Safe infection prevention and control practices with compassion – A positive legacy of COVID-19

To the editor:

We read with interest Kim et al's letter in the October 2020 issue of AJIC, Lessons learned – Outbreaks of COVID-19 in nursing homes. The letter summarizes the authors’ experiences of developing guidance designed to prevent the spread of COVID-19 within a nursing home setting. As the authors state, the lessons come from the perspective of infectious disease doctors and health care epidemiologists and 5 lessons are presented. The authors call for a reimagining of how care is delivered in nursing homes, including greater investment moving forward in both infrastructure and access to infection prevention expertise in order to keep residents and staff healthy. We support this call to action.

However, we would like to draw the reader's attention to the first and last of the 5 lessons, since both touch on the issue of visitor restrictions, what the authors refer to as “prohibitions.” In considering prohibitions, it is interesting to note that the authors do not address the impact of such restrictions, as part of infection prevention actions, on either residents or their families. In many countries, there has been a growing level of “noise” on how infection prevention and control (IPC) measures in the context of COVID-19 are being employed in nursing homes, and the implications that can arise in terms of collateral harms to both residents and families. As IPC experts, we became increasingly alarmed to see reports in the media, and particularly social media, of prohibitions on all visits to such settings that were implemented at the start of the pandemic in the name of infection prevention. In too many instances, these have remained in place. With few exceptions it is apparent that even when some visits were re-established, these were outdoors or behind windows or even from parked cars, to ensure physical distancing. Multiple shocking stories have been shared where, even in end of life situations, entry has been restricted to only one family member, at distance, wearing full personal protective equipment and for a limited period of time – minutes rather than hours. These heartbreaking stories influenced a group of us, including many infection prevention experts, to come together via social media (Twitter) and rapidly draft what we deemed to be the first step in an engaging approach, and issued an open letter in a UK nursing journal.¹ The letter has received widespread attention in the United Kingdom and beyond, from both other infection preventionists and many concerned people including within campaign groups and political positions. Here we share our own 5 considerations, described in more detail in the letter.

• 1.The “rules” of IPC do not and should not prevent family members and close friends of residents entering a home, even during lockdown;
• 2.IPC should instead be used as an enabler and supporter of safe entry to homes. If masks, hand hygiene, appropriate use of other personal protective equipment and a hygienic environment are promoted in all settings, these measures can protect vulnerable residents in homes, when applied properly;
• 3.The longer the current situation prevails, the more likely it is to become routinized and de-implementation could become a concern in the future. Already we are hearing, for example, that some homes are considering outdoor heaters to support outdoor “visits” by families in winter and the use of video call technology is becoming an unacceptable “norm.” This is not the answer; these are peoples’ own homes, often at the later stages of their lives;
• 4.IPC and compassionate care are not mutually exclusive. The restrictions or bans must be lifted and not just for immediate end of life situations.
• 5.Families provide (unpaid) care too – all IPC recommendations for paid caregivers can be applied to others; In summary, IPC should be applied as a force for good.

The letter also calls on a range of different groups who have the opportunity to influence this agenda in a positive way going forward, outlining a call to action to positively address the prohibitions, emphasizing` that infection prevention measures can allow for safe and compassionate interactions. Additionally, there is the very worrying matter of deimplementation to address. Once in place, examples such as outdoor visits and the use of technology to replace face-to-face family interactions become routinized.

Finally, in preparation for this letter and to help grow this narrative, a rapid search of the grey and published literature on IPC and compassion per se was also undertaken. This yielded a small number of papers and reports, the majority of the former related to HIV and AIDS. Of note a United Nations Policy Brief issued in May 2020² describes the untold fear and suffering to older people as a result of the pandemic including the less visible but no less worrisome dramatic impact it has had on their well-being and mental health.

Our intention in writing this letter is to intensify the spotlight on this matter and in particular on the need for IPC experts in all countries to redress what we believe to be an imbalance in focus between the technical, practical measures, which naturally need to be employed to keep everyone safe, and the urgent need to ensure measures always takes place in a compassionate milieu. We believe this is of relevance to all and note with interest the inclusion of APIC president as part of the Independent Coronavirus Commission on Safety and Quality in Nursing Homes.³ Our voice, our focused messaging, relates more to the application, implementation and interpretation of infection prevention measures rather than guidance itself. We now have the opportunity for a new conversation on infection prevention and compassion; one that ensures measures are always applied in a humane context. In conclusion, IPC works⁴ and we believe that safe IPC practices can be implemented with compassion. Strengthening compassion throughout infection prevention guidance and practices could be a positive legacy of COVID-19.

RESPONDING TO THE LETTER FROM

Kim J, Coffey KC, Morgan DJ, Roghmann M-C (2020) Lessons learned – Outbreaks of COVID-19 in nursing homes. AJIC vol 48, issue 10, p1279-1280