COVID-19 in French nursing homes during the second pandemic wave: a mixed-methods cross-sectional study

Abstract

Introduction: French nursing homes were deeply affected by the first wave of the COVID-19 pandemic, with 38% of all residents infected and 5% dying. Yet, little was done to prepare these facilities for the second pandemic wave, and subsequent outbreak response strategies largely duplicated what had been done in the spring of 2020, regardless of the unique needs of the care home environment.

Methods: A cross-sectional, mixed-methods study using a retrospective, quantitative data from residents of 14 nursing homes between November 2020 and mid-January 2021. Four facilities were purposively selected as qualitative study sites for additional in-person, in-depth interviews in January and February 2021.

Results: The average attack rate in the 14 participating nursing facilities was 39% among staff and 61% among residents. One-fifth (20) of infected residents ultimately died from COVID-19 and its complications. Failure to thrive syndrome (FTTS) was diagnosed in 23% of COVID-19-positive residents. Those at highest risk of death were men (HR=1.78; 95% CI: 1.18 to 2.70; p=0.006), with FTTS (HR=4.04; 95% CI: 1.93 to 8.48; p<0.001) or in facilities with delayed implementation of universal FFP2 masking policies (HR=1.05; 95% CI: 1.02 to 1.07; p<0.001). The lowest mortality was found in residents of facilities with a partial (HR=0.30; 95% CI: 0.18 to 0.51; p<0.001) or full-time physician on staff (HR=0.20; 95% CI: 0.08 to 0.53; p=0.001). Significant themes emerging from qualitative analysis centred on (1) the structural, chronic neglect of nursing homes, (2) the negative effects of the top-down, bureaucratic nature of COVID-19 crisis response, and (3) the counterproductive effects of lockdowns on both residents and staff.

Conclusion: Despite high resident mortality during the first pandemic wave, French nursing homes were ill-prepared for the second, with risk factors (especially staffing, lack of medical support, isolation/quarantine policy, etc) that affected case fatality and residents' and caregivers' overall well-being and mental health.

Keywords: COVID-19; Epidemiology; GERIATRIC MEDICINE; Public health; QUALITATIVE RESEARCH.

Figure 1

Likelihood of survival by resident and nursing facility characteristic, univariate (Kaplan-Meier) analysis, Provence and Occitania provinces, France, 2021. On the x-axis: number of weeks from 15 October 2020; on the y-axis: the probability of resident survival. FTT, failure to thrive; MSF, Médecins Sans Frontières.

Figure 2

Final Cox model: forest plot of mortality-associated factors in French nursing facilities, Provence and Occitania provinces, 2021. On the x-axis: adjusted HRs are represented by a diamond. Full lines in red for 95% CIs of significant risk factors (HR >1), full lines in green for protective factors (HR<1) and dashed lines in grey for 95% CI of non-significant factors. AWAS, Average Weighted Autonomy Score; FTT, failure to thrive.