By Maria Pierce, Independent Research and Adjunct Faculty Member, Dublin City University
3rd April 2020
This is a short preliminary report on nursing homes and Covid-19 providing an overview of key events and measures introduced at a national level and responses by key relevant stakeholders since the first case of Covid-19 was confirmed at the end of February 2020, and will be updated in due course.
Nursing homes in Ireland
In Ireland, there is a mixture of nursing homes operated by the private and voluntary sector, and those operated by the public sector. All nursing homes in Ireland must be registered with the Health Information and Quality Authority (HIQA), the statutory body responsible for monitoring the safety and quality of care in nursing homes in Ireland. As of Dec 2018, there were 581 nursing homes registered with HIQA (https://www.hiqa.ie/areas-we-work/older-peoples-services). More than three-quarters of nursing homes in Ireland are private and voluntary nursing homes. According to Nursing Homes Ireland (NHI), the national representative body for private and voluntary nursing homes in Ireland, there are over 460 private and voluntary nursing homes providing care to over 25,000 people (https://nhi.ie/), There are approximately 5,000 people resident in public nursing homes.
A significant proportion of residents in nursing homes are people with dementia; it is estimated that there are between 15,000 and 20,000 with dementia are residing in nursing homes in Ireland. There are also close to 1,500 younger people with disabilities residing in nursing homes in Ireland.
The National Public Health Emergency Team (NPHET) was established on 27.01.2020 in the Department of Health, chaired by the Chief Medical Officer, to oversee and provide national direction, guidance, support and expert advice on the development and implementation of a strategy to contain COVID-19 in Ireland. HIQA is the authority with responsibility for inspecting nursing homes in Ireland, and is represented on NPHET. While not represented on the NPHET, NHI reports that it is in continuous contact with the Department of Health, NPHET, the Health Service Executive (HSE) and all relevant health authorities during the Covid-19 crisis
Restrictions on visiting to nursing homes
The first case of Covid-19 in Ireland was announced on 29.02.2020, and NHI began to offer advice to private and voluntary nursing homes soon after. Less than a week after the first confirmed case of Covid-19, NHI announced on 06.03.2020 that visiting restrictions were in place across private and voluntary nursing homes in Ireland with a view to protecting residents. This was a number of days before the government’s announcement to close schools and universities. NHI came in for some criticism for taking this decision unilaterally. The Department of Health’s view was that a blanket ban on visiting nursing homes at this time was unnecessary. At the time, HIQA urged service providers, and staff to follow all public health advice from the HSE as the primary source of information and guidance on COVID-19.
One of the most immediate concerns following the announcement of visiting restrictions was the impact on residents of social isolation and separation from their families. NHI carried out a survey of nursing homes to gather information on activities used to mitigate the negative impact on residents and safeguard their well-being. Following this a list was compiled of the types of activities that staff could offer to nursing homes residents and ways of ensuring residents could remain in contact with their families. Comfort Words, a national initiative encouraging children to reach out to older people in nursing homes during Covid-19 by writing to them was launched by NHI on 23.03.2020.
Residential respite in nursing homes has also been cancelled during Covid-19.
Early response from HIQA
Nursing homes are required to notify the Chief Inspector of Social Services in HIQA of any outbreak of COVID-19 as a notifiable disease, and soon after the first case of COVID-19 in Ireland, HIQA reminded nursing homes of this requirement. HIQA initially continued to carry out inspections in nursing homes but with changes to its inspection process. This decision was later changed with all routine inspections of nursing homes cancelled until further notice on 12.03.2020.
National Action Plan – Maintaining capacity in nursing homes and transfer from hospital to nursing homes
In response to the arrival of COVID-19 to Ireland, the Irish Government prepared a National Action Plan issued on the 16.03.2020. One of its cross-cutting action areas is Maintaining critical and ongoing services for essential patient care. This includes long-term care services for older people and other groups such as people with disabilities. It stated that capacity in long-stay settings is to be maintained, but specific details are not included. The Action Plan has a specific action on Caring for our people who are ‘At Risk’ or vulnerable.
Another priority action area is Caring for people in Acute Services, which includes ‘Maximising patient flow through our hospitals and making efficient use of existing resources’. Private nursing homes were identified as playing a key role, with nursing homes identified as an existing resource, which could potentially be used to facilitate the early discharge of patients from hospital or patients delayed in hospitals. Guidance on Transfer of Hospitalised Patients from an Acute Hospital to a Residential Care Facility in the Context of Covid-19 was later published by the HSE on 19.03.2020, which was circulated by HIQA on the request of the HSE. It included guidance on both transfer from acute hospitals to residential care facilities and from residential care facilities to acute hospitals.
Staff recruitment campaigns
On the 17.03.2020, the HSE launched a recruitment campaign, Be on Call for Ireland, asking all healthcare professionals from all disciplines who are not already working in the public health service to register to be on call for Ireland. On the same day, NHI also launched a recruitment campaign for private and voluntary nursing homes. There were concerns that an unintended consequence of the HSE’s Be on Call for Ireland campaign may divert staff from the private and voluntary nursing home sector to the public sector, at a time when the staff needs in private and voluntary nursing homes will increase.
Review of contingency plans in nursing homes
On 23.03.2020, HIQA wrote to nursing homes asking them to review the contingency plans they have in place to manage the COVID-19 outbreak, which would involve, for example, taking account of staffing considerations, governance and management arrangements, and infection prevention and control procedures. Providers were also advised to refer to current HSE (www.hse.ie) and Government (www.gov.ie) guidance and advice when updating their plans.
Assessment and testing
From 26.03.2020, the case definition for Covid-19 tests changed in Ireland, and people in certain groups were prioritised for testing. Staff and residents of nursing homes were included as a priority group for testing. However, there have been ongoing delays in testing in Ireland due to global shortage of testing kits and chemical reagents needed to carry out the tests.
Guidance on the Assessment and testing pathway for symptomatic resident in Residential facilities (RF) and Long Term Care Facilities (LTCF) was issued on 27.03.2020 by the HSE.
Rising numbers of Covid-19 in nursing homes
On 27.03.2020, Ireland moved to a more intensive phase of restrictive actions and the Irish government announced additional public health measures urging everyone to stay at home wherever possible. NHI, while directing nursing homes to the HSE and HPSC, as the primary sites for information on covid-19, was continually briefing nursing homes as to the precautions that nursing homes should take and planning in relation to Covid-19. Despite this advice, the visiting restrictions to nursing homes, cancellation of residential respite, and issuing of public health guidance and more restrictive measures, there have been outbreaks of Covid-19 in nursing homes. Data from the Health Protection and Surveillance Centre (HPSC) shows that on 28.03.2020 there were 2,475 confirmed cases of Covid-22 in Ireland. A total of 23 clusters/outbreaks of coronavirus had been reported in nursing homes across Ireland, all of which were in the east or northeast of the country, representing 20% of all clusters. These figures have caused great concern, likely to be heightened by reports from Spain of abandonments and deaths of residents in nursing homes in the Irish media. There are increased pressures on staffing at some nursing homes as a result of Covid-19.
People over the age of 70 and vulnerable people with certain medical conditions have been advised by the government that they must stay indoors in what is referred to as ‘cocooning’ and guidance on cocooning has been issued ‘Cocooning’ also applies to people aged 70 years and over in long-stay residential settings. Care providers in these settings are instructed to ’carefully discuss this advice with the families, carers and specialist doctors caring for such persons to ensure this guidance is strictly adhered to’. However, ‘cocooning’ presents many issues and challenges for residents in nursing homes, their families and staff in nursing homes, and there are particular challenges for people with dementia. However, what ‘cocooning’ means in practice in nursing homes and how the issues and challenges emerging can be addressed is not covered in this guidance document.
Prioritisation of nursing homes in emergency planning
Concerns have been expressed by the NHI that the nursing home sector, rather than being prioritised in public health emergency planning for Covid-19, was being ignored and left unsupported. In response to these concerns and the rising clusters of Covid-19 in nursing homes, the NHI sought an urgent meeting with the Minister of Health to discuss the nursing home sector and related issues including specific guidance for nursing homes, staff shortages in nursing homes, issues in relation to the procurement of PPE, and called on the government to regard private and voluntary nursing homes as part of the national health infrastructure during the crisis. A meeting between NHI, representatives working within nursing homes, the Minister for Health and Secretary General of the Department of Health took place on the 30.03.2020. Challenges discussed included timely access to PPE and oxygen, priority coronavirus testing for staff working in nursing homes, the need for support around staffing, and additional funding of the sector.
This coincided with the issuing of an updated version of Preliminary Covid-19 Infection Outbreak and Control Guidance including Outbreak Control in Residential Care Facilities and other similar units by the HSE.
The issue of nursing homes was examined by the NPHET in its meeting on 31.03.2020, following a request from the Minister of Health, and efforts to tackle outbreaks in nursing homes are to be ramped up to interrupt the spread of COVID-19 in nursing homes.
A suite of measures for nursing homes has since been introduced aimed at keeping residents in long-stay residential settings as far as possible, whilst preventing the spread of the virus within nursing homes. The NPHET recommended that HIQA conduct a risk assessment to see which nursing homes need extra support to deal with COVID-19, with a view to ensuring the facilities have adequate PPE, oxygen and staff, including replacement staff, and helping make these available if needed. National and regional outbreak teams have been set up to oversee long-term residential care settings and to tackle specific clusters of COVID-19 in nursing homes and prevent further spread within the nursing home. It also recommended more personal protection equipment (PPE) for staff working in nursing homes, and the supply of PPE to health care workers is being prioritised to areas where it is most needed. Health checks for nursing home staff have also been recommended. Training and preparedness plans for infection outbreaks are other measures.
In an attempt to break the chain of transmission of the disease, nursing homes residents who contract COVID-19 are to be cared for in nursing homes, unless there is a clinical or other advantage to them being transferred to another setting.
To minimise the risk of onward transmission of the virus, restrictions may be introduced to discourage nursing home staff, particularly locum staff, from working in different locations. Consideration is also being given to providing separate accommodation for some nursing home staff.
There are emerging concerns about staff in nursing homes who are working between different nursing homes, and the increased risk this poses to both nursing home staff and residents.
The Home and Care Community Ireland (HCCI), the national membership organisation for home care providers in Ireland, has agreed at the request of the government/HSE to measures aimed at the voluntary redeployment of some home care workers to support frontline staff in nursing homes. Home care workers are to be redeployed from caring for people at home with low levels of care needs, and where family members can step in to provide care. Between 700 and 1,000 home care workers are expected to be redeployed to work in nursing homes under the agreement. This measure has major implications for home care, for people in receipt of home care, home care workers, and family carers.
 Pierce, M. and Pierse, T. (2017) ‘Prevalence of dementia’ in Cahill, S. and Pierce, M. (eds.) Developing and Implementing Dementia Policy in Ireland, Galway: National University of Ireland Galway.
 Pierce, M., Duffy, M. and Kilcullen, S. (2018) The Situation of Younger People with Disabilities living in Nursing Homes in Ireland, Dublin: Disability Federation of Ireland.
Suggested citation: Pierce M (2020) A short preliminary report on nursing homes and Covid-19: Measures introduced in Ireland. Article in LTCcovid.org, International Long-Term Care Policy Network, CPEC-LSE. Available at https://ltccovid.org/2020/04/03/a-short-preliminary-report-on-nursing-homes-and-covid-19-measures-introduced-in-ireland/