Enhanced Lateral Flow Testing Strategies in Care Homes Are Associated with Poor Adherence and Were Insufficient to Prevent COVID-19 Outbreaks: Results from a Mixed Methods Implementation Study

Abstract

Introduction: Care homes have been severely affected by the SARS-CoV-2 pandemic. Rapid antigen testing could identify most SARS-CoV-2 infected staff and visitors before they enter homes. We explored implementation of staff and visitor testing protocols using lateral flow devices (LFDs).

Methods: An evaluation of a SARS-CoV-2 LFD based testing protocol in 11 care homes in Liverpool, UK, including staff and visitor testing, plus a qualitative exploratory study in 9 of these homes. The proportion of pilot homes with outbreaks, and outbreak size, were compared to non-pilot homes in Liverpool. Adherence to testing protocols was evaluated. Fifteen staff were interviewed, and transcript data were thematically coded using an iterative analysis to identify and categorize factors influencing testing implementation.

Results: 1638 LFD rapid tests were performed on 407 staff. Protocol adherence was poor with 8.6% of staff achieving >75% protocol adherence, and 25.3% achieving ≥50%. Six care homes had outbreaks during the study. Compared to non-pilot care homes, there was no evidence of significant difference in the proportion of homes with outbreaks, or the size of outbreaks. Qualitative data showed difficulty implementing testing strategies due to excessive work burden. Factors influencing adherence related to test integration and procedural factors, socio-economic factors, cognitive overload, and the emotional value of testing.

Conclusion: Implementation of staff and visitor care home LFD testing protocols was poorly adhered to and did not reduce the number or scale of COVID-19 outbreaks. More focus is needed on the contextual and behavioural factors that influence protocol adherence.

Note: Funding Statement: This quantitative evaluation was commissioned by the UK Department of Health and Social Care. The qualitative evaluation was supported by National Institute for Health Research (NIHR), Asthma UK and the British Lung Foundation, as a part of the CONDOR study. MM, PK, AM, and PB are supported by the NIHR London In Vitro Diagnostics Co-operative; AG is funded in part by the NIHR Applied Research Collaboration-East Midlands (ARC-EM). MGF acknowledges support of the UK EPSRC grant EP/N014499/1. The views expressed are those of the authors and not necessarily those of the funders, the NHS, the NIHR or the Department of Health and Social Care.

Declaration of Interests: MM, PB, PK, KL, AM, AG, and MG have nothing to declare. JT has been contracted to provide epidemiological support to Liverpool City Council during the COVID-19 pandemic. IB is NIHR Senior Investigator and Chief Data Scientist advisor for AstraZeneca. PP, MA and SP are employed by Liverpool City Council.

Ethics Approval Statement: Testing of care home staff and visitors with Innova lateral flow devices was commissioned by the Department of Health and Social Care (DHSC). The anonymised evaluation of the secondary data resultant of these testing data by members of the University of Liverpool were considered Service Evaluation by DHSC and not classified as research, and so does not require research ethics committee review (see http://www.hra-decisiontools.org.uk/research/docs/DefiningResearchTable_Oct2017-1.pdf). The human factor analysis in this paper form part of the wider CONDOR (COVID-19 National DiagnOstic Research and Evaluation Platform) initiative. This was approved as a Service Evaluation by Imperial College Healthcare NHS Trust (ICHNT)—registration no. 471.

Keywords: lateral flow devices, antigen test, SARS-CoV-2, care homes, COVID-19, rapid point-of-care testing