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Predictable, not inevitable? How Covid-19 spread through Irish nursing homes

Questions remain about how the coronavirus spread so easily through nursing homes.

The government has increasingly suggested that some kind of outbreak in nursing homes was inevitable.
The government has increasingly suggested that some kind of outbreak in nursing homes was inevitable.
Image: Shutterstock/hxdbzxy

THE SPREAD OF Covid-19 through Irish nursing homes has prompted questions about what exactly went wrong. But as the crisis continues, the government has increasingly sought to imply that such an outbreak was inevitable. 

As testing in residential care facilities increases, the number of cases are growing. Last night, the Department of Health confirmed that there are 191 clusters of the virus in nursing homes, composed of 2,231 cases. 

It’s clearer now than ever before that while the virus is under control in the general population, the danger remains high in nursing homes. 

“This is a very transmissible virus,” Chief Medical Officer Dr Tony Holohan said at the start of the week.

“It’s more transmissible than the flu. It’s not realistic for us to think that we could keep this entirely out of nursing homes when we consider that fact.”

On RTÉ One’s Prime Time this week, Taoiseach Leo Varadkar cited analysis by the London School of Economics to stress that Ireland’s nursing home crisis was no worse than that in other European countries. 

“In most European countries that they looked at, the percentage of people who are dying in care homes is somewhere between 40% and 60%,” Varadkar said.

In Ireland it is 45% in nursing homes, 53% if you include all care homes. We’re in that range other countries are. Why is that? It’s because of the virus. It’s a virus that targets older people, that targets people with chronic conditions, people who are frail.

And while Varadkar acknowledged that perhaps some things might have been done differently, the government and the HSE have insisted that they were prepared for the impact of the virus on these vulnerable communities. 

It’s clear that the HSE was aware of the threat posed. In some of the earliest guidance issued to nursing homes on 21 March, the health officials acknowledged the very real danger posed to older people by the disease. 

“While all respiratory viruses can cause outbreaks and significant morbidity and mortality, COVID-19 is acknowledged as a very particular threat” in residential care facilities, the guidance states. 

“The outcome of the disease is much poorer in older people and individuals with co-morbidities or impaired immune function.”

But while this crisis was certainly predictable, was it inevitable? 

TheJournal.ie spoke to people in the sector – from healthcare workers to senior figures – to get a sense of why we’ve seen staggering number of deaths in nursing home settings. 

At every level of the sector there is a sense that things are getting better – but only after weeks of delay, uncertainty and fear. 

Major challenge

A significant problem for residential care facilities is that they function more like homes than hospitals. Many residents are accustomed to considerably more freedoms than would otherwise be the case in a clinical setting.

And with communal meals, activities and events all making up the fabric of a well-run nursing home, trying to reverse all that in the space of a few weeks can be incredibly difficult. 

Such a sea change is particularly difficult for nursing homes that cater for people who may be especially vulnerable – whether suffering from dementia or mental health issues.

It’s very hard to police the movement of people who may have little idea that there is a pandemic at all. 

As one nursing home worker in Galway told TheJournal.ie, this can make even some of the most basic infection control practices difficult.

“Even though residents have dementia, they still know the voices and recognise faces. For them to see somebody coming towards them with a mask or gown protection would be really scary for them,” they said. 

Even while praising the measures taken in their workplace, the same staff member said that there was a feeling that if coronavirus entered the nursing home, it’d be impossible to stop. 

“All you need is one case to get in and unless we know one person is infected it could run rampant in the building. We all know that,” they said. 

“Everyone is petrified, because we have such vulnerable people in the home. Even when the post comes in, they disinfect it,” they said. 

Blame

Speaking to TheJournal.ie, CEO of Nursing Homes Ireland (NHI) Tadhg Daly is adamant that the crisis in nursing homes was not inevitable. 

“I don’t believe it was inevitable in terms of the scale of the challenge we find ourselves now in,” he says.

“Yes, it was clear that the nursing home sector was at the most high risk because of the vulnerability of the resident profile, the age profile and, of course, given that you’re in a congregated setting.”

But this doesn’t equate to deaths being purely “inevitable”, he said.

Publicly, relations have appeared strained between Nursing Homes Ireland and the government since the start of the crisis. From clashes over the lack of PPE to a much-discussed divergence on visitor policy, the public health officials and the private sector often appeared at odds over how best to prepare for Covid-19. 

Daly says it was on 30 January that Nursing Homes Ireland first issued a note to members, warning about a new disease called coronavirus.

In early February, the organisation started talking to the HSE about preparing for an outbreak. At that point, there were no cases of Covid-19 in Ireland.

“I was very concerned at the level of preparedness,” he said.

The sector “wasn’t as high on the agenda as I would have felt it should have been”, he said. 

For NHI, the month was spent looking at international guidance and talking to the HSE about trying to put it in an Irish context. 

The first public dispute came on visiting guidelines. After a conference call with providers on 6 March, Nursing Homes Ireland announced strict new visitor restrictions, stating that visitors should only attend in “urgent circumstances”.

It noted that “management reserve the right to impose full restrictions where necessary”. 

Choosing a Friday was no accident, says Daly.

“Traditionally you would have larger numbers coming in and out of nursing homes on a weekend in terms of visitors,” he said.

This was long before the HSE would recommend similar actions. By 17 March, guidance from the HSE seen by TheJournal.ie was still not calling for a suspension of all visits.  It took days for guidance on visiting to become clear. 

In the meantime, health officials insisted that such action was unnecessary. Publicly, Holohan even said that such measures were “not necessary” because of the impact such a decision could have on residents. 

Testing Latest guidance from the HSE to nursing homes includes the new requirements on testing.

Daly says that the focus was almost exclusively on acute hospitals in the early days of the crisis: “As a country, I’m not sure that we took the right steps early enough given the scale of the pandemic.”

This wouldn’t be the final dispute between NHI and the HSE. PPE shortages in nursing homes remained a live issue for much of March and April, even as official advice emphasised the importance of protective equipment in battling Covid-19. 

And staff and senior officials in the nursing some sector are still complaining about the HSE’s decision to lift the ban on recruitment at the end of March, which saw many who worked in nursing homes deciding to move to an organisation that offered better pay and conditions. 

Certainly, HSE guidance appeared slow to materialise. The first comprehensive guidance document published on the HPSC website was issued on 21 March. A month later, it’s been updated only five times – in contrast, health guidance to healthcare workers is now on its 13th iteration. 

Tensions

Recent days had seen something of an easing of tensions between Nursing Home Ireland – the body that represents private nursing homes – and the government. 

With supplies of PPE now being readily delivered to many of the nursing homes that need it and a pledge for widespread testing in care homes finally being realised, Daly suggested that the situation has drastically improved from several weeks ago. 

Still, this doesn’t mean that problems have gone away. Despite the HSE saying that it has sent over two million pieces of PPE to nursing homes in the past month, some nursing homes are still privately ordering equipment. And more seriously, many nursing homes are also reporting major staffing pressures. 

0646 Tony Holohan There were early clashes between the HSE and Nursing Homes Ireland. Source: Leah Farrell/RollingNews.ie

Staffing

These pressures are set to become the next major test for the government’s pledge to support nursing homes. 

In a statement issued last night, Daly warned that “many nursing homes are faced with a staffing crisis”. 

“The challenge is likely to escalate as mass testing is undertaken within nursing homes across Ireland and the number of staff unavailable increases,” he said. 

Latest figures from the NHI indicate that over a hundred nursing homes reported that 223 nurses were absent because of Covid-19, while 158 homes reported that 427 healthcare assistants were absent.

“We simply cannot get this wrong. It is absolutely vital the promise that healthcare staff will be redeployed to support nursing homes start translating into feet on the ground,” Daly said.

St Joseph’s in Shankill, a nursing home for dementia care patients, is managed by St John of God Hospital. CEO Emma Balmaine told TheJournal.ie that there have been no outbreaks so far in her nursing home. 

Balmaine says that while the centre is managing so far, the loss of staff to self-isolation for a full 14 days is taking its toll.

“We have had days when we might have had 11 staff out,” she says.

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While official HSE guidance suggests a “derogation” for staff to return to work early in some cases – even if they’re close contacts of a confirmed case – Balmaine says she’s “nervous” about the prospect.

“We’re aware of that and have agreed at the moment, because we’re able to manage the staff levels, we’re not using the derogation,” she said.

Praising the support of the HSE, she says that management and staff have worked together to ensure the nursing home is safe for residents. 

St Joseph’s started an emergency planning group in January, which until recently met daily to discuss preparations for Covid-19.

“None of us thought we would be where we are today,” she says. “Little did we know how much preparation we had to do to keep it out.”

“My concern goes out to families, who I’m sure are out of their minds with worry,” she said.“But there are a lot of nursing homes who are coping and taking it day by day.”

Not every nursing home can tell the same story.

One nursing home worker in Dublin told TheJournal.ie that short-staffing is a “big problem”.

The staff member, who works in a nursing home that has seen a “few” deaths from Covid-19, said that on some days less than 10 staff were trying to care for 100 residents. 

There, some workers were forced to come back to work early and even suspected cases weren’t able to self-isolate because of the staffing pressures. 

And while things have improved over the course of the crisis, they said that it took too long to respond to the scale of the virus. 

“I feel like everything was too late. They knew the severity of it, but I don’t think they thought it through,” they said. “By the time they came up with a plan, it was too late.”

Cohorting – the placement of suspected or confirmed Covid-19 residents together in one space – is being attempted, they said, but it’s difficult given the challenge of even identifying suspected cases. 

In many cases, older people in nursing homes don’t show a fever or even a cough – despite having the virus.  “You have to treat every resident like they have the virus,” they said.

Officials last night insisted that help is coming. HSE Chief Clinical Officer Dr Colm Henry called it a “dynamic” situation.

“We see places where the staff levels have got so low, and that may happen with the testing in the coming days. We may have to step in and give more intensive support than we’ve been giving up until now,” he said. 

Henry said that the HSE will try to finalise an agreement in the coming days with NHI to provide 40,000 hours per week of home-care workers to nursing homes. 

But HSE and the government are not the only groups facing criticism. 

TheJournal.ie understands that some operators have privately criticised the response of the Health Information and Quality Authority (HIQA) for its slow response to the crisis. 

And while not everyone TheJournal.ie spoke to shared that criticism, there were questions raised about why it took until 21 April for HIQA to issue an assessment framework to help prepare nursing homes for a Covid-19 outbreak. 

A spokesperson for HIQA, which is represented on the National Public Health Emergency Team, said: “Since early March, HIQA has been in frequent contact with the providers of nursing homes, the Department of Health and the HSE to ensure that residents are protected and continue to receive safe care during the Covid-19 outbreak.”

The spokesperson said that HIQA had issued regular communications to nursing homes, including launching an Infection and Prevention Control Hub. 

What next?

The crisis is far from over. The success of extra testing brings with it the reality that more and more staff – identified as close contacts with a confirmed case – will be forced to self-isolate, piling extra pressure on nursing homes across the country.

Last night, health officials raised the prospect of re-deploying more staff from acute hospitals into nursing homes to fill the gap. 

And while a significant proportion of nursing homes still don’t have a coronavirus outbreak, many are living in fear of a confirmed case inside their walls. And some have called for radical action.

Trade union Siptu has called on the government to bring the private nursing home sector under State control for the duration of the Covid-19 crisis. 

Others says that the middle of a crisis is not the time for contemplation or criticism of Ireland’s response. 

“The main lesson is that we should have been better prepared,” says Daly. 

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