Covid-19 and nursing homes: delivering safe care for our patients

The Covid-19 pandemic is providing many painful lessons, particularly the vulnerability of individuals living with chronic conditions and the need for coordination and monitoring in the delivery of care within long-term care facilities.

A recent European public health publication reported that long-term care facilities are severely affected by Covid-19, with deaths among residents accounting for between 37-66% of all Covid-19-related deaths in individual European countries.¹

There is an inherent vulnerability of patients residing in nursing homes due to frailty and multi-morbidity, with evidence that immunosenescence and comorbid disorders are more likely to promote a viral-induced cytokine storm resulting in life-threatening respiratory failure and multisystemic involvement.²

Challenges in care homes

There have been well documented challenges, which have further led to an increased risk of transmission of Covid-19 including staffing shortages, frequent staff turnover/use of agency staff, high resident-to-staff ratios, personal protective equipment (PPE) supply shortages, atypical presentation of disease in residents and inadequate infection prevention and control measures.^2-3

In particular, the numbers of registered nurses likely to be found in nursing homes are low with nursing assistants providing the majority of care, which can be challenging for some patients with the highest health-care needs.⁴

There has been extensive work over the last few months right across Europe, working to identify viral circulation at an early stage within long-term care units through enhanced surveillance, restructuring of care units to improve infection control, enhancing supply chains for PPE and support care staff deliver care safely and effectively.⁵

With Covid-19 cases rising once again across Europe,⁵ a recent paper reporting the evolution and effects of Covid-19 on 189 care homes in Lothian⁶ provides an opportunity to reflect upon previous practice and consider our response for future clinical practice.

Covid and care homes: a Scottish perspective

The recent population analysis of testing, cases and deaths in care homes in the NHS Lothian region has been an extremely useful paper in terms of structuring our response to future Covid-19 outbreaks.⁶

The authors utilised local public health data for testing of care home residents for Covid-19 between March and August 2020, and then linked these with publicly available data on care home services, collated by the national regulator, which included the type of care home (elderly care, learning disabilities etc), number of beds, care home ownership, recent Care Inspectorate risk assessment score and locality. Previous infectious outbreaks (norovirus, scabies and influenza) within care homes were also recorded as a measure of historical infection control practice, using NHS Lothian public health data.

This paper is timely, given that current data-sets for patients residing in UK nursing homes can be patchy leading to challenges for researchers.⁷

The authors reported that 189 care homes, with a total of 5,843 beds, had patients tested within the study period. 5,227 beds (89%) were for older adults. Only 37% of the care homes had a confirmed Covid-19 outbreak during the study period. 432 care home residents died and had Covid-19 recorded on their death certificates, with the majority dying within the care home environment.

The impact of these outbreaks upon care homes varied extensively, since a quarter of cases and deaths were in just five care homes and half were in 13 care homes. After bed numbers within the homes were accounted for, there was no other characteristic associated with a presence of Covid-19 cases. Evidence to date has suggested that Covid-19 cases in nursing homes are related to facility location and size and not traditional quality metrics such as star rating and prior infection control citations⁸, and this has been extended within a Scottish care home population.

Implications for practice

There is clearly continued vulnerability for patients residing in care homes with the majority of care homes not experiencing a Covid-19 outbreak to date. Nursing homes need continued support from policy makers and clinicians to facilitate access to testing, PPE, and support for staff. Particular measures that have been of benefit have included extended access to staff and resident testing.^6,9

Testing accessibility, which blighted the early response within long-term care, is vital given the risk of asymptomatic transmission, with a US study reporting that over 50% of patients who were positive having no symptoms at the time of the test.¹⁰

The positive impact of a broad testing strategy on containing outbreaks in these settings has also been reported in another US study where rapid and serial testing was performed.¹¹ Other areas of focus include investing in effective contact tracing and isolation programmes¹² alongside access to financial support for staff requiring to isolate and cooperation between private and public sector for community care staff to assist staff shortages in times of outbreaks.¹³

Managing staff crisis is vital, as without appropriate staffing levels nursing homes will struggle to fulfil their duty of care to residents, even in the presence of financial penalties.¹³ Work to balance the physical health benefits and the mental health harms of shielding and isolating nursing home residents should continue.

Given the atypical presentation of Covid-19 in older patients,¹⁴ a broader approach to testing should be considered in this patient group. Table 1 summarises symptoms that could prompt clinicians and nursing staff to consider whether a Covid-19 test should be requested to isolate cases at an early stage.

Table 1: Suggested indicators for the identification of possible Covid-19 case in nursing home¹

Finally, there are concerns that Covid-19 has triggered a broader crisis for nursing homes. There are huge challenges in line with difficulties in admitting new patients, reducing bed occupancy rates and difficulty in accessing funding streams.¹⁵

The fundamental flaws in the organisation of long-term care in the UK require a concerted effort to address. This will need to include a review of how social care is funded, how informal carers are supported and how other residential options (such as the Dutch ‘dementia-village’) may be utilised to support older patients.

With close inter-disciplinary team working, the risk to nursing home residents of a second Covid-19 wave may be reduced. However, the longer-term structural challenge to the nursing home care sector will likely continue to hamper responses to pandemics.

Dr Lloyd Hughes is a GP, NHS Fife

References

1. ECDC Public Health Emergency Team, Danis K, Fonteneau L, et al. High impact of COVID-19 in long-term care facilities, suggestion for monitoring in the EU/EEA, May 2020. Euro Surveill. 2020;25(22):2000956.
2. Perrotta F, Corbi G, Mazzeo G, et al. COVID-19 and the elderly: insights into pathogenesis and clinical decision-making [published correction appears in Aging Clin Exp Res. 2020 Sep;32(9):1909]. Aging Clin Exp Res. 2020;32(8):1599-1608.
3. Centers for Disease Control and Prevention . (2020). Preparing for COVID-19: Long-term care facilities, nursing homes. Available at: https://www.cdc.gov/coronavirus/2019-ncov/healthcare-facilities/prevent-spread-in-long-term-care-facilities.html Last Accessed: 15th November 2020
4. Laxer K. Jacobsen FF, Lloyd L. et al. Comparing nursing home assistive personnel in five countries. Ageing International, 2016. 41, 62-78.
5. Comas-Herrera A, Zalakaín J, Lemmon E et al. Mortality associated with COVID-19 in care homes: international evidence. Article in LTCcovid.org, International Long-Term Care Policy Network, CPEC-LSE, 14 October 2020.
6. Burton JK, Bayne G, Evans C et al. Evolution and effects of COVID-19 outbreaks in care homes: a population analysis in 189 care homes in one geographical region of the UK. Lancet Healthy Longev 2020; 1: e21-31
7. Burton JK, Guthrie B. Identifying who lives in a care home: a challenge to be conquered. Age Ageing 2018; 47: 322-23.
8. Abrams HR, Loomer L, Gandhi A, Grabowski DC. Characteristics of U.S. Nursing Homes with COVID-19 Cases. J Am Geriatr Soc. 2020 Aug;68(8):1653-1656.
9. European Centre for Disease Prevention and Control (ECDC). Infection prevention and control and preparedness for COVID-19 in healthcare settings – fifth update. Stockholm: ECDC; 6 Oct 2020. Available from: https://www.ecdc.europa.eu/en/publications-data/infection-prevention-and-control-and-preparedness-covid-19-healthcare-settings Last accessed 15th November 2020
10. Arons MM Hatfield KM Reddy SC et al. Presymptomatic SARS-CoV-2 infections and transmission in a skilled nursing facility. N Engl J Med. 2020; 382: 2081-2090
11. Roxby AC, Greninger AL, Hatfield KM et al. Outbreak Investigation of COVID-19 Among Residents and Staff of an Independent and Assisted Living Community for Older Adults in Seattle, Washington. JAMA Intern Med. 2020 Aug 1;180(8):1101-1105
12. European Centre for Disease Prevention and Control (ECDC). Surveillance of COVID-19 at long-term care facilities in the EU/EEA. Stockholm: ECDC; 19 May 2020. Available from: https://www.ecdc.europa.eu/en/publications-data/surveillance-COVID-19-long-term-care-facilities-EU-EEA Last accessed 15th November 2020
13. Xu H, Intrator O, Bowblis JR. Shortages of Staff in Nursing Homes During the COVID-19 Pandemic: What are the Driving Factors?. J Am Med Dir Assoc. 2020;21(10):1371-1377
14. Lithander FE Neumann S Tenison E et al. COVID-19 in older people: a rapid clinical review. Age Ageing. 2020; 49: 501-515
15. Daly M. COVID-19 and care homes in England: What happened and why? Soc PolicyAdm. 2020;1-14