A cross-sectional survey assessing the preparedness of the long-term care sector to respond to the COVID-19 pandemic in Ontario, Canada

We conducted a cross-sectional survey of clinicians from the Ontario Long-Term Care Clinicians (OLTCC) and Nurse-led Outreach Teams (NLOTs) from March 30, 2020 to May 25, 2020 in Ontario, Canada. The OLTCC is a not-for-profit organization with a mission to provide advocacy and education to physicians, nurse practitioners, pharmacists and other LTC healthcare providers. NLOTs are teams of specialized clinicians who provide consultative nursing services to LTC residents and support LTC home capacity building by optimizing access to ambulatory hospital services (e.g. reduction of potentially avoidable emergency department transfers, support end-of-life care provision in LTC homes, on-site rapid assessment of residents demonstrating clinical change). At the time of this study, the survey was sent to 294 clinicians (240 members of the OLTCC and 54 Nurse Practitioners, Registered Nurses or Allied Health professionals affiliated with NLOTs).

An anonymous electronic questionnaire was sent to all OLTCC and NLOT clinicians using the email distribution list of each organization.

The COVID-19 pandemic response in LTC questionnaire was co-developed with study investigators that included two OLTCC board members (LK, FM). The final survey was subsequently approved by the executive board of the OLTCC prior to distribution amongst their membership. The survey consists of four sections. The first section collects demographic information about participants. The second section asks participants about screening measures, communication, information, and preparation for future outbreaks in their LTC home. The third section asks participants to rate their agreement with statements about information, communication, and preparation for COVID-19 in LTC on a five-point Likert scale (strongly disagree to strongly agree). The fourth section consists of six open-ended questions asking participants to reflect on the current COVID-19 pandemic, and the public health and government responses to the pandemic in LTC.

A modified Dillman method was used to maximize response rates [16, 17]. A study invitation letter was mailed out 1 week prior to the study information letter, which included a link to a digital survey hosted on the RedCap platform (https://​www.​project-redcap.​org/​). Two subsequent email reminders were sent out 2 and 4 weeks following the survey link. An opt-in approach was used; all clinicians with an active email address received a survey link and were instructed to only complete the survey once. Completion, and submission of questionnaires implied a respondent’s consent to participate in the study. Questionnaires completed by May 25, 2020 were included in the analysis.

Data from completed questionnaires were electronically collated using the RedCap platform. Planned subgroup analyses were performed for the following: age, sex, rurality status, medical director status, attending physician status, number of LTC homes a respondent worked in, the number of LTC residents under a respondent’s care, and the timeframe of survey completion (March 30 to April 22; and April 22 to May 25). LTC home rurality status was derived from the having a Rural Index of Ontario (RIO) score greater than 40 [18]. The timeframe for survey completion was determined by the date set by MOHLTC in their directive restricting LTC staff to a single location of employment. Directives for visitor restrictions and active staff screening were in place as of March 30, 2020. While universal masking appears to have been officially mandated by April 15, 2020 in public health documents, many LTC homes had already enacted universal masking policies before this date. As a result, the authors were unable to identify a definitive date before which respondents’ LTC homes were not masking universally.

The top five outbreak preventions measures implemented in respondent LTC homes were: 1) instituting established isolation protocols for respiratory conditions (92.5%, 148/160); 2) active screening of new LTC admissions (90.0%, 144/160); 3) increasing staff education about infection control processes (83.1%, 133/160); 4) active coordination with regional public health officials (83.1%, 133/160); and 5) encouraging sick staff members to take time off work (83.1%, 133/160). Thirty-eight respondents provided additional unlisted measures that were undertaken by their LTC home. Half of these respondents (50%, 19/38) indicated that visitor restrictions were also implemented. Other measures reported were active screening of staff and essential visitors (39.5%, 15/38), implementing virtual health solutions for patient care delivery (13.2%, 5/38), cohorting of LTC residents (10.5%, 4/38), increasing staffing levels (5.3%, 2/38), and coordination with acute care (5.3%, 2/38).

Respondents reported receiving significant communication regarding COVID-19 pandemic preparation from multiple sources, such as their professional associations (92.5%, 148/160), MOHLTC (90.0%, 144/160), and local public health authorities (80.6%, 129/160). In contrast, the head office of LTC operators (e.g. private corporations that own and run a chain of LTC homes) provided the least amount of communication (25.6%, 41/160) and were not deemed as sources of additional guidance (27.5%, 44/160) by respondents. Respondents indicated they would preferentially seek advice and guidance from local public health authorities (92.5%, 148/160), MOHLTC (63.8%, 102/160), and their professional associations (53.1%, 85/160) (Table 2).

There were no statistical differences in responses relating to instituted measures and communication based on individual characteristics of the sample or response timeframe except for medical director status. Regardless of medical director status, respondents overwhelmingly indicated that their LTC homes instituted active screening for new LTC admissions (89.5% vs. 90.8%, p = 0.788), and to a lesser extent, provided increased updates to staff and LTC stakeholders (72.6% vs. 63.1%, p = 0.200) (Table 2). For all other prevention measures, medical directors indicated a much higher rate of measure implementation in their LTC homes. The top five statistically different prevention measures were: 1) increased availability of hand sanitizer (91.6% vs. 69.2%; p = 0.000); 2) increased coordination with public health officials (92.6% vs. 69.2%; p = 0.000); 3) increased passive screening of visitors and staff (85.3% vs. 66.2%; p = 0.004); 4) instituted established respiratory isolation procedures (97.9% vs. 84.6%; p = 0.004); and 5) encouraged sick staff to take time off work (88.4% vs. 75.4%; p = 0.019). There were no statistical differences between medical director status for communication-focused responses.

Overall, only 35.7% (57/160) of respondents agreed that the LTC sector was sufficiently engaged in planning a coordinated primary care response to COVID-19 outbreaks in the community (Table 3). While 76.3% (122/160) of respondents agreed with local public health recommendations for LTC; only 54.4% (87/160) agreed that the recommendations were feasible for LTC. When asked if their LTC home is ready to manage a potential COVID-19 outbreak, 31.9% (51/160) of respondents were neutral or chose not to respond; combined with the 19.4% (31/160) of respondents that indicated disagreement, over half of respondents (51.3%, 82/160) were unsure or felt their LTC home could manage a COVID-19 outbreak. Sufficient resource availability on-site to manage an outbreak was a concern for 30% (48/160) of respondents. Furthermore, only 31.9% (51/160) of respondents agreed that securing additional resources during an outbreak would be possible.

There were no statistical differences in responses relating to LTC pandemic preparedness or engagement in planning based on individual characteristics of the sample or response timeframe except for medical director status. Specifically, medical directors indicated more agreement that their LTC homes had access to reliable sources of information about COVID-19 to educate staff and the public (p = 0.027), and that their LTC homes had the resources on-site to manage a COVID-19 outbreak (Table 4).

This study has several strengths that support the validity of our results. First, our survey was co-developed with a key LTC stakeholder and organization in Ontario. This approach allowed the OLTCC to take a participatory role in defining the nature of the information to be collected. Second, the response and item completion rate for a survey of this length is very robust, especially during a period when LTC clinicians juggled significant priorities. Third, respondent demographics represented a diverse LTC clinician population, which included an equal split amongst male and female providers, and good representation across the age and LTC work experience spectrum. Lastly, it should be noted that respondents used the entire range of the Likert scale in their responses; no ceiling or floor effect were noted in section 3 of the questionnaire.

The authors also acknowledge several limitations. First, although we have a good response rate for an online questionnaire study, our respondents were mainly physicians in urban areas. Frontline nursing staff and clinicians from rural settings are under-represented in our respondent population. Our sample was also older, as over half of the respondents were above the age of 51; however, previous Canadian data reported an average age for medical directors of 52.4 years [20]. Second, LTC clinicians that are actively affiliated with a professional LTC association would be more interested in attending continuing medical education events and review the regular updates being sent during the COVID-19 pandemic. As a result, these clinicians may be more aware of pandemic mitigation strategies, and more willing to complete an online questionnaire. Therefore, the results presented here may not represent the opinions of those LTC clinicians that are not members of professional associations. Third, while our data suggest that public health interventions were widely implemented, our questionnaire was not designed to demonstrate whether these interventions were meaningful enough to prevent a potential individual outbreak. Similarly, our survey does not assess the extent to which our respondents felt that public health interventions could result in potentially negative impacts on their LTC residents. It is important to note that recommended public health interventions could result in worsening cognition and functional decline because of the restriction of external visitors and in-home recreational activities [21]. This negative impact ultimately lowers the quality of life for LTC residents, and should to be considered when planning future pandemic responses in LTC.

Lastly, the survey was created and distributed in a rapidly changing LTC landscape during the COVID-19 pandemic. Because recommendations from public health and local government officials were being communicated daily, responses from later respondents may be different than earlier respondents. To mitigate this limitation, we identified key recommendations that could impact the nature of responses (e.g. LTC staff have one work location, visitor restrictions, active staff screening, masking protocols). Visitor restrictions and active screening recommendations pre-dated the survey distribution. Masking protocols were implemented variably and did not correspond necessarily to the date of the mandatory universal masking directive. As a result, the authors decided to use the recommendation date (i.e. LTC staff being restricted to a single location of work - April 22, 2020), because this resulted in two distinct respondent cohorts with sufficient number of responses to allow for a formal sub-analysis.