McGarry BE, Gandhi AD, Chugtai MA, Yin J, Barnett ML.
IMPORTANCE
During the COVID-19 pandemic, stabilized COVID-19–positive patients were
discharged to skilled nursing facilities (SNFs) to alleviate hospital crowding. These discharges
generated controversy due to fears of seeding outbreaks, but there is little empirical evidence
to inform policy.
OBJECTIVE
To assess the association between the admission to SNFs of COVID-19–positive
patients and subsequent COVID-19 cases and death rates among residents.
DESIGN, SETTING, AND PARTICIPANTS
This cohort study analyzed survey data from the
National Healthcare Safety Network of the Centers for Disease Control and Prevention.
The cohort included SNFs in the US from June 2020 to March 2021. Exposed facilities
(ie, with initial admission of COVID-19–positive patients) were matched to control facilities
(ie, without initial admission of COVID-19–positive patients) in the same county and with
similar preadmission case counts. Data were analyzed from June 2023 to February 2024.
EXPOSURE
The week of the first observable admission of COVID-19–positive patients (defined
as those previously diagnosed with COVID-19 and continued to require transmission-based
precautions) during the study period.
MAIN OUTCOMES AND MEASURES
Weekly counts of new cases of COVID-19, COVID-19–related
deaths, and all-cause deaths per 100 residents in the week prior to the initial admission.
A stacked difference-in-differences approach was used to compare outcomes for 10 weeks
before and 15 weeks after the first admission. Additional analyses examined whether
outcomes differed in facilities with staff or personal protective equipment (PPE) shortages.
RESULTS
A matched group of 264 exposed facilities and 518 control facilities was identified.
Over the 15-week follow-up period, exposed SNFs had a cumulative increase of 6.94 (95% CI,
2.91-10.98) additional COVID-19 cases per 100 residents compared with control SNFs, a 31.3%
increase compared with the sample mean (SD) of 22.2 (26.4). Exposed facilities experienced
2.31 (95% CI, 1.39-3.24) additional cumulative COVID-19–related deaths per 100 residents
compared with control facilities, representing a 72.4% increase compared with the sample
mean (SD) of 3.19 (5.5). Exposed facilities experiencing potential staff shortage and PPE
shortage had larger increases in COVID-19 cases per 100 residents (additional 10.97 [95% CI,
2.76-19.19] cases and additional 14.81 [95% CI, 2.38-27.25] cases, respectively) compared
with those without such shortages.
CONCLUSION
This cohort study suggests that admission of COVID-19–positive patients into
SNFs early in the pandemic was associated with preventable COVID-19 cases and mortality
among residents, particularly in facilities with potential staff and PPE shortages. The findings
speak to the importance of equipping SNFs to adhere to infection-control best practices as
they continue to face COVID-19 strains and other respiratory diseases.