Guidelines for preventing respiratory illness in older adults aged 60 years and above living in long-term care

March 28, 2020

Patricia Rios, Amruta Radhakrishnan, Sonia M. Thomas, Nazia Darvesh, Sharon E. Straus, Andrea C. Tricco

This work was supported through the Canadian Institutes of Health Research (CIHR) through the Strategy for Patient Oriented-Research (SPOR) Evidence Alliance and commissioned by the Infection Prevention & Control, Health Emergency Programme, World Health Organization. We have prepared a summary of our report on behalf of the Oxford COVID-19 Evidence Service Team

Centre for Evidence-Based Medicine, Nuffield Department of Primary Care Health Sciences
University of Oxford
Li Ka Shing Research Institute, Knowledge Translation Program, St. Michael’s Hospital

Correspondence to Andrea.Tricco@unityhealth.to

VERDICT
The recommendations from current guidelines overall seem to support environmental measures for infection prevention and antiviral chemoprophylaxis for infection management as the most appropriate first-line response to viral respiratory illness in long-term care. However, these recommendations should be viewed with caution as it is unclear how many of these guidelines are based on the best available evidence due to their poor overall quality.

BACKGROUND
The Infection Prevention & Control of the World Health Organization (WHO) Health Emergency Programme commissioned a review on preventing and managing COVID-19 in older adults aged 60 years and above living in long-term care facilities. The overall objective of this rapid review of clinical practice guidelines was to identify infection protection and control measures for adults aged 60 years and older in long-term care settings. In order to focus the research question to increase feasibility, we proposed the following key research questions:

  1. What are the infection prevention and control practices/measures for preventing or reducing respiratory viruses (including coronavirus and influenza) in older adults aged 60 years and above living in long-term care?
  2. How do infection prevention and control practices differ for adults aged 60 years and above living in long-term care with respiratory illness and severe comorbidities or frailty differ than those without such severe comorbidities/frailty?
  3. How do infection prevention and control practices differ for adults aged 60 years and above living in long-term care with respiratory illness from low- and middle-income economy countries (LMIC) differ than those living in high-income economy countries and do differences exist across different cultural contexts?

CURRENT EVIDENCE
Preventing respiratory illness in long-term care facilities:

Two or more clinical practice guidelines recommended the following: hand hygiene1,3,4-13,16 (n=13), wearing personal protective equipment2-11,13,14,16 (n=13), social distancing/isolation2-8,10-14,16 (n=13), disinfecting surfaces3-9,11-14,16 (n=12), droplet precautions3-6,8-14,16 (n=12), surveillance and evaluation2,4-6,9-11,13-16 (n=11), conducting diagnostic testing to confirm suspected respiratory illness1-4,6,9-12,14 (n=10), policies and procedures for visitors3-6,8-11,14,16 (n=9), respiratory hygiene/cough etiquette2-6,9-12,16 (n=9), policies and procedures for staff and/or residents1-4,6,9-11,13 (n=9), providing supplies3-6,9-11,13,16 (n=9), education of staff and/or residents3-6,9,11,13,14 (n=8), increasing communication2-4,6,10,16 (n=6), consulting or notifying health professionals5-7,9,10,16 (n=6), appropriate ventilation practices3,13 (n=2), and cohorting equipment7,16 (n=2). One clinical practice guideline each recommended appropriate air ventilation3 or smoking cessation1.

Managing respiratory illness in long-term care facilities:

Ten clinical practice guidelines2,4,6,10-12,14-17 recommended the use of antivirals for prophylaxis of staff and/or residents and one17 recommended early mobilization of residents.

Summary of Clinical Practice Guideline recommendations

Type of infection prevention or management approachNumber of CPGs recommending the approach
PREVENTION
Appropriate ventilation2 CPGs
Cohorting equipment2 CPGs
Communication6 CPGs
Consulting/notifying health professionals 6 CPGs
Diagnostic testing10 CPGs
Disinfecting surfaces12 CPGs
Droplet precautions12 CPGs
Education 8 CPGs
Hand hygiene13 CPGs
Personal protective equipment13 CPGs
Policies for visitors10 CPGs
Policies for staff/residents9 CPGs
Provide supplies9 CPGs
Respiratory hygiene/cough etiquette 10 CPGs
Smoking cessation1 CPGs
Social distancing/ isolation/cohorting 13 CPGs
Surveillance/monitoring/evaluation11 CPGs
MANAGEMENT
Antivirals for prophylaxis for staff/residents10 CPGs
Early mobilization1 CPGs

 

EMERGING EVIDENCE IN COVID-19
Two guidelines, published by the CDC5 and the Ontario Ministry of Health9 respectively, provided recommendations specific to COVID-19 that included:

  • restricting visitors and enforcing sick leave policies for health care providers
  • screening all visitors and staff entering a facility
  • educating residents, personnel, and visitors about COVID-19 infection control
  • educate and train healthcare providers to adhere to infection control measures including hand hygiene and proper use of personal protective equipment
  • provide appropriate supplies for infection prevention and control
  • encourage respiratory hygiene and cough etiquette
  • proper environmental cleaning and disinfection
  • evaluate and monitor residents and enforce restrictions on resident movement when necessary
  • reporting suspected cases of COVID-19 to local public health authorities for testing and assessment

CONCLUSIONS

  • The most commonly recommended prevention strategies across the clinical practice guidelines were hand hygiene, wearing personal protective equipment, social distancing/isolation, disinfecting surfaces, droplet precautions, surveillance and evaluation, conducting diagnostic testing to confirm suspected respiratory illness, policies and procedures for visitors, policies and procedures for staff, and respiratory hygiene/cough etiquette
  • For managing respiratory illness in long-term care facilities, the majority of the clinical practice guidelines recommended antivirals for prophylaxis of staff and/or residents
  • Most of the clinical practice guidelines failed to address multiple AGREE-II items, suggesting that they are most likely based on expert opinion.

medrxiv.rog pre-print link: https://www.medrxiv.org/content/10.1101/2020.03.19.20039180v1

End.

Disclaimer:  the article has not been peer-reviewed; it should not replace individual clinical judgement and the sources cited should be checked. The views expressed in this commentary represent the views of the authors and not necessarily those of the host institution, the NHS, the NIHR, or the Department of Health and social Care. The views are not a substitute for professional medical advice.

SEARCH TERMS
Comprehensive literature searches addressing all research questions were developed by an experienced librarian for MEDLINE, EMBASE, the Cochrane Library, as well as online guideline repositories (e.g., guidelines.ecri.org, joulecma.ca/cpg, www.guidelinecentral.com).

Funding Statement: This work was funded by the Canadian Institutes of Health Research (CIHR) through the Strategy for Patient Oriented-Research (SPOR) Evidence Alliance

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