- 14 April 2020
- 16 min read
Care Homes vs Covid – Fighting an invisible enemy
Care Home Manager Liam Palmer, assesses the risks to frontline healthcare workers and asks can we limit outbreaks in our care homes?
Topics covered in this article
I've been asked again to share some thoughts on the effect of the outbreak on the residential sector.
At the time of writing (11/4/20), the residential care sector is starting to report clusters of deaths at care homes.
All those who work in residential care know how a virus can go through a home, we’re used to using barrier nursing techniques / isolation in response to outbreaks of norovirus, it’s not new to us but that this particular virus is more contagious and brings a higher level of threat to life.
We also have the concerns for the welfare and safety of staff to consider about working in this environment and contracting it themselves.
I think the current level of departures in care homes due to Covid is underestimated for many reasons.
Up to this point, it has not been included in the daily death rate quoted from hospitals.
In some cases, when a resident passes then there is a sudden surge in deaths in a care home.
I’ve read in the media that often these other individuals are not being tested to see whether their death was due to this outbreak.
The care sector is different from the NHS
The care sector is different to the NHS, it’s a large group of independent operators, there is no central reporting like with the NHS (aside from to the CQC).
Also knowing it is happening, what can be done?
Family can’t visit anyway.
Doctors will advise but avoid home visits where possible for their own protection.
It’s really a tough time, some care homes are having their staff or manager live there to reduce the risk.
We all feel for families that lose their loved ones over this time as they are not able to visit as they would, not able to comfort and reassure in person.
Of course, we are all embracing technology more but not everyone is able to adapt.
Our hearts break for those losing loved ones without the goodbye they had hoped for.
A resident (wife) was in tears at how she couldn’t comfort her husband in his final days and hours at a site I oversee.
That moment can’t be re-run.
The actual end of her long marriage.
It’s really tough.
The government has given clear guidelines on which PPE to use, it is regularly being updated and adhering to this gives a real level of protection against this virus, though our understanding is still limited.
Naturally, securing suppliers to meet these guidelines is a first priority and the government is stepping up to assist with this, a massive logistics effort.
It’s great to see how social care is being acknowledged more and more.
We employ around 1.6m staff versus 1.4m staff in the NHS.
It’s not a competition, we are 2 parts of healthcare delivery but the recognition of the importance of the work within social care is long overdue.
As per my previous article, this post does not claim to provide advice on how to respond to the pandemic but rather to question our assumptions as we swiftly respond in real time to this outbreak.
Disclaimer complete. Let's continue.
Acknowledging the Government’s limitations
The administrators, managers and leaders of nearly all private, charity, government organisations are now at home, as per government advice, deciding how best to respond to this pandemic.
That’s a lot of talent now working from home.
In this time of chaos, it's right and reassuring to put a degree of trust in authority (government, the organisation, respected media channels) and yet at the same time, we must acknowledge the limitation of their current knowledge.
The same government we are following is the same one that really underestimated the threat to the UK, didn’t impose checks on those returning from high risk countries, put the lockdown a bit too late and has been slow to roll out mass testing.
Not a criticism, just reality.
No one gets it right all the time.
We must follow all relevant government guidelines but retain responsibility for making informed choices to keep our facilities and residents / teams safe.
So much is not known yet.
In some cases, we may need to create some additional measures to reduce the likelihood of outbreak in our services and take more stringent action to protect our vulnerable residents and loyal staff from harm.
Less people on the ground reporting what is actually happening
As of 11.4.20, there are a few dynamics at play which are worth being aware of, they compound the difficulty to clearly assess and respond to developments effectively; With the media also at home, you have everyone at home, looking on the web to see what's going on, to see what is everyone else is doing!
Let me confidently predict what is happening - everyone is at home, watching the news, on the web, checking what is going on.
That's pretty much it!
Unless of course, you work in an essential service or at a healthcare facility – hospital, hospice or care home for example.
There has never been less people on the ground reporting what is actually happening.
I've been visiting sites for essential support visits to residential services these last few weeks.
Let me be your eyes for a moment; Carers are scared, very scared.
I witnessed one shouting at a manager.
It's palpable fear, fear of contracting it today.
The media has stoked it and yet the risk is real but the daily updates are paralysing for some.
Colleagues in various organisations have told me that when carers hear there is someone with Covid, some are refusing to come on shift.
The fact that most cases are mild does little to reassure staff who are working on the frontline.
Staff may be overestimating their risk of serious harm but we can understand and respect why that may be.
This made me think about what happened recently in Spain where many old people were left to die in a care home.
It's incomprehensible and also understandable; It is incomprehensible to leave vulnerable old people to die in a care service, unforgivable and yet if you were a staff member, it's understandable.
If you knew there was a potentially deadly, highly contagious virus in your workplace and you didn't have adequate protection to shield yourself from it, or didn't believe that the PPE was sufficient you, what would you do?
No need to answer.
Self-preservation is a primary instinct for us all.
Therein is part of the dilemma, how do we balance the needs of the service with ensuring the highest levels of safety for our trusted staff within the services?
Following PPE guidelines
Naturally, we are all following to the letter the guidelines for PPE.
This certainly gives strong protection.
I think it is worth taking a moment to think about risk to reassure staff and also for a sense check for ourselves.
We know that medical teams working in intensive care are being given full hazard suits and full masks as those that they are treating will have lungs full of the virus, one cough (and a symptom is continual coughing) can be deadly to those medical staff.
This seems proportionate.
In the media, I’ve seen in South Korea, (very well managed Covid response with minimal loss to life), the A&E emergency hospital staff there have full head gear to reduce the risk of contamination even further.
Makes you think doesn’t it?
But what about paramedics, district nurses who may be spending up to 30 mins with a patient / resident with Covid symptoms, do they need this higher level of protection?
I’ve heard conflicting anecdotes but many in this group are wearing a full suit when visiting someone is confirmed / highly likely to have Covid, as it is so contagious, using an extra barrier of protection.
With doctors, nurses and carers succumbing to the outbreak (a carer friend of mine in Birmingham nearly died last week of due to Covid), it makes me question whether the experts recommended levels of PPE are adequate for these groups with high levels of patient contact?
Makes you think doesn’t it?
Lastly, what about the carers?
Those who are spending several hours a day providing personal care to residents – washing their hair, assisting them to shower or wash themselves, assisting with continence support, cleaning their teeth.
The level of contact for carers is high, especially with nursing homes and their residents with higher levels of care required.
Do they warrant this additional level of PPE protection?
What do you think?
The risk of transmission through the closeness and duration of contact is surely something the healthcare community needs to think about?
Is this a contributory factor as to why when Covid enters a care home, it often spreads so swiftly and leads to so much harm?
I am no expert but again, it does make you think doesn’t it?
It could be that the healthcare community after reflecting on new research and findings around the transmission of the virus will update these PPE protocols for frontline workers.
In the future, it could be that we learn that once Covid is present in a healthcare setting (or a similar type virus) a far more stringent lockdown and infection control protocol is required.
If I was a betting man, I would guess that the best way to contain this contagious virus in a healthcare facility would be a massive ramp up of infection control / deep cleaning with operatives fully protected and those providing care with higher level infection control to limit transmission.
It would be where those with Covid or suspected would be physically quarantined in an area of the home so that the carers don’t carry the virus throughout the home!
Then you could manage the staff in that area and have the highest levels of infection control there.
That may help limit the spread.
I’d also look at the strength of the disinfectants being used during the outbreak – are they fit for purpose in killing the virus during cleaning?
Obviously it is preferable that an outbreak in the general population is blocked earlier but we are where we are in the UK right now.
Limiting the spread (if it does come in the care home) needs to be our focus.
Check your employers liability insurance is current, that you have risk assessments in place for the virus and adequate training for the correct use of PPE.
It's also worth taking a moment to consider our legal obligations around employee safety – it is the duty of an employer to provide a safe working environment and a further duty to provide the necessary safety equipment to keep them safe in the performance of that job.
This week, the nurses union (RCN) are advising nurses about potentially declining to provide nursing care if not given the correct PPE equipment.
No doubt there will eventually be compensation claims where an employer has not provided adequate PPE and the employee passes.
In the meantime, let's look at what we can do to minimise the risks.
What can we do to reduce possible outbreak in our services / reduce the risk to our staff?
- Continue to try every means necessary to get hold of adequate appropriate supplies.
- Talk to staff to manage usage of items that are harder to source / replace – e.g. masks. Do staff use them once after seeing each resident? Change every few hours? You need to balance managing risk with availability and practicality and science.
- Understand that managing an outbreak is an infection control matter. Get an infection control subject expert to help you and your teams strengthen their good practice in use of PPE. Do regular drills, updates, meetings to reinforce this essential point.
- Regularly talk to staff about the chain of infection and how their interactions outside the home can bring the virus into the home. Everyone must be vigilant and this message is unchanging until this passes. A chain is only as strong as the weakest link.
- Vigilance with first line of infection control – wash your hands after work, wash your clothes after work. Repeat.
- Think about implementing a quarantine area in the home to move residents with Covid. At the same time massively upping efforts around infection control to block the transmission.
- Put on many more housekeeping shifts. Buy more appropriate disenfectant for cleaning that kills all viruses. Cover all bases!
- Don’t forget to apply all this to yourself. These services need leading and we need you if you are working there to stay well for your sake and ours.
- As much as possible be reassuring to your staff whilst managing the most stringent controls possible. The staff need to know you care for the residents and for them and will back you as they see that / hear that from you.
Why might we consider going to a higher level up of infection control PPE for our front-line care staff now?
On Weds 08.04.20, a nursing home in the USA recently moved out all their 83 residents as no staff turned up for several days.
This is a threat to our services too.
Re carers having full hazard suits - it seems improbable it's needed and impossible to source yet that's what the government said in January about locking down the UK!
It happened two months later.
Just in case we do decide to take action on this, how could we source and plan this higher level of PPE protection?
- Start with the maths – number of suits needed per day for x carers to support 1 resident with Covid. Multiply by more residents. Make it a weekly total. Plan for 10%, 25% and 33% of the residents in your homes getting Covid and work out how many you'd need. Multiply that by your number of homes. That's the maths for the suits.
- Do the same for masks
- Don't focus on the extra cost. Staffing costs for residential care are likely to dramatically increase with covering sickness and occupancy will likely vary significantly. In the midst of this unprecedented time, finding more money for PPE will be simply good sense.
- If you are wondering…how am I going to get 10,000 suits made and 1500 high spec masks?! Remember nearly all the factories are closed, all the staff are at home, councils, CCG's everyone wants to help. There is production capacity out there at this time. Do what you need to. Get prepared! Follow your instincts if that means going beyond current government guidelines. Just do it.
In closing, we have to remember that nobody has ever experienced a situation such as this before.
These are unprecedented times we are living in.
It is easy to criticise government agencies for example for not providing all of the PPE we require and for not ensuring that PPE supplies match the advice given, but these are real people doing their best, like us, they are scared for their wellbeing and for their families.
Senior managers and owners and other stakeholders across healthcare are all working tirelessly around the clock to keep everyone safe and do their very best for their staff and residents.
After this has passed, in retrospect it may be clearer what steps we missed but in the midst of this fight against this virus, let’s focus on collaboration, helping each other in our shared time of need.
Who knows what we can achieve when we pull together.