Social/physical distancing

The terms ‘social distancing’ and ‘physical distancing’ were used interchangeably within and across papers, but for purposes of consistency in this review, they will be referred to herein as ‘social distancing’. There was little discussion of social distancing interventions to prevent the transmission of COVID-19 within CHs. Generally, there was no definition provided in the literature of the term or what it meant in practice, other than that CHs must adhere to ‘government guidance’ or ‘national rules’ on distancing. Those who did describe their understanding of distancing stated this was maintaining a distance from other people of at least 1 to 2 m in Europe or 6 feet in the USA.^{41,46,68,79,97,124,127} Social distancing was regularly referred to in conjunction with other infection control measures, such as hand hygiene and mask-wearing,^73,79,90,97 but these measures were beyond the scope of this review.

Social distancing in CHs generally referred to those residents who had not been exposed to COVID-19 being able to continue with some regular routines and group activities while maintaining a physical distance from other residents.^{46,56,59,62,69,73,79,84,90,97,104,105,112,119,124,127,130} This involved CHs working innovatively to organise, for example, small-group, socially distanced mealtimes in the dining room;^{69,73,84,119,127} separating chairs in common rooms;⁷³ instigating one-way movement around the home⁶³ and placing spacing indicators on the floors.⁷³ Some guidance documents recommended that any spaces where social distancing was not possible should be ‘taped off’ to prevent residents from accessing them⁶⁸ and that any activities that could not be carried out under social distancing guidelines should be cancelled.⁷³ One policy document stated that social distancing measures had enabled residents to maintain a ‘normal’ life within the CH during the pandemic.⁴⁶

Other grey literature discussed the importance of staff maintaining a social distance from each other, for example in staff rooms and other areas around the CH.^{38,68,73,95,97,127,130} Guidance/policy documents referred to the need to separate chairs in staff rooms;⁷³ to stagger breaks to limit the density of staff in specific areas;⁷⁹ and to restrict staff car sharing to and from work.⁷⁹ Others discussed the need to ensure visitors maintained an appropriate social distance from residents and staff^60,90,127 – for more on this, see the ‘Visitor restrictions’ section.

Isolation/quarantine

The terms ‘quarantine’ and ‘isolation’ were used interchangeably within and across reports, but for the purposes of consistency in this review, they will be referred to herein as ‘isolation’. It is important to note that many other interventions were again discussed in relation to isolation, such as the importance of testing, good ventilation in rooms, adequate hygiene procedures and the use of PPE,^{56,59,60,104,105,119,130} but this was beyond the scope of this review. There were several reported ways in which CHs used isolation in a preventive capacity during the COVID-19 pandemic:

Restrictions

Although this review focussed on social distancing and isolation interventions, other interventions related to restrictions were also regularly discussed. This included placing restrictions upon residents;^{25,32,34,40,46,52,53,55,58,66,68,73,80,97,105,119,122,126,128} CH staff;^{32,39,46,51,53,55,62,64,73–75,77–79,83,92,94,99,105,106,108,129,130} visitors;^{9,24,25,32,34,35,38–40,42,43,46–48,50–53,55–58,60,62,64,66–69,73,74,78,79,82–85,90–92,94,95,97,99,103,105–107,109,110,112,113,115–117,119,120,122–130} and other professionals/services.^{25,34,39,40,42,58,62,68,84,92,94,97,112,117,119,122,130} For the purposes ofthis review, the term ‘restriction’ refers to any instances where an individual was prevented from doing something they would normally do (e.g. cancelling all groups and activities so that residents were no longer able to attend) or asked to modify the way in which they would normally do something (e.g. asking staff to work different shift patterns). This differs from ‘social distancing’, which, for the purposes of this review, refers to instances where an individual could carry on activities of normal life, while remaining at a distance from other individuals (e.g. resident groups and activities continued, but residents were required to maintain a 2 m distance from others throughout).

Surveillance

Once again, while this review focused on social distancing and isolation interventions, the importance of surveillance in preventing COVID-19 in CHs was highlighted in the literature. A relatively limited discussion was given to the importance of surveillance for COVID-19 (though more information around surveillance of other infectious diseases is highlighted in the ‘Non-COVID-19’ section). However, there was some mention in the grey literature of the importance of using data to conduct active surveillance of COVID-19 in CHs during the pandemic.^{97,107,123,126,127} This included the need for the early detection of symptoms and the systematic collection, consolidation and analysis of data, such as the number of staff and residents with COVID-19; the number of COVID-19 deaths (probable and confirmed); and the number of residents transferred to hospital.^{97,107,115,123,127} It was suggested that such data be disaggregated by gender, age, disability and existing health condition and integrated with existing surveillance systems.¹²³ Examples were provided where such data had been used to help identify possible COVID-19 outbreaks before being confirmed.⁹⁷ Policy documents also discussed the importance of having either a designated staff member to lead on infection prevention/control measures and surveillance⁶⁸ or a committee tasked with implementing a surveillance programme for the rapid recognition of outbreaks.^107,126

Isolation

‘Zoning’ and ‘cohorting’

Finally, while this review focused on social distancing and isolation interventions, the importance of zoning and cohorting in controlling the spread of COVID-19 in CHs was also highlighted in the literature. The terms ‘zoning’ and ‘cohorting’ are understood in different ways and were used interchangeably across reports.^{9,22,34,40,41,49–51,55,57,58,60,64,68,73,74,82,85,87,90,94,97,99,103,105–107,110,112,117,126,127,129,130} Similarly, some reports discussed ways of separating residents without using any specific terms to describe these interventions. For this review, we refer to ‘zoning’ as creating physical separation areas within a CH, for example separating residents with and without COVID-19 onto separate floors or disparate wings of a CH. We use the term ‘cohorting’ to refer to all other imposed means of grouping residents, including allocating specific groups of residents to particular areas within a floor. Again, other interventions, such as the appropriate use of testing, PPE, cleaning, handwashing and ventilation, were thought to be vital to the success of zoning and cohorting, but are beyond the scope of this review for example.^{34,68,90,103,110,112,119}

As previously stated, in this review, ‘zoning’ refers to the creation of separate physical spaces or locations within a CH, such as different floors, wings, wards or units, to care for those residents with a positive COVID-19 test result/suspected COVID-19 away from those without.^{9,34,41,49,51,55,57,58,64,68,74,90,103,106,110,112,129,130} A zone may have multiple-occupancy rooms but, according to the grey literature, a series of single rooms with en suite bathrooms within a zone was preferable.^126,127,130 This may have required the rearrangement of rooms or the repurposing of other areas to make this possible.^58,63 The grey literature reported the intervention of zoning to offer CHs a clear delineation of risk zones throughout the building, and it was stated that staff, residents and equipment should not move between the zones to reduce cross-contamination.^{34,41,51,55,63,68,74,130} Other examples of zoning included separating areas of CHs to create a traffic-light system, with ‘green’ areas for residents who were free of COVID-19 symptoms or who had received a negative test result; ‘yellow’ areas for those at risk of infection (i.e. those isolating after being discharged from the hospital); and ‘red’ areas for those who had received a positive test result or had come into contact with someone with a positive test result.^38,68 This zoning method had been found to reduce the number of infections in previous SARS and Ebola outbreaks.⁶⁸ Others referred to similar zones within a CH, known as the ‘clean’, ‘semiclean’ and ‘contaminated’ environments¹¹⁹ or the ‘hot’, ‘warm’ and ‘cold’ zones.¹³⁰

In general, zones were described as self-sufficient care bubbles,⁷⁴ enabling residents to have limited freedoms within their own zone.^9,49,64,103 This was considered to encourage socialisation and activity between residents within the zones and help decrease their feelings of isolation and loneliness.¹¹² A crucial part of successful zoning included having separate staffing teams allocated to each zone.^{41,51,63,68,74} Examples from the grey literature included staff wearing different-coloured T-shirts or badges to distinguish what floor they worked on, with staff needing to keep their distance from those wearing a different colour.^64,84 Separate staff entrances, exits and corridors for each zone were also utilised, where possible^{41,63,68,74,112,119} with separate staff rooms, and staff communicating via text, telephone, or video call.^63,74 Although it was not always easy to reconfigure CHs in this way, some innovative examples of how this had been undertaken were highlighted, including the use of ‘Derby doors’, an inflatable barrier that sits flush against walls and ceilings to form a complete seal.¹¹² Where not possible to separate areas entirely, the use of any common spaces (such as lifts and pantries) should be staggered and cleaned between staff usage from different zones.⁷⁴ It was also crucial that all zoning policies and procedures were clearly articulated, and clear signage displayed to highlight the designated zone.¹¹⁹

In this review, ‘cohorting’ refers to other imposed means of grouping residents, which did not involve dividing floors or units of a CH into physically separate ‘zones’. Cohorting was sometimes suggested for settings where it was impossible to physically separate residents in this manner.⁴¹ Examples of cohorting were organising residents into small groups or dedicated areas within a floor (rather than separate floors or wings) of a CH with the same staff continuously assigned to them.^{41,63,73,80,85,97,117,126,127,129} The rationale for this was that, in case of infection within this small group, as few residents and staff as possible would require isolation.⁸⁰ Another example of cohorting involved assessing residents’ preferences around risk tolerance and using these preferences to create a ‘risk-accepting’ group of residents who could convene together and be given an opportunity for increased social interactions and group dining opportunities.⁴⁰ Again, the need to have separate staffing teams for each cohort was identified as essential to minimise chances of spreading infection.^{50,55,64,73,79,85,97,112,127}

Zoning and cohorting were often recommended in the grey literature when isolation practices were not possible, due to the physical constraints of the CH or the individual needs of the residents. For example, it was suggested that residents who were contacts of someone with confirmed/suspected COVID-19 should ideally be isolated within a single room with a private en suite bathroom but could be cohorted/zoned in small groups where isolation was not possible.^{55,68,79,97,107,129} Similarly, some reported that zoning or cohorting might be more appropriate for residents living with dementia, mood disorders or who ‘walked with purpose’, as these individuals may find it more challenging to isolate.^41,117 However, it was noted that ‘shielding’ residents (i.e. clinically vulnerable individuals who were asked to isolate in order to protect themselves from COVID-19) should not be placed in a cohort and should be prioritised for single occupancy rooms.⁷⁹ Similarly, suspected or confirmed COVID-19 cases should not be cohorted next to immunocompromised residents.¹²⁷ Nevertheless, the physical constraints of some CH buildings and layouts meant that it was also not always possible to implement zoning and cohorting interventions within CHs^94,112 (see ‘Challenges and facilitators’ section for more on this). Furthermore, such interventions were also dependent upon CHs having sufficient staff resources to work in this way.¹¹² Indeed, some reports noted that zoning and cohorting interventions required CHs to rely upon the recruitment of new team members or upon ‘surge staffing’ (i.e. a contact list of casual staff members and external nursing agencies to enable timely recruitment).^58,63 Moving residents from their usual room to a new cohort or zone could create some confusion, anxiety or distress for residents,^62,112 but it was acknowledged that for many the benefits of this were likely to outweigh the negative consequences.¹¹² Where possible, CHs should, however, aim to maintain residents’ usual routines as much as possible when they are placed within a specific cohort or zone.⁶²

Challenges and facilitators of COVID-19 interventions

Several challenges were highlighted, which negatively impacted the success of implementing social distancing and isolation interventions for COVID-19 in CHs. The most frequently stated of these challenges were related to staffing and workload. Before the COVID-19 pandemic, many CHs were already poorly prepared to implement infection control interventions due to a shortage of staff, a lack of appropriate training and equipment and excessive workloads.^{39,66,92,95,103} The pandemic exacerbated these issues, by adding additional staff sickness leave/absence due to quarantine or shielding, as well as other restrictions placed on the use of agency staff and the limited number of settings that staff could work in.^{22,46,66,69,77,82–84,89,90,92,94,95,112,116,123,129} Indeed, in some CHs, all (or almost all) care staff needed to be replaced with new employees due to quarantine regulations.^69,74 In some instances, this led to the care of residents being jeopardised,⁶⁹ including residents being moved to hospitals when staffing of CHs became unsustainable.⁹⁴ Workload also increased for staff, due to the new tasks they had to undertake, which relatives had previously carried out or other professionals, such as hairdressers;^{69,95,103,123} as well as the extra preparations staff needed to undertake for the introduction of new COVID-19 interventions.²⁵ Care homes around the world used various methods to address these staff shortages. For example, in Australia, an emergency surge workforce was organised and funded by Healthcare Australia;³⁶ in the USA, retired care workers and healthcare providers from other sectors were encouraged to assist with staff shortages;⁷⁷ and in Sweden, those in recently unemployed groups, such as flight attendants and restaurant staff, were retrained as care aides.⁸⁵ Other countries encouraged CHs to use volunteers to help manage staff workload^83,90,117 or hire new staff.^46,64,83 Yet for many CHs, staffing shortages and inadequate staff training, particularly around IPC measures and the correct use of PPE, remained a challenge.^{83,84,116,123}

Another frequently mentioned challenge to implementing COVID-19 interventions in CHs was a lack of guidance and clarity from governments around when and how interventions should be applied, with policy measures often scarce, flawed or adopted late.^{43,46,52,56,77,82,84,103,116,128} An example of this was highlighted in the UK, where Public Health England initially published guidance stating that negative COVID-19 tests were unnecessary for CHs to accept transfers from hospitals, because symptomatic residents could be safely cared for if they were appropriately isolated in the home.⁵⁶ The assumption by the government that CHs could isolate residents in the same way as a hospital has been described as an ‘appalling error’ by the Public Accounts Committee, who stated, ‘Our care homes were effectively thrown to the wolves’ (p25).⁷⁰ By the time the government agreed that all patients should be tested for COVID-19 before discharge, over 28,000 patients had been discharged from a hospital to a CH.⁷⁰ By this stage it was clear that asymptomatic transmission could occur, and 5700 CH resident deaths had occurred.⁷⁰ The policy of discharging hospital patients to CHs without testing is now the subject of a legal challenge from residents’ family members.⁷⁰ Therefore, CH managers in the UK reported struggling to persuade their staff that government advice was credible.¹⁰³ Other flawed policies were seen elsewhere, such as CH workers not initially identified as ‘key workers’ and therefore unable to travel to work during lockdown measures and curfews.¹²³ Therefore, some examples were provided of CHs taking their own initiative on interventions before policy guidance came into place.^43,56 For example, a policy paper highlighting the Netherlands’ response to the COVID-19 pandemic stated that some CHs applied their own ban on visitors 1 month earlier than the government issued it.⁴³ Due to these issues surrounding policy and guidance, rebuilding trust in government may be difficult but is essential if future policies are to be adhered to.¹⁰³

The physical space and layout of CHs were identified as an additional issue that could make the implementation of COVID-19 interventions challenging. Not all CHs had the space to provide single rooms, create separate zones or ensure sufficient walking space around the home was in line with social distancing measures.^{33,60,64,78,82,84,103,112,123,129} These difficulties with physical layout were particularly notable when attempting to isolate or zone residents – especially those living with dementia, cognitive impairment or who ‘walked with purpose’ – which meant that residents could unintentionally infect each other through their movements around the home.^{60,85,103,112,116} Moving equipment across the home to enable resident cohorting also proved complicated.¹⁰³ Making changes to CHs to enable COVID-19 interventions (e.g. reconfiguring entrances and exits and other building works) could have significant cost implications. Therefore, the innovative use of space may be required.^63,64 Examples of innovative solutions to space issues included renting out motor homes to be used as staff sleeping facilities on CH driveways and utilising empty basements as staff rooms.⁶⁴ One discussion paper suggested that CHs operating with ‘household models’ (i.e. small-scale, homelike settings) had improved outcomes for residents, but that more research was required in this area.³³

Several factors were also identified in helping to facilitate the introduction of interventions within CHs. Reports from countries such as the UK and Ireland, USA and China highlighted the importance of innovative technology, which was often successfully used to remotely support residents and their families during periods of restriction and help reduce the impact of social isolation.^{55,64,66,82,112,119} However, some concerns were noted around the ethics of using video calls with dying residents.¹¹² Furthermore, some CHs lacked sufficient broadband, Wi-Fi, laptops or iPads to support these innovative technology uses,⁵² while others felt staff, families and residents required training on using it.¹²⁷ The appointment of a ‘social media champion’ in CHs was one beneficial way of supporting residents and families in engaging with this new technology.⁶⁴

Also identified was the importance of ensuring sufficient staff support, both in terms of funds to pay for the extra costs associated with COVID-19 interventions and initiatives to support their well-being. For example, many countries provided CHs with additional budgets to aid COVID-19-related spending, including increased staffing costs, infection control training, extra cleaning and the cost of new technology.^{36,52,56,70,97,108} This funding could also help pay staff in full for any time they were required to spend in isolation^{56,70,103,127} and help minimise reliance upon agency staff, thereby reducing the number of care workers across multiple locations.^70,108 In addition, some authors discussed the benefits of providing CH staff with rewards, such as annual pay increases or bonuses, gifts, care packages or additional leave days.^56,74,83,103 Others implemented food and water stations or ‘staff shops’ to ensure their staff were adequately fed and hydrated or provided access to well-being initiatives, counselling and emotional support.^64,74,103

Finally, good communication and the availability of informational materials, such as brochures, posters and signage on COVID-19 and the associated policies, were deemed to help explain the reasons behind restrictions to residents and their families/friends.^{36,50,58,62,97,124} In addition, to be easy to understand, printed materials needed to be both language and reading-level appropriate.^50,124

Impact of COVID-19 interventions

The COVID-19 pandemic has had a devastating effect upon the CH sector, and in many countries, CHs have been at the epicentre of deaths from the disease.^{40,103,108,119} Figures vary widely across the world and, although specific details are not provided, some international reports state that as many as half of all COVID-19 deaths in some countries have been among CH residents,⁵⁵ while others state they account for up to 72%²² or even around 80% of all deaths.^95,113,123 Furthermore, there have also been reports of an increase in non-COVID-19-related deaths in CHs, attributed to a combination of undiagnosed COVID-19 and disruptions in care for people without COVID-19.^24,43,56

The negative consequences of IPC measures have been wide-reaching, impacting residents’ mental and physical health and quality of life.^80,112 Relatives and CH employees have also been affected both physically and mentally by these measures, and their experiences of stress and anxiety have increased considerably during the pandemic.^{22,56,59,69,70,80,103,127} Some of the direct impacts of specific prevention and control measures implemented within CHs during the COVID-19 pandemic are presented below.

The impact of social distancing measures

Very little was stated about the impact of social distancing measures on CH staff, residents or their family members, other than an acknowledgement from the World Health Organization that social distancing may have severe implications for residents’ mental health and well-being.¹²⁷ Once again, residents living with cognitive impairment or dementia were reported in the grey literature to have greater difficulty understanding social distancing measures and maintaining a physical distance from others.^9,24 For example, one document stated that some residents could not understand the need to wash hands frequently, wear masks or keep a suitable distance from other residents; they needed to be informed about this by staff every day.⁸⁴ Other CHs decided not to enforce social distancing procedures, knowing that their residents would not be able to adhere to such rules.⁸⁴ Once again, it was noted that restraint should not be used on residents unable to meet social distancing requirements.⁶²

The impact of isolation

In addition to being cut off from family members and friends externally, some CH residents have also been isolated from their friends within the home.^82,123 For example, as previously mentioned, one recommendation was that residents who were required to leave the home for medical treatment should be placed in isolation upon their return.¹¹⁷ However, this practice became heavily criticised by residents and family members, as those who had to regularly attend hospital visits (e.g. for dialysis treatment) found themselves almost permanently in isolation.¹¹⁷

Like the impact of restrictions, isolation of residents also had a negative effect on residents’ physical, cognitive and mental health and well-being.^{9,24,25,34,46,56,70,84,112,123,126} This was particularly notable for those residents living with dementia, cognitive problems, autism and learning difficulties, who might not be able to fully comprehend instructions.^{24,37,56,60,84,90,112,127} For these individuals, agitation, ‘walking with purpose’ and behavioural disturbances have been reported,^37,70,127 which may have required the increased use of restraint.³⁷ Isolation has been associated in the grey literature with decreased movement and mobility in residents;^{46,69,126,127} increased postural disorders⁴⁶ and risk of falls;⁴⁶ increased sarcopenia and risk of deep vein thrombosis;⁴¹ and increased depression and anxiety.⁴¹ Isolated residents have been reported in the grey literature and empirical research to have poorer oral fluid and food intake, leading to weight loss, malnutrition and difficulties maintaining hydration.^{46,48,70,103,110} This may be because some residents do not like eating or drinking in their rooms¹⁰³ or because they do not have their family members around them to encourage them to eat and drink.⁴⁸ However, despite these concerns, it is notable that non-compliance with isolation requirements can also have adverse effects on CHs. Policy papers highlighted that where CHs did not effectively isolate residents with COVID-19 symptoms, the virus spread among CH staff, which, in turn, impacted the overall level of care provided to residents, with reports of some being confined to bed or left for days without support.³⁵ There were also accounts of situations with COVID-19 spreading among residents, which ultimately led to deaths.⁶⁹ One (pre-peer-review) empirical research study¹⁰⁸ found that non-compliance with isolation requirements was associated with increased odds of infection in other residents [adjusted odds ratio (aOR) 1.33, 95% CI 1.28 to 1.38; p < 0.001], staff (aOR 1.48, 95% CI 1.41 to 1.56; p < 0.001) and large outbreaks (aOR 1.62, 95% CI 1.24 to 2.11; p < 0.001).

In one empirical study, CH staff described the importance of residents maintaining hope during periods of isolation and talked about the ways in which they could ensure residents could still ‘see’ them, even when they were confined to their rooms.¹¹² This included residents being able to see staff through the window or when passing by their door, which helped reduce their feelings of isolation.¹¹² Reports have also talked of the importance of residents maintaining exercise routines when confined to their room to limit their risks of developing deep vein thrombosis or their risk of falling.^{41,112,126,127} Examples were provided in the grey literature of CHs instigating specific and adapted exercises, such as ‘seated knee extensions’, ‘sit to stands’ and ‘wall squats’ to help counterbalance the effects of being isolated.⁴¹ Isolation interventions could also have a negative impact upon residents’ family members, as knowing your relative is in isolation and being unable to physically see them was reported in the grey literature to take a psychological toll and could cause significant distress, despite the availability of communication devices and other innovative methods of communicating remotely.^34,46,84 As previously mentioned, isolation guidelines for staff could also have a negative impact upon CHs by creating significant staff shortages.^43,55,89 In some cases, this led to residents being required to be transferred to the hospital due to insufficient staff available to care for them within the CH.⁹⁴

The impact of restrictions

Compared to other infection control measures, the restriction of CH visitors is reported to be relatively easy and cheap to implement.^57,123 However, restrictive measures within CHs have been reported as having an enormous impact on residents’ health and well-being.^{24,25,37,40,48,52,56,58,70,73,84,85,89,91,95,123,127} Indeed, concerns have been expressed in empirical studies and the grey literature that ongoing restrictions have begun to outweigh any potential benefits for residents.^40,113 Many CHs did report initiating new events and activities for their residents to improve their well-being and morale. These events included barbeques, tea parties, concerts and singalongs, drama productions and church services.^64,84,85,103 In addition, physical activity opportunities were also promoted by introducing initiatives such as Nintendo Wii games, treadmills, dancing events and increased gardening activities.^64,103 However, despite these innovative solutions being employed by CHs, restrictions have led residents to experience physical, cognitive, psychological and functional declines.^{24,37,40,56,80,103,113,126,127} Residents’ moods have declined as a consequence of restrictions,^37,56,91,103 as has their oral fluid and food intake,¹⁰³ while agitation, irritability, behavioural disturbances, anxiety and psychotropic medication use have increased.^{37,57,84,91,103,113,127} Many residents have reported feeling socially isolated and lonely due to the lack of physical closeness and comfort of relatives and friends during periods of restrictions;^{25,57,70,80,110,113,120,123,126} an issue reported to be particularly important for residents living with dementia.^{24,25,32,56,60,80,84,103,123,127,128} Residents living with dementia were reported to be confused, distressed and frustrated by not being able to see their family and friends^{24,32,84,123,128} and this could lead to a significant decline in their health and well-being.^24,123 One study reported that residents did not recognise their family members after periods of restrictions.²⁵ Restrictions may also be particularly difficult for those with learning difficulties or autism.⁶⁰ Visiting restrictions have, in some cases, prevented residents from receiving necessary medical and social care.^67,116,127 They further pose a serious challenge to the autonomy of CH residents in an era where much progress has been made in eliminating restraints.²⁵

In addition to this, restrictions have had a devastating effect upon the relatives of CH residents, with reports of negative social and emotional impacts, such as guilt, fear, worry and isolation.^{48,56,69,91,95,112,117,123,127} Reports in the Netherlands highlighted family members demonstrating significant resistance to visiting restrictions, which led to CHs implementing harsh enforcement measures, such as hiring surveillance services or fencing off buildings to keep relatives away.⁴³ In addition, the legality of visitation bans has been contested by family members in the Netherlands, and cases have been taken to court.⁴³ Concerns have also been raised about the quality of care provided to residents during periods of restrictions, as regulators were unable to enter CHs to undertake inspections for quality assessments or carry out advisory visits.^{52,55,70,77,92,116} Indeed, there was a 55% increase in complaints to the CQC in the UK from CH staff concerned about poor practice in their workplace during the pandemic.⁷⁰ Furthermore, as family members were not able to enter CHs at this time (and family members often provide additional care for residents during their visits), there have been fears that this too has impacted negatively on the overall quality of care that residents have received during the pandemic.^57,70,123

Restrictions related to the COVID-19 pandemic have also had consequences for CHs and their managers and employees. For example, CH staff have reported finding it challenging to implement strict restrictions, especially those staff who believed the restrictions were too harsh or disproportional to the risks.⁴³ In addition, there have been reports of staff experiencing violence and abuse from frustrated residents and family members in response to the restrictions being imposed upon them.^103,123 New ways of working and increased staff absences have also increased staff workloads and led to stress, exhaustion and burnout.^{46,49,56,57,70,84,91,123} Others have discussed the psychological impact on care staff working throughout the pandemic and the toll this may have taken on their mental health and well-being.^{22,84,91,116,123} They state that high-quality psychological support needs to be provided for staff who have worked during the pandemic and experience anxiety or post-traumatic stress disorder symptoms.^{22,91,116,120} Some CHs have experienced financial difficulties because of implementing restrictions due to a reluctance of older people to move to CHs due to fears they would be isolated from their families.⁴³ These facilities report that, despite waiting lists, they have faced difficulties in filling their vacancies.^43,69

Finally, due to COVID-19 restrictions, some CH residents died without being able to have their family members with them, which impacted negatively on their EoL support and dignity and, in some cases, went against their expressed wishes.^{80,82,85,113,117} This was reported to be distressing for family members and may have negatively impacted their bereavement process.^{56,82,112,117} Furthermore, where relatives could not be present, it fell to CH staff to provide residents with emotional support and comfort at the end of their lives, which may have negatively impacted their own mental health and well-being.^82,112

Considering these issues, many authors have highlighted the importance of reintroducing visitors into CHs as soon as it is safe to do so.^{25,56,57,62,73,80,123,127} Some countries, such as the Netherlands, have recommended that CHs take a more flexible, risk-assessment based approach to visitations, with discretion to make visiting policies appropriate to local COVID-19 rates and the individual needs and vulnerabilities of residents.^60,89 A Delphi study of 21 US and Canadian post-acute and long-term care experts in clinical medicine, administration and patient care advocacy has made five strong recommendations around welcoming back CH visitors.⁴⁰ These were the need to (1) maintain stringent IPC measures, (2) facilitate both indoor and outdoor visits, (3) allow limited physical contact with appropriate precautions, (4) assess residents’ own care preferences and level of risk tolerance and (5) dedicate an essential caregiver and extend the definition of compassionate care visits to include care that promotes the psychosocial well-being of residents.⁴⁰ A Dutch study of 26 nursing homes also explored the impact of allowing visitors back into nursing homes during the COVID-19 pandemic and found that compliance with guidelines was sufficient, and no new infections were reported.²⁵ Other authors have highlighted the importance of allowing volunteers and other care professionals (offering, e.g. assistance with grooming and emotional support) to return to CHs as soon as it is safe to do so.⁵⁷ However, it has been noted that in countries such as Australia, several CHs have continued with strict lockdown restrictions to protect their residents, despite government instructions to end them.⁵² Others have highlighted the complications when visitations are reintroduced into CHs. For example, difficulties have been reported for those residents and relatives who do not understand why they cannot touch each other or find it difficult not to have physical contact.²⁵ Furthermore, some staff and relatives have experienced concerns for their own health when visitations have been reintroduced, particularly if they are in a high-risk category themselves.²⁵

The impact of zoning/cohorting

There was limited discussion of the direct impact of zoning or cohorting of residents. There was some suggestion in the grey literature that a distinction should be made between those who could understand and abide by isolation guidelines and those who could not, notably those living with dementia, mood disorders or those who ‘walked with purpose’.^41,117 In these instances, it was proposed that zoning or cohorting may be more beneficial for residents than isolation.^41,117 Others, however, reported that such residents might also struggle to follow zoning/cohorting restrictions.⁹ There was some empirical evidence to support the need for staff to work only within their allocated zone/cohort of residents to prevent the spread of infections. For example, a study¹⁰⁸ found that CHs where staff cared for both infected and uninfected residents had higher odds of infection in residents (aOR 1.30, 95% CI 1.23 to 1.37; p < 0.001) and staff (aOR 1.20, 95% CI 1.13 to 1.29; p < 0.001) than CHs where staff were cohorted. Finally, one guidance document also stated that there could be possible costs for CHs after ending the cohorting of residents.⁶³ These costs would be required for returning homes to their original state, as well as the costs associated with the redundancy, redeployment or retraining of staff.⁶³

Strategies used by care homes to prevent the transmission of other (non-COVID-19) infectious diseases

Nine papers discussed strategies used by CHs to prevent the transmission of infectious diseases other than the COVID-19.^{76,88,96,98,102,111,114,118,121} These papers discussed infectious diseases and healthcare-associated infections (HAIs), such as influenza, urinary tract infections (UTIs), respiratory infections, pneumonia, MRSA and gastroenteritis.

Surveillance

Surveillance was the strategy most discussed as being used by CHs to prevent the transmission of infectious diseases and HAIs, such as influenza, UTIs, respiratory infections, pneumonia and gastroenteritis.^{76,96,98,102,111,114,118,121} This involved the systematic collection, consolidation and analysis of data related to infectious diseases. Surveillance aimed to ensure the early identification of symptoms in residents and staff preceding a potential outbreak so that IPC measures could be implemented in CHs as soon as possible.⁹⁶ One discussion paper¹¹¹ reported that the seven stages of surveillance of infectious diseases involved assessing the population; selecting the outcome or process for surveillance; using surveillance definitions; collecting surveillance data; calculating and analysing infection rates; applying risk stratification methodology; and reporting, using the surveillance information. This paper¹¹¹ also stated that surveillance should be conducted weekly and that data standardisation was desirable. The grey literature also notes that CHs should have a comprehensive set of policies and procedures related to infectious disease surveillance to enable them to detect the presence of illness through significant deviations from the baseline rate.^96,111,121 Targeted surveillance may also be required during critical points of the year for some illnesses, such as influenza season for respiratory infections.⁹⁶

While all staff in CHs should be trained to monitor for signs of illness in residents, it was highlighted as necessary that one designated staff member, with experience and expertise in IPC practices, take responsibility for co-ordinating surveillance and outbreak management activities within each home.^96,98,121 There was also discussion of the importance of both local infection control committees and national surveillance programmes for overseeing levels of infectious diseases in CHs.^{76,98,114,118} For example, one study⁷⁶ discussed a national sentinel surveillance network developed in 2009 to examine infectious diseases and HAIs in CHs in the Netherlands and reported that the incidence of influenza-like illness and probable pneumonia decreased significantly for every year a CH participated in the network. Though not statistically significant, a similar decrease was also identified with the incidence of UTIs and gastroenteritis.⁷⁶

Restrictions

Only one review discussed the use of restrictions for preventing the transmission of non-COVID-19-related infectious diseases in CHs.⁸⁸ This review stated that there was no evidence that banning or restricting visitations to CHs impacted the prevention of infectious diseases.

Strategies used by care homes to control the transmission of other infectious diseases

Evidence in this area was limited, with only 17 papers discussing the strategies used by CHs to control the transmission of infectious diseases other than COVID-19 when there was already an outbreak or suspected case of illness.^{44,45,54,65,71,72,81,86,93,96,98,100–102,111,114,118} This was a greater number of papers than those discussing preventing infectious diseases occurring in CHs, although some publications talked about prevention and control measures. Once again, these papers discussed infectious diseases, such as MRSA, influenza and respiratory infections, as well as MDROs and C. diff.

Isolation

Several papers discussed how isolation had been used to control the spread of other infectious diseases within CHs, such as MRSA, influenza and C. diff.^{44,45,54,65,71,72,81,86,93,96,98,100–102,111,118} Again, this tended to involve isolating infectious residents within single rooms where this was possible or cohorting residents (i.e. grouping those with the same illness together or pairing residents with someone ‘low risk’) where it was not.^{44,45,71,72,86,93,96,98,100–102,111,118} Where neither isolation nor cohorting was possible, the grey literature suggested that CHs could maintain at least 1 m between beds with privacy curtains between.^102,118 Some papers talked of the need to restrict admissions of new residents into the home and/or prevent the readmission of those who had been in hospital during severe outbreaks.^45,96 Although most papers did not discuss how long residents were required to isolate, some stated that residents with influenza or respiratory infections should remain in isolation for 5 days after the onset of their illness or until their symptoms had resolved entirely and for 48 hours after being symptom-free for residents with C. diff.^{45,96,101,118} Some of the highlighted examples also suggested there was less of a ‘blanket approach’ to isolation for other infectious diseases than for COVID-19. For example, a study⁵⁴ noted that known MRSA carriers were asked to be separated from vulnerable residents with skin lesions or indwelling catheters. However, they were otherwise allowed to continue with usual social activities. The importance of making decisions around isolation on a case-by-case basis was emphasised in policy documents, as was the importance of not over-isolating residents and the need to ensure both physical and psychological needs of isolated residents were met.^{44,65,101,111} There were also examples of staff being asked to isolate to control the spread of infectious diseases. For instance, during outbreaks of influenza, CH staff were required to self-monitor for symptoms of illness and stay away from work if feeling unwell.⁴⁵

Restrictions

Some policy documents reported that restricting the movement of residents and visitors during an outbreak of infectious disease could be beneficial.^{45,72,93,96,102,111,114,118} This included the restriction of group activities or the mixing of residents within communal areas, as well as minimising the movement of visitors within the home, such as only allowing visits within a resident’s private room or limiting the number of visitors.^{45,96,102,111,118} A Canadian toolkit reported that complete closure of CHs to visitors should not be permitted unless the Medical Officer of Health had issued an order due to the potential hardship this could cause residents and their family members.⁹⁶ Furthermore, there was some evidence from the grey literature that there was less of a ‘blanket approach’ to resident restrictions for other infectious diseases than for COVID-19. This included, for example, residents only being restricted from group activities when wound drainage or diarrhoea could not be contained⁹³ or activities only restricted for residents in an outbreak ‘zone’ but still able to proceed within non-affected areas.⁹⁶ Again, it was reported that clear signage and communication were important for residents and their family members during any restriction periods.¹¹⁸

Some papers also discussed the restrictions that should be placed upon staff working patterns to control the spread of infectious diseases in CHs.^45,96,111 For example, during influenza outbreaks, one guidance document⁴⁵ stated that the movement of staff across CHs or other healthcare facilities should be minimised. Similarly, where zoning/cohorting restrictions were in place, staff working within affected units should not also work within non-affected areas of the home.^45,96,118 Finally, it was suggested in the grey literature that only staff who had been vaccinated against influenza should care for those residents with suspected or confirmed illnesses.^45,96

Social distancing

Only two guidance documents discussed social distancing measures outside COVID-19.^102,118 One stated that there should always be at least 2 m between residents with signs and symptoms of influenza and those without.¹⁰² Another suggested that CHs should maintain a 1-m distance between all residents during an outbreak of respiratory infections.¹¹⁸

Surveillance

Surveillance was also identified as an intervention for controlling the spread of infectious diseases within CHs, with outbreaks being carefully monitored, recorded and reported.^45,86,111 In addition, some of the grey literature stated that it was a requirement that public health authorities be notified when there was a confirmed case of certain infectious diseases, such as influenza or MRSA.^45,71

Challenges and facilitators of other infectious disease interventions

A few specific challenges were highlighted, which negatively impacted the success of implementing interventions for (non-COVID-19) infectious diseases within CHs. One challenge was focused on staff education and training, where CH staff – particularly agency staff – were felt to have less knowledge and training around infectious diseases and their means of prevention and control.^65,86,88 Therefore, implementing staff education programmes around IPC was felt to be important in reducing the number of infections within CHs.^96,121 In addition, staff movement across different care settings, including the reliance upon ‘bank’ or agency staff, was also identified as a source of outbreaks of infectious diseases within CHs.^65,86,88

Some authors identified the design and layout of CH buildings as a challenge, as many homes lacked appropriate space where residents with infectious diseases could isolate.^72,86 However, a study⁷⁶ reported no clear evidence linking the physical space and layout of CHs with the incidence of HAIs. Finally, CH residents were felt to bring specific challenges themselves. Many were living with dementia or other chronic conditions that compromised their ability to adhere to interventions or exhibited behaviours that hindered infection control.^86,88 Only one facilitator of successful interventions was highlighted in the grey literature. Again, this was the need for good communication to help educate residents and their visitors about any outbreaks of infectious diseases and how they could help prevent their transmission.⁸⁶

Impact of other infectious disease interventions

There was little discussion of the impact of IPC strategies for non-COVID-19-related infectious diseases. It was acknowledged that CH residents could become fearful and confused during outbreaks of contagious diseases. Therefore, it was important to ensure they remained fully informed about any interventions being put in place and that any fears were addressed by staff.⁸⁸ In addition, isolation practices could stigmatise residents and may adversely affect the quality of care delivered.⁹³ Some of the grey literature reported that long periods of isolation for residents with influenza or MRSA could contribute to depression, anxiety and distress,^71,72 while others were concerned that restrictions on visitors or CH activities could increase loneliness and depression.⁸⁸ Finally, it was acknowledged that isolation practices could be costly for CHs and take up limited resources that could be used for other purposes to benefit residents.⁹³

Strengths and limitations of this review

Keys strengths of this review include the following:

• Conducting searches of several of the main and specialised databases for peer-reviewed publications and the grey literature.
• Several research team members conducted the screening of results to enhance rigour.
• Clarifying and defining key terminology related to the concepts of social distancing and isolation is an important strength of this review.

Key limitations include the following:

• Our searches were limited to papers published in the English language because of resource constraints.
• There were some limitations for the 10 empirical studies, which should be considered when examining their findings.
• Many other strategies in the prevention and control of COVID-19 and other infectious diseases in CHs, such as the use of PPE, testing, ventilation and adequate hygiene procedures, were excluded as they were outside the scope of this review.