Staffing Increasingly Linked to Nursing Home COVID Outbreaks — But Community Spread Still Top Predictor

A new study has added to growing evidence that nursing facilities with staffing issues are likelier to experience COVID-19 outbreaks, though the prevalence of the novel coronavirus in a given community still remains the strongest predictor of danger in long-term care.

Two researchers from the University of Chicago examined various characteristics of facilities with confirmed COVID-19 cases and wider outbreaks, determining that nursing homes with higher total numbers of nurse staffing hours had a lower probability of outbreaks, along with fewer total coronavirus deaths.

But that conclusion belies a series of complex and often counterintuitive trends: Properties with better staffing coverage actually were likelier to have at least one case, an effect that study authors Rebecca Gorges and R. Tamara Konetzka speculatively attributed to the increased traffic of outside personnel in such facilities.


“We find a nuanced story: Staffing levels may play one role (or no role) in the probability that COVID-19 gets into a nursing home, and another role in trying to stem transmission and deaths once it is in,” Gorges and Konetzka wrote in the study, published in the Journal of the American Geriatrics Society.

The study, which analyzed COVID-19 data from more than 13,000 nursing facilities nationwide, determined that 71% of properties had at least one case, with 27% of them experiencing wider outbreaks; the mean number of deaths across the sample was 3.2.

Within those numbers lie a series of curious associations. Facilities with cases and outbreaks were more likely to report shortages of personal protective equipment (PPE) — but also had better access to testing. Properties with no reported cases or outbreaks had better health inspection ratings, but worse quality-measure rankings from the Centers for Medicare & Medicaid Services (CMS). Greater proportions of residents covered under Medicaid seemed to correlate with outbreaks; so did non-chain status.


“Larger facilities, non-profit ownership, fewer white residents, metropolitan county, and more county-level cases are associated with higher probability of having any cases,” the researchers determined. “The associations are of the same direction for probability of an outbreak for all characteristics except ownership: for-profit ownership is associated with higher probability of an outbreak among facilities with at least one case.”

Even the staffing connection, the study concludes, isn’t striking.

“The effect sizes of staffing are relatively small. For example, being in the top third of the distribution of NA [nurse aide] hours is associated with 1 fewer death; similarly, being in the top third of total nursing hours is associated with 1.1 fewer deaths,” the authors wrote.

Instead, the strongest connection remains the one previously established in earlier research: The total number of cases in a given area.

“While potentially meaningful, these effects are dwarfed by the effect of where the virus is circulating,” Gorges and Konetzka wrote of staffing differences. “The largest magnitude effects we find are for county metropolitan status and county-level number of COVID-19 cases per capita that occur among the general population.”

A facility located in a county with overall per capita COVID-19 infection rates in the top 20th percentile nationwide had more than six times the likelihood of reporting at least one case; among those with at least one case, the outbreak risk was also more than six times higher.

The results led Gorges and Konetzka to call for an increased focus on staffing support for facilities, while also acknowledging that given necessary employee traffic into and out of facilities, preventing the virus from entering a nursing home “may be close to impossible.”

“While nursing homes in neighborhoods with the highest virus prevalence will continue to be the most vulnerable and in need of assistance in the short run, a critical and longer-run focus must be to improve nursing home staffing,” they concluded. “This is a longstanding challenge that is likely to become even more important as the pandemic continues.”

A separate research letter determined that among the three primary domains that go into a facility’s five-star CMS rating — health inspection, quality measures, and staffing — only staffing coverage served as a reliable predictor of COVID-19 outbreak size.

“Across 8 states, high-performing NHs for nurse staffing had fewer COVID-19 cases than low-performing NHs,” the study, published online by the JAMA Network, determined. “In contrast, there was no significant difference in the burden of COVID-19 cases between high- vs low-performing NHs for health inspection or quality measure ratings. These findings suggest that poorly resourced NHs with nurse staffing shortages may be more susceptible to the spread of COVID-19.”

Those eight states — California, Connecticut, Florida, Illinois, Maryland, Massachusetts, New Jersey, and Pennsylvania — represent areas hit particularly hard by the novel coronavirus, though the researchers acknowledged that the data only represents a portion of the nation’s long-term care infrastructure.

Still, the team argued that the data should prompt CMS to focus more on bolstering the nursing home workforce to prevent further outbreaks.

“Although guidance on best practices on infection control are important, which has been the primary strategy used by CMS to date, policies that provide immediate staffing support may be more effective at mitigating the spread of COVID-19,” the letter concluded.

The letter was written by Jose Figueroa of the Harvard T.H. Chan School of Public Health, Rishi Wadhera of Beth Israel Deaconess Medical Center in Boston, and Irene Papanicolas of the London School of Economics.