Introduction by Dr Diarmuid O'Shea, President of the Irish Gerontological Society
One of the many areas this pandemic will change is the focus it brings on our Nursing Home Sector.
At the outset, I would like to acknowledge the trojan, skilled and compassionate work of the front line staff in the nursing home sector over the years and in recent times. Many have shown enormous dedication in what have been very challenging and difficult circumstances. They have also had to rapidly adapt to changing evidence and new support structures. We all owe them a sincere debt of gratitude, and our support as they advocate for change, improvements and progress for the people they care for and support.
We have a lot to learn and reflect on. COVID 19 is teaching us all lessons as it evolves. Some of these learnings can be applied to and in the Nursing home sector.
I am grateful to Dr Ruth Martin for the following reflection.
Experience of COVID 19 Outbreaks in Residential Care Facilities
By Dr Ruth Martin, Community Geriatrician, Connolly Hospital
The novel corona virus, severe acute respiratory syndrome coronavirus 2, was first noted following a cluster of pneumonias in Wuhan, China. It’s virulence has helped it spread throughout the world, resulting in the WHO reporting a global pandemic in March 2020. There are currently more than five million cases worldwide and more than 320,000 deaths directly attributable to COVID -19 , the name given to the disease process it causes. From the early stages of the outbreak it was clear that older people with comorbidities were more susceptible to the severe and critical forms of the disease and thus more likely to die from COVID-19 with a case fatality rate for those over 80 years being 18% (1).
The fact that Residential Care Facilities (RCF) were at such high risk for severe outbreaks was first reported from Kings County, Washington State in March 2020 (2). They described high morbidity and case fatality rates for residents, with 81/130 residents testing positive and a case fatality rate of 27%. They also found high rates of staff infection (34/170 staff), leading to high absenteeism, but no fatalities in this group. Since this time across Europe outbreaks in RCF have been responsible for 51% of all COVID-19 deaths in Belgium (3), 66% of deaths in Spain (4), 50% of deaths in France (5) and 55.2 % of deaths in Ireland (6). Case fatalities within healthcare workers, although rare, have occurred both in Ireland and worldwide.
With COVID-19 we have been ‘learning as we go’, which has led to knowledge and guidelines being regularly updated. This has been especially difficult in the RCF sector in relation to symptoms, testing, PPE, visitors and certification of death. The early delays in test results led to tremendous difficulty with outbreak response measures, especially with cohorting of affected patients to prevent cross infection amongst residents. Initially limited availability of PPE, followed by inappropriate use of PPE, led to cross infection amongst residents and staff. The amount of viral spread from asymptomatic and pre-symptomatic shedding of the virus is still unquantified. One study in Belgium showed that systematic testing of all RCF residents found 73% of positive cases to be asymptomatic at the time of their testing(3) making the approach to isolation and containment difficult. In terms of viral load, this is known to be highest when one becomes symptomatic and in severe infections, so perhaps the virulence of infection from these asymptomatic people is low.
The Community Liaison team in Connolly hospital has been providing support to RCF in the catchment area for over 10 years, so strong links were already in place when the pandemic hit. Communication with Directors’ of Nursing and GPs became a daily occurrence and support in whatever way possible, through assistance with swabbing, advice, medical reviews, staffing was provided. COVID crisis response teams in the CHOs and provision of support for the RCF sector through HSE and public health then developed, as well as outbreak control meetings for those requiring it.
At the time of onsite reviews residents were noted to have varied symptoms and illness severity. Those with mild disease often had simply a deterioration in oral intake, either due to loss of appetite and thirst, or loss of independence with oral intake. Slight deterioration in mobility and function was also noted with mild disease. Fever and respiratory symptoms were often not present at all in this cohort. Those with severe disease were at times distressed and symptomatic with respiratory secretions but then again others tolerated very low oxygenation levels without respiratory distress. Perfusion issues were often noted on examination. RCF with outbreaks had a high stress environment with staff having hugely increased workloads and often low staffing levels or unfamiliar staff providing care. The RCF itself was more like a hospital than a home.
The psychological impact of this pandemic on residents, staff and families who have experienced COVID-19 outbreaks is huge. The impact on residents, staff and families who haven’t experienced an outbreak has also been huge due to the worry and imposed isolation the pandemic has mandated. Many of those that have survived the disease process suffer sequelae, including weight loss, deterioration in mobility and function and mood issues. A rehabilitative phase must be built into the recovery for all. Recovery is upon us with more people recovered in our RCFs than infected now. Until we are safe from COVID-19, a new normal in RCF life is upon us and it is beholden to not just RCF staff, but Public Health, the HSE, HIQA and Gerontogical nurses and doctors to provide the support required for safe care of our most vulnerable population.
- Nanshan Chen, Min Zhou, Xuan Dong, Jieming Qu, Fengyun Gong, Yang Han, Yang Qiu, Jingli Wang, Ying Liu, Yuan Wei, Jia'an Xia, Ting Yu, Xinxin Zhang, Li Zhang, Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study, The Lancet, Volume 395, Issue 10223, 2020,Pages 507-513,ISSN 0140-6736,https://doi.org/10.1016/S0140-6736(20)30211-7.
- McMichael TM et al. Epidemiology of Covid-19 in a Long-Term Care Facility in King County, Washington. N Engl J Med. 2020 Mar 27. doi: 10.1056/NEJMoa2005412
- Sciensano. Coronavirus Covid-19, Overall Epidemiological Situation 2020 [18 May 2020]. Available from: https://covid-19.sciensano.be/fr/covid-19-situation-epidemiologique
- rtve.es. Coronavirus: Radiografía del coronavirus en residencias de ancianos: más de 17.200 fallecidos a falta de test generalizados 2020 [12 May 2020]. Available from: https://www.rtve.es/noticias/20200505/radiografia-del-coronavirus-reside...
- Santé Publique France. Infection au nouveau Coronavirus (SARS-CoV-2), COVID-19, France et Monde 2020 [11 May 2020]. Available from: https://www.santepubliquefrance.fr/maladies-et-traumatismes/maladies-et-infections-respiratoires/infection-a-coronavirus/articles/infection-au-nouveau-coronavirus-sars-cov-2-covid-19-france-et-monde#block-244210.
- Health Protection Surveillance Centre (HPSC). Epidemiology of COVID-19 in Ireland: Report prepared by HPSC on 20 April 2020 for NPHET [21 April 2020]. Available from:https://www.hpsc.ie/a-z/respiratory/coronavirus/novelcoronavirus/casesinireland/epidemiologyofcovid-19inireland/april2020/COVID19%20Epidemiology%20report%20for%20NPHET%2021.04.2020%20website.pdf