COVID-19 outbreak in long-term care facilities from Spain. Many lessons to learn
Marta Mas Romero, Almudena Avendaño Céspedes, María Teresa Tabernero Sahuquillo, Elisa Belén Cortés Zamora, Cristina Gómez Ballesteros, Victoria Sánchez-Flor Alfaro, Rita López Bru, Melisa López Utiel, Sara Celaya Cifuentes, Luz María Peña Longobardo, Antonio Murillo Romero, Laura Plaza Carmona, Borja Gil García, Ana Pérez Fernández-Rius, Rubén Alcantud Córcoles, Belén Roldán García, Luis Romero Rizos, Pedro Manuel Sánchez Jurado, Matilde León Ortiz, Pilar Atienzar Núñez, Alicia Noguerón García, María Fe Ruiz García, Rafael García Molina, Juan De Dios Estrella Cazalla, Juan Oliva Moreno, Pedro Abizanda
PLOS ONE, doi:10.1371/journal.pone.0241030
Background/Objectives To analyze mortality, costs, residents and personnel characteristics, in six long-term care facilities (LTCF) during the outbreak of COVID-19 in Spain.
Design Epidemiological study.
Setting Six open LTCFs in Albacete (Spain).
Participants 198 residents and 190 workers from LTCF A were included, between 2020 March 6 and April 5. Epidemiological data were also collected from six LTCFs of Albacete for the same period of time, including 1,084 residents.
Measurements Baseline demographic, clinical, functional, cognitive and nutritional variables were collected. 1-month and 3-month mortality was determined, excess mortality was calculated, and costs associated with the pandemics were analyzed.
Results The pooled mortality rate for the first month and first three months of the outbreak were 15.3% and 28.0%, and the pooled excess mortality for these periods were 564% and 315%
References
Abizanda, Rodrı ´guez-Mañas, Function But Not Multimorbidity at The Cornerstone of Geriatric Medicine, J Am Geriatr Soc,
doi:10.1111/jgs.15021Abizanda, Romero, Sa ´nchez-Jurado, Martı ´nez-Reig, Alfonso et al., Age, frailty, disability, institutionalization, multimorbidity or comorbidity. Which are the main targets in older adults?, J Nutr Health Aging,
doi:10.1007/s12603-014-0033-3Abizanda, Romero, Sanchez-Jurado, Martı ´nez-Reig, ´mez-Arnedo et al., Frailty and mortality, disability and mobility loss in a Spanish cohort of older adults: the FRADEA study, Maturitas,
doi:10.1016/j.maturitas.2012.09.018Abrams, Loomer, Gandhi, Grabowski, Characteristics of U.S. Nursing Homes with COVID-19 cases, J Am Geriatr Soc,
doi:10.1111/jgs.16661Chidambaram, Kaiser, Family Foundation Issue Brief: state reporting of cases and deaths due to COVID-19 in long-term care facilities
Comas-Herrera, Zalakaı ´n, Litwin, Hsu, Lemmon et al., Mortality associated with COVID-19 outbreaks in care homes: early international evidence
Graham, Junghans, Downes, Sendall, Lai et al., SARS-CoV-2 infection, clinical features and outcome of COVID-19 in United Kingdom nursing homes, J Infection,
doi:10.1016/j.jinf.2020.05.073Guan, Ni, Hu, Liang, Ou et al., Clinical Characteristics of Coronavirus Disease 2019 in China, N Engl J Med,
doi:10.1056/NEJMoa2002032Holden, Gill, Magliozzi, Nathan, Baker, Clinical gait assessment in the neurologically impaired. Reliability and meaningfulness, Phys Ther,
doi:10.1093/ptj/64.1.35Hoogendijk, Romero, Sa ´nchez-Jurado, Flores-Ruano, Viña et al., A New Functional Classification Based on Frailty and Disability Stratifies the Risk for Mortality Among Older Adults: The FRADEA Study, J Am Med Dir Assoc,
doi:10.1016/j.jamda.2019.01.129Kaiser, Bauer, Ra ¨msch, Uter, Guigoz et al., Validation of the Mini Nutritional Assessment short-form (MNA-SF): a practical tool for identification of nutritional status, J Nutr Health Aging,
doi:10.1007/s12603-009-0214-7Kalache, Mckee, Derbyshire, Geffen, Casas, WHO must prioritise the needs of older people in its response to the covid-19 pandemic, BMJ,
doi:10.1136/bmj.m1164Kunz, Minder, COVID-19 pandemic: palliative care for elderly and frail patients at home and in residential and nursing homes, Swiss Med Wkly,
doi:10.4414/smw.2020.20235Lawton, Brody, Assessment of older people: self-maintaining and instrumental activities of daily living, Gerontologist
Lipsitch, Swerdlow, Finelli, Defining the Epidemiology of Covid-19-Studies Needed, N Engl J Med,
doi:10.1056/NEJMp2002125Mahoney, Barthel, Functional evaluation: the Barthel Index, Maryland State Med J
Mcmichael, Currie, Clark, Pogosjans, Kay et al., Epidemiology of Covid-19 in a Long-Term Care Facility in King County, Washington, N Eng J Med,
doi:10.1056/NEJMoa2005412Ministry, Health, Government of Spain. Prevention and control guidelines against COVID-19 in nursing homes and other residential social services centres, Boletı ´n Oficial del Estado, orden SND
Morley, Malmstrom, Miller, A simple frailty questionnaire (FRAIL) predicts outcomes in middle aged African Americans, J Nutr Health Aging,
doi:10.1007/s12603-012-0084-2Stall, Farquharson, Lun, Wiesenfeld, Loftus et al., A Hospital Partnership with a Nursing Home Experiencing a COVID-19 Outbreak: Description of a Multi-Phase Emergency Response in Toronto, Canada, J Am Geriatr Soc,
doi:10.1111/jgs.16625Stineman, Xie, Pan, Kurichi, Zhang et al., All-cause 1-, 5-, and 10-year mortality in elderly people according to activities of daily livingstage, J Am Geriatr Soc,
doi:10.1111/j.1532-5415.2011.03867.xTan, Seetharaman, Preventing the Spread of COVID-19 to Nursing Homes: Experience from a Singapore Geriatric Centre, J Am Geriatr Soc,
doi:10.1111/jgs.16447Wu, Mcgoogan, Characteristics of and Important Lessons From the Coronavirus Disease 2019 (COVID-19) Outbreak in China: Summary of a Report of 72 314 Cases From the Chinese Center for Disease Control and Prevention, JAMA,
doi:10.1001/jama.2020.2648{ 'indexed': {'date-parts': [[2024, 7, 18]], 'date-time': '2024-07-18T11:09:45Z', 'timestamp': 1721300985178},
'reference-count': 41,
'publisher': 'Public Library of Science (PLoS)',
'issue': '10',
'license': [ { 'start': { 'date-parts': [[2020, 10, 27]],
'date-time': '2020-10-27T00:00:00Z',
'timestamp': 1603756800000},
'content-version': 'vor',
'delay-in-days': 0,
'URL': 'http://creativecommons.org/licenses/by/4.0/'}],
'funder': [ { 'DOI': '10.13039/100012619',
'name': 'Centro de Investigación Biomédica en Red Fragilidad y Envejecimiento Saludable',
'doi-asserted-by': 'publisher',
'award': ['CB16/10/00408']},
{ 'DOI': '10.13039/501100004587',
'name': 'Instituto de Salud Carlos III',
'doi-asserted-by': 'publisher',
'award': ['COV20/00004']}],
'content-domain': {'domain': ['www.plosone.org'], 'crossmark-restriction': False},
'DOI': '10.1371/journal.pone.0241030',
'type': 'journal-article',
'created': { 'date-parts': [[2020, 10, 27]],
'date-time': '2020-10-27T13:36:32Z',
'timestamp': 1603805792000},
'page': 'e0241030',
'update-policy': 'http://dx.doi.org/10.1371/journal.pone.corrections_policy',
'source': 'Crossref',
'is-referenced-by-count': 54,
'title': 'COVID-19 outbreak in long-term care facilities from Spain. Many lessons to learn',
'prefix': '10.1371',
'volume': '15',
'author': [ {'given': 'Marta', 'family': 'Mas Romero', 'sequence': 'first', 'affiliation': []},
{ 'given': 'Almudena',
'family': 'Avendaño Céspedes',
'sequence': 'additional',
'affiliation': []},
{ 'given': 'María Teresa',
'family': 'Tabernero Sahuquillo',
'sequence': 'additional',
'affiliation': []},
{ 'given': 'Elisa Belén',
'family': 'Cortés Zamora',
'sequence': 'additional',
'affiliation': []},
{ 'given': 'Cristina',
'family': 'Gómez Ballesteros',
'sequence': 'additional',
'affiliation': []},
{ 'given': 'Victoria',
'family': 'Sánchez-Flor Alfaro',
'sequence': 'additional',
'affiliation': []},
{'given': 'Rita', 'family': 'López Bru', 'sequence': 'additional', 'affiliation': []},
{'given': 'Melisa', 'family': 'López Utiel', 'sequence': 'additional', 'affiliation': []},
{'given': 'Sara', 'family': 'Celaya Cifuentes', 'sequence': 'additional', 'affiliation': []},
{ 'given': 'Luz María',
'family': 'Peña Longobardo',
'sequence': 'additional',
'affiliation': []},
{'given': 'Antonio', 'family': 'Murillo Romero', 'sequence': 'additional', 'affiliation': []},
{'given': 'Laura', 'family': 'Plaza Carmona', 'sequence': 'additional', 'affiliation': []},
{'given': 'Borja', 'family': 'Gil García', 'sequence': 'additional', 'affiliation': []},
{'given': 'Ana', 'family': 'Pérez Fernández-Rius', 'sequence': 'additional', 'affiliation': []},
{ 'ORCID': 'http://orcid.org/0000-0002-5773-0835',
'authenticated-orcid': True,
'given': 'Rubén',
'family': 'Alcantud Córcoles',
'sequence': 'additional',
'affiliation': []},
{'given': 'Belén', 'family': 'Roldán García', 'sequence': 'additional', 'affiliation': []},
{'given': 'Luis', 'family': 'Romero Rizos', 'sequence': 'additional', 'affiliation': []},
{ 'given': 'Pedro Manuel',
'family': 'Sánchez Jurado',
'sequence': 'additional',
'affiliation': []},
{'given': 'Matilde', 'family': 'León Ortiz', 'sequence': 'additional', 'affiliation': []},
{'given': 'Pilar', 'family': 'Atienzar Núñez', 'sequence': 'additional', 'affiliation': []},
{'given': 'Alicia', 'family': 'Noguerón García', 'sequence': 'additional', 'affiliation': []},
{'given': 'María Fe', 'family': 'Ruiz García', 'sequence': 'additional', 'affiliation': []},
{'given': 'Rafael', 'family': 'García Molina', 'sequence': 'additional', 'affiliation': []},
{ 'given': 'Juan de Dios',
'family': 'Estrella Cazalla',
'sequence': 'additional',
'affiliation': []},
{'given': 'Juan', 'family': 'Oliva Moreno', 'sequence': 'additional', 'affiliation': []},
{ 'ORCID': 'http://orcid.org/0000-0002-4707-2963',
'authenticated-orcid': True,
'given': 'Pedro',
'family': 'Abizanda',
'sequence': 'additional',
'affiliation': []}],
'member': '340',
'published-online': {'date-parts': [[2020, 10, 27]]},
'reference': [ { 'issue': '21',
'key': 'pone.0241030.ref001',
'doi-asserted-by': 'crossref',
'first-page': '2005',
'DOI': '10.1056/NEJMoa2005412',
'article-title': 'Epidemiology of Covid-19 in a Long-Term Care Facility in King County, '
'Washington',
'volume': '382',
'author': 'TM McMichael',
'year': '2020',
'journal-title': 'N Eng J Med'},
{ 'key': 'pone.0241030.ref002',
'doi-asserted-by': 'crossref',
'first-page': '411',
'DOI': '10.1016/j.jinf.2020.05.073',
'article-title': 'SARS-CoV-2 infection, clinical features and outcome of COVID-19 in '
'United Kingdom nursing homes',
'volume': '81',
'author': 'NSN Graham',
'year': '2020',
'journal-title': 'J Infection'},
{ 'key': 'pone.0241030.ref003',
'doi-asserted-by': 'crossref',
'first-page': 'm1164',
'DOI': '10.1136/bmj.m1164',
'article-title': 'WHO must prioritise the needs of older people in its response to the '
'covid-19 pandemic',
'volume': '368',
'author': 'PG Lloyd-Sherlock',
'year': '2020',
'journal-title': 'BMJ'},
{ 'key': 'pone.0241030.ref004',
'unstructured': 'World Health Organization. Coronavirus disease (COVID-19) technical '
'guidance: Guidancefor schools, workplaces, and institutions. '
'https://www.who.int/emergencies/diseases/novel-coronavirus-2019/technical-guidance/guidance-for-schools-workplaces-institutions.'},
{ 'key': 'pone.0241030.ref005',
'unstructured': 'Centers for Disease Control and Prevention. Coronavirus Disease 2019 '
'(COVID-19) Preparedness Checklist for Nursing Homes and other Long-Term '
'Care Settings. Accesible in: '
'https://www.cdc.gov/coronavirus/2019-ncov/downloads/novel-coronavirus-2019-Nursing-Homes-Preparedness-Checklist_3_13.pdf'},
{ 'key': 'pone.0241030.ref006',
'unstructured': 'Centers for Medicare & Medicaid Services. Guidance for Infection Control '
'and Prevention of Coronavirus Disease 2019(COVID-19) in Nursing Homes. '
'Accesible in: '
'https://www.cms.gov/files/document/qso-20-14-nh-revised.pdf.'},
{ 'key': 'pone.0241030.ref007',
'doi-asserted-by': 'crossref',
'first-page': '908',
'DOI': '10.1111/jgs.16477',
'article-title': 'American Geriatrics Society Policy Brief: COVID-19 and Nursing Homes',
'volume': '68',
'author': 'American Geriatrics Society',
'year': '2020',
'journal-title': 'J Am Geriatrc Soc'},
{ 'key': 'pone.0241030.ref008',
'unstructured': 'Ministry of Health, Government of Spain. COVID-19 actualization number '
'185. 14.08.2020. Accesible in: '
'https://www.mscbs.gob.es/profesionales/saludPublica/ccayes/ [accessed on '
'2020 August 16th].'},
{ 'key': 'pone.0241030.ref009',
'unstructured': 'Covid-19: the precarious position of Spain’s nursing homes. Accesible '
'in: https://www.bmj.com/content/369/bmj.m1554.'},
{ 'key': 'pone.0241030.ref010',
'unstructured': "Coronavirus: Inside story of Spain's care home tragedy. Accesible in: "
'https://www.bbc.com/news/world-europe-52188820.'},
{ 'key': 'pone.0241030.ref011',
'unstructured': 'A Deluged System Leaves Some Elderly to Die, Rocking Spain’s Self-Image. '
'Accesible in: '
'https://www.nytimes.com/2020/03/25/world/europe/Spain-coronavirus-nursing-homes.html.'},
{ 'key': 'pone.0241030.ref012',
'unstructured': 'Lockdown: Nursing homes in Spain a vector for deadly coronavirus. '
'Accesible in: '
'https://www.reuters.com/article/us-health-coronavirus-spain-lockdown-ins/lockdown-nursing-homes-in-spain-a-vector-for-deadly-coronavirus-idUSKBN2190N1.'},
{ 'key': 'pone.0241030.ref013',
'first-page': '26758',
'article-title': 'Prevention and control guidelines against COVID-19 in nursing homes and '
'other residential social services centres',
'volume': '81',
'author': 'Ministry of Health, Government of Spain',
'journal-title': 'Boletín Oficial del Estado, orden SND/275/2020 from 20 March 2020'},
{ 'issue': '13',
'key': 'pone.0241030.ref014',
'doi-asserted-by': 'crossref',
'first-page': '1194',
'DOI': '10.1056/NEJMp2002125',
'article-title': 'Defining the Epidemiology of Covid-19—Studies Needed',
'volume': '382',
'author': 'M Lipsitch',
'year': '2020',
'journal-title': 'N Engl J Med'},
{ 'key': 'pone.0241030.ref015',
'first-page': '61',
'article-title': 'Functional evaluation: the Barthel Index',
'volume': '14',
'author': 'FI Mahoney',
'year': '1965',
'journal-title': 'Maryland State Med J'},
{ 'issue': '3',
'key': 'pone.0241030.ref016',
'doi-asserted-by': 'crossref',
'first-page': '179',
'DOI': '10.1093/geront/9.3_Part_1.179',
'article-title': 'Assessment of older people: self-maintaining and instrumental '
'activities of daily living',
'volume': '9',
'author': 'MP Lawton',
'year': '1969',
'journal-title': 'Gerontologist'},
{ 'issue': '7',
'key': 'pone.0241030.ref017',
'doi-asserted-by': 'crossref',
'first-page': '601',
'DOI': '10.1007/s12603-012-0084-2',
'article-title': 'A simple frailty questionnaire (FRAIL) predicts outcomes in middle aged '
'African Americans',
'volume': '16',
'author': 'JE Morley',
'year': '2012',
'journal-title': 'J Nutr Health Aging'},
{ 'issue': '1',
'key': 'pone.0241030.ref018',
'doi-asserted-by': 'crossref',
'first-page': '35',
'DOI': '10.1093/ptj/64.1.35',
'article-title': 'Clinical gait assessment in the neurologically impaired. Reliability '
'and meaningfulness',
'volume': '64',
'author': 'MK Holden',
'year': '1984',
'journal-title': 'Phys Ther'},
{ 'issue': '9',
'key': 'pone.0241030.ref019',
'doi-asserted-by': 'crossref',
'first-page': '1105',
'DOI': '10.1016/j.jamda.2019.01.129',
'article-title': 'A New Functional Classification Based on Frailty and Disability '
'Stratifies the Risk for Mortality Among Older Adults: The FRADEA Study',
'volume': '20',
'author': 'EO Hoogendijk',
'year': '2019',
'journal-title': 'J Am Med Dir Assoc'},
{ 'issue': '9',
'key': 'pone.0241030.ref020',
'doi-asserted-by': 'crossref',
'first-page': '782',
'DOI': '10.1007/s12603-009-0214-7',
'article-title': 'Validation of the Mini Nutritional Assessment short-form (MNA-SF): a '
'practical tool for identification of nutritional status',
'volume': '13',
'author': 'MJ Kaiser',
'year': '2009',
'journal-title': 'J Nutr Health Aging'},
{ 'issue': '11',
'key': 'pone.0241030.ref021',
'doi-asserted-by': 'crossref',
'first-page': '1245',
'DOI': '10.1016/0895-4356(94)90129-5',
'article-title': 'Validation of a combined comorbidity index',
'volume': '47',
'author': 'M Charlson',
'year': '1994',
'journal-title': 'J Clin Epidemiol'},
{ 'key': 'pone.0241030.ref022',
'unstructured': 'Orden de 17/11/2014, de la Consejería de Sanidad y Asuntos Sociales, por '
'la que se establecen los precios públicos de la asistencia sanitaria y '
'de los servicios prestados en la red de centros sanitarios dependientes '
'del Servicio de Salud de Castilla-La Mancha. [2014/15022] (Available at: '
'https://docm.jccm.es/portaldocm/descargarArchivo.do?ruta=2014/11/21/pdf/2014_15022.pdf&tipo=rutaDocm)'},
{ 'key': 'pone.0241030.ref023',
'unstructured': 'Ministry of Health, Consumption and Social Welfare. Estimation of '
'weights and costs of hospital processes in the National Health System: '
'methodology and main results. Project 2017 (Available at: '
'https://www.mscbs.gob.es/estadEstudios/estadisticas/inforRecopilaciones/anaDesarrolloGDR.htm)'},
{ 'key': 'pone.0241030.ref024',
'unstructured': 'Instituto Nacional de Estadística (INE). Encuesta de Estructura '
'Salarial. Available at: '
'https://www.ine.es/dyngs/INEbase/es/operacion.htm?c=Estadistica_C&cid=1254736177025&menu=ultiDatos&idp=1254735976596'},
{ 'key': 'pone.0241030.ref025',
'unstructured': 'National Institute of Statistics. Consumer Price Index. Available at: '
'https://www.ine.es/dynt3/inebase/es/index.htm?padre=3464&capsel=3466'},
{ 'key': 'pone.0241030.ref026',
'volume-title': 'International Ethical Guidelines for Health-related Research Involving '
'Humans',
'year': '2016',
'edition': '4'},
{ 'key': 'pone.0241030.ref027',
'article-title': 'Characteristics of and Important Lessons From the Coronavirus Disease '
'2019 (COVID-19) Outbreak in China: Summary of a Report of 72 314 Cases '
'From the Chinese Center for Disease Control and Prevention',
'author': 'Z Wu',
'year': '2020',
'journal-title': 'JAMA'},
{ 'key': 'pone.0241030.ref028',
'unstructured': 'Chidambaram P. Kaiser Family Foundation Issue Brief: state reporting of '
'cases and deaths due to COVID-19 in long-term care facilities. Accessed '
'May 26, 2020. '
'https://www.kff.org/medicaid/issue-brief/state-reporting-of-cases-and-deaths-due-to-covid-19-in-long-term-care-facilities/'},
{ 'key': 'pone.0241030.ref029',
'article-title': 'Mortality associated with COVID-19 outbreaks in care homes: early '
'international evidence',
'author': 'A Comas-Herrera',
'year': '2020',
'journal-title': 'Article in LTCcovid.org, International Long-Term Care Policy Network, '
'CPEC-LSE'},
{ 'issue': '3',
'key': 'pone.0241030.ref030',
'doi-asserted-by': 'crossref',
'first-page': '485',
'DOI': '10.1111/j.1532-5415.2011.03867.x',
'article-title': 'All-cause 1-, 5-, and 10-year mortality in elderly people according to '
'activities of daily livingstage',
'volume': '60',
'author': 'MG Stineman',
'year': '2012',
'journal-title': 'J Am Geriatr Soc'},
{ 'issue': '1',
'key': 'pone.0241030.ref031',
'doi-asserted-by': 'crossref',
'first-page': '54',
'DOI': '10.1016/j.maturitas.2012.09.018',
'article-title': 'Frailty and mortality, disability and mobility loss in a Spanish cohort '
'of older adults: the FRADEA study',
'volume': '74',
'author': 'P Abizanda',
'year': '2013',
'journal-title': 'Maturitas'},
{ 'issue': '6',
'key': 'pone.0241030.ref032',
'doi-asserted-by': 'crossref',
'first-page': '622',
'DOI': '10.1007/s12603-014-0033-3',
'article-title': 'Age, frailty, disability, institutionalization, multimorbidity or '
'comorbidity. Which are the main targets in older adults?',
'volume': '18',
'author': 'P Abizanda',
'year': '2014',
'journal-title': 'J Nutr Health Aging'},
{ 'issue': '10',
'key': 'pone.0241030.ref033',
'doi-asserted-by': 'crossref',
'first-page': '2333',
'DOI': '10.1111/jgs.15021',
'article-title': 'Function But Not Multimorbidity at The Cornerstone of Geriatric '
'Medicine',
'volume': '65',
'author': 'P Abizanda',
'year': '2017',
'journal-title': 'J Am Geriatr Soc'},
{ 'key': 'pone.0241030.ref034',
'article-title': 'Characteristics of U.S. Nursing Homes with COVID-19 cases',
'author': 'HR Abrams',
'year': '2020',
'journal-title': 'J Am Geriatr Soc'},
{ 'issue': '5',
'key': 'pone.0241030.ref035',
'doi-asserted-by': 'crossref',
'first-page': '453',
'DOI': '10.1007/s12603-020-1357-9',
'article-title': 'COVID-19 Spiraling of Frailty in Older Italian Patients',
'volume': '24',
'author': 'AM Abbatecola',
'year': '2020',
'journal-title': 'J Nutr Health Aging'},
{ 'issue': '18',
'key': 'pone.0241030.ref036',
'doi-asserted-by': 'crossref',
'first-page': '1708',
'DOI': '10.1056/NEJMoa2002032',
'article-title': 'Clinical Characteristics of Coronavirus Disease 2019 in China',
'volume': '382',
'author': 'WJ Guan',
'year': '2020',
'journal-title': 'N Engl J Med'},
{ 'issue': '5',
'key': 'pone.0241030.ref037',
'doi-asserted-by': 'crossref',
'first-page': '942',
'DOI': '10.1111/jgs.16447',
'article-title': 'Preventing the Spread of COVID-19 to Nursing Homes: Experience from a '
'Singapore Geriatric Centre',
'volume': '68',
'author': 'LF Tan',
'year': '2020',
'journal-title': 'J Am Geriatr Soc'},
{ 'issue': '7',
'key': 'pone.0241030.ref038',
'doi-asserted-by': 'crossref',
'first-page': '1376',
'DOI': '10.1111/jgs.16625',
'article-title': 'A Hospital Partnership with a Nursing Home Experiencing a COVID-19 '
'Outbreak: Description of a Multi-Phase Emergency Response in Toronto, '
'Canada',
'volume': '68',
'author': 'NM Stall',
'year': '2020',
'journal-title': 'J Am Geriatr Soc'},
{ 'key': 'pone.0241030.ref039',
'first-page': 'w20235',
'article-title': 'COVID-19 pandemic: palliative care for elderly and frail patients at '
'home and in residential and nursing homes',
'volume': '150',
'author': 'R Kunz',
'year': '2020',
'journal-title': 'Swiss Med Wkly'},
{ 'issue': '5',
'key': 'pone.0241030.ref040',
'doi-asserted-by': 'crossref',
'first-page': '459',
'DOI': '10.1007/s12603-020-1354-z',
'article-title': 'Geriatric medicine in Italy in the time of Covid-19',
'volume': '24',
'author': 'M Cesari',
'year': '2020',
'journal-title': 'J Nutr Health Aging'},
{ 'key': 'pone.0241030.ref041',
'article-title': 'Nursing Home care in crisis in the wake of COVID-19',
'author': 'DC Grabowski',
'year': '2020',
'journal-title': 'JAMA'}],
'container-title': 'PLOS ONE',
'original-title': [],
'language': 'en',
'link': [ { 'URL': 'https://dx.plos.org/10.1371/journal.pone.0241030',
'content-type': 'unspecified',
'content-version': 'vor',
'intended-application': 'similarity-checking'}],
'deposited': { 'date-parts': [[2020, 10, 27]],
'date-time': '2020-10-27T13:37:29Z',
'timestamp': 1603805849000},
'score': 1,
'resource': {'primary': {'URL': 'https://dx.plos.org/10.1371/journal.pone.0241030'}},
'subtitle': [],
'editor': [{'given': 'Tim', 'family': 'Luckett', 'sequence': 'first', 'affiliation': []}],
'short-title': [],
'issued': {'date-parts': [[2020, 10, 27]]},
'references-count': 41,
'journal-issue': {'issue': '10', 'published-online': {'date-parts': [[2020, 10, 27]]}},
'URL': 'http://dx.doi.org/10.1371/journal.pone.0241030',
'relation': {},
'ISSN': ['1932-6203'],
'subject': [],
'container-title-short': 'PLoS ONE',
'published': {'date-parts': [[2020, 10, 27]]}}
