Why Minimum Standards Are Not the Best Way to Monitor Staffing During Covid Outbreaks

Staff-to-resident ratios in nursing homes were confirmed to be stable or higher than pre-pandemic levels during Covid outbreaks, as declining resident census outpaced reductions in staffing.

Such findings fly in the face of federal efforts to establish a minimum staffing ratio.

A JAMA Health Forum study published on Friday found that facility managers were more likely to report staffing shortages during severe outbreaks, suggesting a per-resident staffing measure may not be the best benchmark for really understanding staffing capacity during outbreaks.

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“It might not be enough to look at hours per resident,” said Karen Shen, lead author of the study and assistant professor of health policy and management at Johns Hopkins University. Other measures might be needed to get the full picture of capacity during outbreaks, she said.

Shen said turnover and infection control monitoring could be better potential routes to measure nursing home staffing during an outbreak – and to identify when something is going wrong.

The finding builds on a previous study published in May 2021 by Health Affairs that found nursing home staffing levels didn’t change significantly during Covid.

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Another key finding in the JAMA study links severe Covid outbreaks in the nursing home to permanent departures in the space; temporary absences associated with quarantine and a flurry of new hires were also connected to outbreaks.

Authors found the link to permanent departures was a critical data point, especially in the face of requirements from the Centers for Medicare & Medicaid Services (CMS) and the Biden administration to establish a minimum staffing requirement.

Federal regulation also adds more weight to appropriate staffing through the five-star rating system, including three new measures on staffing levels and three on turnover.

Total nurse staffing hours per resident per day on weekends, nurse turnover within a given year, annual registered nurse turnover and annual number of administrators who left the sector will be incorporated into staffing measures.

Surveys will be another way to monitor and measure adequate staffing levels – Payroll Based Journal data will be used for inspections effective Oct. 24. Through the PBJ, surveyors will have a lot data to ask specific, directed questions about day-to-day operations; looking back, that includes days during a severe Covid outbreak.

“We thought maybe the main source of stress would be staff having to quarantine but you know, we’re really finding that when a severe outbreak happens, staff just leave permanently,” said Shen.

Workers continued to leave pemranently even after the outbreak peaked at four weeks, Shen said. Meanwhile, absences returned to normal after that timeframe.

Data showed absences are prevalent during peak outbreak weeks – about a month in – but the departures slowly add up on the back end, anywhere between eight to 16 weeks after the outbreak.

“People aren’t so much absent as people are leaving. Maybe they’re frustrated with how the outbreak was handled, maybe they get scared during the outbreak,” added Shen.

Nursing home staffing levels were 2.6% less than average workforce volume about four weeks after a severe Covid outbreak, according to the JAMA study.

Staffing declined further 16 weeks after an outbreak to 5.5% below pre-outbreak levels. Facilities were able to partially offset losses through new hires, overtime and agency staff – this suggests a lasting effect of severe outbreaks on facility staffing.

Declines were greatest among certified nursing assistants (CNAs), as operators hired less of this position compared to licensed practical nurses (LPNs) and registered nurses (RNs).

CNA staff size was down an average of 4.7%, while average hours were down 5.8%.

Authors took into account agency staff as well – there was a change in contract hours that hit roughly 30 hours per week a month after the outbreak before plateauing to about 10 hours per week two months and on.

In-house staffing hours declined steeply at the one-month mark in comparison, dropping about 80 hours and continuing at that reduced hourly rate four months after outbreak.

Further research needs to be done to determine if staffing reductions have had adverse effects on resident quality of life, morbidity and mortality, including additional risk tied to more infection outbreaks, according to the study.

Authors suggest emergency staffing plans be in place for resident safety. Strike teams, like those announced as part of the American Rescue Plan Act of 2021, could be formed at the state or federal level to add supplemental staffing relief for short periods of time, authors said.

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