INTRODUCTION
During the early stages of the coronavirus disease-2019 (COVID-19) pandemic, 30%–50% of COVID-19-related deaths occurred in long-term care facilities, including long-term care hospitals (LTCHs), in countries such as the United States, England, France, and Spain.1-3) In Korea, numerous COVID-19 outbreaks occurred in LTCHs during the pandemic, with an estimated 30%–40% of deaths occurring among residents of these institutions.4) LTCHs primarily provide palliative care and rehabilitation and other medical services for acute care discharge patients.5) Patients in LTCHs are typically older adults and often have multiple comorbidities, making them particularly vulnerable to infections and higher mortality rates after infection.6-8) Close and frequent contact between residents and staff in LTCHs care settings can contribute to an easier occurrence of internal outbreaks.9) Tailored infection control measures are essential to prevent the spread of COVID-19 within LTCHs.
Despite increased awareness of infection control following the Middle East respiratory syndrome (MERS) outbreak in 2015, LTCHs in Korea have continued to face systemic limitations in establishing infection control infrastructure. Unlike acute care hospitals, LTCHs were not eligible for infection control reimbursement until July 2023, making it difficult for them to secure dedicated personnel or implement sustainable prevention programs.10) Consequently, many institutions are under-resourced and vulnerable to large-scale outbreaks during health crises such as the COVID-19 pandemic. These limitations have hindered the implementation of sustainable infection prevention systems within LTCHs, despite their high-risk population.
Previous studies have partially explored infection control in Korean healthcare institutions. Hwang et al.4) reported that over 70% of LTCHs in the Gyeongbuk region experienced in-house COVID-19 outbreaks during the Omicron surge, revealing practical difficulties such as delayed isolation and workforce shortages. In response, the Korea Disease Control and Prevention Agency developed facility-specific infection prevention control guidelines and later summarized key experiences and gaps in the Four Years of COVID-19 white paper, noting critical delays in resource mobilization and limited staff preparedness in LTCHs.11) However, these efforts lacked a unified, nationwide quantitative assessment of preparedness and real-world outbreak response. This study aimed to address this gap by conducting a comprehensive national survey of LTCHs to evaluate their capacity and experience during the COVID-19 pandemic, with the objective of informing future preparedness strategies for emerging infectious diseases.
MATERIALS AND METHODS
Study Design
We conducted a national survey on preparedness for and responses to COVID-19 in LTCHs in Korea between June 19 and June 30, 2023.
Questionnaire Development
An anonymous online survey was administered. A research team composed of LTCH administrators and infection control experts created an initial survey based on the guidelines for responding to COVID-19.12-16) The initial draft of the questionnaire comprised 116 items. To assess content validity, the research team independently evaluated each item using a 5-point Likert scale, where 1 indicated “not relevant” and 5 indicated “highly relevant.” In addition to numerical ratings, reviewers provided written comments on each item regarding clarity, relevance, and feasibility. Based on the results, items with an average score below 4.0 or those with overlapping or unclear content were identified for revision. Two cycles of online panel discussions were conducted to review the feedback and reach consensus on item retention, deletion, or modification. As a result, 10 items were deleted and 15 items were revised, yielding a final questionnaire version with 106 items (Supplement A).
The survey was divided into five main sections with the following number of questions: general characteristics of participating hospitals (12 items), LTCH preparedness for infectious disease disaster before the COVID-19 pandemic (7 items), preparedness for in-house outbreaks during the COVID-19 pandemic (17 items), experience in responding to in-house COVID-19 outbreaks (45 items), and vaccines and treatments (25 items). To ascertain the characteristics of the participating hospitals, we conducted inquiries regarding licensed bed capacity, location, nursing grade, and characteristics of the inpatient populations. “Preparedness during the COVID-19 pandemic” refers to proactive planning and capacity-building efforts, such as the establishment of response teams and protocols. Meanwhile, “experience in responding to in-house outbreaks” captures the actual management practices and challenges encountered during confirmed outbreak events. For preparedness during the COVID-19 pandemic, the items covered three main areas: (1) establishment of an in-house COVID-19 response system, (2) COVID-19 screening and management, and (3) personal protective equipment (PPE). Experience in responding to in-house COVID-19 outbreaks was divided into seven subcategories: (1) the scale of in-house outbreaks, (2) response system, (3) management of confirmed cases, (4) close contact management, (5) supplies management, (6) staffing issues, and (7) compensation for losses. An in-house outbreak was defined as when 10% or more of the hospitalized patients or staff represented confirmed cases. This threshold was determined through expert consensus among the research team, based on practical considerations for outbreak management in LTCHs. LTCHs provided responses regarding the highest number of confirmed COVID-19 cases during the in-house outbreaks. In the section on vaccines and treatments, responses were sought regarding domestically available treatments, including nirmatrelvir/ritonavir, molnupiravir, and remdesivir. Respondents were instructed to complete the survey accordingly.
Data Collection
The survey was conducted between June 19 and June 30, 2023. With the cooperation of the Korean Association of LTCHs, the survey link was distributed via email to all 1,425 registered LTCHs across Korea using each institution’s official contact address. To encourage participation, the initial email included a description of the study’s purpose along with the survey link. Participation was voluntary, and responses were received from physicians, nurses, and administrative staff. A follow-up email reminder was also sent during the survey period.
Statistical Analysis
Descriptive statistics were used to summarize respondent characteristics. Categorical variables were presented as frequencies and percentages. The chi-square and Fisher exact tests were used to compare categorical variables. Continuous variables were presented as mean±standard deviation or median (interquartile range [IQR]), as appropriate. A p<0.05 was considered statistically significant. Statistical analyses were performed using SPSS Statistics for Windows, version 27 (IBM Corp., Armonk, NY, USA).
RESULTS
Baseline Characteristics of Participating LTCHs
Among the 1,425 domestic LTCHs, 276 (19.4%) and 201 (14.1%) responded and completed the survey, respectively. The median licensed bed capacity was 192 beds (IQR 149–240), and the median daily number of inpatients at the time of the survey was 150 (IQR 112–182) (Table 1). All regions responded, with Seoul, Sejong, Gangwon, Chungcheong, and Jeju having fewer than five responding institutions. Of the inpatients from the LTCHs, 94.0% required nursing care, 23.9% required rehabilitation, and 18.4% required cancer care. The median number of single rooms in the hospital was 1 (IQR 0–1).
LTCH Preparedness for Infectious Disease Disaster before the COVID-19 Pandemic
Before the COVID-19 pandemic, 50 LTCHs (24.9%) had a disaster preparedness team specifically for infectious diseases (Table 2). A total of 56 institutions (27.9%) conducted training on infectious disease disaster preparedness and 70 institutions (34.8%) implemented a response education. A total of 81 LTCHs (40.3%) were equipped with infectious disease disaster response guidelines, and the contents of these guidelines included measures such as standard and transmission-based precautions (n=77, 95.1%), reporting procedures for suspected symptoms (n=64, 79.0%), and occupational infection prevention programs (n=61, 75.3%).
Preparedness for In-house Outbreaks during the COVID-19 Pandemic
In-house COVID-19 response system
During the COVID-19 pandemic, 99.0% of the institutions (n=199) established response teams for preparedness against COVID-19 (Table 3). A total of 198 LTCHs (98.5%) formulated response plans, including COVID-19 response and infection prevention activities (n=195, 98.5%), measures to prevent the transmission of COVID-19 within the facility (n=193, 97.5%), and isolation procedures to minimize the spread of COVID-19 within the facility (n=189, 95.5%). Response plans were most commonly modified following each revision of national guidelines or recommendations (166 [83.8%] institutions). Most institutions (n=190, 94.5%) provided COVID-19 response education and training to their employees. Among those who did, 93.7% (n=178) primarily referred to the Korea Disease Control and Prevention Agency materials, and document distribution was the most common method of education, accounting for 76.8%.
COVID-19 screening and management
Nearly all institutions (n=199, 99.0%) included in this study conducted screening tests for newly admitted patients, and 78.1% (n=157) admitted only those with negative test results. The screening methods for inpatients, staff, and caregivers included fever measurement (n=196, 97.5%; n=188, 93.5%; and n=187, 93.0%) and checking for respiratory infection symptoms (n=185, 92.0%; n=184, 91.5%; and n=182, 90.5%), respectively. A total of 138 institutions (68.7%) periodically conducted COVID-19 tests for inpatients, with weekly tests being the most common in 97 LTCHs (70.3%). In addition, 175 institutions (87.1%) conducted periodic COVID-19 tests for staff and caregivers.
PPE
Until the supply of PPE for pandemic preparedness, 185 institutions (92.0%) had their own stock, 91 (45.3%) had a very limited supply, and 16 (8.0%) had no stock (Table 4). A total of 187 LTCHs (93.0%) reported experiencing PPE shortages. Among these, 162 institutions (86.6%) independently purchased additional supplies during shortages.
Experience in Responding to In-house COVID-19 Outbreaks
The scale of in-house outbreaks
A total of 179 institutions, accounting for 89.1% of all responding institutions, experienced in-house outbreaks. Among them, 88 (49.2%) experienced two outbreaks, 53 (29.6%) reported three or more, and 38 (21.2%) had one outbreak. The Omicron variant outbreak was the most prevalent in-house outbreak, and involves the highest number of COVID-19 cases (n=107, 59.8%). The presence of a preparedness team, training, education, and in-house guidelines, before pandemic, was not significantly associated with the experience of an outbreak (p=0.425, p=0.948, p=0.745, and p=0.326, respectively).
Response system
The response system worked efficiently during in-house outbreaks in 71.5% of participating LTCHs. The contact system with public health centers was deemed clear, with a response rate of 95.5%, and actual communication was reported to be efficient in 72.1%.
Management of confirmed cases
During the in-house outbreaks, cohort isolation, reported by 85.5% of LTCHs, was the most commonly implemented measure for isolating confirmed cases (Table 5). Dedicated medical equipment and devices for isolated patients were reported by 75.4% of institutions, and a shortage in the use of equipment or devices was reported by 57.5%. Among the restricted-use medical equipment and devices, X-ray was the most common (n=48, 46.6%), followed by thermometers (n=47, 45.6%), blood pressure monitors (n=46, 44.7%), and blood glucose monitors (n=44, 42.7%). During the outbreak, 66.5% of patients experienced difficulties with transfers, and insufficient hospital capacity was the primary cause (n=103, 86.6%).
Close contact management
Criteria for identifying close contacts were established in 94.4% of LTCHs, and a designated person for contact identification was present in 91.6%. The most common method for isolating contacts was cohort isolation, reported by 75.4% of institutions. Difficulty with cohort isolation was reported due to the extension of isolation periods resulting from additional confirmed cases within the cohort, with complaints from 57.8%.
Supplies management
During in-house outbreaks, 78.8% (n=141) of the institutions experienced shortages of materials and 86.5% resolved these shortages by purchasing materials on their own. The majority of institutions (n=90, 50.3%) reported the cost of materials as a burden on hospital finances.
Staffing issues
During in-house outbreaks, 96.1% of the institutions experienced a shortage of staff, and 11.6% took steps to supplement staff shortages (Table 6); however, 88.3% experienced shortages in caregivers. A total of 14.0% of the institutions received national support, primarily by auxiliary staff assisting with public health measures such as fever checks (n=14, 56.0%). In 79.3% of institutions, no local government office was available to respond to staff supplementation.
Vaccine and Treatments
In total, 174 institutions (86.6%) prescribed nirmatrelvir/ritonavir as the treatment for COVID-19, 74 (36.8%) prescribed molnupiravir, and 45 (22.4%) prescribed remdesivir (Table 7). Medication shortages were reported by 25.9%, 16.2%, and 11.1% of institutions regarding nirmatrelvir/ritonavir, molnupiravir, and remdesivir, respectively.
Regarding vaccination, 99% of the institutions conducted vaccinations independently, whereas 1% delegated vaccination to the public health centers (Table 7). The majority (75.9%) found the vaccine supply procedures straightforward. Additionally, 55.2% of the participating institutions found the process for reporting side effects to be inconvenient.
DISCUSSION
This nationwide study investigated the preparedness and actual COVID-19 outbreak response of LTCHs in Korea. The findings provide insight into how structural readiness translated into operational effectiveness during a public health crisis and offer implications for policy planning in infection-vulnerable facilities.
Despite having in-house response teams before the in-house outbreak in accordance with government guidelines, over 90% of the institutions experienced large-scale outbreaks. In addition, over one-third of the institutions encountered outbreaks more than twice. Many LTCHs experienced a peak outbreak during the period of the Omicron variant, known for its high transmission rate, and when the number of confirmed cases increased domestically.17) This indicates that formal preparedness measures, although broadly adopted, did not necessarily translate to effective outbreak prevention in practice, especially under high transmission pressures such as those during the Omicron wave.17)
Infection control systems present before the pandemic—including disaster preparedness teams, internal guidelines, and training programs—were not significantly associated with outbreak occurrence. This lack of association may reflect variations in the implementation of these measures. Furthermore, the quality and intensity of training and education likely varied widely across institutions. During the pandemic, 94.5% of LTCHs reported providing COVID-19-related training to their staff, representing a substantial increase from the pre-pandemic period. However, much of this training relied on passive methods such as document distribution, with limited opportunities for interactive or scenario-based learning. These inconsistencies may have weakened the impact of education efforts on actual outbreak responsiveness.18) In the future, regular in-person training sessions and simulation-based exercises should be institutionalized to improve practical outbreak management capabilities.19) In addition, the designation of infection control personnel with the responsibility of maintaining training programs may help ensure long-term retention and institutional preparedness.
Workforce shortage emerged as the most important challenge during in-house outbreaks. A total of 96.1% of LTCHs reported staff shortages and 88.3% experienced caregiver shortages. In most cases, facilities responded using internal personnel, and only 14% received national-level staffing support. The externally deployed staff were often temporary and required time to adapt to facility-specific workflows, limiting their immediate effectiveness. These findings demonstrate the need for a formalized national system to support surge staffing during public health emergencies. In particular, the deployment of auxiliary staff for basic public health tasks—such as temperature checks or cohort movement guidance—may offer a practical short-term strategy with minimal training requirements. However, such measures should be supplemented by long-term investments in in-house staffing capacity. These include securing a sufficient regular workforce and offering flexible financial compensation for additional responsibilities during outbreaks. Establishing a proactive and coordinated staffing reserve system would significantly enhance the resilience of LTCHs against future large-scale infectious disease outbreaks.
Furthermore, material shortages were common during in-house outbreaks. Over 90% of institutions experienced shortages in PPE and basic medical devices, including thermometers, radiography machines, and pulse oximeters. Besides, facilities with initial stockpiles frequently exhausted their supplies during prolonged outbreaks. These limitations underscore the importance of maintaining regional PPE reserves and establishing reliable government-supported supply chains.20)
Isolation and patient transfer practices presented significant challenges during in-house outbreaks in LTCHs. Owing to a median of one single room per facility, most institutions implemented cohort isolation as the primary strategy for managing confirmed cases. However, when additional infections occurred within the cohort, isolation periods were extended, often resulting in care disruptions and logistical burden on facilities. More than half of the institutions reported difficulties in maintaining isolation due to continuous case occurrence and space limitations. Besides, despite clinical need, transferring confirmed cases was often delayed due to insufficient hospital capacity and poor coordination mechanisms. According to the survey, 66.5% of institutions experienced transfer delays, with 86.6% citing lack of available beds as the primary reason. These delays were particularly evident during the Omicron surge, when hospitals were quickly overwhelmed and LTCHs were required to independently manage COVID-19 patients.17) Although this shift demonstrated institutional adaptability, it also underscored the structural limitations of the long-term care system in responding to high-burden outbreaks. Therefore, in the future, it is essential to develop regionally coordinated systems for patient triage and transfer. Establishing standardized criteria for escalation of care and allocating emergency reserve beds for LTCH patients with clinical deterioration can help mitigate delays. In addition, strengthening collaboration between LTCHs, acute care hospitals, and public health authorities is crucial to ensuring timely care transitions in future public health emergencies.
In Korea, starting from March 2020, LTCHs were provided with infection prevention management fees of 1,180 Korean won per day per inpatient through a temporary fee system. However, before this, LTCHs did not receive infection prevention management fees. Besides, infection control fees were introduced in LTCHs in Korea in July 2023, although at a lower level than those for acute care settings.10) Given the considerable infection control efforts required in LTCHs—particularly during large-scale outbreaks—this reimbursement gap poses a structural barrier to preparedness. Future reforms must move beyond temporary, crisis-based compensation schemes and establish a sustainable fee system that reflects the operational demands of infection control in long-term care settings. In addition, the system should consider additional costs incurred during emerging infectious disease outbreaks, including staffing, equipment, and isolation infrastructure.
This study had some limitations. First, the responding institutions may have been relatively well prepared or responsive to COVID-19, leading to potential selection bias. However, the survey responses were obtained from more than 14% of all LTCHs. Second, there is a potential for recall bias, as the survey relied on the retrospective reporting of experiences during the outbreak. Third, this study did not include internal workforce-related indicators such as staff burnout, turnover, or changes in infection control awareness among healthcare workers before and after the pandemic. These factors may have affected outbreak management capacity and staff responsiveness during crises. Future follow-up surveys should incorporate these dimensions to provide a more comprehensive understanding of LTCH preparedness and support workforce resilience planning in policy development. Nevertheless, this study is the first to investigate the preparedness for and actual response to the COVID-19 outbreak in domestic LTCHs. Given that the situation may change over time, regular surveys are necessary to assess the status at specific points in time.
In conclusion, although most LTCHs had established response systems during the COVID-19 pandemic, most LTCHs experienced in-house outbreaks during the COVID-19 pandemic. These institutions commonly faced challenges such as staffing shortages and supply constraints. To ensure better preparedness for future outbreaks, infection control systems should be regularly evaluated and maintained through ongoing training, even during non-outbreak periods.
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