By Michaël R. Laurent, MD PhD, geriatrician, Imelda Hospital Bonheiden
5th April, 2020
Residents of long-term care facilities (LTCFs) already account for one-third of deaths due to COVID-19 in Belgium. Despite a lockdown with no visitors allowed for weeks, it is estimated that 90% of care homes currently face outbreaks (see links to news report below for sources). This post summarizes which strategies failed to control the spread SARS-CoV-2.
Internal social distancing
The first mistake was to think that banning all visitors would keep the virus out. Nursing home residents need care from staff, who inevitably might transmit COVID-19.
Unfortunately, the social distancing measures that were so successful in flattening the curve in the rest of society, were believed not to be necessary within LTCFs. Residents could still visit each other, and group activities continued.
In one facility, five friends kept regular contact during quarantine. While they were isolated from the outside world, they could continue to have lunch in the cafeteria every day. Only after their death made the news, was it realized that social distancing within LTCFs was overlooked.
Lack of PPE
The second problem is the obvious lack of personal protective equipment (PPE). For weeks, the government could not provide any PPE. Hospitals generally had sufficient stockpiles of PPE, and they were successful in securing additional orders. They bought raw materials and called on their volunteers to stitch masks.
However, this left most LTCFs (as well as primary care practitioners) empty-handed. They quickly ran out of masks and never had aprons or protective goggles, and couldn’t order more. Sadly but understandably, hospitals generally refused to provide supplies to LTCFs, fearing that they would run out themselves.
Not only does this leave the most vulnerable population of frail, older adults in LTCFs exposed. The same applies to nurses, nursing assistants and other healthcare workers. Even when available, training and expertise in PPE use was completely lacking. One of the youngest victims yet was a 30-year-old nursing home aid. Here name was Isaura.
Weak policies
Most LTCFs strictly adhered to governmental guidelines. However, these guidelines didn’t recommend the same level of PPE as was used in hospitals -probably because there wasn’t any PPE available!
Instead, guidelines focused on what not to do. Which patients NOT to refer to hospital anymore. Which older adults no longer should be referred to intensive care. Directives for what LTCFs should do however, were flimsy. Probably out of necessity, because they were given low priority. As a consequences, primary care physicians responsible for medical coordination turned to Facebook groups to find answers and advise.
Lessons learned
The sad mortality statistic, with overrepresentation of not only older adults but even more so residents of LTCFs, may even be underestimated. While the incidence curve is already flattening in our country, hospitals are experiencing a second wave of admissions from LTCFs. Diagnostic testing in still severely restricted in Belgian care homes. Likely, more deaths will follow.
To summarize, the following actions have been implemented, but probably would have been more successful if implemented early on:
- Keep everyone in their rooms, or separated from each other
- Prevent residents from getting infection from staff, by implementing universal masking
- LTCFs should get top priority, to prevent healthcare system overload. Policymakers should seriously consider sending them PPE and expertise as soon as possible.
Links to news articles used for some the information provided in this article (in Dutch):
https://www.tijd.be/dossiers/coronavirus/rusthuizen-moeten-onbeschermd-corona-te-lijf/10217057.html
Suggested citation: Laurent M.R. (2020) Report: Lessons from failed COVID-19 control in Belgian nursing homes. Article in LTCcovid.org, International Long-Term Care Policy Network, CPEC-LSE. Available at https://ltccovid.org/2020/04/06/report-lessons-from-failed-covid-19-control-in-belgian-nursing-homes/