Care home facilities as new COVID-19 hotspots: Lombardy Region (Italy) case study

To the Editor

On March 8 2020, Lombardy Region passed the Council Deliberation n. XI / 2906, establishing urgent measures to create surge capacity for COVID-19 patients, while maintaining continuity of essential services (Ulteriori determinazioni in ordine di emergenza epidemiologica da Covid-19; DGR N° XI / 2906 seduta del 08/03/2020, 2020).

The Decree introduced a major healthcare system reconfiguration, demanding, among others: 1) to postpone non-urgent elective surgery and procedures to preserve equipment and protect staff/patients from unnecessary risk of viral exposure; 2) to redefine the time-sensitive hub-and-spoke networks for the management of stroke units, trauma centers and vascular surgery; 3) to early discharge hospitalized patients (included COVID-19 in stabilized status) to step-down bedded facilities. The Directive also provided eligibility criteria for COVID-19 admission to the recipient facilities (afebrile status for >3 days and improved respiratory symptoms) and called on coordination with downstream private and public providers.

According to the Decree, the care home (Residenza Sanitaria Assistenziale, RSA) should be equipped for patient isolation, avoid mixing COVID-19 cases with other residents, and provide dedicated staff to care exclusively for suspected/confirmed COVID-19, to mitigate the risk of further SARS-CoV-2 spread.

On March 30 2020, Lombardy Region passed a second Council Deliberation (n. XI / 3018) establishing further guidelines for the admission and care of care homes residents. These include, among others: 1) the temporary cut of patients’ turnover in RSA due to the emergency; 2) restrictions on family visits to the care homes; 3) for RSA providing continuous medical assistance, the obligation to reserve 50 % of the available beds for COVID-19 cases (Ulteriori determinazioni in ordine all’emergenza epidemiologica da Covid-19- indicazioni per gestioni operative per RSA e RSD, 2020).

The measure resulted in unprecedented death toll among RSA residents in Lombardy (1.822, 17 April 2020) (Survey nazionale sul contagio COVID-19 nelle strutture residenziali e sociosanitarie SECONDO REPORT Aggiornamento 06 aprile ore 9.00, 2020). Although the number of SARS-CoV-2 testing for viral clearance performed across the care homes was limited, evidence suggests that the percentage of deaths due to suspected/confirmed COVID-19 cases ranges from 40 to 51.3 %. A commission from the Italian National Health Institute and Lombardy Region has been set up to further investigate the outbreak (Coronavirus Lombardia, 2020).

In part, the outcome reflects the wider issues afflicting infection control compliance in Italy: 1) the systematic failure in the provision of personal protective equipment (PPE), posing at risk both health workers (34.1 % infection rate among RSA personnel reported in Lombardy) and residents; 2) the lack of care providers, preventing exclusive health assistance for suspected/confirmed COVID-19; 3) and the COVID-19 inadequate testing policy, facilitating the transmission of SARS-CoV-2 by asymptomatic or paucisymptomatic cases.

The COVID-19 pandemic disproportionately impacts on the oldest and frailest people. Unprepared care homes have emerged as new COVID-19 hotspots, struggling to secure safe lockdown for elderly residents, at risk for severe and fatal SARS-CoV-2 infections. As the umbrella group for Italian Nursing Homes (Associazione Nazionale Strutture Terza Età, ANSTE) is committed to provide additional support for all member care centers, strong political consistency and social action are imperative to build the momentum for a coherent elderly care during COVID-19.

Authorship contributions

All persons listed as authors have contributed to preparing the manuscript and their authorship meets the International Committee of Medical Journal Editors (ICMJE) criteria.

Declaration of Competing Interest

We have read and understood the Journal policy on declaration of interests and have no relevant interests to declare.