How did experts miss crisis in nursing homes?
How was the deadly Covid-19 storm in nursing homes missed?
‘The disability sector is only going on that curve now’
Our care facilities have become the focus point in the coronavirus pandemic, reports Maeve Sheehan
ON April 3, the first case of Covid19 was recorded in the Maryborough Centre in Co Laois. Public health authorities are unsure how the virus was introduced to this old building, according to sources. The psychiatric facility for elderly people, which is also known as St Fintan’s Hospital, is an old building where older people share rooms.
Staff at the hospital are not speaking about the tragedy that unfolded there last weekend — their employment contracts don’t permit them to. But informed sources say the public health officials are still unclear how the virus got through. The suspicion is that it was introduced to this captive group of vulnerable people from the community, possibly by a health worker. Once in, it multiplied to devastating effect. Within a matter of five days, half of the ward had been infected. In 14 days, nine people were dead, eight of them from Covid-19.
Older residents were tested as they developed symptoms. Staff attempted to cohort all the Covid-19 patients together, which is considered good practice when patients have to share rooms.
As Easter weekend approached, several patients had deteriorated. According to one source, consultants from the Midlands Regional Hospital in Portlaoise treated the patients via “teleconference” and called in person over that weekend. Patients were given palliative care. Local priests visited the hospital in person and prayed for staff and residents from within the grounds.
Ger O’Neill, Theresa Sherlock and Velma Jackson died on Easter Sunday. Danny Delaney died last Tuesday, after the bank holiday weekend. The death notices pay tribute to staff, and Mr Delaney’s wife, Doreen, praised them to RTE’s Prime Time last week. “I thought, well I’m going to speak up for them [the staff ] because there is not one derogatory thing I could say about them, not the smallest thing. They were brilliant,” she said.
Her late husband, who played football for Laois and was a senior official in the GAA, was ill with other conditions.
“Covid-19 only presented itself in the last two weeks,” she said. The worst part was that she wasn’t allowed into see him, even from a distance. “I wasn’t allowed anywhere near him,” she said. “But the staff did absolutely everything. They held a phone up to him and let me speak to him on the phone.”
Despite the eight deaths, the way Maryborough has handled the outbreak has been held up by the health authorities as a model of care at a time when the coronavirus pandemic has ripped through one third of the country’s nursing homes with devastating effect.
Contrast that with another public care facility in Dublin which struggled for two weeks to contain an outbreak that, according to one source, has infected more than 50 residents.
TESTING AND SUPPORT
Two week ago, as the outbreak was brewing, the geriatric medical team at St Mary’s Hospital, in the Phoenix, reached out to Jack Lambert, consultant in infectious diseases at the Mater Misericordiae Hospital in north Dublin city.
They asked for his help in getting residents tested for Covid-19. The Mater, like other hospitals, has its own testing facilities, but the national testing service, rolled out by the Department of Health and the HSE, was running a massive backlog.
“Our hospital came to bat to do the testing because no other facilities were available to them,” Dr Lambert said. “Our doctors have been going in there to support the staff.”
The hospital has also been testing other care facilities across its catchment area, and previously unreported cases of Covid-19 have been detected.
“We detected many Covid-positives in care homes that were never previously identified because no testing had been done,” Dr Lambert added. “People have died in nursing homes and they have not been tested. The numbers of unaccounted deaths is much higher. The scale of infection in nursing homes is more than likely greatly underreported.”
Dr Lambert last week called the level of infection in nursing homes a “catastrophe”. “The Mater is doing this off its own bat. But this can’t be done as a “special favour” to nursing homes — it has to be done as a national mandate that we all have to step up and do this,” he said.
Yesterday the HSE confirmed that 12 residents of St Mary’s have died over the past fortnight, 11 of whom were confirmed as being Covid-positive, and it said significant numbers of residents have been infected.
The Government’s response to the coronavirus pandemic has been commended internationally; the restrictions are working, the curve is flattening, the expected surge of critically ill Covid-19 patients that risked overwhelming the health system has failed to materialise.
However, cracks are appearing and nursing homes are the fault line.
There is mounting concern that the authorities in charge of the health service, the experts on the National Public Health Emergency Team that advises the Government on policy, the Health Service Executive, the Department of Health and ultimately the Health Minister, Simon Harris, failed to anticipate the contagion that has swept through public and private nursing homes.
This weekend coronoavirus clusters are in 196 nursing homes and another 139 residential care settings. More than 250 nursing home residents have died since the beginning of the pandemic — accounting for more than half of all Covid-19 deaths in Ireland — and that number is expected to rise.
Nursing homes report continuing shortages of personal protective equipment (PPE) and several consultants have privately confirmed that there are big concerns that staff are not being trained properly on how to use it.
In a confidential memo circulated to nursing home providers last week, Dr Colm Henry, of the HSE, advised that gowns and respirator masks will become depleted shortly unless new supplies are secured. The demand was in part because the HSE had had to supply nursing homes with PPE — something the email suggests it hadn’t envisaged having to do. Dr Henry’s advice to staff was to spare gowns and not to wear them if they are at low risk of infection, and to save them for Covid-positive cases only. “Given the critical supply situation, the session may need to include care of patients with confirmed Covid-19 and those with suspect Covid-19,” the memo said.
It advised staff to cover cloth gowns with plastic aprons as a temporary measure if required.
One private nursing home operator in Dublin emailed politicians about the “crazy situation” involved in trying to get staff tested so they can return to work.
“The only way that they can get tested is through their GPs who are refusing to test them as they do not show symptoms,” they said. “We have contacted the HSE and they advised that it has to be done through their GPs. We need to protect our residents and staff. These people are needed in the home as the present staff are working long hours and this is unsustainable going forward.”
At a press briefing last Friday, Dr Henry was asked if action should have been taken sooner.
“Time will tell,” he replied. He added that nursing homes are a “huge challenge” with staff moving between different care settings and a population of older, frail people, in whom the disease is harder to detect. They appear to show different types of symptoms for Covid-19 than younger people, who typically develop fevers, dry coughs and headaches.
But his answer does not explain why an expert group of key health officials, drawn from the regulator Hiqa, various government departments and health agencies, and academics, was not more prepared for the contagion that puts the lives of some 30,000 residents at more than 500 nursing homes at risk, and has killed some already.
When asked about this last week, Dr Siobhan Ni Bhriain, the HSE’s group lead for mental health, said the HSE had “recognised the potential difficulties in residential facilities very early” and had been working with nursing homes since January.
Private nursing homes — which accommodate 28,000 residents — have been left knocking on the door trying to get in.
CRISIS POINT
Nursing Homes Ireland (NHI), the industry group that represents 300-plus private operators, has spent most of the pandemic dealing with civil servants but had no representation on the National Public Health Emergency Team, and had to wait until infection reached crisis point to secure a meeting with the Health Minister.
In the interim, NHI announced visiting restrictions across all private nursing homes to protect residents from the risk of infection. Four days later, Chief Medical Officer Dr Tony Holohan declared the measures “unnecessary” because of the social impact they would have on residents.
The decision reflected the thinking at the time — the outbreak in Ireland was still in small numbers but Italy was entering the throes of a surge.
On March 19, NHI wrote to Simon Harris seeking an urgent meeting to discuss the risks to vulnerable nursing home residents.
Six days later, still no meeting secured, the organisation issued a public statement demanding one.
On that same day the HSE circulated its first guidance to nursing homes. In effect, it told providers that residents with Covid-19 should be transferred to hospital only if that would confer additional benefit.
It was not only nursing homes that were knocking on the door of the health service trying to have their voice heard on coronavirus.
Back in February, the Disability Federation of Ireland (DFI) had been pushing for representation on the National Public Health Emergency Team (NPHET), the experts guiding Government policy on its response to the crisis. The NPHET has been monitoring coronavirus since January and put together several subgroups to advice the Government on specific issues. Behavioural scientists helped it assess how the public would respond to restrictions and epidemiologists are advising it on how fast and how far the virus might spread.
The DFI eventually got its representation on the NPHET, when it decided to appoint a “vulnerable sub-group” to advise it on the impact of the virus on older people and people with disabilities who were more likely to become severely ill. The sub-group met for the first time on March 6, when Ireland was in the first week of the coronavirus outbreak.
Dr Joanne McCarthy, head of policy and research at the DFI, who sits on the subgroup, said its work has not been straightforward.
She said this weekend that the sub-group had a lot of work to do in translating the expert group’s advice in trying to interpret the NPHET’S guidance for settings where things like social distancing were simply not possible.
There were issues with the health regulator, Hiqa, over residential centres that wanted to alter their layout to accommodate more single rooms or hubs for residents who were Covid-positive. It took two weeks to sort out what sort of permission the centres would need. By then it was mid to late March and Ireland’s Covid-19 rate was rising, and the first clusters had been identified in nursing homes.
CONTAIN THE SPREAD
“We are behind the nursing homes. The disability sector is only going on that Covid-19 curve now. We’re hoping that because most people are living in smaller family units that might contain the spread,” Dr McCarthy said.
“What’s happened is we are learning from what’s gone wrong, and the challenges faced by nursing homes.
“There will be challenges. PPE is an ongoing issue in the sector. I couldn’t be confident in saying that every organisation has three days’ supply of PPE.
“At the same time, I do know where people have needed it and requested it, they have gotten it. We are learning. We have the benefit of hindsight.
“There are 2,000 people in larger centres for people with disabilities that would be particularly vulnerable in this current environment,” she added.
Last Friday, in its third reaction to a crisis that many believe it should have been more proactive in containing, the HSE said it would continue to ship stocks of PPE to nursing homes and care centres that need it. Staff and residents will be tested in nursing homes and residential care settings over the next week. A census of deaths across all these facilities is being carried out this weekend, covering all Covid-19 and non-Covid-19 deaths since the start of the year, regardless of how the deaths occurred, in a bid to address concerns that deaths in nursing homes have been under-reported.
The HSE’s actions have been welcomed but were described as belated last week by senior medics.
Behind the scenes, sources say, cracks are showing in the united national front against coronavirus.
Bill Tormey, a pathology professor at Beaumont and Connolly Hospital, said there are many questions to be answered. What was the role of the nursing homes regulator, Hiqa, in preparing care facilities for the pandemic? Why are all healthcare staff and patients not being urged to wear face masks and are they getting enough support?
“It is important to realise the frightened state of many of the staff in nursing homes who are often of non-EU origin and who have witnessed the deaths of many of their residents at the home. They worry for themselves, their clients and their own families in case they bring home the infection,” Prof Tormey added.
In a statement yesterday the HSE said there was a clear decision to include the vulnerable residents of nursing homes, whether private, public or voluntary, in the consideration as to how to manage the situation.
“Since January of this year the HSE has engaged with nursing homes to assist them and their residents. This has been both nationally, through Nursing Homes Ireland, and locally through individual providers through the Community Healthcare Organisation (CHO) network.”
According to one senior health source, the big concern was protecting hospitals from being overwhelmed with critically-ill patients.
The contingency planning was efficient and expert, beds were cleared, space was found and, in a bold move, private hospitals were taken under public control for the duration of the emergency — although aspects of the deal remain in dispute.
“They were looking at hospitals. They were not looking at nursing homes. You could argue this is forgiveable — all over Europe, the story of older people dying in nursing homes was drowned out by the appalling deaths of people dying in hospitals because there were not enough ventilators,” the source said, pointing out that some countries have not been counting nursing home deaths.
“But these are experts. They look beyond the headlines, they would have had data coming at them from the World Health Organisation. There seems little doubt that they missed a trick.”