Developing improved guidelines for nursing home-associated viral respiratory infections: Learning from the COVID-19 experience

The COVID-19 pandemic highlighted the vulnerability of the nearly 1.4 million nursing home (NH) residentsto respiratory healthcare associated infections (HAI) such as COVID-19. By January 2021, there were over624,000 confirmed cases of COVID-19 with more than 125,000 reported resident deaths. NH residents larevulnerable to respiratory HAI because of multiple comorbidities and physical and cognitive frailty. Thesevulnerabilities are compounded by an institutional environment of common caregivers, shared living spaces,and setting with a history of being under-resourced and ill-prepared to manage infection outbreaks. WhileCOVID-19 related NH infections land mortality continue to increase nationwide, no one has reported on theimpact of COVID-19 on NHs capacity to respond to the pandemic and to understand the impact of theirresponse on clinical, functional, and psychosocial resident outcomes jointly. We are proposing a longitudinal mixed-methods study with the goal to develop knowledge landrecommendations to improve US NHs ability to respond to respiratory HAI outbreaks. We have unique accessto data recorded by the Quality Improvement Program for Missouri (QIPMO), a state-sponsored cooperativeprogram. QIPMO began in March 2020 documenting NH COVID-19 infections and support provided toMissouri NHs. By December, there were over 3,231 documented QIPMO encounters providing us anunprecedented opportunity to study how NHs responded to COVID-19. In aim 1, we will use QIPMO data andstate key informant interviews and interviews with approximately 350 leaders, residents/families, and staff from24 purposively sampled NHs to assess diverse NH pandemic responses, including enactment of federalguidance. In aim 2, using an interrupted time-series analysis, we will leverage statistical data from the NHstandardized assessment instrument (Minimum Data Set) to determine the effects of the COVID-19 responseon NH resident clinical, functional, and psychosocial outcomes. In aim 3, we will converge findings from aims 'Land 2 to identify relationships between contextual differences in NH responses and resident health outcomesto describe practices and strategies that either mitigated or contributed to adverse outcomes. Finally, in aim 4we will convene an expert panel to review and recommend updates to current NH HAI guidelines and identifynew practices and strategies to enhance NHs capacity to respond to infectious disease outbreaks includingidentifying implementation barriers, final dissemination plans, and future intervention development. The likelihood that COVID-19 will become endemic and create needs for ongoing management is growing.Understanding how NHs responses influenced outcomes, including long-term resident effects, will informfuture intervention development for US NHs to systematically prepare and manage infectious diseaseoutbreaks. This study laddresses the AHRQ priority to better prepare NHs for prevention and management,specifically high-risk respiratory HAI illnesses like COVID-19.