Staffing levels, not just hotspots, can predict nursing home COVID deaths, study says

Photo: Zeev Barkan via Flickr

Since the first COVID-19 outbreak in a Seattle-area nursing home in February, at least 55,000 deaths, more than 42% of the U.S. total, have been linked to nursing homes, assisted living and other long-term care facilities as of July 7, according to a national database compiled by The New York Times.

Now a new academic study supports what many already suspected: residents of long-term care facilities with lower nurse staffing levels, poorer quality scores, and higher concentrations of disadvantaged residents suffer from higher rates of confirmed COVID-19 cases and deaths.

Facilities with system-wide disparities, including fewer resources and higher concentrations of socio-economically disadvantaged populations, generally have poorer health outcomes, researchers noted, concluding that these same disparities now are playing out during the coronavirus pandemic.

The study, conducted by researchers at the University of Rochester Medical Center (URMC)  in New York state, examined nursing home-level data available at the Connecticut Department of Health and Human Services website. At the time when the data was first compiled, Connecticut was one of the few states making such information publicly available. The state data was compared to data from the Centers for Medicare & Medicaid Services’ Nursing Home Compare website, which tracks quality, staffing, and health outcomes for nursing homes nationwide.

Analyses of the Connecticut data showed that long-term care facilities with higher concentrations of disadvantaged residents, including Medicaid residents and racial and ethnic minorities, lower nurse staffing levels, notably registered nurses (RN), and lower scores on CMS five-star quality measures, had higher rates of confirmed COVID-19 cases and deaths. Higher nurse staffing ratios, in particular, were was strongly associated with fewer cases and deaths.

“In most nursing homes, RNs are the linchpin for the assessment and provision of medical care, including early identification of and response to emergencies and life-threatening situations,” said lead author Yue Li, Ph.D., a professor at URMC’s Department of Public Health Sciences. “Our findings of the strong negative association between RN staffing and the number of COVID-19 cases and deaths in nursing homes are consistent with research that has demonstrated that increased nursing levels are key to an institution’s ability to respond to outbreaks of emerging infections.”

Similar patterns in nursing homes have been observed in other states, including Florida and California. In April, the federal Centers for Disease Control and Prevention (CDC) required all nursing homes to submit COVID-19 data. A preliminary analysis of the CDC data showed similar associations between nursing home quality and staffing and coronavirus infection rates and deaths. The Washington Post reported back in April that hundreds of these homes violated infection control standards in recent years.

The URMC authors suggest that the findings should be used to recalibrate the nation’s efforts to control infection rates in nursing homes. Efforts to date have concentrated in facilities located in areas with high infection rates. The authors advise that regulators and state nursing home inspectors, going forward, also should target homes with lower RN staffing levels and quality ratings.

The study was published in the June 18 online edition of the Journal of the American Geriatrics Society.

Journalists may want to look into how the quality and staffing ratings for nursing facilities in their community compares to the actual case rate and death rate. Is it better or worse than what is being reported?

It’s a good idea to cross-check nationally-reported data with local or state authorities, or the facility itself. As AHCJ Patient Safety topic editor Cheryl Clark recently reported, numerous discrepancies have been found.

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