Myge, I; Ward, H; Tupper, S; Fox, L; Howell-Spooner, B. What are the roles or function of family caregivers in providing care to other residents in LTC? 2022 Jan 27, Document no.: LTC220101 RR. In: COVID-19 Rapid Evidence Reviews [Internet]. SK: SK COVID Evidence Support Team, c2022. (CEST table).
As essential partners in care, family caregivers support feeding, mobility, personal hygiene, cognitive stimulation, communication, meaningful connection, relational continuity, and assistance in decision-making. 1,2,13,14,15,16,17 Prior to the pandemic, research indicates that on average, 37.4 hours of informal care was provided in LTC per resident each month by informal caregivers, most often described as family. 3 Visitor restrictions inclusive of family caregivers reduced available resources for resident care, intensifying staff shortages.1,2,3,5,13 Designation of essential caregivers, distinct from general visitors, in policy and legislation was in part recognition of these roles and contribution to resident care.1,2,13
Prior to the pandemic, the role family caregivers in providing care for other residents was described as evolving over time as family members and friends become familiar with the needs of other residents. Roles described by family members in their care of other residents include providing companionship, assisting with meals, bring additional food or supplies when brought for their own family member, and assisting with leisure activities. 17
LTC volunteers roles during the pandemic reduced their activities to maintaining (limited) activities for residents, assisting residents with use of technology to communicate with family/physicians, and providing emotional support.4
A commentary article describes an example of family caregivers who were hired on short (90 day) contracts to care for residents during acute staffing shortages (Kensington Health 2021).5 Personal communication intended as an environmental scan (AB and ON) spoke to the variability of staffing needs and the individualized response by LTC homes to address these staffing shortages. If family caregivers were to be invited to provide additional resources in the context of staff shortages, this decision was made by individual homes, in communication with residents and families and aligned with provincial visitation policy.
During the pandemic, a new paid role of comfort care aide was also created by Alberta Health Services The job involved providing comfort, support and assistance to residents, portering residents, mealtime assistance, ensuring PPE was always available, refilling equipment and care supplies as needed, cleaning and disinfecting high touch surfaces, supporting reception duties, supporting screening of staff and visitors, receiving deliveries and stocking supplies, and performing other duties as assigned.6
Myge, I; Ward, H; Tupper, S; Fox, L; Howell-Spooner, B. What are the roles or function of family caregivers in providing care to other residents in LTC? 2022 Jan 27, Document no.: LTC220101 RR. In: COVID-19 Rapid Evidence Reviews [Internet]. SK: SK COVID Evidence Support Team, c2022. 13 p. (CEST rapid review report).
Although evidence is preliminary, vaccines have been effective in decreasing cases of SARSCoV-2 infections (COVID-19) and deaths among long-term care (LTC) residents by 89% and 96% respectively (Brown et al., 2021).
Estimated vaccine uptake among LTC staff in ON has been estimated at 68% as of March 5, 2021. The estimated relative reduction in COVID-19 cases among LTC staff is 79% (Brown et al., 2021).
Vaccination against COVID-19 protects in varying degrees against symptomatic infection and can be expected to have some effect on COVID-19 transmission; however, the extent of the impact on transmission is not fully quantified. In 3 separate small studies, all utilizing Pfizer Bio N Tech™ vaccine, the following results were observed: vaccine efficacy among partially vaccinated residents (n=463) was 63% (Britton et al., 2021), nasopharyngeal viral load was significantly decreased following a single dose (n = 10) (mean -2.4 log10 calculated by Ct value) (McEllistrem et al., 2021) and an immunogenic response was demonstrated following full vaccination (N= 134) as measured by antibody titres (15274 AU/mL) with no associated difference by age, gender, frailty or comorbidity (Salmeron Rios et al., 2021).
It is recommended that both vaccinated and unvaccinated persons in LTC continue to follow infection control measures such as masking, physical distancing, and hand/respiratory hygiene as long as there is community transmission of COVID-19 (European CDC 2021; ON Ministry of Health 2021; AB Ministry of Health 2021; Health Protection Surveillance Ireland, 2021; CDC Mar 5, 2021; WHO 2021; Brown et al., 2021; Centre for Health Policy Evaluation in LTC, 2021; Love et al., 2021; Jaklevic et al., 2020).
Within Canada 5 provinces have currently prioritized designated family care givers for vaccination to facilitate their presence in LTC (British Columbia, Newfoundland, Nova Scotia, Ontario and Prince Edward Island; NIA 2021).
Family and friends provide critical support to residents of LTC homes as partners in care and as visitors, playing an important role in their overall health and well-being (NIA, 2021; Levere et al., 2021; CFHI and CPSI, 2021; WHO, 2021; Ranhoff et al., 2021). Emerging evidence shows that cessation of visiting has had a significantly negative impact on the well-being physical, emotional, and cognitive well-being of LTC residents and on the well-being of their families (WHO, 2021; Levere et al., 2021; Suarez-Gonzalez et al., 2021; NIA, 2021; Dhama et al., 2021).
Policy changes pertaining to COVID-19 should be informed by all impacts on the health and well-being of LTC residents and their families and friends, beyond the direct effects of morbidity and mortality due to COVID-19 (Levere et al., 2021; Suarez-Gonzalez et al., 2021; WHO, 2021; Dhama et al., 2021; NIA, 2021). Policy guidelines for healthcare decision makers have focused attention on the harms of stringent visitor policies and the need to reintegrate family/designated caregivers for every resident (CFHI and CPSI, 2021; NIA, 2021; WHO, 2021; ON Ministry of Health, 2021, BCDC 2021).
Available data to inform policy on the impact of strict visitation policies and social isolation in LTC is limited and ongoing data collection is required (Suarez-Gonzales et al., 2021; WHO, 2021; Levere et al., 2021 ).
Prioritization of family/designated caregivers in vaccine roll out policies is intended to address the balance of a more comprehensive definition of resident safety and well-being inclusive of quality of life and well-being with morbidity and mortality of COVID-19 (NIA, 2021; WHO, 2021; CFHI and CPS, 2021). Policies prioritizing family/designated caregivers may also reduce the enormous burden placed on LTC staff during the remainder of the pandemic (NIA, 2021).
Ward, H; Tupper, S; Boden, C; Dalidowicz, M; Mueller, M. What impact does COVID-19 vaccination have on visitation policies and transmission rates in LTC? 2021 Mar 29; Document no.: LTC012501 RR. In: COVID-19 Rapid Evidence Reviews [Internet]. SK: SK COVID Evidence Support Team, c2020. 44 p. (CEST rapid review report)
Vulnerable populations such as those experiencing homelessness are 20 times more likely to be hospitalised due to COVID-19, 10 times more likely to require intensive care for COVID-19 and 5 times more likely to die within 21 days of a positive test for COVID-19
Many organizations advocate for socially vulnerable populations to be considered priority populations due to their oftencomplex health needs and inability to fully execute best practices for infection prevention and control
Past experiences from Hepatitis vaccination (requiring 3 injections) and H1N1 pandemic influenza vaccination indicate that partnering with community organizations to provide vaccinations in shelters, community centers and other frequently accessed places along with education and access to known, trusted healthcare providers greatly increase the uptake of vaccination among socially vulnerable populations
Beyond sheltered populations experiencing homelessness, considerations for equitable vaccination programs for the general population should include plans for accessibility for all, including underserved geographic regions
Badea, A; Reeder, B; Hanson, L; Miller, L; Howell-Spooner, B. What are the vaccination strategies for vulnerable populations? 2021 Mar 12; Document no.: PH030401 RR. In: COVID-19 Rapid Evidence Reviews [Internet]. SK: SK COVID Evidence Support Team, c2020. 33 p. (CEST rapid review report)
Although rapid antigen point-of-care tests (POCT) to detect SARS-CoV-2 (COVID-19) infection have the advantage of rapid result turn-around time compared to laboratory-based reverse-transcriptase polymerase chain reaction (RT-PCR) test, their sensitivity to correctly detect positive cases is lower (Larremore et al., 2020).
Increased frequency of testing compensates for lower test sensitivity of POCTs (See et al., 2021; Larremore et al., 2020). The majority of policy guidelines and public health directives recommend basing frequency of POCT on rates of community transmission or outbreak status of the setting (Public Health Canada, 2021; Ontario Ministry of Long-term Care [LTC], 2021; CDC, 2021; Arizona Department of Health Services, 2020).
Recommended POCT frequency for screening asymptomatic individuals is 3 times per week of staff, including designated support persons, and residents if the home is in an outbreak situation and once per week of staff and designated support persons in a non-outbreak situation (Ontario Ministry of LTC, 2021; CDC, 2021; Larremore et al., 2020).
Designated support persons (i.e. family caregivers) should be tested at the same frequency as LTC staff (Ontario Ministry of LTC, 2021; Micocci et al., 2020; Vilches et al., 2020; Tennessee Department of Health, 2020).
Recommendations are consistent regarding test interpretation and follow-up actions, with the majority of policies and directives recommending a high degree of caution and follow-up RT-PCR testing after a negative POCT if there is a high pre-test probability for COVID-19 infection (i.e. symptomatic, known contact exposure)(Public Health Canada, 2021; CDC, 2021). All reviewed guidelines recommend confirmatory RT-PCR test following a positive POCT if the individual is asymptomatic in order to avoid unnecessary isolation of residents and work restrictions of staff. Contrary to other guidelines, the Oregon Health Authority (2020) considers all positive antigen tests in a symptomatic individual as a positive test regardless of follow up testing.
Modelling studies consistently show that regular POCT screening of asymptomatic staff and residents in LTC during both outbreak and non-outbreak situations results in significant decreases in projected cases when combined with a multipronged approach to prevent transmission (Larremore et al., 2021; Holmdahl et al., 2020; See et al., 2021; Vilches et al., 2020).
Barriers to frequency of testing are availability of test kits, training of testers, human resources for testing, and a reporting strategy (Micocci et al., 2020).
Prioritization of testing should be given to symptomatic healthcare providers and residents first, then screening for residents and staff during outbreaks (See et al., 2020).
The Saskatchewan Health Authority (SHA) Point of Care COVID Testing: Long Term Care Algorithm contains most of the elements present in other algorithms. Additional information should be added on actions taken for presumptive positive or negative tests in different scenarios. Additional information should be provided on frequency of testing and the context for “high-risk contact”.
Ward, H; Tupper, S; Dalidowicz, M; Mueller, M. What are the efficacies and outcomes of Point-of-Care/Antigen testing in Long Term care? 2021 Feb 26; Document no.: LTC020201 RR. In: COVID-19 Rapid Evidence Reviews [Internet]. SK: SK COVID Evidence Support Team, c2020. 37 p. (CEST rapid review report)
Two congregate living situations were identified in the literature: those in correctional facilities and those with mental health issues.
People in correctional facilities are more susceptible to infection and have higher mortality rates due to COVID-19 than the general population. Managing outbreaks in facilities is difficult due to high levels of movement, the inability to physically distance, and limited personal protective equipment.
People with mental illness have higher risk of morbidity and mortality due to COVID-19. Severe mental illness is positively correlated with other environmental risk factors for contracting COVID-19, including living in crowded settings, homelessness, and institutionalization. Furthermore, those with mental illness find it difficult to adhere to changing public health or government guidelines around reducing the spread of COVID-19.
Fick, F; Groot, G; Young, C; Mueller, M. What evidence is available to inform vaccination planning in congregate living? 2021 Jan 15; Document no.: EOC011102 RR. In: COVID-19 Rapid Evidence Reviews [Internet]. SK: SK COVID Evidence Support Team, c2020. 23 p. (CEST rapid review report)
No evidence was found as rationale for the 14-day isolation period on resident transition to LTC. This requirement likely arose from evidence that active monitoring for 14 days is sufficient to identify symptom onset in 99% of COVID-19+ cases (1).
No alternatives were found in Canada to a 14-day isolation period on transition of a resident into LTC. A rapid review of viral shedding and the need for isolation recommends a minimum 10-day isolation period, with additional consideration for high risk groups (36). The Centers for Disease Control and Prevention (2) in the US is considering decreasing the standard 14-day quarantine period to 7-10 days in recognition that the general two-week quarantine rule is onerous for many people and most of the benefit of quarantine to public health could be gained with a more flexible and contextual approach. Implications for changes in Public Health Agency of Canada’s (PHAC) policy on quarantine or duration of isolation for admission to LTC are not yet established.
The Canadian policies at the provincial government levels align with the PHAC’s recommendation of 14 days of isolation (14). Most jurisdictions across Canada follow guidelines requiring a resident to have a negative test on admission, and 14 days of self-isolation with contact and droplet precautions (4, 17).
However, a few jurisdictions stratify the level of precaution or need for isolation by community transmission (3, 5). For example, the Province of Alberta’s (5) Operational and Outbreak Standards for LTC recommends the following safety precaution: for residents with low or unknown risk of exposure, twice daily symptom checks for 14 days; for residents with medium risk, continuous use of a mask for 14 days while out of resident room; for residents with high risk, quarantine for 14 days.
Best practices on transition to LTC to support residents’ well-being
Some Canadian policies state the importance of protecting resident well-being on transition to LTC but provide little guidance on how to ensure this is done. For residents who might find self-isolation challenging (e.g. those with cognitive challenges), Government of New Brunswick (18) recommends taking efforts to ensure adequate staffing level and support residents’ individualized care plan.
Residents in LTC who have cognitive impairments will have difficulties understanding the need for isolation and absence of families and friends, and complying with isolation procedures (31). There is little guidance for long-term care facilities on how to support safe isolation of those living with cognitive impairments, while maintaining the human dignity and personhood of the individual. Strategies need to be developed to have an isolation care planning that is effective, safe, and compassionate (31).
Maintaining connections between residents and their families should be supported under safety, socio-emotional, and ethical grounds (39). Several provinces and international jurisdictions designate Essential Family Caregivers (EFCs), who are present not for social visits but to provide services and brought into the facilities under the same specific protocols as staff (39, 49, 50, 51).
Gao, Y; Ward, H; Tupper, S; Boden, C; Miller, L; Mueller, M. What is the evidence for 14-day isolation upon move-in to long-term care during COVID-19 pandemic? 2020 Dec 13; Document no.: LTC090801 RR. In: COVID-19 Rapid Evidence Reviews [Internet]. SK: SK COVID Evidence Support Team, c2020. 33 p. (CEST rapid review report)
No scientific evidence was found to support limits of a specific number of visitors. The Newfoundland/Labrador visitor policy referred to evidence supporting restrictions to 6 contact persons including one designated support person and 5 visitors; however, supporting references were not provided (25; 4.1).
The majority of Canadian and international visitation or family presence policies differentiate between general visitors (those attending for social visits) and designated support persons (essential care providers involved in physical, psychosocial, behavioral, cultural, or language support).
Designated support persons are not limited in duration, timing, or frequency of access to resident (3, 7, 9, 11, 12, 14, 16, 24, 26).
The majority of policies limit the number of general visitors to 2 persons. These visits typically have to be scheduled and may be restricted if there is an outbreak, if the resident is COVID+, or if community transmission is high. General visitors are usually not restricted during end of life or other compassionate care reasons.
Although modeling data supports contact restrictions as an effective measure to reduce infection spread, contact restriction can be achieved with infection prevention and control measures of micro-distancing, including hand and respiratory hygiene, physical distancing, and mask use (49). Family presence in LTC can support efforts to reduce resident wandering, micro-distancing, and hand hygiene.
There continues to be no scientific evidence that family presence increases risk of infection spread into and throughout LTC homes (1, 2, 44, 46)
No evidence was found that examined adherence of family caregivers to IPAC practices. A self-report survey of visitors and staff in 87 LTC homes in Hong Kong found that visitors self-reported high compliance with most infection prevention measures despite only one quarter of homes providing education (50). Low knowledge was identified as a primary barrier for infection prevention for visitors.
Education materials have been developed in several jurisdictions for family caregivers regarding COVID-19 IPAC best practices (4, 6, 8, 28).
No evidence was found regarding the impact of staff or family caregiver education on COVID-19 infection or transmission in LTC homes.
Ward, H; Tupper, S; Miller, L; Boden, C; Mueller, M. What is the evidence regarding limiting patient visitors in long-term care facilities to 2 or less, and how are other jurisdictions managing family caregivers? 2020 Dec 4; Document no.: LTC101501 RR. In: COVID-19 Rapid Evidence Reviews [Internet]. SK: SK COVID Evidence Support Team, c2020. 35 p. (CEST rapid review report)
The Hutterian Safety Council has established a COVID-19 taskforce to provide guidance for communities to best prevent and cope with COVID-19
Only one published study has investigated the prevalence of coronaviruses in relation to influenza vaccination/infection in Hutterite populations. This study found that coronaviruses are much less prevalent than influenza, entero/rhinoviruses and pediatric RSV and that it occurred in all age groups.
This study also found a high degree of co-circulation of other respiratory viruses along with influenza, which invites the questioning of signs/symptoms falsely attributed to influenza and therefore influencing empiric use of antivirals
Most studies available focus on influenza, polio and other common vaccine-preventable childhood communicable disease
One study assessing influenza in Hutterite populations found that the immunization of children and adolescents led to a protective effect among the community over multiple years of seasonal influenza and provided ~60% herd protection
Okpalauwaekwe, U; Reeder, B; Howell-Spooner, B; Miller, L. How are Hutterite colonies responding to and coping with COVID-19 prevention and outbreaks? 2020 Jun 12; Document no.: PH061201 RR. In: COVID-19 Rapid Evidence Reviews [Internet]. SK: SK COVID Evidence Support Team, c2020. 16 p. (CEST rapid review report)
· Overall, there is a lack of high quality evidence to support recommended pandemic preparedness strategies (checklist items) to prevent or mitigate respiratory infection outbreaks in LTC.
· In the absence of high-quality or mixed evidence to support strategies for pandemic preparedness, it is advisable to follow clinical practice guideline recommendations that have been based on expert opinion (key sources are identified in red). This is particularly the case for infection control interventions that are likely to have no negative impacts on LTC residents (e.g. hand hygiene, cough etiquette). Strategies that have a potential negative impact on LTC residents (e.g. visitor restrictions) must be handled with more flexibility and individual assessment to determine how infection control can be preserved while minimizing negative consequences for residents and families.
· Internationally recognized pandemic/outbreak preparedness checklists for LTC (e.g. CDC 2020, Buynder et al. 2017) share many similarities to the current SHA Annex R checklists.
· Consideration should be given to converting the checklist into a planner with accountabilities to demonstrate how each item is being addressed (similar to CDC 2020). Links can be embedded in the planner/checklist to more detailed information, such as the PPE burn calculator (CDC 2020), education/training materials (WHO 2020), and communication materials for families (CDC 2020, WHO 2020, Buynder et al. 2017).
· Consider the addition of specific detail to the SHA pandemic preparedness checklists on the date of the next pandemic plan/checklist review, contact names for local resource acquisition or assistance with staffing, tracking forms for dates of education/training with staff and residents, tracking of audits/observation of infection control practices, surge capacity planning items, and expanded items for communication (see attached recommendations from family caregivers of the Saskatchewan LTC Network).
· Discrepancies exist between reported (77-100%) and observed (25-63%) adherence to infection control practices, indicating a need for independent audits. Adherence rates improve with direct observation, frequent education reminders and prompts.
· Even when there is not an outbreak in a home, the pandemic response results in increased workload demands on staff due to infection control practices (e.g. PPE and hand hygiene), loss of family caregiver assistance with resident care, enhanced care needs of residents due to anxiety, increased communication with family caregivers and other members of the care team, monitoring and restricting resident movement in the home, enhanced cleaning, staff absenteeism, and education/training. Consideration is needed for a provincial process for evaluation of needs within individual homes, and allocation of additional human resources, disposable supplies, equipment, or funding to ensure that both infection control and usual care needs of residents are consistently met.
· Maintaining public confidence through communication is a defined infection control strategy. Communication strategies include individual communication between family members and staff, public communication strategies by individual facilities and provincially through dedicated pandemic information pertaining to LTC (e.g. dedicated LTC section on provincial websites).
There is limited information on transferring infected LTC residents to an off-site cohort location such as a purpose-built field hospital. Lessons learned from SARS suggest that transfers to dedicated facilities for cohorting may increase spread.
A greater number of recommendations support on-site cohorting of residents infected with droplet/contact transmitted illnesses. Health Canada’s COVID-19 Interim Guidance for LTC Homes report states that transfers within and between facilities should be avoided except for medically indicated procedures that cannot be provided by the long-term care home e.g. respiratory failure requiring ventilation or hemodynamic compromise.
Family members encourage cohorting a resident in the LTC home if possible. They also recommend following residents’ advanced care directives to determine whether life-sustaining measures are preferred, robust healthcare and psychosocial support for residents who are cohorted, and clear communication with residents and family members.
Cohorting on site includes isolation of residents to their rooms (preferably single occupancy) or dedicated units in the home. Staff and equipment cohorting should also be implemented if possible (i.e.dedicated staff that do not provide care to residents in non-infected units, and resident specific equipment).
Consider cohorting in day program spaces, recreation rooms, palliative care rooms, chapels, or dining rooms in the home that are no longer being used as common spacesas long as call bells or other appropriate communication measures are in place.
Tupper, S; Ward, H; Ellsworth, C; Dalidowicz, M; Boden, C. What are the best practices for cohorting long-term care residents to reduce transmission of COVID-19? 2020 Apr 16; Document no.: LTC041501 RR. In: COVID-19 Rapid Evidence Reviews [Internet]. SK: SK COVID Evidence Support Team, c2020. 10 p. (CEST rapid review report)
Provincial and state policies tend towards disincentivizing removal of residents from LTC during the pandemic due to perceived increased risks in the community.
Planning, risk and resource evaluation, clear communication, and follow-up arerequired to successfully transition a well-selected resident from LTC to the community.
Several tools exist to support communication and decision making around leaving LTC.
Family/informal caregiver fears are heightened by media reports describing abandonmentand lack of proper PPE use.
Fears can be mitigated by frequent, transparent communication that is both push and pull in nature.
Increased oversight of LTC homes by provincial oversight committees during the pandemic can ensure that provision of routine care, infection prevention measures, and effective communicationare in place.
If a resident leaves to community and has to return,appropriate isolation and screening measures would be required.
Tupper, S; Ward, H; Groot, G; Ellsworth, C; Dalidowicz, M; Boden, C. What decision support or communication materials are available for helping LTC directors discuss care options with residents' family members? 2020 Apr 14; Document no.: LTC040801 RR. In: COVID-19 Rapid Evidence Reviews [Internet]. SK: SK COVID Evidence Support Team, c2020. 23 p. (CEST rapid review report)