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Introduction
In Japan, long-term care facilities for individuals with profound intellectual disabilities and physical impairments caused by prenatal (eg, brain malformations chromosomal abnormalities), perinatal (eg, birth complications and low birth weight), or postnatal (eg, meningitis, encephalitis, and epilepsy) factors accommodate patients of various ages, including newborns from the neonatal intensive care units (NICU), infants, those who previously lived at homes, and elderly individuals. These facilities are high risk of outbreaks of respiratory infections, Reference Neu, Plaskett, Hutcheon, Murray, Southwick and Saiman1 such as respiratory syncytial (RS) virus infections, Reference Nakamoto, Katuren, Nakamura, Ando and Izumikawa2 human metapneumovirus (hMP) infections, Reference Goto, Imai, Uemura, Hiramatsu and Hamada3,Reference Yang, Suzuki and Watanabe4 influenza, Reference Irie, Ito, Iwai, Yasunaga, Onari and Morioka5 adenovirus infections, Reference Matsuda and Noda6 and Bordetella parapertussis infections. Reference Sito, Miura and Hosoda7 Patients have underlying conditions such as scoliosis, swallowing difficulties, gastroesophageal reflux disease, weakened immune systems, and aging of respiratory function, making adequate infection management essential.
These facilities provide various activity programs to improve quality of life (QOL). Reference Jung, Park and Kim8 This program, known as Ryouiku, includes indoor and outdoor activities. These activities, which may be conducted individually or in groups, involve the use of large toys (eg, trampolines) to engage in physical movement as well as smaller toys (eg, musical instruments) to engage in creative pursuits. Some of the activities necessitate physical contact between the staff and patients, increasing infection risk, Reference Takayama, Aminaka and Mori9 thus emphasizing the importance of preventive measures such as suspending activities. In addition, during an outbreak, suspending new hospital admissions and limit visitor access is often necessary. Reference Takayama, Aminaka and Mori10 However, these measures can significantly affect patients’ and families’ QOL.
Despite the recognized importance of preventing respiratory infection outbreaks in these facilities, no standardized guidelines have been developed. Reference Dykgraaf, Matenge and Desborough11 Therefore, in 2018, the authors developed the Concurrent Approach for Respiratory Epidemiological Surveillance and Symptom Screening (CARES), a strategy concurrent respiratory syndrome surveillance and symptom screening of staff and visitors. This study aims to verify the effectiveness of CARES in a long-term care facility.
Methods
Development history of Concurrent Approach for Respiratory Epidemiological Surveillance and Symptom Screening (CARES)
The CARES was conceived based on two surveys (Figure 1).
Development history of the new strategy CARES.
A survey of 202 long-term care facilities found that 40% facilities suspended activities during respiratory infection outbreaks, 20% conducted symptom screening on staff and visitors, and 10% conducted respiratory syndrome surveillance. Reference Takayama, Aminaka and Mori10 Another survey on the risk factors of respiratory infections in a care facility identified activity programs as one of the six risk factor. Reference Takayama, Aminaka and Mori9 Among these, only the “activity program” was identified as an intervenable risk factor. These programs involve patient-to-patient contact, which poses a risk of spreading respiratory infections. In such programs, standard infection control measures, including hand hygiene and the use of gloves and aprons, make it difficult to prevent respiratory infections. For this reason, the suspension of activity programs is considered a top priority for the prevention of respiratory infection outbreaks in these facilities. However, these programs support the patients’ QOL. Although the purpose is to prevent respiratory infection outbreaks, the programs should not be easily suspended or indefinitely discontinued. Therefore, it is necessary to implement important measures to prevent respiratory infection outbreaks while simultaneously continuing the activity programs.
First, it is crucial to take measures to prevent the introduction of infections and suppress outbreak frequency. In long-term care facilities, patient admissions and discharges are infrequent, and the primary cause of infectious outbreaks often lies with staff. Thus, screening of symptoms among staff and visitors is important. The second important aspect is the prompt detecting of outbreak signs that are essential for determining whether to suspend or resume activity programs. This detection was performed by respiratory syndrome surveillance. Therefore, we developed CARES, a strategy that concurrently implements symptom screening for staff and visitors and respiratory syndrome surveillance for patients.
How CARES worked
CARES is a respiratory infection prevention strategy that concurrently implements a) screening of staff and visitors for respiratory symptoms and b) surveillance of respiratory syndromes in patients (Figure 2).
Components and flowchart of CARES.
Screening of respiratory symptoms for staffs
All staff entering the care facility were required to undergo temperature measurement upon arrival at work. Their body temperature and the presence or absence of cough, sore throat, nasal discharge, nausea, and diarrhea were recorded in the checklist. The criteria include having a temperature of ≥37.0 °C or the presence of symptoms; if these criteria are met, the workplace supervisor will inquire into symptom progression and assess the need for absence from work. Even if deemed fit to work, participation in the activity programs will be suspended if the staff is symptomatic, and the concerned person should always wear a surgical mask and adhere to hand hygiene practices on duty.
Screening of respiratory symptoms for visitors
At the ward’s entrance upon visit, the body temperature of the visitors was measured, and a checklist indicating their body temperature and the presence or absence of cough, sore throat, nasal discharge, nausea, or diarrhea was completed and submitted to the nurse. The nurse reviewed the checklist, and if the temperature is ≥37.0 °C or any symptoms are present, the nurses will inquire the symptom progression with the visitors and assess the need of halting the visitation. Symptomatic visitors must wear surgical masks and adhere to hand hygiene practices even if deemed permissible.
Respiratory syndrome surveillance Reference Nishioka, Takayama and Aminaka12
Respiratory syndrome surveillance is conducted by an infection control specialist according to the following procedure. Using the sorting function of the electronic medical record, patients with a temperature of ≥38.0 °C for 2 days including the day of fever onset were listed, and checked for decreased oxygen saturation (≤93%), cough, and increased mucus discharge. If any patient is determined to have a respiratory syndrome, immediate consultation with the attending physician will be conducted to assess the need to suspend the activity programs based on patient conditions and respiratory syndrome situations. Even if the programs are not suspended, patients diagnosed with respiratory syndrome are subjected to contact or droplet precautions, include behavioral restrictions, adhere to good hand hygiene practices, and use personal protective equipment. Moreover, during the suspension of activity programs, the infection control specialist and the attending physician will conduct daily evaluations for resuming activities.
Study design and patients
This prospective cohort study using historical controls was conducted in two wards (total: 110 beds) in a long-term care facility for patients with profound intellectual disabilities and physical impairments in Japan. These wards are part of a hospital. The mean duration of patient admission was >500 days, and the patient:nursing staff ratio was 7:1. The study period was 6 months each before and after the introduction of CARES, with patients admitted between October 1, 2018, and March 31, 2019, after the introduction of CARES as the intervention group and patients admitted between October 1, 2017, and March 31, 2018, before the introduction of CARES as the control group. The intervention and control groups included all patients admitted to the facility, and those who were hospitalized or discharged during the study period were excluded. However, deaths of discharged patients were included in the study.
Procedures
Patient demographics and medical history
We conducted a medical record review and collected data on patient demographics, medical-related items, and outcomes. The risk factors for respiratory infections were identified from previous studies Reference Takayama, Aminaka and Mori9 and included sex, age, length of hospitalization (in days), severity (intelligence quotient [IQ] and activities of daily living [ADL]), lack of comprehension of medical orders, inability to roll over, observation of past aspiration pneumonia during chest imaging, use of gastrostomy feeding, presence of activity programs, and type of inpatient ward. Accordingly, these factors were categorized as patient demographic items and medical-related items.
Outcome measures
The outcomes measures of interest included incidence (%) of respiratory infections (ie, RS virus infection, hMP virus infection, influenza A, influenza B, adenovirus infection, B. parapertussis infection, and pneumonia); incidence (%) of respiratory syndromes; mortality (%) due to respiratory infections; and the total number of days preventive measures (ie, suspension of activity programs, new admissions, and visitations) for respiratory infections were implemented. Suspension of new admissions means the suspension of accepting new admissions.
A diagnosis of RS virus, hMP virus, influenza A, influenza B, adenovirus, or B. parapertussis infection was made following detection of the pathogenic microorganisms using antigen identification or bacterial culture tests. A diagnosis of pneumonia was made when a single chest X-ray showed new or progressive consistent infiltrates and the patient exhibited one or more of the following symptoms: (1) axillary body temperature >38.0 °C and (2) leukopenia (<4,000/mm Reference Goto, Imai, Uemura, Hiramatsu and Hamada3 ) or leukocytosis (>12,000/mm Reference Goto, Imai, Uemura, Hiramatsu and Hamada3 ). Reference Takayama, Aminaka and Mori9
A diagnosis of respiratory syndrome was made if the patient exhibited one or more of the following symptoms: a) axillary temperature >38.0 °C for two consecutive days; b) SpO2 <93%; c) increased sputum; and d) cough. Reference Takayama, Aminaka and Mori9,Reference Veugelers, Calis and Penning13
Statistical analyses
Distribution of patient demographics and healthcare-related items
Univariate analyses were used to examine differences between the intervention and control groups for patient attribute items, medical care items, and outcome items, with a significance level set at α = 0.05. SAS OnDemand for Academics (SAS Institute Inc., NC, USA) was used for the analysis.
Incidence and mortality rates of respiratory infections
Univariate analyses were used to compare the incidence and mortality rates of respiratory infections between the two groups.
Total number of days of cancellations
Univariate analyses were used to compare the total number of days of activity programs, new admissions, and visitations suspended between the two groups.
Ethical considerations
This study was carried out in accordance with the Ethical Guidelines for Medical and Health Research Involving Human Subjects and Ethical Guidelines for Nursing Research and was approved by the Institutional Review Boards of the National Center for Global Health and Medicine (approval No. NCGM-G-003279-00), the International University of Health and Welfare (approval No. 22-Ig-29), and the participating hospitals (approval No. 2019-7).
Results
Study participants
The intervention group included 121 registered participants, of which 11 individuals who were admitted for short-stay care and 6 individuals who were admitted or discharged after October 1, 2018, were excluded resulting in a total of 104 participants. The control group included 116 registered participants, of which 10 individuals who were admitted for short-stay care and 8 individuals who were admitted or discharged after October 1, 2017, were excluded resulting in a total of 98 participants.
Distribution of patient demographics and healthcare-related items (Table 1)
Distribution of patient demographics and medical-related items
a χ2 test.
b Wilcoxon rank-sum test.
c Values represent the median and ( ) indicates the range.
d IQ < 35 and daily life independence level is bedridden or able to sit.
The intervention group had a median age of 40 years (range: 1–72 years) and a median length of hospital stay of 2,165 days (range: 182–17,848 days) with 102 (98.1%) patients in this group having severe conditions (IQ < 35 and ADLs: bedridden or sitting). The control group had a median age of 39 years (range: 1–72 years) and a median length of stay of 2,202 days (range: 207–17,488 days); 97 (99.0%) patients with severe conditions. No patient attribute or medical-related item differed between the two groups (α = 0.1). No significant differences in the distribution of patient demographic and healthcare-related variables were observed between the two groups.
Implementation of respiratory symptom screening (Table 2)
Screening findings for fever, respiratory, and gastrointestinal symptoms among hospital staff and visitors
a Unit = times/person week, ( ) as times.
b Some symptoms include fever (≥37.5°C), cough, runny nose, sore throat, nausea, and diarrhea.
Screening was conducted 2.4 times per person week among staff and 0.2 times per person week among visitors, and 0.3 times per person week of staff exhibited symptoms such as fever, cough, runny nose, sore throat, nausea, or diarrhea. Two individuals (one identified by a physician and the other by a nurse) were unaware of their symptom (ie, temperature > 38.0 °C) when they arrived for work, and become aware of it after temperature measurement during screening. Both individuals were advised to stop working until their symptoms improved. Seventeen individuals presented with diarrhea, of which three were instructed by their supervisors to stop working until their symptoms improved.
Incidence and mortality rates of respiratory infections
No significant reduction in mortality due to influenza B, adenovirus infection, pneumonia, respiratory syndrome, or respiratory infections was observed in the intervention group. Moreover, RS virus infection, hMP virus infection, influenza A, and B. parapertussis infections were not seen to occur in either group.
Total number of days of cancellations (Table 3)
Cancellation of activity programs (in days)
The activity programs were cancelled for a total of 11 days in the intervention and control groups (P value = 1.000), with the intervention group exhibiting three instances of cancellations for 2, 4, and 5 days each and the control group exhibiting two instances of cancellations for 4 and 7 days each. There were no cancellations exceeding 6 days in the intervention group.
Number of days of cancellation of activity programs, inpatient admissions, and visitations
a Fisher’s exact probability.
b The study period was 240 d for both groups, excluding weekends (120 d of investigation per ward × 2 wards).
c Breakdown of cancellation period.
d The study period was 364 d for both groups (182 d of investigation × 2 wards).
e “Suspension of new admission” means the suspension of accepting new admissions.
f Due to the 0 cancellation day in the intervention group, the OR and 95%CI could not be calculated.
Suspension of new admissions (in days)
New admissions were suspended for 0 days in the intervention group and 16 days in the control group (P value < 0.001), with the latter representing two instances of suspension for 7 and 9 days each.
Suspension of visitation (in days)
Visitations were suspended for 0 days in the intervention group and 23 days in the control group (P value < 0.001), with the latter representing two instances of suspension for 7 days each and one instance of suspension for 9 days.
Discussion
Need for respiratory infection prevention measures and continuation of activity programs in long-term care facilities
Long-term care facilities often face frequent respiratory infection outbreaks such as COVID-19 and influenza. Reference Danis and Fonteneau14,Reference Lansbury, Brown and Nguyen-Van-Tam15 A survey across 25 countries indicated that 41% of all COVID-19-related deaths occurred among care home residents, Reference Adelina Comas-Herrera, Lemmon and Henderson16 underscoring the threat in such facilities. However, some of these long-term care facilities have insufficient infection control measures in place, Reference Greene and Gibson17,Reference Telford, Bystrom and Fox18 leading to outbreaks and posing a threat to the health of the staff. Therefore, preventing respiratory infection outbreaks is an urgent priority, although effective strategies have not been established. Reference Dykgraaf, Matenge and Desborough11
Activity programs play a vital role in enhancing patients’ QOL in long-term care facilities. Reference Nozaki and Kawasumi19 A survey found that over 40% of facilities suspended activity programs during respiratory infection outbreaks. Reference Takayama, Aminaka and Mori10 While the implementation of such measures is essential to prevent outbreaks, efforts should also be made to continue activity programs where possible due to their beneficial effects on the QOL of patients. Therefore, recognizing the dual importance of both aspects in long-term care facilities is important.
Effectiveness of CARES in preventing respiratory infection outbreaks in long-term care facilities
The findings of the current study showed that, despite a reduction in the number of days that activity programs, new admissions, and visitations were suspended in the intervention and control groups, no significant differences in the incidence of respiratory infections were observed. CARES may have functioned as an effective alternative preventive measure.
Activity programs represent a significant risk factor for respiratory infection outbreaks, Reference Takayama, Aminaka and Mori9 and monitoring patients for respiratory symptoms can prevent the introduction of new infections, allow detection of signs of infection outbreaks, and facilitate prompt suspension and resumption of these activities when necessary. Reference Nishioka, Takayama and Aminaka12 In the current study, the intervention and control groups exhibited three and two instances of suspension of activity programs, respectively. Instead, the maximum number of days of discontinuation was reduced by 2 days in the intervention group. This indicates that respiratory syndrome surveillance enabled timely decisions to discontinue or resume activity programs.
Significance of continuing activity programs, new admissions, and visitations
Respiratory disorders in patients with profound intellectual disabilities and physical impairments can typically be attributed to factors such as narrowing of the upper airways, abnormal or distorted chest respiratory muscle activity, retention of secretions, and aspiration. 20,21 The prolonged suspension of activity programs can exacerbate these factors further, potentially leading to severe respiratory infections. Therefore, minimizing the duration of suspension of activity programs is essential, highlighting the significance of prevention strategies such as CARES, which decrease the duration of suspension of activity programs by two days.
Long-term care facilities serve as a safety net and play a crucial role in protecting the lives of patients with profound intellectual disabilities and physical impairments when their parents are no longer able to continue caring for them. 22 Therefore, suspension of new admissions as a measure to prevent respiratory infection outbreaks can adversely affect the health of these patients and impose a significant burden on their caregivers. These facilities also play a role in the continuous hospitalization of patients transitioning from NICUs, Reference Miyanomae23 and the interruption of planned transfers due to respiratory infection outbreaks can put a strain on these units by affecting bed availability and, consequently, affect the lives of the newborns. Therefore, implementing infection control measures through CARES can help protect newborns, patients, and their families.
Overall, 73.2% (80/112) of long-term care facilities have been found to suspend visitations as part of their measures to prevent and control respiratory infection outbreaks, Reference Takayama, Aminaka and Mori10 leading to psychological distress among patients and their families. Reference Muramatsu, Kishida, Mori, Tamagaki, Yoshida and Saito24 Therefore, CARES can preserve the positive impact on patient–family relationships and reduce the psychological burden on families.
Importance of preventing presenteeism among staff
Respiratory infection outbreaks in long-term care facilities are typically caused by staff and visitors rather than the patients themselves. Reference Goto, Imai, Uemura, Hiramatsu and Hamada3 Healthcare workers are considered to be a high-risk group for presenteeism, defined as the phenomenon where staff continue to attend work despite being unwell. Reference Ablah, Konda, Tinius, Long, Vermie and Burbach25 Webster et al. (2019) reported that, in the past 1 year, 41.4%–65.0% of healthcare workers continued to attend work despite exhibiting symptoms of infectious diseases such as fever or the flu. Reference Webster, Liu, Karimullina, Hall, Amlôt and Rubin26 Another study reported a case of presenteeism by a single healthcare worker that led to a respiratory infection outbreak affecting 17 individuals in a long-term care facility. Reference Takayama, Sakaki and Shirai27 Therefore, preventing presenteeism among healthcare workers is essential.
In the current study, at least five instances involved replacement of staff members exhibiting symptoms, of which two were identified during temperature measurement and the relevant staff was prevented from working until their symptoms improved. These findings suggest that CARES can effectively prevent presenteeism in long-term care facilities.
Study’s strengths and weaknesses
A key strength of this study is demonstrating that CARES can remarkably improve the QOL by preventing respiratory infection outbreaks in long-term care facilities. The study did not show a clear reduction in infection incidence possibly due to the rarity of certain infections in the examined facility. The single-facility study design necessitates further validation through multicenter studies to ensure generalizability. Moreover, the unique context of facilities accommodating children and adults presents distinct challenges. Future investigations should include specialized and typical long-term care settings to validate our findings. Nationwide adoption of CARES could prevent respiratory infections and enhance QOL in long-term care facilities.
Acknowledgments
The authors would like to thank Enago (www.enago.jp) for English language review.
Financial support
This work was supported by grants-in-aid of the “NAKANISHI MUTSUKO NURSING PRACTICE RESEARCH FUND” and JSPS KAKENHI Grant Number JP18H03079.
Competing interests
All authors report no conflicts of interest to this article.
Ethical standard
Ethical approval for data collection and analysis was obtained from the institutional review boards of the affiliated facilities (Approval Numbers: NCGM-G-003279-00; 22-Ig-29, 2019-7).
