Coronavirus Disease 2019 Outcomes in French Nursing Homes That Implemented Staff Confinement With Residents

Key Points Question Was self-confinement of staff members with residents in French nursing homes during the coronavirus disease 2019 (COVID-19) pandemic associated with better outcomes related to COVID-19 compared with overall national outcomes? Findings This cohort study including 17 nursing homes with staff self-confinement and 9513 nursing homes in a national survey found that nursing homes with staff self-confinement experienced lower mortality related to COVID-19 among residents and lower incidence of COVID-19 among residents and staff members than rates recorded in a national survey. Meaning These findings suggest that self-confinement of nursing home staff members with residents may help protect residents from mortality related to COVID-19 and residents and staff from COVID-19 infection.


Introduction
Coronavirus disease 2019 (COVID-19) is a devastating disease for the elderly population. The case fatality rate increases with age and is extremely high in individuals aged 80 years and older. 1,2 Nursing home residents are a high-risk population because of their advanced age, complex medical problems, and disabilities. Nursing homes are at risk for outbreaks of respiratory infections because of the gathering of a large number of residents, health care professionals, and visitors in the facility and the high prevalence of cognitive and behavioral symptoms among residents, making it difficult to appropriately apply barriers to infection. 3 In addition, most nursing homes are poorly prepared to implement infection control policies owing to shortage of staff and equipment and relatively low level of staff training. All these factors help to explain why COVID-19 is a major threat to nursing homes. 4 Recently, an outbreak of COVID-19 was described in a 130-bed long-term care facility in Washington state in the US 5 that resulted in a 78% incidence rate and a 34% case fatality rate among residents. In addition, a further 66 cases of COVID-19 in 50 staff members (incidence rate, 29%) and 16 visitors were traced to this facility. 5,6 Health authorities 7,8 and geriatric societies 9-11 have published guidelines for long-term care facilities and nursing homes to prevent and control infection.
During the COVID-19 pandemic wave that hit France in March and April 2020, there was an initiative of some French nursing homes in which staff members decided to confine themselves to the nursing home with their residents to reduce the risk of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus responsible for COVID-19, being introduced by individuals from outside the facility.
In this cohort study, we conducted a telephonic survey to investigate the occurrence of COVID-19 diagnoses among residents and staff of these facilities and compared their data with those recorded in a national population-based survey of nursing homes conducted by French health authorities during the same period.

Methods
The study was conducted in accordance with the principles of the Declaration of Helsinki. 12 This study was approved by the Sorbonne University ethics committee. Owing to the retrospective design, informed consent of study participants could not be obtained and a waiver of consent was granted, per institutional policy. All the data included have been deidentified. This study is reported following Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline.
In this retrospective cohort study, we identified French nursing homes in which some of the staff decided to confine themselves to the facility with residents on a voluntary basis for a period of 7 days or longer. We first became aware of such an initiative through newspapers and other media, and from April 20 to 24, 2020, we performed a systematic search using the Google search engine (Alphabet) to identify similar experiences. We contacted the directors of these facilities via telephone to inquire on the characteristics of the nursing home, date and duration of self-confinement of the staff, and number of cases of confirmed and possible COVID-19 that occurred from March 1 to April 28, 2020, among residents or staff, as well as the number of COVID-19-related deaths. In addition, we asked directors how staff accommodations, meals, and exceptions to confinement were managed and whether their institution had experienced any difficulties with the availability of personal protective equipment. During the telephone survey, we also identified 1 additional nursing home that had not been identified in the media as one in which staff participated in self-confinement, and we included it in the survey. We called the directors of these facilities for follow-up on June 17 and 18, 2020, to update the survey. In France, visits by relatives to residents of nursing homes were banned by the Ministry of Health from March 10 to May 11, 2020, and confinement of residents in their rooms was recommended during this period. In addition, new admissions were prohibited in the nursing homes with cases of COVID-19 among residents.
We also obtained information on the number of confirmed or possible COVID-19 cases that occurred in French facilities for elderly people using the report from Santé Publique-France, the national agency dedicated to public health, which conducts population-based national surveys on the COVID-19 pandemic in France. As a part of an investigation, directors of all French facilities for elderly people were asked to declare to Santé Publique-France the first diagnosis of confirmed or possible COVID-19 that occurred in their facility after March 1, 2020. For facilities with at least 1 COVID-19 case, directors completed a daily online questionnaire recording new cases and mortality related to COVID-19. 13,14 Owing to the lack of information on the total numbers of facilities, residents, and staff members at the time of this national survey, we used corresponding data recorded in 2016 for French facilities for elderly people. 15,16 The primary outcome was mortality related to confirmed or possible COVID-19 among nursing homes residents, and the secondary outcomes were cases of confirmed or possible COVID-19 among residents and staff. Possible COVID-19 was defined by the presence of fever and respiratory signs (eg, cough, dyspnea) or by a clinical disease compatible with COVID-19 according to the physician, with absence of biological confirmation of COVID-19 (no test or negative test results). Confirmed COVID-19 was defined by the presence of signs of the disease or other and a biological confirmation of COVID-19. In France, positive results on real-time reverse-transcriptase polymerase chain reaction (RT-PCR) for SARS-CoV-2 on nasopharyngeal swabs was the main test used for the biological diagnosis of COVID-19, and serological tests were not widely used until early May.

Statistical Analysis
The number of confirmed or possible COVID-19 cases in nursing homes with staff who self-confined was compared with that obtained from the national survey using odds ratios (ORs) and their 95% CIs, χ 2 test, and Fisher exact test. P values were 2-sided, and P < .05 was considered statistically significant. Stata statistical software version 13 (StataCorp) was used for all statistical calculations.

Nursing Homes With Staff Confinement and Their Characteristics
We identified 17 nursing homes that implemented voluntary staff confinement with residents, with 794 staff members and 1250 residents. Their characteristics are shown in Table 1. These facilities had diverse legal statuses and were located in a variety of geographic areas, including areas where there was a high overall mortality rate from COVID-19 (Table 1; eFigure in the Supplement). Thirteen facilities (76.5%) experienced shortages of personal protective equipment (eTable in the Supplement).

Features of Staff Confinement With Residents
During self-confinement periods, all participating staff members remained in the nursing home 7 days a week and 24 hours a day. Staff members who self-confined included nurses, nurses aids, directors and their assistants, housekeeping staff, kitchen staff, and activities workers, as well as a psychologist, a physician, and an occupational therapist. During self-confinement periods, staff members slept in various unused areas of the nursing home (eg, offices, rehabilitation rooms, dining rooms) using extra beds or camping beds. In 3 nursing homes, there were also mobile homes

Mortality Related to COVID-19
The national survey included a total of 9513 facilities, 695 060 residents, and 385 290 staff members ( ( Table 2). Among facilities with self-confinement, 5 residents (0.4%; all in the same facility) had

Case Report
Nursing home No. 17, in which cases of COVID-19 occurred among residents, is located in a French region that was heavily affected by the pandemic. One resident developed COVID-19 symptoms on March 20, before the facility decided to organize a period of self-confinement. The patient was referred to a hospital, and the diagnosis of COVID-19 was confirmed by a positive RT-PCR test for SARS-CoV-2; the resident came back to the nursing home after 2 days. This event and the regional context led the staff members to propose self-confinement to minimize to virus circulation associated with staff displacements. All staff who volunteered to participate in the first selfconfinement period were screened for SARS-CoV-2 via nasal swab testing and RT-PCR. Three staff members were found to be asymptomatic carriers and were excluded from the self-confinement initiative. The same procedure was performed before the second self-confinement period, and all tests had negative results. During the first self-confinement period, 4 additional residents developed COVID-19 confirmed by positive RT-PCR testing, all of whom were residing in the same unit as the first resident diagnosed with COVID-19. The onset date of the cases is shown in Figure. All 5 residents died.

Discussion
This cohort study found that nursing homes in which staff decided to remain confined to the facility with the residents experienced a significantly lower incidence of COVID-19 among the residents and lower mortality than did those included in the national survey conducted during the same period.
The number of cases of COVID-19 among staff members of facilities with self-confinement was also significantly lower than that reported in the national survey.
All but 1 of the nursing homes remained free of cases of COVID-19 among residents, indicating that in these facilities, staff members fulfilled their common aim to block entry of SARS-CoV-2 into the facility and prevent COVID-19-related mortality. In these facilities, the directors ensured that no staff members had symptomatic COVID-19 before initiating self-confinement; however, screening for asymptomatic SARS-CoV-2 carriers was performed in only a small number of facilities. The presence of an asymptomatic carrier among the staff confined with the residents could have been a source of an outbreak in the facility despite their efforts.

Limitations
This study has several limitations. It is impossible to assert a causal link between the self-confinement initiative and the low incidence of COVID-19. The identification of these initiatives from newspapers and other media is probably not a strong bias, as all were reported by journalists shortly after the start of the confinement of the staff and not on the basis of the outcomes of the residents. The type and size of the nursing homes varied, and most were located in regions of France affected by the pandemic. 13,14 To the extent that the containment experience of staff reflects exceptional dedication to their residents, it may be associated with improved hygiene practices. Another limitation is related to the recording of COVID-19 cases in the study. The definition of COVID-19 cases was similar in our telephone survey and in the national survey, 13 but the latter may have missed some cases of COVID-19 owing to underreporting by some nursing homes directors. In addition, some cases of COVID-19 may have been missed in both surveys owing to atypical clinical presentations or negative RT-PCR test results, but this was probably not common in the nursing homes with selfconfinement owing to the very high level of awareness about COVID-19 among staff members.

Conclusions
The findings of this cohort study suggest that the initiative of staff members to confine themselves to nursing homes with residents was successful in protecting their facilities from an outbreak of COVID-19. These experiences, which are based on a strong voluntary investment of staff, including managers, cannot be presented as a generalizable model because of several barriers, such as low sustainability, labor law regulations, and consequences on staff family life. However, in the context of a pandemic threat, staff members in a nursing home free from COVID-19 cases who have decided to confine themselves to the nursing home should not be discouraged; furthermore, screening for asymptomatic SARS-CoV-2 infections should be offered to staff members before they begin the confinement period with residents to promote better outcomes.