Abstract
Background
Infectious disease outbreaks are common in care homes, often with substantial impact on the rates of infection and mortality of the residents, who primarily are older people vulnerable to infections. There is growing evidence that organisational characteristics of staff and facility might play a role in infectious disease outbreaks however such evidence have not previously been systematically reviewed. Therefore, this systematic review aims to examine the impact of facility and staff characteristics on the risk of infectious disease outbreaks in care homes.
Methods
Five databases (MEDLINE, EMBASE, ProQuest, Web of Science, CINAHL) were searched. Studies considered for inclusion were of any design reporting on an outbreak of any infectious disease in one or more care homes providing care for primarily older people with original data on: facility size, facility location (urban/rural), facility design, use of temporary hired staff, staff compartmentalizing, residence of staff, and/or nursing aides hours per resident. Retrieved studies were screened, assessed for quality using CASP, and analysed employing a narrative synthesis.
Results
Sixteen studies (8 cohort studies, 6 cross-sectional studies, 2 case-control) were included from the search which generated 10,424 unique records. COVID-19 was the most commonly reported cause of outbreak (n = 11). The other studies focused on influenza, respiratory and gastrointestinal outbreaks. Most studies reported on the impact of facility size (n = 11) followed by facility design (n = 4), use of temporary hired staff (n = 3), facility location (n = 2), staff compartmentalizing (n = 2), nurse aides hours (n = 2) and residence of staff (n = 1). Findings suggest that urban location and larger facility size may be associated with greater risks of an infectious disease outbreak. Additionally, the risk of a larger outbreak seems lower in larger facilities. Whilst staff compartmentalizing may be associated with lower risk of an outbreak, staff residing in highly infected areas may be associated with greater risk of outbreak. The influence of facility design, use of temporary staff, and nurse aides hours remains unclear.
Conclusions
This systematic review suggests that larger facilities have greater risks of infectious disease outbreaks, yet the risk of a larger outbreak seems lower in larger facilities. Due to lack of robust findings the impact of facility and staff characteristics on infectious disease outbreaks remain largely unknown.
Prospero
Similar content being viewed by others
Explore related subjects
Find the latest articles, discoveries, and news in related topics.Introduction
Infectious disease outbreaks are common in shared living spaces such as care homes [1]. Infection outbreaks in care homes often have a substantial impact on the rates of infection and mortality of the residents who primarily are frail older people with chronic physical, mental and/or cognitive conditions and thus more vulnerable to infections [2, 3]. The most common types of infectious disease outbreaks in care homes are respiratory infections such as influenza viruses, and gastrointestinal infections (often caused by noroviruses) [4]. Additionally, in the last 1.5 years numerous care homes worldwide have been severely impacted by COVID-19 (SARS-CoV-2), an acute respiratory syndrome with worse outcomes for older adults with multimorbidity compared to younger adults [5]. In several countries such as the United States, England, France, Spain, and Sweden, care home residents have been reported to account for 30–50% of all COVID-19-related deaths [6,7,8].
The prerequisites for infection control vary between care homes (also known as nursing homes or residential long-term care facilities) and depend on a range of factors including organisational factors such as facility characteristics (i.e. the physical building) [9] and staff characteristics (e.g. staff compartmentalizing, temporary hired staff) [10]. In the last few decades there has been a shift from providing traditional nursing home wards with hospital-like features such as shared rooms and no private space towards building care homes where residents have a single room and a common living room in a homelike atmosphere with an interior familiar to them [11]. Providing a homelike environment is considered particularly important to residents with dementia as hospital-like environments can contribute to spatial disorientation, stress and anxiety [11]. The homelike environment has however been reported an obstacle in infection prevention and control [12]. Unlike hospitals, care homes with a homelike environment have no transaction windows into the residents’ apartments and are challenged by facility characteristics such as rarely having a designated space where employees can remove personal protective equipment or get changed after having had close personal contact with an infected resident. Besides providing a homelike atmosphere, care homes are often designed to bring people together for social activities and meals, routines that might have to change during an infectious disease outbreak, with consequences such as loneliness and anxiety among the residents [13]. The design of care homes also affects the possibility of isolating residents or conducting cohort care to prevent transmission of infection during an outbreak. Handling residents with dementia or mental illness who have a strong compulsion to walk becomes particularly challenging when practising isolation and social distancing [14]. Earlier systematic reviews focusing on facility characteristics have shown that residents in care homes with a higher proportion of private rooms have reported better quality of life [15], and that care homes with fewer beds scored higher on service quality [16]. Findings on links between smaller facility size and residents’ quality of life were however inconsistent [15]. The latter systematic review further reported higher quality of life among the residents in care homes in rural areas [15]. However, no systematic review has investigated the impact of these and other facility characteristics such as the facility design on infectious disease outbreaks. Further, in a brief summary of evidence on how COVID-19spreads can be contained in care homes, the authors concluded that movement of staff between care homes should be limited, and that temporary staff are a key potential source of infection [17]. Similarly, a systematic review has reported higher risks of infection in healthcare settings with fewer registered nurses and more nursing aide staff, and with a higher proportion of temporary staff [18]. In the wake of the COVID-19 pandemic, the possible effects of care home staff, particularly nurse aides, working in multiple facilities on infection control has been debated [19]. Staff characteristics in relation to outbreaks of infectious diseases in care homes have however not previously been systematically reviewed. The impact of staff and facility characteristics are less studied aspects in healthcare research [20], yet considered potential modifiable factors for infection control in care homes [9, 10]. This includes community-acquired infectious diseases such as COVID-19 where the spread in the local community might result in infected care workers being the probable source of outbreaks in care homes [21]. Identifying factors of particular importance for infection control in the home care setting is essential to mitigate the spread of infectious diseases. Therefore, we have conducted a systematic review that aims to examine the impact of organisational features such as staff characteristics and facility characteristics on the risk of infectious disease outbreaks in care homes for older adults.
Methods
Search strategy
Five electronic databases were searched for this review: MEDLINE (Ovid), EMBASE, Sociological Abstract (ProQuest), Web of Science Core Collection and CINAHL (Ebsco). The systematic search was performed in April 2021. Key search terms were developed in collaboration with librarians and included long term care, infection, and disease outbreaks, and are presented in Appendix 1. The research protocol has been registered with PROSPERO (identification number CRD42020213585).
Eligibility criteria
In this review, the outcome was an infectious disease outbreak in a care home, referring to one or more residents being infected. A single case of an infectious disease can be considered an outbreak if the disease is rare or has serious public health implications [22]. Table 1 presents the PICO (Population, Intervention, Comparison, Outcome) inclusion and exclusion criteria for eligible studies. Studies included were of quantitative, qualitative and mixed-method design reporting on an infectious disease outbreak in one or more care homes providing care for primarily older adults (≥65 years) with original data on one or more of the exposure features: facility size (typically measured as number of beds), facility location (urban/rural), the design or room layout of the facility, temporary hired staff, staff compartmentalizing (i.e. dividing staff at the care home facility into zones or units to prevent the spread of infection), residence of staff (home address of staff), and nursing aides hours per resident (number of hours certified nurse aides are available to care for residents and undertake administrative work). The seven exposure features assessed were chosen based on facility and staff characteristics identified by the authors prior to the database search, and not previously systematically reviewed. The search was not restricted to certain years or languages. Reviews and commentaries with no original data were excluded.
Study selection, data extraction and quality assessment
References retrieved were downloaded to EndNote X9 reference management and Rayyan for systematic reviews and independently screened for eligibility by two researchers (LM and AL). Any disagreements were resolved through discussion between the reviewers and with a third researcher (JA). Researchers LM and AL extracted the data together and organised the studies according to study outcome using a standardised data extraction form [23]. The two researchers then assessed the studies for quality using the critical appraisal skills Programme (CASP) (https://casp-uk.net/casp-tools-checklists/). The appraisal tool is used to analytically evaluate whether the results are valid, biases have been minimised and confounding factors have been considered, with the answer options yes/no/can’t tell. Studies that were given one or more ‘no’ or ‘can’t tell’ answers in the quality assessment were read again and discussed with the third researcher. If any ‘no’ or ‘can’t tell’ answers remained, the study was considered not to be of high quality and subsequently excluded (Appendix 2). A narrative synthesis allowed for the findings of the heterogenous studies included in the review to be compiled.
Results
Results of the systematic search
A PRISMA flow chart of the screening process is presented in Fig. 1. The search yielded 15,786 records and after removal of duplicates 10,424 records remained, which were screened for eligibility. Two hundred and three studies were read in full text of which 178 studies were excluded, mainly because they did not report on any of the exposure features of interest. The remaining 25 studies were assessed for quality using the CASP tool after which 9 studies were excluded, resulting in a total of 16 studies included in the review. Results on each exposure feature in each individual study were summarised and presented in tables (Tables 2 and 3).
Description of the included studies
The 16 studies included in this review are presented in Table 4. Eight studies were cohort studies of which 5 studies had obtained data during one single outbreak and 3 studies had collected data during two to six years. Six studies were of cross-sectional design and two studies were case-control studies. None of the included studies were of qualitative or mixed-methods design. The majority of studies (n = 11) covered COVID-19 outbreaks, two studies were on influenza outbreaks, two on gastrointestinal outbreaks, and one study on both respiratory and gastrointestinal outbreaks. Ten studies were undertaken in North America, one in Hong Kong and five in Europe.
Facility size
Eleven studies reported on facility size in relation to risk of infection outbreak of which several reported on multiple aspects of facility size as shown in Table 2. Definition of ‘large’ facility varied between the studies and is presented in Table 2 for each study, where available. Two studies reported no association between facility size and risk of infectious disease outbreak [24, 27]. Most studies (8 of 11) reported an association between larger facility size and greater risk of an outbreak [28, 30,31,32,33, 35, 37, 39]. Four studies also reported on larger outbreaks in relation to facility size [24, 27, 35, 37] of which all but one showed a lower risk of a large outbreak in larger care homes [35]. In one study the size of the care home was further associated with the duration of the outbreak with larger care homes having longer lasting outbreaks [29].
Facility location
Two studies assessed the risk of a COVID-19 outbreak in relation to the care homes being in an urban or rural area [24, 38]. Both studies showed that care homes located in urban areas were more likely to report cases of COVID-19 of which one of the studies provided findings for 13,709 care homes across the USA [38]. In their study, they used Census 2010 data to calculate population density per square mile and used population density as a proxy for rurality. When examining the results regionally, the association remained significant in 13 states [38]. The other study was conducted in Ohio [24], one of the states in which the findings by Sugg et al. (2020) [38] remained when examined regionally. In the study from Ohio by Bowblis & Applebaum (2020) [24], measures were taken once a month for three months (April–June 2019) and consistently showed that care homes in rural areas, including rural cities, were less likely to have a COVID-19 outbreak and less likely to have a larger outbreak (defined as at least 20% of residents infected) among facilities with at least one case.
Facility design
The influence on the facility design of the care homes on infectious disease outbreaks was examined in four studies focusing on various design aspects [25, 28, 31, 37]. A study from the Canadian province Ontario showed that multi-occupancy rooms, more common in older than newer care homes, were associated with an almost two-fold risk of a COVID-19 outbreak compared to single rooms (RR 1.88, 95%CI 1.27–2.79) [37]. In a study conducted in California, U.S., facility age measured as years of operation was not associated with an outbreak of one or more cases of COVID-19 (OR 1.006, 95%CI 0.995–1.017) [28]. Similarly, another North American study also comparing older and newer buildings where the new building had installed filters preventing recirculation of air, showed no significant differences in influenza outbreaks observed between the buildings in five subsequent years [25]. Further, having isolation areas for infected residents to control infection was not associated with lower risk of norovirus outbreaks in a study of 748 care homes in Hong Kong [31].
Staff compartmentalizing
Two studies reported on staff compartmentalizing i.e. dividing staff at the care home facility into zones or units to prevent the spread of infection [30, 34]. One of the studies reported 2.5 times higher risks of nosocomial respiratory or gastrointestinal disease outbreaks if staff worked at multiple units compared to having staff compartmentalized (RR 2.51, 95%CI 1.07–5.89) [30]. The other study was conducted during the COVID-19 pandemic and showed that arranging for staff compartmentalizing within zones resulted in a significantly lower likelihood of having any confirmed COVID-19 cases (OR 0.17, 95%CI 0.04–0.67) [34].
Temporary hired staff
Three studies reported on use of temporary hired staff and the likelihood of COVID-19 outbreaks in care homes [24, 34, 35]. The largest of these three studies (care homes n = 5126) showed that use of temporary staff was associated with higher proportion COVID-19 infection among residents compared to having no temporary staff, with the strongest association in care homes that only had temporary staff a few times per month (OR 1.28, 95%CI 1.20–1.37, p < 0.0001) [35]. The other two studies reported no association between use of temporary staff and COVID-19 outbreaks.
Nurse aides hours
The influence of nurse aides hours per resident on disease outbreaks was investigated in two studies of which both reported on COVID-19 outbreaks [24, 26]. Whilst one of the studies showed no consistent effects over three months of nurse aides hours and the number of COVID-19 cases [24], the other study reported no association between high nurse aides hours and an outbreak; yet showed an association between high nurse aides hours and lower risks for a larger COVID-19 outbreak [26].
Residence of staff
Only one study examined the influence of the residence of staff on infectious outbreaks in care homes. The study was conducted at a large care home (approximately 500 beds) and showed that staff living in a community with a high rate of COVID-19 was a significant predictor of COVID-19 outbreaks [36].
Discussion
In this review, a range of organisational facility and staff characteristics assessed in earlier studies on infectious disease outbreaks in care homes have been reported. The findings suggest that urban location and larger facility size may be associated with greater risks of an infectious outbreak. The findings also suggest that the risk of a larger outbreak may be lower in larger facilities. Whilst staff compartmentalizing may be associated with lower risk of outbreak, staff residing in highly infected areas may be associated with greater risk of an outbreak. The influence of facility design, use of temporary staff, and nurse aides hours on infectious outbreaks remains unclear.
There is growing evidence that urban location and larger facilities increase the risk of infectious disease outbreaks in care homes [40, 41]. Larger care home facilities imply managing a greater number of residents including person-to-person contact with a larger number of different residents, staff and visitors, creating opportunities for infectious outbreaks [30]. The greater risk of infectious outbreaks that larger care homes seem to face may further reflect the community spread of infection [41]. As shown in this review, there is some evidence that staff residing in highly infected areas increases the risk of an outbreak at the care home where they work [36]. Previous research has also shown a link between the risk of an outbreak at a care home and the incidence of COVID-19 in the surrounding region [37]. Several earlier studies have implied that staff might contribute to the spread of infection [37, 41, 42]. Beside staff-to-resident and staff-to-staff transmission at the same care home, many care workers often hold second jobs and provide care to family members, which may increase the risk of transmission [42]. They also tend to feel obligated to come to work even when ill, due to low incomes and limited benefits [42]. It has been speculated that spread of infection due to staff working at multiple facilities is most likely to occur among facilities using temporary staff who provide services at multiple care homes [24]. However, findings from the three included studies on use of temporary staff are inconsistent with only one study reporting such an association [35]. This might be explained by the unclarity in whether the outbreaks studied were caused by community transmissions or pre-existing asymptomatic cases within the facility.
Apart from suggesting that larger facility size may be associated with greater risks of an infectious outbreak, this review also suggests that the risk of a larger outbreak seems lower in larger facilities. This might be explained by larger care homes often being purpose built allowing for staff compartmentalizing, suggesting that larger facilities have less crossover of staff between residents [27, 37]. Larger facilities might also have the advantage of ‘economy of scale’ in terms of greater resources (e.g. personnel and financial resources) allowing for high nurse aides hours. According to the findings of this systematic review, high nurse aides hours might not prevent outbreaks yet seem to reduce the risks of a larger outbreak. This supports a recent study showing that care homes that met the minimum staffing standards are likely to be able to prevent or delay COVID-19 resident infections [10]. Having enough nurse aides is considered crucial as implementing infection control such as laboratory testing and staff compartmentalizing at care homes is difficult without sufficient staffing levels [26]. This denotes strong and close links between facility and staff characteristics implying the need to apply a holistic perspective when studying disease outbreaks at care homes.
The included studies on facility design assessed different aspects: multi-occupancy rooms, older facility design, air circulation and isolation areas, aspects which all have been considered important in recent analyses of COVID-19 and the care home environment [9, 43]. Yet, the included studies reported no association on these aspects except multi-occupancy rooms, making it difficult to draw any conclusions on the influence of facility design on infectious outbreaks. Further well-designed studies are needed on the influence of the many aspects of facility design on infectious outbreaks to provide an understanding of their potential impact. Further research is also needed on staff and facility characteristics of large facilities in relation to infectious disease outbreaks, and should include tracking cases to provide possible explanations to this review’s suggested findings on facility size.
Strengths and limitations
A major strength of the study is the novelty of systematically reviewing multiple organisational facility and staff characteristics on infectious disease outbreaks in care homes, a setting that has become increasingly important following the COVID-19 pandemic. The search strategy comprised of seven different outcome features of both facility and staff characteristics, was not restricted to a certain language or time period, and was applied to five different databases. Limitations include that the search did not include grey literature, possibly resulting in relevant data not being considered. Initially we intended to include care homes for older adults only however most studies did not specify the age of the residents making such restriction impossible. Further, whilst the search was not restricted to a certain infectious disease, most of the included studies focus on COVID-19, possibly negatively affecting the generalisability of the findings as COVID-19 has higher severe disease and mortality rates than e.g. influenza. However, not restricting the review to a certain infection is not necessarily a weakness per se. For instance, the lack of associations between facility design and infectious outbreaks in studies not focusing on COVID-19 might indicate that at least some aspects of facility design could be of greater importance to certain specific infections. Furthermore, the included studies did not report whether the care homes targeted provided a hospital-like or homelike environment. It is possible that the hospital-like model positively influences the risk of an infectious disease outbreak, making it difficult to conclude whether the findings are more applicable to a certain environment. Additionally, the methodological heterogeneity of the studies and the fact that the number of eligible studies was small makes it impossible to draw any firm conclusions. However, as the features addressed in the included studies may have an impact on infection control and furthermore are amenable to interventions, further studies are strongly warranted.
Conclusions
In conclusion, this systematic review suggests that larger facilities have greater risks of infectious outbreaks, yet the risk of a larger outbreak seems lower in larger facilities. Following the COVID-19 pandemic, care home managers worldwide are preparing for new infectious outbreaks. This research could help inform policy of future care homes and care home managers in their preparation of future infectious outbreaks. However, evidence showing what actions on organisational characteristics are effective, is needed. Due to lack of robust findings the impact of facility and staff characteristics on infectious outbreaks remain largely unknown. Further research is needed to establish the effect of organisational characteristics of staff and facility on infectious disease outbreaks in care homes.
Availability of data and materials
All relevant data are included in the article and/or its supplementary information files.
Change history
23 March 2022
A Correction to this paper has been published: https://doi.org/10.1186/s12913-022-07796-8
References
Utsumi M, Makimoto K, Quroshi N, Ashida N. Types of infectious outbreaks and their impact in elderly care facilities: a review of the literature. Age Ageing. 2010;39(3):299–305.
Fallon A, Dukelow T, Kennelly SP, O'Neill D. COVID-19 in nursing homes. QJM. 2020;113(6):391–2.
Lindsay L, Wolter J, De Coster I, Van Damme P, Verstraeten T. A decade of norovirus disease risk among older adults in upper-middle and high income countries: a systematic review. BMC Infect Dis. 2015;15:425.
Curran ET. Infection outbreaks in care homes: prevention and management. Nurs Times. 2017;113(9):18–21.
McMichael TM, Clark S, Pogosjans S, Kay M, Lewis J, Baer A, et al. COVID-19 in a long-term care facility - King County, Washington, February 27-march 9, 2020. MMWR Morb Mortal Wkly Rep. 2020;69(12):339–42.
European Centre for Disease Prevention and Control. Surveillance of COVID-19 at long-term care facilities in the EU/EEA 2020. https://www.ecdc.europa.eu/en/publications-data/surveillance-COVID-19-long-term-care-facilities-EU-EEA. Accessed 9 Jun 2021.
Office for National Statistics. Deaths involving COVID-19 in the care sector, England and Wales: deaths registered between week ending 20 March 2020 and week ending 2 April 2021 2021. https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/articles/deathsinvolvingcovid19inthecaresectorenglandandwales/deathsregisteredbetweenweekending20march2020andweekending2april2021. Accessed 10 Aug 2021.
Kaiser Family Foundation. State COVID-19 data and policy actions 2021. https://www.kff.org/coronavirus-covid-19/issue-brief/state-covid-19-data-and-policy-actions/. Accessed 9 Jun 2021.
Wang Z. Use the environment to prevent and control COVID-19 in senior-living facilities: an analysis of the guidelines used in China. HERD: Health Environments Research & Design Journal; 2020. p. 1937586720953519.
Harrington C, Ross L, Chapman S, Halifax E, Spurlock B, Bakerjian D. Nurse staffing and coronavirus infections in California nursing homes. Policy Polit Nurs Pract. 2020;21(3):174–86.
de Boer B, Beerens HC, Katterbach MA, Viduka M, Willemse BM, Verbeek H. The physical environment of nursing homes for people with dementia: traditional nursing homes, small-scale living facilities, and Green Care Farms. Healthcare (Basel, Switzerland). 2018;6(4).
McClean P, Tunney M, Parsons C, Gilpin D, Baldwin N, Hughes C. Infection control and meticillin-resistant Staphylococcus aureus decolonization: the perspective of nursing home staff. J Hosp Infect. 2012;81(4):264–9.
Mo S, Shi J. The psychological consequences of the COVID-19 on residents and staff in nursing homes. Work Aging Retire. 2020;6(4):254–9.
Liddell K, Ruck Keene A, Holland A, Huppert J, Underwood BR, Clark O, et al. Isolating residents including wandering residents in care and group homes: medical ethics and English law in the context of Covid-19. Int J Law Psychiatry. 2021;74:101649.
Xu D, Kane RL, Shamliyan TA. Effect of nursing home characteristics on residents' quality of life: a systematic review. Arch Gerontol Geriatr. 2013;57(2):127–42.
Baldwin R, Chenoweth L, Dela Rama M, Wang AY. Does size matter in aged care facilities? A literature review of the relationship between the number of facility beds and quality. Health Care Manage Rev. 2017;42(4):315–27.
Koshkouei M, Abel L, Pilbeam C. How can pandemic spreads be contained in care homes? : The Centre for. Evid Based Med. 2020; https://www.cebm.net/covid-19/how-can-pandemic-spreads-be-contained-in-care-homes/. Accessed 9 Jun 2021.
Mitchell BG, Gardner A, Stone PW, Hall L, Pogorzelska-Maziarz M. Hospital staffing and health care-associated infections: a systematic review of the literature. Jt Comm J Qual Patient Saf. 2018;44(10):613–22.
Ouslander JG, Grabowski DC. COVID-19 in nursing homes: calming the perfect storm. J Am Geriatr Soc. 2020;68(10):2153–62.
Assariparambil AR, Nayak SG, Sugunan A, Mukhopadhyay C, Shankar R, Devi ES, et al. Structure, staffing, and factors affecting infection control nurses: hospital based exploratory survey- a study protocol. J Adv Nurs. 2021;77(2):1062–9.
Chow EJ, Schwartz NG, Tobolowsky FA, Zacks RLT, Huntington-Frazier M, Reddy SC, et al. Symptom screening at illness onset of health care personnel with SARS-CoV-2 infection in King County, Washington. Jama. 2020;323(20):2087–9.
Aschengrau A, Seage GR. Essentials of epidemiology in public health. Fourth ed. Burlington: Jones and Bartlett Publishers, Inc.; 2020.
University of Canberra. Systematic Reviews in Health. Data Extraction. 2021. https://canberra.libguides.com/systematic/extract. Accessed 15 Nov 2021.
Bowblis J, Applebaum R. Prevalence of COVID-19 in Ohio nursing homes: What's quality got to do with it? J Aging Soc Policy. 2020;1-17.
Drinka PJ, Krause P. Report of an outbreak: nursing home architecture and influenza-a attack rates: update. J Am Geriatr Soc. 2004;52(5):847–8.
Gorges RJ, Konetzka RT. Staffing levels and COVID-19 cases and outbreaks in U.S. nursing homes. J Am Geriatr Soc 2020;08:08.
Halloran NF, Harries AD, Ghebrehewet S, Cleary P. Factors associated with influenza-like illness in care homes in Cheshire and Merseyside during the 2017-2018 influenza season. Public Health. 2020;187:89–96.
He M, Li Y, Fang F. Is there a link between nursing home reported quality and COVID-19 cases? Evidence from California skilled nursing facilities. J Am Med Dir Assoc. 2020;21(7):905–8.
Inns T, Keenan A, Huyton R, Harris J, Iturriza-Gomara M, O'Brien SJ, et al. How timely closure can reduce outbreak duration: gastroenteritis in care homes in north West England, 2012-2016. BMC Public Health. 2018;18(1):488.
Li J, Birkhead GS, Strogatz DS, Coles FB. Impact of institution size, staffing patterns, and infection control practices on communicable disease outbreaks in New York state nursing homes. Am J Epidemiol. 1996;143(10):1042–9.
Lin H, Ng S, Chan S, Chan WM, Lee KC, Ho SC, et al. Institutional risk factors for norovirus outbreaks in Hong Kong elderly homes: a retrospective cohort study. BMC Public Health. 2011;11:297.
Lombardo FL, Bacigalupo I, Salvi E, Lacorte E, Piscopo P, Mayer F, et al. The Italian national survey on coronavirus disease 2019 epidemic spread in nursing homes. Int J Geriatr Psychiatry. 2021;36(6):873–82.
Morciano M, Stokes J, Kontopantelis E, Hall I, Turner AJ. Excess mortality for care home residents during the first 23 weeks of the COVID-19 pandemic in England: a national cohort study. BMC Med. 2021;19(1):71.
Rolland Y, Lacoste MH, de Mauleon A, Ghisolfi A, De Souto BP, Blain H, et al. Guidance for the prevention of the COVID-19 epidemic in long-term care facilities: a short-term prospective study. J Nutr Health Aging. 2020;24(8):812–6.
Shallcross L, Burke D, Abbott O, Donaldson A, Hallatt G, Hayward A, et al. Factors associated with SARS-CoV-2 infection and outbreaks in long-term care facilities in England: a national cross-sectional survey. Lancet Healthy longevity. 2021;2(3):e129–e42.
Shi SM, Bakaev I, Chen H, Travison TG, Berry SD. Risk factors, presentation, and course of coronavirus disease 2019 in a large, academic long-term care facility. J Am Med Dir Assoc. 2020;21(10):1378–83.e1.
Stall NM, Jones A, Brown KA, Rochon PA, Costa AP. For-profit long-term care homes and the risk of COVID-19 outbreaks and resident deaths. CMAJ. 2020;192(33):E946–E55.
Sugg MM, Spaulding TJ, Lane SJ, Runkle JD, Harden SR, Hege A, et al. Mapping community-level determinants of COVID-19 transmission in nursing homes: a multi-scale approach. Sci Total Environ. 2020;752:141946.
White EM, Kosar CM, Feifer RA, Blackman C, Gravenstein S, Ouslander J, et al. Variation in SARS-CoV-2 prevalence in U.S. skilled nursing facilities. J Am Geriatr Soc. 2020;16:16.
Abrams HR, Loomer L, Gandhi A, Grabowski DC. Characteristics of U.S. nursing homes with COVID-19 cases. J Am Geriatr Soc. 2020;68(8):1653–6.
Ochieng N, Chidambaram P, Garfield R, Neuman T. Factors associated with COVID-19 cases and deaths in long-term care facilities: findings from a literature review: Kaiser Family Foundation; 2021. https://www.kff.org/coronavirus-covid-19/issue-brief/factors-associated-with-covid-19-cases-and-deaths-in-long-term-care-facilities-findings-from-a-literature-review/. Accessed 9 Jun 2021.
Van Houtven CH, DePasquale N, Coe NB. Essential long-term care workers commonly hold second jobs and double- or triple-duty caregiving roles. J Am Geriatr Soc. 2020;68(8):1657–60.
Anderson DC, Grey T, Kennelly S, O'Neill D. Nursing home design and COVID-19: balancing infection control, quality of life, and resilience. J Am Med Dir Assoc. 2020;21(11):1519–24.
Acknowledgements
We would like to thank librarians Carl Gornitzki and Jonas Pettersson for conducting the database searches.
Funding
The study is funded by The Swedish Research Council (Vetenskapsrådet) (2020–05850). Open access funding provided by Karolinska Institute.
Author information
Authors and Affiliations
Contributions
AL and BB designed the study. Librarians Carl Gornitzki and Jonas Pettersson at Karolinska Institutet conducted the searches. AL and LM independently screened the abstracts. AL and LM did the study selection, data extraction and quality assessment with input from JA. AL, LM, JA and BB planned the analyses and AL and LM undertook the analyses. All authors contributed to the interpretation of the findings. AL wrote the manuscript and all authors reviewed it. All authors have read and approved the manuscript.
Corresponding author
Ethics declarations
Ethics approval and consent to participate
Not applicable.
Consent for publication
Not applicable.
Competing interests
The authors declare that they have no competing interests and that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
Additional information
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
The original version of this article was revised: an error in the name of the first author was corrected.
Supplementary Information
Additional file 1: Appendix 1.
Search terms used
Additional file 2: Appendix 2.
Results from the CASP quality assessment of the non-included studies presented question by question.
Rights and permissions
Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.
About this article
Cite this article
Liljas, A.E.M., Morath, L.P., Burström, B. et al. The impact of organisational characteristics of staff and facility on infectious disease outbreaks in care homes: a systematic review. BMC Health Serv Res 22, 339 (2022). https://doi.org/10.1186/s12913-022-07481-w
Received:
Accepted:
Published:
DOI: https://doi.org/10.1186/s12913-022-07481-w