Presentation
HE17 - We Weren’t Prepared – Rethinking the Design of Long-Term Care Homes for Infectious Outbreaks
DescriptionBackground
During the height of the coronavirus disease (COVID-19) pandemic, Canada’s Long-Term Care (LTC) sector was severely burdened accounting for 81% of all COVID-19 deaths nationwide (June 2020), and later 43% of deaths (December 2021) despite widespread vaccination. Given the nature of LTC home design (e.g., long-use, shared resident and workspaces) coupled with frequent contact among staff, residents and care partners, supporting infection prevention and control (IPC) through environmental design plays an important role in facilitating the quality of life of residents, and health and safety of workers. Ontario’s Science Table on COVID-19 identified 5 priorities to better respond to infectious outbreaks in LTC homes which included rethinking: staffing, essential caregiver access, timely/high-quality palliative care, building/maintaining IPC expertise within homes, and the design of resident and staff areas. At the time of this study, there was little information on design’s influence on the performance and maintenance of IPC in LTC.
Working with residents, staff and care partners from 8 LTC homes in Ontario between 2020-2022 (pop. 14.57 million, 627 homes serving over 78,000 residents) we documented people’s experiences during the pandemic in relation to the design of the home. We then worked with participants to co-create design concepts aiming to better respond to outbreaks while improving quality of life and working conditions.
Methods and Participants
Our objective was to develop a better understanding of how the design of Ontario LTC homes impacted IPC but also the quality of life of residents, staff and care partners during the pandemic from 2019-2022. As research teams were not permitted to enter homes for some time, we collected data remotely from 8 LTC homes working with 38 participants (8 residents, 16 family members, 14 staff members, 25 female/13 male). Staff members included IPC specialists, nurses, environmental service workers, unit/personal support workers, facilities management, and others with workflow experience related to IPC. Participants shared their experiences of living and working in LTC homes during the pandemic, and more specifically, lockdowns. We consulted homes on the study design to avoid placing an additional burden on participants, while trying to facilitate active participation. We used photo diaries and interviews/focus groups to collect data on people’s experiences followed by co-design sessions to generate concepts to improve outbreak response. The study was approved by both the Bruyère and Carleton University Research Ethics Boards and residents and staff were compensated for their participation.
People commented on ‘worked well’ and ‘not so well’ in the home design related to the pandemic. Staff members shared 9 photo diaries resulting in 528 photos documenting the design of homes and IPC considerations. We held 28 virtual interviews (1-1.5 hours) with staff, residents and care partners, and 1 focus group with 8 care partners (family council members) resulting in ~260,000 words of text data. We coded the photos and text deductively using descriptive coding and pre-determined categories of interest using NVivo qualitative software, followed by inductive evaluative coding of the text data for positive-neutral-negative sentiments.
Results and Discussion
Participants provided details of needed changes to mitigate physical and psychosocial risks associated with infectious outbreaks. Our descriptive coding analysis allowed us to tier what people photographed and talked about ‘most to least’ with regards to the design of homes, categorizing these ‘instances or coded references’ from 1000+ to 100+ references. For example, 1000+ ‘coded references’ related to each category: Storage Design; Design for Cleaning & Disinfection; Design of Shared Spaces (Resident & Staff); and Design to Support Personal Protective Equipment (PPE) Supplies, Donning & Doffing. We used this tiered analysis to help prioritize what policymakers, designers, etc. need to pay closer attention to in developing future homes. Below we highlight some of the qualitative analysis that appeared in these categories requiring ‘attention’.
The pandemic surfaced many weaknesses including issues related to the design of entrances/exits, resident rooms, shared resident and staff areas, outdoor areas, storage, soiled/clean zones, personal protective equipment, and supply logistics, among others. Crowding, a key factor in IPC design, was observed strongly throughout the homes, due to inadequate space, poor layout for resident activity or workflows, and inadequate clearances between people, or between people and equipment/furniture. We studied the ability to physically distance in different areas of the homes or circulate around people and elements using photo diaries and floorplans. We completed 86 planning studies which revealed significant concerns with maintaining distancing in dining and other resident activity areas, corridors, staff work areas, staff rooms, entrances, etc. These studies included wheelchair clearances since homes shared that approximately 70% of their residents, or more, use wheelchairs.
Apart from crowding, other key findings pointed to: severe storage issues for PPE and clean supplies; the absence of designs to support safe donning and doffing; and exposed, unsafe waste handling. The current design of homes is misaligned with clean/soiled supply management (e.g., continence care) and homes reported becoming quickly overwhelmed when pallets of PPE were being delivered taking extraordinary measures to manage PPE (appropriating resident spaces, renting recreational vehicles/off-site storage). We also learned about more nuanced aspects of design negatively impacting residents during lockdowns such as the inability to see ‘my community’ due to window or balcony railing design, or the ‘inability to take care of myself’ due to staff shortages coupled with inaccessible washroom or closet design. These are but a few examples, which we will expand on with the audience. From this analysis, we developed recommendations and design concepts for future LTC homes to better respond to outbreaks which we will share during our presentation through thematic analysis, floorplans and renderings.
Conclusion and Impact
The appropriate design of LTC homes is crucial in balancing IPC with resident quality of life, particularly during pandemic conditions. Four years later, the risks associated with COVID-19 are still with us, coupled with the impacts of other infectious diseases circulating in LTC homes. While IPC protocols are relatively well-established in hospitals, protocols were not well developed for the unique characteristics of LTC. This study aimed to help change this, through a qualitative and quantitative analysis of people’s experiences in LTC homes during the pandemic, while also capturing participants’ thoughts on how homes should be reimagined. Participants talked about residents’ inability to manage basic, daily living activities due to limitations imposed on them by their environment, environmental limitations related to staff shortages, and staff creating workarounds to physically distance both residents and staff.
To the best of our knowledge, this is the only research we are aware of that studied care homes to this depth during the pandemic using unique remote design methods, culminating in co-created design recommendations and concepts. The pandemic revealed many weaknesses about LTC home design and this study in documenting the experiences of 8 homes has contributed to the Canadian historical record. To-date, this work has been disseminated in various Ontario venues and has also informed the development of the CSA Z8004:22, Long-term care home operations and infection prevention and control standard and CSA Z8000 Canadian health care facilities. We feel the design recommendations developed through this study are not unique to Canada and can be considered in designing care homes more broadly to improve the lives of our elders, persons with disabilities and the people who care for them. The lessons learned here have the potential to inform the design of other similar residential, longer-stay care environments in American and international contexts.
During the height of the coronavirus disease (COVID-19) pandemic, Canada’s Long-Term Care (LTC) sector was severely burdened accounting for 81% of all COVID-19 deaths nationwide (June 2020), and later 43% of deaths (December 2021) despite widespread vaccination. Given the nature of LTC home design (e.g., long-use, shared resident and workspaces) coupled with frequent contact among staff, residents and care partners, supporting infection prevention and control (IPC) through environmental design plays an important role in facilitating the quality of life of residents, and health and safety of workers. Ontario’s Science Table on COVID-19 identified 5 priorities to better respond to infectious outbreaks in LTC homes which included rethinking: staffing, essential caregiver access, timely/high-quality palliative care, building/maintaining IPC expertise within homes, and the design of resident and staff areas. At the time of this study, there was little information on design’s influence on the performance and maintenance of IPC in LTC.
Working with residents, staff and care partners from 8 LTC homes in Ontario between 2020-2022 (pop. 14.57 million, 627 homes serving over 78,000 residents) we documented people’s experiences during the pandemic in relation to the design of the home. We then worked with participants to co-create design concepts aiming to better respond to outbreaks while improving quality of life and working conditions.
Methods and Participants
Our objective was to develop a better understanding of how the design of Ontario LTC homes impacted IPC but also the quality of life of residents, staff and care partners during the pandemic from 2019-2022. As research teams were not permitted to enter homes for some time, we collected data remotely from 8 LTC homes working with 38 participants (8 residents, 16 family members, 14 staff members, 25 female/13 male). Staff members included IPC specialists, nurses, environmental service workers, unit/personal support workers, facilities management, and others with workflow experience related to IPC. Participants shared their experiences of living and working in LTC homes during the pandemic, and more specifically, lockdowns. We consulted homes on the study design to avoid placing an additional burden on participants, while trying to facilitate active participation. We used photo diaries and interviews/focus groups to collect data on people’s experiences followed by co-design sessions to generate concepts to improve outbreak response. The study was approved by both the Bruyère and Carleton University Research Ethics Boards and residents and staff were compensated for their participation.
People commented on ‘worked well’ and ‘not so well’ in the home design related to the pandemic. Staff members shared 9 photo diaries resulting in 528 photos documenting the design of homes and IPC considerations. We held 28 virtual interviews (1-1.5 hours) with staff, residents and care partners, and 1 focus group with 8 care partners (family council members) resulting in ~260,000 words of text data. We coded the photos and text deductively using descriptive coding and pre-determined categories of interest using NVivo qualitative software, followed by inductive evaluative coding of the text data for positive-neutral-negative sentiments.
Results and Discussion
Participants provided details of needed changes to mitigate physical and psychosocial risks associated with infectious outbreaks. Our descriptive coding analysis allowed us to tier what people photographed and talked about ‘most to least’ with regards to the design of homes, categorizing these ‘instances or coded references’ from 1000+ to 100+ references. For example, 1000+ ‘coded references’ related to each category: Storage Design; Design for Cleaning & Disinfection; Design of Shared Spaces (Resident & Staff); and Design to Support Personal Protective Equipment (PPE) Supplies, Donning & Doffing. We used this tiered analysis to help prioritize what policymakers, designers, etc. need to pay closer attention to in developing future homes. Below we highlight some of the qualitative analysis that appeared in these categories requiring ‘attention’.
The pandemic surfaced many weaknesses including issues related to the design of entrances/exits, resident rooms, shared resident and staff areas, outdoor areas, storage, soiled/clean zones, personal protective equipment, and supply logistics, among others. Crowding, a key factor in IPC design, was observed strongly throughout the homes, due to inadequate space, poor layout for resident activity or workflows, and inadequate clearances between people, or between people and equipment/furniture. We studied the ability to physically distance in different areas of the homes or circulate around people and elements using photo diaries and floorplans. We completed 86 planning studies which revealed significant concerns with maintaining distancing in dining and other resident activity areas, corridors, staff work areas, staff rooms, entrances, etc. These studies included wheelchair clearances since homes shared that approximately 70% of their residents, or more, use wheelchairs.
Apart from crowding, other key findings pointed to: severe storage issues for PPE and clean supplies; the absence of designs to support safe donning and doffing; and exposed, unsafe waste handling. The current design of homes is misaligned with clean/soiled supply management (e.g., continence care) and homes reported becoming quickly overwhelmed when pallets of PPE were being delivered taking extraordinary measures to manage PPE (appropriating resident spaces, renting recreational vehicles/off-site storage). We also learned about more nuanced aspects of design negatively impacting residents during lockdowns such as the inability to see ‘my community’ due to window or balcony railing design, or the ‘inability to take care of myself’ due to staff shortages coupled with inaccessible washroom or closet design. These are but a few examples, which we will expand on with the audience. From this analysis, we developed recommendations and design concepts for future LTC homes to better respond to outbreaks which we will share during our presentation through thematic analysis, floorplans and renderings.
Conclusion and Impact
The appropriate design of LTC homes is crucial in balancing IPC with resident quality of life, particularly during pandemic conditions. Four years later, the risks associated with COVID-19 are still with us, coupled with the impacts of other infectious diseases circulating in LTC homes. While IPC protocols are relatively well-established in hospitals, protocols were not well developed for the unique characteristics of LTC. This study aimed to help change this, through a qualitative and quantitative analysis of people’s experiences in LTC homes during the pandemic, while also capturing participants’ thoughts on how homes should be reimagined. Participants talked about residents’ inability to manage basic, daily living activities due to limitations imposed on them by their environment, environmental limitations related to staff shortages, and staff creating workarounds to physically distance both residents and staff.
To the best of our knowledge, this is the only research we are aware of that studied care homes to this depth during the pandemic using unique remote design methods, culminating in co-created design recommendations and concepts. The pandemic revealed many weaknesses about LTC home design and this study in documenting the experiences of 8 homes has contributed to the Canadian historical record. To-date, this work has been disseminated in various Ontario venues and has also informed the development of the CSA Z8004:22, Long-term care home operations and infection prevention and control standard and CSA Z8000 Canadian health care facilities. We feel the design recommendations developed through this study are not unique to Canada and can be considered in designing care homes more broadly to improve the lives of our elders, persons with disabilities and the people who care for them. The lessons learned here have the potential to inform the design of other similar residential, longer-stay care environments in American and international contexts.
Event Type
Poster Presentation
TimeMonday, March 254:45pm - 6:15pm CDT
LocationSalon C
Digital Health
Simulation and Education
Hospital Environments
Medical and Drug Delivery Devices
Patient Safety Research and Initiatives