Covid-19 and care homes: hidden clinical challenges

The impact of Covid-19 has been stark throughout the world for residents in care homes and other long-term care facilities, but the health policy and public health decisions made within the UK with regards to the sector have been the subject of much debate.^1,2

According to Martin Green, Chief Executive of Care England, in his evidence to the House of Commons Health and Social Care committee: “We had a policy of emptying hospitals and filling care home, whereas other countries had a policy of taking people out of care homes if there was difficulty isolating them.”³

There is concern that the impact of this policy has been stark.⁴ The Office for National Statistics reported that 27.3% (n=12,526) of all deaths of care home residents between 1^st March and 1^st May 2020 were associated with Covid-19, and 72.2% of these deaths occurred within the care home.⁴

However, alongside the mortality and morbidity of patients with Covid-19, there are other dimensions to the impact of the pandemic. This blog aims to highlight some of the hidden clinical challenges within the long-term care setting that the Covid-19 crisis is having upon clinicians, patients and families. These case vignettes are loosely based on clinical encounters, with appropriate changes made to protect identity.

Psychological harm to healthcare workers in care homes

Joan is a healthcare assistant who works at a local care home that has been significantly affected by Covid-19. She called her GP at breaking point. She could not sleep, she constantly worried about her residents and her own health. She became withdrawn from her family as she didn’t want to worry them about what she is seeing. She cried down the phone saying that she has never lost so many patients in such a short period of time.

Her GP arranged psychological support available through online avenues and put her in touch with the local occupational health physician. Joan is progressing well after some time off work, and space to speak about what she has experienced.

Resuscitation status of care home patients

Brenda is a 90-year old lady who has recently been discharged back to her nursing home after an exacerbation of congestive cardiac failure in the context of end stage dementia with a do not attempt resuscitation (DNaCPR) form in place. A week later, the GP is called by a furious daughter demanding that the DNaCPR form be revoked as it was never discussed with her.

The GP explains in detail the rationale for the form being implemented and that it does not mean that other aspects of clinical care are being withdrawn. The doctor agrees that it would have been helpful if the hospital had discussed this with family members at the time of admission. After a few days of consideration, her daughter agrees that a DNaCPR form is appropriate and it is reinstated.

Infectious disease and palliative care in care homes

Whilst working as the out of hours GP, a doctor is called to review a patient called Jim at a local nursing home. He is 80 years old with a background of severe multi-infarct dementia, ischemic heart disease, and chronic obstructive airways disease. The nursing staff comment he has been listless and off his food for 24 hours. The home has four confirmed cases of Covid-19.

On assessment, Jim is comfortable but the GP is concerned that Jim has Covid-19, with oxygen saturations of 85%, respiratory rate of 35 and a fever of 39.5C. The home has a strict policy of not allowing any family members in the home due to the outbreak.

A long discussion with relevant family members happens outside the care home. The family agreed that Jim should remain within the care home, made not for resuscitation and the focus of treatment should be symptom control.

Appropriate palliative care medications are prescribed to be left and administered as required at the home. He passes away overnight, and the family are distraught that they could only see Jim through the window and could not be with him.

Inappropriate hospital admissions due to poor information sharing

On Monday morning the GP sees that one of his nursing home patients was admitted to the local emergency department with respiratory distress in the context of several patients having confirmed Covid-19 in the home. The patient passed away within one hour of arrival at the emergency department on a trolley. The family were extremely unhappy as they had been keen for the patient to remain within the home and this had been discussed with her own GP.

On reviewing the case there was an agency staff member on duty (due to extensive staff sickness within the home) who was concerned about the resident and called the ambulance. Unfortunately, the patients’ nursing home care plan was not up to date and her GP electronic care summary did not state she was not for admission or for escalation of treatment.

Concluding thoughts

Within the long-term care sector, Covid-19 has led to huge psychological harm to families and healthcare workers, alongside significant morbidity and mortality of residents. As GPs we have an opportunity to prevent the hidden harms of the crisis, and can work to mitigate the impact these have upon our patients.

More broadly the optimist may hope that the crisis within long-term care may start to be addressed following the significant level of sustained attention and engagement that there is presently with healthcare providers, politicians and the general public.

For more news and articles on Covid-19, go to our Covid-19 section

Dr Lloyd Hughes is a GP, NHS Fife

References

Griffin S. Covid-19: Experts urge strategies to prevent further outbreaks in care homes. BMJ 2020;369:m2039
Gordon AL, Goodman C, Achterberg W, et al. Commentary: COVID in Care Homes-Challenges and Dilemmas in Healthcare Delivery [published online ahead of print, 2020 May 13]. Age Ageing. 2020
O’Neill D. Covid-19 in Care Homes: The Many Determinants of This Perfect Storm. BMJ . 2020 May 27;369:m2096.
Office for National Statistics. Deaths involving COVID-19 in the care sector, England and Wales: deaths occurring up to 1 May 2020 and registered up to 9 May 2020 (provisional). London, 2020. Available from: here Last Accessed 3rd June 2020