COVID-19 and Ontario’s Long-Term Care Homes

Abstract

Key Message Ontario long-term care (LTC) home residents have experienced disproportionately high morbidity and mortality, both from COVID-19 and from the conditions associated with the COVID-19 pandemic. There are several measures that could be effective in preventing COVID-19 outbreaks, hospitalizations, and deaths in Ontario’s LTC homes, if implemented. First, temporary staffing could be minimized by improving staff working conditions. Second, homes could be further decrowded by a continued disallowance of three- and four-resident rooms and additional temporary housing for the most crowded homes. Third, the risk of SARS-CoV-2 infection in staff could be minimized by approaches that reduce the risk of transmission in communities with a high burden of COVID-19. Summary Background The Province of Ontario has 626 licensed LTC homes and 77,257 long-stay beds; 58% of homes are privately owned, 24% are non-profit/charitable, 16% are municipal. LTC homes were strongly affected during Ontario’s first and second waves of the COVID-19 pandemic. Questions What do we know about the first and second waves of COVID-19 in Ontario LTC homes? Which risk factors are associated with COVID-19 outbreaks in Ontario LTC homes and the extent and death rates associated with outbreaks? What has been the impact of the COVID-19 pandemic on the general health and wellbeing of LTC residents? How has the existing Ontario evidence on COVID-19 in LTC settings been used to support public health interventions and policy changes in these settings? What are the further measures that could be effective in preventing COVID-19 outbreaks, hospitalizations, and deaths in Ontario’s LTC homes? Findings As of January 14, 2021, a total of 3,211 Ontario LTC home residents have died of COVID-19, totaling 60.7% of all 5,289 COVID-19 deaths in Ontario to date. There have now been more cumulative LTC home outbreaks during the second wave as compared with the first wave. The infection and death rates among LTC residents have been lower during the second wave, as compared with the first wave, and a greater number of LTC outbreaks have involved only staff infections. The growth rate of SARS-CoV-2 infections among LTC residents was slower during the first two months of the second wave in September and October 2020, as compared with the first wave. However, the growth rate after the two-month mark is comparatively faster during the second wave. The majority of second wave infections and deaths in LTC homes have occurred between December 1, 2020, and January 14, 2021 (most recent date of data extraction prior to publication). This highlights the recent intensification of the COVID-19 pandemic in LTC homes that has mirrored the recent increase in community transmission of SARS-CoV-2 across Ontario. Evidence from Ontario demonstrates that the risk factors for SARS-CoV-2 outbreaks and subsequent deaths in LTC are distinct from the risk factors for outbreaks and deaths in the community (Figure 1). The most important risk factors for whether a LTC home will experience an outbreak is the daily incidence of SARS-CoV-2 infections in the communities surrounding the home and the occurrence of staff infections. The most important risk factors for the magnitude of an outbreak and the number of resulting resident deaths are older design, chain ownership, and crowding. Figure 1. Anatomy of Outbreaks and Spread of COVID-19 in LTC Homes and Among Residents Figure from Peter Hamilton, personal communication. Many Ontario LTC home residents have experienced severe and potentially irreversible physical, cognitive, psychological, and functional declines as a result of precautionary public health interventions imposed on homes, such as limiting access to general visitors and essential caregivers, resident absences, and group activities. There has also been an increase in the prescribing of psychoactive drugs to Ontario LTC residents. The accumulating evidence on COVID-19 in Ontario’s LTC homes has been leveraged in several ways to support public health interventions and policy during the pandemic. Ontario evidence showed that SARS-CoV-2 infections among LTC staff was associated with subsequent COVID-19 deaths among LTC residents, which motivated a public order to restrict LTC staff from working in more than one LTC home in the first wave. Emerging Ontario evidence on risk factors for LTC home outbreaks and deaths has been incorporated into provincial pandemic surveillance tools. Public health directives now attempt to limit crowding in LTC homes by restricting occupancy to two residents per room. The LTC visitor policy was also revised to designate a maximum of two essential caregivers who can visit residents without time limits, including when a home is experiencing an outbreak. Several further measures could be effective in preventing COVID-19 outbreaks, hospitalizations, and deaths in Ontario’s LTC homes. First, temporary staffing could be minimized by improving staff working conditions. Second, the risk of SARS-CoV-2 infection in staff could be minimized by measures that reduce the risk of transmission in communities with a high burden of COVID-19. Third, LTC homes could be further decrowded by a continued disallowance of three- and four-resident rooms and additional temporary housing for the most crowded homes. Other important issues include improved prevention and detection of SARS-CoV-2 infection in LTC staff, enhanced infection prevention and control (IPAC) capacity within the LTC homes, a more balanced and nuanced approach to public health measures and IPAC strategies in LTC homes, strategies to promote vaccine acceptance amongst residents and staff, and further improving data collection on LTC homes, residents, staff, visitors and essential caregivers for the duration of the COVID-19 pandemic. Interpretation Comparisons of the first and second waves of the COVID-19 pandemic in the LTC setting reveal improvement in some but not all epidemiological indicators. Despite this, the second wave is now intensifying within LTC homes and without action we will likely experience a substantial additional loss of life before the widespread administration and time-dependent maximal effectiveness of COVID-19 vaccines. The predictors of outbreaks, the spread of infection, and deaths in Ontario’s LTC homes are well documented and have remained unchanged between the first and the second wave. Some of the evidence on COVID-19 in Ontario’s LTC homes has been effectively leveraged to support public health interventions and policies. Several further measures, if implemented, have the potential to prevent additional LTC home COVID-19 outbreaks and deaths.

Barriers and facilitators to person-centred infection prevention and control: results of a survey about the Dementia Isolation Toolkit

“…Long-term care homes (LTCH) and other aged residential care settings have been devastated by the novel coronavirus COVID-19 pandemic. The pandemic has resulted in the death of approximately one in five infected residents [1], and the prolonged use of strict infection control and prevention (ICP) measures including separation from families and isolation to bedrooms. While isolation and quarantine are two highly effective strategies for slowing the spread of infectious diseases, achieving effective isolation is especially challenging when caring for residents with dementia who comprise approximately 70% of the LTCH population [2].…”

“…demen tiais olati ontoo lkit. com) [19] was designed and developed in partnership with a number of LTCH stakeholders to address two aims: (1) To support the compassionate, safe and effective isolation and quarantine of residents of LTC; and (2) To support the moral resilience of LTCH staff. The toolkit includes plainlanguage ethical guidance specific to the use of isolation as an ICP measure in LTCH.…”

“…Finally, the DIT provides a person-centred isolation care-planning tool to guide the development of care plans to support individual residents during a period of isolation. Since its release online on April 23, 2020, the DIT has been downloaded more than 8000 times, and has been widely disseminated [1,20,21].…”

The Impact of the Speed of Vaccine Rollout on COVID-19 Cases and Deaths in Ontario Long-Term Care Homes

“…As of January 17, 2021, there has been a total of 13,337 cumulative SARS-CoV-2 infections and 3,212 cumulative COVID-19 deaths among LTC residents, accounting for 59.1% of Ontario's total 5,433 COVID-19 deaths. 1 Ontario's COVID-19 vaccine rollout began on December 14, 2020, with the Province identifying its approximately 70,000 LTC home residents as a priority group to receive the initial supply of COVID-19 vaccines. 2 Recently, Ontario's COVID-19 vaccination program specified January 21, 2021, as the target date for the provision of first doses of the vaccine to LTC residents in the Toronto, Peel, York and Windsor-Essex public health units.…”

From Cruddiness to Catastrophe: COVID-19 and Long-term Care in Ontario

“…Over 80% of COVID-19 deaths in Canada during the first wave of the pandemic in 2020 occurred in long-term care homes (Estabrooks et al 2020: 5). Among the 16 OECD countries, Canada bore the dubious distinction of having the highest proportion of COVID-19 deaths in long-term care facilities (Stall et al 2021: Figure 2). The provinces of Ontario and Québec experienced particularly high rates of infections and mortality in long-term care.…”