Medical doctor, clinical epidemiologist and Public Health consultant, Dr Paul Nelson, founder of FeverFreeZone™, considers how the pandemic has raised questions on public perception and future viability of care homes.
The pandemic has demonstrated the vulnerability not only of older people, but particularly in environments such as care homes, where the most vulnerable of our society are gathered in enclosed proximity. We have learnt through bitter experience, as well as thoughtful design, that it is difficult but not impossible to protect care homes from contagion.
This can be achieved through the implementation of systematised, high-quality mitigations with training, assessment against standard operating procedures and the collection of data and its evaluation in a regular audit.
Key measures that have proven, in combination, to be successful include:
- Bubbling staff (ensuring that staff and contractors do not visit multiple care homes)
- Advise and train staff to minimise their own exposure outside of working hours.
- Minimising entry and exit to essential visits from staff contractors,
- Protecting any person-to-person interactions with barriers to respiratory spread such as screens, PPE and monitored good ventilation of shared spaces
- Enquiring about symptoms,
- Where possible, by objectively screening for signs of disease and visitors (such as temperature),
- Where possible, undertaking objective diagnostic testing (PCR) with necessary swift results turn around. This has been limited to weekly and report of results taking up to 4 or 5 days have limited the value of this powerful mitigation.
- And through limiting interactions with residents and zoning within the care home.
Limiting interaction with residents is the most difficult, psychologically and socially, as it can be so damaging to human wellbeing, particularly when the person, isolated, too often cannot understand why, and can become extremely distressed. Loneliness and confinement are terrible – used in penal and torture regimes to break people. Often, we hear later, when those torture victims return and tell their tale.
The elderly and frail who live in care homes are by their situation the most vulnerable, and often have little or no voice to express their experience, complain or demand changes and improvements. It is terrible to imagine the intensity and widespread nature of personal torture and tragedy where the elderly often confused people are denied physical contact to ensure their safety.
Now proven effective vaccines are on the way, it is tempting to think that the worst has happened. Yet, for the next 6 months to a year at least, the same tragic painful situation will persist. We will not be anything like back to normal for a long while, and many questions remain as to whether Covid-19 will become endemic and reappear year on year with the necessity to re-vaccinate with risks during that vaccination campaign period.
We cannot afford to coast our way to the vaccine -we must not stop to breathe and sit out and tolerate the ongoing harm in the belief that it will all soon be over while the tragedy of care home covid-mitigation imposed loneliness persists. So how can the sector best deal with managing the Covid crisis and, at the same time, ensuring that the devastating effects of isolation for residents from families, particularly dementia sufferers can be minimised?
We must do everything, use every available mitigation to minimise the isolation and confinement of elderly, vulnerable and often confused care home residents.
Weekly PCR testing of staff is now widespread but delays in the return of test results reduce its effectiveness in protecting care homes. Trials of on the spot testing with lateral flow technology are underway, but relatively low sensitivity (up to 30% false negative) limits the confidence that a negative test gives.
In this context, daily temperature assessment has now been mandated at least by the Scottish Government as part of enhanced measures for care providers.
A focus on ensuring widespread good ventilation in shared spaces, as well as the usual PPE/cleanliness-based mitigations, can vastly reduce the risk of interactions. If these measures are implemented fully and well in a systematised, verifiable and audited manner they can give care home management confidence. If these measures are not in place and implemented well, they may expose care home operators to liability for failing in their duty of care towards residents.
The challenge isn’t so much the absence of strategic and technological solutions but the lack of systems, operational expertise and oversight structures that are required to ensure the mitigation strategies are effective. Data and technology can come to the rescue but only in the context of a fully scoped system designed with continual quality improvement. This continued quality improvement is possible through the systematic automated collection of data, analysis of these data and feedback on performance against key performance indicators.
The challenges to implementing these processes and systems are great and yet solutions already exist to provide key elements such as a symptom recording and body temperature assessment and recording of C-19 test results evidence for staff, visitors and residents. This allows acceptable mitigation of what is a very personal and intimate interaction but in a way that does not impose on the privacy of that interaction.
There is now a window of opportunity to ensure the safety of our most vulnerable. The care home sector must rise to the challenge.