Background and Significance: Nursing homes are ground zero for the COVID-19 pandemic. Pennsylvania nursing homes are particularly devastated, with more than 13,000 cases of COVID-19 and more than 2,800 deaths. Nursing homes are ill-equipped for the pandemic; though facilities are required to have infection control staff, only 3 percent have taken a basic infection control course. Significant research has focused on infection control in the acute care setting. However, little is known about the implementation of practices and effective interventions in long-term care facilities. We propose an intervention utilizing Project ECHO, an evidence-based telehealth model, to connect Penn State University experts with remote nursing home staff and administrators to proactively support evidence-based infection control guideline implementation. Project ECHO uses case-based, collaborative learning to support discussion of learners’ challenges and barriers to guideline implementation. The model’s explosive growth to 240 institutions nationally positions ECHO for outstanding responsiveness in a pandemic. Our study seeks to answer the critical research question of how evidence-based infection control guidelines can be implemented effectively in nursing homes.
Study Aims: Our research and stakeholder team is expertly positioned to produce actionable findings to address our long-term objective of effectively addressing COVID-19 and other infectious outbreaks in nursing homes.
Primary Aim: To compare the effectiveness of COVID-19 Project ECHO intervention (COVID-19 ECHO) with enhanced usual care in reducing the number of nursing home residents with COVID-19. Enhanced usual care will include a monthly newsletter communication about COVID-19 infection control guidelines.
Secondary Aims: 1. To compare the effectiveness of COVID-19 ECHO versus enhanced usual care on other patient-centered outcomes, including quality of life (QOL), hospitalizations, and deaths. 2. To evaluate the impact of the COVID-19 ECHO on key implementation outcomes in nursing home settings using the RE-AIM framework.
Study Design Overview: We propose a stratified cluster randomized design. Using a 1:1 ratio, we will randomly assign 72 Pennsylvania nursing homes to six months of either: 1) Project ECHO COVID-19 intervention that includes 25 weekly telehealth sessions addressing guidelines and best practices, or 2) enhanced usual care (newsletter communication to nursing homes about CDC-recommended COVID-19 guidelines). Patient-centered outcomes will be assessed at baseline, six, 12, and 18 months. Our study is guided by the RE-AIM framework to critically evaluate both effectiveness and implementation outcomes of the proposed intervention.
Comparators: As this project is built on our existing COVID-19 ECHO intervention, the study arms will have the following components: 1) COVID-19 Project ECHO intervention. Nursing homes in this arm will receive the intervention via real-time, interactive videoconferencing using Zoom. Sessions will be 60 minutes in duration and held weekly for six months at regularly scheduled times. Sessions will share the typical ECHO model format: introductions; didactic presentations; case presentations; and close and debrief. Proposed ECHO curriculum will be adapted from the evidence-based Centers for Disease Control and Prevention infection prevention and control program topics for nursing homes, adapted based on stakeholder engagement. 2) Enhanced usual care. We include an enhanced control group to minimize selection bias. We have carefully chosen a newsletter communication about COVID-19 infection control guidelines from CDC and Centers for Medicare and Medicaid Services, and adapted by our stakeholders. We selected this enhancement for our control arm because it is relevant to nursing homes, yet unlikely to contaminate study outcomes as it will only include information available elsewhere.
Study Population and Setting: We will recruit 72 nursing homes with approximately 9,000 residents from across Pennsylvania’s 695 nursing homes through collaborations with our state stakeholders. COVID-19 Project ECHO participants will include infection control staff and other facility leadership (e.g. medical director, director of nursing, administrators). Exclusion criteria will include pilot study participation.
Outcomes: Guided by the RE-AIM framework, we will simultaneously evaluate the study effectiveness and implementation outcomes. Primary outcome: COVID-19 infection rate reduction in nursing homes (data source: Pennsylvania COVID-19 Nursing Home Reporting System). Secondary outcomes: COVID-19 hospitalizations and deaths, nursing home resident quality of life, RE-AIM outcomes (Reach, Adoption, Implementation, and Maintenance).
Timeframe: COVID-19 infection rate reduction will be assessed at six, 12, and 18 months, with actionable results at six months.