COVID-19 in nursing homes

One of the tragic legacies of Hurricane Katrina in public consciousness was the disproportionate loss of life among older nursing home residents.1 Given the similar lack of preparation and reserves in the nursing home sector in the course of many other natural disasters, the coronavirus disease 2019 (COVID-19) pandemic poses urgent questions as to whether healthcare systems and professionals have learned from these experiences. Older age and the presence of comorbidities are associated with increased risk of mortality in the current pandemic. The high prevalence of functional and cognitive impairment and behavioural symptoms add to the risk posed to nursing home residents,2 as well as environments which present barriers to infection control.3 In addition, healthcare professionals globally of all hues have neglected research, recruitment incentivization and quality improvement in nursing home care relative to other areas of clinical practice.4 This is further reflected by evidence of variable and often inadequate preparation for pandemics in the sector,5,6 as well as the absence of infection control from descriptions of the competencies of nurses in care homes.7 The synergy of these factors is reflected in the first major study of COVID-19 in a nursing home. Nearly two-thirds of residents were infected over a 3-week period, with a death rate of 33%: 50 staff members and 16 visitors were also infected.8 In Spain, it has been reported that a significant proportion of COVID-19 associated deaths have been nursing home residents. There is also a concern that many jurisdictions are not including nursing home deaths in the COVID-19 death toll. Although general guidelines emphasize the importance of strict infection control protocols, little acknowledgement is given to the unique challenges faced by nursing homes with significant levels of close-contact physical care. Low staff to resident ratios are further impacted by COVID-19 related sick-leave, quarantine and absconding, threatening the provision of basic care to sick isolated residents. Implementation of isolation procedures and education of residents can be exceptionally complicated for those with significant cognitive impairment and walking with purpose,2 the person-centred term for wandering. Parallels may be drawn between challenges faced in nursing homes during the current pandemic and those seen in previous infectious outbreaks and epidemics. Following the severe acute respiratory syndrome epidemic in 2003, a study showed that the majority of residents in a Hong Kong nursing home reported poor knowledge of the condition and staff reported concerns about contracting the condition themselves9: the willingness and ability of staff to work, and remain at work, may be impacted upon by a disproportionate level of perceived threat during pandemics and disasters. Several governmental agencies and professional bodies have drafted guidelines and statements regarding the provision of residential care during the COVID-19 pandemic of varying quality, scope and emphasis. These sources include the World Health Organization, the Centers for Disease Control and the British Geriatrics Society: the latter laudably highlights that residents who ‘walk with purpose’ will require special consideration.10–12 The implementation of these recommendations requires a more clearly developed governance and leadership structure in nursing homes than is often the case currently, such as the medical director role required by law in the USA. A common strand highlighted is the importance of early, collaborative advanced care planning.10–12 Provision of decision-making support and adequately resourcing facilities to provide good palliative care should also be prioritized.12 Preventive measures and practical advice on social distancing within residential care facilities have been recommended.12 The necessity of these measures in order to protect residents, staff members and the public is widely acknowledged. However, in addition to the challenge of resident understanding and walking with purpose, restriction of visiting and group activities may have a very negative impact on residents’ mental and physical wellbeing and needs to be judiciously implemented. The important role of informal support networks and care staff in the provision of practical and emotional support are undermined during these restrictions. Of considerable importance also is the safeguarding of staff mental and physical wellbeing. On a more fundamental level, education of staff, many of whom will lack dedicated gerontological and healthcare training, is essential in order to dispel myths and impart accurate information concerning the pandemic and optimal support of residents. Older people resident in nursing homes are demonstrably the group most at risk of adverse outcomes and mortality during the current pandemic. Early, collaborative advanced care planning, more formalized leadership and governance, and provision of education and support for residents and staff is essential. At a more fundamental level, a radical rethink is needed on how to develop and integrate high-quality nursing home care into the canon of core healthcare services, with adequate input from a range of gerontological specialities.13 Conflict of interest: None declared.