Abstract
We conducted an electronic survey to determine the state of planning for pandemic influenza in assisted living facilities. A survey instrument was designed with input from a number of experts and sent out to 275 Nebraska assisted living facilities; responses were received from 137. The survey covered approximately 20 areas related to preparedness. About one-third of assisted living facilities had a pandemic influenza plan; 45% had started stockpiling, and 55% expected significant staff shortages in a pandemic. Only 5% were willing to discharge current patients to make room for overflow hospital patients. Assisted living facilities have started pandemic influenza planning, but additional work needs to be done. These facilities are unlikely to be able to assist with hospital patient overflow in a pandemic.
Hospitals are already running at or near full capacity, which means that noncritical patients may need to be moved to accommodate an influx of influenza cases. The burden of taking care of these “overflow” patients will fall to other facilities: assisted living facilities (ALFs), long-term care facilities (LTCFs, also referred to as skilled nursing homes), alternative care sites, and community shelters. The preparedness of these facilities will greatly influence the ability of the healthcare system to handle a large-scale influenza pandemic.5-9
Assisted living is essentially the bridge between a skilled nursing home that attends to residents who require a high level of care and those who live on their own in complete autonomy. There are approximately 38,000 assisted living facilities in the U.S. 10 The chief roles of an ALF, as defined by AARP, are “meeting a resident's scheduled and unscheduled needs, maximizing a resident's independence, privacy, autonomy, and dignity, and minimizing the need for a resident to move when he or she needs change.” 11 Residents of ALFs average 85 years of age and need help with an average of 2.3 activities of daily living, according to a 2000 study of assisted living residences. 11 This demographic is similar to that of LTCFs, with the most notable difference in the average number of activities needing assistance during daily activity: LTCF occupants needed help with an average of 3.8 daily activities according to the same study. 11 ALFs may be expected to accommodate surge capacity excess (hospital overflow), while taking into account the vulnerability of their elderly residents to influenza.12,13
Little information is available on ALF pandemic preparedness status, and we undertook our survey to inform public health and institutional preparedness efforts. We previously published a survey of LTCF preparedness. 14
Methods
A survey to assess the levels of pandemic preparedness was mailed to all 275 assisted living facilities in Nebraska in fall 2007. The survey was developed by a group of experts in infectious diseases, geriatric medicine, and public health and was mailed out to each ALF by the Nebraska Health Care Association (NHCA). After 3 weeks a second mailing was sent out, with a reminder that access to the survey was available on the NHCA website.
The questionnaire asked for the following information:
Facility characteristics, such as number of licensed beds, percentage of occupancy over the past quarter; Status of a pandemic influenza plan (and whether it was part of a general facility disaster plan); Specific components of the pandemic plan, including the presence of a separate staff position for pandemic preparedness, availability of mental health services, stockpiling of various critical items (eg, masks, gloves), willingness to serve as an alternative surge site for hospital patients, pandemic education of staff, access to adequate laboratory facilities, a plan to prioritize vaccine and antivirals during a pandemic, planning for staff shortages, a plan to update families during a pandemic, communication linkages with hospitals and regional health departments, and drills to test preparedness; and Whether the facility felt that pandemic preparedness would entail significant costs.
Data were analyzed using SAS/STAT® software. Descriptive statistics were reported using means, frequencies, and percentages. The study was approved by the University of Nebraska Medical Center IRB.
Results
The survey was mailed to 275 assisted living facilities in Nebraska, and responses were received from 137 (50%). It was found that 68 of the ALFs (49%) that responded had 50 or fewer licensed beds, 34 (25%) had 51-75 beds, and 35 (25%) had more than 75 beds. This compared to the overall population of all ALFs (respondents and nonrespondents) with 215 facilities (78%) with 50 or fewer beds, 35 (13%) with 51-75 beds, and 25 (9%) with 76 or more beds. There was an average occupancy of 84%.
The tables show results for ALFs, LTCFs, and facilities that had both assisted living and skilled nursing beds. Fifty-one of the ALFs that responded classified themselves as having both assisted living and long-term care beds. These responders were included in the total number of responses from ALFs and were separated out into a “combined” column in the tables. General pandemic planning responses are shown in Table 1, while Table 2 addresses the potential role of ALFs in surge capacity.
General Pandemic Planning in Assisted Living and Long-Term Care Facilities
Data previously published in reference 14.
Assisted Living Surge Capacity
When asked about stockpiling, 62 (45%) ALFs reported stockpiling some materials, including gloves (45, or 33%), alcohol-based handwashing agents (40, or 29%), surgical masks (34, or 25%), food (28, or 20%), linens (21, or 15%), and N95 respirators (10, or 7%). We found that 55% (76 of 137) of ALFs reported that they expected to experience staff shortages during a possible influenza pandemic. The main solution planned for staff shortages was to extend current staff hours (87 of 137, or 63%), but help was also expected from nonclinical staff (47, or 34%) and volunteers (36, or 26%).
Discussion
Little information is available on the preparedness status of assisted living facilities; we undertook our survey to inform public health and institutional preparedness efforts. Preparedness is particularly important for ALFs because they serve a population that is at high risk of infection, but they also will likely experience significant staff shortages and have limited resources.
One of the first elements addressed in the CDC planning checklist for long-term care facilities and other residential facilities is a pandemic influenza planning coordinator. 7 It was encouraging to note that 71% of the ALFs that we surveyed had a staff position responsible for pandemic and disaster planning.
The unpredictability of pandemic influenza was again demonstrated by the recent outbreak of novel H1N1 2009 influenza. 1 A pandemic can cause disruption of many aspects of society, including health care. Hospitals will rapidly fill, and planning has focused on alternative sites. Temporary shelters are an option, but they lack built-in staffing, whereas nursing facilities (such as LTCFs and ALFs) do have staff; thus, they have been considered as an option to augment hospital surge capacity. 15
Of note, 68% of ALFs thought that they would be called on to assist with hospital overflow patients in a pandemic. In our survey, 53% of ALFs expressed a willingness to take overflow noninfluenza patients, but only 34% were willing to accept overflow influenza patients requiring a low level of care, and less than 5% were willing to accept ventilator patients or to discharge residents to open up beds (Table 2). Only about a quarter of facilities expected to have beds available—not surprising considering their high baseline occupancy rate (84%). One-third of ALFs were willing to provide community care and services during a pandemic.
In the event of a pandemic, vaccinations will be in short supply for at least 6 months, and antivirals for this vulnerable patient population will also be in short supply, underscoring the importance of preparation and planning. 4 Given these anticipated shortages, it was encouraging that 44% of surveyed facilities had a plan to prioritize staff and residents for receiving antivirals and vaccines, a process that may involve difficult ethical and logistic issues.
Severe staffing shortages for virtually all businesses and facilities can be expected in a pandemic.4,6,8 To combat staffing issues, most ALFs (63%) planned to extend the hours of current staff, while some felt they would be receiving help from nonclinical staff or volunteers. Volunteers will likely be a source of some aid, but they will be spread out among other competing organizations and subject to absenteeism.
Education is emphasized in pandemic planning, 7 and a third of the respondents had provided their staff with introductory education about pandemic influenza and had a plan in place to provide additional training in the event of a pandemic. Other encouraging findings were that two-thirds of ALFs felt they had access to adequate lab facilities for influenza surveillance and case diagnosis, and over half had mental health services available for use in a pandemic.
Overall, ALFs scored lower than LTCFs in a number of preparedness categories (see Table 1); this is not surprising given the lesser patient acuity, number of beds, and resources of ALFs. The vast majority of ALFs (87%) thought that pandemic preparedness would entail significant expenses.
Optimal pandemic planning requires collaboration and communication with local public health agencies and local acute care hospitals—found in fewer than half of the surveyed facilities, thus demonstrating an opportunity for improved practices. While planning is important, exercising of plans prior to an actual pandemic is ideal, but this requires some planning and entails expense. Less than 5% of ALFs had conducted a pandemic influenza exercise.
This study had several limitations. While there was a 50% response rate to the survey, it encompassed only 1 state, potentially limiting generalizability. Also, the distribution of responses was skewed somewhat to larger facilities compared to the entire set of ALFs. We did not perform validation visits to ALFs, which was beyond the scope of the project, and we did not perform any qualitative assessment of preparedness (eg, we did not evaluate the comprehensiveness of the reported pandemic plans). Nevertheless, the survey provides new information that should be useful to public health pandemic planning.
All projections for an influenza pandemic, regardless of type, extend well beyond the current supply of hospital beds, and assisted living facilities have begun planning for an influenza pandemic. About a third have a formal pandemic plan, and 70% have a designated person in charge of pandemic planning. ALFs need to contend with protecting the health and lives of the vulnerable elderly in a pandemic under these conditions.12,13 If they can attain a sufficient level of preparedness, they will be better equipped to endure the inevitable turmoil that would result from trying to implement a last-minute plan with short supplies and a fraction of normal functional staff. If an appropriate level of preparedness is not reached, ALFs will be quickly overwhelmed when an influenza pandemic occurs.
Furthermore, there appears to be a disconnect between what is expected of ALFs by public health agencies and what they can deliver in terms of surge capacity for hospital overflow. ALFs do not appear to be able to accept significant hospital patient overflow admissions in a pandemic. Opportunities for preparedness enhancement could focus on establishing lines of communication with public health planners and exercising their plans, both undertaken by a minority of ALFs in our survey. Health planners need to realistically assess ALF preparedness.