Practice Impact

Our study highlights that measures implemented to prevent the spread of the COVID-19 pandemic have altered the characteristics of nursing home patients who were admitted to a single tertiary general hospital. Even as the pandemic comes increasingly under control with widespread vaccination, further study is needed to determine which policy measures such as visitor limitations, improved hygiene and disinfection, heightened vigilance and higher thresholds for hospital transfer have led to improved health-care outcomes for nursing home residents and should continue to be implemented.

1 INTRODUCTION

The coronavirus disease 2019 (COVID-19) pandemic has altered health-care utilisation in unprecedented ways. As health-care resources were mobilised and deployed to manage the surge in COVID-19 patients, concerns have been raised about the impact on non-COVID-19 cases and health outcomes.1

Nursing homes in particular have been hit hard by the COVID-19 pandemic.2 Nursing home residents are particularly vulnerable to COVID-19 and experience higher rates of mortality and morbidity3 than the general population. Singapore has 16,221 nursing home places across 77 homes as of 2020.4 The first COVID-19 case in a nursing home was detected locally on 31 March 2020, approximately 2 months after the first community cases were reported.5 By the end of 2020, there were a total of 25 COVID-19 infections and 4 mortalities involving nursing home residents. The COVID-19 outbreak in nursing homes was contained over a 2-month period with drastic measures, which included the isolation of staff from the community in designated residential areas, visitor bans, strict segregation and transfer policies across health-care institutions.2, 6 With various restrictions implemented in nursing homes to curb the spread of COVID-19,7 we hypothesise that such measures may have altered the characteristics of hospitalisations of nursing home residents. The inadvertent effects of these pandemic policies are worth studying, as lessons can be learnt from these measures to be implemented for improvements in health-care outcomes of nursing home residents.

1.1 Objective

We sought to understand whether the COVID-19 pandemic had any impact on hospital admissions of nursing home residents and what changes there were in key health-care characteristics such as admission diagnoses, rates of death and causes of death.

2 METHODS

We conducted a retrospective analysis of admissions of nursing home residents to a tertiary general hospital in Singapore. We compared admissions of nursing home residents in 2019 with those in 2020 when the COVID-19 pandemic hit. The patients' demographics, length of stay, primary diagnosis on admission, death and causes of death were recorded. Categorical variables were reported with counts and percentages, and continuous variables were reported with the mean and 1 standard deviation. A comparison of demographic variables, length of stay, primary diagnosis on admission and primary cause of death between groups of patients in 2019 and 2020 was made using the independent T-test for continuous variables and Chi-square or Fisher's exact tests as appropriate for categorical variables. A 2-tailed distribution was assumed for all p-values with p-values of <0.05 defined as being statistically significant. The analysis was performed using IBM SPSS Statistics Version 23 (IBM Corporation). This study was approved by the National Healthcare Group ethics board (No: 2021/00305).

3 RESULTS

There was a 36.6% increase in total hospital admissions to our institution in 2020 compared with 2019. This was driven by the surge in hospitalisations due to the COVID-19 pandemic, and hospital bed capacity was increased to cope with the increase in COVID-19 patients. Twelve percent of total admissions were due to COVID-19 in 2020 (Table 1). The basic characteristics of all hospital admissions in 2019 and 2020 are presented in Table 1. Despite this, the number of admissions of nursing home residents significantly decreased both in absolute (466 vs. 361) and percentage (7% to 4%, p < 0.001) terms during the pandemic year compared with the previous year. Mean age, gender and proportion of deaths within the same year remained similar. Length of stay decreased from 21 days to 17 days although this was not statistically significant (p = 0.108). There was a significant decrease in pneumonia (p < 0.001) but an increase in falls (p = 0.001) as a primary diagnosis on admission. There was a significant decrease in pneumonia as the cause of death (p < 0.001) for nursing home residents admitted to hospital during the COVID-19 pandemic. Mortality rate within the same year of nursing home residents admitted to hospital was not significantly different. Whilst there were cases of COVID-19 found in nursing homes, the spread was controlled very quickly with strict measures.2 The results are summarised in Table 2.

TABLE 1. Baseline characteristics of hospital admissions and primary diagnosis on admission in 2019 and 2020 All hospital admissions

2019

(n = 6519)

2020

(n = 8905)

p-Value Male 3117 (47.8%) 4671 (52.5%) <0.001 Mean age (years) 68.9 ± 19.4 62.2 ± 19.8 <0.001 Length of stay (days) 7.97 ± 14.4 7.05 ± 11.0 <0.001 Primary diagnosis 2019 Primary diagnosis 2020 Falls 371 (5.7%) COVID-19 1090 (12.2%) Non-COVID pneumonia 346 (5.3%) Falls 566 (6.4%) Rehabilitation 346 (5.3%) Rehabilitation 344 (3.9%) Urinary tract infection 293 (4.5%) Cellulitis of lower limb 339 (3.8%) Cellulitis of lower limb 244 (3.7%) Giddiness 318 (3.6%) Giddiness 199 (3.1%) Dengue fever 314 (3.5%) Gastroenteritis 176 (2.7%) Urinary tract infection 304 (3.4%) Dengue fever 169 (2.6%) Non-COVID pneumonia 293 (3.3%) TABLE 2. Baseline demographics of NH admissions and primary diagnosis on admission during hospital stay NH admissions

2019

(n = 466)

2020

(n = 361)

p-Value % of total hospital admissions 7% (466/6519) 4% (361/8904) <0.001 Male 246 (53) 201 (56) 0.439 Mean age (years) 78.2 ± 13.5 76.2 ± 14.6 0.051 Length of stay (days) 20.5 ± 33.7 17.4 ± 21.5 0.108 Primary diagnosis on admission Pneumonia 102 (21.9) 29 (8.0) <0.001 Urinary tract infection 47 (10.1) 41 (11.4) 0.331 Fall 57 (12.2) 68 (18.8) 0.001 Diabetes-related complication 20 (4.3) 16(3.9) 1.000 Delirium 10 (2.1) 13(3.6) 0.191 Dementia 11 (2.4) 11 (3.0) 0.506 Deaths within the same year 81 (17) 55 (15) 0.400 Primary cause of death n = 81 n = 55 Pneumonia 35 (43.2) 6 (10.7) <0.001 Urinary tract infection 17 (21.0) 11 (19.6) 1.000 Malignancy 1 (1.2) 3 (5.4) 0.304 Heart failure 1 (1.2) 2 (3.6) 0.567 Dementia 1 (1.2) 3 (5.4) 0.304 Note Values are expressed as mean ± SD or n (%). Abbreviation: NH, Nursing Home. 4 DISCUSSION

With the ongoing COVID-19 pandemic, differences in total admissions, primary diagnosis on admission and cause of death were observed in nursing home residents admitted to a tertiary general hospital compared with the previous year. Whilst this observation does not prove causality, several hypotheses arise from these data. Drastic reductions in respiratory infections8 have been noted during the severe acute respiratory syndrome (SARS) outbreak in 2003 and in the current COVID-19 pandemic.9 This could be due to the measures taken to control the spread of the pandemic such as stricter hygiene standards, regular disinfection, social distancing and screening of visitors.10 Nursing homes may have higher thresholds to send residents to hospital during a pandemic due to the fear of catching COVID-19 from hospital or the risk of transmission from inter-institutional transfers. Accurate diagnosis of bacterial infection requiring antibiotic treatment and hospitalisation in nursing home residents remains challenging.11 The diagnostic calculus may be altered during a pandemic. It is possible that nursing home residents were observed for longer before transfer to hospital or before a suspicion of pneumonia was made as a reason for transfer. Nursing homes may have had higher thresholds to transfer patients for minor symptoms, as movement across health-care institutions and facilities has been strictly controlled and highly discouraged during the pandemic.5, 12 Lockdowns of nursing homes in Singapore were instituted in May and June 2020 after the first cases of COVID-19 were detected in these residential facilities. Health-care support was augmented when the first COVID-19 outbreak was detected in nursing homes, with the Ministry of Health (MOH) undertaking a nation-wide swabbing program of all nursing home residents and staff. Extra funding, manpower and resources were quickly mobilised to contain the outbreak. Provisions were made such as the hiring of private general practitioners and health-care staff to provide as much on-site care as possible and to assist with measures to contain any SARS-CoV-2 transmission in nursing homes. Free accommodation in hotels and various facilities was even provided to nursing home staff to minimise any possible transmission from the community into nursing homes during the lockdown. The national priority was to maintain the low rate of fatalities.13 Since then, regular rostered testing (RRT) and increased surveillance have been conducted to prevent any major outbreaks in nursing homes. The economic and societal costs of public health measures to contain the pandemic far outweigh the extra spending to augment support to nursing homes. At the end of 2020, there were 29 deaths in total from COVID-19 with nursing home residents accounting for 14% of the mortalities.5, 13 The increased health-care support and scrutiny from the MOH, which led to increased medical reviews and monitoring of nursing home residents, are likely to have contributed to the reduced hospitalisation rates. Nursing homes tend to be less well-funded and staffed compared with other health-care facilities.2 The quality of care provision, which is highly correlated with staffing and resources, has been found to be associated with higher mortality rates of nursing home residents due to COVID-19. Further studies on the cost effectiveness of increased funding and support to nursing homes, and the long-term cost savings and benefits to the health-care system, should be conducted.

The hazards of hospitalisation are well known.14 Unnecessary hospital transfers, especially of institutionalised residents, lead to excess cost, risk delirium and functional decline and also carry the risk of transmission during a pandemic. Thus, measures that reduce hospitalisation of nursing home residents, whether unintended or not, are worthwhile studying and implementing.

The decrease in rates of hospitalisation of nursing home residents and the identification of pneumonia as an admitting diagnosis and cause of death may be unexpected positive outcomes during a pandemic. However, the impact of isolation and decreased physical and social contact due to pandemic measures15 must also be weighed against the decrease in respiratory infections and hospitalisation of nursing home residents. It is worthwhile continuing the implementation of positive aspects of pandemic policies such as increased hygiene, prudent visitor policies and revised criteria for hospital transfers to harness benefits such as unnecessary hospitalisations and reduced incidences of respiratory tract infections, whilst mitigating the negative consequences of social isolation.

5 CONCLUSIONS

The COVID-19 pandemic has impacted the hospitalisation and diagnosis of nursing home residents. Further study into the changes in clinical and on-the-ground practices of nursing homes may lead to improvements in the diagnosis and management of residents.

CONFLICTS OF INTEREST

No conflicts of interest declared.

REFERENCES

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