Williams-Roberts, H; Groot, G; Mueller, M; Dalidowicz, M. Long COVID: What does it mean for the healthcare system and programs? 2021 Oct 29. Document no.: EOC021901v2 RR Table. In: COVID-19 Rapid Evidence Reviews [Internet]. SK: SK COVID Evidence Support Team, c2021. (CEST Table).
In October, WHO released a consensus definition of post COVID-19 condition that includes 12 domains. This development should lead to better standardization of reporting and contribute to more precise prevalence estimates and better understanding of associated risk factors.
The effects of Variants of Concern (VoC) and COVID vaccination on progression of Long COVID symptoms remains unclear.
Risk factors for developing Long COVID symptoms were similar but limited evidence suggests that pre-pandemic psychological distress and poor general health were associated with developing persistent symptoms. Evidence is too limited to determine whether vaccination reduces the risk of developing Long COVID among persons with breakthrough infections.
Given the protean manifestations of Long COVID symptoms, the underlying causes are likely multifactorial; however, strong evidence to substantiate the theories of causation remains limited.
Research related to longer-term consequences of SARS CoV-2 infections in pediatric populations is growing but remains limited.
March 15, 2021
There is a lack of consensus around the clinical definition of Long COVID which in turn causes challenges with understanding the incidence and prevalence as well as the potential impact for the health care system
Information about the natural history of Long COVID is incomplete but limited evidence suggests that the immune response trajectories differ for those with few or no symptoms compared to those with severe disease. Individuals with severe disease are more likely to exhibit immunological marker abnormalities but anyone can experience functional limitations.
The mechanisms underlying the development of persistent symptoms in Long COVID remain an enigma. Despite multiple theories, there is little empirical evidence for specific immunological and or biochemical abnormalities in samples of individuals with symptoms consistent with Long COVID.
Risk factors for Long COVID include female gender, older age, higher body mass index, pre-existing asthma and the number of symptoms.
Few studies explored the short-term impact of Long COVID on health care utilization patterns and found a higher impact for those with severe disease compared with mild disease.
Williams-Roberts, H; Groot, G; Mueller, M; Dalidowicz, M. Long COVID: What does it mean for the healthcare system and programs? 2021 Oct 29. Document no.: EOC021901v2 RR. In: COVID-19 Rapid Evidence Reviews [Internet]. SK: SK COVID Evidence Support Team, c2021. 14 p. (CEST rapid review report).
McLean, M; Williams-Roberts, H; Reeder, B; Howell-Spooner, B; Ellsworth, C. What are long COVID's demands on the healthcare system, and its severity of the illness? 2021 Jul 12, Document no.: EPM210602 RR. In: COVID-19 Rapid Evidence Reviews [Internet]. SK: SK COVID Evidence Support Team, c2021. (CEST table).
Long COVID-19 is likely to increase healthcare demands across the health system, including emergency departments, hospital admissions, primary care visits, specialists appointments, and home care and rehabilitation services.
The clinical care burden of long COVID-19 is the greatest in the first 3 months after testing and is likely to place the greatest demand on primary care services.
Patients with severe COVID-19 illness are more likely to place longer-term demands (4-6 months) on specialist care due to respiratory, circulatory, endocrine, metabolic, psychiatric and unspecified conditions.
McLean, M; Williams-Roberts, H; Reeder, B; Howell-Spooner, B; Ellsworth, C. What are long COVID's demands on the healthcare system, and its severity of the illness? 2021 Jul 12, Document no.: EPM210602 RR. In: COVID-19 Rapid Evidence Reviews [Internet]. SK: SK COVID Evidence Support Team, c2021. 23 p. (CEST rapid review report).
The frequency of Long COVID symptoms varies widely across studies based on populations studied, duration of follow up and methods of assessment of symptoms.
It is estimated that 1 in 50 persons experience Long COVID symptoms after 12 weeks; however, higher estimates up to 80% have been reported in studies with a greater proportion of persons who were previously hospitalized. A recent study of a mixed cohort of 96 persons found that only 22.9% had no symptoms at 12 months post diagnosis.
A wide range of symptoms affecting multiple organ systems has been reported. For many persons symptoms improve over time while others experience persistent and/or new symptoms. Among studies with the longest duration of follow up, the most frequently reported symptoms included fatigue (up to 65%), dyspnea (up to 50%), headache (up to 45%), anosmia/ageusia (up to 25%), cognitive memory/concentration (up to 39.6%) and sleep disorders (up to 26%).
Few studies estimated the duration of symptoms with estimates ranging from 2.2% for 6 months and 27% for 7-9 months.
The mechanism(s) leading to Long COVID remain unclear but those experiencing post acute sequelae tend to be older, have a greater number of symptoms during the acute phase of illness or manifest specific symptoms and live with multiple comorbid conditions such as obesity.
The lack of consensus on a definition of Long COVID contributes to marked variations in robust prevalence estimates.
Williams-Roberts, H; Groot, G; Reeder, B; Howell-Spooner, B; Ellsworth, C. What is the incidence and duration of Long COVID cases? 2021 Jul 09, Document no.: EPM210601 RR. In: COVID-19 Rapid Evidence Reviews [Internet]. SK: SK COVID Evidence Support Team, c2021. 19 p. (CEST rapid review report).
Williams-Roberts, H; Groot, G; Reeder, B; Howell-Spooner, B; Ellsworth, C. What is the incidence and duration of Long COVID cases? 2021 Jul 09; Document no.: EPM210601 RR Table. In: COVID-19 Rapid Evidence Reviews [Internet]. SK: SK COVID Evidence Support Team, c2021. (CEST table).
The group designated in Saskatchewan as Clinically Extremely Vulnerable (CEV) is a heterogenous clinical population with factors that impair their immune response to differing degrees.
Very Limited evidence is currently available to assess the immune response following vaccination is selected clinical populations; no evidence is available to assess vaccine efficacy or effectiveness in these populations. The clinical relevance of measured immune response with respect to protection from disease is still uncertain.
In considering the immune response of the CEV population, it is recommended that the absolute difference in immune response between 1 and 2 doses be considered, as it is possible some patient groups will have lowered protection regardless of vaccine strategy.
In terms of clinical subgroups:
oOrgan transplantation recipients on immunosuppressive medication: solid organ transplant recipients receiving anti-metabolite maintenance immunosuppression therapy were less likely to develop an antibody response to an mRNA vaccine, compared to those receiving other types of therapies (37% vs 63%). In a study of 242 kidney transplant recipients on immunosuppressive therapy only 10.8% became seropositive at 28 days after a single dose of mRNA vaccine.
oCancer: A study of 151 elderly patients with solid and hematological malignancies and 54 healthy controls who received one or two doses of BNT162b2 (Pfizer-BioNTech) vaccine shows approximately 39% of solid cancer patients, 13% of hematological cancer patients, and 97% of healthy controls (p<0.0001) developed anti-S IgG 21 days following a single dose vaccine. However, response in solid cancer patients increased to 95% within 2 weeks of the second dose at 21 days.
oOther immunocompromising conditions (e.g., auto-immune disorders and therapy): some level of immunity is generated with vaccination; however, what this means clinically is unknown. It seems that ensuring the dosing is properly timed around biologic therapy is important.
Azizian, A; Lee, S; Shumilak, G; Groot, G; Reeder, B; Miller, L; Howell-Spooner, B. What are the risks or benefits of extended intervals between doses of COVID-19 vaccines compared to recommended dosing in extremely vulnerable populations? 2021 Apr 20, Document no.: EOC210302 RR. In: COVID-19 Rapid Evidence Reviews [Internet]. SK: SK COVID Evidence Support Team, c2021. 15 p. (CEST rapid review report).
Azizian, A; Lee, S; Shumilak, G; Groot, G; Reeder, B; Miller, L; Howell-Spooner, B. What are the risks or benefits of extended intervals between doses of COVID-19 vaccines compared to recommended dosing in extremely vulnerable populations? 2021 Apr 20, Document no.: EOC210302 RR Table. In: COVID-19 Rapid Evidence Reviews [Internet]. SK: SK COVID Evidence Support Team, c2021. (CEST table).
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)
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)
Badea, A; Groot, G; Fox, L; Mueller, M. What is the risk of COVID-19 transmission during AGMP procedures? 2020 Dec 18; Document no.: PPE120901 RR. In: COVID-19 Rapid Evidence Reviews [Internet]. SK: SK COVID Evidence Support Team, c2020. 30 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 terms cluster and outbreak both describe the occurrence of new disease cases within a particular location and time period. The number of cases within a cluster are not necessarily greater than what is expected, however in an outbreak the number of cases does exceed the usual norm.
· In an outbreak the cases are confirmed to be epidemiologically linked while in a cluster an epidemiological connection is only suspected.
· Not all clusters are outbreaks, however each cluster needs to be investigated
· Understanding how to characterize COVID-19 cases based on a suspected or proven epidemiological link can better guide prevention of disease spreading
Radu, L; Badea, A; Groot, G; Ellsworth, C; Young, C. What is the definition of an outbreak versus a cluster for COVID-19 in different clinical and community settings in Canada, the US, and the UK? 2020 Jul 27; Document no.: EOC071001 RR. In: COVID-19 Rapid Evidence Reviews [Internet]. SK: SK COVID Evidence Support Team, c2020. 11 p. (CEST rapid review report)
Tupper, S; Ward, H; Howell-Spooner, B; Dalidowicz, M; What are the impacts on the family unit from visitation restrictions during an infectious disease outbreak and how can we support the families? 2020 May 14; Document no.: LTC042403 RR. In: COVID-19 Rapid Evidence Reviews [Internet]. SK: SK COVID Evidence Support Team, c2020. 38 p. (CEST rapid review report)
Core concepts of family engagement include dignity and respect, information sharing, participation in care and decision making, and collaboration (Hart 2020).
A careful balance needs to be maintained between attending to patients’ physical and psychological needs and adhering to infection control guidelines, while offering psychological support to family members (Chan 2006).
The word ‘visitation’ does not adequately describe family members’ involvement. Family presence is a more suitable term as it redefines families as partners in care (Hart 2020). However, it is important to recognize that family presence is not a substitute for adequate staffing levels.
Very little guidance is provided in the literature on innovative or specific approaches engage family care providers during a pandemic. The literature mainly focuses on supporting alternate forms of communication such as telephone calls, or technology assisted communication through social media or video/voice calls.
Enhanced communication strategies that provide regular information to a primary family contact on the patient/resident condition and allow chosen care partners to contribute to decision making as much as possible are recommended (Koller 2006).
The negative impact of visitation restrictions places increased stress on patients/residents and families who are unable to provide or receive non-healthcare specific supportive care. Those with neurocognitive disorders or communication barriers are more significantly impacted.
Staff also report increased stress during family visitation restrictions due to the additional time required to take on a “familial role” for the patient/resident. These roles may include providing a supportive environment, social interaction, information sharing, and opportunities for play (Koller 2006a – pediatric hospital setting).
The search question did not specifically look at impact of visitation on infection rates; therefore, there is insufficient information to determine if visitation policies affect infection rates. However, a systematic review in pediatric hospital setting in Ontario found no connection between liberal visiting hours and increased SARS infection rates (Smith 2009).
When facilitating sibling visitation in the NICU, a pre-visit education process is recommended. Maternity settings may wish to consider a 'combination' policy, where the women's partners and/or significant other would have open visiting (all day), with restricted visiting for others. In other general hospital ward settings, open visiting with a 'quiet hour' is suggested (Smith 2009).
Tupper, S; Ward, H; Dalidowicz, M; Boden, C; Ellsworth, C; What are best practices for engaging family care providers during a pandemic? 2020 Apr 16; Document no.: LTC042401 RR. In: COVID-19 Rapid Evidence Reviews [Internet]. SK: SK COVID Evidence Support Team, c2020. 22 p. (CEST rapid review report)
Visitor restrictions in long-term care (LTC) during an outbreak or pandemic are implemented due to the perceived risk of transmission between residents or staff and visitors.
· Social isolation and possible loss of care resulting from visitor restrictions in LTC may place residents at risk of poorer outcomes in terms of both physical and mental health, as well as distress to families and staff (see Saskatchewan LTC Network Family Perspective).
· Visitor restriction policies typically allow visits for compassionate reasons that include end of life, critical care, and support of persons who require assistance beyond that provided by healthcare e.g. support for feeding, mobility, or behaviors, but specific detail on these is not consistent or clear.
· Recent changes to visitation policies in Australia are less restrictive and allow brief visitations (end of table 1, noted in red font).
· Although the majority of policies describe a need for flexibility and case-by-case assessment of visits deemed “essential”, the majority of policies are not clear in who is to conduct this analysis or the criteria that should be used to make these decisions.
Visitation policies differ in detail regarding the number of visitors allowed at one time, total number of visitors allowed, visit duration, mobility within the home and location of the visit.
· Remote and technology assisted visits are to be facilitated by LTC staff.
· Infection control practices are enforced for visitors, and may include screening (e.g. temperature, symptoms, travel and contact history), prohibiting ill visitors, use of personal protective equipment (PPE), hand and cough hygiene.
· Education of visitors and support for proper infection control practices is encouraged in the majority of policies.
Tupper, S; Ward, H; Howell-Spooner, B; Dalidowicz, M; Boden, C. How is "compassionate visit" defined and operationalized in the context of an infectious outbreak or pandemic in long-term care? 2020 May 1; Document no.: LTC042402
RR. In: COVID-19 Rapid Evidence Reviews [Internet]. SK: SK COVID Evidence Support Team, c2020. 17 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).
Screening tools commonly include fever, respiratory symptoms (cough, shortness of breath), and epidemiological risk factors.
· The sensitivity and specificity of screening questionnaires depends considerably on the items used in the questionnaire. The limited published literature demonstrates great variability in the performance of different screening tools: sensitivity ranges from 0 – 48.6 – 84.3 – 100%; specificity ranges from 64.8 – 71.3 – 89.6 – 96%).
· The standard WHO symptom checklist performs poorly, with a sensitivity of 48.6%, and specificity of 89.6%. As such, half of individuals who have SARS-CoV-2 present at the time of testing will be missed by the symptom questionnaire (being either asymptomatic or presymptomatic). Depending on the population being screened the prevalence of the virus may vary widely. Given the sensitivity and specificity of the WHO symptom checklist in a population with prevalence ranging from 0.1% to 1% to 10% the positive predictive value (PPV) will be poor, range from 0.4% to 4.8% to 35%, respectively. Furthermore, the performance characteristics of the screening questionnaire may be poorer than reported if used in a setting or time of year when other respiratory viruses with similar symptoms are circulating.
Fick, F; Neudorf, C; Reeder, B; Dalidowicz, M; Mueller, M. What is the sensitivity and specificity of screening checklists and temperature checks for detecting the presence of COVID-19 in individuals? 2020 Apr 28; Document no.: PH042401 RR. In:
COVID-19 Rapid Evidence Reviews [Internet]. SK: SK COVID Evidence Support Team, c2020. 20 p. (CEST rapid review report)
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 transmision 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)