“Community outbreaks and lack of personal protective equipment were the primary drivers of outbreak occurrence in long-term care homes, and the built environment was the major determinant of outbreak severity,” George Heckman, a professor at the University of Waterloo in Ontario, Canada, said in a statement on the study, which was published in the Journal of the American Medical Directors Association.
The study drew from an international virtual town hall held in fall of last year and hosted by Provincial Geriatrics Leadership Ontario (PGLO). The gathering focused on three themes: updating the built long-term care environment, public health versus individual health, and staffing.
Outbreaks in Ontario during the first wave of COVID-9 “were not uniformly distributed, with 86% of infections occurring in 10% of homes,” according to the study. The primary determinant of nursing home outbreaks in the Canadian province — as in the U.S. — was the extent of COVID-19 circulation in the surrounding community, the study observed.
Simulations found that 31% of infections and 31% of deaths would have been prevented by single rooms for all Ontario long-term care residents — but 30,000 additional private rooms would have been necessary for this to occur.
Research in the U.S. found that outbreaks were more likely when staff members commuted from neighborhoods with high COVID-19 circulation — and in large homes with more staff traffic, with high-occupancy rooms associated with large outbreaks. Nursing homes that were less crowded, such as those built on the Green House model, had better outcomes and lower hospitalization costs, the study noted.
“The fact that smaller homes not only support better resident outcomes but are more resilient against infectious outbreaks should prompt policymakers to reimagine LTC infrastructure in a post-pandemic world,” the authors wrote.
Design features of the built environment for long-term care “that promote greater multiplicity and comingling of viral vectors — staff or residents — are strong determinants of the risk and extent of outbreaks,” according to the study; investing in smaller LTC units could minimize those vectors in addition to supporting better resident outcomes.
“However, excessive down-sizing may leave residents vulnerable to situations similar to those reported by small Italian LTC homes, as in the United States where outbreaks led to critical staff shortages,” the study authors added. “The solution may lie in architectural approaches that distinguish small-scale living from small-scale housing, using uncrowded and home-like residential spaces. Such infrastructure must be supported by dedicated staff embedded in a responsive organizational structure sufficiently large enough to ensure adequate staff coverage and to share operation resources.”
The authors of the JAMDA study went one step further.
“Any new large-scale developments based on clearly unhealthy institutional architectural designs should be strongly discouraged,” they wrote.