Ireland has got many things rights in tackling the coronavirus pandemic but the handling of nursing homes is not one of them.
In less than 10 days, the number of outbreaks in public and private nursing homes has gone from four to 50. That number jumped by 10 in a single day over the weekend, indicating we have some way to go before the disease is brought under control in this kind of residential setting.
This was not without warning. Concerns about the potentially devastating impact of a Covid-19 outbreak in a nursing home were already being flagged at the start of March, when just that had happened in Seattle in the US, leading to multiple deaths.
One of the first cases of the disease, again at the start of March, involved a GP in the west who had worked in a nursing home as well as other healthcare settings before he was diagnosed. It appears this case did not lead to an outbreak in the nursing home in question, but here was a pattern – of key workers moving around different healthcare settings – that perhaps should have been noted more.
Nursing Homes Ireland (NHI) responded to the growing crisis on March 4th by imposing nationwide visiting restrictions on private facilities.
On March 10th, chief medical officer Dr Tony Holohan said the blanket restrictions should be lifted because they were premature and impacted on residents' social interactions.
That stance seems extraordinary now, with the benefit of hindsight, but the National Public Health Emergency Team (NPHET) was anxious not to impose restrictions too soon. Perhaps it, along with the rest of us back then, may not have seen things getting so bad so quickly.
Three days later, on March 13th, the visiting ban was imposed, or re-imposed, as part of a package of restrictive measures recommended by NPHET to Government.
Greater risks
It has been clear from the start of the year that Covid-19 affects the old, and the frail, disproportionately. Residents of nursing homes, and of other care centres, were always liable to be at greater risk of dying.
Yet despite a plethora of new guidelines being developed for the emerging situation, none was specific to the nursing home sector.
On March 25th, when there were only a handful of clusters of Covid-19 in homes, NHI complained that it had made numerous representations to Minister for Health Simon Harris and his officials, but no offer of a meeting had been forthcoming.
NHI appealed for “specific guidance” for what nursing homes should do in the crisis and predicted homes would experience severe staff shortages when staff were most needed.
Asked about the issue of guidance last Friday, Dr Holohan said there were “extensive arrangements” in place across the sector and infection control guidelines for healthcare settings “that should have been applied” in nursing homes.
But, he acknowledged, there is a “wide variation” in standards in nursing homes, which are monitored by the Health Information and Quality Authority. “Some have very high standards and continue to be very safe [while] other places are not quite of that standard. We have to raise the standard of the entire sector.”
Different sectors
It is understandable much of the focus in this epidemic has been on the potential devastation a surge of cases might wreak on hospitals and, in particular, intensive care units.
However, the problem with the one-size-fits-all approach, including the lack of specific guidance for nursing homes (and other care centres, and home care providers) is that it ignores the different environment and culture applying in these sectors.
Typically, staff are paid less and receive less training than their equivalents in hospitals. Staff in these Cinderella sectors are hard to come by and many supplied by locum agencies work across different locations. They may be renting accommodation, sometimes cramped, with other care staff working in other locations; more factors that help the virus spread.
The Government is now recommending the cocooning of all over-70s, who are being advised to remain at home. It is ironic, therefore, that a safe environment is not being offered to the most vulnerable of this age group who are residing in nursing homes where outbreaks have occurred.
It is welcome the problem has been recognised, even if belatedly. The package of measures agreed at the weekend should ensure the chains of transmission in nursing homes are broken. Key to this will be the implementation of proper infection control among staff; after all the residents themselves, who are unlikely to be hospitalised even if they fall ill, have few choices.