By Deba Hafizi

Many countries, including Canada, have implemented strict no-visitor policies in long-term care (LTC) homes. This is in an attempt to reduce the risk of introducing coronavirus disease (COVID-19) into these facilities and to prevent further mortality and infection among its residents and staff. Although these measures have been effective, some jurisdictions are considering relaxing visitation restrictions given growing concerns about the effect of social isolation on the mental health of LTC residents.

While reopening LTC homes to visitors may be beneficial for mental wellbeing, it also leaves both staff and residents at greater risk of infection given the close-contact nature within these facilities. High rates of infection among health care workers have resulted in high levels of anxiety and intensified staff shortages and absenteeism in LTC. This has been linked to worse COVID-19‒related outcomes within these facilities. Countries that have successfully limited the number of COVID-19 cases in LTC, such as Australia and Hungary, provided additional supports for LTC workers early on in the pandemic. These supports include surge staffing, specialized teams, and personal protective equipment (PPE). To support the well-being and safety of LTC staff, who play an essential role in the quality of care and the control of infection within these facilities, it is important to implement measures to support them during the next phase in the pandemic.

CADTH recently compiled a snapshot of the clinical evidence published between January 1, 2014 and July 31, 2020 on best practices that could help support LTC staff and mitigate their concerns during the pandemic and during the reopening of LTC homes to visitors. CADTH is an independent agency that finds, assesses, and summarizes the research on drugs, medical devices, tests, and procedures to find out what the evidence says. To respond to the immediate research needs during the rapidly evolving pandemic, CADTH identified 14 documents from a variety of sources relevant to the topic, including peer-reviewed and non-peer-reviewed articles.

Based on the findings, many safety concerns expressed by LTC staff are related to the proximity of staff to residents during an infectious outbreak in the home. Staff are worried about both the health of residents and about becoming infected themselves, leading to high levels of anxiety in these health care workers. Additional concerns from staff include the lack of pandemic preparedness and infection prevention control (IPC) training; the shortage of PPE (at the start of the pandemic); insufficient staffing levels; delays in testing for residents and staff; confusion stemming from the evolving guidance (especially with respect to PPE); and challenges in fulfilling IPC responsibilities, such as enforcing social distancing among some residents, such as those with dementia, who may not comprehend the reasons for it.

The CADTH review identified general guidance on ways to prevent infection in LTC facilities or to directly support staff throughout the pandemic and/or reopening processes. One observational study specific to reopening LTC homes to visitors found that residents, staff, and visitors reported a positive experience during reopening, and no new COVID-19 infections were reported within the timeline of the study. However, both staff and residents were worried about the increased risk of infection, with staff being concerned not only about their own health but also about their spouse’s health. Staff also reported that the protocol for visits — planning each visit, screening the visitors, communicating risks to residents, and entering related information in each patient’s file — was at times stressful and time consuming. It has been suggested that leveraging digital technology to improve the efficiency of charting might make this process more efficient.

Multiple literature sources recommend having adequate staff-to-patient ratios. According to a report on nurse staffing levels, the recommended staff-to-patient ratio is approximately four hours of direct nursing and personal support care per day per resident. Other notable recommendations for supporting staff include offering adequate education and thorough training on IPC measures related to infectious outbreaks; having adequate PPE and resources for staff; mandating the use of appropriate PPE; actively screening all staff, residents, and visitors; testing when appropriate, such as during an outbreak or when signs and symptoms of infection are present; having IPC specialist teams or medical staff on site; and implementing policies and incentives to limit staff from working in multiple facilities and to promote the use of sick leave when appropriate. Lastly, transparent communication is recommended to help alleviate the anxiety felt by staff, residents, and their families. For example, directors, managers, and policy-makers are encouraged to pay attention to the impact of infection outbreaks on the psychological well-being of health care staff and to have transparent communication regarding updates on the pandemic. These supports, along with regular monitoring of staff well-being, would help LTC workers continue to make meaningful contributions, even as visitor restrictions are relaxed.

For more information, you can find the Synopsis Document here  . If you’d like to learn more about CADTH, visit cadth.ca, follow us on Twitter @CADTH_ACMTS, or speak to a Liaison Officer in your region: cadth.ca/Liaison-Officers.

Deba Hafizi MPH, is a Knowledge Mobilization Officer at CADTH.