Researchers Find Link Between RN Staffing, Severity of COVID-19 Outbreaks in Nursing Homes

Nursing facilities with more registered nursing coverage had lower rates of COVID-19 deaths, a new study has found, while a better federal quality rating correlates with a smaller outbreak size.

“Nursing homes with higher RN staffing and quality ratings have the potential to better control the spread of the novel coronavirus and reduce deaths,” a group of researchers from the University of Rochester Medical Center determined. “Nursing homes caring predominantly for Medicaid or racial and ethnic minority residents tend to have more confirmed cases.”

The study, published last week in the Journal of the American Geriatrics Society, analyzed available COVID-19 data from 215 nursing homes in Connecticut as of April 16, comparing that information against publicly available staffing and quality data from the Centers for Medicare & Medicaid Services (CMS).


Among facilities that had at least one confirmed positive COVID-19 case, every additional 20 minutes of RN coverage correlated with a 22% decline in confirmed cases. For facilities with at least one death, the extra 20 minutes of RN staffing was associated with 26% fewer deaths due to COVID-19.

In addition, facilities with a rating from one to three on CMS’s five-star quality rating scale had 13% fewer cases than those with four or five stars; nursing homes with high proportions of residents covered under Medicaid has 16% more COVID-19 infections than the rest, while those with higher proportions of racial and ethnic minorities saw 15% higher case counts.

The University of Rochester study expands on early research into the characteristics of nursing homes with significant COVID-19 outbreaks, partially aligning with previous inquiries and partially finding new conclusions.


The connection between the racial demographics of a nursing home and the likelihood of COVID-19 infections was previously established in a University of Chicago study — though that research also indicated that there was no clear association between a facility’s star ratings and its number of coronavirus infections and deaths.

Increased RN coverage has long been associated with better care — both in nursing homes and other settings, the University of Rochester researchers observed.

“Previous literature on hospital care has demonstrated that increased RN staffing levels are key to hospitals’ ability to respond to outbreaks of emerging infections,” they noted. “Our findings of the strong negative associations between RN staffing and counts of COVID-19 cases and deaths in nursing homes are consistent with these prior findings, and highlight the critical role of RNs in dealing with COVID-19 outbreaks in nursing homes.”

The team also suggested that due to star ratings’ reflection of performance on a variety of standard metrics, those with four- and five-star ratings were better positioned from the start of the crisis — with a caveat that the leg-up applied only to infections and not subsequent deaths.

“Our results suggest that nursing homes in better compliance with these multifaceted care standards and performing better in resident-oriented quality measures are more able to contain the spread of coronavirus among their residents, although their abilities to prevent COVID-19 related deaths are not found superior compared to other nursing homes,” they noted.

The study’s authors were Yue Li and Helena Temkin-Greener of the University of Rochester’s Department of Public Health Services; and Shan Gao and Xueya Cai of the university’s Department of Biostatistics and Computational Biology.