽

Community Care ◽

Cox Regression ◽

Care Home ◽

Care Homes ◽

Health Conditions ◽

Rank Test ◽

Cox Regression Analysis ◽

Mental Health Conditions ◽

Care Costs

Abstract The aim was to provide evidence of mortality and community care costs of people living in care homes and to investigate its association with mental health based on the Mental Health Clustering Tool (MHCT). In an observational study, 5,782 residents living in 104 care homes were followed from 2014 to 2016. Residents were categorised into four groups using the MCHT: three with mental health conditions, ‘non-psychotic’, ‘psychotic’ or ‘organic’; and one without mental health conditions, ‘non-clustered’. Generalised estimating equations were used to explore associations between mean community care costs over 6 months per patient and the clustering of residents into the four groups. Differences in survival rates of residents were plotted using Kaplan–Meier curves and tested with the log-rank test and Cox regression analysis. Community care costs were similar among residents with dementia (£431) and without mental health conditions (£407), while costs were higher among residents with non-psychotic (£762) and psychotic (£1,724) mental health conditions. After adjusting for patient and care home characteristics, residents with dementia were 30 per cent less likely to die compared with residents without mental health conditions. Similarly, residents with psychotic conditions and residents with non-psychotic conditions were 25 and 20 per cent less likely to die, respectively, than residents without mental health conditions. The MHCT seems to provide an informative stratification of care home residents with regards to survival and community care use.

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Neuraminidase inhibitors, superinfection and corticosteroids affect survival of influenza patients

European Respiratory Journal ◽

10.1183/09031936.00169714 ◽

2015 ◽

Vol 45 (6) ◽

pp. 1642-1652 ◽

Cited By ~ 51

Author(s):

Nelson Lee ◽

Yee-Sin Leo ◽

Bin Cao ◽

Paul K.S. Chan ◽

W.M. Kyaw ◽

...

Keyword(s):

Primary Outcome ◽

Cox Regression ◽

Management Strategies ◽

Patient Characteristics ◽

Primary Outcome Measure ◽

Time Dependent ◽

High Morbidity ◽

Neuraminidase Inhibitors ◽

Systemic Corticosteroids ◽

Time Dependent Analysis

We aimed to study factors influencing outcomes of adults hospitalised for seasonal and pandemic influenza. Individual-patient data from three Asian cohorts (Hong Kong, Singapore and Beijing; N=2649) were analysed. Adults hospitalised for laboratory-confirmed influenza (prospectively diagnosed) during 2008–2011 were studied. The primary outcome measure was 30-day survival. Multivariate Cox regression models (time-fixed and time-dependent) were used.Patients had high morbidity (respiratory/nonrespiratory complications in 68.4%, respiratory failure in 48.6%, pneumonia in 40.8% and bacterial superinfections in 10.8%) and mortality (5.9% at 30 days and 6.9% at 60 days). 75.2% received neuraminidase inhibitors (NAI) (73.8% received oseltamivir and 1.4% received peramivir/zanamivir; 44.5% of patients received NAI ≤2 days and 65.5% ≤5 days after onset of illness); 23.1% received systemic corticosteroids. There were fewer deaths among NAI-treated patients (5.3% versus 7.6%; p=0.032). NAI treatment was independently associated with survival (adjusted hazard ratio (HR) 0.28, 95% CI 0.19–0.43), adjusted for treatment-propensity score and patient characteristics. Superinfections increased (adjusted HR 2.18, 95% CI 1.52–3.11) and chronic statin use decreased (adjusted HR 0.44, 95% CI 0.23–0.84) death risks. Best survival was shown when treatment started within ≤2 days (adjusted HR 0.20, 95% CI 0.12–0.32), but there was benefit with treatment within 3–5 days (adjusted HR 0.35, 95% CI 0.21–0.58). Time-dependent analysis showed consistent results of NAI treatment (adjusted HR 0.39, 95% CI 0.27–0.57). Corticosteroids increased superinfection (9.7% versus 2.7%) and deaths when controlled for indications (adjusted HR 1.73, 95% CI 1.14–2.62). Early NAI treatment was associated with shorter length of stay in a subanalysis.NAI treatment may improve survival of hospitalised influenza patients; benefit is greatest from, but not limited to, treatment started within 2 days of illness. Superinfections and corticosteroids increase mortality. Antiviral and non-antiviral management strategies should be considered.

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Living in a care home during COVID-19: a case study of one person living with dementia

Quality in Ageing and Older Adults ◽

10.1108/qaoa-02-2021-0024 ◽

2021 ◽

Vol ahead-of-print (ahead-of-print) ◽

Author(s):

Ian Davies-Abbott ◽

Catrin Hedd Jones ◽

Gill Windle

Keyword(s):

Study Design ◽

Single Case ◽

Care Home ◽

Care Homes ◽

Single Case Study ◽

Content Type ◽

Case Study Design ◽

People With Dementia ◽

The Impact

Purpose This paper aims to understand the lived experience of a person living with dementia in a care home during the COVID-19 pandemic. It responds to the absence in research of the voices of people with dementia living in care homes during the pandemic. Design/methodology/approach The paper adopts a single case study design applied thematic analysis to semi-structured interview data to discover the experiences of one person living with dementia in a care home during a period of lockdown. Findings Five themes reveal how the participant responded to the practical and emotional challenges of the pandemic: autonomy; fears; keeping connected; keeping safe and other people living with dementia. These themes highlight the participant’s ability to adapt, accept and dispute lockdown restrictions, revealing considerable insight into their situation. Research limitations/implications The pandemic has restricted access to care homes, which informed the single case study design. This approach to the research may restrict the generalisability of the findings. Other researchers are encouraged to include the voices of people with dementia living in care homes in further studies. Practical implications Implications for practice, presented in this paper, promote quality psychosocial approaches when health-care workers engage with people living with dementia during periods of restricted activity. Originality/value Unlike other studies about the impact of the pandemic on care homes, this paper explores the experience of the pandemic in care homes from the perspective of a person living with dementia.

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Residents transitioning between hospital and care homes: protocol for codesigning a systems-level response to safety issues (SafeST study)

BMJ Open ◽

10.1136/bmjopen-2021-050665 ◽

2022 ◽

Vol 12 (1) ◽

pp. e050665

Author(s):

Jason Scott ◽

Katie Brittain ◽

Kate Byrnes ◽

Pam Dawson ◽

Stephanie Mulrine ◽

...

Keyword(s):

Data Extraction ◽

Care Home ◽

Incident Reporting ◽

Care Homes ◽

Structured Interviews ◽

Framework Analysis ◽

Safety Issues ◽

Care Home Staff ◽

Service Specification ◽

The Impact

IntroductionThe aim of this study is to develop a better understanding of incident reporting in relation to transitions in care between hospital and care home, and to codesign a systems-level response to safety issues for patients transitioning between hospital and care home.Methods and analysisTwo workstreams (W) will run in parallel. W1 will aim to develop a taxonomy of incident reporting in care homes, underpinned by structured interviews (N=150) with care home representatives, scoping review of care home incident reporting systems, and a review of incident reporting policy related to care homes. The taxonomy will be developed using a standardised approach to taxonomy development. W2 will be structured in three phases (P). P1a will consist of ≤40 interviews with care home staff to develop a better understanding of their specific internal systems for reporting incidents, and P1b will include ≤30 interviews with others involved in transitions between hospital and care home. P1a and P1b will also examine the impact of the SARS-CoV-2 pandemic on safe transitions. P2 will consist of a retrospective documentary analysis of care home data relating to resident transitions, with data size and sampling determined based on data sources identified in P1a. A validated data extraction form will be adapted before use. P3 will consist of four validation and codesign workshops to develop a service specification using National Health Service Improvement’s service specification framework, which will then be mapped against existing systems and recommendations produced. Framework analysis informed by the heuristic of systemic risk factors will be the primary mode of analysis, with content analysis used for analysing incident reports.Ethics and disseminationThe study has received university ethical approval and Health Research Authority approval. Findings will be disseminated to commissioners, providers and regulators who will be able to use the codesigned service specification to improve integrated care.

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Are we allowed to visit now? Concerns and issues surrounding vaccination and infection risks in UK care homes during COVID-19

10.1101/2021.05.20.21257545 ◽

2021 ◽

Author(s):

Clarissa Marie Giebel ◽

Kerry Hanna ◽

Jacqueline Cannon ◽

Paul Marlow ◽

Hilary Tetlow ◽

...

Keyword(s):

Scientific Evidence ◽

Care Home ◽

Home Visitation ◽

Control Measures ◽

Care Homes ◽

Family Carers ◽

Care Home Staff ◽

The Uk ◽

The Impact

Background: Vaccination uptake in the UK and increased care home testing are likely affecting care home visitation. With scant scientific evidence to date, the aim of this longitudinal qualitative study was to explore the impact of both (vaccination and testing) on the conduct and experiences of care home visits. Methods: Family carers of care home residents with dementia and care home staff from across the UK took part in baseline (October/November 2020) and follow-up interviews (March 2021). Public advisers were involved in all elements of the research. Data were analysed using thematic analysis. Results: Across 62 baseline and follow-up interviews with family carers (n=26; 11) and care home staff (n=16; 9), five core themes were developed: Delayed and inconsistent offers of face-to-face visits; Procedures and facilitation of visits; Frustration and anger among family carers; Variable uptake of the COVID-19 vaccine; Misinformation, education, and free choice. The variable uptake in staff, compared to family carers, was a key factor seemingly influencing visitation, with a lack of clear guidance leading care homes to implement infection control measures and visitation rights differently. Conclusions: We make five recommendations in this paper to enable improved care home visitation in the ongoing, and in future, pandemics. Visits need to be enabled and any changes to visiting rights must be used as a last resort, reviewed regularly in consultation with residents and carers and restored as soon as possible as a top priority, whilst more education needs to be provided surrounding vaccination for care home staff.

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A Qualitative Study Exploring the Impact and Effects Following Hospital Discharge of COVID-19

Journal of Respiration ◽

10.3390/jor1030020 ◽

2021 ◽

Vol 1 (3) ◽

pp. 216-222

Author(s):

Abigail Reay ◽

Avinash Aujayeb ◽

Catherine Dotchin ◽

Ellen Tullo ◽

John Steer ◽

...

Keyword(s):

Qualitative Study ◽

Hospital Discharge ◽

Psychological Effects ◽

Functional Abilities ◽

Long Term Effects ◽

Structured Interviews ◽

Discharge From Hospital ◽

The Impact

Introduction: Research into the long-term effects of coronavirus disease 2019 (COVID-19) continues at an unprecedented pace. Many physical long-term symptoms of COVID-19 have been reported and include headache, fatigue, muscle pain and breathlessness, etc. Psychological effects are not dissimilar to survivors of SARS. There is limited qualitative research exploring the mental health impacts and experiences of hospitalized COVID-19 inpatients. Methods: A prospective qualitative study is planned to explore patient experiences post hospital discharge following a diagnosis of COVID-19. The research aims to gain an understanding of how COVID-19 affects quality of life (QoL) and functional abilities. Patients discharged from the hospital will be invited to take part in semi-structured interviews discussing their experiences of hospitalization and the impact of COVID-19 on their QoL. Interviews will be conducted at three and six months following discharge from hospital. This study will provide important qualitative insight and may inform clinical interventions and commissioning decisions. Trial registration: The study has Research Ethics Committee (REC) and Health Research Authority (HRA) approvals obtained from Health and Care Research Wales (HCRW) [IRAS project ID 293196].

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Relationship Between Multimorbidity, Combination and All-Cause Mortality Among Older Adults: A Retrospective Cohort Analysis

10.21203/rs.3.rs-122536/v1 ◽

2020 ◽

Author(s):

Kun He ◽

Wenli Zhang ◽

Xueqi Hu ◽

Hao Zhao ◽

Bingxin Guo ◽

...

Keyword(s):

Older Adults ◽

Mortality Risk ◽

Cox Regression ◽

Cohort Analysis ◽

Relative Effect ◽

Long Term Conditions ◽

Cox Models ◽

Chinese Older Adults ◽

All Cause Mortality ◽

The Impact

Abstract Background: Previous studies have evaluated the association of multimorbidity with higher mortality, but epidemiologic data on the association between the combination of multimorbidity and all-cause mortality risk are rare. We aimed to examine the relationship between multimorbidity (number/combination) and all-cause mortality in Chinese older adults. Methods: We conducted a population-based study of 50,100 Chinese participants. Cox regression models were used to estimate the impact of long-term conditions (LTCs) on all-cause mortality. Results: The prevalence of multimorbidity was 31.35% and all-cause mortality was 8.01% (50,100 participants). In adjusted Cox models, the hazard rations (HRs) and 95% confidence intervals (CIs) of all-cause mortality risk for those with 1, 2, and ≥ 3 LTCs compared with those with no LTCs was 1.10 (1.01-1.20), 1.21 (1.10-1.33), and 1.46 (1.27-1.67), respectively (Ptrend <0.001). In the LTCs ≥ 2 category, the combination of chronic diseases that included hypertension, diabetes, CHD, COPD, and stroke had the greatest impact on mortality. In the stratified model by age and sex, absolute all-cause mortality was higher among the ≥ 75 age group with an increasing number of LTCs. However, the relative effect size of the increasing number of LTCs on higher mortality risk was larger among those < 75 years.Conclusions: The risk of all-cause mortality is increased with the number of multimorbidity among Chinese older adults, particularly combinations.

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