Lee-Fay Low (University of Sydney)

12^th May 2020

Key points:

• Many governments and care homes have instituted complete lockdowns of care homes banning all visitors. Discussions are starting to occur on the conditions under which visitors will re-enter facilities.
• Once COVID-19 enters a care home, it is difficult to prevent spread and mortality is high
• Despite lockdowns, COVID-19 care home outbreaks are occurring. Hence additional risk reduction strategies need to be put in place.
• Lockdowns are probably resulting in mental and physical deterioration of residents.
• Easing of complete visitor bans should consider regional prevalence of COVID-19 and may include strategies to limit the number of visitors and visits, screening of visitors, and additional infection control.
• Even when some visitors are allowed, additional measures and funding are required to support resident wellbeing during spatial distancing restrictions. Increased staffing, technology and implementing new practices are required to support social, cognitive and physical activity.

Introduction

Many governments worldwide (e.g. China, Italy, Netherlands) have instituted complete lockdowns of care homes restricting entry to staff and other essential workers [1]. Other governments such as Australia introduced restrictions on visitors [1].

Over the last week in Europe and across America stay at home restrictions have been eased, driven by the need to re-open the economy, and public sentiment putting on political pressure [2, 3].

Concurrent with lifting of community lockdowns have been policy discussions on easing care home lockdowns. Draft American guidelines by the Centres for Medicare and Medicaide Services on opening care homes have concerned industry and infection-control experts about fatalities if facilities reopen too fast [4]. In Oklahoma a state legislator called for visitors to be allowed in care homes with risk reduction measures, with the aged care industry responding against this [5]. In Australia the Prime Minster warned care homes with full lockdowns to allow visitors [6], providers resisted before some homes opened to visitors [7]. The debate in Australia led to consumer advocacy and aged care providers collaborating on an industry code for visitor access to encourage nationally consistent practice [8]. This code has been promoted by the Australian Department of Health, it suggests flexibility for some circumstances such as end of life, when there was a previous pattern of very regular visits to help with personal care or provide emotional support and families who travel extensive distances to visit.

This paper presents a summary of the rationale behind lockdowns, suggestions for reducing risk of COVID-19 outbreaks beyond lockdowns, the negative impacts of lockdowns on residents, and discusses conditions to be considered during easing of lockdowns.

The rationale behind lockdowns: It is challenging to prevent COVID-19 outbreaks in care homes, and outbreaks have fatal results

UK government data suggest that between 21% and 38% of care homes in government regions have COVID-19 cases [9]. Data compiled by an American newspaper suggest that one in 10 American skilled nursing facilities have COVID-19 cases [10].

The spread of COVID-19 in care homes appears to be high, possibly because of asymptomatic transmission before an outbreak is detected. Twenty-three days after detection of the first case in a skilled nursing facility in Washington, USA, 58 of 89 residents (64%) tested positive for COVID-19. Further, among 76 residents who participated in point-prevalence surveys 10 and 17 days after the first case was identified, 48 (63%) tested positive of whom 27 (56%) were asymptomatic at the time of testing [11]. In a skilled nursing care facility in King County, USA COVID-19 was identified in 101 residents of 118 tested (86%), 50 health care workers, and 15 visitors [12].

The characteristics of care home residents mean that they are particularly vulnerable when infected with COVID-19. Estimates based on Chinese data suggest that COVID-19 related mortality rises with age, with highest rates of 7.8% in people aged over 80 in comparison with an overall death rate of 0.66% [13]. Analysis of publicly available US county data shows that risk factors for COVID-19 mortality include factors common in care home residents such as decreased health, diabetes, coronary heart disease and physical inactivity [14].

Available data show higher case fatality in care home residents than in the community. Based on publicly available national data case fatality in Canadian care homes is estimated at 25% [15] Twenty days after identification of the first COVID-19 in a skilled nursing facility in Kings County the case mortality rate was 33.7% for residents, 6.2% for visitors and 0% for staff [2]. In an Australian 102-bed care home, official government reports show that 29 days after identification of COVID-19 in a staff member, 37 residents and 32 staff tested positive with 43% resident case fatality and an additional resident passing away after recovering from COVID-19 [16, 17]. These fatality rates are substantially higher than national case mortality rates of 5.72% for the USA and 1.31% for Australia [18].

Analysis of officially released data from Belgium, Canada, Denmark, France, Germany, Hungary, Ireland, Israel and Norway shows that COVID-related deaths among care home residents ranges from 19% to 62% of all COVID-19 deaths [19]. Care home mortality was higher in countries with greater overall infection rates.

The public, families and residents seem to be supportive care home lockdowns

Potentially biased data suggest that the public and residents are supportive of care home lockdowns in Australia and elsewhere. An aged care peak body sponsored poll of 1,093 members of the Australian public found that 69% supported “aged care homes preventing visitors (with exemptions for compassionate reasons and video calls) to reduce the risk to older people of being exposed to Covid-19” [20]. A care home chain survey of their residents reported that 80% of them agreed with visitor restrictions, this was accompanied with videos of residents expressing these views [21].

Lockdowns do not guarantee against outbreak, more needs to be done to reduce risk

The large number of care home COVID-19 outbreaks in some countries suggest that visitor bans are insufficient in preventing outbreaks and that additional risk reduction measures are needed.

Chinese data suggest that 78% of community COVID-19 case (130 of 166 tested) are asymptomatic [22] and data from both China and Singapore has shown that asymptomatic COVID-19 transmission occurs [23, 24].  In Belgian care homes 72% of staff who tested positive for COVID-19 were asymptomatic at time of testing [25].

Actions to prevent transmission through staff might include:

• Ensuring staff have not been in contact with people who have tested positive for COVID-19
• Having good contact tracing in the community so that potentially infected staff can self-quarantine
• Temperature checks before every shift
• Screening staff for COVID-19 symptoms before every shift
• Increased infection control measures including use of masks by staff
• Education for staff on minimising risk of contracting COVID-19 outside of work
• Regular testing of aged care staff and residents in COVID-19 geographical hotspots such in New York [26]
• Dividing the facility into small working units where the same small group of staff work with the same small group of residents
• Ensuring staff have access to sick pay so they do not feel pressured to work while unwell
• Providing on-site or near-by accommodation to staff in geographical hotspots to protect both residents and the families of staff

Facilities would need to be adequately resourced in terms of funding and equipment to implement these measures.  

In Singapore care homes referred all residents with fever and respiratory symptoms to hospital where they were isolated and tested for COVID-19, this prevented care home transmissions [27]. Transfer of suspected potential COVID-19 cases to hospital, and group quarantine of selected facilities also meant that have been no COVID-19 care home deaths in South Korea [28]. Hospitalising residents with symptoms may be too resource-intensive a strategy in countries with stretched healthcare systems.

Lockdowns have negative consequences on residents

Lockdowns are resulting in mental and physical deterioration of residents.

Reports from China and Italy have described some of the negative impacts of increased social isolation on residents during care home lockdowns [29, 30]. Residents in dementia were described as suffering from delirium, refusing to eat or get out of bed [24, 25]. Without family visits, there will be less visibility, and immediate accountability as to the quality of residential care [31].

Family visitors play a large role in the wellbeing and care of care home residents, providing not just love and company, but often help residents with feeding, grooming and recreation [32, 33]. They also play a role in advocacy and timely detection of changes in health of residents [34].

It is likely that without visitors and excursions, and with spatial distancing reducing group activities residents will feel even more lonely and bored. These feelings might be expressed through aggressive or agitated behaviour or social withdrawal and apathy [35], which might be treated with psychotropics if staff are not able to manage. Limited opportunities for physical activity may also result in loss of muscle mass and strength, this deconditioning occurs within a few days of hospitalisation in frail older people [36].  Limited opportunities for cognitive stimulation and activity may result in greater cognitive decline in people with dementia [37].

Reports from China and Italy also described negative impact of lockdowns on staff and family most notably increased stress and anxiety [29, 30].

A staged, data driven, risk-mitigated approach to easing care home lockdowns

Visitors provide love and feelings of belonging to residents. It is a priority to ease restrictions to allow visitors once judged safe.

Governments have been using the R or reproduction number for COVID-19 in their region to guide staged easing of social distancing restrictions. The R number is a measure of viral spread representing the average number of people who are infected by each case [38]. Governments have been aiming for an R number of less than one as this suggests that infection has slowed so that eventually there will be no new cases. The R number depends on the extent of testing in the community, the R number will be lower if only symptomatic people are tested [39]. A scoping review suggested that between 5% and 80% of COVID-19 positive cases in the community are asymptomatic, and population based data including random screening in Iceland found that 43% of positive cases were asymptomatic [40, 41].

The R number is independent of the prevalence of COVID-19 in the community. Therefore, stay at home restrictions may be lifted in regions where there are many undetected cases in the community. Staged easing of care home restrictions in parallel with community social distancing restrictions may increase the risk of care home outbreaks as visitors from the community have greater exposure through increased social contact. Instead of basing decisions about staged easing of visitor bans in care homes on the R number, the current prevalence of known COVID-19 cases in the region might be a better measure of risk, though prevalence will also be biased by testing criteria. As point of reference, there are currently 2.66 COVID-19 cases per 100,000 in Australia and visitors are re-entering many care homes [42].

The first stage of easing care home lockdowns is allowing visitors with risk reduction measures which may include:

Limits on the number of visitors and visits

• Limiting the visitors a resident can receive at any one time (e.g. one or two)
• Limiting the number of different visitors a resident can receive a week (e.g. one or two)
• Limiting the length and number of visitors a resident can receive a week (e.g. hour-long, twice a week)
• Limiting the number of visitors in the care home at any one time
• Not allowing children under 16 years to visit

Screening of visitors

• Requiring visitors to not live, work or have spent time in last two weeks in COVID-19 geographical hotspots as defined by government data
• Requiring visitors to have had flu vaccinations
• Requiring visitors to have a temperature check before the visit
• Requiring visitors to complete a symptom and travel checklist before the visit to ensure they have not experienced symptoms in last weeks
• Registering visitors to facilitate contact tracing if needed

Conditions during the visit

• Handwashing by visitor on entering and leaving the facility
• Visits in outdoor area or well-ventilated private rooms
• Minimising time by visitors walking through other parts of the facility
• Maintaining spatial distancing (could be made clearer by marking zones on the floor)
• Wearing of masks and shoe protection by the visitor and resident if possible

Easing visitor restrictions will not be sufficient to overcome the negative consequences of lockdowns on residents

Resident unfulfilled needs during lockdowns such as for broader social connections, exercise and recreation will not be completely met through visitors. Strategies to meet these needs should be put into place given that restrictions may last for many more months.

Care plans should be discussed with residents and families and updated to reflect how wellbeing, and social connection are being supported during lockdowns. More staff hours are needed so staff can spend time with residents in meaningful activity and exercise to compensate for fewer or no visitors, no volunteers or outings, and less group activities. More staff hours are also needed to help organise and facilitate family visits (either in person, window visits, phone calls or video calls). Families can deliver letters and gifts. Supporting the wellbeing of residents would require purchase of more technological resources (i.e. ipads, mobile phones, videochat facilities, wifi throughout the facility [43]). Finally, resources and support are required to help facilities adopt new practices (e.g. hallway exercise and activities, entertainers through zoom or at windows) to maintain social, cognitive and physical activity in residents while maintaining spatial distancing.

Government responses to COVID-19 have generally not included additional funding to support resident connectedness or wellbeing. Discussion is needed on how to fund the resources needed to maintain resident wellbeing during this period. Greater government monitoring of care home practices may be needed to safeguard against neglect and ensure wellbeing is supported [31].

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