August 2020 Interim EuGMS guidance to prepare European Long-Term Care Facilities for COVID-19

Key summary points Aim To guide LTCFs in preventing the entrance and spread of SARS-CoV-2. Findings The guidance is based upon the literature available on August 17, 2020. It lists (1) measures that can be implemented to keep COVID-19 out of LTCFs, and (2) COVID-19 symptoms that require RT-PCR testing in residents, staff members and visitors. It also (3) indicates the strategy to be used when a first LCTF resident or staff member is infected, and (4) proposes measures to limit adverse effects of the quarantine of residents tested positive for COVID-19. Message The EuGMS guidance enables LTCFs to adapt and suitably implement infection prevention and control measures, considering that the priorities are (1) early detection of symptomatic and asymptomatic COVID-19 residents, staff members and visitors who contribute to the entrance and dissemination of COVID-19 infection in LTCFs and (2) to limit the negative effects of isolation in infected residents.


Introduction
Long-term care facilities (LTCFs) across Europe encompass a broad range of institution types from home-like facilities to those providing specialised medical care. These facilities include nursing homes, skilled nursing facilities, retirement homes, assisted-living facilities, residential care homes, and palliative care or rehabilitation centres. All these services take care of older people who are no longer able to live independently in the community due to a combination of physical, mental, intellectual or sensory impairments. The European Centre for Disease Prevention and Control estimates that in 2016-2017, there were 64,471 nursing homes, rehabilitation centres and mixed LTCFs in EU/EEA countries, representing a total of 3,440,071 beds [1].
As with the common cold, influenza and other commonly circulating human coronaviruses, LTCFs are high risk environments when it comes to severe outbreaks of SARS-CoV-2 or coronavirus disease . Not only are LTCFs enclosed environments in which the virus can spread rapidly but, more importantly, LTCF residents are extremely vulnerable to complications from the virus, with a mortality rate of > 25% [2,3].
Coronavirus outbreaks in LTCFs will probably continue to occur in Europe with the likelihood of tens of thousands of additional deaths if: -Traditional infection-control and public health strategies are not adapted and implemented suitably for the specific features of COVID-19 transmission in LTCFs; -The diagnostic strategy in residents and staff members is not adapted to the strengths and limitations of the SARS-CoV-2 reverse transcription polymerase chain reaction (RT-PCR) testing; -No measures are implemented to reduce the mental and physical adverse effects of quarantine in residents when it is necessary.
Taking into account the fact that countries have developed different approaches to prevent COVID-19 epidemics in LTCFs (https ://www.jnurs ingho meres earch .com/curre ntissue .html), the specific features of COVID-19 transmission in LTCFs ("Specific features of COVID-19 transmission in LTCFs"), properties of the SARS-CoV-2 testing ("Properties of the SARS-CoV-2 reverse transcription polymerase chain reaction (RT-PCR) testing when implemented in residents and staff members"), and adverse effects of social isolation and quarantine in residents ("Adverse effects of social isolation and quarantine in residents"), the EuGMS is launching a second interim [4] guidance with a checklist aiming at the following: Preventing the entrance of COVID-19 into LTCFs ("Measures to prevent the entrance of COVID-19 into LTCFs by LTCF staff, visitors, and residents, depending on the level of SARS-CoV-2 transmission in the community nearby the LTCF [5] (Box 1)"), reducing the risk of COVID-19 spread within LTCFs ("Measures to prevent the risk of COVID-19 spread by LTCF staff, visitors, and residents, depending on the level of SARS-CoV-2 transmission in the community nearby the LTCF [5] (Box 1)"), limiting the outbreak and optimizing residents' care when a first resident, staff member, or visitor is infected ("Measures to implement when a new case of COVID-19 is confirmed in a LTCF resident, staff member, or visitor" and "Palliative care for COVID-19 nursing home residents"), educating and supporting staff members ("Staff education to meet LTCF needs in response to the COVID-19 pandemic" and "Staff support to meet LTCF needs in response to the COVID-19 pandemic").
The current interim EuGMS guidance that is aimed at LTCFs situated in areas with low to substantial community transmission (see Box 1) specifies also policies and waivers ("Policies and waivers to meet LTCF needs in response to the COVID-19 pandemic") and LTCF organization and structure ("COVID-19 and LTCF organization and structure") that may help LTCF to meet needs in response to the COVID-19 pandemic.
The guidance presented here has been formulated by authors from different European countries who have experience with outbreaks of COVID-19 in LTCFs and who are board members of European national geriatric societies or of the EuGMS. The guidance included in this report is based on current knowledge at the time of manuscript transmission (August 25, 2020) (literature review through PubMed and international reports and statements) and will be regularly modified according to newly published data and new experiences. The present guidance, that should not take precedence over local, regional, or national recommendations, should be considered as an aid document for LTCFs to define, depending on local possibilities, the best protection strategy for residents and caregivers and possibly to help write local, Box 1 Adaptation of Infection Prevention and Control Measures to SARS-CoV-2 Transmission Level in the Community nearby the LTCF or in the LTCF regional, or national recommendations when they do not exist. Considering that certain proposed measures (testing, social isolation and quarantine) may have potential adverse effects, the document provides a list of measures that each require an assessment of the risk-benefit ratio on a case-by-case basis. This article also prepares LTCFs for future waves of the pandemic, as the number of COVID-19 cases rises sharply in many countries at the time of manuscript transmission.

Specific features of COVID-19 transmission in LTCFs
SARS-CoV-2 is highly contagious, due to elevated viral loads in the upper respiratory tract. The long incubation period for COVID-19 (up to 14 days) [5] associated with the fact that asymptomatic residents, visitors, and staff members [3,6,7] and residents with atypical COVID-19 symptoms [8][9][10] contribute substantially to transmission complicates the early detection of cases.
• This suggests that infection prevention and control (IPC) measures aimed at keeping COVID-19 out of LTCFs and early detection of SARS-CoV-2 carriers, including those who are asymptomatic and with atypical symptoms, are essential for limiting transmission in LTCFs [11]. • Family, visiting health care professionals, and LTCF staff initially contributed to the transmission of SARS-CoV-2 within LTCFs, leading to a "lockdown" within the facilities. LTCF staff-including interim temporary or agency staff (hired from private organisations to compensate for gaps in LTCF rotas due to COVID) who moved between LTCFs-were then vectors for virus transmission within the facility and spread among the community [2].
• This suggests that, as part of the reopening process, and for as long as the virus circulates outside the LTCFs, any SARS-CoV-2 introduction and transmission within LTCFs will be due to staff members, visitors, or residents who may have had contact with COVID-19 subjects outside the LTCF, especially during medical examination, hospitalisation or when residents go home or go to their family's home for visits [11].

Properties of the SARS-CoV-2 reverse transcription polymerase chain reaction (RT-PCR) testing when implemented in residents and staff members
The reverse transcription polymerase chain reaction (RT-PCR) test, performed using nasopharyngeal swab (or other upper respiratory tract specimens, including throat swab or, more recently, saliva) is currently the most commonly used and reliable test for diagnosing COVID-19 [12]. The United States Centers for Disease Control and Prevention (US CDC) have published useful guidance for Collecting, Handling, and Testing Clinical Specimens for COVID-19 [13]. Quick tests may have low sensitivity compared to the conventional real-time RT-PCR [14]. The RT-PCR test does, however, have some limitations [6,12,14], as displayed in Box 2.

Sensitivity of SARS-CoV-2 RT-PCR
The sensitivity of the RT-PCR test seems acceptable in LTCF residents, probably higher than 90% (i.e. less than 10% of residents who develop SARS-CoV-2 antibodies in the following days have a negative RT-PCR) [15]. Conversely, RT-PCR testing sensitivity may be lower in LTCF staff members than in residents (meaning that infected staff Box 2 RT-PCR test properties useful when interpreting testing results in LTCF residents, staff members, or visitors [5,12,14,15,17,18,60] -False negaƟve results may occur in asymptomaƟc or weakly symptomaƟc subjects. -False negaƟve results may be due to inappropriate Ɵming of sample collecƟon (too early or too late). -False negaƟve results mays be due to deficiency in sampling technique, especially for nasopharyngeal swabs. -An RT-PCR posiƟve test for SARS CoV-2 reflects only the detecƟon of viral RNA and does not necessarily indicate the presence of a viable virus. -DuraƟon of culturable viral shedding longer than the 10 days previously described is possible in immunocompromised subjects, and possibly therefore in residents of LTCFs, and in paƟents with severe illness. -The cycle threshold (Ct) value of the quanƟtaƟve RT-PCR targeƟng E gene represents an indicator of the viral load (the Ct value is the number of replicaƟon cycles required to produce a fluorescent signal, with lower Ct values represenƟng higher viral RNA loads, considering that a Ct value of less than 40 is clinically reported as RT-PCR posiƟve). -The successful isolaƟon of a virus in a cell culture and the Ct value of quanƟtaƟve RT-PCR targeƟng E gene seem correlated. -PaƟents with a Ct of above 33-34 (dependent however on the RT-PCR system) may not be contagious and therefore may be discharged from strict confinement.
members may more often test negative by RT-PCR than infected residents) [15]. This suggests that: • Testing (when possible) residents, staff members, and visitors with COVID-19 symptoms may be an appropriate strategy for the early diagnosis of the first COVID-19 cases in LTCFs [11]. • When a new case of COVID-19 is confirmed in a LTCF resident, staff member, or visitor having entered the LTCF over the past 14 days, LTCF-wide testing (when possible) of all residents and staff members (even asymptomatic) and repeating this testing strategy once a week in all previously negative subjects until the testing identifies no new COVID-19 cases for at least 14 days may be an appropriate strategy for diagnosing asymptomatic SARS-Cov-2 carriers and for preventing SARS-Cov-2 dissemination [11]. • Because RT-PCR testing sensitivity is lower in staff members than in residents (partly because they are less immunocompromised and therefore less often symptomatic than residents when infected) [12], general IPC measures in staff members-including facemasks over the mouth and nose to contain respiratory secretions, hand hygiene and social distancing-is necessary to reduce the risk of transmission of SARS CoV-2 by staff members, even in the case of negative RT-PCR testing [14][15][16].

Duration of positive SARS-CoV-2 test results
The duration of the positive SARS-CoV-2 test result may be higher in immunocompromised than in non-immunocompromised subjects (positive RT-PCR testing lasts longer in residents than in staff members), and in subjects with severe disease [12]. Thus, around half of all nursing home residents still have positive test results 14 days after the initial positive results [15]. However, detection of viral RNA 10 days after positive testing in non-immunocompromised asymptomatic subjects and 20 days after positive testing in immunocompromised asymptomatic subjects does not indicate the presence of a viable virus [5,17]. After that period, most asymptomatic subjects who continue to have detectable SARS-CoV-2 RNA are no longer infectious [17,18].
• This suggests the need to adapt the duration of isolation and the precautions implemented in subjects tested positive for COVID-19 to their health status (longer in immunocompromised subjects, such as residents, than in nonimmunocompromised subjects, such as staff members) and to their symptoms (longer in the case of severe disease or of remaining symptoms) [11,12,19].
A few cases have also been reported positive after an initially negative RT-PCR test result. It is unclear as to whether this represents testing error, reinfection, or reactivation [12].
• This suggests that testing may be warranted in subjects who remain or become symptomatic after the above isolation period (10 or 20 days), and in whom an evaluation fails to identify a diagnosis other than SARS-CoV-2 infection [11,12,19].

Box 3 Tasks of the Infection Prevention Control (IPC) focal point in LTCFs
-Coordinate COVID-19 IPC training for all employees, including consultant personnel (e.g. wound care, podiatry, barber) and volunteers.
-Coordinate informaƟon sessions for residents and their family since they can be exposed to (or serve as a source of) pathogen transmission.
-Provide audits on IPC pracƟces and feedback to employees.
-Ensure adequate supplies of masks, alcohol-based hand rub, posters (targeƟng employees, residents and visitors to regularly use alcohol-based hand rub or wash hands), Ɵssues and appropriate waste disposal.
-Help to establish physical distancing in the facility, especially during meals and group acƟviƟes.
-Apply specific guidance and measures, especially for residents in whom physical distancing can present parƟcular challenges (residents walking with purpose, for example) 25,26 -Organize the condiƟons of visitors' entrance according to local and naƟonal guidelines.
-Organize the use of video conferencing soŌware (on smartphones, tablets, portable computers), as well as plasƟc or glass barriers as much as possible to maintain human contact for residents and visitors 23,24,49-51 -Organize the use of video consultaƟon technology to bring together nursing home staff, physicians and hospital-based clinicians, family members and legal representaƟves and to thus maintain a high level of care during the COVID-19 pandemic period. 21-24 -Avoid the sharing of health care workers among different wards within the same LTCF and between LTCFs to limit the risk of COVID-19 spread within and between LTCFs.
-Organize and implement an adequate tesƟng strategy ( which can be intensified if necessary).
-Organise the ending procedures of a necessarily imposed visitors' lockdown, when the LTCF gradually opens its doors again.

Adverse effects of social isolation and quarantine in residents
Many older adults in LTCFs undergoing strict social isolation have developed depression, anxiety, worsening dementia, sarcopenia, functional impairment, and failure to thrive.
• This suggests that social isolation has to be restricted to infected subjects and to those in close contact with Box 4 Recommended hygiene and distancing measures in the daily life of the health care personnel, visitors, and residents who go outside the LTCF, for as long as the virus is circulating outside the LTCF -Wash hands frequently and carefully with water and soap for a minimum of 40 seconds or with an alcohol-based hand rub (containing at least 60% alcohol) for a minimum of 20 seconds. Especially aŌer touching any frequently used items or hard surfaces outside the home, including tables, door knobs, light switches, countertops, handles, desks, phones, keyboards, toilets, taps, and sinks.
-Frequently disinfect used items and surfaces as much as possible.
-When sneezing, cover the mouth and nose with a Ɵssue or sneeze into the elbow to keep hands as clean as possible. Wash hands carefully aŌer sneezing or coughing.
-Avoid touching the face when hands have not been cleaned with water and soap or with an alcohol-based hand rub.
-Take social distancing seriously: stay at home as much as possible when not working. If a staff member needs to go out for necessiƟes, keep a distance of at least 1 to 2 meters (Europe) or 6 feet (in the USA) from other people. Do not share personal items such as phones. Disinfect areas aŌer bringing groceries or packages into the home, and wash fresh groceries.
-Wear a cloth mask (or a surgical mask if available), especially in enclosed spaces and even in open spaces when social distancing may be difficult to maintain. Staff members should avoid touching the front of their mask or should wash their hands if they do so. In all cases, naƟonal rules should be followed. infected subjects. When necessary, isolation has to be associated as much as possible with measures to prevent negative effects on residents' mental and health status [20][21][22][23][24].

Second interim EuGMS guidance to prepare European long-term care facilities for COVID-19
The EuGMS guidance supports the IPC World Health Organization guidance [25] and recommends that an infection prevention and control focal point (IPCFP) should be set up in every LTCF for supervising measures (1)

Measures to prevent the entrance of COVID-19 into LTCFs by LTCF staff, visitors, and residents, depending on the level of SARS-CoV-2 transmission in the community nearby the LTCF [11] (Box 1)
Box 3 displays IPCFP missions to prevent the entrance of COVID-19 into the LTCF, in accordance with the IPC World Health Organization guidance [25]. The main missions include the following tasks: -Limitation of the number of visitors, with due consideration that the isolation of residents may have a negative effect on their mental and somatic health status (allowance should be made for this). Indeed, the need to protect residents from the spread of COVID-19 should be balanced with the critical need of support provided by families and other persons [20,[26][27][28][29]. LTCF lockdown should therefore be restricted to LTCFs with COVID-19 positive cases or, temporarily, when SARS-CoV-2 circulates strongly outside the LTCF, according to national or local rules. -General measures in accordance with national rules for residents, staff members, and visitors, especially those relating to hygiene and social distancing, for all activities conducted outside the LTCF (Boxes 4, 5) [19,[30][31][32]. -Screening for COVID-19 symptoms (the screener should be wearing a surgical mask) before allowing staff members, visitors, or residents to enter the facility (Table 1) [11,25]. Any contact with suspected or confirmed COVID-19 cases also needs to be checked. Subjects with COVID-19 symptoms or those in contact with suspected or confirmed COVID-19 cases should not be allowed to enter the LTCF unless their RT-PCR test is negative [11]. -Systematic testing before admission of new residents.
Only RT-PCR-negative residents can be admitted if the LTCF is free of COVID-19 cases [11]. -Consider testing the residents who have spent a period of time outside the LTCF (at hospital for example), especially when the virus is circulating substantially in the visited area [11]. -Consider regular testing (for example weekly in areas with substantial community transmission) of staff members, visitors, and residents who are at a high risk of Box 6 Measures that should be taken by staff members, visitors, and residents during their stay in the LTCF for as long as the virus is circulating outside the LTCF, especially in areas with substantial community transmission -Residents, staff and visitors should constantly maintain social distancing (keep a distance from other people of at least one to two metres in many European countries, 6 feet in the US, considering that the greate r the distance between people, the more human-to-human transmission is avoided), especially when mask wearing is difficult (e.g. during breaks and meals).
-Staff and visitors should not share personal items such as phones. They should wash their hands frequently (with soap and water for a minimum of 40 seconds or with alcohol-based hand rub for a minimum of 20 seconds), especially when hands are dirty, before and aŌer touching residents (although this should be avoided as much as possible), aŌer using the toilet, before and aŌer preparing food, before eaƟng, and aŌer coughing or sneezing.
-Staff should help residents with frequent hand hygiene, in parƟcular when hands are dirty, before and aŌer touching other people (although this should be avoided as much as possible), aŌer using the toilet, before eaƟng, and aŌer coughing or sneezing.
-Staff should disinfect items and surfaces used or touched for the care of residents (e.g. stethoscope). They should avoid touching their face or the resident's face and wash their hands if they touch the front of their mask.

Measures to prevent the risk of COVID-19 spread by LTCF staff, visitors, and residents, depending on the level of SARS-CoV-2 transmission in the community nearby the LTCF [11] (Box 1)
The infection prevention and control focal point (IPCFP) should also organize the following tasks: -Healthcare professionals and family members visiting the LTCF and allowed to enter the facilities should sign a form agreeing to adhere to standard and transmissionbased precautions to prevent a COVID- 19 [34]. -Administrative records should be updated daily on the basis of COVID-19 symptoms, to record whether a resident has received a COVID-19 test, has been isolated due to COVID-compatible symptoms, and/or has required any other non-standard IPC measures.
The IPCFP should also: -Provide information to the residents and their family/ health care providers and organize advance care planning to support them in understanding and sharing their personal values, life goals, and preferences regarding medical care, including appropriate advance directives (ADs) and decisions about escalation to hospital in the event of any future COVID-19 outbreak in the LTCF. An explanation of the limited success of mechanical ventilation in older adults with COVID-19 should be given as well as a description of care that can be provided in the LTCF in the event of non-hospitalization [35]. Advance care planning has to be timely and proactively executed to provide high-quality long-term care, contributing to the quality of life in the remaining life span of the residents [35]. -Prepare a file with all data necessary for the laboratory to organize testing and test result reporting (name, address, date of birth, insurance data, etc. of all residents, staff members, and visitors) in the event of a COVID-19 outbreak in the LTCF. There should also be a list of those responsible for performing specimen collection, including the facility's trained staff members. These people need to be trained to collect specimens correctly, using the appropriate personal protective equipment (PPE) [36].
In a cohort study of French LTCFs, mortality rates related to COVID-19 were lower among nursing homes that implemented staff confinement with residents compared with those in a national survey, suggesting that self-confinement of staff members with residents in areas with substantial community transmission may help protect LTCF residents from mortality related to COVID-19 and residents and staff from COVID-19 infection [37].

Measures to implement when a new case of COVID-19 is confirmed in a LTCF resident, staff member, or visitor
In some countries, COVID-19 geriatric support platforms have been set up in local hospitals, often in conjunction with public health, with a hotline for LTCFs [38]. These support platforms have been shown to be helpful for LTCFs in organizing IPC measures, especially repeated facility-wide RT-PCR testing and reporting of test results. The hotline can be useful for responding to the information requirements of the LTCF staff regarding care procedures, in connection with other specialized units, (emergency, intensive care, palliative care, pulmonary medicine, infectious diseases and hygiene units), possibly by telemedicine [39].
Measures that need to be taken as quickly as possible when a new case of COVID-19 is confirmed in a resident, staff member, or visitor include the following: Within the first 12 h: -Staff should be made aware of the existence of the advance care planning, including advance preferences or directives for all residents who provide consent [35]. -Residents should be restricted to their room and visits reduced to essential health care professionals only (situation to be adapted for end-of-life residents and for those suffering psychological distress, and associated with measures to limit the negative effects of social isolation on residents' mental/health status and well-being) [19,20,26 [11,15,34,41]. Excluding all new positive residents during each facility-wide testing may reduce the LTCF staff workload, optimize IPCs and reduce the LTCF "viral load", therefore reducing COVID-19 spread in the LTCF. If the LTCF can provide appropriate isolation and staffing, an area of the facility should be dedicated for the care of residents with suspected or confirmed COVID-19. There should be a specific staff and a clear delineation of risk zones [41]. Organized staff into teams who work exclusively within COVID-19 and non-COVID-19 zones is strongly recommended [38,42]. Because work-Box 7 Precautions for LTCF staff who enter the room of a patient with known or suspected COVID-19 [25,30,32,44] -Standard precauƟons -Use contact and droplet precauƟons and PPE including -Filtering face piece respirator (N95 respirator or equivalent protecƟon mask) 5 -Gown -Gloves -Eye protecƟon (protecƟve eyewear with gaps between glasses and the face are not likely to protect eyes from all splashes and sprays) -PPE should be put on and removed carefully following the recommended procedures to avoid contaminaƟon. -Employees should remove PPE just before leaving the resident's room, and discard it in the medical waste bin. Hand hygiene should always be performed before puƫng on and aŌer removing PPE.
LTCF: Long-term care facility; PPE: personal protecƟve equipment 1 3 ing exclusively with COVID-19 residents is physically and emotionally exhausting, thought should be given as to how to rotate staff teams, allowing appropriate periods of leave (at least 7 days), between working in COVID-19 units and returning to the mainstream. Distinction should also be made between residents able to understand/tolerate their isolation (e.g. cognitively intact residents) and those more likely to suffer from isolation (e.g. residents with dementia and depressed mood or who walk with purpose) who may be better cared for in cohorted or zoned areas. LTCF COVID-19 units should receive transfers from within the facility as well as new admissions/re-admissions from COVID-19-positive hospitals. In Lombardy (Italy) however, public policies aimed at discharging COVID-19 cases from hospitals to LTCFs to improve the capacity of the health systems to face the lack of hospital beds are suspected to have also increased the risk of infection in the nursing homes' hosts [43,44].
Therefore, if possible, such a COVID-19 LTCF unit should have a separate entrance/exit or try to install temporary walls or doorways at the entrance. If it is not possible to segregate COVID-19-positive patients in a separate unit, such patients should be cohorted in one area of the affected unit and dedicated staff should be assigned to care for them. This is particularly important for residents with dementia [45].
-The establishment of COVID-positive "red" areas also enables residents, with and without dementia, to mobilise safely outside their rooms, minimising the risk of deconditioning associated with prolonged isolation in a private room [41,42].
Any staff member entering the room of a resident with known or suspected COVID-19 (including those with atypical symptoms) should adhere to standard precautions [45], apply contact and droplet precautions and use personal protective equipment (PPE) (Box 7).
Within the first 24-48 h: -Facility-wide testing of all LTCF residents, staff members, and visitors having entered the LTCF over the past 14 days, including those without symptoms. This can be challenging for some of the residents, especially with cognitive impairment, for staff members, and for visitors who may refuse testing. All subjects who cannot be tested have to be managed in the same way as COVID-19 positive subjects [45]. -Repeat this testing strategy once a week in all previously negative subjects until the testing identifies no new COVID-19 cases for at least 14 days since the most recent positive result. The US CDC has published guidance for preparing LTCFs to perform facility-wide testing [46]. The LTCFs should be prioritized for rapid, point of care testing as this is the best way to manage the epidemic in real time [34]. -Report positive SARS-CoV-2 results to local authorities and maintain records of staff members and residents who have positive tests to facilitate the reporting of aggregate data to national databases [11]. -Assess IPC practices with help from the proximity COVID-19 support platform for LTCFs or a hygiene platform in the proximity hospital while conducting facilitywide testing [47]. -Entries are only possible at least 14 days after the end of the isolation of the last resident tested positive when no new residents and staff members have any signs of COVID-19 [11]. -Because immobility may lead to sarcopenia and functional impairment [29], measures should also be implemented to limit the physical effects of quarantine in residents [48], associated with measures to limit the risk of deep vein thrombosis, COVID-19 being associated with a procoagulant state [34,49]. One example of physical activity programme that can be proposed in residents who are isolated in their room is the MATCH (Maintenance of Autonomy Through exercise Care during Hospitalization) programme that comprise specific and adapted exercises (e.g., seated knee extension, sit to stand, step aside, chair for-ward bend, bipedal and unipedal static balance, and wall squat) and walking time. This programme, available for notebook with optional and additional training video, has been tested and imple-mented during this COVID-19 pandemic in geriatric hospital units and long-term care with no individual Internet access [48].

Palliative care for COVID-19 nursing home residents
As indicated previously, advance care planning has to be timely and proactively discussed with the resident and/or their family, including "do not resuscitate", "do not intubate", and "do not hospitalize" [35]. Physicians, nurse practitioners, physician assistants, and social workers can contribute to the discussion. Conversations should include an explanation of the limited success of mechanical ventilation in older adults with COVID-19, and a description of the type of care which can be provided if non-hospitalization is decided. Conversations should emphasise the fact that symptoms of a resident with COVID-19 can worsen rapidly [34]. Proposals for the management of COVID-19 end-of-life symptoms consistent with realistic goals of care, and tailored with respect to comorbidities and symptom burden, are displayed in Table 2. The discontinuation of non-essential medications should be considered (including intravenous fluids that can induce dyspnoea and increase secretions and prophylactic anticoagulation, weighing this against the fact that COVID-19 is procoagulant) to improve resident comfort and reduce nursing administration time. Checking labs or examinations that can expose residents and staff should be avoided [49].
COVID-19 makes it difficult to hold face-to-face endof-life discussions and increases the chances of the resident dying without someone present [50]. To avoid situations in which the infected residents die without the possibility to say goodbye to their relatives, LTCFs should organize a separate room in which the infected resident may be placed and should take special precautions to allow families to be present when the loved one passes. In some cases, the resident will have no relatives and an LTCF staff member becomes his/her very close everyday caregiver. In this case, the death of the resident may have a detrimental impact on the mental health of the care assistants/nurses, justifying the need to develop programmes allowing reflection and relief of emotions to reduce the burden for both the relatives and the nursing home staff [51].

Staff education to meet LTCF needs in response to the COVID-19 pandemic
The COVID pandemic highlights the need for universal adoption of standards of medical care for physicians and other staff members in nursing homes in Europe [52]. Indeed, in this COVID-19 pandemic period, the assessment of patients prior to admission by a specialist in geriatric medicine or old-age psychiatry (or both if necessary) is more useful than ever, to (1) detect and remediate illness and functional loss, and (2) better delineate care needs for the older person, so as to clarify whether NH admission can be avoided or deferred. The multiple missions of IPCFP necessitate a medical leadership (the US medical director can serve as a model) to coordinate the implementation of the above measures. These measure should be set up in collaboration with (1) nurses who have gerontological training, especially in dementia and palliative care, (2) care attendants who have due training in the care of older people, (3) physicians with a formal competencies in geriatric medicine and old-age psychiatry, and (4) specialist gerontology services, including geriatricians, old-age psychiatry and clinical nurse specialists as well as (5) specialists in palliative care support. COVID-19 geriatric support platforms can serve to liaise with IPCFP, hospital geriatric units (public or private), clinical nurse specialists, specialists in palliative care and infectious diseases, IPCFP of other LTCFs in the region, and public health [47]. In a recent study, every 20 min (per resident day) increase in registered nurse staffing was associated with a 22% reduction in the number of confirmed COVID-19 cases (in facilities with at least one confirmed case) and with 26% fewer COVID-19 deaths (in facilities with at least one death due to this infection). This confirms the importance of the qualified staff in preventing SARS-CoV-2 dissemination in LTCFs [53].

Staff support to meet LTCF needs in response to the COVID-19 pandemic
The chronic understaffing in LTCFs-due to part-time employment, punitive measures related to sick leave, low wages, obligation to work when unwell-explains why it may be difficult in most LTCFs to (1) monitor residents for COVID-19, (2) follow protocols to keep residents physically distant and (3) implement public health measures to reduce the transmission of the virus. This is particularly the case when isolating COVID-19 residents with dementia who may not understand or follow the procedure exacerbates their behaviour [54].
The workload of LTCF staff members is has been increased by the pandemic because of: the ban of family members and other volunteers who provide supportive care; and the increase of staff absenteeism due to COVID-19 symptom and/or fear of contracting the virus or transmitting it to their loved ones. In addition, due to the COVID-19 pandemic, the actions of health authorities have generated a feeling of abandonment in LTCF staff members and of degrading [55]. Coupled with the moral distress of losing residents they have cared for over many years, the potential guilt of their own role in transmission, and the feeling of violating their own ethical or moral codes when working under high pressure, there is a high risk of staff experiencing psychological trauma in LTCFs. Because LTCF staff members need more support and recognition than ever, considerations for nursing home leaders and regulators to support the health and well-being of nursing home staff and residents have been proposed. These include (1) measures to keep staff informed (because expert advice evolves) and (2) health measures (focussing on stress management and meeting the basic needs of staff) [54], by (a) optimizing human resources (redeploying and educating staff from other health care facilities (such as hospitals) to work in nursing homes), (b) implementing new clinical practices related to COVID-19, especially end-of-life care including advanced care planning, symptom relief, and post mortem care, (c) providing education and training, and (d) acquiring PPE [56]. In Hong Kong, for example, all health care institutions keep PPE in stock (exchanged every 3 months) [56].

Policies and waivers to meet LTCF needs in response to the COVID-19 pandemic
Policies and waivers implemented by the American Centers for Medicare and Medicaid Services (CMS) to give long-term care providers and professionals flexibility to meet the demands of resident and patient care needs in response to the COVID-19 pandemic can be very useful for the European countries [57]. These policies and waivers include the possibility for hospitals to deliver care in temporary expansion sites to accommodate COVID-19 patients, including COVID-19 residents. LTCFs can be repurposed as expansion sites and designated as COVID-19 patient care facilities to achieve population separation and transmission mitigation.
CMS have also enabled the opening or use of non-LTCF buildings for unmet COVID-19 isolation and treatment as well as the temporary use of rooms in the facilities (activity rooms, meeting/conference rooms, or dining rooms) for resident care, to expand surge capacity and for purposes of cohorting and infection control.
As described in Box 3, telehealth provides new opportunities to enhance healthcare quality in LTCFs that include specialty consultations by physicians and non-physician practitioners where appropriate [22].
CMS also allow for physician delegation of tasks or required visits to a physician assistant, nurse practitioner, or clinical nurse specialist. CMS recommend that a LTCF may not employ a nurse assistant for longer than four months unless he/she meets certain training/certification requirements. The CMS allow for the redeployment of employed physicians, utilization of available trainee staff, and recruitment of community and retired physicians in LTCFs.
It must however be strongly reminded that all new HCPs must adhere to standard and transmission-based precautions to prevent a COVID-19 spread within the LTCF (Box 6).
To enable clinicians to better focus on the care needs of residents, CMS have temporarily given LTCF providers relief from paperwork, reporting and audit requirements [57].

COVID-19 and LTCF organization and structure
The probability of having a COVID-19 case in LTCFs, such as other infections (influenza, Norovirus, Clostridium difficile), is higher for larger facilities in urban locations [58]. The COVID-19 pandemic offers the opportunity to rethink the design of LTCFs so as to provide a high quality of regulating ventilation and temperature, divide them into smaller wards by clustering smaller numbers of residents in living and/or dining rooms, or even in small-scale freestanding living facilities (such as the Green House Model or Green Care Farms), with more space per resident, separate offices spaces and additional separate rooms for residents who need isolation due to infection, and to provide the possibility for family members to stay with the resident at the time of his/ her death [52,59].

Conclusion
This second EuGMS Interim guidance to prepare European Long-term care facilities for COVID-19 takes into account studies, guidance, documents, and experience available up to August 25, 2020. Any changes to the current guidance will be published according to new knowledge on this topic, especially once data are available on the follow-up of symptoms, interventions, course of the disease in COVID-19-positive residents, vaccination schedules, point of care testing, interactions between COVID-19 and flu, and on serology in residents, visitors, and staff members.