We present in this study the results of a systematic survey of Ontario LTC clinicians about the communication, preparedness, and engagement of the LTC sector during the COVID-19 pandemic. Overall, our survey reports the widespread implementation of several important interventions in LTC homes during the COVID-19 pandemic (e.g. instituting established respiratory isolation protocols, active screening of new LTC admissions, actively coordinating with regional public health and encouraging sick staff members to take time of work). Respondents also felt that there was ample communication pertinent to the pandemic from provincial LTC organizations, the government and public health officials. However, the feasibility of implementing these public health recommendations in LTC was a concern.
Most importantly, our respondents indicated that the engagement of the LTC sector in a coordinated community-based primary care response was lacking. This indicates a strong recommendation that expert LTC clinicians need to be invited and engaged early in the process of any future planning for coordinated community response. Developing and strengthening the working relationship between the LTC sector and the government should be a key priority. This could result in the development of future preventive measures that are acceptable, feasible, rapidly spreadable, and informed by clinical evidence and experience. As it was so eloquently stated in an earlier publication, a successful response and management of COVID-19 in LTC relies not only on rapid diagnosis, the ability to manage the clinical manifestations in LTC, early initiation of policies to mitigate and prevent future spread; but requires the awareness of key members in the LTC sector about the decisions being made by various levels of government.(19)
Interestingly, respondents indicated that LTC operators provided the least amount of communication and were unlikely sources of additional guidance during the pandemic. LTC outbreaks in the Washington county, as well as the reports out of Europe were harbingers of what would be inevitable in Ontario. LTC operators could have taken this opportunity to provide strong leadership to their LTC homes during this time. Our study results highlight an important future opportunity for LTC operators to play a more essential role in protecting their residents and ensuring that their LTC homes could successfully and feasibly implement public health recommendations.
The authors have defined “preparedness” in this questionnaire as a function of three factors: 1) timeliness and appropriateness of recommendation communication (Tables 3 and 4, statements 1-4); 2) resources available to manage and respond to the changing demands of the pandemic (Tables 3 and 4, statements 5 - 7); and 3) perception of LTC sector engagement (Tables 3 and 4, statements 8). Not surprising, and consistent with the responses received in section 2 of the questionnaire, the lowest level of neutral responses was for statements 2 and 3, which inquired about the reliability and relevancy of the information received.
The statements with the highest proportion of neutral and “prefer not to respond/unsure” responses were for statements 6 and 7. These two statements inquired about the ability of the LTC home to respond to the growing resource demand in the event of a pandemic (statement 6), as well as a respondent’s confidence in their own LTC home to manage an outbreak (statement 7). In the context of these two statements, a high rate of neutral responses in combination compounds the rate of disagreeing responses; this indicates that respondents did not feel their LTC home had the ability to secure additional resources or manage a COVID-19 outbreak. This finding highlights the need to address the underlying issues (e.g. chronic under-funding, inadequate staffing, and the physical environment of LTC homes) that increase the vulnerability of the LTC sector to the pandemic. Mounting a successful future coordinated LTC outbreak management response will first require a meaningful collaboration between all LTC stakeholders (e.g. LTC residents and families, LTC clinicians, politicians, advocacy groups, private corporations, and others) to address the complex systemic challenges inherent to this sector.
The authors had hypothesized a priori that factors such as rurality, the number LTC homes and residents under a respondent’s care, the timeframe of response, and medical director status could impact responses. However, of all these variables, only medical director status was found to result in statistically different responses in the questionnaire. Medical directors have a unique role in the LTC home; they sit with LTC home leadership regularly to ensure high quality care is being provided to LTC residents. Medical directors would have numerous opportunities to be aware, reminded and up to date with the regular public health communications, and which mitigation strategies were implemented in their LTC homes. On the other hand, attending physicians may not be as up to date on the local policies and recommendations being implemented within the home during this time. We hypothesize that this knowledge gap could have been the result of inconsistent communication between the LTC leadership and attending physicians and frontline staff; this could explain the statistical difference observed in our survey responses. As a result, establishing a more efficient and effective communication structure within individual LTC homes could have more effectively disseminated vital knowledge to frontline clinicians not in positions of leadership during the COVID-19 pandemic.
Strengths and Limitations
This study has several strengths that support the validity of our results. First, our survey was co-developed with a key LTC stakeholder and organization in Ontario. This approach allowed the OLTCC to review and direct the information to be collected. Second, the response and item completion rate for a survey of this length is very robust, especially during a period where LTC clinicians have significant priorities to juggle. Third, respondent demographics represented a diverse LTC clinician population, which included an equal split amongst male and female providers, and good representation across the age and LTC work experience spectrum. Lastly, it should be noted that respondents used the entire range of the Likert scale in their responses; no ceiling or floor effect were noted in section 3 of the questionnaire.
The authors also acknowledge several limitations. First, although we have a good response rate for an online questionnaire study, our respondents were mainly physicians in urban areas. Frontline nursing staff and clinicians from rural settings are under-represented in our respondent population. Our sample was also older, as over half of the respondents were above the age of 51; however, previous Canadian data which reported an average age of 52.4 years.(20) Second, LTC clinicians that are actively affiliated with a professional LTC association would be more interested in attending continuing medical education events and review the regular updates being sent during the COVID-19 pandemic. As a result, these clinicians may be more aware of pandemic mitigation strategies, and more willing to complete an online questionnaire. Therefore, the results presented here may not represent the opinions of those LTC clinicians that are not members of professional associations. Third, while our data suggest that public health interventions were widely implemented, our questionnaire was not designed to demonstrate whether these interventions were meaningful enough to prevent a potential individual outbreak. Similarly, our survey does not assess the extent to which our respondents felt that public health interventions could result in potentially negative impacts on their LTC residents. It is important to note that recommended public health interventions could result in worsening cognition and functional decline because of the restriction of external visitors and in-home recreational activities.(21) This negative impact ultimately lowers the quality of life for LTC residents, and should to be considered when planning future pandemic responses in LTC.
Lastly, the survey was created and distributed during a rapidly changing LTC landscape during the COVID-19 pandemic. Because recommendations from public health and local government officials were being communicated daily, responses from later respondents may be different than earlier respondents. To mitigate this limitation, we identified key recommendations that could impact the nature of responses (e.g. LTC staff have one work location, visitor restrictions, active staff screening, masking protocols). Visitor restrictions and active screening recommendations pre-dated the survey distribution. Masking protocols were implemented variably and did not correspond necessarily to the date of the mandatory universal masking directive. As a result, the authors decided to use the recommendation date (i.e. LTC staff being restricted to a single location of work - April 22, 2020), because this resulted in two distinct respondent cohorts, with sufficient number of responses, to allow for a formal sub-analysis.