INTERNATIONAL REPORTS

Responses to 3.07. Infection Prevention and Control measures in the Long-Term Care sector: guidance, training and implementation support


Australia

The Australian government provided over $1.5 billion to the aged care sector for COVID-19 support, a portion of which were to be used for IPC training. However, the Royal Commission into Aged Care Quality and Safety found that high-level infection control expertise was still lacking in the aged care sector and further systematic training is required. Additionally, they found that, while the Aged Care Quality and Safety Commission issued infection control self-assessment checklists, they did not conduct comprehensive on-site visits (https://agedcare.royalcommission.gov.au/sites/default/files/2021-03/final-report-volume-1.pdf; https://ltccovid.org/wp-content/uploads/2020/10/Australia-LTC-COVID19-situation-12-October-2020-1-1.pdf).

Last updated: September 9th, 2021


Austria

In Austria responsibility for the development of guidance in LTC settings, their implementation and monitoring has been given to newly established national task forces (https://apps.who.int/iris/bitstream/handle/10665/336303/Eurohealth-26-2-77-82-eng.pdf).

Last updated: September 9th, 2021


Canada (British Columbia)

At the beginning of the pandemic, LTC providers did not feel confident with IPC and emergency management practices and felt unaware of emergency support resources that could be used such as IPC specialists and staffing support. Providers did not receive regular training and education on IPC, emergency management, and how to use PPE. When guidance about PPE was given, they were inconsistent and unclear. There was also a lack of guidance for community care providers and for residents with advanced dementia or behaviour and aggression challenges, who generally do not understand or comply with social distancing requirements.

These concerns have since been addressed by the BC Centre for Disease Control releasing frequently updated IPC guidelines for LTC facilities and assisted living (https://news.gov.bc.ca/files/1.25.2021_LTC_COVID-19_Response_Review.pdf;  http://www.bccdc.ca/Health-Professionals-Site/Documents/COVID19_HomeCommunityCareIPCGuidance.pdf; http://www.bccdc.ca/health-professionals/clinical-resources/covid-19-care/clinical-care/long-term-care-facilities-assisted-living).

Last updated: September 9th, 2021


Chile

Guidance for care homes on use of PPE, cleaning and disinfection, implementation of isolation areas and clean areas for staff, and actions to manage and mitigate suspected and confirmed COVID-19 cases was issued by the Ministry of Health (MoH), the National Service for Older People (Servicio Nacional de Personas Mayores, SENAMA) and the Chilean Geriatrics and Gerontology Society (SGGCh). Additionally, the SENAMA supported care homes with face-to-face technical support, supplies of PPE, staff replacement, testing and transfer of residents with COVID to isolation facilities. A survey of care homes staff showed that, in July 2020, the majority of managers had a high degree of knowledge of COVID-19 prevention and control and reported high degrees of agreement and support for the measures. Around 20% of managers reported PPE shortages, but there were reports of improvement in availability PPE over time. Half of all managers reported that the infrastructure of the homes was inadequate to implement measures, and lack of trained staff, support for staff and trust were identified as other barriers to the implementation of Infection Prevention and Control measures (https://journal.ilpnetwork.org/articles/10.31389/jltc.72/).

Last updated: September 9th, 2021


Denmark

There is a dedicated page on Danish Health Authority website on how to manage COVID-19 among older populations on the Danish Health Authority website. These are updated on a bi-weekly basis, or more frequently, if needed. On May 12th an extensive publication providing new guidelines on how to organize visits in nursing homes was published by the Board of Health.

Last updated: September 9th, 2021


England (UK)

Guidance for home care providers was provided relatively late in the pandemic. On April 27, 2020, Public Health England issued guidance on PPE use for care workers providing domiciliary care. In addition to hand hygiene, respiratory hygiene, and avoiding touching their face, care workers should also follow standard infection prevention and control precautions (https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/881296/Domiciliary_care_guidance_final.pdf).

The Government published wider guidance for domiciliary care providers on May 22, 2020, much later than equivalent guidance for other long-term care settings was issued (https://www.gov.uk/government/publications/coronavirus-covid-19-providing-home-care/coronavirus-covid-19-provision-of-home-care). This covered PPE, shielding of clinically vulnerable people, hospital discharge, and government and local authority support. The guidance has continued to be updated, including advice for providers to divide the people they care for into ‘care groups’ and allocate teams of staff to provide care specifically to those care groups (https://www.gov.uk/government/publications/coronavirus-covid-19-providing-home-care/coronavirus-covid-19-provision-of-home-care#shielding-and-care-groups).

The government issued guidance for unpaid carers, which recommends carers to develop an emergency plan with the person they care for in case the carer becomes unable to continue to provide support, to follow hygiene rules, to maintain their own health, and advice on how to react in case the person with care needs or the carer themselves develop symptoms of COVID-19 (https://www.gov.uk/government/publications/coronavirus-covid-19-providing-unpaid-care/guidance-for-those-who-provide-unpaid-care-to-friends-or-family).

Guidance for unpaid carers of adults with learning disabilities and autistic adults is very similar to the general advice for unpaid care (published on April 24,2020). There are, however, specific points raised around communication and coping with bereavement (https://www.gov.uk/government/publications/covid-19-providing-unpaid-care-to-adults-with-learning-disabilities-and-autistic-adults).

As of December 2020, government guidance for care staff supporting adults with intellectual disabilities and autistic adults (https://www.gov.uk/government/publications/covid-19-supporting-adults-with-learning-disabilities-and-autistic-adults/coronavirus-covid-19-guidance-for-care-staff-supporting-adults-with-learning-disabilities-and-autistic-adults)was last updated on November 5, 2020, which links to a range of other relevant guidance and resources. This includes more detailed guidance from the Social Care Institute for Excellence on supporting autistic people and people with intellectual disabilities, including guidance for social workers and occupational therapists, guidance for care staff, and guidance for carers and family (https://www.scie.org.uk/care-providers/coronavirus-covid-19/learning-disabilities-autism).

Government guidance has not always been accompanied by accessible versions for people with intellectual disabilities, autistic people, and family members, and several NGOs (including some financially supported by the government for this purpose) have been producing easy-read and other accessible information, resources and guidance (https://www.learningdisabilityengland.org.uk/what-we-do/keeping-informed-and-in-touch-during-coronavirus/information-and-guidance/).

 

Last updated: September 9th, 2021


Finland

Guidance specific to LTC units and home care was relatively timely, with specific guidelines/mandates released in March and supplemented in April and May. Most of the municipalities have acted quickly to prevent the spread of the virus and followed the given instructions. Many municipalities have also introduced additional measures on their own initiative to address regional variations in the spread of the virus.  They can be seen summarized in a table on Page 9 of this report.

In 5.6 of LTC Covid Report for Finland (page 14) there is a summary of measures/dealings with people living with dementia.

Last updated: September 9th, 2021


France

Guidance specific to social care was much delayed compared to the health care sector, for example guidance on 20th Feb includes no reference to care homes at all. As a result, 9 large stakeholders wrote to the government and media on 9th March decrying the need for guidance for care homes. No guidance was published for domiciliary care until 2nd April (https://www2.assemblee-nationale.fr/static/15/pdf/rapport/i3633.pdf). Guidance since the second wave has been more targeted to specific groups e.g. people with disabilities (https://www.cnsa.fr/documentation/covid-19_-_developpement_des_mesures_dhygiene_au_sein_des_essms.pdf), and require LTCFs to have protocols for infection control (https://solidarites-sante.gouv.fr/IMG/pdf/10_reperes_pour_proteger_les_aines_sans_les_isoler.pdf).

Guidance has also been developed for infection control among specific groups, such as people with disabilities (https://solidarites-sante.gouv.fr/IMG/pdf/covid_protocole_ph.pdf) and some specific guidance has been published to support older people and protect carers (https://solidarites-sante.gouv.fr/IMG/pdf/plan_protection-personnes_agees_a_domicile-covid-19_1_.pdf ).

 

Last updated: September 9th, 2021


Germany

Residential care

The RKI provides guidance on infection prevention and control in residential settings. These guidance documents have been regularly updated throughout the pandemic reflecting improved knowledge around virus transmission (https://www.rki.de/DE/Content/InfAZ/N/Neuartiges_Coronavirus/Alten_Pflegeeinrichtung_Empfehlung.pdf?__blob=publicationFile ; https://www.rki.de/DE/Content/InfAZ/N/Neuartiges_Coronavirus/Altenpflegeheime.html).

For domiciliary care only a short notice has been issued.

Domiciliary care

A working group of the German Society of Nursing Science have developed a guideline on domiciliary care during the pandemic which also discusses some of the challenges around infection prevention and control guidance but also making suggestions of how these can be overcome.

Among the barriers identified to effective infection prevention and control in domiciliary care the expert group has identified that home care service providers are not being reimbursed for tasks that are not part of the long-term care insurance scheme. This means that for instance communication and coordination between different service providers or patient, family and carer education are not covered under the reimbursement agreements with the LTC insurance, even though these services could be particularly useful in a pandemic situation.

The document also highlights that domiciliary carers are guests in the home of the person with care needs and that any measures undertaken for infection prevention and control that affect the person with care needs and other people living in the household need to be agreed with them (e.g. isolating a person with COVID-19 in the home). Domiciliary care workers can advise and inform, however, implementing requires the consent of the residents. A domiciliary carer is entitled to protect themselves. The guidance emphasises the importance of consensus between clients and the domiciliary carers.

Suggestions provided in the document include: the development of pandemic plan that centers around the dignity of the person with care needs; the development of a continuity plan should domiciliary care have to stop; domiciliary care workers to receive training on measures for infection prevention; people with care needs to have a say on treatment and care should they develop a COVID-19 infection; infection control measures in the case of a COVID-19 infection; adherence to infection prevention protocols and guidance; adjusting of communication for people with visual, hearing and cognitive impairments; supporting the person with care needs in maintaining social contacts; enabling the person with care needs to maintain and promote mobility; support with nutrition; providing relevant information on pandemic measures to people with care needs and their family carers; in case of a COVID-19 infection there should be regular contact between domiciliary carers and the GP of the person with care needs; domiciliary carers should be able to recognise signs of maltreatment, neglect and abuse and where necessary take steps to protect the person with care needs.

Day care

Day care and night care services were generally closed during the first phase of the pandemic. The states allowed these services to reopen in autumn in generally, given they had infection control measures in place. Depending on incidence rates, a reduction of the maximum number of users was mandated.

Last updated: September 9th, 2021


Hong Kong

Early on in the pandemic care home resident were advised not to leave their rooms and to avoid contact with others. Instead they were encouraged to have their meals in their rooms and to use designated toilets. If they needed to leave the room, they were advised to wear a surgical mask. Hygiene protocols were supposed to clean the rooms on a daily basis and at least twice a day for areas that were frequently touched (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


Ireland

In Ireland, a new Infection Prevention and Control Hub offered residential LTC settings guidance for outbreak preparation and management, information on infection prevention and control, and support with applying national advice. Some of this support is provided via telementoring interventions and webinars for nursing homes. In addition, the national membership organisation of home care providers developed a COVID-19-specific National Action Plan (https://apps.who.int/iris/bitstream/handle/10665/336303/Eurohealth-26-2-77-82-eng.pdf).

 

Last updated: September 9th, 2021


Israel

Guidelines, procedures, and information for professional teams (e.g. public health system, justice system, medical staff, airports, food delivery systems) regarding COVID prevention and control are accessible on the Ministry of Health’s website. Guidance was timely; reports were first published in Spring 2020 and regularly updated. JDC-Eshel’s work with the Shield of Fathers and Mothers taskforce was primarily responsible for training and implementation of support of carers/people relying on care in community.

Last updated: September 9th, 2021


Italy

In Italy, the guidelines for nursing homes published by the Ministry of Health require providers to ensure the COVID-related training of care workers. (https://apps.who.int/iris/bitstream/handle/10665/336303/Eurohealth-26-2-77-82-eng.pdf)

Last updated: September 9th, 2021


Japan

Early in the response, local LTCI officials had triggered well-established infection control measures put in place and regularly used for outbreaks of TB & influenza. A disease prevention manual was published; stricter hygiene practices put in place; and staff and visitor health screening and limited resident visitation (https://programs.wcfia.harvard.edu/files/us-japan/files/margarita_estevez-abe_covid19_and_japanese_ltcfs.pdf; https://ageingasia.org/wp-content/uploads/2020/12/COVID_LTC_Report-Final-20-November-2020.pdf).

Last updated: September 9th, 2021


Netherlands

On 20 March 2020 the National Institute for Health and the Environment (RIVM) issued their first Covid-19 guidelines to the LTC sector. These guidelines were regularly updated and new guidance was added. Some guidelines were difficult to follow, especially where there were shortages of PPE and staff absent due to illness (https://ltccovid.org/wp-content/uploads/2020/11/COVID-19-Long-Term-Care-situation-in-the-Netherlands-_-the-second-wave-25-November-2020-2.pdf).

Last updated: September 9th, 2021


Spain

According to a study of the experience of care home managers and local officials, lack of information and guidance at the beginning of the pandemic resulted in chaos and uncertainty and made it difficult to develop adequate responses. While some care homes were able to react quickly, some care homes had not adopted any protocols until they had support from a primary health care centre in mid-April. Staff responsible for “quality reporting” were usually tasked with developing care home protocols and contingency plans but in some care homes that had medical support the protocols were developed by multidisciplinary teams. Care homes were fearful of legal repercussions if they did not get things right. All care homes were required to develop contingency plans to fight the pandemic in June 2020 and were supported by the regional governments in developing these. Too many updates and changes in the guidance made it difficult to adopt them. Quite often guidance was difficult or impossible to implement because it did not reflect the reality of care homes, for example physical layout of care homes, staffing constraints, or the characteristics of residents. Early protocols did not account for the possibility of asymptomatic transmission. Care homes would have found it helpful to have some support with checking their plans, as well as the monitoring of implementation. Care homes found it very difficult to train staff to reflect changes in guidance, in part because many members of staff were new and had had little training or relevant experience (https://digital.csic.es/bitstream/10261/220460/5/Informe_residencias_COVID-19_IPP-CSIC.pdf).

Last updated: September 9th, 2021


Sweden

Guidance on measures to prevent infections in elderly care was delayed due to the fact that central government agencies responsible for providing recommendations and check-lists (i.e.: The Public Health Agency of Sweden and the National Board of Health and Welfare) did not have an adequate overview of the problems and deficiencies in municipal elderly care (https://coronakommissionen.com/wp-content/uploads/2020/12/summary.pdf). Moreover, the  national authorities’ main recommendation to avoid spreading the virus in LTC was to follow the legislation on basic hygiene routines. A national e-training program  focusing on hygiene was developed early and, by July 2020 has been completed by more than  140,000 care workers. It was not until the 25th of June 2020 when the Public Health Agency recommended the use of shields and facemask in personal care of care recipients with suspected or confirmed COVID-19 (https://ltccovid.org/wp-content/uploads/2020/07/The-COVID-19-Long-Term-Care-situation-in-Sweden-22-July-2020-1.pdf).

Last updated: September 9th, 2021


United States

Guidance for LTCFs in the United States regarding COVID-19 infection prevention and control is regularly provided and updated by the Center for Disease Control (CDC). The instructions (e.g. on PPE, distancing, quarantining) can be found here (https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html).

Last updated: September 9th, 2021