key: cord-0854674-e08xux3f authors: Vogazianos, Paris; Argyropoulos, Christos D.; Haralambous, Christos; Varianou Mikellidou, Cleo; Boustras, George; Andreou, Michalis; Silvestros, Valentinos; Theofanous, Fani; Soteriou, Soteroulla; Gregoriou, Ioanna; Jaber Apostolidou, Andri; Demetriou, Anna; Athanasiadou, Maria; Stylianou, Carolina; Michael, Maria; Herodotou, Herodotos; Alexandrou, Denise; Kalakouta, Olga; Dorothea Pana, Zoi title: Impact assessment of COVID-19 non-pharmaceutical interventions in long term care facilities in Cyprus: safety improvement strategy date: 2021-07-17 journal: Saf Sci DOI: 10.1016/j.ssci.2021.105415 sha: d90bfebb84d1938907442e8b88ae2dceec23d164 doc_id: 854674 cord_uid: e08xux3f The current COVID-19 crisis has changed our everyday lives almost in every aspect. Many people worldwide have died or hospitalised due to the severe impact of COVID-19 on the vulnerable population, and in particular to the elderly residents of long term care facilities (LTCF). The problem is amplified due to the fact that many of those occupants also suffer from comorbidities (e.g. respiratory and cardiovascular diseases, hypertension, etc.) and are therefore regarded as a susceptible host to severe COVID-19 disease. Impacts can be felt in the wider societal safety level. The aim of the present study is, therefore, to present the first National multimodal quality and safety improvement strategy plan for the LTCF in the Republic of Cyprus. The current program focused on the intensification of COVID-19 epidemiological surveillance, the promotion of educational training on best practises in infection control and prevention, and the implementation of additional non-pharmaceutical interventions (NPIs), according to the recommendations of ECDC (European Centre for Disease Prevention and Control) and WHO (World Health Organization). This innovative program fostered the interconnectivity and collaboration among the local authorities, academia and the local leaders of the LTCF. In addition, this program reinforced the importance of volunteerism and active participation of medical students in the National initiatives against the COVID-19 pandemic. The effectiveness of the adopted multimodal advanced care-safety planning program is appraised based on the reported new confirmed COVID-19 cases among LTCF healthcare workers and occupants, after the introducing and implementation of the selected NPIs. This multimodal strategy plan seems to be capable of reducing significantly the number of new cases of COVID-19 infections in LTCF and as a result, to also affect the residents’ death number. The problem is amplified due to the fact that many of those occupants also suffer from comorbidities (e.g. respiratory and cardiovascular diseases, hypertension, etc.) and are therefore regarded as a susceptible host to severe COVID-19 disease. Impacts can be felt in the wider societal safety level. The aim of the present study is, therefore, to present the first National multimodal quality and safety improvement strategy plan for the LTCF in the Republic of Cyprus. The current program focused on the intensification of COVID-19 epidemiological surveillance, the promotion of educational training on best practises in infection control and prevention, and the implementation In December 2019, the first confirmed case of COVID-19 in human was reported by Chinese authorities in Wuhan, China, and since then the virus has spread rapidly over the entire world, with tremendous impact on our daily lives and habits (Bruinen de Bruin et al., 2020) , as well as the way we interact among each others (Huynh, 2020) . Moreover, the unique COVID-19 pandemic outburst has also indicated the high importance of preparedness and response for coping with the outbreak crisis, and the perpetual struggle of healthcare personnel, working day and night to provide care for patients with COVID-19, while new confirmed cases and deaths are continuously reported worldwide (Dong et al., 2020) . Many of these reported deaths are among elderly people, a high percentage of which occupants in long term care facilities (LTCF) McMichael et al., 2020) and also suffered from serious respiratory illnesses [e.g. asthma, Chronic Obstructive Pulmonary Disease (COPD) and emphysema] (Cohen and Tavares, 2020) . It is important to note that in the EU/EEA and UK there are approximately 3.5 million occupants in 62,000 LTCF, who represent ~0.7% of the total population (ECDC, 2020). According to data collected from 21 countries in the report of Comas-Herrera et al. (2020) , the share of deaths for occupants in LTCF was estimated to be 46% of the total COVID-19 deaths, while the percentage of occupants who have died due to COVID-19 in different countries as percentage of all occupants ranges from 0.01% (Korea) to over 4% (Ireland, Belgium, Spain, UK and USA). By February 3, 2021, in the USA the reported number for the COVID-19 cases and deaths, among the staff and occupants in LTCF, was 1,238,599 (5% of the total state COVID-19 cases) and 146,888 (37% of total deaths), respectively (KFF, 2021). Furthermore, it is estimated that the frontline healthcare personnel are exposed to 3.4-times higher risk of coronavirus infection compared to the people in general population, while the percentage of reported cases of COVID-19 in healthcare personnel are up to 10% in China and 11, 4% in Ireland of all cases, respectively (ECDC, 2021). The size of "outbreaks" and the large number of deaths due to COVID-19 in LTCF can be attributed to many factors such as the asymptomatic healthcare and working personnel (Hoxha et al., 2020) , the number of residents in congested rooms (e.g. 2-4 beds) and sharing bathroom (Brown et al., 2021) , insufficient training of staff to conduct effective infection control and monitoring practices for COVID-19 cases (ECDC, 2020), and deficiency of infection control precautions (e.g. hand hygiene, face masks, effective staff cohorting, etc.), among others. To address those issues, many countries recognized the urgent need for introducing several public health measures and policies (Chen et al., 2020; Fan et al., 2021) , namely nonpharmaceutical interventions (NPIs), in order to reduce the severe impact of COVID-19 on the occupants of LTCF (Rios et al., 2020) and the healthcare staff. NPIs for mitigating the risk of coronavirus transmission in LTCF include: a) the adoption of practical guidelines, procedures and ensuring continuous communication (Dosa et al., 2020) for tackling with COVID-19 infected occupants (e.g. patient's isolation, training, implementation of infection prevention and control (IPC) practices, awareness of prevalent symptoms of COVID-19); b) mitigation strategies for reducing the cross-infection risk in confined spaces (e.g. physical distancing, wearing facial masks, adequate ventilation and hand hygiene); c) utilising policies for diagnostic testing and screening of residents and healthcare personnel, d) limiting the risk of virus transmission in the LTCF through restricting visitors' access. However, it is important to mention that many of the adopted measures for the protection of elderly occupants in LTCF led to social isolation, depression and loneliness posing additional health risks (Simard and Volicer, 2020; Verbeek et al., 2020; Wu, 2020) . Dolveck et al. (2020) presented results of the activation of a task force using an urgent intervention for the limitation of COVID-19 infections in eight French nursing facilities. The adopted intervention was based on four type of actions: a) daily update of deaths; b) inspection for suspicious COVID-19 cases and assessment of the provided nursing facility care; c) emergency team actions for the implementation of nursing and medical policies; d) visits of a geriatric team. Their results showed that the mortality among elderly residents is not only due to COVID-19 but is also associated with the "confinement disease", while the task force's intervention decreased significantly the number of deaths (83/770; 11% vs 35/687; 5%, p = 0.0001) and new COVID-19 cases for staff and residents (348/770; 45% vs 123/422; 29%, p < 0.001). Recently, more studies are conducted to investigate the COVID-19 outbreaks in LTCF, with the aim of detecting early SARS-CoV-2 infections (Graham et al., 2020; Roxby et al., 2020) , preventing the spread of virus (Feaster and Goh, 2020; McMichael et al., 2020; Patel et al., 2020; Rios et al., 2020) , avoiding crowding (Brown et al., 2021) , appraising the presence of comorbidities (Gmehlin and Munoz-Price, 2020), appraising healthcare deficiencies and containment intervention (Arons et al., 2020; Blackman et al., 2020; Blain et al., 2020; Escobar et al., 2020) . Undoubtedly, the current COVID-19 pandemic has revealed and highlighted several gaps and deficiencies, while little attention has been given to NPIs concerning outbreaks in LTCFs (Rainwater-Lovett et al., 2014; Simard and Volicer, 2020) . Therefore, it is essential to understand the transmission mechanisms and protect occupants and healthcare personnel (Greene and Gibson, 2021) . In this study, the adopted term "LTCF" includes institutions for elderly people with disabilities, chronic illness, nursing homes, assisted-living facilities and rehabilitation centers. The purpose of the present effort is to exhibit the implementation of the first national multimodal safety and quality improvement strategy against COVID-19 pandemic implemented in all LTCFs in the Republic of Cyprus, as well as to present the effectiveness of the program in reducing the number of new confirmed COVID-19 cases and deaths among the residents and healthcare personnel. Gaps and limitations are identified and presented, while a number of recommendations gained from the experience of the national program is outlined. The present National initiative started on mid-November 2020 as a collaborative effort of the Protective Equipment (PPE) was centrally provided freely if needed to ensure that public health measures were upheld. The aim of the checklist is to address the current situation regarding the management of COVID-19 pandemic in LTCF. Originally, there are two version of checklists. The first one is for the health and safety inspectors and the second one is for the volunteers who participated in audits. The version presented in Appendix is a merged version which has been used for the purpose of this study. The checklist is divided into nine sections as can be seen in Appendix. The first and second sections are dealing with the overall health and safety management along with the applied health protocols. The third section is specifically about the cleaning and disinfection procedures. The next two sections (4th and 5th) are focused on the nursing homes' occupants and employees. The proper use of suitable Personal Protective Equipment (PPE) is also important to be addressed. The last four sections (6th, 7th, 8th and 9th) are monitoring whether the right procedures are taken when dealing with confirmed or suspicious COVID-19 cases. The data regarding the demographics of the LTCF in the Republic of Cyprus Republic are collected by the Health Monitoring Unit, Ministry of Health, Nicosia, Cyprus, from a total number of 165 LTCF including residents and working personnel (summarized in Table 1 ). The weekly rapid antigen testing data of the LTCF (personnel and residents) were collected by the Unit for The standard error of the prevalence for the population under risk was calculated using the modified Wald method, for computing the confidence interval of a proportion and thus, using the resulting margin of error, the 95% Confidence Intervals for the prevalence for the population under risk were constructed. For inferential statistical analysis, the χ 2 -test was performed with the statistical significance level set at p < 0.05 adjusting with Yates correction. Nicosia (61) 1033 1567 Limassol (54) 522 874 Larnaca (21) 252 410 Paphos (18) 125 136 Famagusta (11) 83 113 Total (165) 2015 3100 Overall 5115 people were included in the study (3100 residents and 2015 staff) distributed over 165 LTCF facilities, as shown in Table 1 . During the study period, the number of new COVID-19 cases peaked at 138 in the first decade of December (Table 2 ) reaching 2.83% of population at risk as shown in Table 3 . The preliminary study started on mid-November and the actual interventional part of the study with all six pillars was implemented at the beginning of December. Figure 1 shows the evolution of new COVID-19 total cases in LTCF facilities every ten days throughout November and December as well as individually for residents and staff throughout December. This study presented the first National COVID-19 quality and safety improvement strategy plan for the LTCFs in the Republic of Cyprus for the period of 1.5 months (mid-November to end of December 2020). The current program was focused on a multimodal approach to enhance the culture change within the establishment or strengthening of a safety climate and to reduce the risk of COVID-19 infection transmission inside the LTCF. The standardization of procedures (checklists) promoted a comparable risk assessment among the different LTCF in Cyprus revealing initially qualitative data (monitoring infrastructures, practices and processes). The initial assessment reported significant heterogeneity among LTCF in terms of: the size of the nursing homes (>50 occupants to <10 occupants per estate), the occupants and their underlying diseases, the infrastructure, the compliance rates on personal protection measures/health protocols and the educational level of the staff on COVID-19 related issues. Based on the initial qualitative assessment the following measures were recommended and adapted nationally: a) limiting the use of shared common areas at the nursing home; b) recommendation on the use only of a plain surgical face mask by the staff (especially those who have close and continuous contact with the occupants); c) also, for the tenants who do not fall under the exceptions to wear mask, were able we recommended the use of a mask especially in commonly shared areas; d) intensification of educational courses for the staff personnel to promote awareness, preparedness and engagement, outbreak management and best practices e) knowledge sharing through lessons learnt from other LTCF cases and providing feedback to the LTCF leaders. In addition based on the quantitative assessment we observed a significant reduction of the reported COVID-19 cases during the interventional study period. The comparison was performed individually for LTCF Residents, Staff and for the whole population in the LTCF. During the interventional period, a significant decrease of 47% in COVID-19 cases was observed in the LTCFs (reduction of the prevalence from 2.83% to 1.5%). This decrease was mainly attributed to a statistically significant reduction in the prevalence of COVID-19 resident cases among the facilities (from 3.65% to 1.74%, respectively). These preliminary results indicate the importance of designing and implementing multimodal quality and safety strategies in the LTCFs that include regular COVID-19 testing and audits, simultaneously with the promotion of education, communication and engagement culture. 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Management of suspected COVID-19 case Daily COVID-19 screening for occupants Proper management of confirmed COVID-19 case. Management of confirmed COVID-19 case Clinical assessment of the cases from healthcare providers Prompt isolation and treatment of the cases Prompt isolation of positive occupant cases and close contacts at home according to the local national protocols and policies. PPE of COVID-19 suspicious cases and COVID-19 confirmed cases 9.1 Proper use and removal of PPE (donning and doffing) The authors wish to thank all the directors of the LTCF of the Cyprus and the medical students In case of COVID-19 symptoms, workers are not allowed to enter the building. Employees are trained to inform the visitors about the H&S measures.