Larger nursing home staffs are a strong predictor of COVID-19 outbreaks at those facilities, according to research published Wednesday.
Summer 2020 COVID-19 case rates at nursing homes with the most unique staff members were 92% higher than at facilities with the lowest numbers of staff, the Health Affairs study found. Those same nursing homes with large staff volumes also had cumulative staff and resident death rates that were 69% and 133% higher than their counterparts, respectively. The study controlled for staffing ratios, skill mixes and community spread. It calculated historical turnover but didn't find it to be a predictor or one of the key reasons nursing homes' daily staff sizes change.
"We don't interpret our findings as saying there should be less staffing in nursing homes," said Brian McGarry, assistant professor in the division of geriatrics and aging at the University of Rochester's Department of Medicine and one of the report's authors.
Rather, the study shows how important it is to have screening and testing programs in place and for nursing home staffs to be vaccinated, McGarry said.
"It's critical that as many staff as possible get vaccinated. I think our results sort of show it's not just direct care staff. It's anyone who is coming in the nursing home. Kitchen staff, housekeeping, administrators, they should all be vaccinated," McGarry said.
The study aims to address something that had been left out of existing research on staffing in nursing homes and COVID-19 infections. While other studies had examined staffing ratios and how often staff traveled to different sites, none had looked solely at staff size, McGarry said.
"It's one of those things that I think seems obvious or intuitive after the fact," McGarry said. With visitation restricted, as it was for much of 2020, generally the only people coming into nursing homes and potentially exposing residents were the staff.
While facilities could try to limit the number of unique employees in a facility by using more full-time employees and having employees who aren't providing care work from home, they are largely limited on reducing the number of people in the building if they want to maintain care and staffing ratios, McGarry said.
Much like community spread, "what really most strongly predicts COVID-19 outbreaks in nursing homes is, by and large, out of the control of nursing homes," McGarry said. "I think that is maybe another call to rethink how we deliver nursing home care and long-term care services to older adults."
Home-based models and other alternatives to large, institutional congregate settings could reduce some of the risks residents face in terms of disease transmission in nursing homes, he said.
The American Health Care Association and National Center for Assisted Living (AHCA/NCAL) said the study "underscores the need to address staff recruitment and retention challenges in long-term care, so that residents have more consistent caregivers."
"Once again, independent research has shown that even the best nursing homes with the most rigorous standards could not stop this highly contagious and invisible virus," AHCA/NCAL said.