INTERNATIONAL REPORTS

Responses to 3.07.01. Measures in relation to transfers to and from hospital, from community to care homes and between settings


Australia

Approaches to hospital transfers vary depending on the state and individual aged care home. Some experts suggested not transferring COVID-19 positive residents to hospital unless it is the only solution to improve their survival rate and reduce risk of transmission. However, South Australia has an automatic transfer policy in which a resident who tests positive will immediately be transferred to a hospital. As of October 2020, the Communicable Diseases Network Australia (CDNA) has yet to introduce a specific recommendation on hospital transfers (https://agedcare.royalcommission.gov.au/sites/default/files/2020-12/aged-care-and-covid-19-a-special-report.pdf).

Last updated: September 9th, 2021


Austria

After 7 April 2020, which marked the peak use of capacity in hospitals during the first wave, patients were transferred from hospitals to care homes, ‘often without testing.’

By 16 April 2020, the Austrian government had announced that people discharged from hospital to care homes should be systematically tested (https://journal.ilpnetwork.org/articles/10.31389/jltc.54/).

Last updated: September 9th, 2021


Canada (British Columbia)

Temporary suspension of interfacility transfers, except for cases of intolerable risk to the patient. Facilities were required to notify the receiving facility if an outbreak occurred within a 14-day period of the transfer. The outbreak protocol states that residents transferred to acute care for treatment of COVID-19 or its complications, can return to facility when medically stable. July 15, 2020 – Notification that interfacility transfers may resume if precautions are taken. Services must follow regional MHO directions (including restricting transfers between facilities with active COVID-19 outbreaks). Precautions (e.g., 14-day isolation) for interfacility transfers will be at the direction of the MHO based on assessed regional risk (https://news.gov.bc.ca/files/1.25.2021_LTC_COVID-19_Response_Review.pdf).

Last updated: September 9th, 2021


Chile

According to a report published in July 2020, at the time there was no specific protocol for hospital discharges to nursing homes and due to the high pressure on health services, people were being discharged from hospital to nursing homes without the requirement of COVID-19 testing, but discharged residents were required to remain in an isolation area for 14 days (Browne et al, 2020 https://ltccovid.org/wp-content/uploads/2020/07/The-COVID-19-Long-Term-Care-situation-in-Chile-24-July-2020-3.pdf).

Last updated: September 9th, 2021


England (UK)

One of the most controversial policy decisions taken at an early stage in the management of the coronavirus crisis was the rapid discharge of older patients from hospitals to care homes around the country without testing for COVID-19. The British Medical Journal has referred to this as a ‘reckless policy’, a sentiment echoed by the Public Accounts Committee. On 17 March 2020 the Chief Executive of the NHS, instructed managers to urgently discharge all hospital patients who were medically fit to leave in order to free up substantial numbers of hospital beds. Discharges, including to care homes, may already have been taking place at this point in readiness for the expected surge in COVID-19 admissions.

Guidance issued on March 19, 2020, in support of hospital discharge arrangements, announced that the existing North of England Commissioning Support (NECS) care home tracker, designed to facilitate rapid search for available capacity in care homes, would be expanded to cover all care homes across England. All care home providers were to sign up and use the tracker to identify vacancies from Monday 23 March 2020. Even if the available care home was not their first choice, patients were to be moved to a care home as soon as possible and could be moved to their preferred care home as soon as possible. The guidance also outlined funding to provide care for people discharged from hospital into institutional care settings irrespective of whether a care assessment had been completed or where their ordinary residence was. Care homes were to receive funding out of the NHS COVID-19 budget to expand their capacity to provide care. Funding to support people leaving hospital was renewed in August with £588m being allocated to the NHS to pay for additional support and rehabilitation for up to 6 weeks (https://www.gov.uk/government/news/more-than-half-a-billion-pounds-to-help-people-return-home-from-hospital). At this time testing capacity was limited and available primarily for patients in critical care and those requiring hospital admission with symptoms of pneumonia, acute respiratory stress syndrome or flu like illness. The guidance of 2 April was explicit that ‘Negative tests are not required prior to transfers / admissions into the care home’ (https://www.northamptonshire.gov.uk/coronavirus-updates/Documents/covid-19-care-homes-guidance.pdf).

The National Audit Office estimated that around 25,000 people were discharged from hospitals to care homes between 17 March and 15 April 2020. Using an approach which also accounted for discharges for new as well as existing residents of care homes, the Health Foundation estimated that, for the period of 17 March to 30 April, 46,700 people had been discharged to care homes, 7,700 fewer than in previous years. However, the pattern of discharges differed between residential care and nursing homes. While residential care homes saw a decrease in discharges (with 12,400 discharges) compared to previous years, nursing homes saw an increase with 17,000 discharges. National bodies representing care homes complained about homes being pressured to accept residents that had not been tested. The guidance of 2 April stated that ‘patients can be safely cared for in a care home if this guidance is followed’. However, clinicians acknowledged that it was a ‘major error’ to assume ‘that care homes could cope with isolating patients and infection control measures in the same way a hospital could’. It has been reported that the Care Quality Commission had been informed by care home managers that several hospitals discharged people to their care home despite suspecting – or even knowing – they were infected. NHS Providers, the membership organisation for NHS hospitals, has strongly rejected the suggestion that hospitals ‘knowingly’ transferred infected patients to care homes but do acknowledge that some asymptomatic patients may have been transferred early though ‘not in large numbers’. Evidence is lacking for any accurate assessment of the extent to which hospital discharges in this period led to transmission of infection into care homes and genomic analyses suggest multiple routes of ingress into care homes.

In its COVID-19 adult social care action plan published on 15 April 2020, the government declared that it was ‘mindful that some care providers are concerned about being able to effectively isolate COVID-positive residents’ and in this context set out the commitment to test all residents prior to their admission to care homes, including on discharge from hospital. In cases where the results of the test cannot be obtained in time for discharge, patients should be cared for in isolation as if they had tested positive for COVID-19. Asymptomatic patients who have tested negative should also be cared for in isolation for 14 days. The same was recommended for patients with COVID-19 symptoms and a positive test result where the patient needed to be discharged from acute NHS care within the 14-day period since the beginning of the symptoms. The action plan recognised that not all providers will be able to accommodate these individuals through appropriate isolation or cohorted care (a reality supported by a survey of 43 English care home managers), and in these circumstances the individual’s local authority will be asked to secure alternative appropriate accommodation and care for the remainder of the required isolation period. For admissions from the community, it is assumed they will be tested prior to admission and in consultation with the family, the care home can decide whether isolation is appropriate.

Last updated: September 9th, 2021


Finland

A key LTC guideline, early on in the pandemic, was to avoid transfers between the care sites, such as between care homes and hospitals, whenever possible. Transfers were allowed only for medical reasons, and the new treatment site had to be notified on whether the person had had respiratory symptoms (https://ltccovid.org/wp-content/uploads/2020/06/ltccovid-country-reports_Finland_120620.pdf).

Last updated: September 9th, 2021


France

National Assembly report highlights that lack of support to the sector, especially in domiciliary care, meant that many services were reticent to taking on covid-positive service users, leading to discontinuity of care (https://www2.assemblee-nationale.fr/static/15/pdf/rapport/i3633.pdf).

Last updated: September 9th, 2021


Germany

The Robert Koch Institute provides guidelines on infection prevention measures to be taken when transferring a person with a suspected/ confirmed COVID-19 infection between settings. ().

Last updated: September 9th, 2021


Staff in residential care settings were advised to monitor the health and body temperature of residents newly discharged from hospitals and to pay extra attention when providing personal care. Residents with respiratory symptoms must wear surgical masks and should continue isolating/cohorting. Furthermore, some nursing homes set up ‘temporary isolation wards’ for residents returning from hospital (https://ltccovid.org/wp-content/uploads/2020/07/Hong-Kong-COVID-19-Long-term-Care-situation_updates-on-8-July-1.pdf).

Last updated: September 9th, 2021


Israel

Different measures were introduced to minimize the transfer of LTCF residents between hospitals and facilities, including the opening of specialized COVID-19 wards within LTCFs and Geriatric Hospitals for those with mild or moderate cases. Required testing and potential quarantining following hospital visits and before returning to facilities was also introduced (https://journal.ilpnetwork.org/articles/10.31389/jltc.75/).

Magen David Adom is the state ambulance and emergency medical service, providing primary assistance for testing, vaccination and ambulatory transfers between hospitals, care homes, and communities (https://www.mdais.org/en/activities/articles-covid19).

Last updated: September 9th, 2021


Netherlands

Many people died in nursing homes and were not transferred to hospitals, therefore it was seen that nursing homes reduced pressure on hospital Intensive Care Units. It is customary to treat older people when they fall ill in the nursing home, perhaps explaining why few were referred to hospital (https://drive.google.com/file/d/1Ji-iDCjC-8EbBpV0dW_xlz780uvU7F–/view).

Last updated: September 24th, 2021


Singapore

As the DORSCON level reached orange in February 2020, elective surgical procedures and non-essential health/dental services were suspended. Hospitals continued to discharge residents to nursing homes throughout the Circuit Breaker period. The referrals were coordinated by the Agency for Integrated Care. At first, residents could be discharged if they did not have an acute respiratory infection and COVID-19 related symptoms. Those with an acute respiratory infection or pneumonia were required to provide a negative test. In May the policy changed as knowledge of asymptomatic COVID-19 increased. From then onwards, all patients discharged from hospital to nursing homes had to be tested (https://ltccovid.org/wp-content/uploads/2020/08/The-COVID-19-Long-Term-Care-situation-in-Singapore-27July-2020.pdf).

Last updated: September 9th, 2021


Spain

In the early part of the pandemic residents returning to a care home, without a test, from a hospital stay for some other reason where suspected to be a main source of COVID-19 outbreaks. On the other hand, there were many instances where care homes were not able to access any health care support, from either primary care or hospitals. There were examples of hospitals that were systematically restricting admissions from care homes (https://digital.csic.es/bitstream/10261/220460/5/Informe_residencias_COVID-19_IPP-CSIC.pdf).

Last updated: September 9th, 2021


United States

In New York, following a hugely controversial directive from New York State’s Health Department on March 25, 2020, approximately 6,300 recovering coronavirus patients were transferred from hospitals into nursing homes throughout April (the peak of New York’s pandemic surge). The policy was defended by the Governor’s office, which argued that not only was this based on federal guidance, but that the devastation in nursing and long-term care facilities had more to do with the infection rates amongst staff. Regardless, the policy was overturned by mid-May and replaced with a new mandate such that patients could not enter nursing homes without a negative COVID test. News sources also counted over 2,700 “readmissions” of patients sent back from hospital to nursing homes they had previously lived in during that time. The executive board of The Society for Post-Acute and Long-Term Care Medicine (AMDA) estimated that 5,000 deaths in nursing homes and LTCFs are a direct result of that order (https://apnews.com/article/new-york-andrew-cuomo-us-news-coronavirus-pandemic-nursing-homes-512cae0abb55a55f375b3192f2cdd6b5; https://apnews.com/article/5ebc0ad45b73a899efa81f098330204c).

Last updated: September 9th, 2021