3rd April, 2020
There is growing evidence from Spain, Italy and the United States that people living in care homes are particularly vulnerable to severe COVID-19 infections and that they are experiencing high rates of mortality as a result. There are also numerous examples from those countries of care homes becoming unviable as sometimes as much as half of all staff members need to self-isolate.
This post providers a quick overview of key measures that have been adopted internationally to mitigate the impact of COVID-19 on the population who live in care homes and the staff who support them and considers the viability of implementing them in, for example, the United Kingdom, where there are enormous constraints in terms of testing capacity, availability of personal protection equipment (PPE), existing care workforce recruitment problems and relatively low numbers of critical care beds and ventilators.
This post is intending to start a conversation and comments and additional contributions on this topic are very welcome.
Measures to prevent infection: testing and isolating suspected (vs. symptomatic) cases
Countries that, at this early stage, appear to have had relative success in preventing COVID-19 entering care homes, such as Singapore and South Korea, have very strict processes to isolate and test all care home residents and staff who not only have symptoms, but who may had contact with people who have COVID-19.
At least in the UK, timely and systematic testing of care home residents and staff does not appear to be likely to happen quickly, as testing capacity is still very limited and the stated priorities are to test health service staff and people in hospitals.
This means that decisions about who to isolate in care homes will need to be based on assumptions about who is likely to have the disease. Current guidelines in the UK only require the isolation of residents and staff who are symptomatic. Similar guidelines were in place in Spain until the 24th of March. In contrast, the World Health Organization’s guidelines require isolation of residents and staff who are suspected to have COVID-19.
Following the large number of deaths in a very short amount of time (and many reports of homes that had become overwhelmed), Spain updated its guidance on the 24th March and this now focuses on the isolation of all possible, probable and confirmed cases among residents and staff. Possible and probable cases are defined as those having potentially been in close contact with someone with COVID-19.
There is also new evidence that supports the isolation of asymptomatic residents and staff. The Centers for Disease Control and Prevention (US) tested 76 (93%) residents in a skilled nursing facility where there was an outbreak of COVID-19. They found that 23 (30%) residents tested positive. Of these, 10 (43%) had symptoms on the date of the test. The remaining 13 (57%) were asymptomatic. 7 days after testing, 10 out of 13 of the asymptomatic residents had developed symptoms. This suggests that symptom-based screening in long-term care facilities could fail to identify approximately half of residents with COVID-19.
However, isolating a large number of residents is challenging in a care home setting, there tend to be space limitations, particularly as large proportions of them are likely to have dementia and may find it very difficult or impossible to stay in their rooms. Also, particularly where PPE is not readily available, staff are likely to spread the virus if they provide care to more than one resident.
Other additional measures to prevent or limit the spread of COVID-19 in care homes:
- Restrictions of visitors, this seems to have been implemented in many countries, sometimes alongside measures to increase access to video and telephone contact with family members and friends. In most countries there are exceptions that allow visitors for people who are at the end of life.
- Isolation (or testing) of all new admissions, this may be in the care home itself if there is enough capacity, or as in South Korea, could happen in a dedicated quarantine facility (which could be a hotel, university accommodation…).
- Care home “lockdowns”, there are growing examples of staff self-isolating with residents (e.g. South Korea, Spain, UK, New Zealand…). The examples so far seem to involve two week rotas between two teams. In South Korea staff are compensated financially. In the UK, Spain and New Zealand the examples so far seem to have been at the initiative of the care home staff themselves.
- Avoid staff working across more than one home where possible
- Ensuring all staff are trained in processes to minimize risk of infection (WHO guidance)
- Where possible, encourage residents to stay in their rooms (Hong Kong, WHO guidance)
- Consider whether some residents could be cared for back in the community (provided there is adequate support) or in hotels or other facilities in order to make it easier to isolate within the home if needed later on, also prepare capacity for hospital discharges.
- Establish notification system, so the public health system has early notice of outbreaks in care homes, this should generate alert that the home may require rapid response teams if staff become sick (Spain)
- Ensure affected care homes have priority access to funeral services to remove deceased residents (Spain)