8th April 2020
The current COVID-19 guidance for care homes in the UK was issued on the 2nd of April: (https://www.gov.uk/government/publications/coronavirus-covid-19-admission-and-care-of-people-in-care-homes. This note seeks to highlight two key aspects of this guidance that are of concern given early international evidence on the impact of COVID-19 on residents and staff in care homes. The first issue concerns isolation guidance, the second concerns capacity constraints in care homes.
- Isolation of symptomatic residents and staff
In both UK guidance documents, the advice is to isolate both residents and staff who have symptoms of COVID-19. However, early evidence new evidence suggests that this will not be effective in preventing the spread of infection within care homes.
There is growing evidence of asymptomatic transmission of COVID-19, as for example a recently published study of COVID-19 clusters in Singapore (Wei et al, 2020). There is also a study carried out by the Centers for Disease Control and Prevention (United States), which 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 study suggests that symptom-based screening in long-term care facilities could fail to identify approximately half of residents with COVID-19 (Kimball et al, 2020).
International guidance and experience of other countries:
The World Health Organization’s guidelines require isolation of residents and staff who are suspected to have COVID-19. While it is not entirely clear how “suspected is defined, this could cover both having symptoms and having been in contact with someone with the disease.
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 (Tan and Seetharaman, 2020 and Lyu Jy, 2020).
Spain, where there have been large numbers of deaths in care homes, initially had similar guidance as the current one in the UK, based on only isolating residents and staff with symptoms. However, this was changed on the 24th of March following large numbers of deaths in care homes and also many cases of homes where so many staff were absent that care provision was no longer viable, resulting in the army and fire service (or even local politicians) having to step in. The new guidance in Spain now requires 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 (Davey, 2020).
2. Care home capacity and isolation capabilities
Isolating a large proportion of residents is challenging in a care home setting due to space limitations (Barnett and Grabowski, 2020) and the fact that a large proportion of residents are likely to have dementia and may find it very difficult or impossible to stay confined in their rooms all day. Also, particularly where PPE is scarce, there is a high risk that staff will spread infection if they provide care to more than one resident.
While in the UK care homes are expected to accept people who are discharged from hospital with COVID-19, in a few of the countries that are ahead in terms of the infection rates, such as South Korea, Singapore (and some regions of Spain and states in the USA) the policy is to discharge COVID-19 patients into quarantine centres instead, where they are cared for by primary health care services. They are only admitted into care homes after this quarantine period has ended. The quarantine centres are usually hotels or accommodation that has become empty due to the social distancing measures.
Given the high vulnerability of care homes to COVID-19, rather than seeking to use them to capacity, countries such as Spain are now looking to discharge residents who are not positive with COVID-19 back into the community with additional home care support, or in some cases to hotels where care is provided and where it may be easier to isolate them if necessary. Having lower number of residents is seen as way to lower the risk of the care home become overwhelmed.
Barnett ML and Grabowski DC (2020) Nursing homes are Ground Zero for COVID-19 pandemic. JAMA Health Forum, March 2020.
Davey V (2020) Report: The COVID-19 crisis in care homes in Spain, recipe for a perfect storm. Article in LTCcovid.org, International Long-Term Care Policy Network, CPEC-LSE. Available at https://ltccovid.org/2020/03/30/report-the-covid19-crisis-in-care-homes-in-spain-recipe-for-a-perfect-storm/
Kimball A, Hatfield KM, Arons M, et al. Asymptomatic and Presymptomatic SARS-CoV-2 Infections in Residents of a Long-Term Care Skilled Nursing Facility — King County, Washington, March 2020. MMWR Morb Mortal Wkly Rep. ePub: 27 March 2020. DOI: http://dx.doi.org/10.15585/mmwr.mm6913e1external icon.
Lyu Jy (2020) Report: The South Korean approach to managing COVID-19 outbreaks in residential care settings and to maintaining community-based care services. Article in LTCcovid.org, International Long-Term Care Policy Network, CPEC-LSE. https://ltccovid.org/2020/03/26/report-the-south-korean-approach-to-managing-covid-19-outbreaks-in-residential-care-settings-and-to-maintaining-community-based-care-services/
Tan, L.F. and Seetharaman, S. (2020), Preventing the Spread of COVID?19 to Nursing Homes: Experience from a Singapore Geriatric Centre. J Am Geriatr Soc. doi:10.1111/jgs.16447
Wei WE, Li Z, Chiew CJ, Yong SE, Toh MP, Lee VJ. Presymptomatic Transmission of SARS-CoV-2 – Singapore, January 23-March 16, 2020. MMWR Morb Mortal Wkly Rep. ePub: 1 April 2020. DOI: http://dx.doi.org/10.15585/mmwr.mm6914e1