Dr Kevin McCarroll
Medical Matters
The death toll from Covid-19 in Ireland has exceeded 1,000 with almost two months passing since the first reported mortality. The number of deaths is more than triple that of even a bad flu season and would be manifold greater if not for restrictions and social distancing.
While huge focus was placed by the government on the preparedness of our acute hospitals to deal with Covid-19, the same can’t be said for nursing homes where a real crisis now exists. For an illness which has its worst effects on frail, older adults with underlying medical conditions, the poignant question of how or why more wasn’t done has taken centre stage. Indeed, about 50% of all deaths due to Covid-19 have been in nursing homes yet the allocation of resources to deal with the issues they face were disproportionately small and the overall response slow. There were also similar failings in other countries including France, Spain, Belgium, Canada and parts of the US where between 40-60% of all Covid-19 deaths were in care homes.
In fact in Ireland, Covid-19 has affected about 40% of all long-term care facilities in what has amounted to over 200 clusters of cases. Indeed, the gravity of the situation was reflected by the HSE designation of about 70 nursing homes as ‘status red’ indicating a major threat to provision of adequate care.
The absence of a coherent strategy early on to address the basic issues in nursing homes is the key factor. Firstly, it was crucial that residents were tested and diagnosed promptly with Covid-19 allowing for appropriate isolation and contact tracing. Lack of access to testing, delays in getting results and shortage of PPE severely hampered containment measures that could have reduced contagion to other residents and staff. Nursing homes (public and private) were effectively de-prioritised and left to compete with hospitals for PPE and resources, in some cases trying to source them from private providers.
Indeed, when staff contracted Covid-19 or had to avoid work due to contact isolation, a crisis of manpower arose where there was simply too few on the ground to provide basic care to residents. There was also likely confusion and fear among staff as to what constituted a close contact with Covid-19 and whether they should continue to work. So bad were staff shortages, that some nursing homes felt they had no choice but to consider sending their residents to hospital prompting a scramble by the HSE to deploy hospital staff or contract agency carers for those facilities.
There are of course a number of factors that helped to compound the problem. For example, older adults often do not present with typical symptoms such as fever, making early diagnosis more difficult. In fact, as we learned many patients who have no symptoms initially showed significant levels of virus yet can go on to develop severe disease. For this reason, there is now more widespread testing in nursing homes.
Trying to isolate confused patients with Covid-19 who tend to wander is also clearly a big challenge. Indeed, some units, particularly public ones, operate in buildings which are too old for modern day purpose meaning the separation of Covid-19 positive patients into other areas may not have been viable. Unfortunately, it is also not uncommon for residents in nursing homes (both public and private) to share rooms making the spread of the virus all the more likely.
Another important issue relates to the care of nursing home residents with Covid-19. Many older people in care homes will survive coronavirus but timely access to the appropriate medical input and guidance on palliative care may have been challenging for some facilities. Indeed, most patients can be managed appropriately in what is effectively their ‘own homes’ rather than transfer to hospital. However, many nursing homes do not have oxygen on site which some patients would have required.
The Covid-19 pandemic has also brought into discussion the model of healthcare delivery in nursing homes in Ireland. There are about 29,000 older adults in long term care facilities in the country. About one third of these are run by the HSE, with most of the remainder managed privately and a small proportion run by the voluntary sector. Public units have medical officers responsible for the oversight of the medical needs of residents. However, elsewhere this is provided by GPs on an individual patient basis. Despite the great effort of many GPs, this model of care can lead to inconsistencies in coverage with regional variations and varied levels of geriatric expertise. Many public nursing homes are also still awaiting improvements in their physical infrastructure on the recommendations of HIQA. Finally, Covid-19 has heightened our awareness of the importance of adequate infection control, yet in this day and age we need to consider why it is, that many older people in long term care still share bedrooms with others.
Dr Kevin McCarroll is a Consultant Physician in Geriatric Medicine, St James’s Hospital, Dublin.