PPE shortages, lack of testing, and a vulnerable population have seen care homes in England and Wales become hotspots of the COVID-19 epidemic. Talha Burki reports.
On May 15, 2020, the UK Office for National Statistics (ONS) released provisional figures on deaths involving COVID-19 in the care sector in England and Wales. From March 2 to May 1, 2020, COVID-19 was confirmed or suspected in the deaths of 12 526 individuals living in care homes in the two nations. Worrying as these figures are, they only capture official notifications; when taking account of excess mortality, the situation appears even worse. In an average year, the care sector in England and Wales sees roughly 20 000 fewer deaths during March and April than have been recorded in 2020.
Once COVID-19 enters a care home, it moves quickly. By the time the first patient displays symptoms, up to half the residents might already be infected. Care homes have found it difficult to obtain adequate quantities of personal protective equipment in a reasonable time, with providers tending to prioritise the National Health Service. A survey by the Alzheimer's Society found that almost half of care homes were not confident in their supply of personal protective equipment; one facility said it had started taping bags over staff members' hands, feet, and hair.
There have also been difficulties in getting hold of enough tests. “People have been trying to isolate residents and manage outbreaks without knowing who had the virus; that is an incredibly difficult task”, said Adam Gordon, professor of the care of older people (University of Nottingham, Nottingham, UK). According to a report by Sky News, homes had been pressured into receiving patients with COVID-19 from hospitals. Until mid-April, official advice stated that “negative tests are not required prior to transfers/admissions into the care home”. It was only on April 28 that the government stipulated that all residents and staff should be tested for the virus.
“You had a situation where care homes were forced to bring in people who probably had the virus, they did not have any means of testing, and they did not have the tools to keep people safe”, points out Adelina Comas-Herrera, a research fellow at the London School of Economics and Political Science, London, UK. “It was a toxic combination.”
The sector is already facing a staffing crisis. Pay for care home workers tends to hover around minimum wage, despite them performing a similar job to nurses. If they do not work, they do not get paid. That makes choosing to self-isolate a costly decision.
The ONS noted that 9039 of the 12 526 deaths involving COVID-19 from March to April occurred within a care home, while 3444 deaths occurred within a hospital. Gordon is not surprised by the disparity. “This is a group of people who are very frail and often have multiple morbidities”, he said. “Many patients in care homes feel that they are coming to the end of their lives; they make a conscious decision not to go to hospital but to receive care within the residential facility, even if that means palliative care”. In the vast majority of registered cases, care home residents who died from COVID-19 had at least one underlying condition, most commonly dementia and Alzheimer's disease. This is hardly surprising; around 80% of residents have some kind of cognitive impairment. Patients may deteriorate so quickly that there is no time to get them to hospital; COVID-19 can kill soon after the initial appearance of symptoms.
Comas-Herrera points out that even if the majority of this year's excess deaths in care homes are not directly attributable to infection with SARS-CoV-2, that does not mean they are not a consequence of the pandemic. “COVID-19 has been hugely disruptive; it has affected all aspects of care”, she said. Isolating residents may mitigate the spread of the virus, but it is associated with morbidity of its own. Care homes are built for communal living and staffed accordingly. The lack of supervision places isolated residents at increased risk of injury, particularly from falls, and their mental health might suffer. People with dementia often stop eating if they are depressed, which can hasten death. Besides, it is no small task to persuade people with dementia to stay in their rooms and maintain physical distancing. No-one wants to see caregivers resort to restraining or sedating residents.
England and Wales are far from being the only countries struggling with an epidemic of COVID-19 within the care sector. The French death toll is not much smaller (12 511). Care home residents represent around a third of the total number of reported deaths from COVID-19 in England and Wales, which is in line with several countries of similar income levels. “Even nations who have done well to control the overall epidemic, such as Germany and Norway, are seeing a high proportion of deaths among people in long-term care”, said Gordon.