covid-19 nursing homes expert panelcovid-19 nursing homes expert panel examination of measures to...

COVID-19 Nursing HomesExpert PanelExamination of Measuresto 2021Report to the Minister for Health

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Abbreviations v

ExecutiveSummary 1 Introduction 1 EstablishmentofPanel&TermsofReference 1 Approach/Methodology 2 Review of Data 2 Evidence Review 4 Stakeholder Engagement 4 KeyFindings&PolicyConsiderations 5

1. Introduction 8 1.1. Long-termResidentialCareandCOVID-19 9 1.2. EstablishmentoftheNursingHomesExpertPanel 10 1.3. ReportOverview 10

2.Methodology 11 2.1. ReviewandAnalysisofEpidemiologicalData 12 2.2. RapidSystematicReview 15 2.3. ConsultationProcess 15 2.4. DirectEngagementswithNursingHomes 18 2.5. EngagementswithResidentsandFamilyMembers 18 2.6. InterimReport 18

3.EpidemiologyAnalysis 19 3.1. IrishNursingHomes:Background 19 3.2. PublicHealthSurveillanceandDataCapture 19 3.3. SupplementaryData 20 3.4. InternationalGuidance:SurveillanceandDefinitionsforCOVID-19CasesandDeaths 21 3.5. Definitions 22 3.6. COVID-19NursingHomeSurveillanceInformation 24 3.7. COVID-19andNursingHomes:InternationalComparisonsofMortality 33 3.8. MortalityCensus:Long-termResidentialCareFacilities 37 3.9. Summary 46

4.EvidenceReview 47 4.1. Introduction 47 4.2. Objective 47 4.3. Methods 47 4.4. SummaryofFindings(PoliciesandReports) 47 4.5. SummaryofFindings(SystematicReview) 48 4.6. Conclusions:ImplicationsforPracticeandResearch 49

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COVID-19 Nursing Homes Expert Panel Examination of Measures to 2021 iii

5.StakeholderConsultation:anIn-ActionandAfter-ActionReview 50 5.1. MeetingswithStakeholders 51 5.2. OrganisationsInvitedtoMakeaWrittenSubmission 56 5.3. NursingHomesConsultation 65 5.4. PublicConsultation 72 5.5. ConsultationonSiteVisitsandwiththosewithIndividualExperienceofCOVID-19 76 5.6. ExpertPanelAcknowledgement 77

6.HealthcarePolicyforOlderPeople:TimetoReviewtheModelofCare 78 6.1. ProvisionofServices 78 6.2. TheNationalTreatmentPurchaseFund(NTPF) 80 6.3. StrategicReformRequirements–theNeedforaPolicyShift 80 6.4. ProgrammeforGovernment(2020) 82

7.DiscussionandRecommendations 83 7.1. Discussion 83 7.2. Recommendations 101

References 114

Appendix1: Terms of Reference and Engagement 122

Appendix2: PublicHealthMeasuresforCOVID-19DiseaseManagement inLTRCsAdoptedbyNPHETatitsMeetingsof31st March 2020and3rdApril2020 124

Appendix3: SystematicRapidReviewofMeasurestoProtectOlderPeople inlong-termResidentialCareFacilitiesfromCOVID-19 125

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Table2.1 Summaryofreports,publications,andguidelinesprovidedtotheExpertPanelby SupportTeam 12

Table3.1 HPSCCIDRNursingHomedataasof27thJune2020 24Table3.2 TotalCasesandCasesAssociatedwithNursingHomeClusters 25Table3.3 COVID-19incidenceratesinnursinghomepopulation,comparedwiththosein

thegeneralpopulation 28Table3.4 ExcessdeathsfromEuroMOMOmodelin2017/2018InfluenzaSeason 30Table3.5 Age-specificcase-fatalityrates 31Table3.6 NumberofCOVID-19-relatedorconfirmeddeathsinthepopulationandincare

homes(oramongcarehomeresidents) 35Table3.7 MortalityCensusofLTRCs1stJanuary–19thApril2020 37Table3.8 OverallSerialTestingResultsto4thJuly2020 39Table3.9 SummaryofTestsandPositiveTestsbyFacilityandRegionto4thJuly 40Table3.10 NumberofHealthcareWorkersinNursingHomesConfirmedtohaveCOVID-19

byMonth 41Table3.11 TransfersfromLTRCincludingnursinghomestohospital 44Table3.12 TransfersfromhospitaltoLTRCincludingnursinghomes 45Table7.1 COVID-19NursingHomesExpertPanelRecommendations 101

Graph3.1 NumberofCOVID-19CasesinNursingHomesbyDateasa5-dayRollingAverage 26Graph3.2 NumberofCOVID-19outbreaksinnursinghomesnotifiedinIreland,byresidential

facilitytype(N=252),uptomidnighton27thJune2020 27Graph3.3 CumulativeincidenceratesofconfirmedcasesofCOVID-19per100,000population

notifiedinIrelandtomidnight28thJune2020 29Graph3.4 TotalnumberofdeathslinkedtoCOVID-19inthetotalpopulationand%of

COVID-relateddeathsamongcarehomeresidents,plottedusingalogarithmicscale fortotaldeaths 34

Graph3.5 Ireland’sreportedexcessmortality2020ascomparedtobaseline 36Graph3.6 Mortalitycensus–LTRCsettings,January–April2020 38

Tables

Graphs

COVID-19 Nursing Homes Expert Panel Examination of Measures to 2021 v

ACMT Area Crisis Management TeamANP AdvancedNursePractitionerCDC Centers for Disease Control CHO CommunityHealthcareOrganisationCIDR ComputerisedInfectiousDiseaseReportingCNM ClinicalNurseManagerCNO ChiefNursingOfficer(DepartmentofHealth)DMHG DublinMidlandsHospitalGroupDoH DepartmentofHealthDPH DepartmentsofPublicHealthECDC EuropeanCentreforDiseasePreventionandControlGRO GeneralRegistrationOfficeHCW HealthcareworkerHIPE HospitalInpatientEnquirySystemHIQA HealthInformationandQualityAuthorityHPSC HealthProtectionandSurveillanceCentreHPSIR HospitalPatientSafetyIndicatorReportHRB HealthResearchBoardHSE HealthServiceExecutiveIADNAM IrishAssociationofDirectorsofNursingandMidwiferyICGP IrishCollegeofGeneralPractitionersIEHG IrelandEastHospitalGroupIEMAG IrishEpidemiologicalModellingAdvisoryGroupIGS IrishGerontologicalSocietyIMO IrishMedicalOrganisationINMO IrishNursesandMidwivesOrganisationInterRAI InternationalResidentAssessmentInstrumentIPC InfectionPreventionandControlISPGM IrishSocietyofPhysiciansinGeriatricMedicineLIMS LaboratoryInformationManagementSystemsLTRC Long-termresidentialcareNGO Non-GovernmentOrganisationNHI NursingHomesIrelandNPHET NationalPublicHealthEmergencyTeamOECD OrganisationforEconomicCooperationandDevelopment PIC Person in ChargePPE PersonalProtectiveEquipmentQQI QualityandQualificationsIrelandRCPI Royal College of Physicians of Ireland RCSI Royal College of Surgeons in IrelandSAT Single Assessment ToolSIPTU Services, Industrial, Professional and Technical UnionSSWHG South/SouthWestHospitalGroupTESSy TheEuropeanSurveillanceSystem(ECDC)TILDA TheIrishLongitudinalStudyonAgeingUCD University College DublinULHG UniversityLimerickHospitalsGroupWHO WorldHealthOrganization

Abbreviations

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COVID-19 represents a significant global threat to public health.

COVID-19 Nursing Homes Expert Panel Examination of Measures to 2021 1

IntroductionCOVID-19representsasignificantglobalthreattopublichealth.On11thMarch2020,theWorldHealthOrganization(WHO)madetheassessmentthatCOVID-19shouldbecharacterisedasapandemic.1

Inamatterofmonthsthisglobalpandemichasseenapproximately13.5millioncasesandover580,000deaths.2 Irelandhasexperiencedsome25,683casesand1,748deathsasof14thJuly2020.3Internationally,thelatestsignsandtrendsremaintroubling.

EvidenceinIrelandandgloballyhasshownthatolderpeople,particularlythosewhoaremedicallycompromisedorfrailerareatsevereriskforpooreroutcomesfromCOVID-19,andthatcongregatedsettingssuchaslong-termresidentialcarefacilitieshavebeenseverelyimpacted.

DatafromtheHealthProtectionSurveillanceCentre(HPSC)indicatesthat,asofmidnighton14thJuly2020,79%ofallnotifieddeathsfromCOVID-19occurredintheover75agegroupsandthatdeathsinnursinghomes(985cases)represented56%oftotaldeaths(1,748cases)inIreland.

EstablishmentofPanel&TermsofReferenceTheresponsetotheCOVID-19pandemicispublichealthled.Theprimarygovernancestructureestablishedtoleadthisresponseisthe,nowwellknown,NationalPublicHealthEmergencyTeam(NPHET).

NPHETrecommendedtheestablishmentofanExpertPanelonNursingHomeson14thMay2020,toexaminethecomplexissuessurroundingthemanagementofCOVID-19amongthisparticularlyvulnerablecohort.Laterthatmonth,theNursingHomesExpertPanelwasappointedbytheMinisterforHealthwiththefollowingtermsofreferenceto: • provideassurancethatthenationalprotectivepublichealthandothermeasuresadoptedtosafeguard

residentsinnursinghomes,inlightofCOVID-19,areappropriate,comprehensiveandinlinewithinternationalguidelinesandanylessonslearnedfromIreland’sresponsetoCOVID-19innursinghomesto date;

• provideanoverviewoftheinternationalresponsetoCOVID-19innursinghomesutilisingasystematicresearch process;

• reporttotheMinisterforHealthbyendJune2020inordertoprovideimmediatereal-timelearningsandrecommendationsinlightoftheexpectedongoingimpactofCOVID-19overthenext12-18months.

TheExpertPanelischairedbyProf.CecilyKelleher.InadditiontotheChair,thePanelcomprisesMs.BrigidDoherty,Ms.PetrinaDonnelly,andProf.CillianTwomey.ThePanelbringstogetherconsiderableexpertiseinthemanagementofpublichealth,geriatricmedicine,nursinghomesandexperienceoftheimpactofCOVID-19inthenursinghomesetting.

1 SeeWorldHealthOrganization,‘TimelineofWHO’sResponsetoCOVID-19’, https://www.who.int/news-room/detail/29-06-2020-covidtimeline(accessed15thJuly2020).

2 SeeEuropeanCentreforDiseasePreventionandControl,‘COVID-19situationupdateworldwide,asof16July2020, https://www.ecdc.europa.eu/en/geographical-distribution-2019-ncov-cases(accessed16thJuly2020).

3 SeeDepartmentofHealth,‘StatementfromtheNationalPublicHealthEmergencyTeam-Wednesday15July’, https://www.gov.ie/en/press-release/4e2a1-statement-from-the-national-public-health-emergency-team-wednesday-15-july/ (accessedpm15thJuly2020).

ExecutiveSummary

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Approach/MethodologyTheExpertPaneladoptedanevidence-informedandconsultativeapproachtocompletingfiveinter-relatedareasofwork: 1) review and analysis of available epidemiological data; 2) rapidsystematicreviewofmeasurestoprotectolderpeopleinLTRCs; 3) athree-partconsultationprocessinvolvingmeetingswithstakeholders,invitingwrittensubmissionsfrom

stakeholders,andapublicconsultation; 4) site‘visits’tothreenursinghomes,and, 5) engagementwithseveralresidents/relatives,identifiedfromindependentadvocacyorganisations,who

expressedthedesiretosharetheirthoughtsandexperienceswiththeExpertPanel.

ThePanelwassupportedinitsworkbyasmallSupportTeam,drawnfromDepartmentofHealthstaff,whoprovidedsecretariatandlogisticalsupport.ThePanel,independentinitsoperation,presentsitsowndeliberations,findingsandrecommendationsinthisreport.

The Panel met with the then Minister, in late June to advise of the progress to date and to inform him that additionaltimewouldberequiredinordertocompleteitswork.ThePanelwasconsciousoftheneedtoexamineinternationalevidence,undertakeacomprehensiveengagementprocessandtoconsiderkeydata.Carefulconsiderationofallofthesecomponentssupportsandinformsthisreport.ThePanelcompletedaninterimprogressreportwhichwasprovidedtotheMinisteron30thJune.TheInterimReportwassubsequentlypublishedbyMinisterDonnellyonthe13thJuly.

ReviewofDataThePaneldecidedattheoutsettodevelopasetofevidence-basedrecommendationsanddeterminedthatathoroughconsiderationoftheavailabledatawouldberequired.

ThePanelreviewedalistofavailabledatasetsrelatingtonursinghomespreparedbytheDepartmentofHealth,fromwhichthePanelidentifiedthefollowingareasforconsideration:mortality;excessmortality;andclusters.ThePanelmetwiththeDepartmentofHealthandtheHPSCtodiscussthedataavailable,toreviewapreliminarypresentationbasedontheareasidentified,andtoidentifyanyadditionalkeydata,trendsanddisaggregationforfurtherconsideration.TheDepartmentofHealthsubsequentlyprovidedananalysisofdatainrelationtothefollowing: • weeklytrendsinCOVID-19casesfromtheHPSC; • trendsinCOVID-19mortality; • COVID-19excessmortality; • trendsinCOVID-19casesamonghealthcareworkers; • influenzaoutbreaks(non-COVID-19); • where available, hospital transfers, and, • casesandclustersbyCHOand/orregionallevel.

TheanalysisofthisdataispresentedinChapter3ofthisreportandseekstounderstandthebasicepidemiologyoftheincidenceofCOVID-19andassociatedmortalityinnursinghomesinIreland,comparedwiththoseinthewiderpopulation.


Atthelastcensusanestimated5.0%ofthoseaged65yearsandolderwerelivingincommunalestablishmentsinIreland.Thereare576registerednursinghomesinIrelandofwhich440areprivateorvoluntarynursinghomesand3.6%oftheover65sresideinthesesettings.

On16thMarch2020,theHPSCwasnotifiedofthefirstcaseandclusterinnursinghomes.Asof27thJune2020,theHPSChadreported252clustersinnursinghomes(18%ofallclusters).195(77%)ofnursinghomesclustershavebeenclosed.Theseclustersareassociatedwith5,608confirmedcases(22%ofcases).Ofthosecasesinnursinghomes,422werehospitalised.971deaths(56%ofalldeaths)wereassociatedatthatpointwithnursinghomeclusters.ThehighestnumberofclustersareinthedenselypopulatedEasternregion.Thisisalsowherethehighestcommunityinfectionswereobserved.

Thepeakofnewcasesinthegeneralpopulationwason28thMarch2020.FromearlyApriltherewasarapidriseincasesinLTRCs.Thepeakinnewconfirmedcasesinthesesettingsinmid-Aprilcoincidedwithexpandedtestingundertakeninthesector.AnalysisbytheIrishEpidemiologicalModellingAdvisoryGroup(IEMAG)showsagreatlyhighernursinghomeincidencerateat14.5%thaninthegeneralpopulationofover65s.

Irelandisinarelativelystrongpositionintermsofaccuratelycapturinginformationondeathsacrossallsettings.Duetodifferencesintheavailabilityoftestingandpolicies,andduetodifferentapproachestorecordingdeaths,internationalcomparisonsaredifficulttomake.TherehavebeenlargenumbersofdeathsincarehomesinsomecountriessuchastheUnitedKingdomandtheUnitedStatesbutofficialdatafortheseandothercountriesiseitherincompleteordifficulttointerpret.Anotherdifficultyincomparingdataondeathsisthatinsomecountriesthedataonlyrecordtheplaceofdeath,whileothersalsoreportdeathsinhospitalofcarehomeresidents.

Challengeswerealsoidentifiedinrelationtoperforminginternationalcomparisonsofexcessmortality.Amongthesearethatexcessmortalityfiguresarenotstableandbestpracticeistowaitforanumberofmonthsbeforeseekingtoestablishtrends.PreliminaryanalysisconductedbyDepartmentofHealthstaffindicatesthatexcessmortalityfiguresobservedinIrelandforthefirsthalfoftheyeararelikelyduetothepandemic.

TheseriousimpactonLTRCswasidentifiedbytheECDCinits9thRapidRiskAssessmentof23rdApril2020.Internationallytheroleplayedbythosewithasymptomaticorverymildlysymptomaticdiseaseinspreadinginfectionisnowmoreclearlyrecognised.Suchasymptomatictransmissionposesasignificantchallengetopublichealthandinfectioncontrolstrategies.Inaddition,aclinicalpictureinvulnerableandolderpopulationshasemergedthatdidnotmeetthedefinitionasestablishedinitiallythroughtheWHO.Attheoutsetofthepandemicthereweremajornationalchallengesintestingandcontacttracingthataffectednursinghomes.Withinnursinghomestestingtoascertainasymptomaticcasesisnowacorestrategy.Ireland’stestingofallstaffinallfacilitiesandallpatientsinaffectedfacilitiescontributedtotheidentificationofasymptomaticcasesandtheinterruptionoftransmission.

TheveryinfectiousnatureofCOVID-19makesitdifficulttopreventandcontrolinresidentialcaresettings.Thetransmissionofthevirusintoandwithinnursinghomesismultifactorial.Peopleinnursinghomesweredisproportionatelylikelytocontractitcomparedtotheirpeer-age-group.Themortalityratesseeninnursinghomeswerealsohigher,thisisinthecontextofamoremedicallyvulnerableandfrailpopulation.

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EvidenceReviewInlinewiththePanel’ssecondtermofreference,arapidsystematicreviewwasundertakenbyaresearchteamfromUCD,underthedirectionofthePanel,toinvestigatemeasuresimplementedinlong-termresidentialcarefacilitiestoreducetransmissionof,morbidityandmortalityresultingfromSARS-CoV-2.Economicissuesassociatedwiththevirus(costissues,costeffectiveness,procurement)werealsoinvestigated.

Threedatabases(PubMed,EMBASE,Cinahl)weresearchedusingkeytermsrelatedtocoronavirus,infectioncontrol,andnursinghomes,frominceptiontopresent.Peerreviewedliteraturewithnorestrictionsonlanguagewereconsideredeligibleforinclusion.Allstudytypeswereconsidered,andtheinclusioncriteriarelatedtointerventionsandpoliciesthatwereimplementedinnursinghomes,longstayfacilities,andwhichaimedtoreducemortality,morbidityrates,andtransmissionofCOVID19.Thepopulationconsideredincludedresidents,staff,andvisitors.

TheHealthInformationandQualityAuthority(HIQA)EvidenceSynthesisProtocol20204 informed the search strategytocapturethepopulation,intervention,andoutcomesofinterest.ThereviewwasalsoregisteredonthePROSPEROdatabase,aninternationalprospectiveregisterofsystematicreviews.

Theresearchteamidentified33piecesofresearchforinclusionandasummaryofthisevidencereviewispresentedinChapter4.Despitelimitationsinthequalityoftheevidenceinthecontextofaverynewlyidentifieddisease,severalimplicationsforpracticearehighlighted.Theuseofpersonalprotectiveequipment(PPE)andotherinfectioncontrolmeasuresareessentialregardlessofwhetheracasehasbeenreportedinafacility.Whereavailable,widescaletestingofresidentsandstaffshouldbeimplementedandsurveillancesystemsshouldbeinplace.Considerationshouldbegiventothewellbeingofresidentsandthevoicesofallinvolvedinthecareandmanagement,especiallythoseofresidentsandtheirfamiliesshouldbeattheheartofpracticedevelopments.Preparednessforfutureoutbreaksincludingstafftrainingininfectionpreventionandcontroliskey.

StakeholderEngagementTheExpertPanelundertookanextensiveprocessofstakeholderengagementinvolvingmeetings,writtensubmissions,andapublicconsultation.Theconsultationprocessreceivedinputfromnursinghomes,representativeandprofessionalorganisations,residents,staff,andfamilymembers.AconsiderablevolumeofprimarymaterialswasreceivedbytheExpertPanelandconsideredinthecontextofitsoverallwork.

A range of survey templates were developed by the Support Team, approved by the Panel, and disseminated throughwritteninvitationsandapubliccallforsubmissionsonbehalfofthePanel.ThePanelmetwitharangeofstakeholderorganisationswhowereinvitedtoprovidethemwithawrittensubmissionsurvey,andadditionalmaterialforconsideration,includingpositionpapers,operationalmaterial,andevidence.Thirteenmeetingswereheldwithkeystakeholdergroupsbetween12thJuneand1stJuly,withatotalof43representatives.ThePanelalsometwiththePersoninCharge,staff,andresidentsofthreenursinghomes,identifiedbyHIQA,andanadvocacyorganisationfacilitatedmeetingswithseveralindividualswithrelevantlivedexperience.

4 SeeHealthInformationandQualityAuthority,‘ProtocolforEvidenceSynthesisSupport:COVID-19’(25thMay2020), https://www.hiqa.ie/sites/default/files/2020-05/Protocol-for-HIQA-COVID-19-evidence-synthesis-support_1-6.pdf.


Writtensubmissionsweresoughtfromafurthertwelvegroups.Registerednursinghomeswerealsoinvitedtomakewrittensubmissions.AttherequestofthePanel,HIQAfacilitatedthedisseminationofaninvitationtomakeasubmissiontoallregisterednursinghomes.Alittleunder10%ofnursinghomesreturnedaresponse.Atotalof25stakeholderand53nursinghomesubmissionswerereceived.Acallforsubmissionsfrommembersofthepublicwasopenforoneweekclosingon18thJune2020.Atotalof60submissionswasreceived.SubmissionswerecollatedbytheSupportTeam,andaqualitativethematicanalysiswasconductedusingtheFrameworkMethod,inordertoidentifyandpresentanoverviewofthethemesandissuesraisedinthesubmissionstothePanel.

Acrossallmeetings,thefollowingkeythemeswereconsistentlyidentified:timelinessofresponse,thechallengespresentedbymanaginganewdisease,implicationsforanyfuturemodelofcare,interdisciplinarycooperation,theroleofGPsinprovidingcareandleadership,staffinginnursinghomes,thecommunityandregionalresponse,andfutureprotectivemeasures.

Acrossallwrittensubmissionssimilarly,thefollowingprimarythemeswereidentified:nursinghomeprocedures,communication,oversightandguidance,futurepreparedness,thenursinghomemodelofcare,andrepresentationandadvocacy.

Many stakeholders focused on the challenges when an outbreak occurred, elements that worked well, areas of ongoingconcernandtheparamountimportanceoftheresidentsandtheirfamilies.Allstakeholdersemphasisedinrelationtooutbreakmanagement,theissuesoftimelytestingturnaround,availabilityofPPEandtheneedforfuturepreparednessaswellastheneedtokeepintrainwithnationalguidelines.Stakeholders,includingnursinghomeproviderswouldliketoseegreaterintegrationofprivateandvoluntaryresidentialsettingsintothehealthservice,togetherwithimprovedcommunityservicesforolderpeople.

KeyFindings&PolicyConsiderationsTheidentificationoflearningsandkeylessonsfromtheIrishresponsetoCOVID-19innursinghomessofar,alongwiththeinternationalexperience,iscomprehensivelyinformedbytheepidemiologyanddataanalysis,theinternationalevidencereview,andtherangeofstakeholderengagementsundertaken.Chapters6and7focusonthePanel’sreflections,deliberationsanddiscussiononreal-timelearning.

ThetaskofthePanelisforward-lookingtoprotecttheat-riskpopulationinnursinghomesintothenearfuture,whetherornotasurgeofCOVID-19occursoriftheinfectionremainsinthecommunityandcontinuestobearisktothoseespeciallyvulnerabletoit.ThePanel’sworkhasbeenguidedbytheprinciplesofin-actionandafter-actionreviewswherelessonslearnedinrealtimeareactedupon.Thisisnotsimplytoidentifythoselessonslearnedbuttoseektoapplytheseinsightsinatightertimescaleinordertoimprovetheoutcomeoftheongoingresponse.

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ThePanel’skeyfindingsandrecommendationsrelateto: • nursing home procedures; • staffinglevelsandskillmix; • communicationacrossthehealthsystem; • oversight and guidance; • future preparedness; • the need for a revised model of care for nursing homes; • representationandadvocacy; • endoflifecare.

Thereisincreasingevidencetoshowthathighlydependentpersonscanlivesafelyandmorehappilyindomesticsettings,providedtheirrequiredhomecaresupportsareinplace.Givenageingdemographicprojections,particularlyforthenumbersaged80yearsorover,therewillbeagrowingneedforarangeoflong-termcare,includingnursinghomecare.Nursinghomesshouldbepartofacontinuousspectrumofcareoftheolderpersoninthewiderhealthcaresystem,withprovisionofmultidisciplinarysupport.

The Panel also assesses the need to focus on the development of a new model of care, including care needs anddependencyassessmentspoliciesandprotocols,andgovernancestructureswithinthenursinghomesettingandacrossthecommunity.Theevidenceconsideredhighlightsarequirementforrobust,accountableclinicaloversightacrossthesector,inadditiontomonitoringwithappropriateenforcementcapabilityandmoredefinedrolesforthePersoninCharge,alongwithanenhancedregulatoryframeworkandincreasedregulatoractivity.

Itisclearfromtheengagementswith,andsubmissionsof,arangeofstakeholdersthathealthcarestaffworkedtirelesslyandwithadmirableresiliencetocontinuetoprovidecaretoresidents.GreatvaluewasplacedonthesignificantpackageofsupportestablishedbytheHSE,notleasttheCOVID-19ResponseTeams.Staffing,theroleofstaffandtheconditionsofemploymentinnursinghomesarecriticalareasthatneedfocusedattention,includingthedevelopmentofeducationandcareerpathways.Itisimportanttonotonlyrecognisethesignificanteffortsmadebynursinghomestaffintheircareofresidentsthroughoutthepandemic,butalsotobefullycognisantoftheimpacts,includingpsychological,arisingfromthisexperience–thesestaffnowneedtobesupportedandcaredfor.Thewrap-aroundsupportsestablishedbytheHSEincludingtheaforementionedCOVID-19ResponseTeams,thesupplyofPPE,emergencystaffingandclinicalsupport,amongstotherthings,havebeencriticalinterventions,playingacentralroleinsupportingnursinghomeresidents.Notonlymustthesesupportscontinue,buttheymustevolveanddevelopascentralplanksoftheresponsetoCOVID-19.

TheExpertPanelmakesasubstantialpackageofrecommendationshavingregardtothereal-timelearningsand,whatisfelt,isrequiredtoensureongoingprotectionandsupportfornursinghomesresidents.Therecommendationsalsoreflectthatsystematicreformisneededinthewaynursinghomecareandolderpersonscareisdelivered.ManyoftheseissueshavebeenamplifiedbythearrivalofCOVID-19andfocusedandsustainedattentionisrequiredinthecontextoftheongoingresponsetoCOVID-19andinthelonger-termprovisionofsafe,qualitycareforIreland’sageingpopulation.


Insummary,thePanel’srecommendationscentrearoundthethematicareasbelow.Considerationhasbeengiventorecommendedtimelines,recognisingurgentandimmediateactionsthatareneeded,aswellasidentifyingrequirementsfortheplanninganddevelopmentofactionsoverthenext18months,inlightoftheexpectedongoingimpactofCOVID-19overthattimeframe.Thethematicareasassociatedwiththerecommendationsare:1)PublicHealthmeasures;2)Infectionpreventionandcontrol;3)Outbreakmanagement;4)Futureadmissionstonursinghomes;5)Nursinghomemanagement;6)Dataanalysis;7)CommunitySupportTeams;8)Clinical–generalpractitionerleadrolesonCommunitySupportTeamsandinnursinghomes;9)Nursinghomestaffing&workforce;10)Education;11)Palliativecare;12)Visitorstonursinghomes;13)Communication;14)Regulations;15)Statutorycaresupports.

ThePanelconcludesthattheseprotectivepublichealthandothermeasuresshouldbeinplace,inlinewithlessonslearnedtodateandinternationalbestpractice,tosafeguardallourcitizensbutespeciallytheresidentsinnursinghomesoverthenext12-18monthsandintothelongertermfuture.Whileoftenoverlookedbythehealthsystemandthecommunitiestheyserve,nursinghomesareessentialtothecontinuumofcareacrossthelifecycle,particularlyintimesofcrisis.AswemourntheprofoundlossoflifeofnursinghomeresidentsinthewakeofCOVID-19,mayweforeverhonourtheselivesbylearningfromthistragedyandcreatingabettersystem.

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1.IntroductionCOVID-19representsasignificantglobalthreattopublichealth.Thevirushasnoregardtocountrybordersanditsimpactsarebeingfeltrightacrosstheworld.Recognisingtheprogressionofthevirusandtheincreasingthreatitposed(andcontinuestopose)topublichealth,on11thMarch2020,theWorldHealthOrganization(WHO)announcedthatCOVID-19shouldbecharacterisedasapandemic.5Inamatterofmonthsthisglobalpandemichasseenapproximately13.5millioncasesandover580,000deaths.6Irelandhasnotbeenleftunaffectedbythevirus,with25,683casesand1,748deathsasof14thJuly2020.7

IndeclaringCOVID-19apandemic,theWHOreiteratedamessageithadalreadycommunicatedinternationally:thatCOVID-19wasnotjustapublichealthcrisisbutonethatwouldtoucheverysector–andcalledforcountriestotakeawhole-of-government,whole-of-societyapproach,builtaroundacomprehensivestrategytopreventinfections,savelivesandminimizeimpact.8

InIreland,thenationalresponsetoCOVID-19issupportedbyadedicatedgovernancestructuretoensureapublichealth-led,whole-of-societyapproach.TheNationalPublicHealthEmergencyTeam(NPHET)wasestablishedinJanuary,chairedbytheChiefMedicalOfficeroftheDepartmentofHealth.Ithelditsfirstmeetingon27thJanuary2020.Itoverseesandprovidesdirection,guidance,supportandexpertadviceonthedevelopmentandimplementationofastrategytorespondtoCOVID-19inIreland.9 A National Action Plan was publishedon16thMarch2020,settingoutanationalresponseandplanforthemobilisationofresourcestocombatthespreadofthevirus.10

ItisnowknownthatolderagegroupshaveahigherriskofmortalityfromCOVID-19.Nursinghomeresidentshavebeenidentifiedasaparticularlyvulnerablecohort.AnalysisofIrishCOVID-19mortalitydataindicatesthatthepopulationoflong-termresidentialcare(LTRC)facilities,includingnursinghomes,havehadsignificantlyhigherriskofcontractingCOVID-19thanthegeneralpopulationofsimilarage.

DatafromtheHealthProtectionSurveillanceCentre(HPSC)indicatesthatasofmidnighton14thJuly2020,79%ofallnotifieddeathsfromCOVID-19occurredintheover75agegroupsandthatdeathsinnursinghomes(985cases)represented56%oftotaldeaths(1,748cases)inIreland.

5 SeeWorldHealthOrganization,‘TimelineofWHO’sResponsetoCOVID-19’, https://www.who.int/news-room/detail/29-06-2020-covidtimeline(accessed15thJuly2020).

6 SeeEuropeanCentreforDiseasePreventionandControl,‘COVID-19situationupdateworldwide,asof16July2020,https://www.ecdc.europa.eu/en/geographical-distribution-2019-ncov-cases(accessed16thJuly2020).

7 SeeDepartmentofHealth,‘StatementfromtheNationalPublicHealthEmergencyTeam-Wednesday15July’,https://www.gov.ie/en/press-release/4e2a1-statement-from-the-national-public-health-emergency-team-wednesday-15-july/(accessedpm15thJuly2020).

8 Ibid.,1.9 SeeDepartmentoftheTaoiseachandDepartmentofHealth,Ireland’s National Action Plan in Response to COVID-19 (Coronavirus): Update

16th March 2020(GovernmentofIreland,2020).10 Ibid.


1.1.Long-termResidentialCareandCOVID-19Long-termresidentialcare(LTRC)facilitiesprovidelong-termcareandshort-stay,transitionalcare,andrespitesupporteitherthroughtheState,section38andsection39organisations,orprivately.11AsignificantnumberofthesefacilitiesareregisteredwiththeHealthInformationandQualityAuthority(HIQA)andaresubjecttotheregulatoryframeworkfordesignatedcentresundertheHealthAct2007andassociatedregulationsandstandards.Thisregulationaimstosafeguardvulnerablepeople,ofanyage,whoarereceivingresidentialcareservices and provide assurance to the public that people living in designated centres are receiving a safe, high-qualityservicethatmeetstherequirementsoftheregulations.12HIQAhasimplementedon-goingriskassessmentsthroughoutthepandemic.

ThisCOVID-19NursingHomesExpertPanelreportisprimarilyfocusedontheapproximately57613 registered nursinghomeswhichprovideabout32,000bedsacrossthecountry.Almost80%ofnursinghomesinIrelandareprivatelyoperatedwithconsiderablevariationbetweenhomesinthefacilitiesoffered.Newernursinghomestypicallyprovidesingleoccupancyensuiteroomswhereasolderhomesoftenhavemulti-bedroomswithcommunalbathroomsandcongregatedrecreationalspaces.14

Uptoapproximately30,000peoplearecurrentlylivinginnursinghomesinIreland,onalong-stayorshort-staybasis.TheimpactofCOVID-19onthoselivinginthesesettingshasbeendisproportionatebycomparisonwiththeimpactonthegeneralpopulation.PeoplelivinginthesesettingsrepresentvulnerablepopulationsandhavebeenidentifiedbytheWHOashavingahigherriskofsusceptibilitytoinfectionfromCOVID-19andtosubsequentadverseoutcomes.15Thishasbeenattributedtoresidentcharacteristics,suchas:olderage,thehighprevalenceofunderlyingmedicalconditions,andcircumstancesinwhichhighcaresupportfortheactivitiesofdailylivingisrequiredincollectivehighphysicalcontactenvironments.

AsoutlinedintheNPHETmeetingpaperof22nd May Overview of the Health System Response to date: Long-term residential healthcare settingscertaincharacteristicsofLTRCfacilitiesinIreland,includingnursinghomes,placethematgreaterriskofexperiencingaCOVID-19outbreakamongresidentsandstaff.Someofthesecharacteristicsinclude: • settingstendtobecongregatedandresidentsmightbeinsharedroomsratherthanindividualrooms,

particularlyinolderhomes; • highcontactenvironmentsi.e.significantlevelsofphysicalcontactandcloseproximitybetweencarestaff

andresidents,particularlyinrelationtopersonalcare; • symptomsofCOVID-19arecommonandmighthavemultipleaetiologiesinthispopulation; • aconfirmedoutbreakcauseshighlevelsofstaffabsenteeismduetosickleaveandself-isolation

requirements; • toprovidecontinuityofserviceabsenteeismmayresultintheneedforhigherusageofagency/temporary

staff,whointurnmaybemovingbetweenfacilities,workinginmultiplefacilitiesandoftensharingaccommodationwithothervulnerablegroups,increasingtheriskoftransmission;

• theemerginginformationontheextentofasymptomaticandpre-symptomaticCOVID-19transmission.16

11 Section38and39organisationsareservice-providerswhicharefundedbytheHealthServiceExecutive(HSE)undersections38and39oftheHealthAct,2004.AcutepsychiatricadmissionunitsarenotconsideredaspartofthementalhealthLTRCprofile.

12 HealthInformationandQualityAuthority,Regulation Handbook: A Guide for Providers and Staff of Designated Centres(HIQA,2019), https://www.hiqa.ie/sites/default/files/2019-10/Regulation-Handbook.pdf.

13 HealthInformationandQualityAuthority,TheImpactofCOVID-19onNursingHomesinIreland(HIQA,21stJuly2020), https://www.hiqa.ie/sites/default/files/2020-07/The-impact-of-COVID-19-on-nursing-homes-in-Ireland_0.pdf

14 HealthInformationandQualityAuthority,TheregulationofhealthandsocialcareservicesbyHIQAduringtheCOVID-19publichealthemergency,(7thMay2020).

15 WorldHealthOrganization2020,InfectionPreventionandControlguidanceforLong-TermCareFacilitiesinthecontextofCOVID19Interimguidance(21stMarch2020),https://apps.who.int/iris/handle/10665/331508

16 SeeDepartmentofHealth,‘OverviewoftheHealthSystemResponsetoDate:Long-termResidentialHealthcareSettings,NPHETMeetingPaper, 22ndMay2020’(26thMay2020),https://www.lenus.ie/handle/10147/627723.

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1.2.EstablishmentoftheNursingHomesExpertPanelTheexperienceofthenursinghomesectorto-dateinIrelandandelsewheredemonstratesthatresidentsofnursinghomesrepresentaparticularlyvulnerablecohort.PublichealthdataforIrelandindicatesthatLTRCsrepresentedaparticularlysusceptibleenvironmentforCOVID-19,especiallynursinghomes.Asof27th June, theHealthProtectionSurveillanceCentre(HPSC)dataindicatesthatapproximately18%ofallclustersnotifieduptothatdateoccurredinnursinghomesettings(seechapter3forfurtheranalysis).Accordingly,amongstotherthings,NPHETrecommendedtheestablishmentofanExpertPanelonNursingHomeson14thMay2020,toexaminethecomplexissuessurroundingthemanagementofCOVID-19amongthisparticularlyvulnerablecohort.Laterthatmonth,theCOVID-19NursingHomesExpertPanelwasappointedbytheMinisterforHealthwiththefollowingtermsofreferenceto: • provideassurancethatthenationalprotectivepublichealthandothermeasuresadoptedtosafeguard


• provideanoverviewoftheinternationalresponsetoCOVID-19innursinghomesutilisingasystematicresearch process; and to

• reporttotheMinisterforHealthbyendJune2020inordertoprovideimmediatereal-timelearningsandrecommendationsinlightoftheexpectedongoingimpactofCOVID-19overthenext12-18months.

TheExpertPanelischairedbyProf.CecilyKelleher,PrincipaloftheUniversityCollegeDublin(UCD)CollegeofHealthandAgriculturalSciences.InadditiontotheChair,thePanelcomprisesMs.BrigidDoherty,Ms.PetrinaDonnelly,andProf.CillianTwomey.ThePanelbringstogetherconsiderableexpertiseinthemanagementofpublichealth,geriatricmedicine,nursinghomesandexperienceoftheimpactofCOVID-19inthenursinghomesetting.

1.3.ReportOverviewInlightoftheexpectedongoingimpactofCOVID-19overthenext12-18monthsandinordertoinformitsrecommendations,thePanelengagedinacomprehensivedatagatheringexerciseinvolvingextensivestakeholderengagement,asystematicreviewofinternationalliteratureanddataanalysis.TheExpertPanel,inconductingitswork,wasparticularlyconsciousoftheneedtocompleteasignificantexaminationandidentifykeylearningsandrecommendationsinarapidtimeframe,inorderforthoselearningsandrecommendationstobeavailabletotheMinisterinearlycourse,giventheseriousnessoftheongoingchallengeofCOVID-19.

ThisreportprovidesasummaryoftheworkconductedbytheExpertPanel,havingregardtoitsTermsofReference.Theevidence-informedandconsultativeapproachtakenbythePanelisdescribedinChapter2.Chapter3presentsanoverviewofrelevantepidemiolocalinformationanddata.Chapter4presentsasummaryandtheresultsofasystematicevidencereviewcompletedunderthedirectionofthePanel.Chapter5givesanoverviewoftheresultsofathree-partconsultationprocessconductedbytheExpertPanel.Chapter6setsouttheviewsandconsiderationsofthePanelinrespectofhealthcarepolicyforolderpersons,andfinally,Chapter7setsoutthein-depthdiscussiononlearningsandtherecommendationsofthePanel.

TheExpertPanelwishestoacknowledgethecommitmentandwillingnessofstakeholderstoprovidetheirinputandviewstotheprocess,especiallynursinghomeresidentsandfront-linestaff.


2.MethodologyTheExpertPaneladoptedanevidence-informedandconsultativeapproachtocompletingfiveinter-relatedareasofwork: 1) review and analysis of available epidemiological data; 2) rapidsystematicreviewofmeasurestoprotectolderpeopleinLTRCs; 3) athree-partconsultationprocessinvolvingmeetingswithstakeholders,invitingwrittensubmissions

fromstakeholders,andapublicconsultation; 4) site‘visits’tothreenursinghomes,and, 5) engagementwithanumberofresidents/relatives,identifiedfromindependentadvocacyorganisations,

whoexpressedthedesiretosharetheirthoughtsandexperienceswiththeExpertPanel.

ThePanelwassupportedinitsworkbyadedicatedDepartmentofHealthSupportTeam(ST)fromSocialCareDivision,ResearchServicesandPolicyUnit,andthePrimaryCareDivision.AteamofreviewersfromUCDwereresponsibleforcompletingtherapidsystematicreviewofmeasurestoprotectolderpeopleinlong-termresidentialcarefacilities.EpidemiologicaldataandanalysiswereprovidedbytheDepartmentofHealth,theHealthProtectionSurveillanceCentre(HPSC),andHIQA,underthedirectionandspecificationofthePanel.TheconsultationprocesswasmanagedbytheSupportTeamaccordingtotherequirementsspecifiedbythePanel.Directengagementswithnursinghomesandwithresidents/relativeswerearrangedandcompletedbythePanel.

Inaccordancewithitstermsofengagement,thePanelisanindependentexpertpanel.ThePanelisresponsibleforthedirectionandorganisationofitsworkanddecisionswithregardtothecontentofthisfinalreport.

Inlinewithpublichealthmeasures,theExpertPanelconducteditsprimarybusinessthroughvideocalls.AtthePanel’sfirstformalmeetingonthe29thMay2020,atermsofengagementdocumentwasagreedsettingoutthemannerinwhichthePanelwouldconductitsbusiness(Appendix1).

Toprogressitswork,theExpertPanelconvenedascheduledcorebusinessmeetingonceperweekwhichallPanelmembersattendedalongwiththePanel’sSupportTeam.ThePanelalsoheldaweeklyscheduleddeliberativemeetingwherethefourmembersofthePanelmetin“closeddoor”sessions.AsthePanel’sworkprogressed,thePanelalsoconveneddailymeetingswithstakeholdersandotheradhocmeetingstoadvanceparticularareasofwork.

Theapproachandmethodsforeachareaaredescribedintheremainderofthischapter.

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2.1.ReviewandAnalysisofEpidemiologicalDataThePanelreviewedalistofavailabledatasetsrelatingtonursinghomespreparedbytheDepartmentofHealth,fromwhichthePanelidentifiedthefollowingareasforconsideration:mortality;excessmortality;andclusters.ThePanelmetwiththeDepartmentofHealthandtheHPSCtodiscussthedataavailable,toreviewapreliminarypresentationbasedontheareasidentified,andtoidentifyanyadditionalkeydata,trendsanddisaggregationforfurtherconsideration.ThefollowingdataonnursinghomeswaspreparedforthePanelatitsspecification: • weeklytrendsinCOVID-19casesfromtheHPSC; • trendsinCOVID-19mortality; • COVID-19excessmortality; • trendsinCOVID-19casesamonghealthcareworkers; • influenzaoutbreaks(non-COVID-19); • where available, hospital transfers, and, • casesandclustersbyCHOand/orregionallevel.

AsummaryofthedataanalysisrequestedispresentedinChapter3.Aviewonthecomprehensiveness,validationandlimitationsofthedataisalsoprovided.

AsuiteofreportswasprovidedtothePanelbytheSupportTeamthatcaptureCOVID-19epidemiologicalanalysis,internationalevidence,andevidence-basedguidelinesrelevanttotheareasofinterestoutlinedbythePanel,summarisedinTable2.1Summaryofreports,publications,andguidelinesprovidedtotheExpertPanelbySupportTeam.

Table 2.1 Summary of reports, publications, and guidelines provided to the Expert Panel by Support Team

Organisation Title/Description Published

HealthServicesInsights AnInternationalMappingofMedicalCareinNursingHomes17

23/01/2019

European Centre for Disease PreventionandControl(ECDC)

RapidRiskAssessment:OutbreakofNovelCoronavirusDisease2019(COVID-19):IncreasedTransmissionGlobally:FifthUpdate18

02/03/2020

ECDC RapidRiskAssessmentNovelCoronavirusDisease2019(COVID-19)Pandemic:IncreasedTransmissionintheEU/EEAandtheUK:SixthUpdate19

12/03/2020

TheIrishLongitudinalStudyonAgeing(TILDA)

TILDAReporttoInformDemographicsforOver50sinIrelandforCOVID-19Crisis20

16/03/2020

17 SeeGudmundÅgotnes,MargaretJ.McGregor,JoelLexchin,MalcolmB.Doupe,BeatriceMüller,andCharleneHarrington,‘AnInternationalMappingofMedicalCareinNursingHomes’,Health Services Insights12(January2019):1–12.

18 SeeEuropeanCentreforDiseasePreventionandControl,‘RapidRiskAssessment:OutbreakofNovelCoronavirusDisease2019(COVID-19):IncreasedTransmissionGlobally:FifthUpdate’,(2ndMarch2020),https://www.ecdc.europa.eu/sites/default/files/documents/RRA-outbreak-novel-coronavirus-disease-2019-increase-transmission-globally-COVID-19.pdf.

19 SeeEuropeanCentreforDiseasePreventionandControl,‘RapidRiskAssessment:NovelCoronavirusDisease2019(COVID-19)Pandemic:IncreasedTransmissionintheEU/EEAandtheUK:SixthUpdate’,(12thMarch2020),https://www.ecdc.europa.eu/sites/default/files/documents/RRA-sixth-update-Outbreak-of-novel-coronavirus-disease-2019-COVID-19.pdf.

20 RoseAnneKenny,BelindaHernández,AislingO’Halloran,FrankMoriarty,andChristineMcGarrigle,TILDAReporttoInformDemographics forOver50sinIrelandforCOVID-19Crisis,(TILDA,March2020),https://tilda.tcd.ie/publications/reports/pdf/Report_DemographicsOver50s.pdf



HPSC ‘InterimPublicHealthandInfectionPreventionControlGuidelinesonthePreventionandManagementofCOVID-19CasesandOutbreaksinResidentialCareFacilitiesandSimilarUnits’.21

21/03/2020

WorldHealthOrganization(WHO) ‘InfectionPreventionandControlGuidanceforLong-TermCareFacilitiesintheContextofCOVID-19:InterimGuidance’.22

21/03/2020

WHO ‘GuidanceonCOVID-19fortheCareofOlderPeopleandPeopleLivinginLong-TermCareFacilities,OtherNon-AcuteFacilitiesandHomeCare’.23

23/03/2020

HealthResearchBoard(HRB) ‘EvidenceSearch:COVID-19andNursingHomes’.[Unpublished.]

24/03/2020

ECDC ‘RapidRiskAssessment:CoronavirusDisease2019(COVID-19)Pandemic:IncreasedTransmissionintheEU/EEAandtheUK:SeventhUpdate’24

25/03/2020

HIQA ‘ProtocolfortheIdentificationandReviewofPublicPolicyResponsestoCOVID-19’.25

21/04/2020

HPSC ‘InterimPublicHealthandInfectionPreventionControlGuidelinesonthePreventionandManagementofCOVID-19CasesandOutbreaksinResidentialCareFacilitiesandSimilarUnitV4.1s’

04/05/2020

HIQA ‘RapidReviewofPublicHealthGuidanceforInfectionPreventionandControlMeasuresinResidentialCareFacilitiesintheContextofCOVID-19’26

6/05/2020

HIQA ‘ReportofNF01andNF02NotificationstoHIQA’.[Unpublished.]

11/05/2020

DepartmentofHealth Consolidateinternationalinterventions-AtimelineofstateinterventionstakeninresponsetoCOVID-19isprovidedfor28countrieswithspecificinformationonnursing homes

12/05/2020

21 SeeHealthProtectionSurveillanceCentre,‘InterimPublicHealthandInfectionPreventionControlGuidelinesonthePreventionandManagementofCOVID-19CasesandOutbreaksinResidentialCareFacilitiesandSimilarUnits’(HSE,21stMarch2020;rev.19thJune2020),http://hdl.handle.net/10147/627376.

22 SeeWorldHealthOrganization,‘InfectionPreventionandControlGuidanceforLong-TermCareFacilitiesintheContextofCOVID-19:InterimGuidance’(21stMarch2020),https://apps.who.int/iris/handle/10665/331508.

23 SeeWorldHealthOrganization,‘GuidanceonCOVID-19fortheCareofOlderPeopleandPeopleLivinginLong-TermCareFacilities,OtherNon-AcuteFacilitiesandHomeCare’(23rdMarch2020),https://iris.wpro.who.int/handle/10665.1/14500.https://iris.wpro.who.int/handle/10665.1/14500

24 SeeEuropeanCentreforDiseasePreventionandControl,‘RapidRiskAssessment:CoronavirusDisease2019(COVID-19)Pandemic:IncreasedTransmissionintheEU/EEAandtheUK:SeventhUpdate’(25thMarch2020),https://www.ecdc.europa.eu/sites/default/files/documents/RRA-seventh-update-Outbreak-of-coronavirus-disease-COVID-19.pdf.

25 SeeHealthInformationandQualityAuthority,‘ProtocolfortheIdentificationandReviewofPublicPolicyResponsestoCOVID-19’(21st April 2020;rev.27thMay2020),https://www.hiqa.ie/sites/default/files/2020-06/Protocol-to-identify-public-policy-responses-to-easing-COVID-19-restrictions.pdf.

26 HealthInformationandQualityAuthority,‘RapidReviewofPublicHealthGuidanceforInfectionPreventionandControlMeasuresinResidentialCareFacilitiesintheContextofCOVID-19’

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InternationalLong-TermCarePolicyNetwork

‘England:EstimatesofMortalityofCareHomeResidentsLinkedtotheCOVID-19Pandemic’.27

17/05/2020

ECDC SurveillanceofCOVID-19atlong-termcarefacilitiesinthe EU/EEA28

19/05/2020

HPSC COVID-19InterimFAQsfortheinterpretationandsubsequentactionrelatedtorepeattesting29

20/05/2020

HIQA Rapidreviewofprotectivemeasuresforvulnerablepeople30

21/052020

DepartmentofHealth ‘OverviewoftheHealthResponsetodate:LongTermResidentialHealthcareSettings’–PapersubmittedtoNPHET31

22/05/2020

TILDA TILDANursingHomeData:AShortReporttoInformCOVID-19.’32

22/05/2020

NPHET ‘COVID-19:ComparisonofMortalityRatesbetweenIrelandandOtherCountriesinEUandInternationally’33

28/05/2020

HPSC EpidemiologyofCOVID-19Outbreaks/ClustersinIreland:WeeklyReport(uptoweek24weekending13thJune2020)34

June2020

NPHETSub-group:EvidenceandGuidance

‘EvidenceandGuidanceSub-groupDatabaseExtract:SummaryReports(EvidenceBriefsandGuidelines)ConsideredRelevanttotheNursingHomeExpertGroup’.[Unpublished.]

01/06/2020

HPSC InterimPublicHealthandInfectionPreventionControlGuidelinesonthePreventionandManagementofCOVID-19CasesandOutbreaksinResidentialCareFacilitiesandSimilarUnitV5.035

19/06/2020

27 SeeAdelinaComas-HerreraandJose-LuisFernández,‘England:EstimatesofMortalityofCareHomeResidentsLinkedtotheCOVID-19Pandemic’(InternationalLong-termCarePolicyNetwork,12thMay2020),https://ltccovid.org/wp-content/uploads/2020/05/England-mortality-among-care-home-residents-report-17-May.pdf.

28 SurveillanceofCOVID-19atlong-termcarefacilitiesintheEU/EEA29 COVID-19InterimFAQsfortheinterpretationandsubsequentactionrelatedtorepeattesting30 HealthInformationandQualityAuthority,‘RapidReviewofPublicHealthGuidanceonProtectiveMeasuresforVulnerableGroupsintheContextofCOVID-19’,Rapidreviewofprotectivemeasuresforvulnerablepeoplehttps://www.hiqa.ie/reports-and-publications/health-technology-assessment/rapid-review-protective-measures-vulnerable

31 Ibid.,9.32 RomanRomero-Ortuno,PeterMay,MinjuanWang,SiobhanScarlett,AnnHever,andRoseAnneKenny,TILDANursingHomeData:AShortReporttoInformCOVID-19(TILDA:May2020),https://tilda.tcd.ie/publications/reports/pdf/Report_Covid19NursingHomes.pdf

33 NationalPublicHealthEmergencyTeam,‘COVID-19:ComparisonofMortalityRatesbetweenIrelandandOtherCountriesinEUandInternationally’,https://www.gov.ie/en/publication/84bc5-covid-19-comparison-of-mortality-rates-between-ireland-and-other-countries-in-eu-and-internationally/.

34 EpidemiologyofCOVID-19Outbreaks/ClustersinIreland:WeeklyReport(uptoweek24weekending13thJune2020)35 InterimPublicHealthandInfectionPreventionControlGuidelinesonthePreventionandManagementofCOVID-19CasesandOutbreaksinResidentialCareFacilitiesandSimilarUnitV5.0https://www.lenus.ie/handle/10147/627376


2.2.RapidSystematicReviewArapidsystematicreviewwascompletedtoinvestigatemeasuresimplementedinlong-termresidentialcarefacilitiestoreducetransmissionof,morbidityandmortalityresultingfrom,SARS-CoV-2.Economicissuesassociatedwiththevirus(costissues,costeffectiveness,procurement)werealsoinvestigated.

Threedatabases(PubMed,EMBASE,Cinahl)weresearchedusingkeytermsrelatedtocoronavirus,infectioncontrol,andnursinghomes,frominceptiontopresent.Peerreviewedliteraturewithnorestrictionsonlanguagewereconsideredeligibleforinclusion.Allstudytypeswereconsidered,withinclusioncriteriarelatedtothefollowing:interventionsandpoliciesthatwereimplementedinnursinghomes;long-stayfacilities;andwhichaimedtoreducemortality,morbidityrates,andtransmissionofCOVID-19.Thepopulationconsideredincludedresidents,staff,andvisitors.TheHIQAevidencesynthesisprotocol202036 informed the search strategy to capturethepopulation,intervention,andoutcomesofinterest.

Thetitlesandabstractsofidentifiedpaperswerescreenedforeligibility.Fulltextsofpapersidentifiedthroughscreeningwerethenexaminedanddatawasextractedfromthesestudies.TheCovidenceprogrammewasusedtoconductthereview.Thecriticalappraisalskillsprogramme(CASP)checklisttoolwasusedtoappraisethequalityofqualitativeresearchretrieved.37Theresultsofthesystematicsearch,andthefindingsofthereviewaredescribedinChapter4.

2.3.ConsultationProcess2.3.1.StakeholderMeetingsThePanelheldstructuredmeetingswiththefollowingstakeholderorganisations: • AllianceoftheAgeSectorNGOs; • DepartmentofHealth: - SecretaryGeneral; - ChiefNursingOfficer; - Assistant Secretary, Social Care Division; • Chief directors of nursing for two hospital groups; • HIQA; • HSE: - Communityoperations:includingnursinghomes,community,testing,andprocurementofficers; - AntimicrobialResistance&InfectionControl(AMRIC); - relevantNationalClinicalAdvisorsandGroupLeads(NCAGL);and, - HPSC; • IrishAssociationofDirectorsofNursingandMidwifery(IADNAM); • IrishCollegeofGeneralPractitioners(ICGP); • IrishGerontologicalSociety(IGS); • IrishHospiceFoundation; • IrishMedicalOrganisation(IMO);

36 SeeHealthInformationandQualityAuthority,‘ProtocolforEvidenceSynthesisSupport:COVID-19’(25thMay2020),https://www.hiqa.ie/sites/default/files/2020-05/Protocol-for-HIQA-COVID-19-evidence-synthesis-support_1-6.pdf.

37 SeeCriticalAppraisalSkillsProgramme,‘CASPChecklist:10QuestionstoHelpYouMakeSenseofaQualitativeResearch’(2018),https://casp-uk.net/wp-content/uploads/2018/01/CASP-Qualitative-Checklist-2018.pdf.

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• IrishNurses&MidwivesOrganisation(INMO); • IrishSocietyofPhysiciansinGeriatricMedicinegroup-meeting; • NPHETrepresentatives: - ChairofNPHET; - ChairofExpertAdvisoryGrouptoNPHET; - ChairofIrishEpidemiologicalModellingAdvisoryGrouptoNPHET; - AssistantSecretary,SocialCare,DepartmentofHealth; • NursingHomesIreland(NHI); • RoyalCollegeofPhysiciansofIreland(RCPI)PolicyGrouponAgeing; • Safeguarding Ireland; • Sage Advocacy; and • ServicesIndustrialProfessionalandTechnicalUnion(SIPTU).

Attendeeswereaskedtoprovideawrittensubmissionusingadedicatedform,inadvanceofthemeeting.Stakeholderswerealsoinvitedtosubmituptoamaximumofthreekeypublications/documentsthattheywouldliketobringtothePanel’sattention.Themeetingsinvolveda10-minutepresentationcoveringthefollowingareas: 1) key lessons for the immediate term; 2) keyactionsforthemedium-to-longerterm; 3) prioritynationalprotectivepublichealthmeasures;and 4) othermattersattendeeswishedtobringtotheattentionofthePanel.

Thepresentationswerefollowedbyabout30-50minutesofquestions,clarificationsandgeneraldiscussion.Tosupporttheefficientmanagementoftheengagements,stakeholderswererequestedtolimitattendeestoamaximumofthreerepresentativesforsinglestakeholdermeetingsandtworepresentativesperorganisationforgroupmeetings.

Thirteenmeetingswereheldbetweenthe12thJuneand1stJuly,withatotalof43representatives.

2.3.2.WrittenStakeholderSubmissionsThefollowingstakeholderorganisationswereinvitedtosubmitawrittensubmissiontotheExpertPanel,usingthesameformthatwasprovidedinadvanceofstakeholdermeetings: • AllIrelandInstituteofHospiceandPalliativeCare(AIIHPC); • CentreforEconomicandSocialResearchonDementia-NUIGalway(CESRD); • Coroner for the District of Kildare; • DepartmentofHousing,PlanningandLocalGovernment; • DepartmentofPublicExpenditureandReform; • EconomicandSocialResearchInstitute(ESRI); • HomeandCommunityCareIreland(HCCI); • HospitalGroups(DMHG;IEHG;SSWHG;ULHG;Saolta;RCSI); • HSECommunityHealthOrganisations(CHO1–9); • InstituteofPublicHealth(IPH); • IrishAssociationofSocialWorkers(IASW); • NationalTreatmentPurchaseFund(NTPF).


InvitationlettersweresenttoeachstakeholderfromthePanel.IncludedintheinvitationlistforwrittensubmissionswerestakeholderswhocommunicatedwiththePanelatanearlystageofitswork.RegisterednursinghomeswerealsoinvitedtomakewrittensubmissionstothePanelaspartofthisprocessandHIQAprovidedadditionalsupportincirculatingtheseinvitations,onthebasisthattheAuthorityisindirectcommunicationwithallregisterednursinghomes.Stakeholdersandnursinghomeswereaskedtomaketheirsubmissionbythe18thJune2020.Atotalof25stakeholderand53nursinghomesubmissionswerereceived.WrittensubmissionsfromstakeholdersandnursinghomeswerecollatedandanalysedbytheSupportTeaminordertoprovideasummaryofthemesandissuesforthePaneltoconsider.TheSupportTeamusedthe‘frameworkmethod’:aqualitativemethodofthematicanalysisthatisoftenusedinappliedpolicyresearchtoidentifythemesfromstructuredfeedback.38 This method was chosen on the basis that submissions were made usingaformcontainingquestionsandareasforconsideration.AllsubmissionswerealsocollatedandprovidedtothePanelforitsownreviewandconsideration.TheresultsoftheanalysisarepresentedinChapter5.

2.3.3.PublicConsultationApublic-facingconsultationwasconductedtoprovideanadditionalpublicvoicetothatofthestakeholders.Aswithotherstakeholderconsultations,astructuredapproachwastaken,andaconsultationformwasprovidedwiththefollowingquestions: • Basedonyourknowledgeorexperience,whatarethekeylessonsfortheimmediatetermarisingfromthe

experienceoftheCOVID-19pandemictodate?; • Basedonyourknowledgeorexperienceorkeylearning,whatkeyactionsormeasuresdoyouthinkare

requiredfortheshort,mediumandlong-termtosafeguardresidentsinnursinghomes,againsttheimpactofCOVID-19?;

• DescribewhatyouthinkaretheexistingandadditionalprioritynationalprotectivepublichealthmeasuresfornursinghomesinthecontextofCOVID-19;and

• OtherrelevantmattersyouwishtobringtotheattentionofthePanel.

AcallforsubmissionsfrommembersofthepublicwaspublishedontheDepartmentofHealth’swebsite39 and a pressreleasewascirculatedbytheDepartment’sPressOfficetopublicisetheconsultation.Theconsultationwasopenforsubmissionsforoneweekclosingon18thJune2020.

Atotalof60submissionswerereceivedfrommembersofthepublic.TheSupportTeamalsousedtheframeworkmethodtoconductathematicanalysisofthesubmissionsreceived.AllsubmissionswerealsocollatedandprovidedtothePanelfortheirownreview.TheresultsoftheanalysisarepresentedinChapter5.

38 Onthe‘frameworkmethod’seeJaneRitchieandLizSpencer,‘QualitativeDataAnalysisforAppliedPolicyResearch’inTheQualitativeResearcher’sCompanion,A.MichaelHubermanandMatthewB.Miles(eds),(Sage,2002):305–330.

39 SeeDepartmentofHealth,‘PressRelease:COVID-19NursingHomesExpertPanelInvitesWrittenSubmissions’,10thJune2020, https://www.gov.ie/en/press-release/a2960-covid-19-nursing-homes-expert-panel-invites-written-submissions/

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2.4.DirectEngagementswithNursingHomesThePanelmetwithasmallnumberofnursinghomesinordertoengagedirectlywithandheartheexperiencesofstaffandcarerswhohavebeenmanagingtheresponsetoCOVID-19onthefront-lineandprovidingcareinnursinghomesthroughoutthepandemic,andtoheartheexperiencesandperspectivesofpeoplewhohavebeenresidentinnursinghomesthroughoutthepandemic.

ThePanelconductedbothvirtualmeetingsandonesitevisit,followingallpublichealthprecautionsandguidanceforvisitingnursinghomes.ThroughtheseengagementsthePanelmetwith: • the Person in Charge; • front-linestaff;and, • residents.

TheSupportTeamassistedtheExpertPanelinsettingupthesemeetingswiththerelevantrepresentativesfromeachofthenursinghomes.TheselectionofnursinghomeswasfacilitatedbyHIQA,wherebyHIQArecommendednursinghomesbasedonselectioncriteria(publicandprivatemix;COVID-19andnon-COVID-19affectedmix)providedbythePanel.Thenursinghomes‘visited’includedbothpublicandprivateoperatednursinghomesandnursinghomesthathadandhadnotexperiencedCOVID-19cases.

2.5.EngagementswithResidentsandFamilyMembersTheExpertPanelengagedwithanumberofresidentsandrelatives,identifiedfromindependentadvocacysources,whohadexpressedthedesiretosharetheirthoughts,experiencesandperspectiveswiththeExpertPanel.ThiswasaparticularlyvaluablecontributiontothePanel’swork.

2.6.InterimReportOnthe30thJune2020,theCOVID-19NursingHomesExpertPanelsubmittedaninterimreporttotheMinisterforHealth.ThepurposeofthatreportwastoprovideashortupdatetotheMinisterontheworkofthePaneltothatpoint,alongwithadescriptionofitsapproachtotheworkandthePanel’sintendednextsteps.TheMinisterpublishedtheInterimReporton13thJuly2020.40

40 SeeDepartmentofHealth,‘PressRelease:MinisterforHealthpublishesinterimreportoftheCOVID-19NursingHomesExpertPanel’,13thJuly2020,https://www.gov.ie/en/press-release/ad16e-minister-for-health-publishes-interim-report-of-the-covid-19-nursing-homes-expert-panel/

41 SeeCentralStatisticsOffice,‘CensusofPopulation2016:Profile3:AnAgeProfileofIreland’, https://www.cso.ie/en/releasesandpublications/ep/p-cp3oy/cp3/agr/.

42 SeeWorldHealthOrganization,‘Coronavirus:Overview’,https://www.who.int/health-topics/coronavirus#tab=tab_1.43 EuropeanCentreforDiseasePreventionandControl,‘GuidanceontheProvisionofSupportforMedicallyandSociallyVulnerablePopulationsinEU/EEACountriesandtheUnitedKingdomDuringtheCOVID-19Pandemic’,3rdJuly2020,https://www.ecdc.europa.eu/sites/default/files/documents/Medically-and-socially-vulnerable-populations-COVID-19.pdf.


3.EpidemiologyAnalysis3.1IrishNursingHomes:BackgroundTheCensus2016providesdataonthenumbersofolderpeoplelivingincommunalestablishmentsincludingnursinghomes.41Thecensusenumerated637,567persons65yearsandolder,ofwhom32,139(5.0%)werelivingincommunalestablishmentsinIreland:22,762(3.6%)innursinghomes,3,689(0.6%)inhospitals,and5,688inothercommunalestablishments(0.9%).Ofapopulationof67,555whowere85yearsandolder,17%(11,454)werelivinginnursinghomes.Two-thirdsofallnursinghomeresidentsaged65andolder,andthree-quartersofthose85yearsandolder,werewomen(seetable3insection3.6).Thereare576registerednursinghomesinIrelandofwhichabout440areprivateorvoluntarynursinghomes.Theaveragecapacityofanursinghomeis55beds(rangingfrom9-184beds)andapproximately30,000staffareemployedinthesesettings.

AsinternationalorganisationshaveincreasedtheirunderstandingofCOVID-19,42 they have advised that olderpeopleandthosewhoaremedicallyvulnerablearemoresusceptibletoCOVID-19infectionandmayexperiencemoreadversehealthoutcomesasaresult.43 For this reason, analyses of data to understand the basic epidemiologyoftheincidenceofCOVID-19andassociatedmortalityinnursinghomesinIreland,comparedwiththoseinthewiderpopulationisimportant.

3.2.PublicHealthSurveillanceandDataCaptureThereareanumberofreasonswhylong-termresidentialcaresettings(LTRCs)havebeenmoreseverelyimpactedbytheCOVID-19pandemicandtheselessonsarebecomingincreasinglyapparentasepidemiologistsandpublichealthexpertshavelearnedmoreaboutthetransmissionofthisnovelvirusovertheprecedingweeksandmonths.

Prompt,effectivepublichealthsurveillanceandresponseiscriticaltotheidentificationandcontrolofoutbreaksinhealthcaresettings.IrelandhasanationalpublichealthsurveillancesystemcalledCIDR(ComputerisedInfectiousDiseaseReporting)inplace,managedbytheHSEHealthProtectionSurveillanceCentre(HPSC),tomanagethesurveillanceandcontrolofinfectiousdiseasesinIreland.

20

TheprocessfordatacaptureonCIDRisasfollows: • outbreaksandprobablecasesarenotifiedtotheeightregionaldepartmentsofpublichealth(DPH)who

create the CIDR records for these cases; • separately,positivelaboratoryresultsgenerateCIDRfilesforconfirmedcases–senttoDPHbeforethe

HPSC; • those records of cases and outbreaks are then manually linked/merged with one another as contact

tracing is completed; • theclassificationofoutbreakslocationtypeisthenmade–nursinghomesareonesuchclassification.

ClassificationofthesesettingsisdeterminedbytheDPHs; • underlegislationalldeathsassociatedwithCOVID-19asanotifiablediseasemustbenotifiedtothe

HPSC; • thisdataisthenanalysedbytheHPSC; • thedatadoesnotdifferentiatebetweenpublicandprivatefacilities;and • dataarealsoreceivedbyHPSConadailybasisfromtheGeneralRegistrationOffice(GRO)onalldeaths

byage,gender,locationofdeath(hospital/non-hospital)dateofdeath,dateofregistrationandcauseofdeathnationally.

DeathregistrationdatacollectedbyGROprovidesthemostcompletemortalitydatabutisnottimelyduetoregistrationlag-time.Thecurrentlegislationprovides3monthsforadeathtobeformallyregistered.TheDepartmentofHealthunderstandsthatapproximately80%ofdeathsareregisteredwithinthistimeframe.Normallythismustbedoneinperson.InresponsetotheCOVID-19pandemic,theGROhasprovidedanonlineportalfortheregistrationofdeaths.

CIDR records a case as being associated with nursing home care only if it is linked to an outbreak in a nursing homesetting.AsingleisolatedcasewillnotbeidentifiedonCIDRasacaseinanursinghome.

3.3.SupplementaryDataHIQAalsocollectsrelevantinformation: • outbreaksofnotifiablediseasesinHIQAregisteredcentresaresubmittedwithin36hoursbythecentre

usingtheNF02notification;and • unexpecteddeathsinHIQAregisteredcentresarereportedtoHIQAthroughNF01notificationsfrom

designatedcentresforolderpeople.

Differentcountriesmeasuremortalityratesindifferentwaysandthereforethedataarenotalwaysconsistentorcomparableataninternationallevel.Forexample,somecountriesdonotcountdeathsthatoccurinprobableorpossibleCOVID-19caseswithintheircountofCOVID-19relateddeaths.

Similarly,somecountriesarenotcurrentlyabletoreportCOVID-19relateddeathsiftheyoccuroutsidetheacutehospitalsetting.ThisisincontrasttoIreland,whereconfirmedandprobableCOVID-19relateddeathsarereportedregardlessofwheretheyoccur.SomecountriesdonotreportdeathsininstanceswhichCOVID-19maynothavebeenconsideredthemaincauseofdeathbutratherasasecondarycause.Moreover,manycountriesreport completely separately on the registered deaths and are unable to link them with the deaths by place of deathsuchashospitalornursinghome.


In Ireland, this level of detail is available but there can be a lag while data is collated and to allow for the notificationofdeathstoreachtheHPSCandtheDepartmentofHealth.NumerouseffortshavebeenmadetoreportonalldeathslinkedtoCOVID-19,including: • allclinicianshavebeenwrittento,toemphasisetothemtheimportanceofdeathcertificationand

notificationofdeaths; • outbreakcontrolteamshavebeenaskedtoensurethatallconfirmedorsuspectedcasesinLTRCsare

notified; • acensusofmortalityinresidentialcaresettingshasbeenundertaken(seebelow); • funeraldirectorshavebeenwrittentorequestingthattheyencouragefamiliestousetheonlineoption

fordeathcertificationandtosubmitdeathcertificationinatimelymanner; • theHPSCismonitoring‘allcause’mortalityandIrelandisparticipatinginaEuropeannetwork

(EuroMOMO)whichismonitoring‘allcause’mortality;and • continuedengagementwiththeGROregardingtheimportanceoftimelymortalityinformation.

IrelandisthereforeinarelativelystrongdatacollectionpositionasCIDRcapturesdata(cases,clustersanddeaths)fromboththecommunityaswellasacutehospitalsandhasdonesosincethecommencementofthepandemic.TheinformationinCIDRcanthenbecross-checkedagainstotherdatacollectionsystemssuchasthatcollectedviaHIQA,theGRO,andexternally,RIP.ie.ThisaddstotheunderstandingofthevalidityofdatacollectedinCIDR.Todate,whenchecked,thedatacontainedwithinCIDRwassimilartothatcontainedwithinHIQAandRIP.ie.

TheapproachhasbeenclearandconsistentinrecordingCOVID-19casesanddeathsinnursinghomesfromthebeginningofthispandemic.ThisplacesIrelandasoneoftheveryfewcountriestotakeacomprehensiveapproachandusethisdatatoinformpublichealthactionsinameasured,decisiveandscientificmanner.

3.4.InternationalGuidance:SurveillanceandDefinitionsforCOVID-19CasesandDeathsInconsideringtheappropriatecasedefinitions,theNPHEThasbeeninformedbytheguidanceandadvicegivenbytheWHOandtheEuropeanCentreforDiseasePreventionandControl(ECDC).Ireland’scasedefinitionwasdevelopedwithregardtothecurrentEUdefinitionandcurrentlyusestheECDCsurveillancedefinitionofaCOVID-19death.44

Onthe17thJune2020,theECDCpublishedMonitoring and Evaluation Framework for COVID-19 Response Activities in the EU/EEA and the UK.45Pillar3ofthisdocumentdescribesthekeyfeaturesandindicatorsofacomprehensivesurveillancesystem.Irelandcurrentlyregularlyreportsorcancalculatethevastmajorityofmetricslistedusingcurrentlyavailabledatawiththeexceptionofpopulationserologystudies,oneofwhichiscurrentlyinprogress.Thissectionalsoreferstotheuseoftechnologyforcontacttracing.AcontacttracingappinIrelandhasbeendevelopedandlaunched.Thismeansthatbyinternationalstandards,Irelandhasareasonablycomprehensivesurveillancesysteminplace.

44 SeeEuropeanCentreforDiseasePreventionandControl,‘SurveillanceDefinitionsforCOVID-19’, https://www.ecdc.europa.eu/en/covid-19/surveillance/surveillance-definitions.

45 SeeEuropeanCentreforDiseasePreventionandControl,‘MonitoringandEvaluationFrameworkforCOVID-19ResponseActivitiesintheEU/EEAandtheUK’(17thJune2020),https://www.ecdc.europa.eu/sites/default/files/documents/covid-19-framework-monitor-responses.pdf

22

3.5.DefinitionsTheCOVID-19casedefinitionhasevolvedinlinewithinternationaldefinitionsandnewinformationoverthecourseofthepandemic.CurrentdefinitionsareoutlinedbelowandarepublishedontheHPSCwebsite.46

Box1:COVID-19CaseDefinitionVersion5.8Datelastupdated:19June2020

Clinicalcriteria • Apatientwithacuterespiratoryinfection(suddenonsetofatleastoneofthefollowing;cough,

fever,1shortnessofbreath) • OR Sudden onset of anosmia,2 ageusia3 and dysgeusia4 ANDwithnootheraetiologythatfully

explainstheclinicalpresentation • ORApatientwithanyacuterespiratorytractinfectionwhohasbeeninclosecontact5 with a

confirmedorprobableCOVID-19caseinthe14dayspriortoonsetofsymptoms. • ORApatientwithacuterespiratoryinfection(e.g.cough,fever,shortnessofbreath) • ORsuddenonsetofanosmia,ageusiaanddysgeusia)ANDhavingbeenaresidentorastaff

member,inthe14dayspriortoonsetofsymptoms,inaresidentialinstitutionforvulnerablepeoplewhereongoingCOVID-19transmissionhasbeenconfirmed.

• ORApatientwithsevereacuterespiratoryinfection(feverandatleastonesign/symptomofrespiratorydisease(e.g.cough,fever,shortnessofbreath))ANDrequiringhospitalisation(SARI)ANDwithnootheraetiologythatfullyexplainstheclinicalpresentation.

Clinical judgement should be applied in application of these criteria to determine who requires testing.

Diagnosticimagingcriteria RadiologicalevidenceshowinglesionscompatiblewithCOVID-19

Laboratorycriteria DetectionofSARS-CoV-2nucleicacidinaclinicalspecimen

Caseclassification • Possible:Anypersonmeetingtheclinicalcriteria • Probable case:Anypersonmeetingtheclinicalcriteriawithanepidemiologicallink

ORAnypersonmeetingthediagnosticimagingcriteria • Confirmed case:Anypersonmeetingthelaboratorycriteria

Notes: 1 Fevermaybesubjectiveorconfirmedbyhealthcareworker(≥380C);2 Lossofsenseofsmell;3 Lossofsenseoftaste;4 Distortionofsenseoftaste;5 Closecontact:<2metresface-to-facecontactforgreaterthan15minutes.

46 SeeHealthProtectionSurveillanceCentre,‘Covid-19CaseDefinitions’(15thMay2020), https://www.hpsc.ie/a-z/respiratory/coronavirus/novelcoronavirus/casedefinitions/


Box2:COVID-19OutbreakCaseDefinition

DefinitionConfirmedCase • Acluster/outbreak,withtwoormorecasesoflaboratoryconfirmedCOVID-19infection

regardlessofsymptomstatus.Thisincludescaseswithsymptomsandcaseswhoareasymptomatic.

• OR A cluster/outbreak, with two or more cases of illness with symptoms consistent with COVID-19infection(aspertheCOVID-19casedefinition),andatleastonepersonisaconfirmedcaseofCOVID-19.

DefinitionSuspectedCase • Acluster/outbreak,withtwoormorecasesofillnesswithsymptomsconsistentwithCOVID-19

infection(aspertheCOVID-19casedefinition).

Box3:SurveillanceDefinitionforCOVID-19Death

MortalitymonitoringshouldbeconductedaccordingtotheWHOdefinition:

ACOVID-19deathisdefinedforsurveillancepurposesasadeathresultingfromaclinicallycompatibleillnessinaprobableorconfirmedCOVID-19case,unlessthereisaclearalternativecauseofdeaththatcannotberelatedtoCOVID-19disease(e.g.,trauma).Thereshouldbenoperiodofcompleterecoverybetweentheillnessanddeath.

AdeathduetoCOVID-19maynotbeattributedtoanotherdisease(e.g.cancer)andshouldbecountedindependentlyofpre-existingconditionsthataresuspectedoftriggeringaseverecourseofCOVID-19.

ThenumberofdeathsduetoCOVID-19shouldbereportedtotheEuropeanSurveillanceSystem(TESSy)onaweeklybasis(case-basedoraggregateddata).47,48

47 SeeWorldHealthOrganization,‘EmergencyUseICDCodesforCOVID-19DiseaseOutbreak’, https://www.who.int/classifications/icd/covid19/en/(accessed13thJuly2020).

48 SeeEuropeanCentreforDiseasePreventionandControl,‘SurveillancedefinitionsforCOVID-19’, https://www.ecdc.europa.eu/en/covid-19/surveillance/surveillance-definitions(accessed13thJuly2020).

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3.6.COVID-19NursingHomeSurveillanceInformationOn16thMarch2020,theHPSCwasnotifiedofthefirstcaseandclusterinnursinghomes(twoclusterswerenotifiedonthatdayinseparatenursinghomeswithOutbreakControlTeamsinplace).

• Asof27thJune2020,theHPSChadreported252clustersinnursinghomes(18%ofallclusters).195(77%)nursinghomeclustershadbeenclosed.Theseclustersareassociatedwith5,608confirmedcases(22%ofallcases).

• Ofthosecasesinnursinghomes,422werehospitalised. • 971deaths(56%ofalldeaths)wereassociatedwithnursinghomeclusters.

Table 3.1 HPSC CIDR Nursing Home data as of 27th June 2020 and Table 3.2 provide further breakdown per region. The highest number of clusters are in the densely populated Eastern region. This is also where the highest community infections were observed.

HSEArea NumberofNH

Outbreaks

PercentofAll

OutbreaksNotified

ConfirmedCases

AssociatedwithNHOutbreaks

PercentofAllCasesNotifiedNationally

NumberofAllDeaths

PercentageofDeathsNotifiedNationally

NumberofHospitalisa-tions

PercentofHospital-isationsNotifiedNationally

East 121 8.5% 3,400 13.4% 621 35.7% 189 5.7%

Midlands 10 0.7% 240 0.9% 22 1.3% 19 0.6%

MidWest 16 1.1% 315 1.2% 52 3.0% 58 1.8%

NorthEast 38 2.7% 1,037 4.1% 175 10.0% 93 2.8%

SouthWest 5 0.4% 117 0.5% 21 1.2% 20 0.6%

SouthEast 17 1.2% 153 0.6% 25 1.4% 16 0.5%

South 9 0.6% 79 0.3% 11 0.6% 5 0.2%

West 36 2.5% 267 1.0% 44 2.5% 22 0.7%

Total 252 17.7% 5,608 22.0% 971 55.6% 422 12.9%

Source: HPSC Weekly Outbreak Report 29th June 2020


Table 3.2 Total Cases and Cases Associated with Nursing Home Clusters

County TotalCases PercentofTotalCases

CasesassociatedwithNHClusters

PercentofTotalCasesassociatedwithNHClusters

Carlow 169 0.7% 72 1.3%

Cavan 863 3.4% 256 4.5%

Clare 371 1.5% 176 3.1%

Cork 1,538 6.0% 126 2.2%

Donegal 463 1.8% 72 1.3%

Dublin 12,403 48.7% 2,726 48.0%

Galway 490 1.9% 30 0.5%

Kerry 309 1.2% 1 0.0%

Kildare 1,393 5.5% 493 8.7%

Kilkenny 358 1.4% 9 0.2%

Laois 264 1.0% 15 0.3%

Leitrim 82 0.3% 8 0.1%

Limerick 581 2.3% 78 1.4%

Longford 282 1.1% 33 0.6%

Louth 782 3.1% 294 5.2%

Mayo 560 2.2% 156 2.7%

Meath 807 3.2% 217 3.8%

Monaghan 537 2.1% 269 4.7%

Offaly 489 1.9% 56 1.0%

Roscommon 348 1.4% 81 1.4%

Sligo 144 0.6% 37 0.7%

Tipperary 546 2.1% 61 1.1%

Waterford 154 0.6% 14 0.2%

Westmeath 673 2.6% 136 2.4%

Wexford 218 0.9% 57 1.0%

Wicklow 649 2.5% 209 3.7%

Total* 25,473 100.0% 5,682 100.0%

Source:CIDR,Dataasof26thJune2020.

Note:Totalsmaynotmatchduetodifferencesindataavailableattimeofdataextraction.CIDRisalivedataset.

26

Graph3.1showsthatthepeaknumberofnewcasesinthegeneralpopulationwasonthe28thMarch2020.ItwasonlywhenthispeakwasreachedthatthenumberofcasesinLTRCsbegantoincrease.FromearlyApriltherewasarapidriseincasesinLTRCs.Thepeakinnewconfirmedcasesinthesesettingsinmid-Aprilcoincidedwiththeexpandedtestingundertakeninthesector.

Graph 3.1 Number of COVID-19 Cases in Nursing Homes by Date as a 5-day Rolling Average

Source: CIDR, July 2020

Data 5-day rolling average. Community: all cases excluding healthcare workers, and cases associated with outbreaks in long term residential care setting.


Graph 3.2 Number of COVID-19 outbreaks in nursing homes notified in Ireland, by residential facility type (N=252), up to midnight on 27th June 2020

Source: HPSC, 29th June 2020

28

Analysesofthetrajectoryoftheepidemicamongthegeneralpopulation,healthcareworkers,andLTRCresidentshasbeenconductedbytheIrishEpidemiologicalModellingAdvisoryGroup(IEMAG).ItsworkshowsthatthepeaknumberofnewconfirmedcasesinthegeneralpopulationwasobservedinthelastweekofMarch.Therate of increase of new cases among nursing home residents was slower and lagged behind both the general and healthcareworkerpopulations.Thefirstoutbreakinnursinghomeswasnotidentifieduntilthe16thMarch2020.Mostoutbreakswereidentifiedafter23rdMarchandintothefirstweekofApril.

Graph3.2providesaviewofthenumberofCOVID-19outbreaksbydateinLTRCsettings.Thefirstarrowcorrespondstothetimeatwhichthefirstpublichealthmeasures,includingtherestrictionofvisitorstoresidentialcarefacilities,wereimplemented.Thesecondarrowreferstotheimplementationoftheexpandedtestingprogrammeofresidentsandstaffinnursinghomes.Thefirstoutbreakwasnotidentifieduntilthe16th March2020–4daysaftertheimplementationofvisitingrestrictions(12thMarch).49Inaddition,mostoutbreakswereidentifiedafterthe23rdMarchandintothefirstweekofApril.AnotherspikeintheidentificationofoutbreakscoincidedwiththeimplementationoftheexpandedtestingprogrammeinthelastweekofApril(secondarrow).ThegraphshowsthetimelinealongwhichnewclustersinnursinghomeswereidentifiedandnotifiedtotheHPSCbylocalDepartmentsofPublicHealth.

AnalysisoftheimpactofCOVID-19ondifferentagegroupswasconducted.AcomparisonofcasesofpeopleinnursinghomesascomparedtothoseinthegeneralpopulationisdescribedinTable3.3below.

TheincidencerateandrelativeriskofcontractingCOVID-19wasgreatlyhigherinnursinghomeresidentsthanpeopleinthesameagegroupsinthegeneralpopulation.

Table 3.3 COVID-19 incidence rates in nursing home population, compared with those in the general population

Age Population Nursinghome

population

%populationinnursinghomes

Populationoutsidenursinghomes

Casesinnursinghomes

Nursinghome

incidencerate

Casesingeneralpopulation

Incidencerategeneralpopulation

65-69 211,236 1,384 0.7% 209,852 143 10.3% 567 0.27%

70-74 162,272 1,983 1.2% 160,289 310 15.6% 581 0.36%

75-79 115,467 3,035 2.6% 112,432 423 13.9% 519 0.46%

80-84 81,037 4,906 6.1% 76,131 724 14.8% 452 0.59%

85-89 44,862 5,730 12.8% 39,132 897 15.7% 302 0.77%

90-94 17,974 4,175 23.2% 13,799 593 14.2% 140 1.01%

95+ 4,719 1,549 32.8% 3,170 219 14.1% 24 0.76%

Total 637,567 22,762 3.6% 614,805 3,309 14.5% 2,585 0.4%

Source: CSO Census 2016 and CIDR June 2020Notes: Population statistics from CSO Census 2016. Cases in nursing homes: all cases associated with nursing home outbreaks excluding those identified as healthcare workers. Cases in general population: all cases excluding those associated with outbreaks in other long-term residential care settings and those identified as healthcare workers.

49 ImplementationofNPHETrecommendationsfromthemeetingof11thMarchwereannouncedbytheTaoiseachon12th March


Graph 3.3 Cumulative incidence rates of confirmed cases of COVID-19 per 100,000 population notified in Ireland to midnight 28th June 2020

Source: HPSC, Epidemiology of COVID-19 in Ireland, 30th June 2020

30

ImpactofCOVID-19ascomparedtootherinfectiousdiseasesTheimpactofCOVID-19inLTRCfacilitiesinIrelandhas,likemanyothercountries,beenconsiderableandmuchhigherthanseenwithinfluenzaoutbreaks.InrecentyearstheimpactofinfluenzaonthissectorhasbeenrecordedbytheHPSCinitsweeklyandannualreportsdescribingtheannualinfluenzaepidemics.50 In the most recentsevereseasonof2017/2018,200influenzaoutbreakswerereportedincluding158influenzaoutbreaksthatseasoninresidentialcarefacilities.53deathswerelaboratoryconfirmedtobeassociatedwiththeseoutbreaks.

Table 3.4 Excess deaths from EuroMOMO model in 2017/2018 Influenza Season

Week402017-20201851 15-64years ≥65years AllAges

TotalDeaths 3,495 17,371 21,051

ExpectedDeaths 3,372 16,061 19,595

ExcessDeaths 123 1,310 1,456

Source: Communication from HPSC, June 2020

TheCOVID-19virusisamuchmoreinfectiousvirusthaninfluenzaandisunderstoodtohavesimilarmodesoftransmission.Areviewof12modellingstudiesreportedthemeanbasicreproductivenumber(R0)forCOVID-19at3.28,withamedianof2.79.52ThemedianRvalueforthepandemicofinfluenzaH1N12009was1.46andforseasonalinfluenzawas1.28.53ThismeansthateverypersonwithCOVID-19spreadstheinfectiontodoublethenumberofpeopleasapersonwithinfluenza.

TheECDCinits5th Rapid Risk Assessment of 2ndMarch2020,statedthatthereremainsnostrongevidenceoftransmissionprecedingsymptomonset.However,intheir6thRapidRiskAssessmentreleasedonthe12th March 2020theECDCdescribedasingularcasereportinwhichpossibleasymptomatictransmissionhadoccurredandadvisedthatmajoruncertaintiesremaininassessingtheroleofpre-symptomatictransmission.

TheseriousimpactonLTRCswassubsequentlyidentifiedbytheECDCinits9thRapidRiskassessmentof23rd April2020.Internationallytheroleplayedbythosewithasymptomaticorverymildlysymptomaticdiseaseinspreadinginfectionisnowmuchmoreclearlyrecognised.Suchasymptomatictransmissionposesasignificantchallengetopublichealthandinfectioncontrolstrategies.Animportantcomponentofsuchstrategiesistoachieveoverallreductionandcontrolofviruslevelsinthecommunitysoastoavoiditsunwittingspreadintovulnerablesettings,suchasnursinghomes,bythosethatareasymptomatic.Withinnursinghomestestingtoascertainasymptomaticcasesisnowacorestrategy.Ireland’stestingofallstaffinallfacilitiesandallpatientsinaffectedfacilitiescontributedtotheidentificationofasymptomaticcasesandtheinterruptionoftransmission.

50 SeeHealthProtectionSurveillanceCentre,‘AnnualEpidemiologicalReport’(HSE,December2018),https://www.hpsc.ie/a-z/respiratory/influenza/seasonalinfluenza/surveillance/influenzasurveillancereports/seasonsummaries/Influenza%202017-2018%20Annual%20Summary_Final.pdf

51 EuroMOMO,‘GraphsandMaps’,https://www.euromomo.eu/graphs-and-maps/52 SeeEuropeanCentreforDiseasePreventionandControl,‘CoronavirusDisease2019(COVID-19)intheEU/EEAandtheUK:EighthUpdate’(8thApril2020),https://www.ecdc.europa.eu/sites/default/files/documents/covid-19-rapid-risk-assessment-coronavirus-disease-2019-eighth-update-8-april-2020.pdf

53 SeeMatthewBiggerstaff,SimonCauchemez,CarrieReed,ManojGambhirandLynFinelli,‘EstimatesoftheReproductionNumberforSeasonal,Pandemic,andZoonoticInfluenza:ASystematicReviewoftheLiterature’,BMC Infectious Diseases14/1(September2014):480–499.


Inaddition,aclinicalpictureinvulnerableandolderpopulationshasemergedthatdidnotmeetthecasedefinitionasestablishedinitiallythroughtheWHO.EvidencehasemergedthatpresentationofCOVID-19inLTRCscandifferfromthatofthegeneralpopulationfromnotemperaturetoconfusionandthepaceofprogressionofdiseaseismuchfaster,likelyduetotheageandfrailtyofolderpeopleinsuchsettings.

MortalityinthosewithconfirmedcasesofCOVID-19MortalityinCOVID-19risesverysteeplywithage,bothinthegeneralpopulationandincongregatedsettings.TheDepartmentofHealthcomparedcrudeage-specificcase-fatalityratesforthegeneralpopulationandpresumedresidentsofnursinghomes.

Table3.5showsthiscomparisonforallcasesto30thJune2020.Theage-specificcase-fatalityratewassimilarforolderpeopleinthetwosettingsbutishigherinyoungeragegroups(under65yearsofage).However,thisanalysisshouldbetreatedwithcaution,astherearesmallnumbersofdeathsinloweragegroupsinnursinghomes.Inaddition,mass(nearuniversal)testinginnursinghomeswillhavedetectedasymptomaticandmildcaseswhichmaynothavebeenreferredfortestinginthegeneralpopulation,therebyincreasingcasenumbersinnursinghomesrelativetothegeneralpopulationanddecreasingthecase-fatalityrate.

Table 3.5 Age-specific case-fatality rates

AgeGroupGeneralpopulation Nursinghomes

Cases Deaths CFR Cases Deaths CFR

0-19 833 <5 0.1% 12 0 0.0%

20-39 3,872 9 0.2% 152 <5 0.7%

40-59 4,419 40 0.9% 219 10 4.6%

60-64 834 23 2.8% 87 7 8.0%

65-69 567 49 8.6% 143 20 14.0%

70-74 581 76 13.1% 310 54 17.4%

75-79 519 110 21.2% 423 73 17.3%

80-84 452 109 24.1% 724 178 24.6%

85+ 466 147 31.5% 1,709 449 26.3%

Total 12,543 564 4.5% 3,779 792 21.0%

Source: CIDR, 30th June Notes: The general population refers to all cases not associated with outbreaks in nursing homes, in non-nursing home long-term residential care settings or those identified as healthcare workers. Nursing homes refers to all cases associated with outbreaks in nursing homes not identified as healthcare workers. Note that an unknown number of cases in younger age groups may be healthcare workers or close contacts associated with the outbreak. This may lead to an underestimate of case-fatality rate in these younger age groups.

32

InternationalapproachestomortalityComparativeanalysisofpandemic-relatedmortalityindifferentcountriesisimportanttodescribetheimpactofthepandemiconpopulations,toinformhealthsystemresponses,andtoassesstheeffectivenessofcountermeasurestakenatnationallevelbydifferentcountries.CountriesacrosstheworldcurrentlyreportwidelydifferentmortalityexperienceswithCOVID-19.

However,thereareseveralfactorsaffectingmortalitywhichmakedirectcomparisonsbetweencountriesdifficult.Theseinclude: • differencesintestingavailability,testingstrategies,andcaseascertainment; • differencesinmortalitycasedefinitionandreportinge.g.probableandconfirmed,community,and

hospitalised cases; • demographicfactorsincludinghowage,socio-economicprofilesdifferacrossjurisdictions:-forexample,

agestructure–percentageofpopulation65+:Italy23%,Sweden20%,Austria19%,Spain19%,UK18%,Ireland13%;

• geographicfactorssuchaspopulationdensityandurbandistribution; • internationaltravelpatternsincludingthenumberofinitialseedings/ongoingimportationpatterns:

Transporthubs–Paris,BrusselsandLondonasmajorinternationalaviationhubsarejudgedtohaveledtomultipleintroductionsandcontributedtorapidincreaseininitialcasesinFrance,BelgiumandtheUK;

• pointontheepidemiccurve–risingorfalling; • timing,stringency,andeffectivenessofpublichealthmeasures–casedetection,contacttracing,isolation,

socialdistancing,travelrestrictions:-countrieswithearlyimpositionoflockdownmeasuresincludingNewZealand,Austria,DenmarkandNorwayhadlowercasenotificationanddeathrates;

• effectivenessatcontrollingoutbreaksinnursinghomesandothercongregatedsettings; • healthservicecapacityandefficacyconsiderations.-ICUbedcapacity,availabilityofventilatorsamajor

factorinmortalityinoutbreakswherehealthservicecapacitywasoverwhelmed,suchasItalyandSpain.

Mortalitydatahavebeenthesubjectofmuchinternationaldiscussionparticularlyinrelationtothereportingofmortalityinnursinghomes.UnlikeIreland,officialdataonthenumbersofdeathsamongcarehomeresidentslinkedtoCOVID-19isnotavailableformanycountries.Inaddition,internationalcomparisonsaredifficulttomakeduetodifferencesintestingavailabilityandapproachestorecordingdeaths.

TheNPHEThasrecommendedtheuseofWHOandECDCdefinitionsofaCOVID-19deathforsurveillancepurposes(seeBox3).ThisapproachisbroadinnatureandseekstocountdeathsinthosewhowerebothconfirmedandpossibleCOVID-19cases.

HIQA’sreport,Analysis of Excess All-cause Mortality in Ireland During the COVID-19 Epidemic(3rdJuly2020),usingdatafromthedeathnoticeswebsite,RIP.ie,observesthattheapproachtoCOVID-19mortalityreportinginIreland “has been one of precaution […] as recommended by WHO guidance”.54 The report goes on to note that theofficiallyreportedCOVID-19deathfiguresmaybeanoverestimate.Forexample,deathsinthosewhowereknowntobeinfectedwithcoronavirusatthetimeofdeathbutwhowereatorclosetoend-of–lifeindependentlyofCOVID-19mayhavebeenincludedinthecount,asthisisinlinewithinternationaldefinitions.ItisalsopossiblethataproportionofthedeathsoccurredamongpeoplewhowereknowntobeinfectedwithCOVID-19atthetimeofdeathbutwhosecauseofdeathmayhavebeenpredominantlyduetootherfactors.Furthermore,someofthedeathswhichwereofficiallyreportedasbeingdueto‘clinicallysuspected’COVID-19maynothavebeen,therebeinguncertaintyinsuchcasesintheabsenceofconfirmatorytestresults.

54 SeeHealthInformationandQualityAuthority,AnalysisofExcessAll-causeMortalityinIrelandDuringtheCOVID-19Epidemic(HIQA,3rd July2020),21,https://www.hiqa.ie/sites/default/files/2020-07/Analysis-of-excess-all-cause-mortality-in-Ireland-during-the-COVID-19-epidemic_0.pdf.


Atthispointintime,itisnotpossibletosaywithcertaintythatthisisthetrueimpactofCOVID-19onoverallmortality,whichshouldcontinuetobemonitoredviatheexcessmortalitystatisticsreportedbyEuroMOMO.

3.7.COVID-19andNursingHomes:InternationalComparisonsofMortalityOfficialdataonthenumbersofpeopleaffectedbyCOVID-19isnotavailableinmanycountries.Duetodifferencesintheavailabilityoftestingandpolicies,andduetodifferentapproachestorecordingdeaths,internationalcomparisonsaredifficulttomake.55Incountriesinwhichtherehavebeenatleast100deathsintotalandofficialdataisavailable,thepercentageofCOVID-19-relateddeathsamongcarehomeresidentsrangesfrom24%inHungaryto85%inCanada.Itshouldbenotedthatthesefiguresaresubjecttochangeascountriesupdatetheirofficialfiguresandprogressalongtheirownindividualnationalepidemictrajectories.

There have been large numbers of deaths in care homes in some countries such as the United Kingdom and the UnitedStatesbutofficialdatafortheseandothercountriesiseitherincompleteordifficulttointerpret.Anotherdifficultyincomparingdataondeathsisthatinsomecountriesthedataonlyrecordtheplaceofdeath,whileothersalsoreportdeathsinhospitalofcarehomeresidentsascarehomedeaths.Table3.6setsoutthemostrecentdatafromofficialsourcesbutiscaveatedwithrespecttothedifficultiesincomparingdataininstanceswhichthereexistdifferencesintestingavailabilityandpolicies,andinwhichdifferentapproachestorecordingdeathsareadopted,renderinginternationalcomparisonsdifficult.

On28thMay2020theNPHETpublishedCOVID-19: Comparison of Mortality Rates between Ireland and other countries in EU and Internationally.56

Graph3.4andTable3.6belowdescribethenumberofCOVID-19relateddeathsreportednationallyandthepercentageofthosethatoccurredamongstlong-termcareresidents.

ItshouldbesaidthatinadditiontotheaforementioneddifficultiesindrawinginternationalcomparisonswithregardtoCOVID-19motality,thereisanadditionallevelofcomplexityincomparinglong-termcareresidents.Thereisnointernationallyagreeddefinitionofthetermandaccordingly,comparisonsshouldbetreatedwithcaution.

55 SeeComas-Herrera,Adelina,JosebaZalakaín,CharlesLitwin,AmyT.Hsu,ElizabethLemmon,DavidHendersonandJose-LuisFernández,‘MortalityAssociatedwithCOVID-19OutbreaksinCareHomes:EarlyInternationalEvidence’(InternationalLong-TermCarePolicyNetwork,26thJune2020),https://ltccovid.org/2020/04/12/mortality-associated-with-covid-19-outbreaks-in-care-homes-early-international-evidence/.

56 SeeDepartmentofHealthNationalPublicHealthEmergencyTeam,‘COVID-19:ComparisonofMortalityRatesbetweenIrelandandotherCountriesinEUandInternationally’,28thMay2020,https://www.gov.ie/en/publication/84bc5-covid-19-comparison-of-mortality-rates-between-ireland-and-other-countries-in-eu-and-internationally/.

34

Graph 3.4 Total number of deaths linked to COVID-19 in the total population and % of COVID-related deaths among care home residents, plotted using a logarithmic scale for total deaths

SourceComas-Herrera,JosebaZalakaín,CharlesLitwin,AmyT.Hsu,ElizabethLemmon,DavidHendersonandJose-LuisFernández,‘MortalityAssociatedwithCOVID-19OutbreaksinCareHomes:EarlyInternationalEvidence’,InternationalLongTermCarePolicyNetwork,26thJune20201ReportingbothconfirmedandprobableCOVID-relateddeaths.2Referstonumberofdeathsincarehomes.Note:AlsoincludesdataforIrelandconfirmedonlyasrequestedbyExpertPanel.


Table 3.6 Number of COVID-19-related or confirmed deaths in the population and in care homes (or among carehome residents)

Country Date Approachtomeasuringdeaths

TotalnumberdeathslinkedtoCOVID-19

NumberofdeathsofcarehomeresidentslinkedtoCOVID-19

Numberofdeathsincarehomes

Numberofcarehomeresidentdeathsas%ofallCOVID-19deaths

Numberofdeathsincarehomesas%ofallCOVID-19deaths

Australia 21/06/2020 Confirmed 102 29 31%

Austria 05/06/2020 Confirmed 646 222 34%

Belgium 20/06/2020 Confirmed+Probable

9,696 6213 4,851 64% 50%

Canada 01/06/2020 Confirmed+Probable

7,326 6,236 85%

Denmark 15/06/2020 Confirmed 598 211 35%

Finland 23/06/2020 Confirmed 327 147 45%

France 16/06/2020 Confirmed+Probable

29,547 14,341 10,457 49% 35%

Germany 23/06/2020 Confirmed 8,895 3,491 39%

HongKong 22/06/2020 Confirmed 4 0 0 0% 0%

Hungary 02/06/2020 Confirmed 532 127 24%

Ireland 22/06/2020 Confirmed+Probable

1,717 1,086 63%

Israel 24/06/2020 Confirmed 307 137 45%

Jordan 22/04/2020 Confirmed 9 0 0 0% 0%

Malta 23/06/2020 Confirmed 9 0 0 0% 0%

NewZealand 10/06/2020 Confirmed+Probable

22 16 72%

Norway 19/06/2020 Confirmed 244 144 59%

Portugal 09/05/2020 1,125 450 40%

Singapore 22/06/2020 Confirmed 26 2 0 8%

Slovenia 22/05/2020 Confirmed 105 85 55 81% 52%

South Korea 30/04/2020 Confirmed 247 84 0 34% 0%

Spain 23/06/2020 Confirmed+Probable

28,318(confirmed)

9,679(confirmed)19,553

(confirmed+probable)

34%(confirmed)68%

(confirmed+probable)

Sweden 15/06/2020 Confirmed+probable

4,810 2,280 47%

England & Wales(UK)

12/06/2020 Confirmed+probable

48,538 19,700 14,364 41% 30%

NorthernIreland(UK)

12/06/2020 Confirmed+probable

795 412 338 52% 43%

Scotland(UK) 14/06/2020 Confirmed+probable

4,070 1,777 1,896 44% 47%

United States 18/06/2020 Confirmed 240,138 50,185 45% Source: Comas-Herrera, Joseba Zalakaín, Charles Litwin, Amy T. Hsu, Elizabeth Lemmon, David Henderson and Jose-Luis Fernández, ‘Mortality Associated with COVID-19 Outbreaks in Care Homes: Early International Evidence’, International Long Term Care Policy Network, 26th June 2020.

36

ExcessMortalityExcessall-causemortalityisanimportantmeasuretoconsiderinlookingattheeffectsofCOVID-19inIreland.EstimatesofexcessdeathscanprovideinformationaboutthescaleofmortalitypotentiallyrelatedtotheCOVID-19pandemic,includingdeathsthataredirectlyorindirectlyattributedtoCOVID-19.Excessdeathsaretypicallydefinedasthedifferencebetweentheobservednumbersofdeathsinspecifictimeperiodsandexpectednumbersofdeathsinthesametime-periods.

Therearemanywaysandmethodologiestomeasureexcessmortality.TheagreedandacceptedstandardisedapproachacrossEuropeistheEuropeanMortalityMonitoringProject,(EuroMOMO).EuroMOMOissupportedbyandworkscloselywiththeECDCandtheWHORegionalOfficeforEurope.

EuroMOMO’spreliminaryanalysisshowsthatIrelandexperiencedexcessmortalityfrommid-Marchtomid-April.ThiscoincidedwiththejumpinmortalitythatwasseenwithCOVID-19.Sincemid-May,Irelandhasrecordedmortalityratesthathaveactuallybeenlowerthanexpected.

Graph 3.5 Ireland’s reported excess mortality 2020 as compared to baseline

Source: EuroMOMO

ExcessmortalityfiguresarenotstableforthisyearbecauseofourexperienceswithCOVID-19.Atthisstageinapandemicitisnotvalidtostandoveranalysesofexcessmortalityanddiseaseincidencewithcertainty.Bestpracticeistowaitforanumberofmonthsbeforeseekingtoestablishtrendsinexcessmortalityanalyses.Thiscanallowtimeforcountriestosharefulldatagiventhedifferentdatacollectioncycles.Otherdifferencesbetweencountriessuchasage-breakdownsandpopulationdensityneedtobeconsideredwhenmeasuringindictorssuchasall-causeexcessmortality.

EuroMOMOalsodoesnotdifferentiatebetweenreasonfordeathorplaceofdeath.Inthiswayitwouldnotbepossibletoidentifyexcessdeathsinspecificsettings(e.g.nursinghomes).


Intheinterim,theDepartmentofHealthhasundertakenapreliminaryanalysisofexcessmortalityinrelationtothenumberofdeathsassociatedwithconfirmedcasesofCOVID-19.Itshowsthattheexcessmortalityweexperiencedinthefirsthalfofthisyearisexplainedbythepandemic.ThisreporthasbeenpublishedontheDepartmentofHealthwebsite.57

3.8.MortalityCensus:Long-termResidentialCareFacilitiesInordertobeassuredthatalldeathsinLTRCsinIreland,bothlaboratory-confirmedandprobable,werebeingcaptured,theDepartmentofHealthundertookamortalitycensusofallLTRCfacilitiesinmid-April.Datafromthecensusofmortalitywascomparedwithothersourcesofmortalitydata,includingtheHIQANF02notificationsandCIDR.Thiscomparisondemonstratedaclosealignmentbetweenthesourcesintermsofthenumberofcases.Thecensusreportedthat3,367totaldeathsoccurredinLTRCsfrom1stJanuaryto19th April 2020,assetoutinTable3.7.

Table 3.7 Mortality Census of LTRCs 1st January – 19th April 2020

COVID-19Labconfirmeddeaths

COVID-19Probabledeaths

TotalCOVID-19deaths

Alldeaths

NursingHomes 376 209 585 3,243

Disability 8 8 16 73

MentalHealth* 10 4 14 51

Total 394 221 615 3,367

Source: Department of Health, June 2020Notes: Survey respondents were asked to identify if any “confirmed” or “suspected” COVID-19 deaths had occurred in their facility. In line with updated terminology used to describe COVID-19, “suspected” deaths as reported by respondents are noted as probable in reporting the results of this census.

* Includes multiple responses from houses in the community – central validation of response rate in process

DatawascomparedbetweenthecensusofmortalityandothersourcesofmortalitydataincludingtheHIQANF02notificationsandtheHPSC.Itdemonstratedthatthenumberofcasesreportedinthesesourcescloselyaligned.ThedatainGraph3.6wouldsuggestthatexcessdeathsinthisperiodwereCOVID-19related.

57 DepartmentofHealth,COVID-19:ComparisonofMortalityRatesbetweenIrelandandothercountriesinEUandInternationally, (May2020)https://assets.gov.ie/75031/2c4aee04-baca-4b12-90a0-e999621b82e5.pdf

38

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ThedataindicatesanincreaseinmortalityinLTRCsfromaroundtheweekbeginning16thMarch2020onwards.Thisdataprovidesasnapshotandasthecensusdataisself-reportedtherewillinevitablybesomevariancebetweenthisdataandotherdatasources.TheobservedincreaseinmortalitywouldappeartobeattributabletoCOVID-19relateddeaths.Datawasalsocollectedontheplaceofdeathofresidents.Deathsoccurredoutsideofresidentialcentreandinhospitalsasfollows:26%forCOVID-19confirmedcases;5%COVID-19probable;15%ofalldeaths.ThecurrentHSEguidanceisthatpeoplearetobemanagedinthefacilitiesinwhichtheyliveunlessatransfertohospitalisdeemedclinicallyappropriateandwillconferadditionalbenefit.

WhiletheinformationlikelyindicatesthatCOVID-19infectioniscontributingtomortalityinthispopulationduringthepandemic,itwillultimatelyrequiretheoutputsofEuropeanandIrishall-causemortalitysurveillancesystemstodeterminethelevelofexcessmortalityabovewhatwouldbeexpectedandparticularlyincomparisonwithpastsevereinfluenzaseasonsinwhichexcessdeathscanreachlevelsof>1,000.

StaffTestingIrelandisoneofthefewcountriesthathasundertakenamasstestingprogrammeinLTRC.FollowingaNPHETrecommendationof17thApril2020,thetestingofallstaffinLTRCfacilitieswasconducted.Over95,900testswerecompletedwitharelativelylowoverallpositivityrate(5.5%)atthattime.AsrecommendedbyECDC,HSEisnowundertakingaweeklyrollingprogrammeoftestingstaffinnursinghomesforafour-weekperiodsothatanynewemerginginfectioncanbecontinuouslytrackedandtargeted.

On29thJune2020theHPSCreportedthenumberofhealthcareworkercasesinnursinghomesas1,892(7.4%ofallcases).

InlateJune,aprogrammeofserialtestingforstaffworkinginnursinghomesbegan.Asof4thJuly2020,15,662testshadbeencompleted.Atotalof27staffwerefoundtobepositiveforCOVID-19across20facilities.

Table3.8andTable3.9belowsummarisetheworkandfindingsofthisserialtestingprogrammeupto4thJuly.

Table 3.8 Overall Serial Testing Results to 4th July 2020

ResultsSummary Yeartodate

Results received 15,662

Detected 27(0.2%)

NotDetected 15,624(99.8%)

Inhibitory 2(0.01%)

Nottested 2(0.01%)

Invalid 7(0.04%)

Source: HSE Daily Report for Serial Testing of all staff in Residential Care Facilities (Older People)

Date: 4th July 2020

40

Table 3.9 Summary of Tests and Positive Tests by Facility and Region to 4th July

NursingHomeLocation

NursingHomeNumber

TotalEst.StaffinFacility

(basedonFTE)

TotalStafftested

NumberDetected(%)

DateResultReported

NorthWest(CHO1) Facility1 40 34 1(2.9%) July4th

West(CHO2) Facility1 34 33 1(3.0%) June30th

Mid-West(CH03) Facility1 30 41 1(2.4%) June30th

Facility 2 57 56 1(1.8%) June30th

Facility3 36.5 21 1(4.8%) July1st

East(CHO6) Facility1 64 70 1(1.4%) July4th

East(CHO7) Facility1 148 93 1(1.1%) July4th

Facility2 134 63 1(1.6%) July4th

Midlands(CHO8) Facility1 60.5 76 1(1.3%) July 2nd



East(CHO9) Facility1 170 170

93 144

5(5.4%) 1(0.7%)

June26th July4th


Facility3 170 103 1(0.6%) June28th


Facility5 185 68 1(1.5%) June30th


Total 27

Source: HSE Daily Report for Serial Testing of all staff in Residential Care Facilities (Older People)Date: 4th July 2020

Table3.10showsthenumberofhealthcareworkersinoutbreaknursinghomesconfirmedtohaveCOVID-19bymonth.ThemajorityofcaseswereidentifiedinApril,whichcoincidedwiththeintroductionoftheenhancedtestingprogrammeinthesector.


Table 3.10 Number of Healthcare Workers in Nursing Homes Confirmed to have COVID-19 by Month

March April May June Total

Carlow <5 25 6 <5 33

Cavan <5 103 20 <5 123

Clare <5 36 6 <5 43

Cork 11 33 5 <5 49

Donegal <5 33 <5 <5 33

Dublin 23 575 155 25 778

Galway <5 7 <5 <5 10

Kerry <5 <5 <5 <5 <5

Kildare <5 72 28 10 111

Kilkenny <5 5 <5 <5 6

Laois <5 6 <5 <5 8

Leitrim <5 <5 5 <5 5

Limerick <5 45 7 <5 55

Longford <5 12 <5 <5 13

Louth <5 125 14 <5 140

Mayo <5 47 <5 <5 51

Meath <5 68 <5 <5 72

Monaghan <5 98 11 <5 109

Offaly <5 22 <5 <5 23

Roscommon <5 5 28 <5 35

Sligo <5 13 <5 <5 15

Tipperary 5 21 6 <5 32

Waterford <5 <5 <5 <5 5

Westmeath <5 37 9 <5 46

Wexford <5 21 <5 <5 21

Wicklow <5 56 16 <5 76

Total 1,892

Source: CIDR, 29th June 2020

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HospitalTransfersAtthebeginningofthepandemic,effortsweremadetoensurethatsufficientacutehospitalcapacitywasavailable,whichincludeddischargingpatientswhoweremedicallyfitwherepossible,includingdischargesofpatientstonursinghomes.Thisprotectedpatientsfrompotentialhospital-acquiredinfections,andtheHSEandHPSCdevelopedguidanceforsuchdischargesandpatienttransfers:

PatientsdiagnosedwithCOVID-19.From10thMarch2020,testingofpeopleinlinewiththenationaltestingcriteriaandtwonegativeswabsforthoseCOVID-19positivebeforetransferfromhospitaltoanursinghomewasintroduced.Thisguidancewasreviewedonthe6thAprilbytheExpertAdvisoryGrouptoNPHETwhoadvisedthattherewasnoneedtochangethedischargecriteriaforhospitalisedpatientsreturningLTRCs–thoseCOVID-19positivewouldcontinuetohave2negativetests24hoursapartbeforetransfer.TheNPHETacceptedthisadviceon7thApril.

In-hospitalcontactsofpatientsdiagnosedwithCOVID-19.Since10th March, the guidance has been that COVID-19contactscouldbedischargedbacktonursinghomessolongastheywereisolatedinasingleroominthenursinghomefor14days.

Allpeoplebeingtransferred,regardlessofCOVID-19diagnosticorcontacthistory;From8th April, arequirementtoisolateall people transferred to nursing homes in a single room, where possible, for a monitoringperiodof14dayswasintroducedbytheHPSC.Thiswasdoneonthebasisthattestingthatfailedtodetectthevirusdidnotgivesufficientassurancethatthepersonwasnotinfected(forexample,presymptomaticincubationofthevirus);

• theHSEconfirmedthatMarch10th guidance remained the protocol in place for hospital discharges untilitwassupersededbyHPSC8th April guidance;

• on10thMarchtherewere34confirmedCOVID-19casesinIreland; • the comprehensive Interim Public Health and Infection Prevention Control Guidelines on the Prevention

and Management of COVID-19 Cases and Outbreaks in Residential Care Facilities and Similar Units, last updatedon19thJune2020,indicatesthat:

- allpatientsforadmissiontoLTRCsshouldbetestedforCOVID-19.Thisistohelpidentifymostofthosewhohavetheinfectionbutitwillnotdetectallofthosewiththeinfection.

- everyresidenttransferredtoaresidentialcaresettingmustbeaccommodatedinasingleroomwithcontactanddropletprecautionsfor14daysaftertransferandmonitoredfornewsymptomsconsistentwithCOVID-19duringthattime.ThisapplieseveniftheyhavehadatestforCOVID-19reportedasnot-detectedor“negative”.58

AvailableHospitalisationDataTheHealthPricingOffice’sHospitalInpatientEnquirySystem(HIPE)wasadaptedduringtheCOVID-19pandemictocollectinformationspecificallyonCOVID-19positivecasesintheacutehospitalsystem.Intheearly stages of the pandemic there was uncertainty about the level of acute hospital system capacity that may berequired.Consequently,therewereeffortsmadetoensurethatadequatecapacitywouldbeavailable.Thisincludedrescheduling/cancellingelectiveproceduresandattemptingtoensurethatpatientswhowereassessedtobefitfordischargedidnotexperiencedelaysintheirdischargetotheirplaceofresidence.

58 SeeHealthProtectionSurveillanceCentre,‘InterimPublicHealthandInfectionPreventionControlGuidelinesonthePreventionandManagementofCOVID-19CasesandOutbreaksinResidentialCareFacilitiesandSimilarUnits’,19thJune2020,https://www.hpsc.ie/a-z/respiratory/coronavirus/novelcoronavirus/guidance/outbreakmanagementguidance/RCF%20guidance%20document.pdf


Table3.11andTable3.12belowdetailthenumberofadmissionsanddischargesfromnursinghomesandotherlong-staysettingsinto,andfrom,acutehospitalsbyweekin2020.Itshouldbenotedthatduringthetimeofthepandemic,certainactivitiesremainedessentialsuchasdialysistreatmentsandchemotherapy.Thisshouldbeconsideredwhenexaminingthesetables.Thetestingofpatientswasinlinewiththecasedefinitionsinuseatthetime.

Therewasadecreaseintheoverallnumberofadmissionsfromnursinghomesandotherlong-staysettingsinthesecondquarterof2020bycomparisonwiththefirstquarter.Therewasalsoanincreaseinthenumberofdischargestonursinghomesandotherlong-staysettingsinFebruaryandMarch,thoughmostofthesearenotedasbeing“Non-COVID-19”.Thenumberofdischargesroughlycorrelateswiththenumberofadmissionsinthiscohortonaweek-by-weekbasis.

Itshouldalsobenotedthat“COVID-19confirmed”indicatesthatthepatientsreferredtowerenotedashavingCOVID-19atsomepointintheirhospitalstay.ItdoesnotmeanthattheywereconfirmedashavingCOVID-19atthetimeoftheirdischarge.Furthermore,itdoesnotindicatethatthepatientmaynothavedevelopedCOVID-19subsequently.AllCOVID-19statusisrepresentativeofapointintime.Finallyinrelationtotable3.11,thedateofadmissionreferstothedatepatientswereadmitted,andassociatedCOVID-19“confirmed”orCOVID-19“probable”datadoesnotmeanthatthepatientwas“confirmed”or“probable”COVID-19onthatdate,rathertheywereidentifiedatsomepointintheirhospitalstayasconfirmedorprobabletohaveCOVID-19(i.e.theassociatedadmissiondateisthedateofadmissiontohospitalandnotthedateofconfirmedorprobableCOVID-19infection).

Unfortunately,intheabsenceofanindividualhealthidentifier,itisnotpossibletocomprehensivelyandreliablytrackthespreadofCOVID-19bypatientbetweentheacutehospitalandnursinghomessectors.Evenifsuchanidentifierwereavailable,thissortofanalysiswouldbesubjecttoanumberofconfoundingvariablessuchasthemovementofstaff,thetimingofnotificationofcasesandoutbreaks,outbreakcontrolteaminterventionsorasymptomatictransmission(knowntobeapossiblesourceoftransmissionfrommid-MarchaspertheECDC).

44

Table 3.11 Transfers from LTRC including nursing homes to hospital

Admittedfrom Transferfromnursinghome/convalescenthomeorotherlongstayaccommodation

Other(non-LTRCs)

COVConfirmed

COVProbable

NonCOVID

Total COVConfirmed

COVProbable

NegativeCOVI

Total NonCOVID

Admissiondate

Weekbeginning

. . . . . . -

Week01 30/12/2019 . . 239 239 3 1 . 4 34,294

Week02 06/01/2020 . . 254 254 14 . . 14 34,670

Week03 13/01/2020 . . 237 237 8 . . 8 34,746

Week04 20/01/2020 . . 236 236 8 1 . 9 35,242

Week05 27/01/2020 . . 227 227 14 . . 14 35,310

Week06 03/02/2020 1 . 242 243 15 . . 15 35,277

Week07 10/02/2020 . . 258 258 20 . . 20 34,303

Week08 17/02/2020 1 . 203 204 28 . . 28 35,342

Week09 24/02/2020 1 . 229 230 61 2 . 63 35,219

Week10 02/03/2020 5 . 189 194 156 5 . 161 31,846

Week11 09/03/2020 6 1 121 128 397 9 . 406 18,238

Week12 16/03/2020 29 1 101 131 605 40 . 645 18,073

Week13 23/03/2020 54 . 93 147 546 33 . 579 16,898

Week14 30/03/2020 62 1 100 163 509 37 . 546 17,651

Week15 06/04/2020 57 2 109 168 341 28 . 369 16,789

Week16 13/04/2020 49 . 127 176 276 19 . 295 19,032

Week17 20/04/2020 30 2 101 133 212 23 . 235 19,616

Week18 27/04/2020 30 1 83 114 154 15 . 169 18,399

Week19 04/05/2020 7 . 109 116 74 9 . 83 20,318

Week20 11/05/2020 8 . 71 79 50 3 . 53 20,774

Week21 18/05/2020 7 1 43 51 18 1 . 19 20,628

Week22 25/05/2020 . . 8 8 2 2 . 4 6,288

Week23 01/06/2020 . . . 0 . . . 0 38

348 9 3,891 4,248 3,540 230 1 3,771 583,678

Source: HIPE, Health Pricing Office, June 2020


Table 3.12 Transfers from hospital to LTRC including nursing homes

Dischargedto Nursinghome,convalescenthomeor

longstayaccommodation

Other

COVConfirmed

COVProbable

NonCOVID

Total COVConfirmed

COVProbable

NegativeCOVI

NonCOVID

Total

Dischargedate

WeekBeginning

. . . . .

Week01 30/12/2019 . . 691 691 . . . 34,061 34,061

Week02 06/01/2020 . . 704 704 . . . 34,144 34,144

Week03 13/01/2020 . . 681 681 . . . 34,395 34,395

Week04 20/01/2020 . . 656 656 . . . 34,780 34,780

Week05 27/01/2020 . . 667 667 . . . 35,072 35,072

Week06 03/02/2020 . . 595 595 . . . 34,758 34,758

Week07 10/02/2020 . . 637 637 . . . 34,126 34,126

Week08 17/02/2020 . . 605 605 . . . 35,015 35,015

Week09 24/02/2020 . . 682 682 2 1 . 35,443 35,446

Week10 02/03/2020 2 . 777 779 45 2 . 32,928 32,975

Week11 09/03/2020 2 . 570 572 119 7 . 19,653 19,779

Week12 16/03/2020 2 . 481 483 300 19 . 18,605 18,924

Week13 23/03/2020 14 . 272 286 478 39 . 16,998 17,515

Week14 30/03/2020 43 . 252 295 586 26 . 17,551 18,163

Week15 06/04/2020 29 . 169 198 487 30 . 16,198 16,715

Week16 13/04/2020 50 . 208 258 386 27 . 18,778 19,191

Week17 20/04/2020 77 5 203 285 330 27 . 19,440 19,797

Week18 27/04/2020 50 2 190 242 264 22 1 17,878 18,165

Week19 04/05/2020 60 . 244 304 210 10 . 20,399 20,619

Week20 11/05/2020 32 1 275 308 163 7 . 21,172 21,342

Week21 18/05/2020 30 2 305 337 101 8 . 23,027 23,136

Week22 25/05/2020 10 1 102 113 16 3 . 8,359 8,378

Week23 01/06/2020 . . . . . . . 71 71

401 11 10,298 10,710 3,487 228 1 577,271 580,987

Source: HIPE, Health Pricing Office, June 2020

46

3.9.SummaryTheveryinfectiousnatureoftheCOVID-19virusmakesitdifficulttopreventandcontrolinresidentialcaresettings,anexperiencereplicatedinternationally.Thetransmissionofthevirusinto,andwithin,nursinghomesismultifactorial.ActionstakentomitigatethespreadofCOVID-19areaimedatprotectingresidentsandstaffthroughactionstodeterCOVID-19fromcominginthenursinghomedoorand,ifitgetsinthedoor,tominimisespread.

Asanewdisease,healthauthoritiesacrosstheworldarelearningaboutCOVID-19andadaptingasnewevidenceandunderstandingisformed.Thecasedefinitionevolvedasnewinformationbecameknown,evidenceisnowavailablethatindicatesthatolderpeoplecanhaveatypicalpresentationsandthelevelofasymptomatictransmissionishigherthanpreviouslyknown.

PeopleinnursinghomesandequivalentcentresweredisproportionatelylikelytocontractCOVID-19comparedtothoseintheirpeerage-grouplivinginthecommunity.Themortalityratesseeninnursinghomeswerealsohigherthanthoseseeninthegeneralpopulationformostagegroups.Thisisinthecontextofamoremedicallyvulnerablepopulationinnursinghomes.

COVID-19spreadtonursinghomeslaterthanacrossthegeneralpopulation.Whilethemajorityofclustersarenowclosed,theinformationfromthedatamustinformprotectiveactionsandpolicies.AddingtothedatasetsandmaximisingavailableinformationwillbeimportantasIrelandandtherestoftheworldcontinuestoadapttothisnovelvirus.


4.EvidenceReview4.1.IntroductionThischapterpresentsabriefoverviewoftherapidreviewofliteratureundertakenonbehalfoftheExpertPanelbyaReviewTeamatUniversityCollegeDublin(UCD).Thefullreportoftherapidreview–Systematic Rapid Review of Measures to Protect Older People in Long-Term Residential Care Facilities from COVID-19-undertakenonbehalfof,andunderthedirectionofthePanelisprovided,infull,atAppendix3.FirstpersonreferencesinthischapterrefertotheReviewTeam.

4.2.ObjectiveArapidreviewofliteratureprovidesanoverviewoftheinternationalresponsetoCOVID-19innursinghomesandassessestheextenttowhichmeasuresimplementedinlong-termresidentialcarefacilitiesreducedtransmissionandevaluatedtheimpactonmorbidityandmortalityoutcomes.

4.3.MethodsGoogleScholardatabase(from1stJanuary2019tocurrent),websitesforpolicydocumentsandreportsincludingtheagileplatformLong-TermCareResponsestoCOVID-19,WorldHealthOrganization(WHO),andCentersforDiseaseControl(CDC)andfourdatabases(inceptionto12thJune2020)weresearched: • EMBASE(viaOVID); • PubMed(viaOVID); • CumulativeIndextoNursingandAlliedHealthLiterature(CINAHL); • CochraneDatabaseandRepositoryforCOVID-19evidence.

Weincludedapre-publishedrepositoryMedRXivdatabase(searchedinceptionupto3rdJuly2020).59

4.4.SummaryofFindings(PoliciesandReports)Policyguidancefornineothercountriesincludedrecommendationsontesting,screening,monitoring,isolation,cohorting,socialdistancing,visitation,environmentalcleaning,immunisation,providingcarefornon-cases,caringfortherecentlydeceased,andgovernanceandleadership.Differencesemergedforcriteriafortesting,lengthofisolationofsymptomaticresidents,recommendationsfortheuseoffacemasksbystaffandresidents,immunisationrequirements,useofnebulisers,ontemporaryresidenttransfertothehomesoffamilyorfriends,ventilation,andonlimitingstaffmovementbetweenfacilitiesandmanagingdeliveries.

59 Seehttps://www.medrxiv.org/

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4.5.SummaryofFindings(SystematicReview)Intotal,33paperspresentlimiteddataonthemanagementofoutbreaksandtheabsenceofasystemsapproachtothemanagementofCOVID-19innursinghomes.Severalstudiesimplementedlarge-scalesurveillance/testingofresidentsandemployeestoreducetransmission,butavailabilityoftestingkitswaslimitedearlierinthepandemicandpreventedbroadertesting.60,61Testingofsymptomaticresidentswasprioritisedwhichneglectspre-symptomaticcases(residents,visitors,andstaff).Onlytestingsymptomaticindividualswasinsufficienttopreventtransmission.

Increasedmovementofresidents,workers,andvisitorsraisesthelikelihoodofviraltransmissioninlong-termresidentialcarefacilities(LTRCs).EvidenceofreducedtransmissionisapparentwhenLTRCsinstigatedcohortingandlockdownprocedureslimitingmovementsofstaffandpreventingaccesstovisitors.Rapidisolationofcases,prohibitingentryofstaffandvisitorspresentingwithsymptomsorwithrecentoverseastravel,andrestrictingstaffmovementbetweenwards,assistedinlimitingresidentcasenumbersto19ofatotalof96residentsandemployeecasenumbersto8ofatotalof136staffmembers.60

TheuseofPPEisanessentialstrategyforreducingtransmissioninnursinghomes.Gloves,masks,gowns,andeyeprotectionwereallinvestigatedintheincludedreports.AnincreaseinthespreadofCOVID-19wasdemonstrated,aseyeprotectionandfacemaskswerelessavailabletostaffinUKnursinghomes.62Useofinfectioncontrolmeasuresincludingdropletandcontactprecautions,handandpersonalhygiene,regulardisinfectionofsurfaces,andcreationofspecificzonesforremovalofcontaminatedPPEwasreported.

Frequentscreeningofresidentsforsymptoms(onceortwiceperday)andofstaffbeforecommencingashiftshouldbeimplementedtoidentifyat-riskindividuals.Residentsidentifiedbysuchstrategiesshouldbeisolatedandtestingundertaken.Staffpresentingwithsymptomsshouldquarantineathomeandawaitresultsofatestbeforereturningtothefacility.Closingfacilitiestovisitorslimitstransmissionofthevirusfurther,asdoesdelayingthetransferofresidentstoafacilityuntilafteranegativetestresultisconfirmed.

Numerousfacility-specificcharacteristicswereassociatedwithanincreasedriskofCOVID-19cases.TheOfficeofNationalStatisticsreport(2020)identifiedemploymentcontractsofstaffwithnosickpaymentswereassociatedwithahigherriskoftransmissionofCOVID-19,aswastheadditionaluseofagencycarestaff.InUSnursinghomes,largerfacilitysizeincreasedtheoddsofcasepresentation,asdidthepercentageofAfricanAmericanresidentsandafor-profitstatus.63 Increased rates of cases were reported in residents associated with increased numbersofworkers/agencystaffemployedinthefacility.62 In Irish nursing homes, resident case numbers were associatedwiththeproportionofsymptomaticstaff,64withasimilaroutcomereportedinUKnursinghomes.65 Thatsaidmanyofthesecharacteristicsarenotacutelymodifiable,e.g.for-profitstatus,numberofbedsavailable,percentageofAfricanAmericanresidents,awarenessidentifiesfacilitiesforurgentaction.

60 SeeAmyV.Dora,AlexanderWinnett,LaurenP.Jatt,KushaDavar,MikaWatanabe,LindaSohn,HannahS.Kern,ChristopherJ.Graber,andMatthewB.Goetz,‘UniversalandSerialLaboratoryTestingforSARS-CoV-2ataLong-TermCareSkilledNursingFacilityforVeterans-LosAngeles,California,2020’,MorbidityandMortalityWeeklyReport69/21(2020):651–655.

61 SeeN.S.N.Graham,C.Junghans,R.Downes,C.Sendall,H.Lai,A.McKirdy,P.Elliott,R.Howard,D.Wingfield,M.Priestman,M.Ciechonska,andL.Cameronetal,‘SARS-CoV-2Infection,ClinicalFeaturesandOutcomeofCOVID-19inUnitedKingdomNursingHomes’,JournalofInfection(3rdJune2020):1–9,https://www.medrxiv.org/content/10.1101/2020.05.19.20105460v1.full.pdf.

62 SeeJuliiSuzanneBrainard,StevenRushton,TimWinters,andPaulRHunter,‘IntroductiontoandSpreadofCOVID-19inCareHomesinNorfolk,UK’,medRxivpreprint(18thJune2020),https://www.medrxiv.org/content/10.1101/2020.06.17.20133629v1.

63 SeeHannahR.Abrams,LaceyLoomer,AshvinGandhi,andDavidC.Grabowski,‘CharacteristicsofU.S.NursingHomeswithCOVID-19Cases’,JournaloftheAmericanGeriatricsSociety(2ndJune2020):1–4.

64 SeeSeánP.Kennelly,AdamH.Dyer,RuthMartin,SiobhánM.Kennelly,AlanMartin,DesmondO’Neill,andAoifeFallon,‘AsymptomaticCarriageRatesandCase-FatalityofSARS-CoV-2InfectioninResidentsandStaffinIrishNursingHomes’,medRxivpreprint(12th June 2020),https://www.medrxiv.org/content/10.1101/2020.06.11.20128199v1.

65 SeeOfficeofNationalStatistics,‘ImpactofcoronavirusincarehomesinEngland:26Mayto19June2020’(3July2020)https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/conditionsanddiseases/articles/impactofcoronavirusincarehomesinenglandvivaldi/26mayto19june2020,


4.6.Conclusions:ImplicationsforPracticeandResearchDespitelimitationsinthequalityoftheavailableevidence,severalimplicationsforpracticearehighlighted.TheuseofPPEandotherinfectioncontrolmeasures(dropletandcontactprecautions,handhygiene)areessentialregardlessofwhetheracasehasbeenreportedinafacility.Frequentscreeningofresidentsforsymptoms(onceortwiceperday),andscreeningofstaffpriortocommencingashiftshouldbeimplementedtoidentifyat-riskindividuals.Residentsidentifiedbysuchstrategiesshouldbeisolatedandtestingshouldbeundertaken.Staffpresentingwithsymptomsshouldbeisolatedathomeandawaitresultsofatestbeforereturningtothefacility.Closinghomestovisitorslimitsopportunitiesforthevirustobeintroduced,asdoesdelayingthetransferofresidentstoafacilityuntilafteranegativetestresulthasbeenproduced.

Whereavailable,widescaletestingofresidentsandstaffshouldbeimplemented,withrapidisolationofpositivecases.EnsuringPPEandinfectioncontrolpracticesarefollowedwithsuchcasesisessential.Giventhepresenceofasymptomaticandpresymptomaticcases,itisnotrecommendedtowithholdtestinguntilsymptomsdevelop.Surveillance systems recording the health status of residents should be in place to monitor health outcomes includingassessmentsoffrailtyanddelirium.

Considerationmustbegiventothementalwellbeingofresidentswhohavebeenisolated,particularlygiventheyhavelikelyalreadyexperiencedaperiodofreducedvisitationfromfamily.Furthermore,residentssufferingfromdementiawhomaywalkwithpurposemayrequireadditionalattention.Considerationoftheimpactonfamiliesandthesystemsthatarerequiredtosupportthemduringperiodsofreducedvisitations.

ThepreparednessoffacilitiesforfutureoutbreaksincludesdevelopmentofstafftrainingandeducationprogrammesoninfectionpreventionandcontrolandtheappropriateuseofPPEforallemployeesofLTRCs.Thisshouldincludequalityreviewwithregularmonitoringofknowledgeandpractice.ThisisessentialgiventheimplicationstoLTRCswhereemploymentofagencystaffingisadoptedandgiventheadditionalrisksoftransmissionnotedfromtheevidence.Similarly,theevidenceidentifiedrisksoftransmissionoftheviruswhennotdirectlyinvolvedincaringduties.

ConsiderationmustbegiventosupportingthehealthandwellbeingofallstaffemployedinLTRCfacilitiesduringanoutbreak,includingfinancialsupportduringperiodsofisolationandquarantining.

The voices of all involved in the care and management, especially those of residents and their families, should be attheheartofpracticedevelopments.

Giventherapidnatureofdatacollectionduringthecurrentpandemicandtheshortfollow-uptime,opportunitiestoimplementcontrolledinterventionsarelimited.Assuch,theretrospective,descriptivenatureofstudiesidentifiedforthisreviewdonotallowthedeterminationofcauseandeffect.Longitudinalfollow-upwillbeessential.Futureresearchshould: • implementinterventions,ideallywithacontrolorusualcarecomparisongrouptoassistinelucidatingthe

most appropriate strategies to reduce transmission; • developrobustsurveillancesystemformonitoringofresidents’healthandwellbeingprospectively

including assessment of frailty and delirium; • assesstheinfectioncontrolpreparednessofLTRCfacilities; • evaluatetheimpactofoutbreaksandisolationonthehealthandwellbeingofresidents,employees,and

families; • includethevoicesofresidents,familiesandallinvolvedinthecareandprotectionofolderpeopleinLTRC

facilities.

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5.StakeholderConsultation:anIn-ActionandAfter-ActionReviewTheExpertPanelwastaskedwithprovidingassurancethatthenationalprotectivepublichealthandothermeasuresadoptedtosafeguardresidentsinnursinghomesspecifically,inlightofCOVID-19areappropriate,comprehensiveandinlinewithinternationalguidelinesandidentifyanylessonslearnedfromIreland’sresponsetoCOVID-19innursinghomestodate.WhilstatthetimeofwritingtheepidemicinIrelandhasbeenarrestedfor now, albeit with recent worrying developments in case incidents and an increased R number, an unintended buttragicconsequencehasbeenthedeathtollinolderpeopleresidentinlong-termresidentialcarefacilities,particularlynursinghomes.

ThetaskofthePanelisforward-lookingtoprotectthatvulnerablepopulationintothenearfuture,whetherornotasurgeofCOVID-19occursoriftheinfectionremainsinthecommunityandcontinuestobearisktothoseespeciallyvulnerabletoit.ThePanel’sworkhasbeenguidedbytheprinciplesofin-actionandafter-actionreviewswherelessonslearnedinrealtimeareactedupon.Thisisnotsimplytoidentifythoselessonslearnedbuttoseektoapplytheseinsightsinatightertimescaleinordertoimprovetheoutcomeoftheongoingresponse.Finally,itassistsinassessingstrategicoptionsintheupcomingphasesofthepandemic.66

ThePaneladoptedthestrategyofstakeholderconsultationandtocompletethereportwithintwomonthsofthegroup’sestablishment.AninterimreportontheprocessesentailedandinitialadvicetocontinuetheexistingsupportstonursinghomesinplacewasgiventotheMinisteron30thJune.Here,thePanelreportsonthesubmissionsmadeandfollow-updiscussionshadwiththosekeystakeholders.Engagementwiththisprocesswastimely,constructive,well-preparedandinspiredbyaneedtoensurethatbestpracticeinanongoinglearningenvironmentwasimplemented.ThePanelhasconcludedtheneedtosustaintheimmediatesupportsinplaceforthissector,theimportanceofpreparationplanningforupcomingwinter2020/2021,butalsothattheexperienceof this epidemic worldwide has revealed the need to focus now on the care of older persons more generally in oursocietyandtheframeworkrequiredtodoso.

ThePanelhasworkedtotheProgrammeforGovernmentpublishedinJune202067 which advocates for an AgeFriendlyIreland,proposestheestablishmentofaCommissiononCareanda10-pointplanforhomeandcommunitycaresupport,focusesondeliveringchoiceandsetsoutproposalsforthefutureoflong-termresidentialcare,enhancingdementiacareandend-of-lifecare.Inthiscontextwehaveapproachedthetaskasbeingexpresslyabouttheshort-termprotectionsrequiredbutalsoasanopportunityforthefuture.WeareatacrossroadsalsoinhealthcarepolicyinIrelandinthatmanyaspectsofthetraditionaltwo-tierhealthcaredeliverymodelacrossallpartsofourhealthcaresystem,fromgeneralpracticeandprimarycarethroughtotheacutehospitalsystemandhighlyspecialisthealthcaremanagement,aresubjectcurrentlytopolicyreview.Wemustseizetheopportunityandswiftly.

TheExpertPanelengagedinanextensiveprocessofstakeholderengagementinvolvingmeetings,writtensubmissions,andapublicconsultation.Allprimarymaterials,includingcompletedsubmissions,werereceivedbytheExpertPanelandconsideredinthecontextofitsoverallwork.

66 SeeEuropeanCentreforDiseasePreventionandControl,‘ECDCTechnicalReport:ConductingIn-ActionandAfter-ActionReviewsofthePublicHealthResponsetoCOVID-19’(June2020),https://www.ecdc.europa.eu/sites/default/files/documents/In-Action-and-After-Action-Reviews-of-the-public-health-response-to-COVID-19.pdf.

67 SeeGovernmentofIreland,ProgrammeforGovernment–OurSharedFuture,(June2020)


SubmissionswerecollatedbytheSupportTeam,andaqualitativethematicanalysiswasconductedusingtheFrameworkMethod,inordertoidentifyandpresentanoverviewofthethemesandissuesraisedinthesubmissionstothePanel.ThisapproachisdescribedinChapter2,Methodology.

Therestofthischapterprovidestheanalysisandsummaryoftheviewsandinputsreceivedfromstakeholders.It is important for the reader to recognise that this chapter presents the views and statements made by respondentswithoutthecommentorthevalidationofthePanel.

5.1.MeetingswithStakeholdersHIQAhasregulatoryresponsibilityforoversightofthenursinghomesectorwith576registeredfacilitiesacrossthecountry.ItssubmissiontothePanelwasthroughthelensofregulation.NursingHomesIreland(NHI)isanationalrepresentativebodyforprivateandvoluntarynursinghomesinthesector.Its385membersprovidequalitycaretoover25,000residents.

ThePanelengagedwithseveralgroupsandbodiesrepresentinggeriatricians/gerontologyandreceivedasubmissionfromtheRoyalCollegeofPhysiciansofIreland(RCPI)ClinicalAdvisoryGroupforGeriatricMedicine,apositionpaperfromtheIrishGerontologicalSociety(IGS)aswellasseveralpapersandreportsfrompractitionersindifferentpartsofthecountryontheexperienceofestablishingintegratedandinter-disciplinaryandoutreachsupportteamsforresidentialfacilitiesduringtheoutbreak.

TheIrishCollegeofGeneralPractitioners(ICGP)submittedanumberofdocumentsincludingthoseonaprimarycareleadfortheIntegratedCareProgrammeforOlderPeople(ICPOP),accesstospecialistadviceandsupportviaIntegratedReferralManagementSystem,telemedicineandvirtualclinicsintheresidentialcaresettingandthecaseforanurgentevaluationofelectronicmedicalrecordsinlong-termresidentialcarefacilities.

TheOlderPersonsSubgroupoftheIrishAssociationofDirectorsofNursingandMidwifery(IADNAM)madeaformalsubmissionandattendedasessionwithtwoofthechiefdirectorsofnursingandmidwiferyfromthehospitalgroups.

BoththeIrishMedicalOrganisation(IMO)andtheIrishNursesandMidwivesOrganisation(INMO)havesignificantmembershipwhocaterforandsupportstaffinthissector.SIPTUHealthDivisionwhichrepresentsover42,000healthworkersinnursing,midwiferyandalliedhealthaswellasarangeofservicesincludingtheNationalAmbulanceService,catering,porterandtechnicalservicesaswellashealthcareassistantsemployedinbothresidentialandcommunitysettings,engagedwiththePanel.

ThePanelmetwithbothclinicalandoperationalleadsfromtheHSE,withseniormembersofpublichealthfromtheHSEandtheHealthProtectionSurveillanceCentre,aswellasreceivingseveralsubmissionsfromtheregionalDepartmentsofPublicHealth,fromHSECHOleadsandfromHospitalGroups.TheHSEalsosubmittedapositiondocument.

The‘AdvocacyandEndofLifethematicengagement’comprisedengagementwithmembersfromSageAdvocacy,theAllianceofAgeSectorNGOs,theIrishHospiceFoundationandSafeguardingIreland.

TheExpertPanelmetwithmembersoftheNationalPublicHealthEmergencyTeam(NPHET),includingtheChairandChiefMedicalOfficer,theSecretaryGeneralandChiefNursingOfficerandadatateamestablishedbytheDepartmentofHealthtosupportitswork.

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5.1.1.KeyLearningsandActions

5.1.1.1. Timeliness of ResponseTheCensus2016showednearly30,000peopleareresidentinnursinghomesand€1billionisinvestedbytheStatethroughtheNursingHomeSupportScheme(NHSS)withsignificantfurthercontributionspaiddirectlybyNHSSresidentsandnon-NHSSresidents.Additionally,theStatehasprovided€30mtoprivatenursinghomesfordeliveryofshort-staytransitionalcareservices.Inthefirstinstance,theprimaryresponsibilityfortheprovisionofsafecareandservicetonursinghomesrestswithindividualnursinghomeoperators.TheState’sresponsibilityto respond to the public health emergency created the need to establish a structured support system further toNPHETrecommendations.FormalisedcontactbegantotakeplacebetweenHSE,NHIandHIQAfromearlyFebruaryandtheVulnerablePersonsSubgroupofNPHETwasestablishedsoonafter.

A common theme in the discussions with stakeholders focused on the challenges when an outbreak occurred, elements that worked well, areas of ongoing concern and the paramount importance of the residents and their families.Allstakeholdersemphasisedtheissuesoftimelytestingturnaround,availabilityofpersonalprotectiveequipment(PPE)andexamplesweregivenbyonestakeholdernotingthatpracticalneedtohavedeepcleanprocessesinplace,comfortablePPE,protocolsforstorageandtheavoidanceofstaffclusteringwhennotdirectlyengagedincare.Stakeholdersstressedtheneedfortimelyresponseandfuturepreparednessaswellastheneedtokeepintrainwithnationalguidelines.

Thetimelinesofthehealthsectorresponsefrom9thMarchonwardsweredescribedbystakeholders.TheAreaCrisisManagementTeams(ACMTs)wereestablishedtomanageanintegratedresponseacrossacuteandcommunityorganisationsandtoengagewithnursinghomesandnationalguidancedocumentswerealsoproduced.InadditiontotheDepartmentofHealth,theHSEalsohadregulardiscussionswithHIQAandNHI.On27thMarchresponseteamswithnationaloversightwereestablishedbytheHSE.ThefirstCOVID-19caseinIrelandwason29thFebruaryandthefirstinanursinghomeon16thMarch.Casespeakedinthegeneralpopulationon28thMarchbutinnursinghomes,fourweekslater.

On18thMarch2020,NPHETestablishedaNursingHomeWorkingGroupandon31stMarchNPHETapprovedasix-pointplan(seeappendix2)forLTRCfacilitieswhichstrengthenedHSEnationalandregionalgovernancestructures,putinplacetransmissionriskmitigationmeasuresinsuspectedorCOVID-19positivesettingsandmadeaseriousofrecommendationswithregardtohomecarestaff,staffscreeningandprioritisationforCOVID-19testing,HSEprovisionofPPEandoxygen,trainingandpreparednessplanning.TheHSE’ssubmissionnotesthatitdoesnothavealegislativebasedauthoritytohaveaspecificordirectrolefororoversightofprivateandvoluntaryresidentialcentres.

Notwithstandingthatthelegalresponsibilityforcarerestswiththenursinghomeprovider,theHSEandDepartmentofHealthprovidedthenecessaryfundingandsupports,rangingfromclinicaladvice,infectioncontrol,largescaleprovisionofPPE,atemporaryfinancialsupportschemeandstaffinginordertomaintaintheseservicesasitwasclearthatsomewerenotabletosupportthemselvestodoso.Allstakeholders,includingthenursinghomeproviders,wouldliketoseegreaterintegrationofprivateandvoluntaryresidentialsettingsintothehealthservice,improvedcommunityservicesforolderpeopleandaheavyfocusontestingandquickturnaroundofresults.


5.1.1.2. A New DiseaseTherewasbroadconsensusthatCOVID-19isanewdiseasewithatypicalpresentationinolderpersonsandconsequentlyiscomplextomanageandthecongregatednatureofthenursinghomesettingposedchallenges.Stakeholdersstressedtheneedforpreparednessandinfectionpreventionandcontrolmeasuresthatweresystemic,comprehensiveandresponsive.Animportantlearningisthepreventionofvirusentrytoandwithinresidentialcarefacilitiesincludingnursinghomes.

KeylessonsincludedthechallengeofmanagingCOVID-19inanursinghomeenvironmentversusasterilehealthcareenvironmentwithenhancedinfectionpreventionrequirements.ThenatureofCOVID-19,includingitslevelofinfectiousness,theextentofatypicalpresentationandthelevelofasymptomatictransmissionandthegenerallyevolvingepidemiologicalknowledgeposedmanagementproblems.

Theevolvingdiagnosticcriteriawereimportantandinthefutureabalancehastobestruckinrelationtovisitoraccessthatrecognisesthatresidentshavearighttohavetheirnursinghomeplaceconsideredahome.InitsengagementwiththePaneltheHSEexpressedconfidencethattheissuesregardingprovisionoftestingandcontacttracingwereresolved,withreadinessforafuturewaveinplace.Protocolsforinterimassessment,testingandoutbreakguidanceinresidentialandlong-stayfacilitiesareinplaceandkeptunderreview.Theseincludemanagementprotocolsforwherethereisnocase,asinglecaseoracurrentoutbreakongoing.

5.1.1.3. A Model for Future CareTheCOVID-19experienceprovidedanopportunitytoinformacontinuumofcare,includingstaffing,governance,fundingandfuturemodelsforcongregatedsettings.FuturemodelsofLTRCshouldincludeoutreachsupportfromhospitalsandin-reachsupportfromcommunities.Thereshouldbeafocusonempoweringtheolderpersontoremainathome,innovativemodelsincludingsmallerdomestic-styleunitsintegratedintotownsandcitycommunityareas.SeveralstakeholdersreferredtotheexperienceinDenmarkwhichhasmovedawayfrombuildingnewfacilities.Whilecitingresearchthatindicatedsizeofunitswasafactorinrapidspread,paradoxicallymanyofthesefacilitieshadmodernhigh-qualityfacilitiesandcompliancewithHIQAregulationswasnotakeyfactor.

Manyofthesubmissionsandpositionpapersstressedtheimportanceofinter-disciplinarycooperationbutalsokeyleadsatcommunitylevelinthemajordisciplines.TherewasaconsensusthattheCOVID-19pandemicexposedthedeficienciesinthesystemandthelackofanoverarchinggovernancestructurewithintheLTRCsector,bothwithpublicandprivatehomes.TheRCPIsubmission,alsocitedbytheHSE,recommendsareviewoftheclinicalgovernance,anupdatingofHIQA’sinspectioncriteria,theintroductionoftheSingleAssessmentTool(InterRAI)andtherevisionoftheCHOandregionalhealthareaboundariestoalignwiththeAcuteHospitalGroupsaspartofimplementationofSláintecare.Anumberofrecommendationsonstaffingandteamleadswerealsomade.

HIQAasserteditsroleasavitallineofcommunicationbetweenindividualfacilitiesandtheagenciesofgovernmentregardingCOVID-19.Initsviewtheescalationpathwaysworkedwell.HIQAalsoproducedaseriesofanalyses,rapidreviewsandactionreportswhicharereferencedelsewhere,includingintherapidsystematicreviewundertakenforthisreport.HIQAnotedtherelativelackofaccesstoinfectioncontrolspecialists.Italsonotedthatthecurrentregulationswereoutdatedandtheydidnotspecificallycapturetheissuesaroundinfectionpreventionandcontrolwhichshouldhavegreaterfocusintothefuture.ManyrespondentsagreedthatHIQAregulationsshouldbeupdatedandthatcoordinationbetweenagencieswasvital,aswellaseffectiveandlinkedinformationsystems.

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TheChiefInspectorofSocialCareServicesofHIQAdecidedon13thMarch2020tosuspendallroutineregulatoryandmonitoringinspectionswithimmediateeffect.Aqualityassuranceprocesswassetupandfrom25thMarchtothedateofwritingthereportpublishedon21stJuly,2,851callsweremadetonursinghomesbyinspectorsandaninfectionpreventionandcontrolservicewassetup.HIQAassesseswhetherunitsarecompliant,substantiallycompliantornotcompliantacrosstheregulatoryareasincludingcriticallygovernanceandinfectionpreventionandcontrol.Accordingtothisprocessthe189nursinghomeswere96%compliant,with3%notcompliant.However,riskinspectionswerethenresumedinlateMay2020withhomeswhereoutbreakshadoccurredprioritised.Todate44inspectionshadtakenplacewithadvancenoticebythetimeofpublishingthereport.Thesewereconsiderablypoorerfindings,28%werefullycompliantwithgovernanceandmanagement,27%withinfectionpreventionandcontrolprocedures,39%withpremisesand67%withstaffing.ItistheopinionoftheChiefInspectorthatthecurrentregulationoninfectionpreventionandcontrolinnursinghomeisnotcommensuratewithwhatisrequiredtorespondandmanageaCOVID-19outbreak.68

Governanceissuesraisedincludedthemixofservicemodelsandheterogeneityofnursinghomes,theneedtoholdorhaveaccesstoastandardbase-linestockofPPEandtheclinicalsupportsandrelationshipsbetweennursinghomesandcommunityservices.

Severalrespondentsalsonotedthatseasonalinfluenzaoutbreaksalwaysposeachallengeforthissector,butthatatleasthasavaccine,andCOVID-19isbothmoreinfectiousandchallengingbecauseofitsatypicalandpotentiallyasymptomaticpresentation.Manyalsostressedtherequirementforagreedprotocolswithpublichealthforvisitors.Theneedfortrainingofstaffinon-siteswabbingwasalsostressed.

5.1.1.4. Role of the GPAccordingtorespondentstherole/inputofthegeneralpractitionerwasnotconsistentduringthepandemicbutitwassuggestedthattheGPshouldhaveakeyroletoplayintothefuture.Theformatofazoom-facilitated,participant-directedCOVID-19educationseriesfornursinghomeswasdescribed,withseveralhundredparticipants,addressinga“burningissue”oneachoccasion.

AcooperativeGPmodelwascitedbytheICGP,whichoperatedamixedapproachofsitevisits,telepracticeandregularphonecontact.Acrisisofthiskindposedchallengesforsingle-handedGPsinparticular.PrioritiesforimprovementincludingappointingaGPleadforolderpersoncare,connectivitybetweensectorsandcontinuingeducationinolderpersoncare.TheICGPadvocatesawiderapplicationofbettereHealthsystems,withparticularreferencetotheuniversaluseofelectronicpatientrecords.

5.1.1.5. Future Staffing Therewasunanimityontheneedforadequatestaffing,contingencyplansandtraining.TheINMOnotedthatstaffingrequirementsaretypicallybasedonacostofcaremodel,ratherthanondependencyassessment.Italsohighlightedtheshiftsinguidelinesforstaffatworkandthefactthatcurrentknowledgearoundinfectivityandtransmissionmighthaveprecludedsomeearlieradvicesuchasclosecontactswhowereasymptomaticbeingassumedsafetocontinueworking.

Severalhighlightedtheneedtosupporthealthcareassistantsatworkandintheirlivingstandards.TheINMOalsohighlightedtheimportanceofutilisingqualifiednursingstafftotheirfullpotentialandoptimisingtheirscopeofpracticeandroleofthenurseinthecareoftheolderperson.TheyalsosupportedtheimplementationofSláintecareandtheintroductionofcollectivebargainingfortheworkersinprivatecarehomes.

68 SeeHealthInformationandQualityAuthority,TheimpactofCOVID-19onnursinghomesinIreland,(July2029), https://www.hiqa.ie/sites/default/files/2020-07/The-impact-of-COVID-19-on-nursing-homes-in-Ireland_0.pdf


Anumberofrespondentsstressedresilientrostersandsufficientstaff,theneedforisolationfacilitiesandforaHIQAreviewofappropriatepoliciesandguidelines.Longerterm,theIMOadvocatedforafundingmodelthatincludeda“gerontologicaltariff”whichwouldrecognisethecomplexityofneedsofveryoldpeople,formalintroductionofintegratedpathwaysofcareandcontinuityofcarewiththeroleofGPasprimarycaregiverinthissetting.TheIMOalsostressedtheroleofpublichealthspecialistsandtheneedtoimplementthefindingsfromtheCroweHowarth69 and Scally70,71 reports that would strengthen the public health surveillance and community functions.Italsohighlightedtheupcominginfluenzavaccinecampaign,theneedforinfectionpreventionandcontrol(IPC)protocolsandriskassessmentineveryfacility.Italsosupportedflexiblecarepackagesandthecentralconceptofchoicebyolderpeopleinselectingtheirbestoptionforthefuture.

Somerespondentsthoughttherewasanover-relianceontheprivatesectortoprovidenursinghomecareandhighlightedpayandconditionsforworkersinprivatenursinghomes,theneedtodefinestaffratiosandskillmixandtheneedtorefocustheState’sattentiononLong-termresidentialcarethroughdirectly-provided,publicly-ownedorganisationsthatarenotforprofitintheirintent.

5.1.1.6. Community and Regional ResponseExampleswerecitedofhowregionalteamsinteractedwithnursinghomesandhowIPCprincipleswereoperationalisedwellinashorttimeframe.Manyalsohighlightedthechallengesinsupplyingthefacilitiesandinmanaginghighlevelsofanxietyforstaff.

SomeoutlinedthatananalysisisrequiredofthePersoninChargeroleacrosstypesofresidenceandlong-stayfacilityandtheongoingworkforcechallengesrelatedtodependencylevelsinolderpersons.Gerontologicalqualificationsshouldbeapre-requisiteforworkinginthissectoraccordingtosomerespondents.Itwasalsoproposedthattheskillmixandnurse:clientratioinnursinghomesbedefined.TheimportanceofIPCandIPCcompetenceinthisenvironmentwasfurtherhighlighted.Respondentsnotedthatitwasimportanttoensurethateachfacilityhadaresourceplanaswellasaworkforceplaninplaceandthatoperationalisingofguidelinesoccurredontheground.Anintegratedapproachfornursinghomesandcommunitysupportsgoingforwardwasfurtherstressed.

Sage Advocacy proposed that clear responsibility for clinical care in all nursing homes should rest with community-baseddoctorswithaspecialistinterestinmedicineforolderpeopleaswellasgerontologicallytrainedAdvancedNursePractitioners(ANPs)andclearprotocolsforinteractionsbetweencommunityservicesandnursinghomesshouldbedevised.

Severalgroupsquestionedthelargecongregatedsettingsmodel,notingthatthatmodelisnolongerrecommendedinrespectofdisabilityormentalhealthsettings.Severalfocusedalsoonarights-basedapproachtocare,andproposinganindependentreviewintothecircumstancesofeverydeathinresidentialcaresettingsandofthegovernanceinnursinghomes.Are-evaluationofthechoiceofcareforolderpeopleonacontinuumwhichincludesremainingathomewasalsoproposed.TheIrishHospiceFoundationproposedamodelfortheextensionofend-of-lifeandpalliativecareprovisionintonursinghomes.InIreland,23%ofdeathsoccurinresidentialcaresettings.Dying,deathandbereavementarecorepartsoftheworkofthenursinghomesector,evenmoresoduringCOVID-19.TheIrishHospiceFoundationproposedthatapalliativecare,end-of-lifecareandbereavementsupportmodel,notunliketheacutehospitals‘hospice-friendlyhospital’programme,mightbeprovided,withbenefittothenursinghomessector.

69 SeeCroweHowarth,FinalReportto:theDepartmentofHealthontheRole,Training,andCareerStructuresofPublicHealthPhysiciansinIreland,(April2018),https://assets.gov.ie/9446/56efd96dac314a9692b785706b5a5ecb.pdf

70 SeeDr.GabrielScally,ScopingInquiryintotheCervicalCheckScreeningProgramme,FinalReport,(DepartmentofHealthSeptember2018),https://www.gov.ie/en/publication/aa6159-dr-gabriel-scallys-scoping-inquiry-into-cervicalcheck/

71 SeeDr.GabrielScally,ScopingInquiryintotheCervicalCheckScreeningProgramme,SupplementaryReport,(DepartmentofHealthJune2019),https://www.gov.ie/pdf/?file=https://assets.gov.ie/10738/ba4f9a6299bb4ab6aa8d239b951eb71a.pdf#page=1

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Several respondent groups pointed out that many people, if given the choice, would not be resident in nursing homesifreasonablealternativeswereavailabletothemsuchashomecaresupport,shelteredhousing,homesharearrangements,retirementvillagesorTeaghlach-typehousingcarearrangements.

5.1.1.7. Required MeasuresTheshort-termmeasuresrequiredarecontinuationofthecurrentactions,inthemediumtermtheintegrationoftheseonasustainablebasis,accelerationofphase3oftheSafeStaffingandSkillmixFrameworkandinthelong-term,capitalandenvironmentplanningandamodelofcarereview.IntermsoftheSafeStaffingandSkillmixFramework,Phase1wasmanagedoverthreepilothospitalsites.Phase2isbasedintheEmergencyCaresettingandphase3isplannedforthenon-acutesetting.TheChiefNursingOfficer(CNO)NursingWorkforceStrategyproposesaradicalnewapproachtodeterminingnursestaffinglevels,designedtoputpatientneedsfirstandfocusondeliveringpositivepatientoutcomes.

5.2.OrganisationsInvitedtoMakeaWrittenSubmissionThissectionprovidesasummaryofthethemesidentifiedthroughaqualitativeanalysisofallwrittensubmissionsfromstakeholderorganisationsinvitedtomakeasubmission.Thesummariesprovidedinthischapterrepresenttheviewsfromtherangeofstakeholders,takendirectlyfromreturnedcompletedsurveyforms.

Twentyfivesubmissionswerereceivedfromorganisationsinvitedtomakeawrittensubmission.Arangeofmaterial(referencestopapers,reports,andtimelines)werealsoprovidedbytheseorganisationsforthePaneltoconsider.

5.2.1.NursingHomeProceduresIn terms of ways of working and procedures followed on the ground, many respondents feedback typically referred tothemanagementapproachfollowedinanursinghome,theissueofpatienttransfersfromacutehospitaltoresidentialsettings,staffingissues,andvisitorprotocols.

5.2.1.1. Management ApproachSeveralrespondentsdescribedthemanagementapproachasbeingthecriticalsuccessfactorinacrisisresponse.Thisleadstogoodpreparednesstorespondtofuturecrises.Leadershiphierarchieswerealsosuggested,sothatstrongnursingleadershipismaintainedintheabsenceofmoreseniorpersonnel.

5.2.1.2. Transfers from Acute Hospital to Long-term Residential Care Facilities Theconcernofintroductionofinfectionviaacutehospitaltoresidentialsettingswasalsoevidentinrespondents’comments.Anumbercalledforthecompletecessationinacrisiswhileothersnotedthatthisshouldbeafactorforconsiderationincrisismanagementplanning.

5.2.1.3. Staffing and MonitoringInrelationtostaffingandmonitoring,severalconceptsforconsiderationemerged: • theneedforstaffinglevelsandnurse-to-residentratios,forboth“normal”timeandinthecontextofacrisis; • provisionofemployeeassistanceprogrammesorothercounsellingsupportsforstaffaffectedduringthe

crisis; • developmentofclearplansandproceduresforreconfiguringand/orsuspendingcertainstaffdutiesto

refocuson‘crisisresponsemode’.Areasmentionedinclude: - agencystaffuse; - redeployment; - orderingofstockandotheradministrativeactions; - communicationtofamilies; - completionofstandardformsandtemplates.


5.2.1.4. Visitor ProtocolsRespondents advocated for the empowerment of the person in charge of a centre to make decisions regarding whethervisitorsshouldbeallowed.Itisalsosuggestedthatthisshouldbeundercontinuousreviewinthecontextofadynamicsituation.

Concernwasalsoexpressedforthecircumstancesandcriteriathattriggerthecurrent28-daylockdownofanursinghomerequirement,andwhethertheserulesneedtobere-evaluated.Additionally,protocolsandsupportstofacilitatevisitorsforresidentswhoareunderend-of-lifecarewasalsoadvocatedfor.

5.2.1.5. Other Suggestions and Advice • staffandresidentinfluenzaimmunisationsneedhighuptakethiswinter; • isolationcapacityinfacilitiesinLTRCSshouldbeconsidered; • contingencyplanningforwhenstaffmembersgetsick;andto • supportmanagementandstafftoremainvigilantandengageinon-goingsurveillanceoftherisksofthe

COVID-19.

5.2.2.Communication

Severalrespondentsfeltthatcommunicationduringthecrisiswasparticularlychallengingfornursinghomes,andthiswasrelatedtogovernance,decision-making,andthemedia.Respondentshighlightedthefollowing: • governanceofclinicaldecision-makingintermsofHSE,publichealth,HPSC,localcliniciansand

nationaldecision-makingintermsoftheNPHETledtosomemixedmessagesandconfusionrelatingtoinstructionsgiven;

• clearidentificationofthegovernance,accountabilityanddecision-makingofeachrelevantDepartmentisrequired;

• mixedmessagesfromdifferentsourcesandtheconstantproliferationofmedia‘specialists’ledtoconfusioninLTRCs,challengestoadheringtoguidanceandadditionalstressforstaff,residents,andtheirfamilies;

• theprocessofcommunicatingresultstostaff,andadviceonmanagingvisitationsforresidents;and • stigmaassociatedwithfacilitieswheretherewereCOVID-19casesandnegativereportinginthemedia,

whichcausedadditionaldistresstoresidents,staff,andfamilies.

Thelackofdatasharingcapabilitywasalsolinkedtocommunicationchallenges,andanumberofrespondentsnotedthattheinterRAI(SingleAssessmentTool)forsharingofdataacrosscommunity,acuteandresidentialcaresettingsisneededtoovercomethisissue.Respondentsunderlinedtheimportanceofestablishingformalcommunicationchannelstosupporttheongoingresponsethatisrequired.Forexample,linksbetweendirectorsofnursinginthecommunityandthepersonsinchargeofnursinghomes.

OnerespondenthighlightedthatitiscriticalthatthecommunicationchannelsestablishedduringtheCOVID-19pandemicbetweentheHSEandtheprivatenursinghomesremaininplaceandshouldbeformalised.Severalrespondentsnotedthatclearandconsistentpublichealthmessaginghelps,butthatinacrisistherewasnotimetoreadguidelinesorexplorealternatives,andthereforepersonsinchargerelyonpublichealthforadviceandguidance.Furtherimprovementstocommunicationsweresuggestedbyrespondents: • improvedcommunicationbetweentestingcentres,departmentsofpublichealthandcontacttracing

centres; • amorestreamlinedapproachtothedisseminationofinformation/guidelinesandrequestsforinformation

frommultiplesources,intheeventofanotherCOVID-19surge; • nursinghomesandHSECommunityNursingUnits(CNUs)needtobeawareofwhotocontactinthe

departmentofpublichealthintheirarea;whotocontactfortesting,PPEandoxygensupplies;and,thecontactdetailsforthelocalspecialistpalliativecareteam(s);

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• informationandcommunicationstechnology(ICT)systemsshouldbeinplacetoalleviatetheneedforrepeatedrequestsfrombothnationalandregionalofficesfordatatofrontlinestaff;

• communicationsteamtoimmediatelyprovidemeaningfulupdatestoallfamilymembersusinganagreedtemplate.(Thisshouldbecarriedoutbystaffnotinvolvedinthedirect24/7careinunits);

• greateruseofICT/telehealth,e.g.Glad/AcornICTsystem,whichfacilitateoutreachconsultantgeriatriciansupport;

• promotionoftheinfluenzacampaignforthiscomingseason.

Communicationofinformationtoresidentsandfamilieswasalsoraisedforconsideration.Respondentssuggestedthattimely,transparent,andstandardisedinformationaboutCOVID-19infectionlevelsineachnursinghomewouldhelpaddressresidentandfamilyconcernsandavoiduncertaintyandstress–e.g.thenumberofcurrentcases,dayssincelastcase.Inaddition,havingeasilyaccessibleandsimplified“COVID-19actionplans”foreachnursinghomesoresidentsandfamiliescanaccessdetailsofcurrentmeasuresandcriteriaforeasingofrestrictions,wouldalsobeofvaluetoresidentsandfamilies.

Intermsoffacilitatingcommunicationbetweenresidentsandtheirfamilyandfriends,itwassuggestedthattheimplementationofappropriatetechnologicalsolutionstoallowmoreresidentstoavailofdigitalcommunicationtoolsiskeynowandinthefuture.Thisshouldrecognisethatmanyresidentsarenotdigitallyliterateandmayhavephysical,dexterity,mobility,hearing,visualandcognitiveissues.

5.2.3.OversightandGuidance

5.2.3.1. ComplianceSeveralrespondentsdiscussedtheongoingroleofinspectiontoensurecompliancewithinfectionpreventionandcontrol(IPC)standards,andthatconsiderationshouldbegiventomakingitcompulsoryforallservicestoparticipateininspectionsandcompliance.InadditiontotheimmediateissueofmanagingCOVID-19,themeasures referred to above would also serve to protect vulnerable residents of nursing homes from other threats includinginfluenza,pneumonia,andclostridium difficile.

5.2.3.2. Governance and Clinical OversightSeveralrespondentsdiscussedaneedtoreviewandupdatetheexistinggovernancestructuresforbothpublicandprivatenursinghomefacilities,forcleargovernancestructurestobeputinplaceforboth,andforinformationinrelationtothesestructurestobemadepublic.Othersfeltthatgovernancechangesincludingaregionalstructure,whichbuildsupontheemergencyresponsesdevelopedinthefirstphaseoftheCOVID-19pandemic,arerequired.Withinthis,theissueofregulationwasalsoraised,includingtheregulationofstafftraining.

SeveralrespondentsdiscussedtheroleofHIQA,notingtheneedtoimprovecommunicationbetweenHIQAandpublichealthoutbreakcontrolteams.OtherssoughtclarificationontheroleofHIQAasregulatorincertaincircumstancesarisingduringthepandemicresponse,forexamplepriortore-openingafacilityonceanoutbreakofCOVID-19hasbeenclosed,andintermsoftheirroleinoverseeingissuessuchasmanagementatnursinghomes,employmentpolicyandpracticesandaccommodationarrangementsforallstaff,includingnon-healthcareworkers.

Broadly,respondentsnotedthatthepublichealthdepartmentoftheHSEissupportiveofHIQA’sdrivetoimprove physical infrastructure standards in nursing homes, having encountered a number of instances where the designandlayoutofbuildingsactedasabarriertoensuringadequateinfectionpreventionandcontrol.


OnerespondentfeltthatHIQA’sregulatoryrolehasbroughtanationalstandardisationtotheprivatenursinghomesector,notingitssignificanceascapacityexpandedtoaccommodatethegrowingpopulationofolderdependentindividualsinIreland.However,thelimitationsofanationalapproach,removedfromlocalhealthservicedeliveryandplanningstructureshavebecomeevident,aslocalHSEservicesrushedtoestablishemergencyCOVID-19supportsincludingnursinghomesupportunits,whichhaveprovidedstaffing,PPE,andtechnicalservices(suchasoxygen).

5.2.3.3. Guidelines and Care PathwaysSeveralrespondentsdiscussedtheneedfordiseasepreparednessandplanningandthatanew“infectiousdiseases”planshouldrapidlybeagreedforthehomecareandnursinghomesectors.Thechallengeofdatacollectionandreportingwasraisedaspartofthisplanning,whereanumberofagenciesarecollectingsimilardata,HSE,HIQA,publichealth;andthereisalotofdatarequireddailyfromanalreadystretchedworkforce.Onerespondentcalledforthedevelopmentofintegratedreportingbetweenpublichealthandregulatoryagenciessothatdatacanbeaccessedbyallrelevantagenciesunderthedirectionofpublichealth.

Inadditiontooutliningmeasurestodealwithasecond,orsuccessive,outbreaksofCOVID-19,thisplanwouldsetouttheprotocolandrenumerationpolicyforcarerswhoprovidecaretothosewithCOVID-19andotherdiseases;workforcemanagementguidance(tokeepstaffhealthy,motivatedandengaged);theexpectationsoftheHSEandotherproviders;howthevariousStatebodiesandprivatesectorbodieswillconsultoneanother;hownon-agreeditemswillbepaidfor,suchasthermometersandPPE,toavoidconfusioninthemidstofapandemicwave;andotherrelevantmatters.

Detailed validated preparedness plans outlining measures to be put in place, should a surge occur, should be a requirementofproviders.Intheprivatesectorclearoversightforthemonitoringofthesepreparednessplansisrequired.Infectioncontrolprocedures,definedplanstodealwithhighlevelsofsickleave,accesstooccupationalhealth,workforceplanning,andagencymanagementshouldbeincludedintheseplans.

Onerespondentnotedthatakeysuccessfactorwastheoutreachserviceprovidedbyconsultantgeriatriciansfromthelocalhospitalsthatsupportedclinicalstaff(GPsandnurses)caringforresidentswithcomplexneedsassociatedwithCOVID-19.Respondentsfeltthatconsiderationshouldbegiventotheformalisationofthisservice,particularlyinadvanceofwinter2020.

5.2.4.FuturePreparedness

5.2.4.1. Access to ServicesRespondentsidentifiedthatcertainservicesandexpertisewereprovidedduringthecrisisthatwouldbeinvaluabletothenursinghomesectorgoingforwardandforfuture-proofingmeasures.Theconceptofutilisingtechnology,suchasTelehealth,wasalsoraisedasameansofprovidingtheseservicesandgreaterintegrationofnursinghomesinamoreefficientmanner.

A list of relevant medical and public health services to aid future preparedness was provided by respondents and aresummarisedasfollows: • consultant geriatrician and medical team; • IPC(nurseandconsultantmicrobiologist); • advancednursepractitioner(ANP)forolderpersonstosupportnursingteams;

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• communitynursespecialist(CNS)forolderpersons; • tissueviabilitynurse; • HPSCservices; • occupationalhealth; • bereavementandcounsellingservicesforstaffandresidents; • psychiatry; • palliativecare; • HSEcentralresource,includingIPC,contacttracing,andstaffingneedssupport;and • qualitymanagers,healthandsafetyandriskcoordinators.

5.2.4.2. Training Respondentsnotedtheneedforcurrentstafftrainingtobeprioritisedandreviewedintermsofskillmix.Further,somerespondentsfeltthatstafftrainingshouldbemandatedforallaspectsofcareincludinghealthandsafety,IPC,correctuseofPPE,andend-of-lifecare.Onerespondentsuggestedthatallstaffshouldbeaccreditedbyanationaltrainingandaccreditationsystem.Furthermore,allstaffshouldbetrainedtotheappropriatelevelinrelationtoinfectioncontrol,andprocessesshouldbeputinplacetomonitortheeffectivenessofsame,beforetheAutumnandasecondwaveofinfection.

5.2.4.3. COVID-19 TestingConsiderationshighlightedinclude: • thelogisticsaroundthereturnofsmall-scaleswabbinginruralareastoacollectionpoint,thenonto

laboratoriesneedstobeestablishedanddevelopedtoallowroutineandregulartesting; • theadditionalstaffingrequirementstosupportmasstesting; • theusefulnessofregularmasstestinginareaswherethediseasehasbeeneradicated.

5.2.4.4. Personal Protective Equipment (PPE)Anumberofrespondentshighlightedtheneedforallpossiblemeasurestosafeguardresidentsfromcontractingthevirus,includingmaintainingadequatesuppliesofPPEinstockinallhealthcarefacilitiesandtrainingofstaffinthecorrectuseanddisposalofPPEtobeadopted.Further,severalrespondentsunderlinedtherequirementforclearpathwaysfornursinghomestoaccessandmanagePPE.Onerespondentnotedthatthereshouldbeatimelyanduser-friendlyorderingsystemonsiteforcurrentandfutureoutbreaks,whichwouldenablenursinghomestorespondtoevolvingrequirements.AbaselinestockofPPE,todealwithaninfectionrateof25%,shouldalsobeavailable.

5.2.4.5. Facilities Thephysicalinfrastructureofnursinghomeswasdiscussedbyseveralparticipants,andimprovementsareneededtocovercapacity,occupancy,design,space,singleroomoccupancy,adequatedayandleisurespace,isolation,andmedicalcarefacilities.Itwassuggestedthatthisshouldberegulated,monitored,andsubjecttoapproval,andthefacilityshouldbelicencedtooperateonanongoingbasis.Itwasnotedthatthecurrentdesignandlayoutofmanyfacilitiesdoesnotreflectthecomplexneedsofresidentsandhasactedasabarriertoensuringadequateinfectionpreventionandcontrol.ItwasalsonotedthatthereshouldbesufficientITinfrastructureavailableforcommunicationbetweenresidents,healthprofessionalsandwithfamilies.

5.2.4.6. Infection Prevention and Control (IPC)ItwasnotedthatIPCmeasureshaveplayedacentralroleinpreventingandcontrollingthetransmissionofCOVID-19tonursinghomesandintacklingthespreadofCOVID-19infacilitieswherethevirusispresent.

RespondentsdiscussedtheneedforaccesstoIPCexpertiseforeachfacility,andthatthereshouldbeclarityonIPCstrategiesforresidentialunitswithco-locatedrehabilitation,transitional,andrespitecareservices.Further,theneedforfurthertailorededucationisemphasised.Onerespondentnotedthatwhileonlineresourceswerehelpful,incertaincircumstancesface-to-face/onsiteinfectioncontroltrainingisnecessaryandmorebeneficial.IPCtrainingshouldbedeemedapriorityandmademandatory.


OnerespondentsuggestedthatnursinghomesshouldhaveaccesstoaClinicalNurseSpecialistinIPCtoensureongoingmonitoringofinfectioncontrol.Furtherspecificmeasuressuggestedincluded: • increaseofcleaningservicestocarryoutcleaningofhightouchpoints,5timesperday; • designatedIPCleadon-sitetocoordinateresponseandliaisewithpublichealthandexternalIPC

specialistratherthanthisbeingdonebythedirectorofnursingwhoneedstobeavailabletomanagestaffand support family members;

• HIQAbaselinebenchmarking(audit)againstnationalIPCstandardstoestablishan‘asoftoday’pictureofnursing home preparedness;

• accesstoIPCresourcesimmediatelytoaddressgapsinbothpracticeandtraining;and • anIPCleadineachnursinghometocoordinateresponseatlocallevel.

5.2.4.7. Assistive TechnologySomerespondentssuggestedthatassistivetechnologywillplayakeyroleinfosteringinclusion,participation,autonomyandindependenceforolderpeopleandpeoplewithdisabilitiesbymaintainingorimprovingtheirfunctionalcapabilities.TheCOVID-19pandemichasunderscoredtheimportanceandpotentialofassistivetechnologiesinenablingolderpeopleandpeoplewithdisabilitiestoliveindependentlyinthecommunity,awayfromresidentialfacilities,suchasnursinghomes,wherethevirusismorereadilytransmissible.

5.2.5.TheNursingHomeModelinIreland

Severalrespondentsdiscussedtheroleofnationalpolicyforolderpeople,andthatasharedobjectiveofmaintaining residents in their place of residence for as long as is appropriate to their needs, should be adopted byallrelevantstakeholdersincludingnursinghomeproviders,nursinghomerepresentativegroups,theregulator,GPsandHSEservicesincludingpublichealth,CHOsandhospitals.Thissharedobjective,respondentssuggest,willhelpinformandclarifydecision-makingbyallparties.Furtherthemesarediscussedbelow.

5.2.5.1. Lack of Policy Recognition Someorganisationsdescribedhownursinghomesareanintegralpartofthehealthandsocialcaresystem,whichhasneverbeenfullyrecognisedinpolicymakinginIrelandandneedstochangeimmediately.Severalorganisationsacknowledgedtheimportantroleofnursinghomesintheprovisionofcareforpeoplewithhighlevelsofneed.

IntermsofCOVID-19,someorganisationsstatedthatnursinghomesshouldhavebeenprioritisedearlierinpublichealthemergencyplanningandthatpolicydecisionsinresponsetoCOVID-19highlightedthelackofprioritythatnursinghomesreceive,bothintermsofresidentsandstaff.

TheLTRCsectorisaconsiderablecomponentofhealthandsocialcareinIreland,moresothaninSouthernEuropeancountries,likeItaly.OlderpeopleinneedofcareinIreland,andinNorthernEuropemoregenerally,havemuchgreateruseofLTRCthaninSouthernEurope,bydouble,insomecomparisons.Therefore,policestoreducetheriskandconsequencesofCOVID-19maybemorefocuseduponLTRCintheimmediateterm.

Asonerespondentsuggests:

Lack of representation makes it exceptionally difficult to raise or receive a response to valid concerns, as the current planning process does not value professional concerns. The dominance of the medical model in the planning process, without broad consultation to include views of the wider, modern healthcare service, has resulted in a narrow view and response to the needs of residents.

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5.2.5.2. Funding ModelSeveralorganisationsdiscussedthecurrentmodelofnursinghomefunding,theNationalTreatmentPurchaseFund(NTPF)andthecomplexityofcare.Organisationsnotedthatthecostofcare,ascurrentlyconfiguredandutilisedbytheNTPF,doesnotrecognisethelevelsofcareandservicesprovided,andthesubstantialcross-subsidisationrequired,forwhichabudgetisnotallocated.Further,thefundingofnursinghomecarebytheNTPFdoesnotalignwiththecomplexityandevolvingcareneedsofresidents.

Itwasnotedthatthehigherdependencylevelsoffuturenursinghomeresidentswillrequireagreaterlevelofmulti-disciplinaryexpertiseintheprovisionofcare,includingpalliativecare.Thiswillnotbemetwithoutareviewofthemechanismsforcalculatingcostofcare.SeveralorganisationssuggestedthattheNTPFwouldbenefitfromgreatergerontologicalinputintermsofstrategy,policy,andassessmentprocesses.

Severalrespondentshighlightedthatadditionalinvestmentinthesectorwillberequiredinordertoprovideforinhousestaffing,PPE,trainingandenhancedsickleavearrangementsforstaff.

As another respondent notes,

the challenges posed by COVID-19 for the LTRC sector in Ireland has uncovered a disconnect between regulation, purchasing of care, and oversight. The current system of access to and eligibility for publicly-funded or subsidised residential care was established on a statutory basis in 2009 with the introduction of the Nursing Homes Support Scheme (NHSS – ‘Fair Deal’). The state funds the majority of the cost of LTRC by means of the Fair Deal scheme. The NTPF agrees rates of payment for providers under the scheme, acting as purchaser for the state.

5.2.5.3. Model of CareSeveralorganisationsdiscussedalternativeapproachestothemodelofcareforolderpeople,withastrongcommunityfocusincludinghomecare,supportedhousing,andthecontinuedde-congregationofresidentstosmaller,community-basedsettings.Whiletheseissuespre-datetheCOVID-19pandemic,ashiftawayfromnursinghomesasthedominantmodelofcarewasseenasawaytomitigatetheriskofCOVID-19byseveralrespondents.Asonerespondentexplained:

The Covid-19 pandemic illustrated the speed with which an infectious disease can spread through a nursing home, due to a combination of factors including reduced opportunities for both staff and residents to physically distance from one another and self-isolate in the event of illness or exposure to the virus. Changeover in rosters and the attendance of nursing home staff can also give rise to further opportunities for cross-contamination between the community and the residents in the facility. As a means of reducing the high concentration of persons in nursing homes most at risk from Covid-19 … there may need to be a future recalibration of care for older persons away from traditional nursing homes to community-based supported living guided by individual choice.

However,asanotherrespondentputsforward,whilefuturemodelsofcaremay,correctly,focusongreaterprovisionofcareforolderpeopleathome,thenursinghomessectorwillremainakeysector.TheESRIestimatesthatevenunderoptimistichealthyageingscenarios,between2015and2030,therewillbeanatleast44%increaseindemandforLTRC.Mediumtolong-termplanningshouldfocusonthemanagementandsustainabilityofLTRC.

5.2.5.4. Service Delivery ModelIntegrationwith,andoversightfrom,thewiderhealthcaresectorwasstronglyadvocatedforbymanyoftherespondents.Whilethecrisiswasdevastatinginthenursinghomesector,theresponseimplementeddemonstratedhowthesectorcouldimprovegoingforwardandbebetterpreparedforfuturecrises.Onerespondent noted that “ensuring that all national guidance being implemented to avoid reinventing the really good work and collegiality that has emerged during this pandemic.”


Anumberofsuggestionsaremadeinthisregard,including: • thedevelopmentofaspecificliaisonroleforpublichealthineachCHOarea; • community consultant geriatricians; • communityadvancednursepractitioners; • hospital–communityoutreach;and; • regionalIPCroles.

Policiestoremovethedisjointednatureoffinancing,provision,andregulationneedtobeconsidered.Forexample,despiteHIQArequiringnursinghomestomeetstandardsfortheprovisionofcareforresidentslivingwithdementia,theNursingHomesSupportSchemedoesnotcurrentlyallocateadditionalfundingforcognitiveimpairment.InordertobetterintegrateLTRCaspartofawidermodelofcareforolderpeople,andcoordinatecarealongsideanewstatutoryhomesupportscheme,considerationmayneedtobegivenastowhetheritisnecessarytoestablishHSEresponsibilityfortheoversight,planningandprovisionofLRTCservicesbystatute.ThechallengesposedbyCOVID-19forLTRChaveshedlightontheneedtodiscusswhatLTRCcarewilllooklikeandplanaccordinglytomeetresidentsneeds.

5.2.5.5. Home Care Respondents suggested that, although not appropriate in every case, home care should become the default dischargeoptionfromhospitalforvulnerablepeoplewhohavecontinuingcareneeds.Utilisingtheexistingtransitionalcarebudgetisonewayofexploringhowtodothis,respondentsproposed.

Severalorganisationsdiscussedthepilotstatutoryhomecarescheme,andthatitshouldberesumedasamatterofprioritysinceitwassuspendedattheonsetoftheCOVID-19pandemic.

The pilot testing of the new statutory home care scheme for older people proposed to be introduced during 2020/2021 should not be delayed because of the current pandemic.

Regulationsshouldconsiderde-congregationofresidentsfromlargenursinghomestosmallerdwellings.Onerespondentexplainedthatnursinghomesthatprovideresidentswithsingleroomsandbathroomswerebetterequippedtocareforresidents.Whenthereismulti-occupancyitisextremelydifficulttocohortandcontrolthespreadofinfection.Outbreaksinotherresidentialcarefacilitiessuchasintellectualdisabilityresidences,wereeasiertomanageasthenumberofclosecontacts(staffandresidents)werefewerthaninthecongregatedsettingsofnursinghomesandCommunityNursingUnits(CNU).

5.2.5.6. Housing with Supports Respondents discussed the need to progress work underway on developing models of housing with supports, andtoputinplaceandincentivisealternativemodelstomeethighsupportneeds,i.e.housingwithcareandrespiteathomewashighlightedasvitalinlightofCOVID-19insupportingpeopletoremainathome.Itwasnotedthatallnewbuildingsshouldbeinformedbytheadoptionoftheuniversaldesignapproachtobuildingsandthebuiltenvironment.

Severalrespondentsnotedtheongoingsituationwherebyolderpeoplearebeingprematurelymovedtonursinghomesbecausetheycouldnotavailofthesupporttheyneededtoliveindependentlyathome.Whilenursinghomes play a vital role in the provision of care for older people with high levels of need, there is a need to tailor supportstosuittherequirementsoftheindividualandtoimplementmodelsofhousingwithsupportstomeetdiverseneedsinthecommunity.

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5.2.5.7. Persons with Cognitive Impairment and DementiaSeveralrespondentsfeltthatthecurrentmodeloflong-termcareinIrelandshouldbeurgentlyrecalibratedwithreferencetorecentlypublishedpolicydocumentsonhousingforolderpeopleandthecontinuumofcareforpeoplewithdementia.Areviewofdementiacareandhowsocialdistancingcanbemanagedforresidentswithdementiawerealsorecommended.

Itwasnotedthatnursinghomefacilitiescaterformanyolderpeoplewithdisabilities,includingpersonswithcognitivedisabilities,suchasdementia,andpersonswithphysicaldisabilities.Tobeeffective,infectioncontrolandpreventionmeasuresmusttakeaccountofandbesensitivetotheneedsofpersonswithdisabilities,andcommunications,whetherwritten,digital,verbalorsigned,mustbeaccessible.

OnerespondentnotedtheHSEeffortstosupportpeoplewithdementiaandcognitivedisabilitiesinnursinghomesduringthepandemic,includingthecompilationofarangeofpracticalresources,suchasCOVID-19 Related Hygiene and the Person Living with Dementia and COVID-19: Managing Isolation and Non-Cognitive Symptoms of People with Dementia in Residential Care Facilities for Older People.

5.2.5.8 De-congregationSeveral respondents discussed the need for older people to move to households with low numbers of residents livingtogether,similartootherservices(specialistservicesforpeoplewithintellectualdisabilitiesandpeoplewithenduringmentalhealthissues),andamoveawayfrombuildinglargefacilities.Othershighlightedtheprogressmadeinthedisabilitysectorinmovingpeoplewithdisabilitiesoutofcongregatedsettings,andinlinewith current policy, to enable them to live independently with appropriate supports and to be included in the community.Itwasnotedthatthecurrentsituationregardingpersonswithdisabilitiesundertheageof65yearslivinginnursinghomesforolderpersonsneedstobeurgentlyaddressed.Effectivelyaddressingthisissuewouldrequireappropriatehousing,careandsupportstobeprovidedtosuchpersonsinthecommunityandplanningtoensurethatthepracticeofinappropriateplacementsofpersonswithdisabilitiesinnursinghomesinthefuturecanalsobeaddressed.Itwouldalsorequireacoordinatedeffortbetweentherelevantauthoritiesandactors,particularlytheHSEandlocalauthorities,aswellasotherstakeholdersinthecommunity,toenablesame.

5.2.5.9. Personal AssistanceHomesupportandpersonalassistanceserviceswerealsoemphasisedasplayinganimportantroleinenablingolderpersonsandpersonswithadisabilitytoliveindependentlivesinthecommunityforaslongaspossible.Suchservicesareimportant,notjustinempoweringpeopletopursuetheirlifechoices,butalsotoremainconnectedwiththeircommunity,neighboursandfriends,aswellasthenaturalsupportsintheirlives.Itwasnotedthatpersonalassistanceservicesarenotavailabletothoseovertheageof65andthattheCOVID-19pandemichasfurtherhighlightedtheneedforworkonanationalpersonalassistancepolicyandhomecarestandardstobeexpedited.

5.2.6.RepresentationandAdvocacySeveralrespondentsraisedtheissueofadvocacyandtheongoingneedforexternaladvocacyservicesforresidents,families,andfriendsbothlocallyandnationally.Itwasnotedthatduringanoutbreakthephysicalandpsychologicalcareneedsoftheresidentnecessitatedskilled,knowledgeable,andexperiencednurses,healthcareassistants,andGPsworkingtogetherwithseniordecision-makerssuchasANPs.

Severalrespondentsemphasisedtheneedtocreateanewnarrativeofcareinrelationtoolderpeople,incorporatingthelanguageofinclusion,empowerment,andcitizenship.Theserespondentsalsonotedthat,unfortunately, ageism and paternalism characterised much of the earliest public policy response to the crisis and thiscreatedunnecessaryandunwantedstigmaforolderpeopleinallsettings.


Otherissuesraisedincluded: • Needsandrightsofthedyingandbereaved:communicationcare,psychosocial,endoflifecareand

bereavement support; • Safeguarding:lackofunderstandingoftherisksofabuseandneglectinnursinghomes.Essentialpublic

health measures inadvertently increased risk, by reducing resident access to their social supports; • Inclusion:thevoicesofresidentsandfamiliesthemselves,areabsentfromanyplanningprocess.

Understandingthelived-experienceofnursinghomelivingisimportant; • Indirectimpacts:pandemic-relatedsocialisolationislinkedtoasteepdeteriorationinpeople’smental,

cognitive,andphysicalhealth.Thisisparticularlyrelevanttovulnerablegroupswithcognitiveimpairmentanddementiacomorbidities.

5.3.NursingHomesConsultationAtotalof53submissionswerereceivedbytheExpertPanelfromnursinghomes.Thissectionpresentsthemainthemesthatwereidentified.Thesummariesprovidedinthischapterrepresenttheviewsfromnursinghomes,takendirectlyfromreturnedcompletedsurveyforms.

5.3.1.NursingHomeProcedures

Feedbackfromthe“on-the-ground”stakeholderscoveredseveralthemesthatprovideaperspectiveontheproceduresandstepsthatweretakeninlightofCOVID-19,andreflectionsonwhatthefutureapproachshouldbe.

5.3.1.1. Learnings and ReflectionsSeveralrespondentssharedtheirstoriesofhowtheypreparedforandexperiencedthecrisisasitunfolded.SomereportfromtheperspectiveofanexperienceofCOVID-19intheirsetting,whileothersreportfromthepositionofreliefatavoidingandpreventingthediseasefromenteringtheirfacilities.

5.3.1.2. Management ApproachEarlyplanning,strongleadership,andactingaheadofnationalpublichealthguidancearerecurringthemesinwhatrespondentsidentifyasthecriticalsuccessfactorstheybelievehelpedsetthemonagoodpathforpreventingtheintroductionandtransmissionofCOVID-19intheirnursinghomes.

5.3.1.3. Transfers from Acute Hospital to Long-term Residential Care FacilitiesManyrespondentsreportdissatisfactionwithhowthistranspired.Thereisastrongbeliefamongrespondentsthatthiswasakeysourceofinfectionintroductionintothehomes.Severalrespondentsadvocatethatgoingforwardthereshouldbestricttestingandisolationproceduresinplaceatthepointoftransfer.

5.3.1.4. Staffing and MonitoringAt the onset of a crisis, one response advises that designated crisis response teams should be established for eachsetting.Thisisreflectiveoftheapproachreportedbyotherrespondents.Ensuringnocross-overoftheseteamstodifferentsettingsorbetweendifferentteamswasanimportantfeature.Itwasadvisedthatagencystaffusewouldbeeithersuspendedentirelyfortheduration,orfailingthis,thatsuchstaffwouldbededicatedtoonesettingonly.Thehealthofstaffshouldalsobemonitoredfortemperatureandsymptoms,andtheadvocacyofvaccinationsamonghealthcareworkers(HCW)encouragedorrequired.

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5.3.1.5. Visitor ProtocolsManyrespondentsaskedthatcurrentrestrictionsonvisitorsbemaintainedforlonger,andforthedecisiontolifttheserestrictionstobemadeatalocallevel.Clearguidelinesforvisitorsarealsoaskedfor,particularlyaroundhygieneprotocolsandthewearingoffacecoverings,bothduringvisitsandintheirwiderdailyinteractionsandcontacts.

5.3.1.6. Other Suggestions and Advice Included: • asinglededicatedGPassignedtothenursinghomeratherthanatindividualpatientlevel; • enhancedobservationrecordingfortemperatureandoxygensaturation; • resumequalityoflifeactivitiesatasmallerscale; • haveacontingencyplaninplace; • have all policies and procedures up to date; • gooddocumentationprocedures; • followallpublichealthguidance.

5.3.1.7. Cost and FinanceNursinghomeshaveincurredsignificantadditionalcostsasaresultofthecrisis.Manyrespondentsdrawattentiontothisandcallforcontinuedfinancialsupportinthisregard.Anadditionalrequestraisedbyseveralisfortheadministrativeburdenofsuchfundingtobestreamlinedandburdenless.

5.3.2.Communication

5.3.2.1. Impact on Residents Manyrespondentsrecognisedthedetrimentaleffectthatlonelinessandisolationhadontheirresidents.Counsellingsupportsmaybeneededforresidentsandstaffintheaftermathofthecrisis.Theyalsospokeoftheneedforsettingupcommunicationsteamstofacilitatevirtualvisitsandtodevelopprogrammesofengagingactivitiesandforsocialinteraction.

Onapracticallevel,severalrespondentsnotedthatnotallfacilitieshadaccesstoWi-Fifacilitiesandcalledforthistobeaddressed.

5.3.2.2. Families and the General Public Respondentsrecognisedtheimportanceofgoodcommunicationforfamiliesandthegeneralpublicandhavesuggestedseveralasksandrecommendationsinthisregard: • summaryinformationsheets,uniformacrossallnursinghomesandwiththemostup-to-dateadviceand

guidanceshouldbeprovidedtonursinghomesassomeguidancedocumentsarelengthy.Theseshouldbeuserfriendlyforanaudienceofstaff,residents,andfamilies;

• communicationandacknowledgementoftheexpandedroleandpressuresonstaffatthistime; • thatproposedchangestonursinghomepractice,suchasvisitingrestrictions,wouldbecommunicated

with the nursing home sector before being announced; • consistencybetweenvisitingguidelinesfornursinghomesandforhospitals; • publiccommunicationsabouttheriskstoolderpeopletopreventcomplacencyandincrease

understandingoftherationaleforthevisitingrestrictions; • includeinformationonthelevelofCOVID-19-freestatusofnursinghomes.

5.3.2.3. Miscommunication and DuplicationManysubmissionshighlightedthattheywerereceivingduplicateinformation,sometimeswithconflictingguidanceonthesametopic.Onerespondentsuggestedthatwhenupdatesarebeingissued,thesewouldbeissuedin“markedup”format,soastomakeiteasiertoidentifychangesinguidanceandrecommendations.


5.3.2.4. What Worked WellSeveralrespondentstooktheopportunitytohighlightthebenefittheyexperiencedfromsomeWhatsAppgroupsthatweresetupinresponsetothecrisis.

5.3.2.5. Improving CommunicationsRespondentshighlightedseveralareaswheretheywouldbenefitfromimprovementsincommunications,bothatanationallevelandintermsofpublichealthprocesses: • clearcommunicationonorabouthospital-to-nursinghomedischarges; • haveaclearsingle-point-of-contactbetweennursinghomeandpublichealth; • highlightthesuccessstoriesandwhat-went-wellinnursinghomes; • weeklyreportingofinfectionsbygeographicarea,inlinewithcurrentpracticeforinfluenzaandnorovirus; • ahelplineforaccesstourgentexpertadvice.

Auser-friendlyone-stop-shopwebsiteorplatformasasingle-sourceofeducation,information,graphics,andtrainingresources.


5.3.3.1. Governance and Clinical Oversight Theconceptofleadershipandcollaborationwerereflectedinmanysubmissionsreceived.Severalrespondentscalled for robust clinical governance and oversight supports from consultant geriatricians, clinical nurse specialists,oldagepsychiatryandmentalhealthclinicianstosupportthecareforresidents.Theestablishmentofoneoverarchingbodywasalsocalledfortocoordinateallpartiesinvolved,includingthenursinghomesector.

Manyfeltthateffectiveleadershipandaccountabilityareneededtoimplementawell-thought-outstrategytoprotectthevulnerablenursinghomecommunitygoingforward.Alliedtothis,itwashighlightedthatsometimestherehavebeendiscordancebetweenthepublichealthandoccupationalhealthauthoritiesastohowtomanageanddealwithrealtime,pointofcarechallengesforHCWs.Thiscanaddtothestressofdeliveringregulatedcareintheseun-precedentedtimes.

SomerespondentshighlightedtheexistingregulationsgoverningtheoperationofLTRCfacilitiesandotherscallformorestringentconsequencesfornon-compliancetobeimplemented.

5.3.3.2. Guidelines and Care PathwaysManysubmissionsincludedcallsforguidance,protocols,orclarityatnationallevelaroundspecifictopics,including: • CHOandlocalacutehospitaloversight; • formalisedcommunicationandoversightlinkswithinthehealthcareecosystem; • infectioncontrolcommitteeestablishedforeachnursinghome; • guidelinesforGPreferralsforolderpersonsservices; • visitorguidelinesunderCOVID-19; • contingencyplanandoutbreakmanagement; • singlesourceinformationdisseminationpathways; • patientneedscentredguidelinesonstaffingratios; • pathwaysofcarefocusedonminimisingtimespentinhospitalsoremergencydepartmentsforolder

people; • guidelinesforstaffwearinguniformsbetweenworkandhome; • guidelinesforstaffreturningfromannualleave; • regulationandregistrationofworkersinthissector;and • residenttransferprotocols–particularlyCOVID-19related.

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Intermsofpersonswithdementia,somerespondentsviewedthattheimpactoftheCOVID-19restrictionswaslesspronouncedfordementiapatientswhencomparedtomentalhealthpatients,overtheperiod.Otherssuggestedthattheimpactwascatastrophicforbothdementiapatients,andtheircarers.Practicalinformationandbespokeguidelinesforthesesubgroupsofresidentswerecalledfor,aswellasmoreinnovativewaystocareforthespecificneedsoftheseresidents.


5.3.4.1. Access to Services Manysubmissionsincludedacallforspecificservicesandforeithertheresumptionofservicesthathadbeensuspendedorcontinuanceofnewservicesthathadbeenprovidedinresponsetothecrisis: • generalpractice; • alliedhealthservices,including: - rehabilitationservices; - occupationaltherapy; - speech and language therapy; - physiotherapy; - clinicalnutrition; • tissueviability; • infectionpreventionandcontrolspecialists; • frailty assessment; • gerontologicalexpertise; • IVantibioticadministrationinthehome; • diabetes screening; • accesstodialysisandradiotherapyservices.

5.3.4.2. Training Needs Keyareasoftrainingsupporthighlightedinthesubmissionsfocusedon: • accesstotheHSEforallhealthcareworkersregardlessofpublic/privatestatus; • improvementofHPSCwebsiteforaccessandnavigation; • infectioncontroldrillsandpracticaltrainingprogrammes; • trainingininfectionpreventionandcontrol; • gerontology and clinical frailty assessment; • professionaldevelopmentandincreasedskillse.g.IVadministration; • crisis management training; • dementiainthecontextofcrisismanagementandinfectioncontrolscenarios; • mental health and resilience training; • trainingdeliveredthroughmultiplelanguages; • swab test training; • contact tracing training; • verificationofdeathtraining;and • theestablishmentofaninterimgradeofstaffbetweennurseandhealthcareassistant.


5.3.4.3. Staffing and RecruitmentSeveralrespondentstooktheopportunitytocommendthededicationandcommitmenttheirstaffhadshownthroughthiscrisisandtheimportantimpactthishadonoutcomesforresidentsintheircare.

Staffingandrecruitingconcernsraisedbyrespondentsincluded: • areviewofpayandconditionsforhealthcareworkersinthissector; • clarity on the wage subsidy scheme as it applies to this sector of workers; • processingandapprovingnon-nationalstoworkinIrelandasahighpriority; • theissueofcompetitionbetweenHSEandnursinghomesforstaff–bothdirectlyandindirectly; • COVID-19requiresanincreaseofstaffinglevelsfromnormalpractice; • therequirementforincreasedadministrativesupport; • recruitmentsupportwouldbebeneficial; • redeploymentinitiativewasunsuccessful.

5.3.4.4. COVID-19 TestingIntermsofCOVID-19testing,anumberofrecommendationsweresuggestedacrossmanysubmissions: • thereshouldbefrequenttestingofstaffandresidentsandcompulsorystafftesting; • consideringthediscomfortandinvasivenessoftesting,thefrequencyshouldbebalancedwiththelevel

ofthreatorriskofinfection; • theturn-aroundtimeinresultsneedstobewithin24–48hours; • antibodytestingshouldalsocommence; • contact tracing needs to be improved; • informationsharingoftestresultsshouldbeefficientandappropriate; • frequentsymptommonitoringshouldcomplementatestingregime; • concernoverasymptomaticspreadofthevirus.

5.3.4.5. Personal Protective Equipment (PPE)ManyrespondentsreflectedonthePPEcrisisthattheyexperienced,competingagainsttheHSEandfailingtosecurethenecessarysupplies.Severalhighlightedthattheuncertaintyofsupplycausedgreatanxietyforthepeoplewithintheirfacilities.Goingforward,boththecostofPPEandsuretyofsupplyarerecurringconcernsinthesubmissions.

5.3.4.6. Nursing Home FacilitiesAsaresultofthepracticalchangesrequiredinresponsetoCOVID-19,manyrespondentshavehighlightedtheadditionalfacilitiesthatwillneedtobeprovided(orcontinued)tosupportthis,including: • eliminationofmulti-occupancyrooms; • provisionofisolationfacilitiesfornewadmissionsandCOVID-19-positivepatients; • provisionofstaffaccommodation; • designatedvisitingareaswithCOVID-19protectiveinfrastructure;and • separateentryandexitchangingroomsforstaff.

5.3.4.7. Infection Prevention and ControlWhilesomefocusedonthebasicsofhand-washing,andregularaudio-cuestorewash,othershavehighlightedtheneedforspecificIPCdeep-cleanregimesandservicesfortheirfacilities.E-Documentationwassuggestedbyoneasanimportantfactor,andanothernotedanobservedreductioninchestinfectionsintheircentrefortheperiod.AlthoughnursinghomesareexperiencedinmanagingpatientswithMethicillin-resistantStaphylococcusaureus(MRSA)andClostridium difficile(C.diff),onerespondentpositsthatitwastheunprecedentednatureoftheglobalcrisisofCOVID-19thatwasthedifferentiatingfactorwiththisvirus.

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5.3.4.8. Other Measures SeveralrespondentsfeltdisappointedthattheemergingsignalsfromtheexperiencesbeingwitnessedinotherjurisdictionsdidnottranslatetomorerobustearlypreparationinIrelandforthenursinghomeandLTRCsetting.

Goingforward,somerespondentshavesuggestedthattravellersfromCOVID-19affectedcountriesshouldberequiredtocomplete14-dayisolation,whileothershaveaskedforclearguidanceandprotocolsonmask-wearingtobeimplemented,particularlyforthosewhomightintendtovisitanursinghome.

Widersuggestionsconcerningsociety’sresponsibilitytowardprotectingolderpeopleandvulnerableadultsincludedcallsforittobemademandatoryforHCWstoavailofvaccinationprogrammessuchastheannualinfluenzaprogrammeandhepatitisCprogramme.Sickpaysupportswerealsosuggested.

SeveralrespondentshighlighttheexistingregulationsgoverningtheoperationofLTRCsandsomeaskformorestringentconsequencesfornon-compliancetobeimplemented.


5.3.5.1. Funding ModelTheunfairnessinthefundingasdeterminedbytheNationalTreatmentPurchaseFund(NTPF),thatadministerstheNursingHomesSupportScheme(NHSS)wasarecurringthemeofsubmissions.Theperceiveddisparitybetweenthefundingprovidedincomparisontotheresident’srequiredservicecarecostsishighlightedwhiletheinequityoffundingasbetweenprivateversuspublicsectornursinghomesisalsounderlined.

Itisaclearsourceofdissatisfactionforprivatesectoroperators.ManycalledforthisanomalyintheNHSStobeaddressed.

Manyrespondentsclaimedthatthereisadisparitybetweenthelevelsoffundingprovided,particularlythroughtheNHSS,andtheactualcostofprovidingtherequiredcare.ThisisfurtherunderlinedbythenotedabsenceofalinkbetweenHIQAstandardsandrequirementsandthefundingonoffer.

AnalternativeviewsuggestedisthatCOVID-19is,fundamentally,auniquepublichealththreatandthatthecost-consequencesofthisextra-ordinarycrisisshouldbeaState-fundedliability,fallingoutsidetheremitofthepublic-privatedebate.

5.3.5.2. Model of CareNationalpolicyonthemodelofcareforolderpeopleisalsoraisedinresponses.Thereisacallforthistobeexaminedandforsocietytomakeaconsciousdecisionaboutthedirectionofpolicywewishtopursueasacountry.SeveralrespondentsadvocateforsupportingandpromotingindependentlivingandencouragingtheelderlytoliveathomeforlongerratherthanthecurrentLTRCmodel.

5.3.5.3. Service Delivery ModelConceptually,manyexpressedabeliefthatnursinghomesshouldnotbeconsideredinisolation,butthattheywerepartofacontinuumofcareoftheolderperson.Theintegrationofnursinghomesintothewiderhealthcaresystemwasastrongthemefromtherespondents.Severalrespondentsreferencedthecomprehensiveandmultidisciplinarysupportthatwasdeployedasaresultofthecrisisandaskedthatthiscaremodelwouldbeformalisedandmaintainedgoingforward.

Severalsubmissionscalledforgreatersharingofinformationpertainingtolocalclusters.


5.3.5.4. The Role of CHOsTheinvolvementoftherelevantHSECommunityHealthcareOrganisation(CHO)(e.g.throughCOVID-19ResponseTeams)waslargelyseenasapositivemovewithmanyrespondentscallingfortheircontinuedinvolvementinthesectorintothefuture.Therewereseveraladditionalsuggestionsrelatedtothelonger-termestablishmentoflinks,suchastheset-upofCHOteamsandsingle-points-of-contactforcommunications.

5.3.5.5. The Nursing Home as a “home”Concernswereraisedthatnursinghomeswereincreasinglybeingseenasmedicalsettings,withsomerespondentsnotingthatnursinghomesareprimarilyresidenciesforcommunalliving.Therefore,qualityoflifeforresidentsshouldbeconsideredinthatcontext.

5.3.6.RepresentationandAdvocacy

5.3.6.1. RepresentationManyrespondentsfeltthatthenursinghomesectorshouldhavebeenincludedonNPHETorasub-groupthereofintheplanningandmanagementofCOVID-19inIreland.Thereisafurthercallforthenursinghomesectortobeincludedandrepresentedonanyrelevantpanels,committees,orworkinggroups.Consultationandinclusionarecalledforseveraltimesthroughouttheresponses.

Inthecontextofthenationallevel,manyrespondentsexpressedtheirdisappointmentathowthesectorwasportrayedbyHIQAduringadebateattheCOVID-19OireachtasCommittee.SeveralquestionedwhythepurportedconcernsofHIQAwereonlycomingtolightasaresultofCOVID-19,pointingtothe2019HIQAAnnualReportthathadexpressedsatisfactionwiththelevelsofgovernanceandcompliancewithinthesector.

Somerespondentstooktheopportunitytohighlightthecontributionsoftheirstaffandtoshowtheirgratitudeandpraise.Themediaportrayalofthenursinghomesector,particularlytheprivateoperators,wasasourceofrepeateddisquietthroughoutthesubmissionsreceived.ConcernswereraisedaboutthetoneandcommentaryofanOireachtasCommitteehearingonthenursinghomesector.

5.3.6.2. Advocacy Severalrespondentscalledforthenursinghomessectortobeacknowledgedandrespectatnationalandgovernmentlevel,andthethemeofadvocacyandsupportaroseseveraltimesthroughoutthesubmissions.Somerespondentscommentedonrepresentationandadvocacyforthenursinghomesector,andothersdiscussedadvocatingfortheirresidentsandthosethatarevulnerable.Thetoneofmanyofthesubmissionsreflectedasenseof“powerlessness”and“loneliness”inthefaceofthecrisisasitunfolded.

Respondents reiterate that a nursing home is primarily the residence of a person and not a medical facility, and thattherightsofresidentsintermsofdignity,freedom,choice,andequalityneedtoberespectedandattheforefrontofpolicygoingforward.

Intermsofnursinghomeorganisations,respondentsexpressasenseofabandonmentandlackofsupport,withonerespondentnotingthattheyfeltthatthey“must paddle [their] own canoe”.

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5.4.PublicConsultationAtotalof60submissionswerereceivedbytheExpertPanel.Thirtyfiverespondentsprovidedinformationontheirorganisationoremploymentaffiliation,while25didnot.Fourteenrespondentsidentifiedthemselvesasfamilymembersofaresident,3respondentsasresidents,10asstaff,and29classifiedthemselvesas“other”.

Thischapterpresentsthemainthemesthatwereidentified.Thesummariesprovidedinthischapterrepresenttheviewsofarangeofstakeholders,takendirectlyfromreturnedcompletedsurveyforms.

5.4.1.NursingHomeProceduresPersonalaccountsofindividualsexperiencesofthecrisiswerealsosharedwiththeExpertPanel.Experiencesrecountedincludedsurvivors,familymembers,andfront-linehealthcareworkers.Eachwerekeentooffertheirrecollectionsonhoweventsunfoldedandreflectionsonwhereimprovementscouldbemadeinthefuture.

Contingencyplanninganddevelopingclearprocessesandprocedures,suchasentryandexit,zoning,andisolation,aresuggestedbymanyrespondents.Increaseduseofoutdoorspacesandinitiativestoensurethatnon-COVID-19relatedhealthneedsarealsomaintainedwerealsoproposed.

Theneedforwrittenbespoke‘careplans’foreachresidentwasalsosuggestedbyseveralrespondents,highlightingthatinthecontextofacrisis,residentsarenotalwayscaredforbythosewhoarefamiliarwitharesident’spersonalneeds,preferences,andchoices.

There is a strong belief among respondents that acute hospital transfers into nursing homes was a key source ofinfectionintroductionintothehomes.Severalrespondentsadvocatethatthereshouldbestricttestingandisolationproceduresinplaceatthepointoftransfer.Staffshortages,theneedforstreamlinedrecruitment,gardavetting,andvisasforforeignnationalswerealsoraised.

RespondentsrecommendedencouragingtheuptakeofvaccinationsforHCWs,withsomesuggestingtheybemademandatorybyemployers.Dedicatingstafftospecificnursinghomesorunitsfeaturedstrongly,asdidcontinuoushealthandtemperaturemonitoringofstaff.

Adiverserangeofviewsonvisitorprotocolsandrecreationalandoccupationalactivitieswereprovided.Somewerekeenfortherestrictionstoremaininplaceaslongastheriskwasthere.Othershowever,prioritisedthesocial, physical, and psychological needs of residents to resume visits with family and also with other personal careprofessionals.

5.4.2.CommunicationTheconceptofcommunicationandinformationsharingfrequentlyarisesintheresponses.

Family/NursingHome: • callsweremadeforclearercommunications,suchaswelfareupdates,availabilityofwrittencareplans,

outbreakstatusofthefacility,andconsultationbeingcarriedoutinrelationtopatientcaredecisions.Respondentsreporteda‘senseofretreat’bynursinghomeswhenitbecamedifficultorimpossibletoreachthembyphoneasthecrisissetin.

• otherrespondentsraisedtheneedforrestorationoftrustandconfidencebetweennursinghomesandfamilies.

• theneedforstructuresandguidelinesforadvancedcareplanningwasalsoraised.


Resident/Family: • manyquestionedthetimingorlengthoftimethatvisitorrestrictionswere/areinplace,andtheseverity

ofthoserestrictions.Somereportedthatwindowvisitswerenotallowed,andthatvirtualvisitswerenotbeingfacilitated.

• additionalsupportsmaynowberequiredforresidentswhohavesufferedtheimpactoflong-termisolationandlonelinessasaconsequenceofvisitingrestrictions.

NursingHome/Healthservices: • severalrespondentssuggestedthattelephonetriageandvideoconsultationscouldbeintroducedto

optimiseaccesstohealthservicesforresidents,eitherCOVID-19ornon-COVID-19-related. • theneedforITinfrastructuretofacilitategreaterintegrationandconnectivityisalsoraised.


5.4.3.1. Clinical Governance and OversightDesignationofgovernanceresponsibilityandstrengtheningofHIQA’smandateforeffectiveenforcementofappropriatecarestandardsandinvestigationofindividualcomplaintswerecalledforinsomeresponses.Othersaddedthattheyfelttheexperiencegainedoverrecentmonthshasdemonstratedalackofadequateclinicaloversight, clear governance structures and monitoring with appropriate enforcement capability in the nursing homesector.

SeveralrespondentscommentedonHIQA’scurrentauditprocess,andsuggestedthatitneedstobeupdated,includingunannouncedinspections,publiclyavailableresults,andclearcomplianceprocedures.

Onerespondentalsoraisedaconcernregardingthestatusofreligiouscongregationsintermsofoversight,notingthattheycurrentlydonotfallwithintheremitofHIQA.


5.4.4.1. Access to ServicesThe concept of nursing home care being viewed broadly in terms of the wider spectrum of all available services andsupportsoperatinginanintegratedwaywasarecurringthemeinthesubmissionsreceived.Itwassuggestedthatnursinghomes,includingprivatefacilities,shouldbeintegratedintothewiderframeworkofhealthandsocialcare,andconsideredpartofintegratedcarepathwaystoincludenursinghomesvisits.Respondentssuggested that allied healthcare professionals should also be involved in older peoples care in nursing homes, as theyareincommunities.Respondentscalledforclearresponsibilityandoversightinallcarefacilitiesforolderpeopleatbothregionalandnationallevel.

5.4.4.2. Training NeedsSpecifictoCOVID-19,trainingforinfectionpreventionandcontrol,COVID-19testing,traininginthecorrectuseofPPE,andsimulationtrainingforanoutbreakweresuggested.Reflectingconcernsregardinginfluenzavaccinationuptakeratesinthesector,somerespondentssuggestedtrainingforstaffontheimportanceandimpactofgoodvaccinationuptake.Thementalhealthneedsofstaffasaresultofthecrisiswasalsoaconcernforrespondents,andtrainingandsupportinthisareawasalsosuggested.

Moregenerally,respondentssuggestedtrainingintheadministrationofIVantibiotics,oralcare,gerontology,dementia,frailty,andpalliativecare.Formalisingthegradeandqualificationsforhealthcareassistantswerealsoproposed.

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5.4.4.3. Staffing and RecruitmentTherewasastrongrecognitionoffront-linestafffortheir“courageous persistence in the face of a frightening outbreak”,fromthewitnessaccountssharedwiththeExpertPanel.Intermsoffuturepreparedness,onerespondentexpressedconcernatapotentialrelianceonstaffmobilityasasolutioninacrisis,suggestingthatthismayhavecontributedtotheinitial‘seeding’ofnursinghomesinthiscrisis.

Monitoringofstaffingnumbersanddefiningstaffratiorequirementswasalsosuggestedasanapproachtoensuringsufficientstafflevelsandanabilitytoidentifywherestaffinglevelsarebecomingarisk.Redeploymentwasalsoraisedasbothasuggestionandanissue.Itwasnotedthatinpractice,somestaffwhowereapproacheddidnotfacilitatetheneedforredeploymentduringthecrisis.

5.4.4.4. COVID-19 TestingRegularandrapidtestingprocedureswerecalledforbymanyrespondents.Somefurthersuggestedincludinganominatedfamilymemberinregularscreeningsoastoensurecontinuedvisitingabilityfortheresident.Timelyresults,especiallyforresidentsinisolationasasuspectedcase,wasaskedtobeconsidered.Thecommunicationoftestresults,forbothpositiveandnegatives,needtobetreatedequallyurgently.

Testingsensitivityisnot100%accurate,asonerespondentpointedout.Itissuggestedthatwhereclinicalpresentationcastsdoubtonthetest,thenallprecautionsmustbefollowedforthe14-dayperiod.Over-relianceonthetestresultiscautionedagainst.Onerespondentsuggestedthatkeepingflowchartforeachresidentofvitalstatisticsthroughouttheperiodinordertoidentifyanychangebeforeillnesswouldbeausefulpractice.

Confusionovercasualcontactsversusclosecontactsisapointraisedseveraltimes,withconsequencesfordiseaseidentificationaswellasunnecessaryisolationofresidentsandlossofstafffor2-weekperiodsbeinghighlightedasaresult.

5.4.4.5. Personal Protective Equipment (PPE)Theneedforpersonalprotectiveequipmentisrecognisedbymanyrespondents.Severalsuggestthataminimumemergencystockshouldberetainedineachnursinghome.Itwasalsosuggestedthatincertaincircumstances,sterilisationandreuseofPPEisfeasible.

SomerespondentsrecalledseeingstaffnotwearingtheirPPEcorrectly,oronlypartially(e.g.wearinggownsbutnotgloves).TrainingwashighlightedasbeingequallyimportantasaccesstoPPE.

5.4.4.6. Nursing Home FacilitiesManyrespondentsrecognisedthatwiththeliftingofvisitorrestrictions,nursinghomeswillneedtoputphysicalinfrastructureinplacetoaidthecontinuedprotectionofresidents.Dedicatedvisitingroomswithclearscreensweresuggested,aswellasfullPPEforvisitorsentering.Sanitationroomsforentryandexitofthebuildingwerealsosuggested,forbothstaffandvisitors.Concernswereexpressedwithregardtoaccommodationfacilitiesforstaffwhocannotself-isolateathome.Improvementsandupgradingofoutdoorspaceswerealsosuggestedtofacilitatevisitsaswellastheeliminationofsharedoccupancyroomsforresidents.

5.4.4.7. Infection Prevention and Control (IPC)ThereisafinelinebetweengoodgeriatricnursingandeffectiveIPC,orevenconflict,asonerespondentnotes.Notwithstandingthis,respondentsmadeseveralsuggestionswithregardtothemethodsandproceduresthatshouldbeconsideredaspartofinfectioncontrol,fromfirstprinciplesofgoodhygienetodeep-cleanmeasures,toelectrostaticsterilisationusinghydrogenperoxideand0.5%silver.Additionalsuggestionsincluded: • areviewoftheHIQAIPCguidelinesorstandards; • an IPC audit schedule to be established; • accesstoanIPCqualifiednurseon-site;and • arigorousinfluenzavaccinationcampaignfor2020.


5.4.4.8. Vulnerable SubgroupsAcrossallcategoriesidentified,thespecificneedsofcertainsubgroupswerealsoraisedforconsideration,suchasforthosewithdementia.Individualriskassessmentplansaresuggestedforallresidentstoensurethatallneedsandadjustmentsaretakenintoconsideration.


Manyrespondentsreflectedonthenursinghomemodelofcare,questioningwhetherthesizeoflargernursinghomesarefitforpurpose.Othersnotedtheneedforpoliciesthatwillsupportolderpeopletoliveindependentlyforaslongaspossible.Thiscorrespondswithrespondentswhoidentifiedthefunctionofnursinghomesasaresidenceoratertiarymedicalfacility.Thesepolicy-levelobservationshelptoexplainthediversesuggestionsonwhatisrequiredgoingforward.Somerespondentscalledformeasuresthatwouldincreasethemedicalisationofthenursinghomesetting,whileotherscallfortherestorationofresidenciestobeing“ahome”assoonaspossible.

Investmentandfundingforthissectorto“bringitintothe21stcentury”wasalsomentionedbysome.Specificsincludecapitalinfrastructure,andmodificationrequirementstoaccommodateCOVID-relatedchanges,ITinfrastructure,andincreasedfundingundertheNHSSarecited.

Manysubmissionsreflectedtheopinionthatnursinghomesshouldbeconsideredaspartofthenationalhealthinfrastructure,believingthatthiswouldfurtherenhanceconsistencyandstandardisationacrossfacilities.Sharedguidelinesonnursing,staffing,skilllevelsandmedicalcareacrossthesectorwerealsocalledfor.Theconceptofintegrationofnursinghomeswiththewiderhealthcaresystemalsoincludedaspectssuchas,relationshipsandarrangementswithlocalhospitals,localauthorityfacilities,dental,physioandotherpersonalandtherapeutichealthcareservices.

Morebroadly,awidersocietaldiscussionwasadvocatedfor,inparticular,toexaminewhetherwe,asasociety,wishtopursuetheprovisionofsupportsforolderpeopleinacongregatedordomiciliarybasedcaresetting,aswellaswhethertheseshouldbeviewedthroughthelensofasocialversusaclinicalmodel.


Manyrespondentsexpressedawishthatresidentsattheheartofthisconsultationbegivenavoice.Somefeltthattheirvoicesandconcernswerenotheardduringthecrisis.Thepsychologicalimpactofthenursinghomelockdownisarecurringconcern,asisthelossofchoiceforresidentsofthehomes.Thepointisraisedinthiscontextthatanursinghomeisprimarilytheresident’shomeandthereforethey,theirfamilyorotherrelevantadvocate,shouldbeincludedandconsultedindecision-making.Appropriaterepresentationandadvocacyonbehalfofresidentsatthenationallevel,suchasNPHET,wasalsoaconcernforrespondents.

AdignityCharterforeverypatientandrepresentationofresidentsatnationalstrategicdiscussionswerealsosuggested.Additionally,representationofnursinghomesatthatlevelwasalsosuggested.

Reflectingontheneedforadvocacy,onerespondentnotedthat in the decade of austerity organisations that represented those on the margins were de funded or changed or

amalgamated. The Human Rights Commission was amalgamated, The National Council of Ageing and Older People was disbanded, funding for advocacy was reduced, so a voice for the most voiceless was lost. Independent Advocacy groups like SAGE and Older People Councils under ‘Age Friendly Ireland’ may need further support. Active Retired Groups and Network do advocate for their members but who advocates on behalf of the most vulnerable Older People? residents of long stay units are often highly dependent and voiceless; this needs to be remedied. There needs to be a clear and supported charter of rights.

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Another respondent considers that The COVID-19 crisis has shown that care is not valued in Irish society. The pandemic has laid bare the weaknesses

in the provision of home care and nursing home and the lack of integration between both sectors. With an increasing number of people living into older age, Government policy on the provision of long-term care is central to ensuring care is accessible, high-quality, efficient and secure - even in crisis situations.

5.5.ConsultationonSiteVisitsandwiththosewithIndividualExperienceofCOVID-19TheExpertPanelestablishedanumberofrapidconsultationprocesseswithnationalstakeholdersandthepublic.ThePanelwasparticularlykeentoengagewithandhearfromthosewho: i) hadbeenmanagingtheresponsetoCOVID-19onthefront-lineofnursinghomes; ii) have been providing care in nursing homes throughout the pandemic so far, and iii) thosewithlivedexperienceasresidentsinnursinghomesthroughoutthepandemic.

Thevoices,experienceandlearningsfromthesekeystakeholdersprovidedakeyinputtothedeliberationsofthePanel.

ThePaneldecidedtoholddiscussionswiththestaffandresidentsinanumberofpublicandprivatenursinghomes.HIQAwasaskedtoidentifynursinghomesthatwouldbewillingandavailabletoparticipateinsuchaprocessandtosuggestthenamesoffourfacilities,twopublicandtwoprivate.Duetotheprevailingtravelrestrictions,outofcountytravelwasnotpossiblesovirtualvisitswithPanelmembersweretobearranged.ThePanelaskedthatthepersonincharge,twoseniorstaffmembersandresidents,ifavailable,wouldparticipate.QuestionsposedbythePanelwerepre-suppliedbyletter.Theserelatedtostaffandresident’sexperienceofthepandemic,supportsrequiredandkeylearningsforthenext18months.ThePanelheldvirtualsessionswithtwonursinghomes,athirdobligedwithanon-sitevisitandthefourthhadtowithdrawatthelastmoment.

5.5.1.ImpactofthePandemic

COVID-19wasadevastatingrealityfortwoofthehomeswithwhichthePanelengaged.Inadditiontoasignificantnumberofdeaths,manyotherresidentsandstaffmemberscontractedCOVID-19whichplacedasignificantstrainonthemaintenanceofbasicstaffinglevels.Theoveralllevelofupsetsufferedbyresidents,relativesandstaffconnectedwiththesenursinghomescannotbeoverstated.Manywillrequireongoingsupportandunderstandinginthecomingmonths.ThethirdnursinghomehadasmallnumberofCOVID-19positivecasesbut,becauseoftheirforesight,staffhadprocuredagoodsupplyofmasks,glovesandPPEbylateFebruary/earlyMarch,inanticipationofwhatwastocome.

Thekeypointsemergingfromallthree‘visits’are: 1) whenCOVIDgotintothefacility,itseemedtospreadwithunduehaste;(threeresidentsdiedinasingle

12-hourperiod,anotherthreewithinafurther48hours–“whatwerewetodo?”); 2) theHSECOVID-19ResponseTeamsupportwascrucial; 3) speedyaccesstoPPEvaried,especiallyintheearlyweeksofthepandemic(itwasacknowledgedthatthis

wasanationwide,indeedglobalreality); 4) staffinglevelswereoverstretchedduetoillness,theneedtoisolate–somethingthatstillcausesmanyof

thestaffconcernedongoingdistressandguilt;


5) thevisitingrestrictions,whoserationalewasunderstood,werestillthoughttohavebeencruel,especiallyforresidentswhowereclosetodeathandalsoforresidentswithdementiawhosediminishedinsightastowhatwasgoingonwascompoundedbynotseeingtheirrelatives.Theroleoffamiliesinsupportingstaffinthesecriticalareaswasstressed.

5.5.2.KeyLearningsfortheNext18Months

Thesekeylearningsprimarilyrelatedtopreparedness.Onefacilitystressedtheimportanceofasolidteamandhadalreadyputcounsellingandothersupportsinplaceforstaff.Theimportanceoftimelytestingavailabilityandturnaroundtimeswasstressedandprovisionforthiswasalreadyinplace.TherewerealsoplansintrainfortheimplementationoffurtherIPCtraining.Abalancehadtobefoundto“livesafelywiththevirus”ratherthaninitiatingconstantlockdown-typerestrictions.Contingencymeasureswereplannedfor,includingself-isolationfacilities.TheintegrationofprivatenursinghomesintotheHSEservicesandsupportsshouldbesustainedandthelevelofsupportsreceivedwasofahighstandardandappreciated.Stafftrainingandoccupationalhealthsupportswerealsoveryimportanttomaintain.

Inadditiontotheaboveengagementswithresidentsandstaffofthenursinghomes,separatearrangementswerealsomadetoengagewithanumberofresidents/relatives,identifiedfromindependentadvocacysources,andwhohadexpressedthedesiretosharetheirthoughtsandexperienceswiththeExpertPanel.Virtualmeetingswerearrangedwithfourindividuals,twoofwhomwereresidentinnursinghomesandtwowerecloserelativesofnursinghomeresidents.Theyagreed,throughSageAdvocacy,toparticipate.Theirstoriesandconcernsweredifferentinsomerespects,butcommonthemeswerealsoevident.

Firstly,allexpressedtheirutterfrustrationborderingonangerregardingthe‘novisiting’policy,particularlywhena family member was close to death ‘and no family member allowed in to say goodbye’.Thiswasabiggerissueforlargerfamilieswhenonlyaspecificnumberfromthatfamilycouldeverbepermittedtovisit.Communicationoptionssuchasmobilephone,FaceTime,Skypeandothersystemswereused,withvaryingbenefit.

Thethemesthatdifferedwithinthegroupincludedoneresidentwhooutlinedherfrustrationthatshecouldnot,duetoCOVID-19,getoutforherusualweekendvisitstofamily,nottomentiontoadvanceherpreferencetogettinghomepermanently.Asecondthemethatemergedrelatedtoanoverallqualityofcarematter,whichwasnotspecificallyCOVID-19-relatedandisbeingaddressedinanotherforum.

Overall,bothresidentsandtheirrelativeswerewarmintheirpraiseofallnursinghomestaffandexpressedtheirsinceregratitudeandappreciation,acknowledgingthattheyhavebeenworkingunderextraordinarystressthesepastseveralmonths.Thesecontributionsresonatedwithsubmissionsfromotheraffectedfamilymembers,whorecountedtheirexperienceoflosingalovedoneduringthepandemic.

5.6.ExpertPanelAcknowledgementThePanelwouldliketoagainacknowledgethehighlevelofcommitmentandengagementfromorganisationsandindividualsinrespondingtoinvitationsand,sincerelyappreciatesallofthosewhohavesharedtheirexperiences,expertise,insightsandideaswiththePanel,whichweremostvaluableinputsforthedeliberationsofthePanel.

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6.HealthcarePolicyforOlderPeople:TimetoReviewtheModelofCareAcrosstheOECD-26overa10-yearperiod,therehasbeen,onaverage,almostnochangeinthenumberoflong-termbedsper1,000populationagedover65.However,thereisgreatvariationbetweencountries;forexample,from2005to2015,Swedenreducedthenumberoflong-termbedsby23.5perthousandpopulationagedover65yearswhereasIrelandincreasedby6.5bedsper1,000overthesametimeperiod.72ThereductioninSwedenwasattributabletoamovetoagreaterprovisionofolderpersons’careinthecommunity.ThisisinlinewiththeSláintecareImplementationStrategyandassociatedactionplanandwasalsoreflectedinthecaretransitionsduringCOVID-19.Iceland,CanadaandNorwayhavealsoshiftedemphasisonthecareofolderpeoplefromresidentialtocommunitysettings.73Theconsequenceofthisshiftisthatresidentialcareisreservedforthosewiththegreatestneed.

6.1.ProvisionofServicesInthepast20yearssignificantfinancialincentives,74reportedlyupto50%oftheconstructioncosts,weregiventowardmeetingthecostsofnewprivatenursinghomes.Thismajorpolicyshifteffectivelyhandedfutureresponsibilityfortheresidentialcareneedsofanincreasingnumberoffrailoldervulnerablemembersofsocietytotheprivatesector.Thirtyyearsago,80%ofresidentsinlong-termresidentialcarewereinpublicly-funded.Todaytheexactreverseapplieswith80%inprivatenursinghomes.

AnextractfromChapter9oftheReportoftheWorkingPartyonServicesfortheElderlyThe Years Ahead – a Policy for the Elderly,(seeparagraph9.23)publishedinOctober1988,75statesthat:

Comhairle na nOspidéal described the large geriatric hospital as ‘inappropriate to the needs of the elderly, (apart from patients that come from the immediate vicinity of the institution) and such institutions should, as soon as possible, be replaced by smaller-scale, long-term accommodation related to the local community in which they are located’. Comhairle na nOspidéal Report (1985)

Inthosedaysthesuggestedappropriatesize/capacityforaCommunityHospitalwas50-60beds–anditwouldprovidethewiderangeofservicesaswellasmeetingthelocallong-termresidentialcareneed.Theseotherservicesincludedi)shortstayacuteadmissionforanacuteillness,ii)furtherinpatientrehabilitationofpatientsdischargedfromtheacuteservice–e.g.poststroke,hipfracture,iii)daycareservices,iv)scheduledflexiblerespitecare,v)end-of-lifecareforpatientsadmittedfromhomeorforthosealreadyresidentinthefacility,supportedbytheexcellentspecialistpalliativecarehomecareprogramme.

The Years Ahead reportincludesrecommendationsstillrelevanttoday.Itisalsonoteworthyinthatitincludedafullchapter(Chapter12)onimplementingitsproposals–novelinthosedays.Itisironicthat,32yearson,farfromtakingtheaboveadvice,therearemanynursinghomesdevelopedsince,withbedcapacitiessimilarto,ifnotgreater,thanthoseofthe‘geriatrichospital’ofold.

72 SeeOrganisationforEconomicCooperationandDevelopment,HealthataGlance2017:OECDIndicators(Paris:OECD,2017). https://doi.org/10.1787/health_glance-2017-en

73 SeeOrganisationforEconomicCooperationandDevelopment,HealthataGlance2017:OECDIndicators(Paris:OECD,2017). https://doi.org/10.1787/health_glance-2017-en

74 Suchasthroughs.268oftheTaxesConsolidationAct1997,asamendedbys.22oftheFinanceAct1998-providesforaschemeofcapitalallowancesforexpenditureincurredontheconstructionandrefurbishmentofbuildingsandstructuresinuseforthepurposesofanursinghome.

75 SeeGovernmentofIreland,TheYearsAhead:APolicyfortheElderly:ReportoftheWorkingPartyonServicesfortheElderly(Dublin:TheStationeryOffice,October1988),


TheWHOhasstatedthattraditionalmodelsofresidential/nursinghomecareperpetuateoutdatedwaysofworkingrepresenting:

outdated ideas and ways of working which often focus on keeping older people alive rather than on supporting dignified living and maintaining their intrinsic capacity.76

Thereisincreasingevidencetoshowthathighlydependentpersonscanlivesafelyandmorehappilyindomesticsettings,providedtheirrequiredhomecaresupportsareinplace.Smallerhouseholdmodelsofresidentialcarepermitchangesininfrastructurefromthetraditionalinstitutionalmodeltoanenvironmentthatmoreresemblesafamilyhome(accommodating6-12people).ConstructionoffacilitieslikethisarenationalpolicyandthismodelhasbecomethenorminsomeEuropeancountriesfor10ormanyyears.77

The residential care model in Ireland, ‘does not adequately reflect international practice, which has moved towards domestic scale households’. ‘The current prevailing models will continue to drive practice that prioritizes economies of scale and routinized care over quality of life and as such represents a lost opportunity to move beyond mere compliance to holistic person centred supports for individuals at this stage of their lives'. (submissiontothePanel)

‘Creatingcommunity’(asopposedtomerelyprovidingcare)hasbeenidentifiedasawayofshiftingfromenvironmentswhereresidentsareseenaspassiverecipientsofcaretooneswherepeople(staffandresidents)areengagedinmutuallysupportingeachother78,79)ThePanelagreesthatafocusonnewenablingmodelsofhome-basedcareisrequired.AnothersubmissiontothePanelbestdescribestherequiredchangeinapproachandattitudeasfollows: Create a new narrative of care in relation to older people, incorporating the language of inclusion, empowerment and

citizenship. Unfortunately, ageism and paternalism characterised much of the earliest public policy response to the crisis, creating un-necessary and unwanted stigma for older people in all settings.

Givenageingdemographicprojections,particularlyforthenumbersaged80yearsorover,therewillbeacontinuingneedforlong-termnursinghomecarefortheincreasingnumberofassociatedoffrailandhighlydependentindividualswho,despitetheabove,cannotanylongerbecaredintheirownhomes.Forthispopulationcoexistingdementiamaypresentanaddeddimensiontotheircareneeds.Approximately70%ofresidentsinlongstayfacilities(publicandprivate)haveadementia.80

Promotingamorepatient-centredsocialmodelofcarehasbeenadvancedasapreferredalternativetothetraditionalmedical/institutionalmodel–suchafacilityshouldbea‘home’ratherthana‘hospital’.Whilstunderstandingthis,therealityremainsofanincreasingnumberofolderfrail,vulnerablepeoplewithmultipleco-morbiditieswhowillrequiretheskillsofacombinedmedicalandsocialmodelsofcare.ThiswasamplydemonstratedatthepeakoftheCOVID-19pandemictransmissioninournursinghomesespeciallyinthelatterhalfofMarchandthroughoutApril.

76 SeeWorldHealthOrganization,World Report on Ageing and Health(Geneva:WHO,2015).77 SeeSelmateBoekhorst,MariaF.I.A.Depla,JacominedeLange,AnneMargrietPot,andJanA.Eefsting,‘TheEffectsofGroupLivingHomesonOlderPeoplewithDementia:AComparisonwithTraditionalNursingHomeCare’,International Journal of Geriatric Psychiatry 24/9(September2009):970–978;AndrianaSandraP.A.vanBeek,DinnusH.M.Frijters,CordulaWagner,PeterP.Groenewegen,andMielW.Ribbe,‘SocialEngagementandDepressiveSymptomsofElderlyResidentswithDementia:ACross-SectionalStudyof37Long-Term Care Units’, International Psychogeriatrics23/4(2011):625–633.

78 SeeSonyaBrownieandSusanNancarrow,‘EffectsofPerson-CenteredCareonResidentsandStaffinAged-CareFacilities:ASystematicReview’, Clinical Interventions in Aging8(2013):1–10.https://doi.org/10.2147/CIA.S38589

79 SeeChristineBrownWilson,‘DevelopingCommunityinCareHomesThroughaRelationship-CentredApproach’,Health and Social Care in the Community17/2(2009):177–186.https://doi.org/10.1111/j.1365-2524.2008.00815.x

80 SeeSusanCahill,EamonO’Shea,andMariaPierce,Creating Excellence in Dementia Care: A Research Review for Ireland’s National Dementia Strategy(DublinandGalway:LivingwithDementiaResearchProgramme,TrinityCollegeandIrishCentreforSocialGerontology,NationalUniversityofIrelandGalway,2012).

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6.2.TheNationalTreatmentPurchaseFund(NTPF)In2006,theStateintroducedafundingmodeltohelpsupportthecostofnursinghomecareinprivateandpublicnursinghomes–theNursingHomeSupportScheme(NHSS).TheschemeisadministeredbytheHSE,andnegotiationofpricestobechargedbyprivateandvoluntarynursinghomesfornursinghomesservicesisundertakenbytheNationalTreatmentPurchaseFund(NTPF)–originallyestablishedforadifferentpurpose(i.e.reducingwaitingtimesforpatientsonwaitinglistsforvariouselective,mainlysurgical,procedures,suchashipreplacementsandcataractextractions).

InitssubmissiontothePanel,theNTPFconfirmedthatitsrole,laiddowninlegislation,is‘to make arrangements regarding the price at which services will be provided, (it) does not provide funding in respect of the services and has no role in overseeing or regulating the nature, quality or the provision of these services, which are matters for other State Agencies’.DuringthecurrentPublicHealthEmergency,theNTPFprovided‘administrative support and advice in relation to the Covid-19 Temporary Assistance Payment Scheme (“TAPS”). At all times, the NTPF defers to the expertise and the statutory responsibilities of the responsible agency when providing this assistance’.

TheoverwhelmingviewexpressedtothePanelwasthattheannualfundingnegotiationsbetweennursinghomestheNTPFwasregardedasachallengethatinvariablyendedwiththenursinghomefeelingthattheagreedsumpayableperresidentwasinsufficient,andintheprivatenursinghomes’view,invariablylessthanfundingprovidedtopublicfundedhomes.Thestrongviewsexpressedarethat,inreachingafinalfigure,inadequateattentionispaidtoresidents’physicalorcognitivedependencylevels.Theintroductionofavalidreliable,assessmenttooltoaddresstheseconcernsisurgentlyrequired.

OverthecourseofthepandemictherehasbeenconsiderablefocusontheStatesupportsprovidedtonursinghomes.TheNHSSisexpectedtocontributeinexcessof€1billiontoprivatenursinghomesin2020(inclusiveofresidentcontributions)alongwithcirca€30mintransitionalcarebedcommissioning.Thesustainabilityofsuchscaleofinterventionposessignificantchallenges,andfurthercreatesapointforconsidereddiscussionwithregardtothescaleandconfigurationoffutureprovision.ButinthePanel’sview,additionalfundingwillberequired.Intheabsenceofpublishedfinancialaccounts,thecontributionfromtheprivateproviderinaddressingareassuchasimprovedstaffskillmix,nurse/careassistantratios,andtheirongoingeducationandtrainingneedsisunknown.InvestmentwillberequiredtoensurenursinghomeadherencetoHIQA’snursinghomestandardsandfurtherongoingcostsarisingfromCOVID-19.

6.3.StrategicReformRequirements–theNeedforaPolicyShiftThe Forum on Long-term Care for Older People(2018)81stronglyadvocatedtheneedforlegislationtosupportandcareforolderpeoplepreferablyintheirownhomesorinsmallercongregatedsettings.Intheabsenceofsuchlegalentitlementthereremainsthepossibilitythatthefundingforservicessuchashomecarepackagesisunderthreat,especiallytowardsyearend.

TheCOVID-19publichealthemergencyhasshownsomeofthemanystrengthsofIrishsociety.Ithasalsoshownsomeweaknesses.Wehaveatwo-tierhealthcaresystemandatwo-tiersiloedapproachtothelong-termsupportandcareofolderpeoplewhichfavoursreferraltolong-termcaresettingsasopposedtopromotingawiderrangeofhomecareoptions.Weoweittoourolderpopulationandourselvestodobetter.

81 SageAdvocacy,RespondingtotheSupport&CareNeedsofourOlderPopulation,(July2016), https://www.sageadvocacy.ie/media/1124/report_of_forum_on_ltc_for_older_people.pdf


AnextractfromasubmissiononthissubjectfromtheDepartmentofHealthsays:

The impacts and the learning from the Covid-19 pandemic has further amplified the urgent need to further develop national policy in this regard. The primary objective is to ensure that the person and their particular needs are at the centre of service delivery, that genuine choice is available and that services, and particularly resource allocation (funding) for services is integrated – ideally through a single pot of funding, with funding following the service user, having regard to the particular care band in which their needs relates’.

AmongthekeythemessubmittedtothePanel(inwrittensubmissionsandindiscussion)areaneedto: a) provideanintegratedsystemofsupportforolderpersons’careneedsregardlessoflocation,undera

single source of funding; b) integrate private nursing homes into the wider framework of public health and social care; c) examinetheappropriatestaffskillmixandnursingstafflevelslinkedtothedependencylevelsof

residents; d) broadentherangeandincentivisetheprovisionofalternativemodelsofhomecaresupportinsmaller,

moredomesticatedsettings.

ManyofthecontributionstothePanelhaveraisedissuesaboutstaffinglevelsinnursinghomesincludingnumberofnursesxgrade,thenumberofhealthcareassistantsandthenurse/healthcareassistantratio.ArequirementthatstaffhavegerontologicalnursingandQQItrainingforhealthcareassistantstaffwasstressed.Theview,asexpressedbyprivatenursinghomes,isthattheirstaffinglevelscomparelessfavourablytothoseinpublicandvoluntaryfundedresidentialcarefacilities.

Thepayratesandoverallworkingconditionsof,atleast,somestaffintheprivatesectorwasraisedasaconcernbyseveralcontributors.Someoftheselowlypaidworkersseekemploymentinmorethanonenursinghometoaugmenttheirincome,acircumstancethat,canpotentiallyposeaseriousriskintermsofCOVID-19transmissionfromonefacilitytoanother.Furthermore,thesededicatedworkers(manyfromoverseas)maylivetogetherincongregatedaccommodation,althoughworkingindifferentnursinghomes,thusfurtherenhancingpotentialCOVID-19transmissionrisk.

TheinstrumentusedbytheNursingHomesSupportScheme(NHSS),todeterminetheeligibilityistheCommonSummaryAssessmentReport(CSAR)whosefindingsdetermineeligibilityforthescheme.ThePanelhasbeenadvisedthattheCSARhasitslimitationsandshouldbereplacedbyamoreappropriateassessmenttool.TheInterRAI(shortforInternationalResidentAssessmentInstrument)throughastandardised(ITbased)assessmenttool(SAT)placestheolderpersonatthecentreofthehealthcaredeliverysystem,throughtheprovisionofacomprehensiveassessmentoftheirhealth,socialcareandsupportneeds(www.interRAI.org).Amoreholisticandstandardisedapproachtocareneedsassessmentisseenasoneofthemostsignificantandurgentareasofreformrequired.Theidentifiedcareneedsthroughthecareneedsassessmentshoulddrivethedevelopmentofan individualised care plan, where the person and their needs are the central component of clinical and service decision-making.TheDepartmentofHealthandtheHSEarecurrentlyexaminingtheintroductionofInterRAI-SATacrossolderpersonsservices.

ThecurrentmodelofprivateresidentialcareforolderpersonshasnoformalclinicalgovernancelinkstothewiderHSE.Moreformalisedlinkswouldfacilitatebetternationaloversightofthecaredeliveredtofrailolderpeople.TheCOVID-19pandemichashighlightedchallengesinrelationtonursinghomegovernanceandtherolesandresponsibilitiesofthemajorstakeholdersincludingDepartmentofHealth,HSE(especiallyHPSCandpublichealth),HIQA,andprivatenursinghomeproviders.

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Nursinghomeshaveanimportantroleintheprovisionofcarefordependentolderpeople.Thesewerechallengingandstressfultimesforresidents,family,staffworkinginlong-termcarefacilities.Theappropriatecareandsupportshouldbeavailabletothosewhorequireit,regardlessoflocation.Stepsmustbetakentomaketimefordiscussionsondecision-making,advancecareplanningandendoflifecareoccurinmoreplanned,timelyconsideredandsympatheticway.ThelessonsgainedfromCOVID-19mustensureeveryoneisbetterpreparedforthefutureCOVID-19orrelatedoutbreaks.

6.4. ProgrammeforGovernment(2020) The impact of Covid-19 has been particularly difficult for older people. It has been challenging for those who live

on their own and for those residing in nursing homes. Learning from Covid-19 we will assess how we care for older people and examine alternatives to meet the diverse needs of our older citizens. We will establish a commission to examine care and supports for older people.

TheCOVID-19NursingHomesExpertPanelisreassuredthatitsviewsarereflectedinthenewgovernment’sownplansforenhancedservicesforolderpeopleinallsettings.

TheExpertPanelreceivedsubmissionsofhighqualityandcalibreinbothwrittenformandduringoralpresentations.ThesubmissionshaveassistedthePanelinframingitsrecommendationsbothintheimmediate,shorterterm,andmediumtolongerterm.TheyhaveprovidedimportantinsightswithrelevancebeyondtheimmediaterequirementsoftheCOVID-19pandemicbutwerealsohighlyrelevantforthispurpose.ThePanelisoftheviewthattherichinformationcontainedinthesesubmissionsshouldbecapturedaspartoftheinitialdeliberationsoftheproposedCommissiononCareoutlinedintheProgrammeforGovernment.

ThePanelrecognisesthevaluesofemergingnationalandinternationalpublicationsontheCOVID-19pandemicwhosefindingsshouldfurtherassistinthemanagementofanyfurtherCOVID-19surgelaterthisyearoroverthecoming18months.


7.DiscussionandRecommendations7.1.DiscussionTheCOVID-19NursingHomesExpertPanelwasappointedbytheMinisterforHealthon20th May to provide immediatereal-timelearningsandrecommendationsinlightoftheexpectedongoingimpactofCOVID-19withregardtonursinghomesoverthenext12-18months.InthischapterthePaneldrawsonthestakeholdersubmissions,thedataanalyses,andevidencereviewundertakenforthePanel’sreportandourowndeliberations,inordertodiscussthosefindingsandtomakerecommendations.

7.1.1.NursingHomeProceduresOverthelast15years,mostcountriesinEuropehaveseenanincreaseinthenumberofhealthcareworkersprovidinglong-termcare.Themajorityofthese,approximatelytwo-thirds,areclassifiedashealthcareassistantsormulti-taskattendants(residentialsettings)orhome-basedcareassistants;one-thirdofhealthcareworkersinthesesettingsarenurses.82

Between2005and2015theproportionofolderpeopleinIrelandaged80yearsandolder(thecohortmostlikelytoneedlonger-termcare)hasincreasedby21%withthenumberoflong-termhealthcareworkersoverthisperiodincreasingby13%.ThisisslightlybelowtheOECD-17average(Europeancountries)wherethepopulationofpeopleaged80yearsandolderhasincreasedbetween2005and2015by24%withthelong-termhealthworkforceincreasingby18%inthisperiod.Itisrecognised,aswithothercountries,thatwehavealackofnurseswithspecialistqualificationsincareoftheolderperson.AlthoughfiguresarenotavailableinIreland,theUSreportsthatfewerthan1%ofregisterednursesand3%ofadvancedpracticenursesholdaqualificationinnursinggerontology.83AcrossEurope,therearevariablelevelsofskillmixinolderpersons’residentialsettings.84 ThereisconsiderablevariabilityinstaffinglevelsacrossnursinghomesandotherLTRCfacilitiesinIreland,andthishasbeenasourceofmuchdebatewithnoagreementtodate.TheIrishAssociationofDirectorsofNursingandMidwifery(IADNAM)hassubmittedproposalsontherequirednursingstaffnumbers,theappropriateskillmixandthepreferrednurse/nurseattendantratios.ManyoftheseproposalshavebeenwiththeDepartmentofHealthandHSEforsometime,andurgentandprioritisedactionisrequiredtoadvancethenextphaseoftheFrameworkforSafeNurseStaffingandSkillMix,asitrelatestonursinghomecare.

Totheireternalcredit,manynursinghomesmanagedtocopewellwithCOVID-19outbreaks/clusterswhentheyarose.Othersweremoreseriouslychallenged,especiallythosewithbiggercasenumbers;indeed,theconsequenceswereoverwhelminganddevastatingfortheirresidents,theirfamiliesandthestaffthemselves.Carefullyplannedpostpandemicsupportwillberequired.ThepeakperiodofCOVID-19andCOVID-19relatedchallenges in nursing homes stretched from late March through April, and many stakeholders commented on the rapidityofspreadofthevirusandthesubsequentnumbersofdeathssoclosetoeachother.Workingastheydowithfrailandvulnerableolderpeople,endoflifecareandcareofthedyingareaspectsofcarethatstaffinnursinghomesareexperiencedinanddowell.However,ashappenedinsomenursinghomes,theexperienceofmanydeathsoneaftertheotherwasnew.Thisexperiencewasbothshatteringandfrightening.

82 SeeOrganisationforEconomicCooperationandDevelopment,HealthataGlance2017.https://doi.org/10.1787/health_glance-2017-en83 SeeJohnW.Rowe,LisaBerkman,LindaFried,TerryFulmer,JamesJackson,MaryNaylor,WilliamNovelli,JayOlshansky,RobynStone,‘DiscussionPaper:PreparingforBetterHealthandHealthCareforanAgingPopulation:AVitalDirectionforHealthandHealthCare’(WashingtonDC:NationalAcademyofMedicine,2016),https://nam.edu/preparing-for-better-health-and-health-care-for-an-aging-popu-lation-a-vital-direction-for-health-and-health-care/.https://doi.org/10.31478/201609n

84 SeeRoyalCollegeofNursing,SafeStaffingforOlderPeople’sWards:RCNFullReportandRecommendations(London:RoyalCollegeofNursing,2012).

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ThehighlytransmissiblenatureoftheCOVID-19virus,toresidentsandstaffthathadtotakesickleaveorself-isolateandtheknock-oneffectsonthosewhohadcontactwithcaseshadseriousconsequencesoneffortstomaintainstaffinglevels.Stafffeltguiltythattheywererequiredtoabsentthemselvesfromworkforthe14days.Intruth,sotoodidstaffwhotestedCOVID-19positive.

ThePanelacknowledgesthathealthcarestaffandprovidersofnursinghomes,privateandpublic,facedanunprecedentedchallenge,neverbeforeexperiencedandoncetheinfectionhadenteredanursinghome,itspreadrapidly.Itisalsoevidenthoweverthatmanynursinghomeshadtheabilitytomanagetheoutbreakeffectively.ItisclearfromthesubmissionsofarangeofstakeholdersthathealthcarestaffworkedtirelesslyandwithadmirableresiliencetocontinuetoprovidecaretotheresidentsandvaluedthesupportoftheHSE’sclinicalsupportteams.PresentationstotheExpertPanelatstakeholdermeetingsandwrittensubmissionstothePanelalsoacknowledgethecommitmentbynursinghomestaffwhomaybetraumatisedbytheirexperience.Despitetheperceptionthatolderpeoplearenotvaluedbyhealthcarepolicymakersandproviders,astheExpertPanelexaminedthesubmissions,thosesubmissionsdemonstratereassuringlythatthereisaveryenthusiasticand‘exercised’interestbyabroadrangeofprofessionalswhoappearpassionateaboutimprovingthecareofoldercitizensincommunityandresidentialsettings.

Thereisaneedforclarityonclinicalgovernanceofallresidentialcarefacilitiesprivate,publicandvoluntaryatregionalandnationallevelandwithdueregardtoincorporatingresiliencetoanticipatepandemicsandnaturaldisasters.Eightypercentoflong-termresidentialcareprovisionisdeliveredwithintheprivatesector.Experiencegainedoverrecentmonthshasdemonstratedthatadequateandrobustclinicaloversight,monitoringwithappropriateenforcementcapabilityandcleargovernancestructuresarerequiredacrossthenursinghomesector.Thereshouldbearequirementforclearclinicalgovernancewithoversightofallnursinghomesandenhancedsupportfromgeneralpractitionersinthisregard.RepresentativesfromtheIGS,whenspeakingtothePanel,proposedthataclinicalgovernanceoversightcommitteeshouldexistinallnursinghomes.

TheHSE’sCOVID-19responseteams,includingtherelevantclinicalsupports,foreachareashouldberesourcedtocontinueforthenext12to18months.Separately,accesstotheCommunityInterventionTeams(CITs)shouldbeextendedtoallnursinghomestoprovidearapidandintegratedresponsetopatientswithanacuteepisodeofillnesswhorequireenhancedservicesoracuteintervention(potentiallyavoidingacutehospitaltransfer);forexample,IVantibioticadministrationinthehomeandshouldbeaccompaniedbyanational,consistentprotocolandstandardoperatingprocedures.

Nursinghomeresidents,withmedicalcardeligibility,shouldhaveaccesstothesameservicesasareavailabletocommunity-basedresidents.Examplesincludefrailtyassessmentandrehabilitationservicessuchasoccupationaltherapy,physiotherapy,speechandlanguagetherapy;andotherservicessuchasclinicalnutrition/dietetics,tissueviabilityadvice,infectionpreventionandcontrol(IPC),IVantibioticadministration,diabetesmanagementandaccesstodialysisandradiotherapyservices,whenrequired.Inaddition,accesstospecialistmedicalopinionfromgeriatricians,consultantsinpalliativemedicine,psychiatryofoldageandothers,asneeded.

Meetingtheindividualandcombinedcareneedsofresidentsinnursinghomesareparamountconsiderationsforeveryoneinvolvedindelivering,commissioningandregulatingcareforolderpeople.


7.1.2.CommunicationAcrosstheHealthcareSystem

Duringthepandemicthemannerinwhichservicesweredeliveredtoresidentsinnursinghomesrequiredanewandenhancedapproachtocaredelivery.OutpatientappointmentswerenecessarilycancelledandtherewasevidencefromstakeholderinterviewsandsubmissionsthatGPcoverinhomeswasreducedandoccasionallynotimmediatelyavailable.Furtherchallengesresultedfromreducedavailabilityofpermanentstaffinmanyhomesduetosickleaveorself-isolation,whichnecessitatedstaffredeploymentacrosstheentiresystem.TheHSEhasbeentheState’sprimaryarmintheresponsetothepandemicandmustcontinuetobecentraltothewiderintegrationofallnursinghomesacrossthehealthcaresystem,particularlyintheinterestsoffrailolderpeople, including through integrated pathways of care for older persons and by the permanent establishment of COVID-19responseinitiatives.TheHospitalGroupsprovidedcrucialmultidisciplinarysupporttonursinghomeswithintheirCHOareas.Thehospitals’responseteamsandapproachdifferedbut,inthemain,theresponsesincluded: • direct medical advice / support, including from a geriatrician via onsite and virtual visits as a supplement

toGPserviceprovision; • dailyhealthcheckstoassessanypotentialchallengesandtooffersupport; • onsitepointofcaretestsandmanagement,e.g.phlebotomy,ultrasound,ECGs,administrationofIV

antibiotics; • management of resident transfers from nursing home to hospital and from hospital back to the nursing

home; • establishmentofcarepathwaysensuringresidentsreceived‘therightcare,intherightplace,attheright

time’; • consultsfromotherspecialties,e.g.occupationalhealth,palliativecare,staffpracticedevelopment; • directinfectionprevention&control(IPC)advice/support/training; • direct nursing advice/support/deployment; • directoperationalcontrolandworkforceprovision; • accesstoswabs,timelytestingandresultsforpatientsandstaff,withguidanceonprioritiesforwhom

and when to test; • nursing/directnursing/healthcareassistant/alliedhealthstaffdeployment; • direct hygiene service support to maintain standards; • provisionofequipment,e.g.O2,IVdripstands,pumpsandIVfluids; • supplyofPersonalProtectiveEquipment(PPE)withtrainingonusage; • administrativesupport; • accesstoimprovingcommunicationchannelse.g.tablet/web-basedsupporttoenablecommunication

withrelatives;and • informationpacksforhomes-leaflets/algorithms/lanyards/noticesalreadydesignedandeasily

printableallsizes/formats/volumes.

Thehospitals’responseteamswerecriticalinthemanagementoftheacutephaseofthepandemic.Manystakeholdersacknowledgedthecontributionandtheresponseprovidedandoutlinedtheimportanceofthiscontinuedstructureofsupport.

EachCommunityHealthcareOrganisation(CHO)arearequiresaninter-disciplinaryteamtofacilitateresidentsreceivingassessmentandcaremanagementintheirownhomeconsistingofgeneralpractitioner,geriatrician,publichealthspecialists,infectioncontrolanddirectorofnursing.IntheeventthatcareneedsrequirehospitaladmissioneachnursinghomeneedstoworkwiththeirlocalCHO/acutehospital(s)toidentifypathwaysofcareto streamline admission, reduce risk of further decline and to avoid delayed transfer back to the person’s nursing home.

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RevisionsofCHOgeographicalboundariestoalignwithacutehospitalssectorgroupsshouldbestronglyconsideredinlinewiththeplannedRegionalHealthAreas(RHAs)intheSláintecareStrategy.AdirectorofnursingshouldbeidentifiedatCHOlevelwitharemitforallresidentialcarefacilitiesintheCHO,supportedbyinfectionpreventionandcontrol,publichealthandolderpersonsoperationswithclearremitovernursinghomes.Anursinghome-baseddirectorofnursingrepresentativeshouldbeamemberoftheCommunitySupportTeam(CST).

Ongoingaccesstooccupationalhealthandhumanresourcesservicesisrequiredtoassistwithstaffadvice,contacttracingandadviceregardingstaffwellbeing.Occupationalhealthandhumanresourcesserviceshaveanimportantroleinprotectinghealthcareworkersandensuringbusinesscontinuityofhealthservices.ExpansionisrequiredofAdvancedNursePractitioner(ANP)rolestosupportspecialistcaredeliverysuchasnurseprescribing,comprehensiveassessmentandliaisonfunctionsacrossacutementalhealthandpalliativecareservicestoenhancecaredeliveryinaresident’shome.

AccesstoprimarycareservicesincludingtheHSEcommunityalliedhealthprofessionalsshouldbebasedonneedforallolderpersonswhetherinprivateorpublicnursinghomesortheirownhomes.ThereisevidenceintheliteraturesuggestingtheneedforrehabilitationandreablementpostCOVID-19asaresultofresidentdeconditioning.PostCOVID-19recoveryplanstoincludepublichealthandreadyandspeedyaccesstohomecarepackagesarerequired.PostCOVID-19recoveryplans,includingrehabilitationaccessandpublichealthwillberequired.Patientsshouldnotbeadmitteddirectlytolong-termresidentialcarewithoutbeinggiventhechoice and a care needs assessment and appropriate opportunity to stay in their own home following appropriate accesstorehabilitationorreablementopportunityandaccesstoahomecarepackagethatmeetstheirneeds.

A number of key stakeholders interviewed sought clarity as to who was in charge in the wider private nursing homessystem.DuringthepandemictherewasevidencethatconnectionsbetweentheHSE,includingcommunityservicesandacutehospitalsandprivatenursinghomesimprovedconsiderably;manywrittensubmissionsstressedtheimportanceofthispartnershipcontinuingonapermanentbasis.Itisevidentthatthemulti-specialtyHSECOVID-19ResponseTeamssetuptosupportnursinghomestaffwereinvaluableandthatinthefaceofthepandemictherewerenobarriers,itwasaseamlessserviceacrosspublicandprivateproviders.Theevidenceofthisisrefreshingandtobecommended.Thelackofstatutoryhomecaresupportentitlementandtheneedtomakeacutebedcapacityquicklyavailableearlyinthepandemicdidresultinsomepatientsbeingtransferredfromacutehospitalstonursinghomefacilitiesratherthantotheirownhome.

Nursinghomesshouldbepartofacontinuousspectrumofcareoftheolderpersonintothewiderhealthcaresystemwithprovisionofmultidisciplinarysupport.ResidentsinsomenursinghomesdidnothavedirectGPsupport-someGPswerethemselvescocooning.InitiallyduringCOVID-19thisdidpresentachallenge,aseachresidentisassignedtotheirownindividualGP,thatwasaddressedwhentheHSECOVID-19ResponseTeamsandpublichealthteamswereestablished.Intheearlystagesofthepandemic,foravarietyofreasons,suchasinsufficienttestingmaterials,anddelaysinthesettingup/staffingtestcentres,accesstorapidturnaroundtestingandtracingwasinadequateinthegeneralcommunity,(includingnursinghomes).Withthemorerecentknowledgethatasymptomaticandatypicalpresentationswereseeninthisoldercohortofpeople,preparednessandpromptactionisequallyurgenttooptimallyprotectthiscohortoffrailoldernursinghomeresidents.InlinewithpublichealthadviceandrecommendationsoftheECDC,nursinghomeresidentsshouldcontinuetobeprioritisedfortesting,notingthecriticalimportanceofrapidreportingofresults.Likewise,thecontinuationofperiodictestingforhealthcareworkersinnursinghomesshouldbeplannedfor,withtherelevantperiodsidentifiedbytheHPSC,havingregardtopublichealthandECDCadviceandrecommendations.


Lookingahead,thereisanobligationtoensurethatasatisfactorylevelofcompetent,skilledandappropriatelytrainednursingandmedicalstaffareavailabletomeettheinevitableclinicalandmedicalneedsofthissignificantnumberofhighlyvulnerableolderpeopleincongregatedsettings,if/whenexposedtoahighlytransmissiblevirussuchasCOVID-19oranyothervirulentoutbreak.Nursinghomesmustalsoensuretheprovisionofavariedrangeofsocialsupportsanddiversionaltherapiesfortheirresidents,thenursinghomealsobeingtheirhome.

There was a general belief from some stakeholders that when comparing the per resident State funding for publicversusprivatenursinghomes,thepublicfacilitiesbenefitbyasmuchas40%.Whistthestatecontributedover€1billion,viatheNursingHomesSupportScheme(NHSS),in2019,thecontributionfromtheownersofprivatenursinghomes,especiallythelargerconsortia,isnotknown.Thefundingandexpenditurespecificallyinvestedbyproviderstoimprovingnursingstaffskillmix,nurse/careassistantratios,addressingHIQAinspectionrecommendations,ongoingeducationandtrainingprogrammesofstaffand,morerecentlytheprivatehomesfinancialcontributiontoCOVID-19enhancedrequirementslikeIPCtraining,sourcingPPE,masks,oxygenuserequiresgreatertransparency.

Duringthecrisis,leadershipandtimelydecision-makingbecameoverwhelmedduetoavacuumofclearguidance,mixedmessaging,alackofaccesstoclinicalexpertiseandresources(oxygen,infusionpumps,PPE).Asubmissionfromacademicnursingwhotookpartinthe‘calltoarms’feltthatforthevastmajorityofnursinghomestherewasnodirectclinicalgovernance;GPs’mainlyfocusedonmanagingtheirindividualpatientseitherinpersonorvirtually.COVID-19veryquicklyexhaustedexistinggovernanceandescalationpathways.

KeylearningshighlightedbytheCOVID-19ResponseTeamsetupintheCork-KerryCommunityHealthcareareainclude: i) clearandconsistentcommunicationbyseniorhealthcareprofessionals,atanationallevel–plan

nationallyandactlocally; ii) ClinicalSupportTeamsoperatinglocallywithclearcommunicationtothehomesabouttheirrole,contact

detailswithavailability24/7andtherangeofsupportsprovidede.g.universaltesting,PPE,trainingandaccess to specialist advice;

iii) clearcommunicationinregardtoInfectionPreventionandControlledbyseniorhealthcareprofessionals,includingadequatenumbersoftrainedinfectionprevention&controlnurses;

iv) adequatePPEandtrainingforstaffintheproperuseofPPE,cohortingandisolationtechniques;and v) timelytestingofstaffandresidentsintheeventofanoutbreak.85

EstablishingCOVID-19ResponseTeamswasabreakthroughandmanybelievethattheyshouldnowbemaintainedonapermanentfooting.ThereisasuggestiontosetupCSTs,withappropriaterepresentation,tosupportalllong-termresidentialcentres(LTRCs).ThereshouldbeoneCSTperCHOarea.

TheExpertPanelstronglysupportstheestablishmentofintegratedCSTs(withjointresponsibilityandleadershipacrossCHOsandhospitalgroups)onapermanentbasis.TheywillplayacriticalroleinprovidingmorerobustgovernanceandleadershipforanyfutureCOVID-19surgeandensuremoreappropriateintegratedoverallcareandoversighttothefrailoldernursinghomeresidentsnotjustinthistimeofCOVID-19butbeyondthispandemic.

85 SeeD.W.Molloy,C.O’Sullivan,R.O’Caoimh,E.Duggan,K.McGrath,M.Nolan,J.Hennessy,G.O’Keeffe,K.O’Connor,‘TheExperienceofManagingCovid-19inIrishNursingHomesin2020:Cork–KerryCommunityHealthcare,CorkIreland’,The Journal of Nursing Home Research6(6thJuly2020):47–49.

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MembershipofCSTsmustincluderepresentationfrom: • generalpractice(aGPleadwithaninterestandsessionalcommitmenttocareinresidentialcare

facilities); • geriatricmedicine(ageriatricianwithaninterestinanddedicatedsessionalcommitmenttocommunity

geriatricmedicine); • public health specialist; • palliativecare(incollaborationwiththeircommunitypalliativecareteams); • seniorinfectioncontrolnurse; • occupationalhealth; • advancednursepractitioner; • nursinghome-baseddirectorofnursing(directliaisonwithcounterpartsinpublic,privateandvoluntary

nursinghomes);and • seniormanagementfromboththecommunityandtheregionalhospitalgroups.

Thesupport,expertise,andcontributionofpalliativecareteamsinthecommunityhasbeenhighlightedasessentialandappreciatedbystaffworkinginallresidentialcaresettings,betheypublic,voluntaryorprivate.Similarly, short periods of stay for convalescence following an acute hospital stay are facilitated in some voluntary andprivateresidentialcarefacilities.Otherspecialtyareasthatshouldbeinvolvedonanasneeded/consultationbasisincludes,butarenotlimitedto,microbiology,infectiousdiseases,andoldagepsychiatry.

TheleadgeneralpractitioneronCSTsandtheGPsdesignatedasthenursinghomeGPleadshouldhaveattainedaccreditationinpostgraduategerontologicaleducationalprogrammesasprovidedbytheirrespectivetrainingbodies(ICGP&RCPI).Thisalsomustapplytoseniornursingstaff,especiallythedirectorofnursing/personincharge,advancednursingpractitionerandclinicalnursemanager(CNM)gradesinnursinghomes.Similarly,allhealthcareassistants(HCAs)requireQQIlevel5accreditation.Nursinghomeproviders,public,voluntaryandprivate,mustalsocontributeresourcestosupporttheirstaffparticipatinginallrelevanteducationandtrainingprogrammestoincludethoserelevanttotheCOVID-19pandemic.Whereapplicable,theyshouldalsoprovidefinancialsupporttothosestaffseekingpostgraduategerontologicalaccreditation.

TheICGP,RCPIanditsfaculties,IGS,IrishSocietyofPhysiciansinGeriatricMedicine(ISPGM),IrishCollegeofPsychiatryandseveralThirdLevelEducationalInstitutionsallrungoodqualitypostgraduateeducationalprogrammes.

InthecontextofcoordinatingtheoptimalmedicalcareoffrailolderpersonsinresidentialcaresettingsthePanelstronglyadvocatesdefinitivecrossCollegecollaboration,specificallybetweentheICGPandRCPI’sClinicalAdvisoryGroupforGeriatricMedicine.GiventhatgeneralpractitionersandgeriatricianswillbeworkingtogetheraskeymembersoftheproposedCSTsandlinkingcloselyatthenursinghomelevel,participatinginjointpostgraduateeducationprogrammes,especiallyforthemedicalcareneedsinnursinghomesettings,shouldbeintroduced.Thiswillalsopresentopportunitiesforcollaborativemuch-needednursinghomeresearch.Theselinksshouldalsobefosteredwithintheframeworkoftheirrespectivepostgraduatespecialisttrainingprogrammes.

ThePanelreceivedmixedviewsontheneedforanidentifiedGPleadineachnursinghome.FeedbacksuggeststhatGPcoverfornursinghomesmaybebettercoordinatedinrural/countytownsettingsratherthaninlargerurbansettings.Thecoordinationchallengeisgreaterinthosenursinghomeswithlargerresidentcapacity-insomecases,asmanyas10-15GPscanattendtheirpatientswhoareresidents,butnooneGPhasanoversightfunctionwithinthatnursinghome.Asignificantquestionarisesinrespectofclinicalgovernance.ThePanelsuggeststhatanidentifiedGPLeadwouldbecontractedand,inadditiontolookingaftertheirownpatientsinthenursinghome,wouldalsoworkcloselywiththePersoninCharge,otherseniornursingstaff,anddesignatedinfectioncontrolnurseandarepresentativefromthehealthcareassistantstaffinthenursinghome.


Theaboveissuesnecessarilyrequireanoverallnursinghome‘teamresponse’andneithercould,norshouldbeaddressedduringindividualGP-residentconsultationvisits.Notallgeneralpractitionerattendeesneed(orindeedwish)tobeinvolvedinthisoversightrolebutitisessentialthatatleastoneleadGPhasthisresponsibilityineachresidentialcarefacility.

Thehistorical‘MedicalOfficer’contractis,inexpectationandsalary,outdatedandisquiteunsuitedtotoday’srequiredrole.Thisdoctormusthavededicatedsessionalcommitmentandbeincentivisedtotakeontherolewithanappropriatecontractandremuneration.Thisapplies,evenmoreso,totheGPLeadmembersoftheproposedCSTswhohaveawiderremitandresponsibilityasthekeyGPcontactwiththeirgeneralpractitionercolleaguesintheCHOarea.

Failuretourgentlyaddresstheseappointmentswillmerelymeanacontinuationofthecurrentunsatisfactorysituationthatappliesinmanynursinghomesthroughoutthecountry.Therefore,itisrecommendedthataGPLeadbeappointedtoeachCHO-basedCommunitySupportTeam,andthateachprovidershouldappointandcontractatleastoneGPtohavealeadroleineachnursinghome.ItmustbeensuredthatappropriatecontractsaredrawnupbetweeneachnursinghomeproviderforeachGPLeadwithspecifiedsessionalcommitmentandsufficientremunerationtosecuretherequiredprofessional,commensuratewiththelevelofresponsibilityattachedtotherole.AnationalframeworkdescribingtheroleandresponsibilitiesoftheGPleadshouldbedevelopedbytheDepartmentofHealthandtheHSEasamatterofurgency,sothatproviderscanoperatewithinaconsistentandclearsetofrequirements.TheDepartmentofHealthshouldexplorewhethertheparticularsofthisframeworkshouldbeincorporatedintothenursinghomesregulatoryframework.

TheExpertPanelfullyrecognisestheexistingsignificantcapacityconstraintswithregardtoGPmanpower.However,theimportanceofthegeneralpractitionerinprovidingclinicalsupportandservicesinnursinghomescannotbeoverstatedandthePanelstronglysupportsthecasebeingmadetoincreasetheGPtrainingprogrammecapacity.TherecruitmentofmoreGPsmustbeplannedandpursuedasamatterofurgency.

Thedevelopment,inthemedium-term,ofclinicalgovernancemodelsinthecommunityshouldbeexploredfurtherbytheDepartmentofHealthinconjunctionwiththeHSE,supportedbyaninternationalevidencereviewofmodelsofclinicalgovernanceinnursinghomesettings.

Thepolicysubjectsthatrequiremultidisciplinarycollaborativeinputinclude: • coordinatingoverallnursinghomepolicyanditsinterfacewithoutsidebodiessuchasHSE,HIQA,DoH; • educationandtrainingofnursinghomestaffingeneralandtoensurepreparednessforaCOVID-19

surge(orotherpredictablefuturewinterinfectionoutbreaks); • responsetoandprogressmaderelatedtoHIQAinspectionreportsandrecommendations,including

identifyingthoseresponsiblefortheirimplementation; • reviewing overall resident care plans; • anticipatorycareplanning:whattodowhenaresidentdeterioratesintheso-calledtwilighthourswhen

medicalaccessistothelocalOn-Callservice(e.g.SouthDoc,ShannonDoc)andadoctorwithnopriorknowledge of the resident;

• promotingthewiderimplementationofadvancedcaredirectives; • endofLifeCarePolicy; • agreedcriteriaforacutehospitalreferral.

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Itisemphasisedbyallstakeholdersandisacharacteristicofthenursinghomesettingthatanursinghomeshouldbeseenasaresident’s‘home’andnotan‘institution’.Thepromotionofapleasantconduciveenvironment,empowermentandparticipationinthenursinghomeaffairsisakeyaspectoftheHIQAinspectionprocessandwithgoodreason.ManyoftheHIQAreportsemphasisedexamplesofgoodpracticeinsocialactivitiesandevents and resident respondents to the Panel’s engagement process poignantly said they felt safe as well as comfortableintheirhome.Residentsoutlinedthatthequalityoffoodandmeetingupwithothersatmealtimeswereimportantpracticalfeaturesofdailylife.

However,fromapublichealthperspectivethereareaspectsofthissettingthatposeinherentrisk.Firstly,residentsareincongregatedlivingconditionswithhighriskofcontaminationandspread.Thereisahighdegreeofphysicalcontactandintimatecaresupportinsuchsettings.Manyofthosewhoarefrailorinfirmmayberestrictedtoachairorbedformuchoftheirtime.Therearealsoinfrastructuralissuesincludingsingle,multipleornightingalebedroomoccupancy,sharedbathroomandcateringfacilitiesandthegeneralissueofhighcapacityoccupancy.Abalancemustbestruckbetweenongoingsocialinteractionandpublichealthconsiderations.

ThissectorisregulatedbyHIQAwhichhasateamcurrentlyof22inspectorsandperformsaseriesofinspections,bothannouncedandunannounced,onaregularbasis,onaverageevery18months,sothateveryregisteredhomeisassessedforcomplianceunderlegislation.Thereportsfollowasimilarqualitativeformatandareconcernedwiththequalityoflifeaswellastheriskassessmentaspects.Inlinewithlegislation,thepersoninchargeisnormallyaregisterednursewithappropriateclinicalexperienceandhealthcareworkersorhealthcareassistantsformasignificantproportionoftheteams.Therearenoclearguidelinesontheminimumnumberofqualifiedstaffwhoshouldbeonduty,theminimumstandardsofqualificationandtrainingandprotocolsforongoingneedsassessment,dependencyandcareplanning.

It is evident that the reports are transparently available and all these issues are addressed at site visits over one ortwodaysbutthestandardscouldbemoretightlydefined.ItmustbesaidthatthereisnoclearrelationshiptothecompliancestandardsthenoperatingandtheCOVID-19pandemicandthereisnosystematicevidencethatinfectionpreventionandcontrolisaddressedintheseinspections,whichoftenfocusmoreonsafetyissuessuchasfiredrillsandevacuationmeasures.Also,itisamatterofrecordinthestakeholderconsultationsthatturnoverofstaff,difficultyinreplacingthoseonsickleaveandtherelianceonasmallpoolofagencystaffplacedhugestrainonprovidersattheheightoftheepidemic.

TheHIQAstandardshavedemonstratedthatevenwhenastandardismet,qualitycanstillbeabsent.Thenursingmetricsdevelopedforuseinresidentialcarefacilitiesareakeyenablertomeasurequalitycareacrossprivateandpublicandprovideopportunitiesforsharing,benchmarkingandlearning.86Likewise,publichospitalsproducetheHospitalPatientSafetyIndicatorReport(HPSIR),whichisamonthlyreportthatcollatesarangeofpatientsafetyindicatorsandisthenreviewedbythesenioraccountableofficeratbothhospital-levelandhospitalgroup-levelbeforepublicationonthewebsite.ThepurposeoftheHPSIRistoassurethepublicthattheindicators selected and published in this report are monitored by senior management of both the hospital and hospitalgrouponamonthlybasis,asakeycomponentofclinicalgovernance.

86 SeeeHealthIreland,‘NursingandMidwiferyQualityCareMetrics’, https://www.ehealthireland.ie/Case%20Studies/Nursing-Midwifery-Quality-Care-Metrics/


ConsideringthenursingmetricsandtheHPSIR,aqualityindicators/residentsafetymodelshouldbedevelopedfornursinghomes,requiringeachnursinghometopublishregularreports.Thiswouldsupportcontinuedserviceimprovementandoutcomesandimprovetransparencywithregardtocompliance.HIQAshouldestablisharegisterofallsuchreportsprovidedbynursinghomes.Thereisanopportunitytoincludeinfectionpreventionandcontroltothesemetricstosupportnursinghomestoprepareandmanageoutbreaks.TheIGSproposedtheestablishmentofaclinicalgovernanceoversightcommitteeinallnursinghomes,andthiswouldbeapracticalmeanstoreviewqualityindicator/residentsafetyreportsandactionappropriatefollow-upandassuringfindingsfromtheongoinginspectionsareimplemented.

Ensuringaqualityassuranceframeworkonpreparednessiscritical.Asamatterofurgency,HIQAinspectorsshouldphysicallyassessnursinghomesagainsttheframework.Whileonsiteinspectionsarelabourintensive,theirfrequencyshouldbeincreasedasthereisevidencethatthereisadisconnectbetweentheself-assessmentsubmittedbyprovidersandHIQA’son-siteassessments.Mandatorytrainingrecords,includinginfectioncontrol,shouldbeincludedintheinspectionprocess.HIQAmaintainsareportingrelationshipwiththeHPSCandcommunicationwithDepartmentofPublicHealth,ifidentifiedpublichealthconcernsregardinganursinghomearise.HIQAandtheHSEshouldensurethatappropriateescalationpathwaysareinplaceespeciallywithregardtotheCSTs,whereinthepublicinterestcareorotherconcernsacrossallnursinghomesareaddressed.


ThefirstcasesofthisnewcoronavirusacquiredinfectionwerereportedbytheWHOon12thJanuary2020.InDecember2019,aseriesofcasesemergedinWuhan,Chinagreatlyresemblingviralpneumonia.COVID-19tookagripinWuhanprovinceinChinainearlyJanuaryandnecessitatedthelargestlockdownsofarseeninhumanhistory.CasesemergedinSoutheastAsiabeforespreadingquicklytoNorthAmerica.IthassweptacrosstheplanetreachingEuropewithcertaintyinlateJanuaryandthefirstdefinitecaseintheRepublicofIrelandwasreportedonthe29thofFebruary.AlthoughtheWHOgavefrequentbriefingsandpublichealthguidancethroughoutJanuaryandFebruary,itwasnotuntil11thMarch2020thataglobalpandemicwasdeclared.Itquicklybecameclearthatasignificantproportionofthosecontractingthevirusbecameveryseriouslyillrequiringintensivecareandthesepatientshadahighmortalityrate.Itwasalsoevidentthatagewasariskfactorinitself,aswasco-morbidityandunderlyingdisease.

Theinfectivityandcontagiousnatureofthediseasewasalsoamatterforconcernandevolvingevidence.Initially,guidancewasinfluencedbytheexperienceofSARS-Cov-1,whichwasknowntocauseseverelowerrespiratorytractinfectionwithappreciablemortalitybutnottobesoeasilytransmissibleasanupperrespiratorytractinfection.ItbecameclearhoweverthatCOVID-19wasamoreinfectiousdisease,withanincubationperiodofupto14days.AseriesofreportsfromtheECDCdocumentedtheevolvingevidence.On2ndMarch2020,itwasconcludedtherewasnostrongevidenceoftransmissionprecedingsymptomonset.87On12th March ECDC reportedthatallEU/EEAcountriesandtheUKwereaffected,andthepaceoftheincreaseofcasesmirroredthatwhichoccurredinChinainJanuary.88

87 SeeEuropeanCentreforDiseasePreventionandControl,‘RapidRiskAssessment:OutbreakofNovelCoronavirusDisease2019(COVID-19):IncreasedTransmissionGlobally:FifthUpdate’.https://www.ecdc.europa.eu/en/publications-data/rapid-risk-assessment-outbreak-novel-coronavirus-disease-2019-covid-19-increased

88 SeeEuropeanCentreforDiseasePreventionandControl,‘RapidRiskAssessment:OutbreakofNovelCoronavirusDisease2019(COVID-19):IncreasedTransmissionGlobally:SixthUpdate’,https://www.ecdc.europa.eu/sites/default/files/documents/RRA-sixth-update-Outbreak-of-novel-coronavirus-disease-2019-COVID-19.pdf

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Clinicalpresentationsrangedfromasymptomatictoseverepneumoniawhichcouldleadtodeath.Inadditiontocasereports,ECDCreportedmodellingstudiesthatinferredthatpre-symptomatictransmissioncouldoccur,butmajoruncertaintiesonthisprocessremained.On24thAprilanepidemiologicaldescriptionofacarehomeoutbreakwaspublishedonlinebytheNewEnglandJournalofMedicine(NEJM)whichconfirmedboththeatypicalpresentationseeninelderlypeopleandspreadfromasymptomaticcarehomeresidentstoothers.89 The accompanyingNEJMeditorialmadeclearthatupperrespiratoryspreadwascommonandhighlycontagious.90

On25th March ECDC reported that risk was moderate for all but very high for older adults and reported that asymptomaticindividualscouldbeinfectedwiththedisease.91On23rdAprilECDCreportedthata“recentmodellingstudysuggestedthatasymptomaticindividualsmightbemajordriversforthegrowthoftheCOVID-19pandemic”.92

By12thMarch,thefirstmeasuresoflockdownwereinstitutedintheRepublicofIrelandincludingtheclosingdownofeducationalinstitutions.TheNationalPublicHealthEmergencyTeam(NPHET)firstestablishedon27thJanuary2020,recommendedaseriesofmeasuresaimedatsuppressionandcontainmentofthevirusatpopulationlevelandthesestringentgeneralmeasuressawaveryhighdegreeofpubliccompliance.Thepeaknumberofrecordedcasesoccurredon28thMarch2020andthereafteraflatteningoftheincidencecurveoccurred, with a fall in all parameters including daily new cases, numbers hospitalised and in intensive care, and deathsfromthediseaseduringAprilandMay.

Age,underlyingmedicalconditions,atypicalpresentationandhightranslationtomoreseriousclinicalmanifestationsareallriskfactorscharacteristicofanursinghomepopulation.Thefirstlinestrategyistopreventincidencebutalsotohaveappropriateclinicalcarefromaleadmedicalpractitioner,accesstointer-disciplinaryteamsupport,properlydevelopedcareplans,accesstospecialistservicesandapre-agreedendoflifeplandiscussedwiththeresident,familymembersandcareproviders.

Inthedatachapterofthisreporttheincidenceandmortalitypatternsarereportedandcomparedtotheinternationaltrends.ThereisclearevidenceofregionalvariationintheimpactoftheCOVID-19pandemicinIrelandandresidentialfacilitiesaremoreconcentratedintheareasmostaffectedbytheepidemic.AccordingtotheHIQAregisterofdesignatedcentresforolderpersons(accessed4thJuly2020),thereare261facilitiesinLeinsterand111oftheseareinDublin.Similarly,thedataanalysisshowsthetotalnumberofcasesbycountyandprovinceandthepercentageoccurringspecificallyinnursinghomesvariesconsiderably.Asageneralobservationthehigherthenumberofcasesinacounty,thehighertheincidenceinnursinghomes,withsomevariabilityseen,forexampleinCork,with1,537cases,(6%ofallcasesnationally),just5%(79cases)occurredinnursinghomes.Thecumulativeriseinreportedclusterswasalsosteeperinnursinghomesthaninotherlong-stayorresidentialfacilities.

89 Arons,M.M.,Hatfield,K.M.,Reddy,S.C.,Kimball,A.,James,A.,Jacobs,J.R.,Taylor,J.,Spicer,K.,Bardossy,A.C.,Oakley,L.P.,Tanwar,S.,Dyal,J.W.,etal.forthePublicHealth–SeattleandKingCountyandCDCCOVID-19InvestigationTeam(2020).PresymptomaticSARS-CoV-2InfectionsandTransmissioninaSkilledNursingFacility.NewEnglandJournalofMedicine,382,2081-2090.DOI:10.1056/NEJMoa2008457

90 Gandhi,M.,Yokoe,D.S.,&Havlir,D.V.(2020).AsymptomaticTransmission,theAchilles’HeelofCurrentStrategiestoControlCovid-19.NewEnglandJournalofMedicine,382,2158-2160.DOI:10.1056/NEJMe2009758

91 SeeEuropeanCentreforDiseasePreventionandControl,‘RapidRiskAssessment:CoronavirusDisease2019(COVID-19)Pandemic:IncreasedTransmissionintheEU/EEAandtheUK:SeventhUpdate’(25thMarch2020),https://www.ecdc.europa.eu/sites/default/files/documents/RRA-seventh-update-Outbreak-of-coronavirus-disease-COVID-19.pdf

92 SeeEuropeanCentreforDiseasePreventionandControl,‘RapidRiskAssessment:CoronavirusDisease2019(COVID-19)intheEU/EEAandUK:NinthUpdate’(23rdApril2020),https://www.ecdc.europa.eu/sites/default/files/documents/covid-19-rapid-risk-assessment-coronavirus-disease-2019-ninth-update-23-april-2020.pdf.


DatafromCIDRsuggestthatmostofthosediagnosedwithCOVID-19inthenursinghomepopulation,aswiththegeneralpopulation,haverecovered.Inbothinstancesastrongagegradientformortalitywasevident.Thisisahighlycontagiousvirusspreadbydropletinfectionwhichcanbetransmittedfromsurfacesbyhandcontacttonoseandmouth.Infectionismorelikelyinindoorsettingsthanoutdoorsandthegreaterthesocialdistancebetweenindividualsandthelesstimeinclosecontactthelowertherisk.Asdescribedearlierthediseasecanbetransmittedbyasymptomaticandpre-symptomaticpeopleandmaypresentatypicallyespeciallyinolderpeople.Thisnecessitatesahighindexofsuspicionandappropriateprotocolsforaction.Therapiditywithwhichtheepidemictookholdoverashortperiodofweeksmustalsobeamajorlearningpoint.

Thereisreasontobelievethatwherethereisongoingcommunitytransmission,settingslikenursinghomeswillbemorevulnerabletoexposurefromthemanyinteractionswithexternalpeople.ThefocusinearlyMarchwasonbanningvisitorsbuttransferprotocolsforpatientsandstabilisingoftheworkforceisalsocritical.Thelockdown in Ireland arrested community spread but the incidence was greater in the capital city and surrounding countiesbecauseofthepresenceofportsandairport,greaterpopulationdensityandrelianceonpublictransport.Otherfactorsatplayincludetheprofileofworkersinnursinghomesandtheinteractionwithotherclusterrisksituationssuchasfamilymembers,sharedaccommodationandcontactwithotherhigh-riskareassuchasthemeatpackingindustry.

Sizemattersinacontagiousdiseasebecausecloseproximitytoalargegroupofpeopleriskstransmissiontoothers.Thereisaneedformoredefinitiveresearchonthisquestion.Forinstance,alistofalldeathsbynursinghomelocationwaspublishedintheIrishTimesfromHSEcompileddata.AnanalysisbyRomero-Ortuño&Kennellyshowedthatthecrudedeathrateshouldbecorrectedforsizeofnursinghome/unitsasmoredeathsoccurredinlargernursinghome/unitsbuttheiranalysisalsoshowednosignificantassociationwithHIQAcompliancereportsonstaffing,governance/management,premises,andinfectioncontrol.93 A review by the ExpertPanelteamoftheHIQAInspectors’mostrecentreportcontentforselectedunitshighconcentrationofdeathsshowedthatmajorcomplianceissueswererare.AsimilaranalysiswiththesamedatasourcesoftheHIQAdatabaseofregisteredunits(StakeholdersubmissiontoExpertPanel2020)94showedthattheaveragemaximumoccupancywasgreaterinnursinghomeswithdeathsrelativetothosewherenoneoccurred.InarecentanalysisoftheevolutionandimpactofCOVID-19incarehomesinonegeographicregioninScotland,itwasreportedthatoutbreakswerestronglyassociatedwithcare-homesizeandrecommendedshieldingofsusceptibleresidentsandrapidactiontominimiseoutbreaksize.95

TheHSEshoulddevelopanintegratedinfectionpreventionandcontrolstrategyinthecommunitywithparticularfocusonallnursinghomes,public,privateorvoluntary.EachindividualnursinghomeshouldadoptaclearIPCstrategyforitselfwhichshouldbeincorporatedintoitspreparednessplan.ItshouldbereviewedregularlytoensureconsistencywiththeHSE’scommunityIPCstrategy.

Itiscrucialtopreparednessthatacomprehensiveinfectionpreventionandcontrolstrategyissustainedduringthenext18months.Itisalsocrucialthatinformationsystemsoperateoptimallyandinalinkedmannertoensuretimelysurveillanceisinplace.

93 Romero-Ortuno,Roman,andSeánKennelly,‘COVID-19DeathsinIrishNursingHomes:ExploringVariationandAssociationwiththeAdherencetoNationalRegulatoryQualityStandards’(6thApril2020),https://www.irishgerontology.com/news/latest-news/Covid-19-deaths-irish-nursing-homes-new-research.

94 Roe,M.,F.Butler,P.Wall,‘AnAnalysisofDeathsRelatedtoCovid-19inIrishNursingHomesUsingPubliclyAvailableData’,18th June 2020[unpublishedsubmissiontotheExpertPanel].

95 Burton,JenniferK.,GwenBayne,ChristineEvans,FrederikeGarbe,DermotGorman,NaomiHonhold,DuncanMcCormick,RichardOthieno,JanetStevenson,StefanieSwietlik,KateTempleton,MetteTranter,LornaWillocksandBruceGuthrie,‘EvolutionandImpactofCovid-19OutbreaksinCareHomes:PopulationAnalysisin189CareHomesinOneGeographicRegion’,medRxivpreprint,10th July 2020,https://www.medrxiv.org/content/10.1101/2020.07.09.20149583v1.full.pdf.

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FurtherdevelopmentworkbetweentheHSE,HPSCandHIQAshouldbeundertakentoensureanintegratedapproachtodatacollation,coordination,sharingandanalysisisundertakentosupportongoingtimelysurveillance.Thedevelopmentofadatarequirementframeworkfornursinghomeprovidersshouldbedevelopedtoidentifyrequireddataflowsandtimingssothatappropriatedataiscollectedregularly,consistentlyand,inastreamlinedway.

Accesstogoodqualitydatainatimelymanneriscriticaltoplanningservicesandresponsesandtherequirementforintegratedinformationmanagementsystemswithdataavailableinrealtimeiscriticalfromanongoingpreparednessperspective.Acrosstherangeofservicesprovidedby,andonbehalfof,theHSE,toolderpeopleinthecommunitythereneedstobecentralisedinformationsystemsto:assistongoingservicesresponses,andreportingbytheHSE;assisttheHSE,DepartmentofHealth,andGovernmentinpolicydevelopment,informingresourceallocation,contingencyplanningandplanningfuturecapacity.ThedevelopmentofanintegratedIT/informationmanagementsystemforolderpersonsservicesisthereforecritical.Allrelevantserviceproviders,shouldensurethattheyinterfacewithandintegratewiththeHSEdevelopedsystem.


Olderpeoplereceivemedicalcareinarangeofsettings.Thegeneralpractitioneristhefirstpersonofcontactinthecommunitysetting.Asforthegeneralpopulation,whenanolderperson,livingintheirownhome,hasahealthconcern,theirGPisthepersontheywillcontactfirst.AsoutlinedinanumberofsubmissionstotheExpertPanel,generalpractitioners(GPs)oftenknowtheirpatients‘fromthecradletothegrave’.Atypicalgeneralpracticelistwillincludeindividuals/familieswhowillhavebeenontheirlistformanyyearsandsowillbewellknowntoeachother.Inotherwords,patientsinolderagewillhavebuiltupastrongbondoftrust,confidenceandoftenfriendshipwiththeirfamilydoctor.

Accordingly,GPsareinauniquepositiontocareforthemedicalneedsoftheirolderpatientsonce/iftheyareadmittedtoresidentialcaresettings.Theyworkasindependentcontractorsinthehealthcaresystemandtheirpatientlistincludesthosewitha)fullmedicalcards(whichfacilitatesaccesstoanextensiverangeofservicesandsupports,includingprescribedmedicationsfreeofcharge);b)aGPOnlycard(everybody>70years,whichgivesaccesstofreeGPconsultation).But,unlikethosewiththefullmedicalcard,thisgroupdoesnothaveautomaticeligibilityforthewiderrangeofservices.Thereisathirdcategorywhoattendtheirgeneralpractitionerasprivatepatients–lessapplicablenowtoolderpeoplesincetheintroductionofthe70years+GPVisitcard.

GPshaveuniversalaccessto‘routine’bloodinvestigationsandx-rayrequests;thisislesssoforothertestssuchasendoscopyandmoresophisticatedradiologylikeCTscanning.GPsshouldhaveeasieraccesstosuchinvestigations,guidedbyrequestprotocolsagreedwiththerelevantconsultantspecialists.ExpandingGPaccesstoabroaderrangeofdiagnosticswouldreducehospitalOPDwaitingtimesandallowforquickeridentificationofthosepatientsrequiringreferraltohospital-basedspecialists.

Mostday-to-dayinteractionsbetweenpatientandGParemanagedatthecommunitylevelwithouttheneedforreferralorseekingasecondopinionfromtheacutehospitalsector.Aminorityinanyoneyearwillrequireemergencyhospitaladmission;alargernumberwillneedanurgent‘elective’referral,buttheneedforeitherismoretheexceptionthantherule.ThosepatientsthathaveaccessedtheacutehospitalserviceforwhateverreasonmayeitherreturntothecareoftheirGPor,forpatientswithmorecomplexillnesses,careissharedbetweenthepatient’sGPandthehospitalspecialistteam(s).

TheGPplaysakeyroleincontinuingtomeetthemedicalcareneedsoftheirpatientsif/whenadmittedtothelocalcommunityhospitalonashorttermormorepermanentbasisortoavoluntaryorprivateresidentialcarefacilityforlong-termresidentialcare.Inrecenttimestherehasbeenatendencytolabelallthesefacilitiesunderthe‘nursinghome’heading,whichignorestheimportantroleofandwiderangeofservicesprovided


byCommunityHospitalsallaroundthecountry.Theservicesinclude:a)Shortstayacuteadmissionforthosewith an acute illness that cannot be safely managed at home, but can be in the local community hospital, thus reducingthereferralloadtotherelevantacutegeneral/regionalhospital;b)Continuingtherequiredfurtherinpatientrehabilitationofpatientsdischargedfromtheacuteservice,e.g.poststroke,hipfracture;c)Daycareservicesforthoseathomerequiringfurthersupportandtherapy;d)Scheduledflexiblerespitecareadmissions–tosupportthecarersoffrailerolderpersonswhootherwisemightbeinlong-termresidentialcare;e)End-of-Lifecare:CommunityHospitalsplayanimportantroleinprovidingtheend-of-lifecarewhetherforpatientsadmittedfromhomeorforthosealreadyresidentintheCommunityHospital,ablyassistedbycommunitypalliativecare.Respiteandconvalescencesupportisalsoprovidedbyprivateandvoluntarynursinghomes.

Contrarytotraditionallyaccepted‘wisdom’,thereisincreasingevidencetoshowthateventhosewithsignificantdependencylevels,includingdementia,canbesafely,andsomewouldarguemoreappropriately,resideindomestic,more‘homely’settings,alwaysprovidedtherequiredhomecaresupportsareputinplace.Thatsaid,therewillbeacontinuingneedforsafehighqualitylong-termresidential/nursinghomecareespeciallyforpersonswithhigherphysicaland/orcognitivedependency.

ThePanelhasbeentold,contrarytopopularbelief,thatthereisnolongeranysignificantdifferenceinthedependencylevelsofolderresidentsinprivate,publicorvoluntaryinstitutions,butthisneedsvalidation.Thereisnoagreednationalvalidatedassessmenttoolformeasuringpersondependencyinresidentialcaretoplanforandmeetresidentscareneedswhichneedtobesubjecttoregularreview.Theintroductionandapplicationof a universal common assessment tool, that is accurate, reliable, reproducible and easily used, measuring dependencylevelshasbeensoughtforyears.Theapplicationofsuchanassessmenttoolisasuitablemechanismforvalidatingtheextent,ifany,ofvariationbetweendependencylevelsinpublic,privateandvoluntarynursinghomes.

RepresentationstothePanelarguedstronglyfortheimplementationoftheInterRAI/SingleAssessmentToolacrossthehealthcaresystemincludingresidentsinnursinghomes.Itprovidesauniversalassessmentoftheneedsofolderpeople.Itwillallowessentialdatatobecollectedtosupportcareplanning,integrationwithcommunity/acutehospitalspecialistservices,andprofessionaldevelopment.ThePanelhasbeenadvisedthatplansareatanadvancedstagewithimminentrolloutnowexpected.However,theassessmenttoolmustbesupportedbynationalpolicy,appropriateprotocolsandstandardoperatingprocedures.TheseshouldbedevelopedasamatterofurgencytosupportthefulladoptionofinterRAIforcareneedsassessmentforolderpersonsservices.

TheQmciScoreisarapideasilyusedandreproduciblescreeningtestofcognitivefunction.Itwasdevelopedusingdatafromawidevarietyofsourcesincludinggeneralpractices,communityrehabilitationfacilitiesandmemoryclinics.Ithasbeenvalidatedinmultiplelanguagesandhasbeenfavourablycomparedwithothershortcognitivescreens(www.qmci.ie).

TheClinicalFrailtyScore(CFS)alsohasgoodpredictiveoutcomesvalue;itcanalsobeusedasaneducationaltoolintrainingprogrammesformedical,nursingandothercarestaffinnursinghomes.TheCFSwasrecentlyfoundtobeabetterguidethanpatientageandco-morbiditiesforinformingdecision-makingaboutmedicalcareintheacutehospitalsetting. TheuseofCFSinnursinghomesmightconferasimilarbenefittothissetting.96 ConsiderationshouldbegiventotheintegrationofQmciorsimilarscreeningtestsandtheCFSorothersuchstandardstoolsintothecareneedsassessmentprocess(interRai)foruseinnursinghomesettings,includinginrelationtoongoingreviewofresidentneeds.

96 SeeJonathanHewitt,BenCarter,ArturoVilches-Moraga,TerenceJ.Quinn,PhilipBraude,AlessiaVerduri,LyndsayPearce,MichaelStechman,RoxannaShort,AngelinePrice,JemimaT.Collins,EilidhBruceetal,‘TheEffectofFrailtyonSurvivalinPatientswithCOVID-19(COPE):AMulti-Centre,European,ObservationalCohortStudy’,TheLancetPublicHealth(30thJune2020), https://www.thelancet.com/pdfs/journals/lanpub/PIIS2468-2667(20)30146-8.pdf.

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Currentlythereisnoagreedsafestaffingandskillmixframeworkappliedtonursinghomes.Staffingrequiresregularreviewandadaptatione.g.duringapandemicwhenstaffinglevelsneedtobealteredtoensurefullimplementationofbestpracticeinfectionpreventionandcontrolguidelines.Thereisalsoevidenceofhighratioofhealthcareassistants(HCAs)totrainedstaff.ManyHCAsareworkingacrossvarioussites,includinghospitalandcommunity.Thelackofdirectlyemployedstaffcompromisestheabilitytomanageandmonitortheircompetenciesandtrainingneeds.On2ndApril2020,HSEaskedstaffagenciestocompletefullrostersforan8-12-weekperiodasopposedtopershift.Pershiftrosteringcompromisescontinuityofcareandassessmentofadeterioratingresident.Somestaffrequiredoccupationalhealthsupportduetonon-registrationwithaGP.

StaffabsenteeismwasaparticularchallengeduringCOVID-19withsomehomesexperiencing40-50%absenteeismplacingdemandonexistingstaffwithlittleoptiontoreplacesickleave.Inmanysituationsthiswasfurtherescalatedasseniormanagerswereinfectedresultingindiminishedleadershipandcapacitytocontainthepandemiceffects.Optionstakentoreplaceleaveincludeagencystaffutilisation,redeploymentfromothercommunitysettingsandacutehospitals.TheHSEplayedanimportantrole,onfootofNPHETadoptedpublichealthmeasures,tosupportnursinghomeswithemergencystaffingprovision.Thisrole,inemergencysituations,wherenursinghomeshaveexhaustedallpossibleresources,shouldcontinue.

ThePersoninCharge(PIC)shouldhavearequirementforgerontologytrainingoraformalqualification,QQIlevel5shouldbenecessaryforhealthcareassistants.AnamendmenttocurrentregulationsrevokedtheobligationforthePICtohaveaformalgerontologyqualification.Continuingeducationshouldbeavailableonanongoingbasis.Contracts,payscalesandstaffdevelopmentinnursinghomesrequirereview.Thereisanimmediateandongoingneedtoattractstafftoworkinthisareabutitneedstobeattractivewithcareerdevelopmentopportunities.Areviewshouldbeundertakenoftheregulatorychangethatremovedtherequirementofthepresenceofaregisterednurseondutyatalltimesincertaincircumstances(i.e.wheretheChiefInspectorofsocialcareservicesissatisfiedthataregisterednurseisnotrequired).97 During the pandemic residents need close monitoring,regularupdatesofcareplansandcareinitiatedtomeetnewchanges-thisrequiresclinicalexpertise.Accesstoinfectionpreventionandcontrol(IPC),includingexternalexpertise,innursinghomeswasinadequate,initiallyatleast.Thislatterroleisrequiredtoensuretheimplementationofbestpracticeguidelines,stafftraininginPPE,standardprecautionsandliaisonwithacuteandHSEIPCsupports.

Person-centrednessiskey.Everyeffortshouldbemadetopreservethechoice,autonomyandneedsofallresidentsatalltimes.Allprovidersshouldbefamiliarwiththe“Ethical Considerations Relating to Long-Term Residential Care Facilities in the context of COVID-19”publishedbytheDepartmentofHealthandshouldincorporateitsprinciplesintocareandservicedelivery.98Duringapandemicoranyfutureinfectionoutbreak,publichealthmeasuresshouldreflecttheseprinciples.PeoplewithdementiaareavulnerablecohortwithdifferentbutparticularneedsandanyCOVID-relatedrestrictionsthatareimplementedneedtobealignedwithaperson-centredapproach;discussionwithfamily/relativesisessential.


Respectingeachindividual’swillandpreferenceonallaspectsoftheircarearefundamentalrights.Preferencesregardingaperson’sfutureanticipatorymedicalcarecanbecapturedinawrittenstatementifanadvancedhealthcaredirectivehasbeencompleted.Suchdirectivesallowindividualsplantheirownfuturehealthcareinadvance.Itmakessuretheirwisheswillbeknown,shouldatimecomewhentheycannolongerunderstandtheiroptionsorcommunicatetheirchoicestoothers.

97 Regulation15(3)oftheHealthAct2007(CareandWelfareofResidentsinDesignatedCentresforOlderPeople)Regulations2013.98 SeeDepartmentofHealth,EthicalConsiderationsRelatingtoLong-TermResidentialCareFacilitiesintheContextofCOVID-19Guidance,(4thJune2020)https://www.gov.ie/en/publication/37ef1-ethical-considerations-relating-to-long-term-residential-care-facilities/


Staffinnursinghomeshaveacknowledgedandbenefitedfromtheirparticipationineducationandtrainingsessions,virtualandfacetoface,onthevalueandcorrectuseofsuchadvancedhealthcaredirectives.EnactingtheAssistedDecisionMaking(Capacity)Act2015islongoverdue,especiallythesectionsrelatedtoadvancedhealthcaredirectivesandcapacity.TheAssistedDecision-MakingCapacityActneedstobeimplementedwithoutfurtherdelay.

Independent advocacy for nursing home residents is not promoted compared to advocacy for other vulnerable/marginalisedcommunitygroupsthroughoutthepandemic.Thereisadegreeofresistancebysomenursinghomestosupportandprovideaccesstoindependentadvocacy,aswasmentionedinanumberofresponsestothePanel.TheHSEsafeguardingservice,whileitisavailabletoallsettings,doesnothaveanylegislativeauthorityinrelationtoprivatenursinghomes.Thereisnolegalorcontractualobligationonprivatenursinghomestocooperateorassistwiththesafeguardingservice.Socialworkservicesforolderpeopleareessential;manyolderpeoplehavetonegotiatedifficultlifealteringdecisionsandtransitions.Whentheydonothaveaccesstosocialworkersupportadvocacyservicesareofincreasedimportance.ThePanelrecommendsthat: • theextensionoftheNationalPatientAdvocacyServicetonursinghomesisexplorednationally,for

bothprivateandpublicandpublicnursinghomes.HIQAshouldcontinuetohighlightandpromoteindependentadvocacyservicesavailabletoresidents.

• establishedindependentadvocacyservicescontinuetobepromotedandintheinterimaspartoftheexplorationoftheextensionoftheNationalPatientAdvocacyService,HIQAandtheDepartmentofHealthshouldexploreintroducingarequirementthatallnursinghomeproviderspromote,facilitateandengagemeaningfullywithindependentadvocacyservices.

• the oversight and governance of safeguarding concerns that occur within private nursing homes needs tobereformed,itissuggestedthattheHSESafeguardingServicebeextendedtocoverallnursinghomes.Intheinterim,whereanindividualcareconcernisraisedtoHIQA,theconcernshouldbereportedtotherelevantSafeguardingandProtectionTeam(SPT)forinvestigation.Allprovidersshouldengagewith,facilitateandsupporttheSPTinitswork.

• accesstosocialworkservicesforolderpeopleisessential;manyolderpeoplehavetonegotiatedifficultlifealteringdecisionsandtransitions.

TheDepartmentofHealthshouldexploreasuitablestructureandprocessforexternaloversightofindividualcareconcerns,onceinternal(nursinghome)processeshavebeenexhaustedwithoutsatisfaction.

TheNationalCareExperienceProgramme(NCEP)wasestablishedin2019toimprovethequalityofhealthandsocialcareservicesinIrelandbyaskingpeopleabouttheirexperiencesofcareandactingontheirfeedback.ItisapartnershipbetweenHIQA,theHSEandtheDepartmentofHealth,withpatientrepresentativesprovidingtheirinputateachstageoftheprogramme.Inthehospitalsetting,ithasaimedtounderstandtheexperienceofpatientsandusesthisfeedbacktoinformthefuturedevelopment,planning,designanddeliveryofimprovedpatient-centredcare.Itisimperativethatnursinghomeresidentsareprovidedanopportunitytohavetheirvoiceandexperienceheardinsuchastructuredmanner,withaviewtoimprovingservicesandthelivedexperience.ThePanelunderstandsthatitisintendedtorollouttheCareExperienceProgrammetonursinghomesinafuturephase.ThePanelrecommendsthatthisbepursuedwithoutdelay.

Regulatoryinspectorswhoarefamiliarwiththenursinghomesectordidnotcontinuetophysicallyinspectnursing homes during the pandemic, especially the nursing homes about which they had previously raised concerns.Tobuildpublicconfidence,tosafeguardresidentsandtosecurecompliancewiththeregulatoryframework,increasedphysicalregulatoryinspectionsmustbemobilised,includingcontinuedoversightofandchecksonpreparedness.Feedbackwasreceivedfromnursinghomerespondentsthatguidelinedocumentsshouldbecoordinatedanddistributedfromonesourcetoavoidduplicationandtoensurethataccurate,consistentandtimelyinformationisprovided.

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Sláintecaresetsouttoredesignourhealthandsocialcareservicestomeetthesechallengesandtoimprovethehealthandwellbeingofthepopulation.Consistentwiththisisthefocusonkeepingpeoplewellintheirhomesandcommunitiesforaslongaspossible,i.e.get“the right care, in the right place, at the right time”.Thepolicyobjectiveistosupportpeoplewithcareneedstocontinuetoliveintheirownhomesandcommunitiesforaslongaspossible.ImportantreformsincludetheplannedStatutoryHomecareSchemeandtheneedtoenhanceaccesstohomecare,expansionoftherangeofhousingoptionswithinlocalcommunitiesaspeople’sneedschangeandintegrationofservicesacrossthecarecontinuum,underpinnedbymulti-disciplinaryteamswithstrongsystemsofclinicalgovernance.ThisrequiresworkingwitharangeofstakeholdersandotherDepartments.

Key relevant policy documents include the National Positive Ageing Strategy,99 the Irish National Dementia Strategy,100 Housing Options for our Ageing Population Policy Statement,101 the National Carers’ Strategy,102 and the Report of the National Advisory Committee on Palliative Care.103 The policy framework, Housing Options for Our Ageing Population Policy Statementdetailsasetofactionstodevelopnewhousingmodels,includingthosewithassociatedcareandsupportmodelswhichfallbetweenhomecareandfull-timenursinghomecare.Theobjectiveistoensureolderpeoplestaysociallyconnectedwithintheircommunityandtoprovideessentialcareandsupportswhereneeded,whilepreservingandprotectingindependence,functionality,andsocialconnectednessforaslongaspossible,inawaythatisasaffordableaspossibleforolderpeoplethemselvesandsustainablefortheState.

7.1.7.EndofLifeCare

Thereisonlyonechancetogetend-of-lifecarerightandweknowthatdyingalonecanbehugelydistressingbothforthedyingpersonandtheirfamilies.Careofthedyingpatientandfamily(despitebeinganoldtitle)isasimportanttodayaswhenDameCecilySaundersfirstintroducedtheconceptofpalliativecare(inthe1950s)104 at theendoflifeandallthatitentails.Dependingontheexperienceofrelatives/friends,ifpoorlymanaged,itwillhaveaprolongedeffectonthenormalgrievingprocess.TheexperienceofdyingintheCOVID-19pandemicmayresultinalargenumberoffamiliessufferingpathologicalgriefintothefuture.Itiswellacknowledgedthatone’sexperienceofthedeathofalovedonewillaffecthowonedealswithone’sownimpendingdeath.

Wemusthaveakeenappreciationfortheimpactofadeathonafellowresident.Forthosewhowitnessedmanylossesandmaysuffervaryingdegreesofemotionaltrauma,itisimportanttorecognisethattheyneedaformalwayofexpressingtheirgriefasacommunity.Ifnotfacilitated,theresidentmayquietlyfeartheirowndeath.Residents need reassurance that their own death will be acknowledged and their life celebrated and that friends andfamilywillbecaredforwhentheirtimecomes.

99 DepartmentofHealth,NationalPositiveAgeingStrategy,30thApril2013,https://www.gov.ie/en/publication/737780-national-positive-ageing-strategy/?referrer=http://www.health.gov.ie/healthy-ireland/national-positive-ageing-strategy/

100 DepartmentofHealth,NationalDementiaStrategy,December2014,https://www.gov.ie/en/publication/62d6a5-national-dementia-strategy/?referrer=http://www.health.gov.ie/healthy-ireland/national-positive-ageing-strategy/the-irish-national-dementia-strategy/

101 DepartmentofHousing,PlanningandLocalGovernmentandDepartmentofHealth,HousingOptionsforOurAgeingPopulation,February2019,https://www.gov.ie/en/publication/ea33c1-housing-options-for-our-ageing-population-policy-statement/

102 DepartmentofHealth,NationalCarersStrategy,July2012,https://www.gov.ie/en/publication/a1e44e-national-carers-strategy/#:~:text=The%20aim%20is%20to%20support,strategy%20was%20published%20in%202012

103 DepartmentofHealth,ReportoftheNationalAdvisoryCommitteeonPalliativeCare,10thJune2001, https://www.gov.ie/en/publication/06aecd-report-of-the-national-advisory-committee-on-palliative-care/

104 SeeCarolineRichmond,‘DameCicelySaunders,FounderoftheModernHospiceMovement,Dies’,BritishMedicalJournal, https://www.bmj.com/content/suppl/2005/07/18/331.7509.DC1.https://www.bmj.com/content/suppl/2005/07/18/331.7509.DC1


Ifanursinghomedoesnothaveadequatenumbersofseniornursingstaffondutyatalltimes,thereisariskthatendoflifecareiscompromised.Manynursinghomesrequiredassistancefromgerontologistsandspecialistpalliativecareteamstoguideandsupportstaffthroughendoflifecareissues.NursingHomesIrelandstatedthattheirmembersareusedtodealingwithandmanagingresidentsatendoflife,howeverwhenCOVID-19arrivedinnursinghomes,thescaleofassistancestaffrequiredbysomewasmorethanexpected.Many,(butnotall)requiredassistancewithanticipatoryprescribingandassessmentofendoflifecareplansasresidents’conditionschanged.Communicationwithrelativesofdyingresidentsrequiredahigherlevelofskillandtimeasdeteriorationoccurredanddeathapproachedatspeed.Lackoffamilyvisitingmaycontributetodelayedsymptomawarenessbystaff.

Itwasevidentthattheexpertiseofgeriatriciansandcommunityorhospitalpalliativecareteams,oncelinkagewasestablished,wasappreciatedbystaffandassistedinendoflifecaredecisionsasrequired.ItisdifficulttoestablishtheeffectoftheisolationofCOVID-19residentsattheendoflife:evidencewasgivenfromgerontologiststhatendoflifecaresymptomswerewellmanaged.Interviewswithandsubmissionsbyrelativesdescribedverydistressingaccountsoftheeffectofphysicalisolationfromeachother.Deathanddyinggriefsupportswerecurtailed/non-existentinsomeinstances.

Communicationwithrelativesregardingadeterioratingrelativeandhowsymptomcontrolisbeingmanagedisimportant.Visitorguidelinesforthefuturecantakeaccountofourbetterpublichealthunderstandingoftherisksassociatedwiththisdiseaseandrequireindividualassessment.CompassionatevisitingwasadvocatedbytheIrishHospiceFoundation.Bereavementsupportforindividualresidentsandthefacilitationofinformalbereavementgatheringsofallresidentswasdiscussed.Bereavementsupportforfamiliesofdeceasedisrequired:feelingofoverwhelminggrief,coupledwithguiltatnotbeingabletobepresentatend-of-lifearesignificantimpactsandfeelingsarising.Communicationisthereforemoreimportantthaneverbefore.Providersshouldoffertoholdfamilymeetingstoprovidefeedbackandanswer/explainthemanyunansweredquestionsasaresultofrestrictions.Thesemeetingsshouldbesupportedwithindependentadvocacy.Staffdebriefingandcounsellingsupportsbyatrainedpersonandindividualongoingsupportshouldbeavailableifrequired.

ThePanelsupportstheinitiationofajointHSE-IHFcollaborativenationalprogrammeonpalliative,end-of-lifeandbereavementcareforthenursinghomesectorthatengagesallstakeholdersandimprovesqualityofcareacrossthesector.ThisinitiativecouldbeestablishedalongthesamelinesastheJointHSE-IHFHospiceFriendlyHospitalsProgramme,launchednationallyin2017.

7.1.8.Conclusion Amajoraspectofmodernpublichealthistheimprovedlifeexpectancyindevelopedeconomies.Manyfactorscontributetothatlongevity,includingthedeclinesincardiovasculardiseasesassociatedwithreductionsinsmokingandanemphasisonhealthierlifestyles.Olderpeoplehavecontributedascitizensandtaxpayersthroughouttheirlivesandthebenefitsofcross-generationinteractionandengagementaremany.Youngadultstodayknowtheirgrandparentsinawaynotseeninthepastandtheybenefitfromtheexperience.

100

Manyyoungergrandparentshaveactedascarersfortheirchildren’schildreninthismoderncommuterage.Thepeopleover65inIrelandtodayincludethebaby-boomergenerationsbornaftertheEmergencyperiod(1946-1955),andtheolderold,thosebornaroundthetimeoftheWarofIndependenceandtheestablishmentoftheFreeStateandthelaterestablishmentoftheRepublicofIreland(1920-1945).Whenwespeakofcommemoratingonehundredyearsofhistorythesecitizensarethelivingembodimentofthatpast.Thesearethepeoplewhosurvivedintooldagebutwereinordinatelythevictimsofthepandemic.Whileoftenoverlookedbythehealthsystemandthecommunitiestheyserve,nursinghomesareessentialtothecontinuumofcareacrossthelifecycle,particularlyintimesofcrisis.AswemourntheprofoundlossoflifeofnursinghomeresidentsinthewakeofCOVID-19,mayweforeverhonourtheselivesbylearningfromthistragedyandcreatingabettersystem.

TheCOVID-19NursingHomesExpertPanelsetsoutbelowarangeofrecommendations.Theserecommendationshavebeendevelopedonfootofandinformedbytheverysubstantialengagementswithavarietyofexpertsandorganisations;examinationofkeydocumentation;dataanalysis;anevidencereviewandimportantlyfromdirectengagementswithnursinghomeresidents,familiesandstaff.ThePanelsubmitstheserecommendationsfollowingconsidereddeliberationsandtheyshouldbereadinlinewiththeentiretyofthisreport,andespeciallyinreferencetothediscussioninthischapter.InthecontextofthesignificantimportanceofthecontinuedresponseandreformofnursinghomecareinthecontextofCOVID-19andbeyond,thePanelrecommendsthattherelevantGovernmentDepartmentsensurethatsufficientresourcesareassignedtotheresponsibleDepartmentsandagenciestoensurethetimelyimplementationoftheserecommendations.


7.2.RecommendationsTable 7.1 COVID-19 Nursing Homes Expert Panel Recommendations

# Recommendation SuggestedLeadAgency

SuggestedTimeframe

1.PublicHealthMeasures1.1. ContinuetheenhancedpublichealthmeasuresforCOVID-19

DiseaseManagementinLong-termResidentialCare(LTRC)adoptedbyNPHETatitsmeetingsof31stMarch2020and3rdApril2020,includingPPEsupplytonursinghomes;staffaccommodation;contingencystaffingteams;preparednessplanningetc.(seeappendix2)

HSE,HIQA,EachNursingHomeProvider as relevant

Ongoing

1.2. HSECOVID-19ResponseTeamshavebeenacriticalinitiative.Theseteamsmustremaininplace.TheseteamsshouldbestandardisedintermsofoperationandcompositionandmustbeoverseenjointlybyHSECHOsandHospitalGroups,whoshouldhavejointresponsibilityandaccountabilityfortheiroperation.

HSEandHospitalGroups

Immediately and ongoing

1.3. Itiscriticalthatregionalpublichealthdepartmentsareprovidedwithsufficientresourcestohaveastaffcomplementandskillmixofteammembersinplacetoprovidelocalsupport.

HSE Immediately

TheCroweHowarthrecommendedimplementationprocessshouldcontinueonatimelybasis.

Ongoing

2.InfectionPreventionandControl(IPC)2.1. Developanintegratedinfectionpreventionandcontrol

strategyinthecommunitywithparticularfocusonallnursinghomes,public,privateorvoluntary.

HSE Within1monthofpublicationofthisreport

2.2. Each nursing home should adopt a clear IPC strategy, including deep clean protocols, for itself which should be incorporatedintoitspreparednessplan.ItshouldbereviewedregularlytoensureconsistencywiththeHSE’scommunityIPCstrategy.

EachNursingHomeProvider

Within1monthofpublicationofthisreport

2.3. In line with public health and ECDC guidance, nursing home residentsshouldcontinuetobeprioritisedfortestingwithrapidreportingofresults.

HSE(HPSC) Immediate and ongoing

2.4. Aplanforandmonitoringofaprogrammeofperiodictestingforhealthcareworkersinnursinghomesshouldbecontinued.Associatedprotocolsshouldidentifytheperiods.

HSE(HPSC) Within1monthofpublicationofthisreport–monitoring and review ongoing

2.5. Ensurethereisrapidturnaroundcapacityintestingandcontacttracingsystem.

HSE(HPSC) Ongoing

102


SuggestedTimeframe

2.6. Itisessentialthatin-housestaffwhocanundertakesampleswabbing and reliable labelling are available, and that there is proximalaccesstoalaboratorywithLaboratoryInformationManagementSystems(LIMS)followupforcontacttracingforbothresidentsandstaff.


Ongoing

2.7. (a)Infectioncontroltrainingshouldbemandatoryforallgradesofnursinghomestaff.

(a)EachNursingHomeProvider

Immediate and ongoing

(b)Nursinghomestaffshouldhaveaccessto‘trainthetrainersinfectioncontrol’trainingprogrammeapprovedbytheHSE.

(b)EachNursingHomeProviderandHSE

(c)CommitmentrequiredbyhealthcareagenciestoformallyconfirmevidenceofIPC,includingPPEtrainingpriortoallocatingstafftonursinghomes.NursinghomeprovidersshouldnotcontractanagencystaffwithoutevidenceofIPC/PPEtraining.Eachprovidershouldhavedocumentaryassurancefromtheagencythatthestaffmemberhashadtherequisitetraining.HIQAshouldundertakecompliancechecks.

(c)StaffAgenciesandeachNursingHomeProvider

(d)Everynursinghomerequiresonsiteaccesstoatrainedinfectioncontrolleadoneachshift.ThatleadwillensureIPCprotocolsareimplementedandwillsupportstafftodoso.

(d)EachNursingHomeProvider

2.8. Auser-friendly,consistentprotocolfororderingandfortheongoingsupplyofadditionalCOVID-19relatedPPEtonursinghomesbytheHSEneedstoberefined.

HSE Ongoing

Similar protocols must be put in place for the ordering and supplyofotheressentialCOVID-19managementrelatedequipment.Theseprotocolsshouldbekeptunderreviewduringthepandemic.

Each nursing home is responsible for and should have an emergencysupplyofPPEandotherCOVID-19relatedequipmentintheeventofacluster.Thisshouldbeincludedinpreparednessplans.


2.9. Influenzavaccineshouldbeprioritisedforallresidentsunless medically contraindicated of all nursing homes once it becomesavailableandconsidermakingitmandatoryforstaff.

HSEandDepartment of Health

Planning should commence immediately

2.10. Managementofentryandexit:Examineoptionsforzoningwithincarehomessodifferententrances/exitscanbeusedfordifferentpartsofthehome.Thisexaminationshouldbedocumentedwithresultsandactionsincorporatedintopreparednessplans.


Within3months



SuggestedTimeframe

3.OutbreakManagementCOVID-19ishighlycontagiousandhasatypicalpresentationsinolderadults.Thereneedstobeastrongclinicalindexofsuspicion.NursinghomesneedanimmediateactionplanforwhenCOVID-19casesaresuspectedandmustincludethefollowingelements,inaccordancewithHSEprotocols:

3.1. Accesstorapidtestingwithfasttrackedresults,asabove. HSE Ongoing

3.2. PPEtobereadilyavailableandstafftrainingwithonsitesupervisiononeveryshifttoensurePPEbeingusedcorrectly.Training should be documented and records available for inspectionbyHIQA.


HIQA(compliance oversight)

Ongoingandallstaffshouldbetrained within 2 months

3.3. Sustainprotocolsforself-isolation,quarantine,cohortingandreferraltoGPLead.


Ongoing

3.4. Suspect cases and close contacts need to be isolated pending theresultsofrapidtesting.


Ongoing

3.5. Facilitiesmusthaveabilityandspacetoisolateandcohortresidentsandaclearplanonhowthiswillhappen.Thisplanshouldbeincorporatedintopreparednessplans.


Ongoing

3.6. Accesstosafestaffinglevelsatalltimesandtoincluderequiredskillsetoneveryshift.


Ongoing

3.7. Socialdistancingfacilitiesforresidentsandstaffshouldbeinplaceandmaintained.


Ongoing

3.8. EachprovidershouldincorporatewrittenplansoneachoftheaboveintotheirpreparednessplanforreviewbyHIQA.


HIQA(compliance oversight)

Ongoing

4.FutureadmissionstoNursinghomes4.1. Ensure all new residents coming from the community or

proposedtransfersfromhospitalaretestedforCOVID-19priortoadmission.

EachNursingHomeProviderandHSE

Ongoing

4.2. Admissions should only be made to nursing homes who can demonstratetheirinfectioncontrolmeasuresareofsufficientstandardtoensurethereisnoriskofonwardinfection.HIQAshould maintain a register of those nursing homes it deems tohavedemonstratedsufficientinfectioncontrolstandardreached, to support informed decisions on admissions in this regard.

EachNursingHomeProvider,HSEandHIQA

Ongoing

4.3. NewResidentsmustbeisolatedaccordingtoHPSCprotocol. EachNursingHomeProvider

Ongoing

104


SuggestedTimeframe

5.NursingHomeManagement5.1. Logofallpersons/staffenteringnursinghomesshouldbe

maintainedbyeachnursinghomeandavailableforinspectionbyHIQA.


HIQA(complianceoversight)

Ongoing

5.2. Nursinghomesshouldhaveaclearwrittenback-upplanwhenregularstaffcannotworkorfailtoturnupforwork.This should be incorporated into the nursing home’s preparednessplanforreviewbyHIQA.



Immediate

5.3. AllHealthcareAssistants(HCAs)shouldhavearelevantQQILevel5qualificationorbeworkingtowardsachievingit.Aphasedpathwaytowardsachievingthisshouldbeinplace.Therequirement’sinclusionintheregulatoryframeworkshouldbeconsidered.


Department ofHealth(ifregulationrequired)

Aneducationplanfor each healthcare assistant should be in place by each provider within 18monthsofthepublicationofthisReport

5.4. FrameworkforSafeStaffingandSkillmix(published2018)shouldbeprioritisedandurgentlydevelopedtoapplyinnursinghomes-publicandprivate,nationally.

Department of Health

Within18monthsofpublicationofthis Report

5.5. WhilePhase3oftheSafeStaffingFrameworkisdeveloped,in the interim, evidence and learnings from earlier phases oftheFrameworkshouldbeexaminedandusedtoinforminterimchangestostaffinginnursinghomes.TheselearningsshouldalsobeusedtodevelopguidanceonstaffinglevelsandskillmixinsurgesituationsarisingfromCOVID-19.ThesechangesshouldbereadjustedasPhase3developsandisrolledout.


2020

5.6. Forthenext18monthsoruntilthedeclarationoftheendoftheGlobalpandemicbyWHO,staffemployedbyanursinghomeshouldbeprecludedfromworkingacrossmultiplesitesandadequatesingle-siteemploymentcontractsshouldbeputinplacetosupportthis.

EachNursingHomeProvider(employment)

Department of Health(ifregulationrequired) HIQA(complianceoversight)




SuggestedTimeframe

5.7. Areviewofemploymenttermsandconditionsofnurseandhealthcareassistantstaffinggradesinnursinghomesshouldbe undertaken with a view to ensuring future capacity and thesupplyofqualifiedstaff.

Department of Enterprise, Trade and Employment

Within18months

5.8. OccupationalhealthandHRsupport,includingpsychologicalsupports,forallstaffisnecessaryandaccessshouldbeputintoplace.


Immediately

5.9. Increasedintegrationofprivateandvoluntarynursinghomesintothewiderhealthandsocialcaresystemsrequiresenhancedtransparencyofoperation,fundingandfinancesofthesenursinghomes.Thefundingandexpenditure(publicandprivatemonies)utilisationbyprivateandvoluntaryproviders in providing and improving services should be clearly transparent and measures should be considered to ensurethis.

Department of Health,NTPF,HSE


6.DataAnalysis6.1. ImprovelinkageamongstdifferentdatasetssuchasCIDRwith

HIQAandGROdatasets.ThismayincludeupdatingtheCIDRoutbreakfiledatafieldstoincludeaHIQAID.

HSE(HPSC)andHIQA

Planning should commence immediately with a viewtocompletinglinkagesin2020

6.2. ImplementationofIndividualHealthIdentifier(IHI)asamatterofprioritytoenabletrackingofpatientsbetweencommunityandacutehospitalsectors.

HSEandDepartment of Health

Progress should be made without delay

6.3. DevelopandintroduceanintegratedITsystemforolderper-sonsservicesincludingresidential,homesupport,daycare,needs assessment and care planning, so as to support the provision,management,deliveryandreportingofservices,andespeciallyforplanningalternativeserviceprovisionandplanned capacity development in the event of evolving public healthmeasures.

HSE Introduce within 18monthsorsooner

6.4. RealignmentofgeographyusedinCIDRtoRegionalHealthAreas(RHAs),countiesorother,inlinewithcurrenthealthsystemstructuresastheyevolve.

HSE(HPSC) Planning should commence immediately

6.5. IntroductionoftheabilitytolinkandtrackcontactsintoCIDRorusinganotherdataprogramme.

HSE(HPSC) Planning should commence immediately

6.6. Havingregardtoimproveddatalinkages(6.1),theHSE(HPSC)shouldproduceadetailedreportonthemanagementandoutcomesofthemultipleclustersthatoccurredduringtheCOVID-19pandemicwithlearningsoncausalfactorsandpreparednessforinfectionpreventionandcontrol.

HSE(HPSC) Within9monthsofthepublicationof this Report

6.7. HPSC,HSEandHIQAshouldproduceadetailedepidemiologicalanalysiscomparingbothriskandprotectionfactors associated with having an outbreak or not at all in HIQAregulatedfacilities.

HSE(HPSC)andHIQA

Within3monthsofthepublicationof this Report

106


SuggestedTimeframe

7.CommunitySupportTeams7.1. Establish new integrated Community Support Teams with

clearlydefinedjointleadershipandresponsibilityacrosseachCHOandhospitalgroupareaonapermanentbasis,inlinewiththediscussioninthischapter.Intheinterim,theexistingCOVID-19ResponseTeamsshouldremaininplace.


Planning to commence immediately

7.2. IntheeventofaCOVID-19surge,adesignatedmemberofthe future Community Support Team should always have 24/7availabilityforthenursinghomesinthecatchmentarea.


Immediately

8.Clinical–GeneralPractitionerleadrolesonCommunitySupportTeamsandinNursingHomes8.1. AGPwillbeakeymemberofeachCommunitySupportTeam

(andintheinterimeachCOVID-19ResponseTeam).HSE Within3months

ofpublicationofthis Report

8.2. OneoftheGPs,alreadycaringfortheirpatientsinanursinghome,willbeappointedtotheadditionalroleasanursinghome’sGPLead,andworkingwiththePersoninChargeandotherseniornursinghomestaffwillcontributetothenursinghome’sgeneraloversightandgovernance.ThePersoninChargehasoverallresponsibilityforclinicalgovernance.

EachNursingHomeProviderandGPs


8.3. ThesessionalcommitmentandremunerationforthepostwillbespecifiedinacontractbetweenthenursinghomeandGPlead;functionswouldincludepromotingtheuseofinstruments like the InterRAI Single Assessment Tool and the ClinicalFrailtyScoreandoptimisingmedicationmanagement,ensuringfullcompliancewithe.g.influenzavaccineuptakeforresidentsandstaffinthenursinghomeandcloseliaisonwithcommunityservicesandoutreachservicesofacuteHospitalGroups.

EachNursingHomeProviderandGPs


8.4. AnationalframeworkdescribingtheroleandresponsibilitiesoftheGPlead,includingtheelementsoutlinedabove,should be developed, so that providers can operate within a consistentandclearsetofrequirements.

Department of HealthandHSE


8.5. TheDepartmentofHealthwithsupportfromHIQAshouldexplore,whethertheparticularsofthisframeworkshouldbeincorporatedintotheregulatoryframework.





SuggestedTimeframe

8.6. Aclinicalgovernanceoversightcommitteeshouldbeestablished in all nursing homes and its inclusion in the regulatoryframeworkshouldbeconsidered–intheinterimguidanceontheroleandcompositionshouldbedeveloped.Intime,oneofthefunctionsofthisoversightcommitteeshouldbetoreviewqualityindicator/residentsafetyreportsandactionappropriatefollowup(seerecommendation9.4).


Within9monthsofpublicationofthisReport.

HSE(Guidance)


Department ofHealth(Regulationifrequired)



9.NursingHomeStaffing/Workforce9.1. HIQAshouldcarryoutandpublishadetailedauditofexisting

staffinglevels(nursingandcareassistant)andqualificationsinallnursinghomes–public,voluntaryandprivate.

HIQA Within6monthsofpublicationofthis Report

9.2. Itisessentialtohavestronginformednursingleadershiponsiteinallnursinghomeswithadocumentedcontingencyplanforwhenleadersareabsent.Theseplansshouldbeincorporatedintopreparednessplans.TheyshouldbeavailableforinspectionbyHIQA.

EachNursingHomeProvider. HIQA(complianceoversight)

Ongoing

9.3. ThereshouldbenationalcriteriaonrolesandresponsibilitiesofthePersoninChargeandregisterednursingstaffinnursinghomes.Thisshouldbeincorporatedintotheregulatoryframework.



9.4. ConsideringthenursingmetricsandtheHPSIR,aqualityindicators and outcomes/resident safety model should be developedfornursinghomes,requiringeachnursinghometopublishregularreportsandtoprovidecopiestoHIQA.HIQAshould establish a public register of all such reports provided bynursinghomes,andoversightandvalidationchecksshouldbeincorporatedintotheregulatoryframework.

Department of Health(model)

EachNursingHomeProvider(Implementation)


Planning for and the development of a model and process should commence immediately with a system developed within9monthsandoperationalwithin18months

9.5. Thedevelopment,inthemedium-term,ofclinicalgovernancemodelsinthecommunityshouldbeexploredfurtherbytheDepartmentofHealthinconjunctionwiththeHSE,supportedbyaninternationalevidencereviewofmodelsofclinicalgovernanceinnursinghomesettings.


Within12months

108


SuggestedTimeframe

10.Education-Discipline-SpecificandInter-disciplinary10.1. HSEtrainingprogrammes,suchase.g.HSELanD,should

continuetobemadeavailabletoprivatenursinghomesandanappropriategovernancestructureestablished.

HSE Ongoing

10.2. Topromotethewiderimplementationofadvancedhealthcaredirectives(AHDs),educationprogrammes,includingsomevirtual, should be put in place and providers should facilitate greaterstaffparticipation.

The Decision Support Service andHSE

EachNursingHomeProvider(facilitatingstaffparticipation)


10.3. Implement relevant aspects of the Assisted Decision Making (Capacity)Act2015,onceenacted,inareassuchascapacityassessment, recognising each resident’s will and the wider use ofadvancedhealthcaredirectives.

Department ofJusticeandEqualityinconsultationwiththe Department ofHealth


10.4. Stafftrainingandcareerdevelopmentprogrammewitharequirementthatseniornursingstaffwillhaveundertakenpost-graduategerontologicaltrainingandshowgeneralevidenceoftrainingcompetency.Aphasedpathwaytowardsachieving this should be in place with clear targets set, and regulatoryoversightprovidedtoensurethattargetsaremet.


Department of HealthandHIQA(Regulationifrequired)

HIQA(Complianceoversight)

Phased pathway and targets should be developed within9months(provider,withregulationdeveloped asrequired(DepartmentofHealth).EachNursingHomeProvidershould have a compliance plan within3monthsthereafter



SuggestedTimeframe

10.5. Mandatorycontinuingeducationforallstaffinareassuchasinfectioncontrol,palliativecare&endoflifeanddementiashould be introduced and a phased pathway towards achieving this should be in place with clear targets set, and regulatoryoversightprovidedtoensurethattargetsaremet.

Department ofHealth(Regulationifrequired)


EachNursingHomeProvider(complianceplanand pathway for allstaff)

Phased pathway and targets should be developed within9monthswithregulationasrequired(DepartmentofHealthregulatory and HIQAcomplianceoversight).EachNursingHomeProvidershould have a compliance plan within3monthsthereafter

11.PalliativeCare11.1. Every nursing home should be linked with the Community

PalliativeCareTeamintheircatchmentarea.HSEandEachNursingHomeProvider

Within2months

11.2. Visitorguidelines–individualassessmentsshouldbeunder-takenanddocumented,andcompassionatevisitingshouldbefollowedasrecommendedbytheHSEandinlinewithHPSCvisitingguidance.TheyshouldbeavailableforinspectionbyHIQA.



Immediately and ongoing

11.3. InitiateajointHSE-IHFcollaborativenationalprogrammeonpalliative,end-of-lifeandbereavementcareforthenursinghome sector that engages all stakeholders and improves qualityofcareacrossthesector.ThisinitiativewouldbeestablishedalongthesamelinesastheHSE-IHFHospiceFriendlyHospitalsProgramme(2017todate).

HSEandIrishHospiceFoundation


12.VisitorstoNursingHomes12.1. HPSCshouldproactively/regularlyreviewvisitingguidelines

in order to achieve a balance between individual freedoms andprotectivepublichealthmeasures,inlinewiththeDepartmentofHealthethicalguidance.

HSE(HPSC) Ongoing

12.2. Infrastructuraladaptationsmaybeneededincludingvisitingroomsthatcanfacilitatevisitsfromfriendsandfamily.


Immediately

12.3. Endoflifevisitingmustbearrangedoncompassionategroundsbasedonclinicaljudgementandtakeaccountofpublichealthmeasures.


Ongoing

110


SuggestedTimeframe

13.CommunicationSupportandcommunicationforresidentsandtheirfamiliesareacontinuingpriority.

13.1. Meaningfulcommunicationswithresidentsandfamiliesshouldtakeplaceregularlyinrelationtovisitingprotocols,changesinprocessesandexplanationsrelatingtosame.


Ongoing

13.2. Clearcommunicationplanswithresidentstoprovideinformationontheongoingsituationshouldbedevelopedanddocumentedregularly.HIQAshouldexaminetheseaspartoftheinspectionprocess.Providersshouldprovideregularupdatesaboutresidentstothefamilies.



Ongoing

13.3. Phonelinesmustbemaintainedandadditionalreception/communicationsstaffplannedforatbusyperiods.PurchasetabletcomputersifrelevantandreviewITsolutionsforuse by individual residents to assist with family and friend communicationandreviewoffacilitiestoensureallhaveaccesstoWi-Fifacilities.Eachprovidershoulddocumentitsreviewandactionplaninthisregardandmakeitavailabletoresidents,familiesandHIQA.


Within3monthsofpublicationofthis report

13.4. Dedicatedstaffshouldbeassigned/appointedtofacilitatesocialactivitiesandcommunicationwithfamily.Assignments/appointmentsshouldbedocumentedwithclearactivityandcommunicationplansandrecordsinplace,andavailableforinspectionbyHIQA.




14.RegulatoryRecommendations14.1. Acleardocumentoutliningtherolesandresponsibilities

of key stakeholders should be developed to include a clear overviewoftherolesandresponsibilitiesofNPHET,theDepartmentofHealth,HSE,HIQA,andindividualproviders.ThisshouldtakeintoaccounttherecommendationsinthisReport.Theongoingapproachtonursinghomesshouldbecoordinatedinlinewiththis.Officialguidelines,keyupdatesandimportantnewsrelatingtoCOVID-19shouldbecoordinated and distributed to providers from one statutory sourcetoavoidduplicationandconfusion.Requestsforinformationfromprovidersshouldbecoordinatedsimilarlysubjecttoexistinglegalrequirements.

Department ofHealthinconsultationwithHSEandHIQA

Document should be developed Within1monthofpublicationofthisreportandHIQAortheHSEshouldbe designated as sector communicationscoordinator

HSEandHIQAshould agree a writtenprotocoloncommunicationwithin1monththereafter



SuggestedTimeframe

14.2. HIQAitselfidentifiedadeficitininfectioncontrolandriskmanagementexpertiseinthissector.Mandatorytrainingrecordsincludinginfectioncontrolshouldbeincludedconsistentlyintheinspectionprocess.

HIQA Planning should commence immediately

14.3. Therearecurrently22inspectorsoverseeingapproximately576facilitieswithavisitfrequencyof18months.Whileonsiteinspectionsarelabourintensive,thefrequencyoftheseshouldbeincreased.

HIQA Immediately

14.4. ThelegislationunderpinningnursinghomesregistrationandoperationandempoweringHIQAisinplace,butthecurrentregulationsneedtobemodernisedandenhancedwithadditionalpowersandrequirements.Theseregulationsshouldbereviewed,includingtogivefulleffecttotherecommendationsofthisreport.

Department of HealthwithinputfromHIQA


14.5. Assessment of compliance with the regulatory assessment framework of the preparedness of designated centres for olderpeopleforaCOVID-19outbreakshouldbepartoftheinspectionprocess.

HIQA Immediately and ongoing

14.6. ProvisionshouldbemadeforregularmandatoryreportingtoHIQAofkeyoperationaldatabyeachnursinghomeproviderincludingdataonstaffnumbersandgrades,qualifications,occupancylevels.ThisdatashouldbeavailabletohealthagenciesincludingtheDepartmentofHealthtoinformongoingplanningforresidentialcareservices.HIQAshouldensurestreamlinedprocessesareinplaceforthecollection,collationandreportingofsuchdata.

Department of Health(Regulationifrequired)

HIQA(operationalprocesses)

EachNursingHomeProvider(submissionofdata)


15.AbroaderrangeofstatutorycaresupportsforOlderPeople15.1. Integrationofprivatenursinghomesintothewider

framework of public health and social care should be advanced.Thisshouldbeprioritisedintheshort-termwiththeimplementationoftherecommendationsinthisReport,andlonger-termreformshouldbepursuedasakeycomponentoftheintendedCommissiononCare.

HSEandEachNursingHomeProvider in the short term

Government,HSE,DepartmentofHealth(long-termreform)

In line with timelinesfor relevant recommendationsinthisreport.

Planning should commence in line with the Commission on Care process

15.2. TheDepartmentofHealthandHIQAshouldexploreintroducingarequirementthatallnursinghomeproviderspromote, facilitate and engage meaningfully with independent advocacyservices.

Department of HealthandHIQA


112


SuggestedTimeframe

15.3. TheDepartmentofHealthshouldexploreasuitablestructureandprocessforexternaloversightofindividualcareconcernsarising in nursing homes, once internal processes have been exhaustedwithoutsatisfaction.


Within12to18monthsofpublicationofthisReport

15.4. HIQAandeachnursinghomeprovidershouldcontinueto highlight and promote independent advocacy services availabletoresidents.

HIQAandEachNursingHomeProvider

Ongoing

15.5. Provide nursing home residents with full medical card eligibilityequalityofaccesstoservicesavailabletocommunity-basedpeers.

HSE Immediately and ongoing

15.6. Accesstohomesupportshouldbeexpandedandprioritised. HSEandDepartment of Health

Immediately

15.7. Standardised care needs assessment should be developed androlledout.Considerationofaperson’ssuitabilityforrehabilitationand/orreablementservicesshouldbemandatorypriortoad-missiontonursinghomeandanopportunityforaccesstosuchservicesshouldbeavailable.Theconsiderationandoutcomeshouldbedocumented.

HSE,Overseenby the Department of Health

Develop models and pathways within9monthsofpublicationofthisReport.

Ensure longer term integrationwithin24 months of publicationofthisReport

15.8. Incentives,includingfinancial,mustbeexploredtohelpprovide a wider range of service and ownership models for both care in the home and in smaller congregated units/settings.Thiswouldacknowledgeandreflectmostpeople’spreferredwishes.

Government,Department of Finance, Department of Public Expenditureand Reform, in consultationwithDepartment of Health


15.9. Review and as appropriate following review develop policyandunderpinninglegislation,asnecessary,fortheintroductionofasingleintegratedsystemoflong-termsupportandcare,spanningallcaresituationswithasinglesourceoffunding.

GovernmentandDepartment of Health

Planning for the review should commence in line with the Commission on Care process

15.10. Thischoicemodelwouldbepayabletothebeneficiaryforuse either to support further care in their own home, in alternativehome-basedsupportivecareorinresidentialcare.

GovernmentandDepartment of Health

Planning for the review should commence in line with the Commission on Care process



SuggestedTimeframe

15.11. Tosupportthispolicyinitiative,andinlinewith15.7nationalintegrated care needs assessment and care planning policy and structures should be developed for older persons services.Examinationoftheroleofresourceallocationmodelsshouldbeundertakenincludinganinternationalevidencereview.


Policy development and commence roll out within9monthsofpublicationofthisReport

ReviewofRe-sourceAllocationModelling within 18monthsofpublicationofthisReport

15.12. TheNationalCareExperienceProgrammeexpansiontonursinghomeresidentsshouldbeprogressedatpace.

HIQA Within18monthsofpublicationofthis Report

114

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VanBeek,AndrianaSandraP.A.,Dinnus,H.M.Frijters,CordulaWagner,PeterP.Groenewegen,andMielW.Ribbe,‘SocialEngagementandDepressiveSymptomsofElderlyResidentswithDementia:ACross-SectionalStudyof37Long-TermCareUnits’,International Psychogeriatrics23/4(2011):625–633.

WorldHealthOrganization,World Report on Ageing and Health(Geneva:WHO,2015).

—————,‘InfectionPreventionandControlGuidanceforLong-TermCareFacilitiesintheContextofCOVID-19:InterimGuidance’(21stMarch2020’),https://apps.who.int/iris/handle/10665/331508.

—————,‘GuidanceonCOVID-19fortheCareofOlderPeopleandPeopleLivinginLong-TermCareFacilities,OtherNon-AcuteFacilitiesandHomeCare’(23rdMarch2020),https://iris.wpro.who.int/handle/10665.1/14500.

—————,‘TimelineofWHO’sResponsetoCOVID-19’(30thJune2020), https://www.who.int/news-room/detail/29-06-2020-covidtimeline.

—————,‘AgeingandLifeCourse’,https://www.who.int/ageing/en/.

—————,‘Coronavirus:Overview’,https://www.who.int/health-topics/coronavirus#tab=tab_1.

—————,‘EmergencyUseICDCodesforCOVID-19DiseaseOutbreak’, https://www.who.int/classifications/icd/covid19/en/.

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Appendix1:

1. Purpose1.1. InlinewiththeTermsofReference,thepurposeoftheExpertPanelistoreporttotheMinisterinorder

toprovideimmediatereal-timelearningsandrecommendationsinlightoftheexpectedongoingimpactofCOVID-19withregardtoNursingHomesoverthenext12-18months.

2. TermsofReference2.1. Provideassurancethatthenationalprotectivepublichealthandothermeasuresadoptedtosafeguard


2.2. ProvideanoverviewoftheinternationalresponsetoCOVID-19innursinghomesutilisingasystematicresearch process;

2.3. ReporttotheMinisterforHealthbyendJune2020inordertoprovideimmediatereal-timelearningsandrecommendationsinlightoftheexpectedongoingimpactofCOVID-19overthenext12-18months.

3. Independence3.1. ThePanelisanindependentexpertPanel.3.2. ItwillbeassistedandsupportedasnecessarybyaDepartmentofHealthprovidedsupportteam.3.3. ThePanelwillberesponsibleforthedirectionofitsworkanddecisionswithregardtotheorganisationof

itsworkandthecontentofitsfinalreport.3.4. ThePanelmaydelegateadministrativeandotherrelevanttasksandadministrativedecisionstothe

SupportTeam.

4. Membership • Prof.CecilyKelleher,Chair • Ms.BrigidDoherty • Ms.PetrinaDonnelly • Prof.CillianTwomey

5. TermsofEngagement/OperationalArrangements5.1. TheChairshall: 5.1.1. Setandmanagetheagendaforeachmeeting. 5.1.2. Managedeclarationsofconflictofinterestastheyarise. 5.1.3. Concludeeachmeetingwithasummaryofdecisionsand/oractions. 5.1.4. SignoffmeetingminutesinconsultationwithPanelmembers. 5.1.5. NominateanalternateshouldtheChairbeunabletoattendameeting. 5.1.6. ReporttotheMinisterforHealthinlinewiththetermsofreference.5.2. TheChairwilldecidethescheduleofmeetingsinconsultationwiththePanel.Itisanticipatedthatthe

Panelwillmeetapproximatelyonceperweek(thisschedulemaybesubjecttochange).5.3. MeetingswillbeheldviaVideocall.

Terms of Reference and Engagement


5.4. ThePanelwillundertakecloseddoormeetingsitselftodeliberateand/orconductanypartofitsworkinconfidence.

5.5. TheDepartmentofHealthwillprovideasupportteamtoassistthePanelwithitswork,includingtheprovisionofsecretariatsupport.

5.6. TheSecretarywillarrangeforcirculationofrelevantdocumentation,recordsofmeetings,andcommunicationswithregardtotheconveningofmeetings.

5.7. MeetingswillbedocumentedbytheSecretary,includingactionstobetaken,mainpointsdiscussed,minutesetc.

5.8. DraftminuteswillbecirculatedtoPanelmembersfollowingeachmeetingandapprovedsubjecttoanyappropriateamendmentsateachsubsequentmeeting[approvedminuteswillgenerallybepublishedontheDepartmentofHealth’swebsitesubjecttolimitedredactionifrequirede.g.toprotecttheintegrityofthedeliberativeprocessand/orothermattersfallingundertheFreedomofInformationAct(FOI)].

5.9. Asummaryofagreedactionpointswillbecirculatedtomembersassoonaspossiblefollowingeachmeeting.

5.10.TheChairmayinvitethirdpartiestoparticipateinmeetingstoprovideexpertinputandadvice.TheChairmayasksuchpersonstopreparediscussiondocumentsasappropriate.

6. Communications,CorrespondenceandMedia6.1. TheSupportTeamwillmanagecorrespondenceonbehalfoftheExpertPanel.6.2. In agreement with the Panel, agreed lines of reply will be used by the Support Team to respond to

correspondenceonbehalfofthePanel.6.3. The Support Team will establish and maintain a correspondence tracker and will report to the Panel

atagreedintervalsprovidingasummaryofcorrespondencereceived,highlightingkeyissuesandcorrespondenceandrequestingagreementontheresponsetobeissuedtoanykeyitems.

6.4. ThroughthesupportteamandinconsultationwiththeChairasnecessary,theDepartmentofHealth’spressofficewillinterfacedirectlywiththemediaonanymediaqueriesandrequestsandthesupportteamwillmaintainatrackerofsuchqueries.

6.5. HavingregardtopublicandparliamentaryinterestintheworkofthePanel,theSupportTeamwillmanageanyparliamentaryworkandMinisterialbriefingwithrespecttotheworkofthePanel,respectingthedeliberativeprocesses.

7. SupportTeam TheSupportTeammembersare: • Susan Callaghan • NiamhCarey • SarahGibney • SinéadMahon • NiallRedmond • Daniel Sheridan

Adedicatedemailaddressforallcommunicationshasbeenestablished:

[email protected](nolongeractiveoncompletionofPanel’sWork)

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Appendix2:

No.1StrengthenedHSENationalandRegionalGovernanceStructures • Establishanationalandregional(CHO)LTRCCOVID-19InfectionPreventionandControl(IPC)

TeamswithanallocatedIPCAdvisortoliaisewitheachLTRCandhomecareprovider • AlocalpublichealthledOutbreakControlTeamforeachoutbreakwhowillberesponsiblefordata

capturewithsupportofLTRCviaCRMsystem • ProvisionofupdatedguidanceincludingLTRCspecificadmissionandtransferguidance • Establishteams(perCHO),buildingonexistingcapacitywherepossible,toprovidemedicaland

nursingsupporttoLTRCs • Establishcapacityandprovideforteamsoflastresort(crisissupportteamtogointoindividualLTRC

facilitiesasrequired)toprovidestaffingforashortperiodoftimetoensureservicecontinuity • HIQA/MHCtoriskrateallLTRCsettingsbasedondiseaseprogression,environ-mentandstaffand

liaisewithnationalandregionalgovernancestructuresandLTRCsasnecessaryinlightofmitigatingactions

No.2TransmissionRiskMitigationinsuspectedorCOVID-19positivesettingsLTRCandhomecarestaff • HSEtoprovidesupportforappropriatealternativeresidenceandtransportforstafflivingin

congregateddomesticlivingarrangementsinvolvingotherLTRCset-tings/homecarestaff • MinimisestaffmovementworkingacrossLTRCs • AgenciesandLTRC/homesupportprovidersagreeprotocolstominimisestaffmovementacross

COVID-19andnon-COVID-19LTRCsettings/homesupportcli-ents

No.3StaffScreeningandPrioritisationforCOVID-19Testing • PrioritiseLTRCstaff/homecarestaffforCOVID-19testing • EachLTRCshouldundertakeactivescreeningofallstaff(Temperaturecheckingtwiceaday)

No.4HSEProvisionofPPEandOxygen • EnsurePPEsupplytoLTRCsettingsandhomesupportproviders • AccesstooxygenforLTRCsettings

No.5Training • TheHSEandLTRCsettingssupportaccesstotheprovisionoftrainingforsufficientstaffinIPC,use

ofPPE,useofoxygen,palliativecareandendoflifecare,pronouncementofdeath • TheHSEandhomesupportproviderssupportaccesstotheprovisionoftrainingforstaffinIPC

No.6FacilitiesandHomecareProviders–Preparednessplanning • DependingonsizeofLTCForhomecareproviderdesignateateamoratleastonefull-timestaff

memberasleadforCOVID-19preparednessandresponse • LTRCsettingshaveCOVID-19preparednessplansinplacetoincludeplanningforcohortingof

patients(COVID-19andnon-COVID-19),enhancedIPC,stafftraining,establishingsurgecapacity,promotingresidentandfamilycommunication,promotingadvancedhealthcaredirectives

Public Health Measures for COVID-19 Disease Management in LTRCs Adopted by NPHET at its Meetings of 31st March 2020 and 3rd April 2020


Appendix3:Systematic Rapid Review of Measures to Protect Older People in long-term Residential Care Facilities from COVID-19

Authorsofthisreport:Dr Kate Frazer, Dr Lachlan Mitchell, Diarmuid Stokes,

Eibhlin Crowley, Professor Cecily Kelleher

126

1. Introduction 128

2. Objective 128

3. SummaryofPolicyLiterature 128 3.1 Searchingotherresources/greyliterature 128

4. Results 128

5. SummaryofIrishLiterature 128 5.1 InfectionPreventionandControlMeasures 128 5.2 At-RiskCohorts 130

6. QualityofLife 131

7. UnexpectedDeaths 131

8. NF01sbycentretype,areatypeanddeprivation 131

9. SummaryofInternationalGreyLiterature 133

10. PreventingandManagingCOVID-19inNursingHomes 133

11. MortalityinCareHomesassociatedwithCOVID-19 134

12. COVID-19andLongTermCareActionsbyCountry 137 12.1 Australia 137 12.2 Canada 137 12.3 China 138 12.4 Finland 138 12.5 Germany 138 12.6 HongKong 138 12.7 Italy 139 12.8 TheNetherlands 139 12.9 SouthAfrica 139

13. ResultsfromSystematicReview 140

14. Methods 140 14.1 Typesofstudiesandevidence 140 14.2 Typesofparticipants 140 14.3 Typesofintervention 140

Contents


15. Primaryoutcomemeasures 140

16. Searchmethodsforidentificationofstudies(seeAppendixforsearchstrategy). 141

17. Searchingotherresources 141

18. Selectionofstudies/evidence 141

19. Dataextractionandmanagement 142

20. Datasynthesis 142

21. Results 142

22. Descriptionofstudies 142

23. Includedstudiesandevidence 143

24. ExcludedStudies 143

25. Effectsofinterventions 148

26. Adverseevents 152

27. Discussion 152 27.1 Qualityoftheevidence 154 27.2 Limitationsinthereviewprocess 154 27.3 Agreementsanddisagreementswithotherstudiesorreviews 154

28. Implicationsforpractice 155

29. Implicationsforresearch 155

30. ReferenceList1ReviewofPolicies 194

31. ReferenceList2SystematicReview 195

32. AppendixExampleofSearchStrategy 199

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1. Introduction ThischapterpresentsarapidreviewliteratureundertakenonbehalfoftheCOVID-19NursingHomes

ExpertPanel.Thischapterpresentsresultsfrom1)areviewofnationalandinternationalpolicydocumentsandgreyliterature,followedby2)presentationofresultsfromarapidsystematicreview(CRD42020191569)ofinternationalevidence.

2. Objective ThisreviewofevidenceaimedtoprovideanoverviewoftheInternationalresponsetoCOVID-19

innursinghomes,toassesstheextenttowhichmeasuresimplementedinlong-termresidentialcarefacilities(RCFs)reducedtransmissionofSARS-CoV-2andtheeffectonmorbidityandmortalityoutcomes.

3. SummaryofPolicyLiterature 3.1Searchingotherresources/greyliterature OneauthorcompletedacomprehensivesearchofthegreyliteratureaccessingGoogleScholardatabase

(from01/01/2019to12/06/2020).WesearchednationalandinternationalwebsitesforallpolicydocumentsandreportsincludingtheagileplatformLongTermCareResponsestoCOVID-19(https://ltccovid.org/),WorldHealthOrganisation(WHO),websitesreportinghealthprofessionalguidelinesandCentersforDiseaseControl(CDC)reports.Weincludeevidencefromnationalandinternationalreportsandpolicies.

4. Results Theresultsfromthegreyliteraturesearchpresentnationalevidencefollowedbyevidencereportedfrom

internationalsources.

5. SummaryofIrishLiteratureDuringthecourseoftheCOVID-19pandemicinIreland,differentstatebodies,particularlytheHealthInformationandQualityAuthority(HIQA)havechartedtheinfectionandmortalityratesofthoseresidinginnursinghomes.Thissummarycompilestheirfindings.

5.1InfectionPreventionandControlMeasuresInJune2020HIQAreleasedareview(RapidReviewofPublichealthGuidanceforResidentialCare,11thJune2020https://www.hiqa.ie/reports-and-publications/health-technology-assessment/rapid-review-public-health-guidance)oftheinfectionpreventionandcontrolmeasuresputinplaceinIrishnursinghomesduringCOVID-19.Thereviewseekstooutlinemeasurestakenoradvisedbyotherorganisationsandgovernmentstoprotectresidentsandstaffofnursinghomes.Thereviewalsofocusedonidentifyingwhetheranyenhancedinfectionpreventionandcontrolmeasures,suchasuniversaltesting,forexample,arebeingtakenelsewheretoprotectRCFsthathavenoknowncasesofCOVID-19. ThereportconcludedthatarangeofguidancewasissuedinternationallytoprotectresidentsandstaffofRCFsinthecontextofCOVID-19.Theguidance,forthemostpart,includesrecommendationsontesting,screening,monitoring,isolation,cohorting,socialdistancing,visitation,environmentalcleaning,immunisation,providingcarefornon-cases,caringfortherecentlydeceasedandgovernanceandleadership.


Thereportfoundthatmanysimilaritiesexistbetweenguidancedocuments,includingrecommendationstoscreenpeopleenteringfacilities,tomonitorstaffandresidentsfornewsymptoms,torestrictvisitationexceptoncompassionategrounds,toisolatesuspectedandconfirmedcases,tocohortresidentswhoweresymptomatic,tocleanfrequentlytouchedsurfacesregularly,andtodevelopoutbreakmanagementplans.Someareasdifferbetweenguidancedocuments,includingcriteriafortesting,lengthofisolationofsymptomaticresidents,recommendationsfortheuseoffacemasksbystaffandresidents,immunisationrequirements,useofnebulisersandguidanceoncaringfortherecentlydeceased. Somerecommendationswerenotcommonandwereissuedbyonlyoneortwoagencies,suchastheguidance on temporary resident transfer to the homes of family or friends, using a single countrywide mechanismforreportingbedvacanciesandventilation.Guidanceonlimitingstaffmovementbetweenfacilitiesandmanagingdeliverieswasalsolimited. Notallguidancedocumentsreviewedincludeddetailonallofthethemesidentified.Forexample,theWHOdoesnotadviseonthecohortingofstaff,eventhoughthecohortingofstaffisrecommendedbymostagenciesreviewed.Ininstanceswhereanagencyhasnotprovidedguidanceonathemeincludedinthisreview,itispossiblethatthisareaiscoveredinotherguidancedocumentsnotspecifictoCOVID-19andRCFsandthusnotcapturedinthisreview. Anewthemeof“reopening”hasalsoemerged.GuidanceforwhenRCFsreopenhasbeenpublishedbytheCentersforMedicare&MedicaidServices(CMS)(20)andadoptedbytheCDC.Thisoutlinesathree-phaseplanwithcriteriaforimplementingandserviceprovisionguidance,includingfortesting,visitation,communaldining,groupactivitiesandmedicaltripsoutsidethefacility,ateachphase.Ireland,HongKong,NewZealandandtheCMShaveissuedguidanceforvisitsduringthereopeningofRCFs.Therecommendationsincludelimitingvisitornumbers,maintainvisitorlogs,screenvisitorsforsymptomsandpotentialcontactwithCOVID-19,maintainphysicaldistancing(exceptNewZealand),implementstricthandhygienemeasuresandtostopvisitsifthereisaconfirmedcaseofCOVID-19withintheRCF.Somecountriesarerelaxingtheprotectivemeasurestheypreviouslyputinplace.NewZealandhasrelaxeditsguidanceonvisitation,isolation,admissions,outingsandhasremovedthephysicaldistancingrequirementforeveryone,includingthoseinRCFs.HongKonghasalsorelaxedtheirguidanceonvisitation,communalactivities,wearingoffacemasksbyresidentsandoutingsforRCFs.Irelandwillallowvisitsfromthe15JuneforRCFswithnocasesofCOVID-19. InMay2020HIQAalsoreleasedtheresultsofarapidreviewofpublichealthguidanceonprotectivemeasuresforvulnerablegroups(RapidreviewofpublichealthguidanceonprotectivemeasuresforvulnerablegroupsHealthInformationandQualityAuthority,21May2020).ThereviewfoundthatavarietyofprotectivemeasurestoprotectvulnerablegroupswhoareathighriskofsevereillnessfromCOVID-19.Thesebroadlyinvolvesocialorphysicaldistancingandprotectiveself-separation.However,highlyprotectivemeasuresareinplacetoshield,orcocoon,thosewhoareconsideredextremelymedicallyvulnerabletosevereillnessfromCOVID-19,asseeninIrelandandtheUK.Sincethe18May,NorthernIrelandhasincludedpeoplewhohavehadasplenectomyasextremelyvulnerablepeople.Singaporehasindicatedthat,asrestrictionseasefrom2June,theadvicetostayathomewillremain. Newguidancehasbeenpublishedforolderpeople,particularlythoseover70,inFinland,includingadviceonimprovingwell-beingandfunctionalabilityduringthecrises.TheMinistryofHealthandSocialAffairsinSwedenpublishedanarticleonmeasures,advice,andrestrictionsspecifictohigh-riskpopulations.

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Althoughsomeofthemeasuresmayseemstringent,research(byFergusonetal.(33)inMarch2020)suggeststhatsocialdistancingofolderpeopleandothersmostatriskofseveredisease,incombinationwithhomeisolationofsuspectedcasesandhomequarantineofthoselivinginthesamehouseholdassuspectedcases,couldreducehospitaldemandandmortality.

5.2At-RiskCohortsInMarch2020TILDAreleasedareporttoinformonthedemographicsforover50’sinIrelandfortheCOVID-19crisis(TILDAreporttoinformdemographicsforover50sinIrelandforCOVID-19crisishttps://tilda.tcd.ie/publications/reports/Covid19Demographics/).TILDAisaLongitudinalStudyonAgeing,whichatwave1(2009)represented1:156peopleaged50andolderinIreland.TILDAcollectsdetailedsubjectiveandobjectivemeasuresofhealth,socialcircumstancesandeconomicseverytwoyears.TheTILDAreportanalyseddatatoidentifynumbersofat-riskcohortsbasedonexistingnationalandinternationaldataforat-riskgroups(i.e.frailty,prefrailty;cardiovascularandchronicconditions;comorbidities;possibleat-riskCVDandanti-inflammatorymedications*);andliving/householdcircumstances(socialisolation)includinggrandparenting;communitysocialcareandhealthservice.Thetablebelow(TILDA2020)presentsresultsindiseaseprevalenceinover50sinIreland.

Table 1: Disease prevalence in TILDA and Population of over 50s Ireland

MedicalCondition NumberofcasesinTILDA(n=5,206)

EstimatedPopulationPrevalence%

EstimatedNumberinPopulation(n=1,446,460)

Asthma 657 12.79 185002

Chronic lung disease such as chronicbronchitisoremphysema

402 8.53 123383

HighCholesterol 3037 58.5 846179

Hypertension 2589 51.84 749845

Arthritis(includingosteoarthritis,orrheumatism)

2256 45.55 658863

Osteoporosis,sometimescalledthinorbrittlebones

1148 22.27 322127

Diabetes 612 12.64 182833

Cancer or a malignant tumour 612 11.58 167500

Thyroid Problems 592 11.11 160702

Angina 337 7.27 105158

Aheartattach(inc.myocardialinfarctionorcoronarythrombosis)

295 6.16 89102

VaricoseUlcers(anulcerduetovaricoseveins)

226 4.75 68707

Ministroke/TIA 242 4.66 67405

Astroke(cerebralvasculardisease) 143 2.45 35438

Congestiveheartfailure 83 1.75 25313

Cirrhosis, or serious liver damage 59 1.4 20250

TILDA report to inform demographics for over 50s in Ireland for COVID-19 crisis.


6. QualityofLife InMay2020TILDAreleasedareporttoinformCOVID-19responsesinnursinghomes(TILDAnursing

homedata:AshortreporttoinformCOVID-19responsesforourmostvulnerable2020https://tilda.tcd.ie/publications/reports/Covid19NursingHomes/index.php).ThissmalldescriptiveseriesofTILDAnursinghomeparticipantsfoundthatparticipantswerechronologicallyveryold,hadveryhighlevelsofphysicalandcognitivemorbidities,andveryhighlevelsofphysicaldisability. Despitetheabove,whenTILDAnursinghomeparticipantswereabletoself-report,amajorityreportedthattheirphysicalandmentalhealthwasfair,good,verygoodorevenexcellent.Notbeingabletoself-reportwasmostlyassociatedwiththepresenceofcognitiveandcommunicationproblems,includingdementia. ThereportfoundthatthepersonalperspectivesoftheTILDAnursinghomeparticipantsprovidedanessentialreminderthatqualityoflifeisoftenratedhigherbyoneselfthanbyproxies,eveninthepresenceofveryadvancedageandextensivecomorbiditiesanddisabilities. However,fromthedatasourcesaloneinthisreport,itisnotpossibletoinfertheproportionorincidenceofinstitutionalisationintheIrishpopulation.ThesmallnumberofparticipantsincludedintheshortreportcomesfromsecondarydataanalysisandisnotnecessarilyrepresentativeofthenursinghomepopulationinIreland.

7. UnexpectedDeaths InMay2020HIQAreleasedareport(AnalysisofNF01andNF02notificationstoHIQA,11thMay2020)

examininganyunexpecteddeathsofresidentsinnursinghomesinIreland.FromMarch2020thesenotificationsofunexpecteddeathsincludedsuspectedorconfirmedCOVID-19asacauseofdeath.ThereportalsolookedatfiguresforconfirmedandsuspectedCOVID-19infectionsinstaffandresidents. ThereportfoundthatthenumberofdeathsattributedtoCOVID-19differsbytypeofnotification(Table2).Atotalof604COVID-19relateddeathswerereportedacross97centresbasedonNF01s.

Table 2: Counts of Centres and Mortality (1st March 2020 to 6th May 2020)

Causeofdeath Centres Deaths

Non-COVID-19related 137 240

COVID-19related 97 604

AllNF01s 193 844

HIQA Analysis of NF01 and NF02 notifications to HIQA

8. NF01sbycentretype,areatypeanddeprivation Theriskratioforallnotifieddeathsindicatestheelevatedriskofdeathobservedsince1March2020

relativetohistoricalpatterns.Ahighriskratiofornon-COVID-19NF01ssuggeststhatthereiseitherunder-classificationofunexpecteddeathsasCOVID-19related,orthatthereisanincreasedriskofunexpecteddeathsnotattributabletoCOVID-19.

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TheriskofunexpecteddeathduetoCOVID-19differsbetweenprivatedesignatedcentresandHSEownedorfundedcentres.Theriskofmortalityfortheperiod1March2020todatewascomparedtotheriskbasedonhistoricalpatterns.Arelativeriskratewascalculatedforallnotifieddeathsandallnon-COVID-19deaths.DeathslistedarebasedonlyontheNF01datatocapturenon-COVID-19relateddeaths. Table 3: Relative risk of mortality: 1 March 2020 to 6 May 2020 versus historical

Factor Type Centres Beds Riskratio(mean[95%CI])

N(%) N(%) AllNF01s Non-Covid-19NF01s

Centretype HSE 138(24%) 6,950(22%) 4.56[3.16to6.67] 1.48[1.03to2.17]

Private 442(76%) 25,288(78%) 5.40[4.58to6.41] 1.50[1.27to1.78]

Areatype City 142(24%) 9,379(29%) 6.84[5.04to9.26] 2.12[1.56to2.87]

Town 228(39%) 12,944(40%) 4.91[3.91to6.30] 1.30[1.03to1.67]

Village 78(13%) 3,603(11%) 5.08[3.04to8.75] 1.31[0.78to2.25]

Rural 132(23%) 6,312 4.44[3.20to6.39] 1.30[0.93to1.87]

Deprivation 1(leastdeprived)

97(17%) 5,807(18%) 5.43[3.94to7.71] 1.94[1.40to2.75]

2 82(14%) 4,677(15%) 5.86[3.97to9.36] 1.65[1.12to2.64]

3 66(11%) 3,680(11%) 11.19[6.29to21.40] 1.88[1.06to3.60]

4 111(19%) 6,536(20%) 5.38[3.75to7.89] 1.58[1.10to2.32]

5(mostdeprived)

224(39%) 11,538(36%) 4.29[3.39to5.53] 1.19[0.94to1.53]

HIQA Analysis of NF01 and NF02 notifications to HIQA

Thisreport’sdatasuggests‘anelevatedriskofnon-COVID-19mortality,whichmayindicateunder-classificationofmortalityasCOVID-19related.Theelevatedriskofnon-COVID-19mortalityismorepronouncedincentreslocatedinurbanareasandthelessdeprivedareas’(Page3ofHIQA'sreport). WithregardstonumbersofresidentswithCOVID-19reportedmortalityduetoCOVID-19inpubliccomparedtoprivatenursinghomesthereportfoundthatHSEcentreswithreportedCOVID-19casesordeathsaccountfor3,721of6,950(53.5%)ofHSEbeds.PrivatecentreswithreportedCOVID-19casesordeathsaccountfor13,887of25,288(54.9%)ofprivatebeds.AstheproportionofbedsinCOVID-19affectedcentresisapproximatelythesameinHSEandprivatecentres,therelativedifferencewillbeunaffectedbychoiceofbedmeasure(Page4ofHIQA'sreport). ThereportalsofoundthattheCOVID-19pandemichasnotaffectedallcountiesequally,withsomehavingamuchmoresignificantburdenofinfection.IntermsofthepercentageofcentreswithoneormoreCOVID-19cases,figuresvaryfrom12.5%inKilkennyto100%inMonaghan(Page7ofHIQA'sreport).ThenumberofCOVID-19relateddeathsperbedvariesconsiderablyacrosscounties,assumingfullcapacityatthestartofMarch,theproportionofdeathsperbedusedtoapproximatethepercentagemortalityfromCOVID-19,whichis1.9%nationally.


9. SummaryofInternationalGreyLiteratureDuringtheCOVID-19pandemicinEurope,differentagencieshavestudiedtheeffectsofinfectioncontrolandproceduresontheinfectionandmortalityratesinnursinghomes.Thissummarydocumentstheirkeyfindings.

10. PreventingandManagingCOVID-19inNursingHomes TheInternationalLongTermCarePolicyNetworkbasedintheLondonSchoolofEconomicspublished

areportinMay2020whichdocumentedinternationalexamplesofmeasurestopreventandmanageCOVID-19outbreaksinresidentialcareandnursinghomesettings(https://ltccovid.org/wp-content/uploads/2020/05/International-measures-to-prevent-and-manage-COVID19-infections-in-care-homes-11-May-2.pdf). Thereportfoundthatwhileboththecharacteristicsofthepopulationincarehomesandthedifficultiesof physical distancing in communal living mean that care home residents are at high risk of dying from COVID-19,thesedeathsarenotinevitable.Countrieswithlowlevelsofinfectioninthepopulationtypicallyalsohavelowlevelsofinfectionsincarehomes. ThereportfoundthattheresponsetoCOVID-19incarehomesneedscoordinatingacrossallrelevantgovernmentdepartmentsandlevels,andwiththeacutehealthsectorresponse.EvidenceofasymptomatictransmissionandatypicalpresentationofCOVID-19inolderpopulationsshouldreflectinguidancedocumentsandtestingpolicies.Regulartestingofresidentsandstaffincarehomesisessential,ideallyfollowedbycontacttracingandeffectiveisolation.Also,timelydataontheimpactofCOVID-19incarehomesisvitaltoensurethatopportunitiesforpreventinglargenumbersofdeathsarenotmissed. Thereportnotedthatstaffpayandlivingconditionsmightbeanessentialbarriertoeffectiveinfectioncontrols,particularlyifstaffdonothaveaccesstosickpayorneedtoworkinmultiplefacilities(orliveincrowdedaccommodation).Accesstohealthcareandpalliativecare(intermsofpersonnel,medicinesandequipment)alsoneedstobeguaranteed,particularlyforhomeswithoutnursingormedicalstaff.However,notallcarehomesaresuitableforisolationfacilities.Technicalsupportandalternativeaccommodationmayberequiredinsomecases.Thereportalsonotesthatmeasurestoaddressthepsychologicalimpactofthepandemiconbothstaffandresidentsneedtobeputinplace,particularlyasmanystaffandresidentswillhaveexperiencedtraumaandgrief.Forsomeresidents,particularlythosewithdementia,thedisruptionintheirnormallivesbythemeasuresmayhavesignificantnegativeimpacts. The report also found that while most countries have restricted visitors, this policy alone has not protectedcarehomesfrominfection.Countriesareincreasinglyconsideringhowtomakevisitssafer,recognizingtheirimpactonwellbeing. TheEuropeanCentreforDiseasePreventionandControl(ECDC)outlinesintheirMay2020report(SurveillanceofCOVID-19atlong-termcarefacilitiesintheEU/EEAhttps://www.ecdc.europa.eu/en/publications-data/surveillance-COVID-19-long-term-care-facilities-EU-EEA)thatenhancedinfectionpreventionandcontrol(IPC)measuresshouldbeinplaceinalllong-termresidentialcarefacilities(LTRCs).Thisincludesseparationofpossiblecaseswithrespiratorysymptoms,evenwithoutlaboratoryconfirmationofCOVID-19.SeveralIPCmeasuresforCOVID-19inhealthcarefacilitiesfocusmainlyonrapididentification,sourcecontrol,administrativecontrols,environmentalmeasuresandpersonalprotectivemeasuresaccordingtonationalorlocalauthorityguidelines.ECDChaspublishedguidancethatincludesoccupationalhealthandsafetyrequirementsinhealthcaresettingsandLTRCs.Inareaswithsustainedcommunitytransmission,inadditiontostricthandhygiene,thewearingofsurgicalmasksorFFP2respiratorsshouldbeconsideredbyallLTRCstaffwhencaringforallresidents.OthermeasurestoconsideraretemporaryclosureofLTRCsforvisitorsandsystematictestingofallLTRCstaff.

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TheWorldHealthOrganisation(WHO)issuedguidanceforLTRCsonpreventingthespreadofCOVID-19withintheirfacilitiesonthe21stofMarch2020(InfectionPreventionandControlGuidanceforLong-TermCareFacilitiesinthecontextofCOVID-19https://apps.who.int/iris/bitstream/handle/10665/331508/WHO-2019-nCoV-IPC_long_term_care-2020.1-eng.pdf)..TheobjectiveofthereportwastoguideIPCinLTRCsinthecontextofCOVID-19to1)preventCOVID-19-virusfromenteringthefacility,2)preventCOVID-19fromspreadingwithinthefacility,and3)preventCOVID-19fromspreadingtooutsidethefacility.Withregardstoprevention,thedocumentoutlinedtheneedforinfectionpreventionandcontrolcommitteeswithanIPCcoordinator,physicaldistancinginplacewithinthefacilityandvisitingreduced. However,onthe12thofMarch,theECDCalsoissuedareportoninfection,preventionandcontrolforCOVID-19inhealthcaresettings(InfectionpreventionandcontrolforCOVID-19inhealthcaresettings-firstupdatehttps://www.ecdc.europa.eu/sites/default/files/documents/COVID-19-infection-prevention-and-control-healthcare-settings-march-2020.pdf)whichadvisesoncontrolsthatshouldbeimplementedinaLTRCs.ThereportgaveanoutlineoftechnicalmeasuresandresourcesforreducingtheriskoftransmissionofCOVID-19inhealthcaresettings(includingLTRCs)andlaboratoriesintheEU/EEA.ItdrewoninterimadviceproducedbyWHOandnationalagencies,andalsoexpertopinion,forLTRCsactionsincludedadministrativemeasures,themanagementofresidentswithCOVID-19symptomsandenvironmentalcleaningandwastemanagement.Additionalmeasuresalsolistedincludedinstitutingdailymonitoringofallresidentsforsymptoms,e.g.measurebodytemperature,restrictedaccesstotheLTRC;onlyadmittingessentialservicesandnewresidentsandreinforcingthemessagethatpeoplewithrespiratorysymptomsshouldnotentertheLTRC.

11. MortalityinCareHomesassociatedwithCOVID-19 TheInternationalLongTermCarePolicyNetworkpublishedareportinMay2020,highlightingtheearly

internationalevidenceonmortalityassociatedwithCOVID-19outbreaksincarehomes(https://ltccovid.org/wp-content/uploads/2020/06/Mortality-associated-with-COVID-21-May.pdf). ThereportfoundthatofficialdataonthenumbersofdeathsamongcarehomeresidentslinkedtoCOVID-19isnotavailableinmanycountries.Still,anincreasingnumberofcountriesarepublishingdata.Duetodifferencesintestingavailabilitiesandpolicies,andtodifferentapproachestorecordingdeaths,internationalcomparisonsaredifficult,howevertherearethreemainapproachestoquantifyingdeathsinrelationtoCOVID-19:deathsofpeoplewhotestpositive(beforeoraftertheirdeath),deathsofpeoplesuspectedtohaveCOVID-19(basedonsymptoms),andexcessdeaths(comparingthetotalnumberofdeathswiththoseinthesameweeksinpreviousyears).Anotherimportantdistinctioniswhetherthedatacoversdeathsofcarehomeresidentsoronlydeathsinthecarehome(astherearevariationsintheshareofcarehomeresidentswhoareadmittedtohospitalandmaydiethere). Reliabledatafrom19countriessuggeststhattheshareofcarehomeresidentswhosedeathsarelinkedtoCOVID-19tendstobelowerincountrieswheretherehavebeenfewerdeathsintotal,althoughasthenumberofdeathsgrowstheshareseemstoreachaplateau,fornow.TherehavebeennoinfectionsordeathsincarehomesinHongKong(only4deathsintotaland1,056casesofinfectionsinthetotalpopulation).Intheothercountrieswheretherehavebeenatleast100deathsintotalandofficialdataisavailable,thepercentageofCOVID-19-relateddeathsamongcarehomeresidentsrangesfrom24%inHungaryto82%inCanada).DatafromEnglandillustrateswelltheimportanceofpayingattentiontodifferencesindefinitionsandmethodsusedtoestimatethesepercentages:theshareofallprobableCOVID-19deathsincarehomesis27%,andtheshareofdeathsofcarehomeresidentsis38%.Theshareofexcessmortalityincarehomesduringthepandemichasbeen44%,andtheshareofdeathsofcarehomeresidentsis52%ofallexcessdeaths.Also,inFrance,deathsincarehomesare34%ofallCOVID-19deaths,whereasdeathsofcarehomeresidentsare51%.

excess


ForafewcountriestheshareofallcarehomeresidentswhosedeathscanbelinkedtoCOVID-19canbeestimated.Theserangefrom0inHongKong,0.3%inAustria,0.4%inGermanyand0.9%inCanada,to2%inSweden,2.4%inFranceand3.7%inBelgium.IntheUK,ifonlydeathsincarehomesregisteredaslinkedtoCOVID-19isconsidered,thefigurewouldbe2.8,whereasifexcessdeathsofcarehomeresidentsareused,itwouldbe6.7%.

Table 4: Number of COVID-related or confirmed deaths in the population and in care homes (or among care home residents). Country Date Approachto

measuringdeathsTotalnumberdeathslinkedtoCOVID-19

NumberofdeathsofcarehomeresidentslinkedtoCOVID-19

Numberofdeathsincarehomes

Numberofcarehomeresidentdeathsas%ofallCOVID-19deaths

Numberofdeathsincarehomesas%ofallCOVID-19deaths

Austria 06/05/2020 Confirmed 510 220 41%

Australia 18/05/2020 Confirmed 99 29 29%

Belgium 18/05/2020 Confirmed+Probable 9,080 4,646 51%

Canada 08/05/2020 Confirmed+Probable 4,740 3,890 82%

Denmark 07/05/2020 Confirmed 506 170 34%

France 18/05/2020 Confirmed+Probable 28,239 14,363 10,650 51% 38%

Germany 20/05/2020 Confirmed 8,090 3,049 37%

HongKong 20/05/2020 Confirmed 4 0 0 0% 0%

Hungary 11/05/2020 Confirmed 421 100 24%

Ireland 06/05/2020 Confirmed+Probable 1,375 857 62%

Israel 29/04/2020 Confirmed 202 65 32%

Norway 18/05/2020 Confirmed 233 135 58%

Portugal 09/05/2020 1,125 450 40%

Singapore 03/05/2020 Confirmed 18 2 0 11%

SouthKorea 30/04/2020 Confirmed 247 84 0 34% 0%

Spain 10/05/2020 Confirmed+Probable 31,889(confirmed)

9,642 (confirmed) 16,678(confirmed+probable)

30%(confirmed)

Sweden 14/05/2020 Confirmed 3,395 1,661 49%

England&Wales(UnitedKingdom)

08/05/2020 Probable+Excessdeaths

37,375(probable) 49,470(excessdeaths)

12,526 (probable) 25,591(excessdeaths)


38% (probable) 52% (excess deaths)


Scotland(UnitedKingdom)

17/05/2020 Probable+Excessdeaths

3,546(probable) 3,946(excessdeaths)



UnitedStates 20/05/2020 Confirmed 93,163 30,130 41%

International Long Term Care Policy Review - Mortality associated with COVID-19 outbreaks in care homes: early international evidence

136

Table 5: Share of care home residents who may have died as a direct or indirect result of the COVID-pandemic

Numberofcarehomeresidents(orbeds)

DeathsattributedtoCOVID(aspertable6)aspercentageofcarehomeresidents

Excessdeathscomparedtopreviousyears,aspercentageofcarehomeresidents

Austria 69,730 0.3%

Belgium 125,000 3.7%

Canada 425,755 0.9%

France 605,061 2.4%

Germany 818,000(beds) 0.4%

Sweden 82,217 2.0%

UnitedKingdom 411,000 3.4% 6.7%


Table 6: Total number of deaths linked to COVID-19 in the total population compared to the number of deaths among care home residents, plotted using a logarithmic scale for the total deaths



12. COVID-19andLongTermCareActionsbyCountry Examplesfrom9countriesfromtheInternationalLongTermCarePolicyNetworkCountryReportson

COVID-19andLongTermCare-https://ltccovid.org/country-reports-on-covid-19-and-long-term-care/arepresentedbelow. 12.1Australia April2020Report TheAustraliangovernmentprioritisedpreparingtheagedcaresectorforCOVID-19.Onthe11thofMarch,$440millionwascommittedtoagedcare,includingtoaddressstaffretentionandsurgestaffingandimproveinfectionpreventionandcontrol.AgedcareprovidershadpriorityaccesstothenationalstockpileofPPE,healthcarerapidresponseteamsandstaffingsupportwhenanoutbreakoccursinafacilityorinhomecare. Nursinghomevisitingruleswereintroducedbythegovernmentonthe18thofMarch,limitingvisitorstotwopeopleaday,toheldinprivaterooms.Manynursinghomesintroducedstricterrules,lockingdownfacilitiessothattherearenovisitorsexceptforunderparticularcircumstances. Therehavebeen55nursinghomeresidentsdiagnosedwithCOVID-19,ofthose13havediedand14recovered,representing<1%ofallCOVID-19casesand17%ofalldeaths. Atthetimeofwriting,AustraliahasflattenedtheCOVID-19curveandgovernmentandpublicdiscussionisshiftingtosofteningprovider-imposedtotalnursinghomelockdownsandsupportingthewellbeingofresidents. 12.2Canada

4thJune2020 WhiletherearemanysourcesofdataontheimpactofCOVID-19ontheCanadianpopulation,ingeneral,timely,consistentandaccurateinformationonthenumberofconfirmedcasesofCOVID-19inCanadianlong-termcarehomescontinuetobeachallengeinthispandemic.Asnewinformationbecomesavailableandcasesevolvedorresolved,therehavebeenchangestopreviouslyestimatedprevalenceandcasefatalityofresidentsinCanadianlong-termcarehomes.Thereisanestimatedcasefatalityrateof36%(range20to42%)amongresidentsinCanadianlong-termcarehomes.Basedonpubliclyavailableinformationfromofficialsources,ithasbeennotedinthisreportthatdeathsinlong-termcareresidentscurrentlyrepresentupto85%ofallCOVID-19deathsinCanada. Thedifferenceinpopulationsizeanddensityineachprovince,whichinfluencestherateofcommunitytransmission,maypartiallyaffectregionaldifferencesintheprevalenceofCOVID-19casesinlong-termcarehomes,ratherthantheproportionsofprovincial/territorialpopulations80yearsorolderlivinginthesesettings. Giventhevulnerabilityofresidentsinlong-termcarehomes,theproperimplementationofinfectionpreventionandcontrolpoliciesisthemosteffectivestrategytoreduceoverallratesofdeathsinthispopulation.KeypolicymeasurestopreventthecontinuedspreadofCOVID-19andassociatedmortalityinCanadianlong-termcarehomeresidentsincludeadequatestaffing,limitationofmovementofhealthcareworkersbetweenmultiplesites,accesstopersonalprotectiveequipmentandensuringstaffknowhowtouseitproperly. Withdecreasingincidencerates,manyprovincesarestartingtoconsiderrelaxingvisitationrestrictions.Continuedscreeningforbothtypicalandatypicalsymptoms,aswellasperiodicsurveillancetestingoflong-termcarestaffandresidents,arecriticalforbalancingresidentsafetyandwell-being.

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12.3China 16thApril2020 InMainlandChina,thenationalministriesandcommissionshaveissuedandupdatedapackageof

guidelinesandcircularstosupportlong-termcare.Thosepoliciesmandatedahighlevelofcross-sectoralcollaborationandprioritizationoflong-termcareservicesforolderpeople.Thereportfoundthatasteeringcommitteeforprovidingguidanceandintegratingresources,andanintegrativeITsystemforinformationanddatasharingarecrucialforpromptandefficientresponses.Keymeasureshavefocusedoncoordinatingacuteandlong-termcareandpreventingthevirusspreadincarehomes.Movingfromthecontainmentphaseintothemitigationstage,theChineseGovernmentisnowfocusingontheprovisionofregularhealthandsocialcareservicesforolderpeople. 12.4Finland

12thJune2020

Finlandhassucceededinprotectingpeopleaged70yearsandoverfromCOVID-19ingeneral.Still,almosthalfofthe318deathsinthecountryhaveoccurredincarehomesforolderpeople(situationon1stJune).However,itislikelythatalldeathsfromCOVID-19havenotbeenrecognisedandclassifiedsimilarly. Therearealsoremarkableregionaldifferencesinthespreadoftheinfection.However,thenationalguidelinesforrestrictionsaresimilarthroughoutthecountry.Thenationallevelguidelineshavebeenmoredetailedandclearerforcarehomesthanforhomecare.Theimplementationofthemeasurestopreventtheinfectionhasvariedbetweenmunicipalities,however,mostofthemunicipalitieshaveactedvigorouslyregardingthepreventionofthevirusandfollowedthegiveninstructions.Incarehomes,visitingrestrictionshaveinsomecasesledtoanxietyconcerningfamilymembers.Inexposurecases,someoftheresidentshavehadrelativelylongperiodsofisolation,duringwhichmobilitywithinthecareunitislimited.Therefore,attemptstopreventapossibledeteriorationinmentalwell-being,includingprovidingvideocallsandphotographstotheresidents. 12.5Germany

26thMay2020 TheGermangovernmenthasissuedfinancialsupportandrelaxedmonitoringofcareprovidersduringthis

pandemicsothattheresidentialandambulatorycarethatpeoplereceivecanbemaintained. ResidentialcaresettingsacrossGermanyhavestartedtoallowtheirresidentstohavevisitors.Thecaresettingshavetodevelopandimplementcomplexsafetyprotectionplanstofacilitatethis. TheRobertKochInstitute(RKI)providesregularlyupdatedguidance,recommendationsandadviceforspecificcaresettings.Thisguidanceincludestheestablishmentofzonestophysicallyseparateresidentsduringtheoutbreakandcontacttracing.TheRKIalsoissuesadailyupdateonthenumberofconfirmedandrecoveredCOVID-19casesaswellasofthenumberofCOVID-19relateddeaths.

12.6HongKong27thApril2020 Therehavebeen1,038confirmedcasesofCOVID-19inHongKongasof27thApril2020.However,therehavebeennofrontlinehealthcareworkersaffected,andnonursinghomeresidentshavebeeninfectedwiththevirussofar.TheGovernmentandsocietyatlargerespondedveryquickly.Theyimposedstrictpoliciestostemthespreadofthevirusincommunityandlong-termresidentialcarefacilities,includingpracticeguidelines,financialsupportandspecialarrangementsonhealthandsocialcare


services.Non-GovernmentalOrganisationsincreasedtheuseofanti-epidemicmeasuresandinformationandcommunicationtechnologytosupportolderpeopleandtheirfamilymembersduringtheepidemic,includingpeoplelivingwithdementia.

12.7Italy

30thApril2020

ThereportoutlinedthattheItaliangovernmentactedlatewithregardtotheCOVID-19outbreakmanagementinnursinghomes.Thefirstoperationalguidelineswerereleasedafterthecountry’stotallockdownonMarch9th,onlyrequiringcarehomestosuspendvisitations.TheMinistryofHealthonlyreleasedanupdateoftheoperationalguidelinesdedicatedtonursinghomesonMarch25th.ThefirstCOVID-19casewasdetectedinItalyonJanuary30th.InItaly,regionalauthoritiesareresponsiblefortheoperationalregulationoftheLTRCsector:aftertheoutbreak,theyenactedlateanddifferentresponseswithoutclearguidancefromthenationallegislator. ItalyalsofacedamassiveshortageofPersonalProtectionEquipment(PPE)andnursinghomeswerenotprioritizedforreceivingnewprocurements.WorkersandcareuserswerethereforenotsufficientlyprotectedfromthespreadofCOVID-19.Coordinationwithhealthcareactors(mainlyacutecarebutalsogeneralpractitioners)hasalsobeenlimitedandpoorlyimplemented,mainlyrelyingonprofessionallinkagesofindividualprofessionalsandwithoutaregionalornationalframework. TheNationalInstituteofHealth(InstituteSuperiorediSanità)launchedasurveytoinvestigatetheincrediblyhighnumbersofdeathsregisteredinlong-termresidentialcarecentresforolderpeopleafterthenationalpressraisedtheattentiononthepotentiallyconsiderableunderestimationofCOVID-19-relateddeathsincarehomes.PreliminaryresultsconfirmthattheactualnumberofCOVID-19relateddeathsmightbemuchhigherthanreportedinofficialdocuments.Asoftoday,currentproceduresdonotforeseetestingolderpeopleincarehomes,neitherthosewhodiedafterpresentingsymptoms.ThereportfoundthattheresponsetotheCOVID-19emergencywaslefttotheinitiativeofeachnursinghomealone,relyingontheircapacityandwillingnesstocopewithextraordinaryconditionswhilehavingpoorsupportfrominstitutions. 12.8TheNetherlands26thMay2020 Afterasignificantpeakinthenumberofdeathsinweek15(6April-12April2020),thenumberofCOVID-19casesanddeathsinnursinghomeshasbeendeclining.TheDutchgovernmentistakingaphasedapproachtorelaxingthenursinghomevisitorbanwhilemonitoringinfectionsanddeaths.Nursesandcarersinnursinghomesandhomecareorganisationscanapplyforpersonalprotectiveequipment(PPE)andcangainaccesstotesting.However,careprofessionalsstillexperiencebarrierstoaccessing(adequate)PPE.InformalcaregiversarealsoeligibletoaccessPPEandtesting.Althoughsomeactionhasbeentakentoimprovethecollectionofinformationinlong-termresidentialcarefacilities(e.g.dataonpeoplewithintellectualdisabilities),significantinformationgapsremainaboutlong-termcareandCOVID-19,especiallyhowCOVID-19affectslong-termcarestaff.

12.9SouthAfrica

31stMary2020 Havingwitnesseddevastatingscenesunfoldinginothercountries,carehomesandcarecentreswithinretirementvillagesdidnotwaitforgovernmentpermissionorguidancebutrespondedrapidlytothethreatofCOVID-19.

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Theresponsewasfirmandunapologetic,erringonthesideofcaution.Actionstakenincluded: • Goingintovoluntarylockdownbeforetheofficialannouncement; • IntroducingaCOVID-19infectioncontrolofficertocoordinatetheimplementationofprotocols; • Increasing monitoring to ensure compliance; • Encouragingstafftostayonsite,andensuringthatthesestaffwereaccommodatedaccordingtothe

zonesinthefacilitywheretheyworked; • Allocatingonepersontodotheshopping,andsanitisingitemsenteringthehome; • Reducingtheuseofpublictransportbytransportingstaffprivately; • Havingacolor-codedsystemtoidentifyisolationzoneswithinthehomeandthestaffallocatedto

thesezones(colour-codedbadges); • Cleaningmorethoroughly.

13. ResultsfromSystematicReviewIntotal1,101titlesandabstractswereuploadedintoCovidence.Followingfurtherdeduplicating1,059titlesandabstractswerescreened.79fulltextpaperswerereviewed,and33papersselectedforinclusion–(Figure1PRISMA).

14. Methods 14.1TypesofstudiesandevidenceAfterapreliminaryreviewofonedatabase,adecisionwastakentoprovideacomprehensiveinclusionofevidencefortheExpertPanel.Inthisreviewincludeallstudydesigns(e.g.experimentalstudies,quasi-experimentalstudies,observationalstudiesincludingcohort,case-controlanduncontrolledbeforeandafterstudies,andqualitativestudies)thatinvolvedanassessmentofmeasurestoreducetransmissionofCOVID-19(includingSARSorMERS).Additionalevidencefromgreyliterature,includingacurrentrepositoryforCOVID-19studies,isreported. 14.2Typesofparticipants

Participantsinthisreviewwereadultscomprisingresidents,employeesandvisitorsinlong-termresidentialcarefacilities.

14.3Typesofintervention To provide as comprehensive a review of the evidence as possible we included evidence for any

interventionimplementedtoreducethetransmissionofCOVID-19inlong-termresidentialcarefacilities,includingsocialdistancing,personalprotectiveequipment,handhygiene.

15. PrimaryoutcomemeasuresMeasuresofoutcomesincludemorbiditydata,casefatalityrates,reductionsinreportedtransmissionrates.Dataarestratified,wherepossible,andreportedfordifferentpopulationgroupsorlong-termcarefacilitiesingeneral.


16. Searchmethodsforidentificationofstudies(seeAppendixforsearchstrategy).

Searchstrategiescomprisedsearchtermsbothforkeywordsandcontrolled-vocabularysearchtermsMESHandEMTREE. Wesearcheddatabasesfrominceptionto20thJune2020:

• EMBASE(viaOVID) • PubMed(viaOVID) • CumulativeIndextoNursingandAlliedHealthLiterature(CINAHL) • CochraneDatabaseandRepositoryforCOVID19evidence • MedRXivpre-publishedrepository

17. SearchingotherresourcesWecheckedreferencelistsandbibliographiesofincludedevidenceforfurtherarticlesupto3July2020.Wedidnotexcludeanypublicationsbasedonlanguageorpublicationdate.

18. Selectionofstudies/evidence Thisreviewprocessconsistedofthefollowingstages:

1. Twoauthorsdevelopedthesearchstringsforeachdatabasesearch(DS&KF).

2. Oneauthorranalldatabasesearchesanddownloadedresultsintoareferencemanagementdatabasewithduplicatecitationsdeleted(DS).

3. OneauthordownloadedthesearchintoCovidencemanagementplatform(LM).Twoauthorsindependentlyscreenedalltitlesandabstractsforpotentiallyeligiblestudiesandobtainedfull-textcopies(LM&KF).

4. Twoauthorsindependentlyreviewedallfull-textpapers(LM&KF).Theeligibilitydecisionwasmadebasedonfull-textscreening.

5. Twoauthorsindependently(LM&KF)extracteddatafromincludedstudies.DuetotherapidnatureofthisreviewforreportingtotheExpertPanel,eachauthorindependentlyextracteddatafrom50%thestudies.Thedatafromeachstudywasthenindependentlycheckedandverified.

6. Weresolvedeligibilitydisagreementsbydiscussion,andbyinvitingathirdreviewauthor(CK)toactasanindependentarbiter.

7. Werecordedreasonsforexclusionofstudies/reports.

142

19. Dataextractionandmanagement Adataextractionformwasdevelopedandmodified.Weadaptedextractionformspreviouslyusedin

publishedCochranesystematicreviews.Twoauthors(LM&KF)extracteddatafromtheincludedstudiesandreports.Allextracteddatawereindependentlycheckedandverified. Weextractedthefollowingdata.

• Title • Leadauthor • Yearofpublication • Referenceforpublication • Country • Studysetting • Study design • Descriptionofintervention • Sizeofpopulation • Numberandcharacteristicsofparticipants • Outcomesandhowmeasured • Lengthoffollow-up • Sources of funding • Peer reviewed • Ethical approval • PotentialConflictsofinterestofstudyauthors

Ifstudyresultswerereportedinmorethanonepublication,weextracteddatafromallincludedpublications.Wehighlightandreportcombinedreportingforthesestudies.

20. Datasynthesis Meta-analysiswasnotpossibleduetoheterogeneityinstudydesigns,participants,outcomes,andnatureoftheinterventions,sowepresentasummaryanddescriptivestatisticsandanarrativesynthesisofresults.Subgroupanalysesarepresentedforstudiesreportingoutcomesforspecialistpopulations,includingresidents,employees,andvisitors.

21. Results

22. Descriptionofstudies WesearchedtheliteratureforthisreviewinJune2020,andthisyielded1,101records.Handsearching

andreferencelistsyieldedthreeadditionalstudies.Intotal,1,059recordswerereviewedfollowingdeduplication.DetailsofthesearcharepresentedinthePRISMAdiagram(Figure1).


23. Includedstudiesandevidence Thirty-threepapersareincludedinthisreview:Abramsetal.,2020,AmericanGeriatricsSociety,2020,Aronsetal.,2020,Brainardetal.,2020,Burki,2020,Clarfieldetal.,2020,Danisetal.,2020,Doraetal.,2020,Fismanetal.,2020,Grahametal.,2020,Gueryetal.,2020,Handetal.,2018,Heungetal.,2006,Hoetal.,2003,Kennellyetal.,2020,Kim,2020,Kimballetal.,2020,Leeetal.,2020,LynchandGoring,2020,McMichaeletal.,2020a,McMichaeletal.,2020b,OfficeforNationalStatistics,2020,Quickeetal.,2020,Riosetal.,2020,Roxbyetal.,2020a,Roxbyetal.,2020b,Smithetal.,2020,Stalletal.,2020,Stowetal.,2020,TrabucchiandDeLeo,2020,Tseetal.,2003,Wassermanetal.,2020,Zazzaraetal.,2020(Table1S).

ItmustbenotedthatanumberofthepapersaremultiplereportingfortheonestudyoroutbreakofCOVID-19,e.g.Aronetal2020andKimballetal2020reportevidenceononeoutbreakintheUSA;McMichael2020aand2020barelinkedpapers,asareRoxby2020aandRoxby2020b. Twenty-fivepapersreportevidenceofmeasurestoreducetransmissionofCOVID-19inlong-termresidentialcarefacilitiesforresidents(Table2S),nineteenpapersreportevidenceforemployeeoutcomes(Table3S),andfourpapersincludeevidenceforvisitors(Table5S).Sevenreportsfocusonsystemsevidenceforlong-termcarefacilities:Abramsetal.(2020),AmericanGeriatricsSociety(2020),LynchandGoring(2020),Riosetal.(2020),Stalletal.(2020),Wassermanetal.(2020),Zazzaraetal.(2020)(Table4S).SeeTables6S,7S,and8Sforfocusedresident,employee,andvisitoroutcomes. Geographically,nineindividualcountriesarerepresentedinthisreviewincludingUSA(Abramsetal.,2020,AmericanGeriatricsSociety,2020,Aronsetal.,2020,Doraetal.,2020,Handetal.,2018,Kimballetal.,2020,LynchandGoring,2020,McMichaeletal.,2020a,McMichaeletal.,2020b,Quickeetal.,2020,Roxbyetal.,2020a,Roxbyetal.,2020b,Wassermanetal.,2020);UK(Brainardetal.,2020,Burki,2020,Grahametal.,2020,OfficeforNationalStatistics,2020,Stowetal.,2020,Zazzaraetal.,2020);Canada(Fismanetal.,2020,Riosetal.,2020,Stalletal.,2020);France(Gueryetal.,2020);HongKong (Heungetal.,2006,Hoetal.,2003,Tseetal.,2003);Ireland(Kennellyetal.,2020);Italy(TrabucchiandDeLeo,2020);Israel(Clarfieldetal.,2020);SouthKorea(Kim,2020,Leeetal.,2020,Smithetal.,2020).Danisetal.(2020)presentevidenceforEU/EEAregions.

24. ExcludedStudiesWeexcluded46studiesandreportsfromthisreviewwhichdidnotmeettheinclusioncriteria.WereportreasonsforexclusioninFigure1,includingwrongintervention,notresearchpapers,systematicreviewsandtopicnotrelatedtoCOVID-19specifically.

144

Table1SCharacteristicsofStudies/Reports

StudyID

Country

Setting

(including

locationand

socialcontext)

ReviewtitleorID

StudyDesign/Publicationtype(e.g.

report,abstract,letter)

Population

Abra

ms

et a

l (2020)

USA

All n

ursin

g ho

mes

elig

ible

CharacteristicsofUSNursingHomeswithCOVID-19cases.Journalof

AmericanGeriatricsSociety

Retrospectivecohortstudy.

(Peerreviewsearch)

Con

stru

cted

dat

abas

e of

nur

sing

homeswithverifiedCOVID-19

case

s

Facilities

Amer

ican

Geriatrics

Soci

ety

PolicyBrief:

COVID-19

andNursing

Homes

USA

NHandLTCFs

AmericanGeriatricsSocietyPolicyBrief:COVID-19andNursingHomes

JAmGeriatrSocMay2020;68(5):908-911

Specialarticlenursinghomes(NHs)

andotherlong-termcarefacilities

(LTCFs).(PolicyBrief)

(Peerreviewsearch)

Staff,residents,and

facilities

Aron

s et

al

(2020)

King

Cou

nty,

Washington

USA

Nursing

hom

e fa

cilit

y,

King

Cou

nty,

Washington

USA

PresymptomaticSARS-CoV-2infectionsandtransmissioninaskillednursing

facility,TheNewEnglandjournalofMedicine.NEnglJMed2020;382:2081-

90.

DOI:10.1056/NEJMoa2008457

Serialpoint-prevalencesurveys1

wee

k ap

art

(Peerreviewsearch)

Residents/staff

Brainardetal

(2020)

Engl

and

Car

e ho

mes

, Norfolk

IntroductiontoandspreadofCOVID-19incarehomesinNorfolk,UK

Crosssectionalstudy(notpeer

reviewed-MedRxiv)

Staff

Burki(2020)

Engl

and

and

Wales

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abovelivinginlong-termcare:Arapidreviewofclinicalpracticeguidelines

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medRxiv2020;():2020.04.19.20071639

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deathsinOntario,Canada.medRxiv2020;():2020.05.25.20112664

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ucch

i et

DeLeo2020

Italy

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PsychiatryMay2020;7(5):387-388

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resp

onde

nce

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careprofessionalsinaHongKongnursinghomeGeriatricNursing

2003;24(5):266-269

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Residents,staff

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etal2020

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Nursing

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Nutrition,Health&Aging2020;24(6):538-543

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148

Figure 1 Search Strategy

25. Effectsofinterventions Personalprotectiveequipment(PPE)Sixstudiesimplementedorprovidedguidanceontheuseofpersonalprotectiveequipment(PPE),includinggloves,eyeprotection,masks,andgowns.Inonenursinghome,48of76residentsscreenedduringpoint-prevalencesurveystestedpositiveforCOVID-19followingrecommendationsforallhealthcarestafftowearPPEwhenenteringrooms(Aronsetal.,2020).ThespreadofCOVID-19inresidentsincreasedwheneyeprotectionandfacemasksbecamelessavailableincarehomesinNorfolk,England(Brainardetal.,2020).UseofPPEwasmonitoredbyaninfectioncontrolnurseinaskillednursingfacilityinCalifornia,where19of90residentstestedpositive(1/19died)(Doraetal.,2020).TheSARSviruswasspreadto6people(2residents,1staffmember,3visitors)afterstaffwereinstructed


ontheuseofPPEfollowingoneresidenttestingpositive(Hoetal.,2003).InasinglenursinghomefacilityinHongKong,staffimplementeduseofPPE,includingadesignatedPPEremovalzonefollowinganoutbreakofCOVID-19,resultinginnoadditionalinfections(Kim,2020).23of76residentstestedpositiveafteranoutbreakinaskillednursingfacilityinWashingtonwherestaffimplementedPPEuse(Kimballetal.,2020) SurveillanceSurveillanceand/orscreeningofresidentsandstaffwasreportedin7of33studies.Surveillanceconsistedofwidespreadtestingforaviralinfectionwhilescreeningincludedsymptomandtemperaturescreeningregularly(residents)anduponenteringafacility(staff,visitors).InaskillednursingfacilityinCalifornia,allresidentsunderwentserialtesting,allclinicalandnon-clinicalstaffunderwentasingleviraltestforCOVID-19.Screeningofallstaffandvisitorsforsymptomswascompletedbeforeenteringthefacility.Intotal,19/96and8/136residentsandstafftestedpositive,respectively(Doraetal.,2020).InaFrenchnursinghome,allstaffunderwentsurveillancetestingfollowingtheoccurrenceofaconfirmedCOVID-19caseinaresident,with3of136stafftestingpositive(Geuryetal.,2020).ComprehensivetestingofallresidentsandarepresentativesampleofstaffwasconductedinfourLondonnursinghomes,where126of313residentsinitiallytestedpositive,withanadditional5testingpositiveonre-testingoneweeklater.Positivetestswerefoundin3of70staff(Grahametal.,2020).SymptomscreeningofresidentsfollowinganoutbreakofHCoV-NL63inaUSnursinghomeresultedin13of130residentstestingpositive(Handetal.,2018). Similarly,residentsandstaffwerescreenedforsymptomsinalong-termcarefacilityinWashingtonwhere23of76residentstestedpositive(Kimballetal.,2020).WeeklytestingwasconductedinresidentsacrossfivenursingfacilitiesinColorado,showingvariedtemporalincidencerates.Onesiteremainedinfection-free,asecondsitebeganwithlowrates,decliningrapidlytozerocases,onefacilitybeganwithahighincidencerate(22.5%)whichdeclinedovertime.Theremainingtwositeshadlowprevalenceinitially,butobservedsignificantriseinincidenceratesovertime(Quickeetal.,2020).StaffwerescreeneddailyforsymptomsandtemperatureinafacilityinWashington,where4/80residentstestedpositivefollowingtwopoint-prevalencesurveys.2of62stafftestedpositiveinasinglepoint-prevalencesurvey(Roxbyetal.,2020a,Roxbyetal.,2020b). Isolation Sixstudies(sevenpapers)reportedonfacilitieswhereresidentisolation/cohortingwasimplementedtoreducetransmissionofCOVID-19.RapidisolationofpositiveresidentswassuggestedtohavecontributedtoreducedviraltransmissioninaCaliforniannursingfacility,where19of96residentsand8of136stafftestedpositive.Staffmovementbetweenwardswasalsorestricted(Doraetal.,2020).Similarly,4nursinghomesacrossLondonimplementedcohortingofpositiveresidents,with131of313residentsand3of70stafftestingpositiveduringobservations(Grahametal.,2020).DuringaSARSoutbreakinHongKong,anursinghomefacilityisolatedallfebrileresidentsandallresidentsreturningfromahospitalaftertheviruswasdetectedinthehome,resultingintransmissiontoonly6otherindividuals(2residents,1staff,3visitors)(Hoetal.,2003).COVID-19positiveresidentsinaKoreannursinghomewereplacedinisolation,andcareworkersforthisisolationcohorthadrestrictedmovements,topreventviraltransmission.Thesemeasuresassistedinpreventingfurtherresidentandstaffinfection,withall142residentsand82stafftestingnegative14daysafterthequarantine(Kim,2020).Along-termcarefacilityinWashingtonimplementedisolationproceduresforsymptomaticresidentsfollowinganoutbreak,with23of76residentstestingpositive(Kimballetal.,2020).Finally,acarehomeinWashingtonisolatedallresidentsfollowingthedetectionofanoutbreakinthefacility,with3of80residentstestingpositiveduringinitialpoint-prevalencetesting,withanadditionaloneresidenttestingpositiveaweeklater.Allresidentsremainedclinicallystable14-daysafterthesecondtest(Roxbyetal.,2020a).

150

Infectioncontrol(dropletprecautions,handhygiene)Infectioncontrolprocedureswerereportedinfivestudies(sixpapers).Handhygieneanddropletandcontactprecautionswereimplementedinalong-termresidentialcarefacilityinCalifornia,where19of96residentsand8of136stafftestedpositive(Doraetal.,2020).Dropletprecautions,aswellashandandpersonalhygienereviews,wereconductedinaLouisiananursinghomefollowinganoutbreakofHCoV-NL63,with7of130residentstestingpositive(Handetal.,2018).SeroprevalencefortheSARS-CoVviruswasassessedinresidentsandstaffofaHongKongnursinghomewherecontactanddropletprecautionswereimplementedduringanoutbreak.Noincludedparticipantswerepositiveforantibodies(0of76residents,0of26staff);however,staffandresidentsreportedtobesymptomaticduringtheoutbreakdidnotparticipateintheassessment(Heungetal.,2006).HandhygienepracticesforhealthcarepersonnelwereincludedintheinfectioncontrolproceduresofaWashingtonskillednursingfacility,with23of76residentstestingpositiveduringanoutbreak(Kimballetal.,2020).Inadditiontohandhygienepracticeswhichincludedincreasedavailabilityofhandhygienestations,disinfectionoffrequentlytouchedsurfaceswasconductedtoreducetransmissioninaWashingtonfacilityfollowinganoutbreak.Repeatedpoint-prevalencesurveysidentified4of80residentsinfected,withallresidentsclinicallystable14-daysafterthefinalsurvey(Roxbyetal.,2020a,Roxbyetal.,2020b). Mortality Mortalityisreportedinelevenreports.McMichaeletal(2020)presenttheinitialUSAoutbreakdatafromalong-termresidentialcarefacilityfor167casesofCOVID-19,including101residents.Thecasefatalityrateforresidentswas33.7%(34of101).Aronsetal(2020)reporteddeathsin26%ofresidents(15of57),with35%ofresidentspresentingwithtypicalsymptoms.Doraetal(2020)reportedonedeathinafacilitywith96residentsinthreewardlocations.Residenttestingcommenced29th-31stMarch,and19casesidentified,andoneresidentdied.Fewerfatalitiesresultedfollowingtheintroductionoftestingregimes,cohortingofresidentsandrestrictingofthetransferofstaffbetweenthethreelocations.Fismanetal(2020)identifiedCOVID-19in43.4%ofresidents(n=272)inlong-termresidentialcarefacilitiesinOntario.Mortalityrateswere13timeshigherinlong-termresidentialcarewhencomparedtodatafromOntarioresidentsforthoseaged>69years.Thedeathratescontinuedtoincreaseovertimeforresidentsduringweek29thMarchto7thApril.Grahametal(2020)reviewedfournursinghomesinEngland,reportingCOVID-19mortalityforallcausesat54%inresidentsandwiththehighestmortalityratesoccurringduringthefirstweekinApril.Mortalityrateswerehighestformenandforthosewithcomorbidities.ArecentreportfromOfficeforNationalStatistics(2020)ondatafor9,081nursinghomesand293,301residentsinEngland,reported55.6%ofhomesexperiencedatleastonecaseofCOVID-19(95%CU54.8to56.4).Therewere15,606deathsreportedinresidentsacrossallhomes.Thereisan11%increasedriskofCOVID-19infectioninaresidentofanursinghome(OR1.1195%CI1.1to1.11)witheachadditionalinfectedemployee.Othervariableslinkedtohighertransmissiontoresidentsincludedhomeswithnosickpayremunerationforemployeesorthoseusingbank/agencystaffonmostoreveryday.Stowetal(2020)studyof460carehomesover46localauthoritiesinEngland,toestablishanationalearlywarningscorereportingsystem,registered1,532COVID-19deathsoverperiod23rdMarchand10thMay2020(additional4,221deathsattributedtoothercauses).Theimpactofnotingresidentuseofhealthsurveillanceinthetwoweeksbeforepeaksinnursinghomedeaths. InHongKong,Heungetal(2020)reportedthreedeaths.Tworesidentsandoneemployeedied.Thedataonthethreecasesidentifiedtransferfromahospitalintoanursinghomeforonecase.Transmissiontotheotherresidentandemployeeconsideredseatingplacementsinadiningroomandhandlingofclinicalwaste.Hoetal(2020)alsoreportedsevencasesinHongKong.Ofthethreeresidents,oneemployeeandthreevisitorswhowereinfectedwithCOVID-19,tworesidentsandoneemployeedied.Kennellyetal(2020)reportevidencefromalargesurveyof28nursinghomesinIrelandwhere63%ofsurveysreturnedprovidedataon2043residents.ACOVID-19outbreakwasrecordedin75%ofnursinghomes


inthestudy.Eightnursinghomeshad≥80%singleroomsinlinewithregulatorystandards,andtherewasnoassociationbetweenadherencetothestandardandaCOVID-19outbreak(χ2=1.37,p=0.24)Morecasesoccurredinpublicnursinghomes.Overthe83daysofthestudy,15.3%(312of2,043)ofresidentsdied.Thecasefatalityratewas27.6%(n=221of764)forcombinedlaboratory-confirmed/suspectedCOVID-19.Casefatalityrateswerehigherinpublicasagainstprivatenursinghomes(22.3%v11.2%);however,thisrepresentsfivefacilities.Stafftestedpositivein24ofthe28homesinthestudy,andunder25%ofthosewereasymptomatic.Kennellyetal(2020)reportthatthetotalnumberofnursinghomesincludedrepresentslessthan10%ofallnursinghomesnationally.WhileDanisetal(2020)presentEU/EEAdataonconfirmedcasesandmortalitiesforseveralcountries,thedeathsamongresidentsaccountfor37to66%ofallCOVID-19relateddeaths.Datafromoutbreaksurveillanceincludedotherclosedsettingsandcouldunderestimatethemortalityratesinresidentsinlong-termresidentialcarefacilitiesforolderpeople(Irishdataincludesfacilitiesforpeoplewithdisabilities,homelesspopulationsanddirectprovisioncentres,andincludesstaffandresidents). ResidentsymptomsSixstudiesreportthesymptomsofresidents,withanadditionalstudyreportingthepresenceofdeliriuminfrailresidentswiththeCOVID-19(Zazzaraetal.,2020).InaWashingtonnursinghome(Aronsetal.,2020)48residentstestedpositiveforCOVID-19,3wereasymptomaticand24werepresymptomatic(symptomsdevelopedwithinsevendaysoftesting).AseparateWashingtonnursinghomeidentified23of76residentstestingpositiveforCOVID-19;however,onlytenresidentsreportedanysymptoms(2/10atypicalsymptoms)(Kimballetal.,2020).Theremainingresidentsreportedeithernosymptoms(3residents)ortheywerepresymptomatic(10residents)andthemeanintervalbetweentestingandsymptomonsetinthepresymptomaticresidentswas3days(Kimballetal.,2020).Amongthe21symptomaticresidents,4hadatypicalsymptoms(Aronsetal.,2020).Doraetal(2002)reportedfiveof19positiveresidentsinaCalifornianursinghomedisplayedsymptomsupontesting,with8of19developingsymptomsintheweekfollowingtesting(presymptomatic)and6of19remainingasymptomatic.Grahametal(2020)reported126of313residentsacross4Londonnursinghomestestedpositive,ofwhich54wereasymptomatic.Amongthesymptomaticresidents,22presentedwithatypicalsymptoms(Grahametal.,2020).Across28nursinghomeinIreland,710residentstestedpositive,with193residentsidentifiedasasymptomatic(Kennellyetal.,2020).AsmallnumberofresidentsinanassistedlivingfacilityinWashingtontestedpositive(4of80),with1residentidentifiedasasymptomatic(Roxbyetal.,2020a,Roxbyetal.,2020b).InalargesampleofthehospitalandcommunityparticipantswithconfirmedorsuspectedCOVID-19,asignificantlyhigherprevalenceofdeliriumwasidentifiedinfrailindividuals.Frailtypredicteddeliriuminthehospitalsample(p=0.013;OR=3.22,95%C.I.(1.44,7.21)),andinthecommunitysample(p=0.038;OR=2.29,95%C.I.(1.33,4.0)).Afterage-matching,deliriumwasreportedin40(38%)offrailand13(12%)ofnon-frailpatientswithCOVID-19(Zazzaraetal.,2020). Visitoroutcomes Fourpapersreportingonthreestudiespresentedoutcomesrelatedtonursinghomevisitors.SixteenindividualswhotestedpositivewereepidemiologicallylinkedtoanoutbreakinaWashingtonnursinghomewhichtheyhadvisited.Noneofthesevisitorsdied(McMichaeletal.,2020a,McMichaeletal.,2020b).FollowinganoutbreakofSARSinaHongKongnursinghome,3individualstestedpositiveaftervisitingthefacility,withallindividualsrecovering(Hoetal.,2003).OnestudyreportedthatvisitorswereprohibitedfromenteringaCaliforniaskillednursingfacilityafteranoutbreakofCOVID-19;however,novisitoroutcomeswerereported(Doraetal.,2020).

152

SystemsmanagementoffacilitiesSeveral papers and reports guide the management of nursing homes, residents, employees, and visitors toreduceandlimitthetransmissionofCOVID-19.Abramsetal(2020)reportontheimpactofsizeandlocationofnursinghomesonoutbreaks.Outbreaksrecordedinlargerfacilities(large:OR6.52Vsmall;medium:OR2.63Vsmall)andurban(OR3.22Vrural).ThehighestnumberofcasesreportedinNewJersey(OR7.16),Massachusetts(OR4.36),Georgia,MarylandandConnecticut.Stalletal(2020)reportednoassociationwithhigherratesofCOVID-19in‘withprofit’homes.Incidencewasassociatedwiththenumberofbeds,butnotprofitstatus;similartoKennellyetal(2020)whoreportedhigherratesinpublicnursinghomes.AmericanGeriatricsSociety(2020),Lynchetal(2020),Riosetal(2020)andWassermanetal(2020)provideevidencefromexpertopinionsanddevelopedrecommendationsonthetesting,reporting,ventilationandPPEstrategiestoreducetransmission.Finally,Zazzaraetal(2020)pointofcareassessmentofhospitalandcommunitycohortsincludedtransfersfromlong-termresidentialcarefacilitiesandtheassessmentoffrailtyandscreeningfordelirium.Deliriumwasreportedin38%(n=40)frailand12%(n=13)nonfrailpatientswithCOVID-19.Frailtywasassociatedwithpredictingdeliriump=0.0013,OR3.22(95%CI1.44to7.21).Systematicimplementationofprocessesforreviewoffrailtyanddeliriumforallsettingforolderpeopleisidentified.

26. AdverseeventsAdverseeventsfollowingtheinterventionarereportedinonestudy.Post-exposureprophylaxis,intheformofhydroxychloroquine,wasadministeredto189patientsand22careworkersinalong-termcarehospitalinKorea.Thirty-twoparticipantsreportedoneormoresymptomsrelatedtothetreatment,ofwhichfiveindividualsdiscontinuedtheintervention(Leeetal.,2020).Nofurtherreportingofadverseeventsintheremainingpapers.

27. Discussion Theprincipalpurposeofthisreviewwastoassesstheextenttowhichmeasuresimplementedinlong-termresidentialcarefacilitiesreducedtransmissionofSARS-CoV-2andeffectonmorbidityandmortalityoutcomes.Wefound33papersprovidingexpertopinions,recommendations,andevidenceofoutcomesfollowingmeasuresimplementedinresidentialcarehomes.Theincludedstudieswerefromnineindividualcountries,whileonepaperreportedontheEU/EEA.Ofthe33includedpapers,25reportresidentrelatedoutcomes,19reportemployee-relatedoutcomes,andfourreportvisitoroutcomes.Allofthesestudiesareretrospectivereportsfollowingtheimplementationofmeasurestoreducetransmission.Therewerenostudieswhichdescribedtheuseofalternativeorcontroltreatments,whichpreventsthedeterminationofcauseandeffectofstudyoutcomes.However,thefindingsinthisreviewcanproviderecommendationsonstrategiestoassistinreducingtransmissionoftheSARS-CoV-2virusinlong-termresidentialcarefacilities. Therapidnatureofdatagatheringandreportinginreal-timeoutbreaksurveillanceisacknowledgedinthepapersreviewed.Limiteddataexistonthemanagementofoutbreaksinnursinghomes/long-termresidentialcarefacilities,andthereisanabsenceofasystemsapproachtothemanagementofCOVID-19innursinghomes.Severalstudiesimplementedlarge-scalesurveillance/testingofresidentsandemployeestoreducetransmission.However,availabilityoftestingkitswaslikelylimitedearlierinthepandemic,whichmayhavepreventedbroadertesting(Doraetal.,2020,Grahametal.,2020).Inthissituation,testingofsymptomaticresidentswasprioritised.However,evidencefromAronsetal(2020),Gueryetal(2020),Grahametal(2020)Brainardetal(2020)andKennellyetal(2020)identifychallengesfortestingamongasymptomaticemployeesandresidents.Giventhescaleofpresymptomaticcases,testingonlysymptomaticindividualswas,therefore,likelytobeinsufficienttopreventtransmission.As


such,implementingbroadtestingsweepswhentestingisavailableisrecommendedtoidentifycases.Whenlimitedtestingisavailable,prioritisingsymptomaticandhigh-riskindividualsmaybethebestresponse.Grouptestingmayalsobeanefficientstrategyfordetectingoutbreaks(Smithetal.,2020). Greatermovementofresidents,workers,andvisitorsincreasestheopportunityforviraltransmissioninlong-termresidentialcarefacilities.Evidenceofreducingtransmissionisevidentwhenfacilitiesinstigatedcohortingandlockdownprocedureslimitingmovementsofstaffandpreventingaccesstovisitors.Forexample,inaCalifornianursinghome,rapidisolationofcases,prohibitingentryofstaffandvisitorspresentingwithsymptomsorwithrecenttraveltocountrieswithCDCwarnings,andrestrictingstaffmovementbetweenwards,assistedinlimitingresidentcasenumbersto19of96andemployeecasenumbersto8of136(Doraetal.,2020).Isolationwasimplementedwithadditionalmeasuresinotherstudies,withvaryingdegreesofsuccess(Grahametal.,2020,Hoetal.,2003,Kim2020,Kimballetal.,2020,Roxbyetal.,2020a),suggestingisolationofresidentspresentingwithsymptomsorfollowingapositivetestisanappropriatemeasure.Considerationofthementalwellbeingofresidentsisnecessary,includingthosewithdementiawhomayhavelimitedcomprehensionofwhymeasuresareinplace(TrabucchiandDeLeo,2020).Walkingwithpurposemayfrequentlyoccurintheseresidentsandisariskfortransmissionofinfection. TheuseofPPEisanessentialstrategyforreducingtransmissioninnursinghomes.Gloves,masks,gowns,andeyeprotectionwereallinvestigatedintheincludedreports.Brainardetal(2020)demonstratedanincreaseinthespreadofCOVID-19aseyeprotectionandfacemasksbecamelessavailabletostaffinUKnursinghomes.AdedicatedzoneforremovalofPPEmaybeconsidered,suchasthatimplementedinaHongKongfacilityfollowinganoutbreak.ThecarparkofthefacilitywasdedicatedtotheremovalofPPE,withuseoftheelevatorlimitedtostafftoaccessthisdedicatedzone(Kim,2020).InadditiontoPPEuse,otherinfectioncontrolmeasuresweredescribed.Thesemeasuresincludeddropletandcontactprecautions,handandpersonalhygiene,anddisinfectionofsurfaces.Theuseofthesestrategieswasshowntoassistinreductionoftransmission(Doraetal.,2020,Handetal.,2020,Heungetal.,2006,Kimballetal.,2020,Roxbyetal.,2020a),andareessentialtolimitviraltransmission. Numerousfacility-specificcharacteristicsareassociatedwithanincreasedriskofCOVID-19cases.TheOfficeofNationalStatistics(2020)identifieshomes,whereemploymentcontractsofstaffhavenosickpayments,areassociatedwithahigherriskoftransmissionofCOVID-19asistheadditionaluseofagencycarestaff.IntheUS,nursinghomes,largerfacilitysizeincreasedtheoddsofcasepresentation,asdidthepercentageofAfricanAmericanresidentsandafor-profitstatus(Abramsetal.,2020).Brainardetal(2020)showedtherateofresidentcasesincreasedasthenumberofworkersinthefacilityincreased.InIrishnursinghomes,residentcasenumberswereassociatedwiththeproportionofsymptomaticstaff(Kennellyetal.,2020),withasimilaroutcomereportedinUKnursinghomes(OfficeofNationalStatistics,2020).Althoughmanyofthesecharacteristicsarenotacutelymodifiable(e.g.for-profitstatus,percentageofAfricanAmericanresidents),awarenessoftheseassociationsshouldassistinidentifyingfacilitieswhereurgentactionmustbetakenwhencommunityand/orfacilitycasesaredetected. AfterthesubmissionoftherapidreviewinearlyJuly,twofurtherpaperswerepublished(Burtonetal.,2020;Fismanetal.,2020a),theevidencewasprovidedtotheExpertPanelduringtheirreview.ThesestudiesreportedmortalitydatafromoutbreaksinScottish(Burtonetal.2020)carehomesandfurtherevidencereportedfromlong-termcarefacilitiesinCanada(Fismanetal.2020a).WeincludeFismanetal(2020)initialpublicationinthereview,thesubsequentpapercontainedmoredetailedevidence(Fismanetal2020a).

154

BurtonetalreportedCOVID-19deathsin109ofthe189Scottishcarehomes.Intotal55outbreakswerereportedoverfiveweeks(16thMarchto19thApril)andafurther15outbreaksfrom19thAprilto31stMay.Ofthe70carehomesreportingapositiveCOVID-19case,66wereinresidentialcarehomesforolderpeople.Intotal,401deathsarereportedincarehomeswithreportedoutbreaks,andtwodeathsoccurredincarehomeswithnooutbreak.Excessmortalitywasassociatedwithlargercapacityhomes(median48bedsV8beds);privateownership(67.9%V30%);andprevioushistoryofinfectiousdiseaseoutbreaks(28.4%V0%).AdjustedOddsRatiosassociatedincreasedmortalityratesinresidentswithanincreasednumberofbedsOR3.50(95%CI2.06to5.94)(per20-bedincrease). Fismanetal(2020a)reportedexcessdeathsinlong-termcarefacilitiesinOntariocomparedtoresidentslivinginthelocality.Intheircohortstudy(datafromJanuarytoMay2020)272ofthe627facilitiesreportedaCOVID-19infectionineitherresidentsorstaff.Thereportedmortalityof0.1%inindividualsaged69yearsandolderlivingintheareaandsimilarforresidentsinlong-termcarefacilities.TheIncidenceRateRatio(IRR)ofCOVID-19deathsinthoselivinginlong-termcareincreasedinashortperiodto13.1(95%CI9.9to17.3)comparedwiththeadultslivinginthecommunity.TheIRRincreasedto87.3(95%credibleinterval,6.4-769.8)byApril11,2020.LaggedinfectioninstaffwasastrongpredictorofdeathinresidentsadjustedIRR1.17(95%CI1.11to1.26ata6-daylagandtheirstudynotedtheimportanceoffocusingontesting,availabilityofPPEandlimitingmovementofstaffinlong-termcarefacilities. Theresultsfromthesetwoobservationalstudiesareconsistentwiththeevidencereportedintherapidreviewandidentifytheexcessmortalityassociatedwiththesizeoffacilities,andtheriskoftransmissionofCOVID-19toresidentsfromstaff.

27.1QualityoftheevidenceAformalreviewofqualitywasnotcompletedduetolimitationsintimeandtheextenttowhichthereportsincludedinthisreviewfulfilledqualitycriteria.Thequalityofevidenceinthisreviewislow,primarilyreportedfromobservationalstudies,expertopinion,reportingofoutbreaksanddescribingtheprocessandmanagement.Otherfactorsassociatedwithlowerqualityofevidenceincludestherelianceofself-reportingofsymptoms,recallbias,useofdatasetswhichmaybeincomplete,andmanystudieswhicharenotcurrentlyinpeerreview.Aformalanalysisofqualitywillbeundertakensubsequently. 27.2Limitationsinthereviewprocess TheextensivereviewofthreedatasourcesandinclusionofMedRxiv,whilenotpeer-reviewed,wasnotalimitation.Languagewasnotalimitationastherewasnorestrictionimposed,andtherewasnorestrictionontimeforsearches.However,itisacknowledgedthatthisreviewwascompletedinfiveweeks,andwemayhavemissedincludingareportorstudy.Additionally,ourdataextractionwasundertakenauthorsindividuallyandthencheckedandverified;thiswasduetothetimelineandmayresultintranscriptionerrors.Duetoourindependentcheckingandverification,weaimedtoreducethislikelihood.Thereisnoformalqualityreviewoftheevidence(designandbias)duetotherapidtimeinvolvedinundertakingthisreview.However,weidentifythelowqualityofthecurrentevidencebaseavailable.Wepresentadescriptivenarrativesummary,duetotheheterogeneity,bothstatisticalandmethodologicalinthestudiesandpapersincludedinthisreview. 27.3AgreementsanddisagreementswithotherstudiesorreviewsTheresultsfromthisreviewareconsistentwiththosereportedbySalcher-Konradetal(2020)limitedevidenceexists.Tolimitstudydesignswouldhavereduced,presentingthemostcomprehensiveevidencebasetosupporttheExpertPanelandthedecisiontoincludereportedrecommendations,guidance,andweakerstudydesignsestablishesthebaselineforfutureresearch.


28. ImplicationsforpracticeDespitelimitationsinthequalityoftheavailableevidence,severalimplicationsforpracticearehighlighted.TheuseofPPEandotherinfectioncontrolmeasures(dropletandcontactprecautions,handhygiene)areessentialregardlessofwhetheracaseisreportedinafacility.Frequentscreeningofresidentsforsymptoms(onceortwiceperday),andscreeningofstaffbeforecommencingashiftshouldbeimplementedtoidentifyat-riskindividuals.Residentsidentifiedbysuchstrategiesshouldbeisolated,andtestingshouldbeinitiated.Staffpresentingwithsymptomsshouldquarantineathomeandawaitresultsofatestbeforereturningtothefacility.Closingnursinghomestovisitorslimitstheopportunitytointroducethevirusintothefacility,asdoesdelayingthetransferofresidentstoafacilityuntilafterconfirmationofanegativetestresult. Widescaletestingofresidentsandstaffshouldbeimplemented,withrapidisolationofpositivecases.Giventheprevalenceofasymptomaticcases,testingonlythosedisplayingsymptomsislikelyineffectiveinpreventingtransmission,andthereforeallresidentsshouldbetestedinfacilitiesexperiencinganoutbreak.StaffshoulddonPPEwhenincontactwithallresidentsinsuchfacilities,andinfectioncontrolpoliciesmustbeimplemented.Surveillancesystemsrecordingthehealthstatusofresidentsshouldbeinplacetomonitorhealthoutcomes,includingassessmentsoffrailtyanddelirium. Thementalwellbeingofresidentswhoareisolated,particularlyduringperiodswithnovisitationfromthefamilymustbeconsidered,andsystemsdevelopedtosupportthemandtheirfamilies.Furthermore,residentswithdementiamayrequireadditionalattention.AreviewoftheimpactofCOVID-19onstaffemployedinlong-termcarefacilitiesduringanoutbreak,includinghealthandwellbeingandfinancialsupports,duringperiodsofisolationandquarantinemustbecompleted. PreparednessoffacilitiesforfutureoutbreaksincludesthedevelopmentofstafftrainingandeducationprogramsoninfectioncontrolandtheappropriateuseofPPEforallemployeesoflong-termcarefacilitieswithaqualityreviewofpracticesandregularmonitoringofknowledgeandpractice.Thesepracticesareessentialgiventheimplicationsforlong-termcarefacilitieswhereemploymentofagencystaffingisadopted,andadditionalrisksoftransmissionnoted.Similarly,theevidenceidentifiedtransmissionrisksamongstaffnotdirectlyinvolvedincaringduties,soallshouldbeincludedinpreparednesstrainingandeducation. The voices of all involved in the care and management of older people, especially those of residents and theirfamilies,shouldbeattheheartofpracticedevelopments.

29. ImplicationsforresearchGiventherapidnatureofdatacollectionduringthecurrentpandemic,andtheshortfollow-uptime,opportunitiestoimplementcontrolledinterventionsarelimited.Assuch,theretrospective,descriptivenatureofstudiesidentifiedforthisreviewdonotallowthedeterminationofcauseandeffect.Longitudinalfollow-upwillbeessential.Futureresearchshould

• Implementinterventions,ideallywithcontrolorusualcarecomparisongrouptoassistinelucidatingthemostappropriatestrategiestoreducetransmission.

• Developarobustsurveillancesystemofmonitoringofresidents’healthandwellbeingprospectively,includingassessmentoffrailtyanddelirium.

• Assesstheinfectioncontrolpreparednessoflong-termcarefacilities. • Evaluatetheimpactofoutbreaksandisolationonthehealthandwellbeingofresidents,employees

andfamilies. • Includethevoicesofresidents,familiesandallinvolvedinthecareandprotectionofolderpeoplein

long-termcarefacilities.

156

Table2SO

utco

mes

for R

esid

ents

StudyID

Country

Setting

Population

Describe/typeof

intervention

Outcomemeasures

Outcomes

Amer

ican

Geriatrics

Soci

ety

PolicyBrief:

COVID-19

and

Nursing

Homes

USA

NHand

LTCFs

Staff,

resid

ents

, an

d facilities

None,reporting

recommendations

CM

S ha

s ro

lled

out

seve

ral p

olic

y ch

ange

s to

sup

port

hea

lthca

re

prof

essio

nals

and

syst

ems

on th

e fr

ontli

ne o

f car

ing

for i

ndiv

idua

ls w

ith

COVID-19.Theseinclude

chan

ges

in h

ow M

edic

are

reim

burs

es fo

r tel

ehea

lth

visit

s an

d up

date

s to

eliminatethe3-day

hosp

ital s

tay

rule

to a

llow

M

edic

are

to c

over

ear

lier

admissionstoNHs.

Issue1:DefenseProductionActandSupplyChain:increasethesupplyofventilators.

However,therearecurrentandpotentialshortagesofequipmentandsuppliesacross

settings.NHs,LTCFs,othercongregatelivingsettings(e.g.,assistedliving),andhome

healthcareagenciesarepriorities.UseofPPE,availabilityofTestingkits,symptom

managementforendoflifecareincludingmedications.ManagementofsafeTransfer

ofCOVID-19Patients.ForindividualswhotestpositiveforCOVID-19orarestrongly

suspectedofcontractingthedisease,severalimportantfactorswillimpacttransitions

betweencaresettings:HospitaltoNHIndividualswhotestpositiveforCOVID-19

shouldnotbedischargedtoamainstreamNHunlessthefacilitycansafelyand

effectivelyisolatethepatientfromotherresidentsandhasadequateinfectioncontrol

protocolsandPPEforstaffandresidents.Thisincludestheabilitytoisolateorcohort

theresident(s)separatelyfromtherestofthecommunityandprovidededicatedstaff

forpeoplewithCOVID-19inlinewithCDCguidance.PublicHealthPlanningPublic

healthplanningincludingcollaboratingwithstakeholdersandacrossseveraldifferent

prioritiesincludingConsultantsandhealthprofessionals,administrators,palliative

carespecialists,localexpertisecollaborationscanhelpstatesencourageNHsand

hospitalstocreatetheirowntransferpolicies,whichmayrequirefrequentadjustment

basedonlocalconditionsandbasedonhospitalresources.Hospitaldischargealso

playsanimportantroleinCOVID-19planninganduseoftelemedicine.Workforce

planningincludingexpertise,trainingandsupports,ratios.Considerationoftaxreliefs

andpayments.

Aron

s et

al

(2020)

King

Cou

nty,

Washington

USA

Nursing

hom

e fa

cilit

y, K

ing

Cou

nty,

Washington

USA

Resid

ents

/staff

(March6)Onsite

infectionprevention

and

cont

rol

mea

sure

s in

clud

ing

reco

mm

ende

d al

l healthcarestaff

enteringsymptomatic

residents'roomswear

eyeprotection,gown,

gloves,facemask.

Positivetest;typical

or ty

pica

l sym

ptom

s;

non-symptomatic;

presymptomatic.Growth

rate,doublingtime.

57of89(64%)residentstestedpositiveduringpoint-prevalencesurveys,clinical

evaluation,orpostmortemexaminationasofMarch26(firstsurveydoneonMarch

13).48of76(63%)whodidfirstsurveytestedpositiveineitherinitialorsubsequent

point-prevalencesurveys.17of48(35%)reportedtypicalsymptoms,4(8%)only

atypicalsymptoms,27(56%)reportednonewsymptomsorchangesinchronic

symptomsattimeoftesting.Of27asymptomatic-12reportedonlystablechronic

symptoms,15reportednosymptoms.Inthe7daysaftertest,24of27asymptomatic

developedsymptoms(thereforepresymptomatic).Mediantimetosymptomonset

was4days.Doublingtimeestimatedat3.4days.Mortality26%(15of57).11of136

fulltimestaffpositiveatfirstsurvey.ByMarch26,55reportedsymptoms,51were

tested,26werepositive.17/26werenursingstaff,9hadoccupationsacrossmultiple

units(therapists,environmentalservice,dietaryservice)

Burki

(2020)

Engl

and

and

Wales

Car

e ho

mes

Resid

ents

None.Reportof

excessdeaths

Reportingexcessmortality

inupdatereport.

OnMay15,2020,theUKOfficeforNationalStatistics(ONS)releasedprovisional

figuresondeathsinvolvingCOVID-19inthecaresectorinEnglandandWales.From

March2toMay1,2020,COVID-19wasconfirmedorsuspectedinthedeathsof

12526individualslivingincarehomesinthetwonations.Facilitiesnotconfident

inhavingappropriatePPEavailable.Difficultiesacquiringtests.Homesreceiving

patientswithnonegativetestresultinmid-April,i.e.probablyinfected.April28th

governmentstipulatedallresidentsandstaffshouldbetestedforthevirus.9039

deathsoccurredinMarchandAprilincarehome(remainderinahospitalsetting).

Majorityhadatleastoneunderlyingcondition-dementiaandAlzheimer'sdisease.

Carehomesarebuiltforcommunallivingandchallengesifplacedisolation-

increasedriskoffalls,mentalhealthimpactandsubsequentimpactonnutritiontoo.


Table2SO

utco

mes

for R

esid

ents

StudyID

Country

Setting

Population

Describe/typeof

intervention

Outcomemeasures

Outcomes

Clarfieldet

al(2020)

Isra

elOlder

peop

le

in th

e co

mm

unity

/ long-

term

car

e institutions

Older

peop

le in

co

mm

unity

in

clud

ing

long-

term

car

e institutions

Set o

f gui

delin

es fo

r ca

re in

Isra

el

Guidelinesforcarein

Isra

el

PresentsaTriagetoolforcaringforolderpeoplewithCOVID-19.Utilizepalliative

caretechniquestoalleviatesuffering;providepalliativecaretrainingtonursinghome

staff.Upstreamrecommendationsincludingassessmentforventilation,treatment,

ICUaccessandinterventions.Downstreaminterventionsincludepalliativecare

(includingtrainingandsupportforstaff).

Dan

is et

al

(2020)

EU/E

EALong-

term

car

e facilities

Resid

ents

Re

port

of s

urve

illan

ce

data-notastudy

Cas

es a

nd fa

talit

y re

port

ed

5,459,526COVID-19casesglobally.1,361,098casesinEU/EEAandUK.

354,994casesfatalofwhich161,063(6.5%)wereinEU/EEAandUK.Majorityof

hospitalisationsanddeathsinoldestagegroups70years+.In2016/2017number

ofbedsinnursinghomes,residentialhomes,mixedlong-termcarefacilitieswas

64,471with3,440,071beds.highriskofspreadCOVID19duetoinsufficientaccess

toPPE,staffwithlimitedIPCtraining,loworabsenttestingcapacity,residentswith

feworatypicalsymptoms,asymptomaticstafforstaffwhoworkwhilesymptomatic,

staffwhoworkinmultiplefacilitiescanfacilitateentryofCOVID-19intoLTCF.

Fewcountrieshavesurveillanceoflong-termcarefacilities.Needtointroducethis

withdatacollectingofresidentsandstafftolimittransmission.Dailysurveillanceas

routinetomeasureclinicaloutcomesincludingtemperature,respiratoryrate,signof

COVID-19.Testingofallresidentsandstaffifconfirmedcase,includingpostmortem

testing.Regularweeklytestingofstaffandmonitoringandfollowup.Visitsto

residentsshouldbelimitedtoabsoluteminimum.

Dor

a et

al

(2020)

Cal

iforn

ia,

USA

Skill

ed

nurs

ing

faci

lity

the

USA

Resid

ents

, staffand

visit

ors

AllSNFresidents,

rega

rdle

ss o

f sy

mpt

oms,

unde

rwen

t ser

ial

approximately

weekly)

naso

phar

ynge

al

SARS-CoV-2RT-PCR

testing,

Testingofallresidents

betweenMarch29and

April23(after3+V2

residentsfoundpositive

betweenMarch28-29),

allstaffbetweenMarch

29-April10.Testingof

allvisitorsMarch6th.

March17thallvisitors

prohibitedfrombuildings.

Implementedinfection

cont

rol p

roce

dure

s an

d st

rate

gies

for c

ase

identification.From28th

Marcheachstaffmember

assignedtoasingleward.

Infectioncontrolnurse

revi

ewed

and

mon

itore

d useofPPEwithallSNF

staffmembers.PPE

prot

ocol

s un

chan

ged

duringoutbreak.Staff

screened.

Residenttesting29-31March:WardA-4/30(13%),WardB-0/30,WardC-10/36

(28%).OnApril3all22remainingWardAwerenegative,transferredtoWardsB

andC,WardAconvertedtoCOVID-19recoveryunit.April6,28wardCtested,2

positive,movedtowardA.April13thirdroundoftesting,all27residentsnegative.

April22-23,allresidentsofwardsBandCtestednegative.19/96residentstested

positive.5/19symptomatic,8/19presymptomatic,6/19asymptomatic.1died.

8/126stafftestedpositive.4/8symptomatic.Reportedswiftisolatingandcohorting

ofresidentswhowereCOVIDpositivetoreducetransmissioninthefacility.

ConvertedwardAintoaCOVID-19recoveryunitallowedquickcohortingofpositive

residents.Restrictedstaffmovementbetweenwardsreducedtransmissionrisks.

Nocasesamongstaffidentifiedafterinitialroundoftesting.Noresultsforvisitors

reported.13/19residentshasunderlyingmedicalconditions.9/19wereBlackor

AfricanAmerican.11/19hadsymptomsattimeoftestingoraftertesting.Intotal

136staffmemberstested,and6%infectionsidentified-allworkedinwardsAandC.

Fourifeightpositivecasesinstaffwereasymptomatic.Testingofsymptomaticstaff

continued(notserialtestingofallstaffduetolimitedsupplies).

158

Table2SO

utco

mes

for R

esid

ents

StudyID

Country

Setting

Population

Describe/typeof

intervention

Outcomemeasures

Outcomes

Fism

an e

t al(2020)

Ontario,

Can

ada

Long-term

care

hom

esRe

siden

ts,

staffand

com

mun

ity

Nonereported

Estimatedincidencerate

ratiosforCOVID-19

deathsinLTCpopulation

com

pare

d to

dea

ths

in

Ontariopopulationaged

>70;evaluatedriskof

deathwithinLTCasa

functionofthenumber

oflab-confirmedinfected

residentsandconfirmed

infectedstaffatlagsfrom

0-7days.

Atotalof627LTCwereincludedintheprovincialdataset;ofthese272(43.4%)were

identifiedashavingeitherconfirmedorsuspectedCOVID-19infectioninresidentsor

staff.NosignificantdifferencesbetweenLTCwithandwithoutconfirmedCOVID-19

infectionswereseeninnumberoflicensedbedsize,operator(e.g.,for-profitvs.

not-forprofit),orgeographiclocationinOntario.Theincidenceofdeathdueto

COVID-19was13-foldhigherintheLTCpopulationthaninOntarioresidentsaged

>69years.Whenthewholepopulationwasusedasthereferent,theIRRfordeath

was>90inthispopulation;incidencewas23-foldhigherwhencomparedtothose

aged>59years,and8-foldhigherwhencomparedtothoseaged80andovernot

residentinLTC.Weidentifiedsignificantinteractionbetweentimeandriskassociated

withLTCresidence.WhileriskofdeathinthosenotresidentinLTCdeclinednon

significantlyovertime,therateratiofordeathinLTCresidentsrosesharply,from

8.03(90%CI2.73to20.42)onMarch29to87.28(90%CI9.98to557.08)by

April7,2020.InanalysesfocusedriskfordeathwithinLTCwefoundthatlagged

infectionsininstitutionstaffwerethestrongestpredictorsofdeathinresidentsand

weresignificantatalllags(0to7days)afteradjustmentfordateandnumbersof

infectedresidents.Thestrongesteffectswereseenwithinfectedstaffata2-daylag

(relativeincreaseindeathperinfectedstaffmember20%,95%CI14-26%)anda6

daylag(17%,95%CI11%-26%).Bycontrasttheassociationbetweeninfectionin

residentsandsubsequentresidentdeathwasvariable,andfarweakerthantheeffect

seenforstaff,andwasstatisticallysignificantonlyatazero-daylag(increasedriskper

infectedresident8%,95%CI1%to15%).IncidencerateratioofdeathinLTCcom-

paredtocommunityresidentsaged>69=13.1,aged>79=7.6,aged>59=23.1,

allages=90.4.Laggedinfectionininstitutionstaffwerethestrongestpredictorsof

deathinresidents.Infectedstaffata2-daylag:relativeincreaseinresidentdeathper

infectedstaffmember=20%95%CI14-26%);6daylag=17%95CI11-26%.

Grahamet

al(2020)

Engl

and

4 nu

rsin

g ho

mes

in

London,

Engl

and

Staffand

resid

ents

C

ompr

ehen

sive

swabbing/testing

of re

siden

ts, m

ass

testing;cohorting

andimplementation

ofadditionalinfection

mea

sure

s w

here

needed.Testingofa

representativesample

ofstaffcommenced

15thApril.

mortalityrate,positivetest

prev

alen

ce, s

ympt

oms

All-causemortality:103/394residents.53/103(54%)confirmedorsuspected

COVID-19(fromdeathcertificate).COVID-19relateddeathshappenedlater

inoutbreakthannon-COVID-19.4deathcertificatesunavailable,butalltested

positiveforCOVID-19,andGPconsidereddeathlikelyduetoCOVID-19.All-cause

mortality26%95%CI22to32n=103.Peakdeathsin1stweekApril.Marked

increasesindeathsinhomesA,BandDcomparedwithprecedingyears203%(95%

CI70to336).Menhasincreasedriskofdeath.48%V34%inthosewhosurvived.

wholegroupmales38%p=0.020.Medianagehigherinthosewhodied.andmore

deathsinthreeormorecomorbidities.126/313(40%)testedpositive.5/173(4%)

remainingtestedpositiveonre-test1weeklater.3/70(4%)stafftestedpositive(596

employeesacross4homes.(mean149/home).Staffabsencerates1stMarchto1st

May2020elevatedatmorethanthreetimesthebackgroundlevel.215.9%increase

CI95%80to352).70staffweretestedcrossthreenursinghomes.3ofthe19staff

inhomeAwerepositive.NostafftestedinhomesCandD.


Table2SO

utco

mes

for R

esid

ents

StudyID

Country

Setting

Population

Describe/typeof

intervention

Outcomemeasures

Outcomes

Handetal

(2018)

Louisiana

USA

Long-term

care

faci

lity

Resid

ents

Ad

here

nce

to

stan

dard

dro

plet

precautionsfor

symptomatic

resid

ents

, rev

iew

ing

hand

and

per

sona

l hy

gien

e po

licie

s, an

d en

hanc

ed

envi

ronm

enta

l cl

eani

ng

envi

ronm

enta

l cl

eani

ng, s

ympt

oms

duringthisoutbreak.

PositivetestCoronavirus

NL63.Followed

adhe

renc

e to

sta

ndar

d anddropletprecautions

forsymptomaticresidents.

Revi

ewed

han

d hy

gien

e po

lices

and

enh

ance

d en

viro

nmen

tal c

lean

ing

on

15thNovember.

20/130residentssuspectedascases.13hadspecimenstested,ofwhichHCoV-

NL63positivein7(54%).DuringNovember1–18,atotalof20case-patients(60%

male)ofamedianageof82(range66–96)yearswereidentified.Thenumberof

casesofrespiratoryillnesspeakedinmid-November.Themostcommonsymptoms

werecough(95%)andchestcongestion(65%).Shortnessofbreath,wheezing,fever,

andalteredmentalstatuswerealsoreported(Table).Sixteen(80%)case-patients

hadabnormalfindingsonchestradiograph;pneumoniawasnotedin14.Allcase-

patientshadconcurrentmedicalconditions;themostcommonwereheartdisease

(70%,14/20),dementia(65%,13/20),hypertension(40%,8/20),diabetes(35%,

7/20),andlungdisease(35%,7/20).Six(30%)case-patientsrequiredhospitalization;

allhadchestradiograph–confirmedpneumonia.HospitalizedLRTIcase-patients

demonstratedshortnessofbreath(50%vs.10%),wheezing(50%vs.0%),andaltered

mentalstatus(33%vs.0%)morefrequentlythandidnon-hospitalisedLRTIcase-

patients.Nonewcasesamongresidentsafter18November.Noreportsofstaff

memberswithreportedsymptoms(nodataforstaff).

Heungetal

(2006)

HongKong

Residential

care

hom

e inHong

Kong

Resid

ents

andstaff

Stafftookdropletand

contactprecautions

whe

n ca

ring

for

resid

ents

SeroprevalenceofSARS-

CoVantibodies.Symptoms

and

tran

smiss

ion

3/90residentsdied.Onemovedoutand19re-fusedtoparticipate.32staff,6

refusedtoparticipate.Noneofremaining93participantswerepositiveforSARS-

CoV.Residentswereaged65+years,79%werefemale,93%wereambulant,90%

didactivitieswithothers,79%wentout.69%ofstaffwereaged31to50years.

85%werefemale.54%engagedinnursingcare.Facetofaceinterviewswithstaff

werecompletedJuly2003.5ofremaining86residentsandthreeof32staffhas

experiencedsymptomsofsubclinicalSARS-CoVduringthestudyperiod.ResidentA

(died)hadbeentransferredfromhospitalandwaschairboundanddependentwith

careneeds.ResidentBwaschairboundandhadnotlefthomeorhadvisitors.She

wasbroughttosharedsittingareaduringmealtimes.ThiswasonlytimeresidentsA

andBwerelocatedneareachother.OneresidentsharedaroomwithpatientBand

testedpositive.StaffCwasdomesticworkerandcontactwasviaclinicalwastein

residentAroom.

Hoet

al.,(2003)

HongKong

A nu

rsin

g ho

me

in

HongKong

Resid

ents

andstaff

and

visit

ors

Com

mun

ity b

ased

outreachteamsincl.

geria

tric

ians

, nur

ses,

mob

ilise

d to

clo

sely

m

onito

r nur

sing

hom

e re

siden

ts

dis-chargedfrom

hospital.

Revi

ew o

f out

brea

k 3residentspositive,1employeepositive,3visitorspositive.Singleresidentinfected

duringhospitalstay,returnedandthevirusspreadto6people.3/7died(2residents,

1employee).4femalesages65yearsto93years.3malesaged27years,28

yearsand88years.Threedeathsrecorded-tworesidentsandonestaffmember.

Transmissionofexposuresdocumentedinnursinghome,viavisitorinteractions.

160

Table2SO

utco

mes

for R

esid

ents

StudyID

Country

Setting

Population

Describe/typeof

intervention

Outcomemeasures

Outcomes

Kenn

elly

et

al(2020)

Irela

ndNursing

hom

esStaffand

resid

ents

Descriptionof

nurs

ing

hom

es

reportingcasesand

outc

omes

num

ber o

f cas

es,

symptomaticand

asymptomaticnumbers,

clinicalout-comes

incl

udin

g m

orta

lity

Completesurveysreturnedfrom62.2%(28/45)ofNHswithatotalof2043

residentsin2303beds(medianoccupancy96.7%,IQR:86.0–96.6%)on

29/02/2020.Anoutbreakwasrecordedin75.0%(21/28)offacilities–fourpublic

andseventeenprivate.Occupancyratesatthestartofthestudyperiodwere95.1%

and87.7%inpublicandprivateNHsrespectively,decreasingto75.2%inpublicand

73.2%inprivateNHsby22/05/2020.EightNHs(38.1%)had≥80%singlerooms

inlinewithregulatorystandards.Therewasnoassociationbetweenadherenceto

thisstandardandoutbreakoccurrence(χ2=1.37,p=0.24).710/1741(40.1%)in

outbreakNHstest-edpositive(193/710,27.2%,asymptomatic;183/710,25.8%

died).54/1741suspectedinfection.Moreresidentswithconfirmed/suspected

COVID-19inpublicvsprivateNHsexperiencingoutbreak.Duringtheeighty-three-

daystudyperiod,312/2043(15.3%)residentsdied.3/28had<3staffmembers

andnoresidentspositive.300/312(96.2%)ofdeathsoccurredinanout-breakNH,

withmortalityrateof300/1741(17.2%).Case-fatalityhigherinpublicvsprivate

(22.3%vs11.2%).Staff:residentratio<1had46.7%infectionrate,52%fatalityof

case;Staff:resident=1-2,48.5%infectionrate,fatality24.8%ofcases;ratio>2=

40.3%infectionrate,10.9%fatalityofcases.675staffpositive,across24/28NHs.

23.6%asymptomatic.Significantcorrelationbetweentheproportionofsymptomatic

staffandnumberofresidentswithconfirmed/suspectedCOVID-19(Spearman's

rho=0.81).NocorrelationbetweenasymptomaticstaffandCOVID-19residents.

Al-mostaquarter(23.6%,159/675)wereasymptomatic,identifiedbymasspoint-

prevalencetesting.WhileallNHsgavedetailsontotalstaffnumberswithCOVID-19,

twelve(42.9%,12/28)re-portedinformationrelativetototalstaffinglevels(all

grades).Atotalof1392staffmembersworkedacrossthesetwelvesiteswithalmost

aquarter(23.8%,331/1392)reportedascon-firmed/suspectedCOVID-19.Over

aquarterwereasymptomatic(27.5%,91/331).TenofthetwelveNHs(83.3%,

10/12)metcriteriaforanoutbreak(oneNHhadnostaff/residentswithCOVID-19,

andanotheronlytwostaffinfected).InthoseNHs,329/1227(26.8%)ofstaffhad

con-firmed/suspectedCOVID-19infection,andoveraquarterwereasymptomatic

(27.1%;89/329)

Kim(2020)

Korea(South)Nursing

hom

e in

Ko

rea

with

142patients

and85staff.

Resid

ents

andstaff

Clo

se c

onta

ct

patientsofpositive

wor

ker w

ho w

ere

disc

harg

ed a

nd

heal

thca

re w

orke

rs

wer

e iso

late

d athome.Beds

repositionedto

mai

ntai

n di

stan

ce

of>2m..Mealsfor

patientsandstaff

prov

ided

from

outside.

Infectionratesfollowing

identificationofpositive

case.Instigatedisolation

proceduresandcohorting

ofresidentswithbeds>2

mdistances.

Staffmovementsinhomewererestricted.14nursesandassistantsvolunteered

tobequarantined.Layoutofspaceandmovementplanned.Parkinglotusedfor

removingPPE.Visitorsprohibitedfromusingelevatorasitwasusedbymedicalstaff

inPPE.PreparednessforandresponsetoCOVID19reducedtransmission.After

managementofoutbreaktherewerenomoreinfectedpersons.Allpatientsand

employeestestednegative14daysfromstartofquarantine.In-hospitalmovementof

isolationcohortcaregiversrestricted.sectionsetupasgreenzoneforworkerswithno

contactwithinfectedresidents.ParkinglotusedtoremovePPE.Elevatoronlyused

for m

edic

al p

erso

nnel

in P

PE


Table2SO

utco

mes

for R

esid

ents

StudyID

Country

Setting

Population

Describe/typeof

intervention

Outcomemeasures

Outcomes

Kim

ball

et

al2020

King

Cou

nty,

Washington,

USA

Long-Term

Car

e Sk

illed

Nursing

Faci

lity

Resid

ents

Reportofoutbreak.

Indexcasein

faci

lity

A on

Mar

ch

1,nursingand

administrative

leadershipinstituted

visitorrestrictions,

twice-daily

asse

ssm

ents

of

COVID-19signsand

sym

ptom

s am

ong

resid

ents

, and

feve

r sc

reen

ing

of a

ll he

alth

ca

re p

erso

nnel

at t

he

startofeachshift.

OnMarch6,Public

Health–Seattle

and

King

Cou

nty,

in

collaborationwith

CD

C, r

ecom

men

ded

infectionprevention

and

cont

rol m

easu

res,

includingisolation

ofallsymptomatic

resid

ents

and

use

of

gow

ns, g

love

s, eyeprotection,

face

mas

ks, a

nd h

and

hygi

ene

for h

ealth

ca

re p

erso

nnel

enteringsymptomatic

residents’rooms.

ACOVID-19outbreakin

along-termcareskilled

nursingfacility(SNF)

82residentsinfacilityA;76(92.7%)underwentsymptomassessmentandtesting;

three(3.7%)refusedtesting,two(2.4%)whohadCOVID-19symptomswere

transferredtoahospitalbeforetesting,andone(1.2%)wasunavailable.Amongthe

76testedresidents,23(30.3%)hadpositivetestresults.Demographiccharacteristics

weresimilaramongthe53(69.7%)residentswithnegativetestresultsandthe23

(30.3%)withpositivetestresults(Table1).Amongthe23residentswithpositive

testresults,10(43.5%)weresymptomatic,and13(56.5%)wereasymptomatic.

EightsymptomaticresidentshadtypicalCOVID-19symptoms,andtwohadonly

atyp

ical

sym

ptom

s; th

e m

ost c

omm

on a

typi

cal s

ympt

oms

repo

rted

wer

e m

alai

se

(fourresidents)andnausea(three).Thirteen(24.5%)residentswhohadnegative

testresultsalsoreportedtypicalandatypicalCOVID-19symptomsduringthe14

daysprecedingtesting.Agepositives80.7(mean)SD8.4Agenegatives75.1MEAN

10.9SD.Oneweekaftertesting,the13residentswhohadpositivetestresults

andwereasymptomaticonthedateoftestingwerereassessed;10haddeveloped

symptomsandwererecategorizedaspresymptomaticatthetimeoftesting(Table2).

Themostcommonsignsandsymptomsthatdevelopedwerefever(eightresidents),

malaise(six),andcough(five).Themeanintervalfromtestingtosymptomonsetin

thepresymptomaticresidentswas3days.Threeresidentswithpositivetestresults

remainedasymptomatic.Real-timeRT-PCRCtvaluesforbothgeneticmarkers

amongresidentswithpositivetestresultsforSARS-CoV-2rangedfrom18.6to29.2

(symptomatic[typicalsymptoms]),24.3to26.3(symptomatic[atypicalsymptoms

only]),15.3to37.9(presymptomatic),and21.9to31.0(asymptomatic)(Figure).There

werenosignificantdifferencesbetweenthemeanCtvaluesinthefoursymptom

statusgroups(p=0.3).ScreeningcouldfailtoidentifyhalfofCOVID-19positive

residents.Unrecognizedsymptoms.Needtoscreenstaffandrestrictvisitors.Oncea

facilityhasapositivecasethenenforcementofCDCrecommendedPPE.

162

Table2SO

utco

mes

for R

esid

ents

StudyID

Country

Setting

Population

Describe/typeof

intervention

Outcomemeasures

Outcomes

Leeetal

(2020)

Kore

aLong-term

care

hos

pita

lRe

siden

ts

andstaff

Post-exposure

prophylaxis

(PEP)using

Hydroxychloroquine

was

adm

inist

ered

to

staffandresidents

follo

win

g a

larg

e exposureevent.

Aftersecondcase

diag

nose

d, h

ealth

care

w

orke

rs a

nd re

siden

ts

beganthe14-dayPEP

intervention.Infection

rate

, com

plia

nce

with

PEP

withHCQforpatientsand

care

wor

kers

was

sta

rted

onFebruary26.Physicians

and

phar

mac

ists

wer

e educatedaboutpotential

ad-verseevents.

Hydroxychloroquine

(HCQ)wasadministrated

orallyatadoseof400mg

dailyuntilthecompletion

of14daysofquarantine.

A ch

eckl

ist fo

r com

mon

ad

vers

e ev

ents

was

distributed.

193patientsand29careworkerswereofferedPEP.189patients,22careworkers,

initiatedPEP.Meanageofpatients(81.0,range15-97,137female),ofcareworkers

(63.4,range51-78,25female),otherhospital(52.2,range24-79,79female).

Completedin184residentsand21careworkers.HCQwasassociatedwithmild

adverseevents.Onepatienthadskinrashre-quiringsteroidsbutdidnotdiscontinue

PEP.FivepatientsdiscontinuedPEPbecauseofgastrointestinalupset,bradycardia,

andforfasting.Allfollow-upPCRtestsafter14dayquarantinewerenegative.


Table2SO

utco

mes

for R

esid

ents

StudyID

Country

Setting

Population

Describe/typeof

intervention

Outcomemeasures

Outcomes

McM

icha

el

etal(2020)

King

Cou

nty,

Washing-ton,

USA

Skill

ed

nurs

ing

faci

lity

in K

ing

Cou

nty,

Washington

Resid

ents

, staff,and

visit

ors

Reportingeventof

outb

reak

OnFebruary28,2020,

fourcasesofCOVID-19

confirmedamong

resid

ents

of K

ing

Cou

nty;

1per-sonhadpresumed

travel-relatedexpo-sure,

and3wereidentified

bytestinghospitalized

patientswhohadsevere

respiratoryillness(e.g.,

pneumonia)andwho

hadtestednegative

forinfluenzaandother

respiratorypathogens.

Oneofthesewasthe

indexpatientfromFacility

A; o

ne w

as a

Fac

ility

A

staffmember.Whenthe

indexcasewasidentified

onFebruary28,atleast

45residentsandstaff

disp

erse

d ac

ross

Fac

ility

A

had

sym

ptom

s of

respiratoryillness;PHSKC

wasnotifiedofthis

incr

ease

by

the

faci

lity

onFebruary27.Asof

March18,atotalof167

personswithCOVID-19

that

was

epi

dem

iolo

gica

lly

linke

d to

Fac

ility

A h

ad

beenidentified,144were

resid

ents

of K

ing

Cou

nty

and23wereresidents

Mostaffectedpersonshadrespiratoryillness;chartreviewoffacilityresidentsfound

thatin7casesnosymptomshadbeendocumented.Clinicalpresentationranged

frommild(nohospitalization)tosevere,including35deathsbyMarch18.Reported

datesofsymptomonsetrangedfromFebruary15toMarch13.Themedianageof

thepatientswas83years(range,51to100)amongfacilityresidents,62.5years

(range,52to88)amongvisitors,and43.5years(range,21to79)amongfacility

personnel;112patients(67.1%)werewomen.Most(94.1%of101)facilityresidents

hadchronicunderlyinghealthconditions,withhypertension(67.3%),cardiacdisease

(60.4%),renaldisease(40.6%),diabetesmellitus(31.7%),pulmonarydisease(31.7%),

andobesity(30.7%)beingmostcommon.Ofthecoexistingconditionsevaluated,

hypertensionwastheonlyunderlyingconditionpresentin7facilityresidentswith

COVID-19.50healthcarepersonnelpositive.Hospitalizationratesforfacilitystaff

were6.0%.AsofMarch18,atotalof30long-termcarefacilitieswithatleastone

confirmedcaseofCOVID-19hadbeenidentifiedinKingCounty.inthefollowing

occupationalcategories:physicaltherapist,occupationaltherapistassistant,speech

pathologist,environmentalcare(housekeeping,maintenance),nurse,certifiednursing

assistant,healthinformationofficer,physician,andcasemanager.16visitorspositive.

Hospitalizationratesforfacilityvisitorswere50.0%.

OnMarch10,2020,thegovernorofWashingtonimplementedmandatoryscreening

ofhealthcareworkersandvisitorrestrictionsMonitoringofstaffabsences.

164

Table2SO

utco

mes

for R

esid

ents

StudyID

Country

Setting

Population

Describe/typeof

intervention

Outcomemeasures

Outcomes

McM

icha

el

etal(2020)

King

Cou

nty,

Washing-ton,

USA

Long-Term

Car

e Sk

illed

Nursing

Faci

lity

Resid

ents

, staffand

visit

ors

Repo

rt o

f out

brea

k Outbreakinformation

includingfatalities.

Identificationofindexcase27thFebruaryfromlong-termcareFacilityA-reviewby

CDCinFacilityA.By9thMarchinFacilityA:129COVID-19cases:(81approx.of

130)residents,34staffmembersand14visitors.CasesinKingCounty-111(86%)

inFacilityAresidents,17staffand13visitors.18casesinresidentsinSnohomish

County(17staffand1visitor).Symptoms16thFebto5thMarch.Medianage81

years.(range54-100)residents;42.5(22-79)staff,62.5years(52-88)visitors.65.1%

ofpatientswerewomen.InFacilityA35.7%ofcaseswerevisitors.Casefatality

residents27.2%andvisitors7.1%.Nodeathsreportedforstaff.Underlyinghealth

:hypertension69.1%,cardiacdisease56.8%,renaldisease43.2%,diabetes37.0%,

obesity33.3%,pulmonarydisease32.1%.At9thMarchatleast8otheroutbreaks

reported.Contributingtotransmission=staffworkingwhilesymptomatic,staff

workinginmorethanonelocation,inadequateknowledgestandardprecautions,eye

protection,PPE,lackofsanitiser,delayedrecognitionofcases,delayedtesting-based

onsignsandsymptomsonly.

Officefor

National

Statistics

(2020)

Engl

and

Car

e ho

mes

, En

glan

dRe

siden

ts

andstaff

Surv

ey o

f nur

sing

homesandreporting

outc

omes

Outcomesbasedon

resp

onse

s of

car

e ho

me

man

ager

s to

sur

vey,

and

nottheswabtests.%

residentsaged65years

and

olde

r and

car

e ho

me

staffwhohavetested

positiveforCOVID-19.

Numberandsizeof

homes:0to40beds

n=5196,41-80beds=

3390,81-120beds

n=436,121-160beds

n=43,morethan160beds

n=16.

Across9081homes,estimatedtobe293,301residents(95%CI:293,168-

293,434),441,498staff(441,240-441,756).92.9%(95%CI:92.5-93.3%)ofhomes

offersickpaytostaff,11.5%(10.9-12.1%)havestaffwhoworkinmultiplelocations,

44.2%(43.4-45.0%)donotemployanybankoragencystaff.97.2%(95%CI:96.8

-97.6%)havebeenclosedtovisitors,19.3%(18.5-20.1%)havebeenclosedto

newadmissions.Ofthe9081homes,estimatedthat55.6%(95%CI:54.8-56.4%)

reportedatleastoneconfirmedcoronaviruscase.Acrossthosehomes,estimated

that19.9%(18.5-21.3%)ofresidentstestedpositive,while6.9%ofstaff(5.9-

7.9%)testedpositive,sincestartofpandemic.Acrossallhomes,estimated10.7%

(10.1-11.3%)ofresidentspositive,4.0%(3.6-4.4%)staffpositive.15,606deathsof

residentsacrossallhomesduetoCOVID-19.Foreachadditionalmemberofinfected

staffworkingatthecarehome,theoddsofresidentinfectionincreaseby11%ieOR

=1.11(95%CI:1.1-1.11).Carehomesusingbankoragencynursesorcarersmost

oreverydaymorelikelytohavecasesinresidents(OR=1.58,1.5-1.65),compared

tothosewhoneverusebankoragencystaff.Residentsincarehomesoutsideof

Londonhadlowerchanceofinfection,exceptWestMidlands(OR=1.09,1.0-

1.17).Homeswherestaffreceivesickpayarelesslikelytohaveresidentcases(OR=

0.82to0.93,95%CI:7-18%),comparedtohomeswherenosickleave.Foreach

additionalinfectedresidentatahome,theoddsofstaffinfectionincreaseby4%(4

-4%)OR=1.04).CarehomesusingbankoragencystaffmostoreverydayOR=1.88

(95%CI:1.77-2.0)comparedtohomesnotusing.Homeswherestaffregularlywork

elsewhere(mostoreveryday)increaseodds(OR=2.4,1.92-3.0)com-paredto

homewhoneverworkelsewhere.StaffathomesoutsideLondonhadhigheroddsof

infection.


Table2SO

utco

mes

for R

esid

ents

StudyID

Country

Setting

Population

Describe/typeof

intervention

Outcomemeasures

Outcomes

Roxbyetal

(2020)

Seattle,

Washing-ton,

USA

Assis

ted

livin

g fa

cilit

y Re

siden

ts

andstaff

Surv

eilla

nce

repo

rt

-linktomainpaper

JAMA2020

SurveillanceforSARS-

CoV2anddescribe

symptomsofCOVID-19in

resid

ents

of i

ndep

ende

nt/

assis

ted

livin

g fa

cilit

y

83residentsand62stafftested.5cases:3residentsand2staff.Anotherresident

testedpositiveday7.Threeresidentsnosymptoms.SARS-CoV-2wasdetectedin

three(3.8%)residentsandtwo(3.2%)staffmembers.Noneoftheresidentswith

positivetestsreportedsymptomsatthetimeoftesting;however,one(resident

C)re-portedresolvedmildcoughandloosestoolduringthepreceding14days.

Allthreeresidentswithpositivetestresultswerelivingonseparatefloorsintheir

ownapartments;onereceivedassistancewithactivitiesofdailyliving.Oneresident

livedonthesamefloorasthetwohospitalizedresidentswithknownCOVID-19,

andonehadknownclosecontactwithoneofthehospitalizedresidents;thethird

residentwhohadpositivetestresultshadnocontactwitheitherofthehospitalized

residents.Whenthesecondroundoftestingwasconducted7dayslater,one

additionalpositivetestresultwasreportedforanasymptomaticresidentwhohad

negativetestresultsonthefirstround.Duringthefirstroundoftestingandsymptom

screening,symptomswerereportedby42%ofresidentsand25%ofstaffmembers

whohadnegativetestresultsforSARS-CoV-2.Symptomsreportedbyresidents

whohadnegativetestresultsincludedsorethroat,chills,confusion,bodyaches,

dizziness,malaise,headaches,cough,shortnessofbreath,anddiarrhoea.Residents

age85.8years(SD7.6),78%female,48%smokedhistory,5%currentsmokers,59%

asymptomatic,41%anysymptomsinlast14days,comorbiditiesincludedchronic

lungdisease47%,diabetes15%,cardiovasculardisease60%.,cognitiveimpairment

36%.Staffmeanage40years(SD15),68%female,10%currentsmokers,72%

asymptomatic,28%anysymptomsinlast14days.

166

Table2SO

utco

mes

for R

esid

ents

StudyID

Country

Setting

Population

Describe/typeof

intervention

Outcomemeasures

Outcomes

Roxbyetal

(2020)

Seattle,

Washing-ton,

USA

Long-

term

car

e facilities

Resid

ents

andstaff

Surv

eilla

nce

for

SARS-CoV-2

infectionina

congregatesetting

implementing

socialisolationand

infectionprevention

protocols.

SARS-CoV-2real-time

polymerasechainreaction

was

per

form

ed o

n na

soph

aryn

geal

sw

abs

fromresidentsandstaff;

asymptomquestionnaire

was

com

plet

ed a

sses

sing

feve

r, co

ugh,

and

ot

her s

ympt

oms

for

thepreceding14days.

Resid

ents

wer

e re

test

ed

forSARS-CoV-27days

afterinitialscreening.

Residentsandstaff

completedaquestionnaire

asse

ssin

g sy

mpt

oms

of

COVID-19includingfever,

coug

h, m

alai

se, d

iarr

hea,

an

d so

re th

roat

, cov

erin

g thepreceding14days,

anddocumentingexisting

healthconditions.

SARS-CoV-2wasdetectedin3of80residents(3.8%);1maleresidentreported

resolvedcoughand1loosestoolduringthepreceding14days.Viruswasalso

detectedin2of62staff(3.2%);bothweresymptomatic.Oneweeklater,resident

SARS-CoV-2testingwasrepeatedand1newinfectiondetected(asymptomatic).All

residentsremainedinisolationandwereclinicallystable14daysafterthesecond

test.asnotcollectedatthe7-dayfollow-uptesting.Thesurveillanceteamcollected

nasopharyngeal(NP)swabsandadministeredquestionnairesinperson;residents

werevisitedintheirroomsandstaffweresurveyedinthediningarea.Of83facility

residents,2werehospitalizedwithCOVID-19and1wasoffsitewithfamilyforthe

entireevaluationperiod.TestingofNPswabsforSARS-CoV-2wascompletedfor142

persons(Table1):all80residentsonsiteand62staff.Symptomquestionnaireswere

collectedfromall80residentsandfrom57(92%)staff.Sixty-tworesidentswere

women(77%),withmean(range)ageof86(69-102)years.Staffhadamean(range)

ageof40(16-70)years,and42werewomen(68%).63of80residents(79%)hadat

least1seriouschronicmedicalconditionand33(41%)reportedsymptomsincluding

cough(7[9%])dizziness(4[5%]),headache(5[6%]),anddiarrhea(5[6%])(Table

1).Of57staffwhocompletedaquestionnaire,16(28%)reportedillnesssymptoms

includingmalaise(6[11%]);sorethroat(7[12%]),andbodyaches(5[9%]).SARS-

CoV-2wasdetectedin3residents:1maninhis70s(Ct,N1=24.4N2=23.0);a

womaninher90s(Ct,N1=31.6,N2=31.3);andawomaninher80s(Ct,N1=30.9

N2=29.7).All3residentswithincidentSARS-CoV-2detectedwerelivingintheir

ownapartments.Onday7,1additionalasymptomaticresident,awomaninher80s

whohadnegativescreeningresultstheweekprior,hadSARS-CoV-2detected(Ct,

N1=35.7;N2=37.1).1casedevelopedamildcough,butcontinuedtofeelwell,

Onday21,allcasescontinuedtoexhibittheirusualstateofhealth,andnonew

casesofCOVID-199werefoundamongresidents.SARS-CoV-2wasdetectedin2

symptomaticfemalestaff;1workedindiningservicesand1wasahealthaide.The

symptomsreportedbystaffwereheadachefor10days,andbodyaches,headache,

andcoughfor5days.Thestaffmemberwith5daysofsymptomshadnotworked

whileill.

Smith

et a

l (2020)

Fran

ce

Sim

ulat

ed

Long-term

Car

e

Resid

ents

andStaff

Statisticalsimulation

Surv

eilla

nce

stra

tegi

es

wer

e ev

alua

ted

base

d on

thei

r abi

lity

to d

etec

t no

soco

mia

l out

brea

ks

usin

g th

ree

mea

sure

s of

timelinessandefficacy.

COVID-19epidemicsweresimulatedusingadynamic,stochastic,individual-based

transmissionmodel,describingdynamicinter-individualcon-tactsamongand

betweenhospitalpatientsandpersonnelinafive-ward,170-bedLong-termcare

facility.Therewereonaverage154patientsand239membersofstaffpresent

inthehospitalperday,thelatterpartitionedacross13distinctcategories(e.g.

nursing,administrativeoroperationsstaff).Bothpatientsandstaffcouldpotentially

becomeinfectedwithCOVID-19and/orexperienceCOVID-likesymptoms.Hospital

structure,demographics,anddynamiccontactnetworkswereestimatedfromclose-

proximityinteractiondata,measuredviasensorswornbyallpatientsandpersonnel

overa12-weekperiodinafive-wardrehabilitationhospitalinnorthernFrance.


Table2SO

utco

mes

for R

esid

ents

StudyID

Country

Setting

Population

Describe/typeof

intervention

Outcomemeasures

Outcomes

Stow

et a

l (2020)

Engl

and

Car

e ho

me

units

and

fr

om lo

cal

auth

ority

ar

eas

in

England.

Resid

ents

Esta

blish

ed b

asel

ine

levelsforNEW

San

d its

com

pone

nt

observations,inour

population

Tim

e se

ries

com

paris

on

withOfficeforNational

Statistics(ONS)weekly

repo

rted

regi

ster

ed d

eath

s of

car

e ho

me

resid

ents

whereCOVID-19was

the

unde

rlyin

g ca

use

of

deat

h, a

nd a

ll ot

her d

eath

s (excludingCOVID-19)up

to10/05/2020

Carehomedatawereavailablefrom6,464individuals,2,007men(meanage80.1

years,SD=12.6)and3,373women(meanage83.0years,SD=12.9).Informationon

genderwasmissingfrom1,086(16.8%)people,andageinformationwasmissing

for116(1.8%)people.Geographicalvariationinreporting29,656NEW

Srecordings

weremadeacross46LocalAuthority(LA)areas,from480uniquecarehomeIDs

(identifiersforthedeviceusedtorecordthemeasurement,representingacare

home,oradistinctunitwithinacarehome).Mostrecordingsweremadeintwo

LAsinthenortheastofEngland(n=11,029andn=10,347),andinoneLondon

borough(n=3,411).DeathsincarehomesTherewere10,407registereddeathsin

carehomesinthe46LAandCCGareasbetween29/12/2019and10/05/2020.

ThefirstdeathfromCOVID-19wasregisteredinweekcommencing23/03/2020.

From23/03/2020to10/05/2020,therewere5,753deathsofcarehomeresidents

-1,532withanunderlyingcauseofCOVID-19and4,221duetocausesexcluding

COVID-19.DeathsduetoCOVID-19between23/03/2020and10/05/2020=

5,753deaths(1,532involvingCOVID-19and4,221othercauses).Theproportion

ofabove-baselineNEW

Sincreasedfrom16/03/2020andcloselyfollowedtherise

andfallinCOVID-19deathsoverthestudyperiod.Theproportionofabove-baseline

oxygensaturation,respiratoryrateandtemperaturemeasurementsalsoincreased

approximatelytwoweeksbeforepeaksincarehomedeathsincorresponding

geographicalareas.NEW

Smaymakeausefulcontributiontodiseasesurveillancein

carehomesduringtheCOVID-19pandemic.Oxygensaturation,respiratoryrateand

temperaturecouldbeprioritisedastheyappeartosignalriseinmortalityalmostas

wellastotalNEW

S.Thisstudyreinforcestheneedtocollatedatafromcarehomes,

tomonitorandprotectresidents’health.

Trab

ucch

i etDeLeo

(2020)

Italy

Nursing

hom

es

Resid

ents

None

EventsinItalyarecausingpainanddemoralizationtoastillincredulousand

shockedgeneralpopulation.Itisparticularlydistressingthatoutbreaksofinfection

havedevelopedrapidlyinmanynursinghomes,wherestaffhavebeencompletely

neglectedbyhealthauthoritiesandcanofferonlylittleprotectiontomanyfrail

andneedyolderpeople.IntheprovinceofBergamo,morethan600nursinghome

residents,fromatotalcapacityof6400beds,diedbetweenMarch7and27,2020.

AsimilarisoccurringinmanyotherpartsoftheadministrativeregionsofLombardy,

Veneto,andEmilia-Romagna,wherenursinghomescommonlyhave10–15deaths

duetoCOVID-19outof70guests.Insomecases,3–4guestsdiedinasingleday.

Exhaustedmedicalstaffandburdenonsociety.Psychologicalsupportsrequired.

ChallengesoflackofPPE.

Table2SO

utco

mes

for R

esid

ents

StudyID

Country

Setting

Population

Describe/typeof

intervention

Outcomemeasures

Outcomes

Roxbyetal

(2020)

Seattle,

Washing-ton,

USA

Long-

term

car

e facilities

Resid

ents

andstaff

Surv

eilla

nce

for

SARS-CoV-2

infectionina

congregatesetting

implementing

socialisolationand

infectionprevention

protocols.

SARS-CoV-2real-time


was

per

form

ed o

n na

soph

aryn

geal

sw

abs



was

com

plet

ed a

sses

sing

feve

r, co

ugh,

and

ot

her s

ympt

oms

for

thepreceding14days.

Resid

ents

wer

e re

test

ed

forSARS-CoV-27days


Residentsandstaff


asse

ssin

g sy

mpt

oms

of


coug

h, m

alai

se, d

iarr

hea,

an

d so

re th

roat

, cov

erin



healthconditions.










entireevaluationperiod.TestingofNPswabsforSARS-CoV-2wascompletedfor142

persons(Table1):all80residentsonsiteand62staff.Symptomquestionnaireswere

collectedfromall80residentsandfrom57(92%)staff.Sixty-tworesidentswere














casesofCOVID-199werefoundamongresidents.SARS-CoV-2wasdetectedin2




whileill.

Smith

et a

l (2020)

Fran

ce

Sim

ulat

ed

Long-term

Car

e

Resid

ents

andStaff


Surv

eilla

nce

stra

tegi

es

wer

e ev

alua

ted

base

d on

thei

r abi

lity

to d

etec

t no

soco

mia

l out

brea

ks

usin

g th

ree

mea

sure

s of


COVID-19epidemicsweresimulatedusingadynamic,stochastic,individual-based

transmissionmodel,describingdynamicinter-individualcon-tactsamongand


facility.Therewereonaverage154patientsand239membersofstaffpresent

inthehospitalperday,thelatterpartitionedacross13distinctcategories(e.g.

nursing,administrativeoroperationsstaff).Bothpatientsandstaffcouldpotentially

becomeinfectedwithCOVID-19and/orexperienceCOVID-likesymptoms.Hospital

structure,demographics,anddynamiccontactnetworkswereestimatedfromclose-

proximityinteractiondata,measuredviasensorswornbyallpatientsandpersonnel

overa12-weekperiodinafive-wardrehabilitationhospitalinnorthernFrance.

168

Table2SO

utco

mes

for R

esid

ents

StudyID

Country

Setting

Population

Describe/typeof

intervention

Outcomemeasures

Outcomes

Tse

et a

l (2003)

HongKong

Nursing

hom

e Re

siden

ts,

staff

Nointervention.Re-

portingknowledgeof

SARS.

Kno

wle

dge

of S

ARS

Veryfewoftheparticipantsinthenursinghomecouldbedescribedas

knowledgeableregardingSARSanditsprevention.Someoftheseresidentswere

worriedaboutcontractingthediseasethemselves.However,themajorityofthe

residentsstudiedhadeitherlittleornoknowledgeaboutSARS.7/40(17.5%)

residentshadgoodknowledgeofSARS,16/40(40%)littleknowledge,17/40

(42.5%)knewvirtuallynothingaboutSARS.Halfofthosewithgoodknowledge

wereworriedaboutcontractingSARS,66%ofthosewithlittleknowledgewere

worriedaboutcontractingSARS,10%ofthosewithnoknowledgewereconcerned

aboutcontracting.GoodknowledgeofSARShadgoodknowledgeofprevention

strategies,thosewithlittleknowledgenamed1-2preventivemeasures,thosewith

noknowledgenamedonly1measure.Manager,Physiotherapist,domesticstaff,

healthcareassistantsfeltfearandconcern,concernaboutvisitorsbringinginSARS.

ManagerandRNnotconcernedaboutanoutbreakastheyrecognisedhygiene

proceduresandconditionsweresatisfactory.Notsurprisinglyperhaps,thosewith

theleastknowledgealsohadtheleastconcernsaboutcontractingthedisease.

The

lack

of k

now

ledg

e an

d co

ncer

n m

ay m

ake

them

mor

e vu

lner

able

in te

rms

of

contractingSARS.ThemajorityofstaffworriedaboutcontractingSARSatworkand

wasconcernedaboutanoutbreakinthenursinghome.Theseworrieswerecaused

largelybyatragiclarge-scaleoutbreakinahousingestatetriggeredbyasinglevisitor

withSARSandaccountedformorethan300SARScasesandmorethan30deaths.

Inaddition,staffwereverymuchawarethatseveralmedicalstaffandahealthcare

assistantinanursinghomehaddiedrecentlyofSARSinHongKong.Tominimizethe

riskofanoutbreak,thenursinghomeproactivelyimplementedpreventivemeasures

includingsendingletterstovisitorsandshorteningthevisitingperiod.Tofurther

alleviatetheworryandfearofthestaff,especiallythehealthcareassistantsand

domesticstaff,inserviceworkshopsandseminarsareindicated,andmorechannels

forcommunicationandsupporttoallstaffarerecommended.


Table2SO

utco

mes

for R

esid

ents

StudyID

Country

Setting

Population

Describe/typeof

intervention

Outcomemeasures

Outcomes

Zazzaraet

al(2020)

London,

Engl

and

Hospital

(and

com

mun

ity

base

d co

hort

Resid

ents

/ Facilities

Assessmentoffrailty.

Weusepoint-of-

care

dat

a fr

om

patientsadmittedto

a la

rge

UK

hosp

ital

trus

t, su

ppor

ted

bycommunity-

basedCOVID-19

Sym

ptom

Stu

dy

mobileapplication

(“app”)data,to

asse

ss h

ow fr

ailty

affectspresentation

ofconfirmed+ve

COVID-19infection

inolderadults.

Multivariatelogistic

regr

essio

n an

alys

is performedonage-

mat

ched

sam

ples

fr

om h

ospi

tal a

nd

community-based

coho

rts

to a

scer

tain

associationoffrailty

with

sym

ptom

s ofconfirmed

COVID-19.

Frai

lty

Hospitalcohort:significantlyhigherprevalenceofdeliriuminthefrailsample,withno

differenceinfeverorcough.Frailtysignificantlypredicteddelirium(p=0.013,OR(95%

CI)=3.22(1.44,7.21).Community-basedcohort:significantlyhigherprevalence

ofprobabledeliriuminfrailer,olderadults,andfatigueandshortnessofbreath.

Frailtysignificantlypredicteddelirium.Frailtyfoundtopredictdelirium(p=0.038,

OR(95%)=2.29(1.33,4.0).Frailtypredictedfatigue(p=0.038,OR=2.23(1.27,3.96);

SOB(p=0.043,OR=2.0(1.19,3.39)).Thisisthefirststudydemonstratinghigher

prevalenceofdeliriumasaCOVID-19symptominolderadultswithfrailtycompared

tootherolderadults.Thisemphasisesneedforsystematicfrailtyassessment

andscreeningfordeliriuminacutelyillolderpatientsinhospitalandcommunity

settings.CliniciansshouldsuspectCOVID-19infrailadultswithdelirium.After

age-matching,deliriumwasreportedin40(38%)offrailand13(12%)ofnon-frail

patientswithCOVID-19.Frailtywasfoundtosignificantlypredictdelirium(P-value:

0.013;OddsRatio(OR)(95%ConfidenceInterval(CI))=3.22(1.44,7.21).There

werenosignificantdifferencesbe-tweenfrailandnotfrailforothersymptoms

(fever(temperature≥37.5C)andcough).Afterage-matching,frailtywasfoundto

significantlypredictdelirium(P-value0.038;OR(95%CI)=2.29(1.33,4.00)).Frailty

alsopredictedfatigue(P-value:0.038;OR=2.23(1.27,3.96))andshortnessof

breath(P-value:0.043;OR=2.00(1.19,3.39)).Therewerenodifferencesbetween

frailandnotfrailfortheother11symptomsanalysed.

170

Table3SO

utco

mes

for S

taff

StudyID

Country

Setting

Population

Describe/typeof

intervention

Outcomemeasures

Outcomes

Amer

ican

Geriatrics

Soci

ety

PolicyBrief:

COVID-19

and

Nursing

Homes

USA

NHand

LTCFs

Staff,

resid

ents

an

d facilities

None,reporting

recommendations

CM

S ha

s ro

lled

out

seve

ral p

olic

y ch

ange

s to

sup

port

hea

lthca

re

prof

essio

nals

and

syst

ems

on th

e fr

ontli

ne o

f car

ing

for i

ndiv

idua

ls w

ith

COVID-19.Theseinclude

chan

ges

in h

ow M

edic

are

reim

burs

es fo

r tel

ehea

lth

visit

s an

d up

date

s to

eliminatethe3-day

hosp

ital s

tay

rule

to a

llow

M

edic

are

to c

over

ear

lier

admissionstoNHs.



settings.NHs,LTCFs,othercongregatelivingsettings(eg,assistedliving),andhome









theresident(s)separatelyfromtherestofthecommunityandprovidededicatedstaff

forpeoplewithCOVID-19inlinewithCDCguidance.PublicHealthPlanningPublic

healthplanningincludingcollaboratingwithstakeholdersandacrossseveraldifferent

prioritiesincludingConsultantsandhealthprofessionals,administrators,palliativecare

specialists,localexpertisecollaborationscanhelpstatesencourageNHsandhospitals

tocreatetheirowntransferpolicies,whichmayrequirefrequentadjustmentbased

onlocalconditionsandbasedonhospitalresources.Hospitaldischargealsoplaysan

importantroleinCOVID-19planninganduseoftelemedicine.Workforceplanning

includingexpertise,trainingandsupports,ratios.Considerationoftaxreliefsand

payments.

Aron

s et

al

(2020)

King

Cou

nty,

Washington

USA

Nursing

hom

e fa

cilit

y, K

ing

Cou

nty,

Washington

USA

Resid

ents

/staff

(March6)Onsite

infectionprevention

and

cont

rol

mea

sure

s in

clud

ing

reco

mm

ende

d al

l healthcarestaff

enteringsymptomatic

residents'roomswear

eyeprotection,gown,

gloves,facemask.

Positivetest;typical

or ty

pica

l sym

ptom

s;

non-symptomatic;

presymptomatic.Growth

rate,doublingtime.

57of89(64%)residentstestedpositiveduringpoint-prevalencesurveys,clinical

evaluation,orpostmortemexaminationasofMarch26(firstsurveydoneonMarch

13).48of76(63%)whodidfirstsurveytestedpositiveineitherinitialorsubsequent

point-prevalencesurveys.17of48(35%)reportedtypicalsymptoms,4(8%)only

atypicalsymptoms,27(56%)reportednonewsymptomsorchangesinchronic

symptomsattimeoftesting.Of27asymptomatic-12reportedonlystablechronic

symptoms,15reportednosymptoms.Inthe7daysaftertest,24of27asymptomatic

developedsymptoms(thereforepresymptomatic).Mediantimetosymptomonset

was4days.Doublingtimeestimatedat3.4days.Mortality26%(15of57).11of136

fulltimestaffpositiveatfirstsurvey.ByMarch26,55reportedsymptoms,51were

tested,26werepositive.17/26werenursingstaff,9hadoccupationsacrossmultiple

units(therapists,environmentalservice,dietaryservice)


Table3SO

utco

mes

for S

taff

StudyID

Country

Setting

Population

Describe/typeof

intervention

Outcomemeasures

Outcomes

Brainardet

al(2020)

Engl

and

Car

e ho

mes

, Norfolk

Staff

PPEavailability:most

to le

ast a

vaila

bilit

yStaffstatus,positive

cases,accesstoPPE.

Relatedin-creasein

case

cou

nts

to le

vels

of

staffandPPE.Positive

resid

ent c

ount

, acc

ess

to

PPE.Stagemodellingfor

detectionofCOVID-19

in h

omes

, the

n re

late

any

in

crea

se in

cas

e co

unts

afterintroductiontostaff-

ing

or P

PE le

vels

248homesincludedinanalysis,ofwhich25re-portedcases(133casesintotal

duringmonitor-ing).Numberofnon-careworkerspredictedifanoutbreakwould

occurinahome(hazardratioincreasesasnumberofworkersincreases).Ab-senceof

masksandeyeprotectionhadbiggestimpactoncases.ReducedavailabilityofPPEfor

eyes(B=1.66)andfacemasks(B=1.26)hadgreatestimpactonspread.Survey1(13

March):23/76positive(1asymptomatic,11presympto-matic,9typicalsymptoms,

2atypicalsymptoms);1previouslypositivetestednegative(hadsymp-toms).Survey

2(19-20March,ontheremaining52negatives,49weretesteddueto3leaving):

24/49positive(2asymptomatic,13presympto-matic,7hadtypicalsymptoms,2

hadatypicalsymptoms).Timingtoinfectionwassignificantlyrelatedtothenumber

ofnon-careworkersem-ployed(Figure1).Riskofinfectionwas6.502timeshigher

(CI:2.614-16.17)incarehomesthatemployed11to20non-careworkers;9.870

timeshigher(CI:3.224-30.22)inhomesemploy-ing21-30careworkersand18.927

timeshigher(CI2.358:151.90)timeshigherincarehomesemployingmorethan30

noncareworkers.Hazardratioofoutbreakoccurring:onlynon-careworkernumber

significant-<10HR=1.0,11-20HR=6.502,21-30HR=9.87,>30HR=18.927.

SpreadofCOVID-19regressionincrementalin-creaseincasesperunitofpredictor

variable:eyeprotection(B=1.66),facemask(B=1.26),countofcareworkersemployed

(B=1.04),countofnursesemployed(B=1.18)

Dor

a et

al

(2020)

Cal

iforn

ia,

USA

Skill

ed

nurs

ing

faci

lity

USA

Resid

ents

, staffand

visit

ors

AllSNFresidents,

rega

rdle

ss o

f sy

mpt

oms,

unde

rwen

t ser

ial

approximatelyweekly)

nasopharyngealSARS-

CoV-2RT-PCRtesting,


betweenMarch29and

April23(after3+V2


betweenMarch28-29),


29-April10.Testingof

allvisitorsMarch6th.

March17thallvisitors

prohibitedfrombuildings.


cont

rol p

roce

dure

s an

d st

rate

gies

for c

ase





revi

ewed

and

mon

itore

d useofPPEwithaSNF

staffmembers.PPE

prot

ocol

s un

chan

ged


screened.








ofresidentswhowereCOVID-19positivetoreducetransmissioninthefacility.






136staffmemberstestedand6%infectionsidentified-allworkedinwardsAandC.



172

Table3SO

utco

mes

for S

taff

StudyID

Country

Setting

Population

Describe/typeof

intervention

Outcomemeasures

Outcomes

Fism

an e

t al(2020)

Ontario,

Can

ada

Long-term

care

hom

esRe

siden

ts,

staffand

com

mun

ity

Nonereported

Estimatedincidencerate

ratiosforCOVID-19

deathsinLTCpopulation

com

pare

d to

dea

ths

in

Ontariopopulationaged

>70;evaluatedriskof

deathwithinLTCasa

functionofthenumber

oflab-confirmedinfected

residentsandconfirmed

infectedstaffatlagsfrom

0-7days.

Atotalof627LTCwereincludedintheprovincialdataset;ofthese272(43.4%)were

identifiedashavingeitherconfirmedorsuspectedCOVID-19infectioninresidentsor

staff.NosignificantdifferencesbetweenLTCwithandwithoutconfirmedCOVID-19

infectionswereseeninnumberoflicensedbedsize,operator(e.g.,for-profitvs.

not-forprofit),orgeographiclocationinOntario.Theincidenceofdeathdueto

COVID-19was13-foldhigherintheLTCpopulationthaninOntarioresidentsaged>

69years.Whenthewholepopulationwasusedasthereferent,theIRRfordeathwas

>90inthispopulation;incidencewas23-foldhigherwhencomparedtothoseaged>

59years,and8-foldhigherwhencomparedtothoseaged80andovernotresidentin

LTC.WeidentifiedsignificantinteractionbetweentimeandriskassociatedwithLTC

residence.WhileriskofdeathinthosenotresidentinLTCdeclinednonsignificantly

overtime,therateratiofordeathinLTCresidentsrosesharply,from8.03(90%CI

2.73to20.42)onMarch29to87.28(90%CI9.98to557.08)byApril7,2020.

InanalysesfocussedriskfordeathwithinLTCwefoundthatlaggedinfections

ininstitutionstaffwerethestrongestpredictorsofdeathinresidentsandwere

significantatalllags(0to7days)afteradjustmentfordateandnumbersofinfected

residents.Thestrongesteffectswereseenwithinfectedstaffata2daylag(relative

increaseindeathperinfectedstaffmember20%,95%CI14-26%)anda6daylag

(17%,95%CI11%-26%).Bycontrasttheassociationbetweeninfectioninresidents

andsubsequentresidentdeathwasvariable,andfarweakerthantheeffectseenfor

staff,andwasstatisticallysignificantonlyatazero-daylag(increasedriskperinfected

resident8%,95%CI1%to15%).IncidencerateratioofdeathinLTCcomparedto

communityresidentsaged>69=13.1,aged>79=7.6,aged>59=23.1,allages=

90.4.Laggedinfectionininstitutionstaffwerethestrongestpredictorsofdeathin

residents.Infectedstaffata2daylag:relativeincreaseinresidentdeathperinfected

staffmember=20%95%CI14-26%);6daylag=17%95CI11-26%.

Geuryetal

(2020)

Nantes,

Fran

ceNursing

hom

e,

Fran

ce

Staff

Testingofallstaff

mem

bers

upo

n oc

curr

ence

of a

confirmedcaseof

COVID-19.

Positivetestoutcome

136staffmemberstested(112female),age(medianIQR)=39[27-48.5].3/136

testedpositive(2.2%),1wassymptomatic,1waspresymptomatic(symptoms

developed24hourspost-testing),1wasasymptomatic.Attimeoftesting98staff

(72%)wereasymptomatic.Promptpointprevalencetestingafterfirstpositivecase

haslimitedeffectivenessasonly2.2%ofstaffpositiveandtwoofthestaffhad

symptomsandwouldhavebeenisolated.Resultscouldsuggestincubationof5days,

orviraltransmissionduringincubationvariesandreducesimpactofsingletesting.The

surveywascarriedout4weeksafterlockdown,solowrateofcommunityvirus.


Table3SO

utco

mes

for S

taff

StudyID

Country

Setting

Population

Describe/typeof

intervention

Outcomemeasures

Outcomes

Grahamet

al(2020)

Engl

and

4 nu

rsin

g ho

mes

in

London,

Engl

and

Staffand

resid

ents

C

ompr

ehen

sive

swabbing/testing

of re

siden

ts, m

ass

testing;cohortingand

implementationof

additionalinfection

mea

sure

s w

here

needed.Testingofa

representativesample

ofstaffcommenced

15thApril.

mortalityrate,positive

test

pre

vale

nce,

sy

mpt

oms

Allcausemortality:103/394residents.53/103(54%)confirmedorsuspected

COVID-19(fromdeathcertificate).COVID-19relateddeathshappenedlaterin

outbreakthannon-COVID-19.4deathcertificatesunavailable,butalltestedpositive

forCOVID-19,andGPconsidereddeathlikelyduetoCOVID-19.Allcausemortality

26%95%CI22to32n=103.Peakdeathsin1stweekApril.Markedincreases

indeathsinhomesA,BandDcomparedwithprecedingyears203%(95%CI

70to336).Menhasincreasedriskofdeath.48%V34%inthosewhosurvived.

wholegroupmales38%p=0.020.Medianagehigherinthosewhodied.andmore

deathsinthreeormorecomorbidities.126/313(40%)testedpositive.5/173(4%)

remainingtestedpositiveonre-test1weeklater.3/70(4%)stafftestedpositive(596

employeesacross4homes.(mean149/home).Staffabsencerates1stMarchto1st

May2020elevatedatmorethanthreetimesthebackgroundlevel.215.9%increase

CI95%80to352).70staffweretestedcrossthreenursinghomes.3ofthe19staff

inhomeAwerepositive.NostafftestedinhomesCandD.

Heungetal

(2006)

HongKong

Residential

care

hom

e inHong

Kong

Resid

ents

andstaff

Stafftookdropletand

contactprecautions

whe

n ca

ring

for

resid

ents

Sero

prev

alen

ce o

f SARS-CoVantibodies.

Sym

ptom

s an

d tr

ansm

issio

n

3/90residentsdied.Onemovedoutand19refusedtoparticipate.32staff,6

refusedtoparticipate.Noneofremaining93participantswerepositiveforSARS-

CoV.Residentswereaged65+years,79%werefemale,93%wereambulant,90%

didactivitieswithothers,79%wentout.69%ofstaffwereaged31to50years.

85%werefemale.54%engagedinnursingcare.Facetofaceinterviewswithstaff

werecompletedJuly2003.5ofremaining86residentsandthreeof32staffhas

experiencedsymptomsofsubclinicalSARS-CoVduringthestudyperiod.ResidentA

(died)hadbeentransferredfromhospitalandwaschairboundanddependentwith

careneeds.ResidentBwaschairboundandhadnotlefthomeorhadvisitors.She

wasbroughttosharedsittingareaduringmealtimes.ThiswasonlytimeresidentsA

andBwerelocatedneareachother.OneresidentsharedaroomwithpatientBand

testedpositive.StaffCwasdomesticworkerandcontactwasviaclinicalwastein

residentAroom.

Hoet

al.,(2003)

HongKong

A nu

rsin

g ho

me

in

HongKong

Resid

ents

andstaff

and

visit

ors

Com

mun

ity b

ased

outreachteamsincl.

geria

tric

ians

, nur

ses,

mob

ilise

d to

clo

sely

m

onito

r nur

sing

hom

e re

siden

ts d

ischa

rged

fromhospital.

Revi

ew o

f out

brea






174

Table3SO

utco

mes

for S

taff

StudyID

Country

Setting

Population

Describe/typeof

intervention

Outcomemeasures

Outcomes

Kenn

elly

et

al(2020)

Irela

ndNursing

hom

esStaffand

resid

ents

Descriptionofnursing

homesreportingcases

and

outc

omes

num

ber o

f cas

es,

symptomatic

asymptomaticnumbers,

clin

ical

out

com

es

incl

udin

g m

orta

lity

Completesurveysreturnedfrom62.2%(28/45)ofNHswithatotalof2043residents

in2303beds(medianoccupancy96.7%,IQR:86.0–96.6%)on29/02/2020.An

outbreakwasrecordedin75.0%(21/28)offacilities–fourpublicandseventeen

private.Occupancyratesatthestartofthestudyperiodwere95.1%and87.7%

inpublicandprivateNHsrespectively,decreasingto75.2%inpublicand73.2%in

privateNHsby22/05/2020.EightNHs(38.1%)had≥80%singleroomsinlinewith

regulatorystandards.Therewasnoassociationbetweenadherencetothisstandard

andoutbreakoccurrence(χ2=1.37,p=0.24).710/1741(40.1%)inoutbreakNHs

test-edpositive(193/710,27.2%,asymptomatic;183/710,25.8%died).54/1741

suspectedinfection.Moreresidentswithconfirmed/suspectedCOVID-19inpublic

vsprivateNHsexperiencingoutbreak.Duringtheeighty-three-daystudyperiod,

312/2043(15.3%)residentsdied.3/28had<3staffmembersandnoresidents

positive.300/312(96.2%)ofdeathsoccurredinanout-breakNH,withmortality

rateof300/1741(17.2%).Case-fatalityhigherinpublicvsprivate(22.3%vs11.2%).

Staff:residentratio<1had46.7%infectionrate,52%fatalityofcase;Staff:resident

=1-2,48.5%infectionrate,fatality24.8%ofcases;ratio>2=40.3%infectionrate,

10.9%fatalityofcases.675staffpositive,across24/28NHs.23.6%asymptomatic.

Significantcorrelationbetweenproportionofsymptomaticstaffandnumberof

residentswithconfirmed/suspectedCOVID-19(Spearman'srho=0.81).Nocorrelation

betweenasymptomaticstaffandCOVID-19residents.Al-mostaquarter(23.6%,

159/675)wereasymptomatic,identifiedbymasspoint-prevalencetesting.While

allNHsgavedetailsontotalstaffnumberswithCOVID-19,twelve(42.9%,12/28)

re-portedinformationrelativetototalstaffinglevels(allgrades).Atotalof1392staff

membersworkedacrossthesetwelvesiteswithalmostaquarter(23.8%,331/1392)

reportedascon-firmed/suspectedCOVID-19.Overaquarterwereasymptomatic

(27.5%,91/331).TenofthetwelveNHs(83.3%,10/12)metcriteriaforanoutbreak

(oneNHhadnostaff/residentswithCOVID-19,andanotheronlytwostaffinfected).

InthoseNHs,329/1227(26.8%)ofstaffhadcon-firmed/suspectedCOVID-19

infection,andoveraquarterwereasymptomatic(27.1%;89/329)

Kim(2020)

Kore

a (South)

Nursing

hom

e in

Ko

rea

with142

patientsand

85staff.

Resid

ents

andstaff

Closecontactpatients

ofpositiveworkerwho

wer

e di

scha

rged

and

he

alth

care

wor

kers

wereisolatedathome.

Bedsrepositionedto

mai

ntai

n di

stan

ce o

f >2m.

Infectionratesfollowing

identificationofpositive

case.Instigatedisolation

proceduresandcohorting

ofresidentswithbeds>2

mdistances.

Staffmovementsinhomewererestricted.14nursesandassistantsvolunteered

tobequarantined.Layoutofspaceandmovementplanned.Parkinglotusedfor

removingPPE.Visitorsprohibitedfromusingelevatorasitwasusedbymedicalstaff

inPPE.PreparednessforandresponsetoCOVID-19reducedtransmission.After

managementofoutbreaktherewerenomoreinfectedpersons.Allpatientsand

employeestestednegative14daysfromstartofquarantine.in-hospitalmovementof

isolationcohortcaregiversrestricted.sectionsetupasgreenzoneforworkerswithno

contactwithinfectedresidents.ParkinglotusedtoremovePPE.Elevatoronlyused

formedicalpersonnelinPPE.Mealsforpatientsandstaffprovidedfromoutside.


Table3SO

utco

mes

for S

taff

StudyID

Country

Setting

Population

Describe/typeof

intervention

Outcomemeasures

Outcomes

Leeetal

(2020)

Kore

aLong-

term

car

e ho

spita

l

Resid

ents

andstaff

Post-exposure

prophylaxis(PEP)using

Hydroxycholoroquine

was

adm

inist

ered

to

staffandresidents

follo

win

g a

larg

e exposureevent.

Aftersecondcase

diag

nose

d, h

ealth

care

w

orke

rs a

nd re

siden

ts

beganthe14dayPEP

intervention.Infection

rate

, com

plia

nce

with

PEPwithHCQfor

patientsandcare

wor

kers

was

sta

rted

on

February26.Physicians

and

phar

mac

ists

wer

e ed

ucat

ed a

bout

potentialadverseevents.

Hydroxycholoroquine

(HCQ)wasadministrated

orallyatadoseof400mg

dailyuntilthecompletion

of14daysofquarantine.

A ch

eckl

ist fo

r com

mon

ad

vers

e ev

ents

was

distributed.

193patientsand29careworkerswereofferedPEP.189patients,22careworkers,

initiatedPEP.Meanageofpatients(81.0,range15-97,137female),ofcareworkers

(63.4,range51-78,25female),otherhospital(52.2,range24-79,79female).

Completedin184residentsand21careworkers.HCQwasassociatedwithmild

adverseevents.Onepatienthadskinrashre-quiringsteroidsbutdidnotdiscontinue

PEP.FivepatientsdiscontinuedPEPbecauseofgastrointestinalupset,bradycardia,

andforfasting.Allfollow-upPCRtestsafter14dayquarantinewerenegative.

176

Table3SO

utco

mes

for S

taff

StudyID

Country

Setting

Population

Describe/typeof

intervention

Outcomemeasures

Outcomes

McM

icha

el

etal(2020)KingCoun-

ty,Washing-

ton,

USA

Skill

ed

nurs

ing

faci

lity

in

KingCoun-

ty,Wash-

ingt

on

Resid

ents

, staffand

visit

ors

Reportingeventof

outb

reak

OnFebruary28,2020,

fourcasesofCOVID-19

confirmedamong

resid

ents

of K

ing

Cou

nty;

1personhadpresumed

travel-relatedexposure,

and3wereidentified




pneumonia)andwho

hadtestednegative



Oneofthesewasthe


A; o

ne w

as a

Fac

ility

A

staffmember.Whenthe



45residentsandstaff

disp

erse

d ac

ross

Fac

ility

A

had

sym

ptom

s of


wasnotifiedofthis

incr

ease

by

the

faci

lity

onFebruary27.Asof

March18,atotalof167

personswithCOVID-19

that

was

epi

dem

iolo

gica

lly

linke

d to

Fac

ility

A h

ad


resid

ents

of K

ing

Cou

nty

and23wereresidents

March18,atotalof167confirmedcasesofCOVID-19affecting101residents.

MostcasesamongresidentsincludedrespiratoryillnessconsistentwithCOVID-19;

however,in7residentsnosymptomsweredocumented.Hospitalizationratesfor

facilityresidentswere54.5%.Thecasefatalityrateforresidentswas33.7%(34

of101).AsofMarch18,atotalof30long-termcarefacilitieswithatleastone

confirmedcaseofCOVID-19hadbeenidentifiedinKingCounty.Amongfacility

residents,118weretested;101resultswerepositiveand17negative.Mostaffected

personshadrespiratoryillness;chartreviewoffacilityresidentsfoundthatin7

casesnosymptomshadbeendocumented.Clinicalpresentationrangedfrommild

(nohospitalization)tosevere,including35deathsbyMarch18.Reporteddates

ofsymptomonsetrangedfromFebruary15toMarch13.Themedianageofthe

patientswas83years(range,51to100)amongfacilityresidents,62.5years(range,

52to88)amongvisitors,and43.5years(range,21to79)amongfacilitypersonnel;

112patients(67.1%)werewomen.Most(94.1%of101)facilityresidentshad

chronicunderlyinghealthconditions,withhypertension(67.3%),cardiacdisease








pathologist,environmentalcare(housekeeping,maintenance),nurse,certified

nursingassistant,healthinformationofficer,physician,andcasemanager.16visitors

positive.Hospitalizationratesforfacilityvisitorswere50.0%.OnMarch10,2020,the

governorofWashingtonimplementedmandatoryscreeningofhealthcareworkers

andvisitorrestrictionsMonitoringofstaffabsences.


Table3SO

utco

mes

for S

taff

StudyID

Country

Setting

Population

Describe/typeof

intervention

Outcomemeasures

Outcomes

McM

icha

el

etal(2020)

King

Cou

nty,

Washington,

USA

Long-Term

Car

e Sk

illed

Nursing

Faci

lity

Resid

ents

, Staffand

visit

ors

Repo

rt o

f out

brea







County(17staffand1visitor).Symptoms16thFebto5thMarch.Medianage81years.

(range54-100)residents;42.5(22-79)staff,62.5years(52-88)visitors.65.1%


residents27.2%andvisitors7.1%.Nodeathsreportedforstaff.Underlyinghealth


obesity33.3%,pulmonarydisease32.1%.At9thMarchatleast8otheroutbreaks

reported.Contributingtotransmission=staffworkingwhilesymptomatic,staff




Officefor

National

Statistics

(2020)

Engl

and

Car

e ho

mes

, En

glan

dRe

siden

ts

andstaff

Surv

ey o

f nur

sing

homesandreporting

outc

omes

Outcomesbasedon

resp

onse

s of

car

e ho

me

man

ager

s to

sur

vey,

and

nottheswabtests.%

residentsaged65years

and

olde

r and

car

e ho

me

staffwhohavetested

positiveforCOVID-19.

Numberandsizeof

homes:0to40beds

n=5196,41-80beds=

3390,81-120beds

n=436,121-160beds

n=43,morethan160

bedsn=16.

Across9081homes,estimatedtobe293,301residents(95%CI:293,168-293,434),

441,498staff(441,240-441,756).92.9%(95%CI:92.5-93.3%)ofhomesoffer

sickpaytostaff,11.5%(10.9-12.1%)havestaffwhoworkinmultiplelocations,

44.2%(43.4-45.0%)donotemployanybankoragencystaff.97.2%(95%CI:96.8

-97.6%)havebeenclosedtovisitors,19.3%(18.5-20.1%)havebeenclosedto

newadmissions.Ofthe9081homes,estimatedthat55.6%(95%CI:54.8-56.4%)

reportedatleastoneconfirmedcoronaviruscase.Acrossthosehomes,estimated

that19.9%(18.5-21.3%)ofresidentstestedpositive,while6.9%ofstaff(5.9-

7.9%)testedpositive,sincestartofpandemic.Acrossallhomes,estimated10.7%

(10.1-11.3%)ofresidentspositive,4.0%(3.6-4.4%)staffpositive.15,606deathsof

residentsacrossallhomesduetoCOVID-19.Foreachadditionalmemberofinfected

staffworkingatthecarehome,theoddsofresidentinfectionincreaseby11%ieOR

=1.11(95%CI:1.1-1.11).Carehomesusingbankoragencynursesorcarersmostor

everydaymorelikelytohavecasesinresidents(OR=1.58,1.5-1.65),comparedto

thosewhoneverusebankoragencystaff.ResidentsincarehomesoutsideofLondon

hadlowerchanceofinfection,exceptWestMidlands(OR=1.09,1.0-1.17).Homes

wherestaffreceivesickpayarelesslikelytohaveresidentcases(OR=0.82to0.93,

95%CI:7-18%),comparedtohomeswherenosickleave.Foreachadditionalinfected

residentatahome,theoddsofstaffinfectionincreaseby4%(4-4%)OR=1.04).Care

homesusingbankoragencystaffmostoreverydayOR=1.88(95%CI:1.77-2.0)

comparedtohomesnotusing.Homeswherestaffregularlyworkelsewhere(most

oreveryday)increaseodds(OR=2.4,1.92-3.0)comparedtohomewhoneverwork

else-where.StaffathomesoutsideLondonhadhigh-eroddsofinfection.

178

Table3SO

utco

mes

for S

taff

StudyID

Country

Setting

Population

Describe/typeof

intervention

Outcomemeasures

Outcomes

Quickeetal

(2020)

Col

orad

o,

USA

Staff

Weekly

nasopharyngeal(NP)

swab

s w

ere

colle

cted

forafivetosixweek.

SampleCollection.

Nasopharyngealswabs

wer

e pe

rfor

med

by

trai

ned

pers

onne

l at

participatingfacilities

onconsentedstaff

members.

To a

sses

s th

e pr

eval

ence

andincidenceofSARS-

CoV-2amongSNF

wor

kers

, det

erm

ine

the

extentofasymptomatic

infectionbySARS-CoV-2,

andprovideinformation

on th

e ge

nom

ic

epid

emio

logy

of t

he v

irus

withintheseuniquecare

settings,wesampled

workersweeklyatfive

SNFsinColorado.

ThepercentageofNPswabsthattestedpositiveforviralRNAeachweekvaried

cons

ider

ably

by

faci

lity,

but

sho

wed

a g

ener

al d

ownw

ard

tren

d ov

er th

e co

urse

of t

he

studyperiod.StaffatSiteAremaineduninfectedthroughouttheentiresixweekstudy

period.Incontrast,22.5%ofworkersatsiteDhadprevalentinfectionsatthestartof

thestudyandincidencewashighinitially(12.2per100workersperweek),declining

overtime.AtsiteC,initialinfectionprevalencewaslower(6.9%)andtheincidence

declinedtozerobyweek3.However,twofacilitieswithlowprevalenceinweek

1(sitesBandE)sawanincreaseincases–including,atsiteB,incidentinfections

detectedafterfourweeksofnoinfections.Infectionswereobservedinworkers

acrossalljobtypes,includingroleswithtypicallyhighpatientcontact(e.g.nursing)

andlowpatientcontact(e.g.,maintenance).LevelsofviralRNAtendtodeclineover

thedurationofinfectionandcorrespondtolowlevelsofinfectiousvirus.Withinthe

studyperiod,incidentinfectionsvariedinlengthfromonetofourweeks.

Roxbyetal

(2020)

Seattle,

Washington,

USA

Assis

ted

livin

g fa

cilit

y Re

siden

ts

andstaff

Surv

eilla

nce

repo

rt

-linktomainpaper

JAMA2020


CoV2anddescribe

symptomsofCOVID-19

in re

siden

ts o

f in

depe

nden

t/ a

ssist

ed

livin

g fa

cilit

y

83residentsand62stafftested.5cases:3residentsand2staff.Anotherresident

testedpositiveday7.Threeresidentsnosymptoms.SARS-CoV-2wasdetectedin

three(3.8%)residentsandtwo(3.2%)staffmembers.Noneoftheresidentswith

positivetestsreportedsymptomsatthetimeoftesting;however,one(resident

C)reportedresolvedmildcoughandloosestoolduringthepreceding14days.All

threeresidentswithpositivetestresultswerelivingonseparatefloorsintheirown

apartments;onereceivedassistancewithactivitiesofdailyliving.Oneresident

livedonthesamefloorasthetwohospitalizedresidentswithknownCOVID-19,

andonehadknownclosecontactwithoneofthehospitalizedresidents;thethird

residentwhohadpositivetestresultshadnocontactwitheitherofthehospitalized

residents.Whenthesecondroundoftestingwasconducted7dayslater,one

additionalpositivetestresultwasreportedforanasymptomaticresidentwhohad

negativetestresultsonthefirstround.Duringthefirstroundoftestingandsymptom

screening,symptomswerereportedby42%ofresidentsand25%ofstaffmembers

whohadnegativetestresultsforSARS-CoV-2.Symptomsreportedbyresidents

whohadnegativetestresultsincludedsorethroat,chills,confusion,bodyaches,

dizziness,malaise,headaches,cough,shortnessofbreath,anddiarrhoea.Residents

age85.8years(SD7.6),78%female,48%smokedhistory,5%currentsmokers,59%

asymptomatic,41%anysymptomsinlast14days,comorbiditiesincludedchronic

lungdisease47%,diabetes15%,cardiovasculardisease60%.,cognitiveimpairment

36%.Staffmeanage40years(SD15),68%female,10%currentsmokers,72%

asymptomatic,28%anysymptomsinlast14days.


Table3SO

utco

mes

for S

taff

StudyID

Country

Setting

Population

Describe/typeof

intervention

Outcomemeasures

Outcomes

Roxbyetal

(2020)

Seattle,

Washington,

USA

Long-

term

car

e facilities

Resid

ents

andstaff


CoV-2infectionina

congregatesetting

implementingsocial

isolationandinfection

preventionprotocols.

SARS-CoV-2real-time


was

per

form

ed o

n na

soph

aryn

geal

sw

abs



was

com

plet

ed a

sses

sing

feve

r, co

ugh,

and

ot

her s

ympt

oms

for

thepreceding14days.

Resid

ents

wer

e re

test

ed

forSARS-CoV-27days


Residentsandstaff


asse

ssin

g sy

mpt

oms

of


coug

h, m

alai

se, d

iarr

hea,

an

d so

re th

roat

, cov

erin



healthconditions.










entireevaluationperiod.TestingofNPswabsforSARS-CoV-2wascompletedfor

142persons(Table1):all80residentsonsiteand62staff.Symptomquestionnaires

werecollectedfromall80residentsandfrom57(92%)staff.Sixty-tworesidentswere














casesofCOVID-19.9werefoundamongresidents.SARS-CoV-2wasdetectedin2




whileill.

Smith

et a

l (2020)

Fran

ce

Sim

ulat

ed

Long-term

Car

e

Resid

ents

andStaff


Surv

eilla

nce

stra

tegi

es

wer

e ev

alua

ted

base

d on

thei

r abi

lity

to d

etec

t no

soco

mia

l out

brea

ks

usin

g th

ree

mea

sure

s of


COVID-19epidemicsweresimulatedusingadynamic,stochastic,individual-

basedtransmissionmodel,describingdynamicinter-individualcontactsamongand


facility.Therewereonaverage154patientsand239membersofstaffpresentin

thehospitalperday,thelatterpartitionedacross13distinctcategories(e.g.nursing,

administrativeoroperationsstaff).Bothpatientsandstaffcouldpotentiallybecome

infectedwithCOVID-19and/orexperienceCOVID-likesymptoms.Hospitalstructure,

demographics,anddynamiccontactnetworkswereestimatedfromclose-proximity

interactiondata,measuredviasensorswornbyallpatientsandpersonnelovera12-

weekperiodinafive-wardrehabilitationhospitalinnorthernFrance.

180

Table3SO

utco

mes

for S

taff

StudyID

Country

Setting

Population

Describe/typeof

intervention

Outcomemeasures

Outcomes

Tse

et a

l (2003)

HongKong

Nursing

hom

e Re

siden

ts,

staff

Nointervention.

Reportingknowledge

ofSARS.

Kno

wle

dge

of S

ARS

Veryfewoftheparticipantsinthenursinghomecouldbedescribedas

knowledgeableregardingSARSanditsprevention.Someoftheseresidentswere

worriedaboutcontractingthediseasethemselves.However,themajorityofthe

residentsstudiedhadeitherlittleornoknowledgeaboutSARS.7/40(17.5%)

residentshadgoodknowledgeofSARS,16/40(40%)littleknowledge,17/40

(42.5%)knewvirtuallynothingaboutSARS.Halfofthosewithgoodknowledge

wereworriedaboutcontractingSARS,66%ofthosewithlittleknowledgewere

worriedaboutcontractingSARS,10%ofthosewithnoknowledgewereconcerned

aboutcontracting.GoodknowledgeofSARShadgoodknowledgeofprevention

strategies,thosewithlittleknowledgenamed1-2preventivemeasures,thosewith

noknowledgenamedonly1measure.Manager,Physiotherapist,domesticstaff,

healthcareassistantsfeltfearandconcern,concernaboutvisitorsbringinginSARS.

ManagerandRNnotconcernedaboutanoutbreakastheyrecognisedhygiene

proceduresandconditionsweresatisfactory.Notsurprisinglyperhaps,thosewith

theleastknowledgealsohadtheleastconcernsaboutcontractingthedisease.

The

lack

of k

now

ledg

e an

d co

ncer

n m

ay m

ake

them

mor

e vu

lner

able

in te

rms

of

contractingSARS.ThemajorityofstaffworriedaboutcontractingSARSatworkand

wasconcernedaboutanoutbreakinthenursinghome.Theseworrieswerecaused

largelybyatragiclarge-scaleoutbreakinahousingestatetriggeredbyasinglevisitor

withSARSandaccountedformorethan300SARScasesandmorethan30deaths.

Inaddition,staffwereverymuchawarethatseveralmedicalstaffandahealthcare

assistantinanursinghomehaddiedrecentlyofSARSinHongKong.Tominimizethe

riskofanoutbreak,thenursinghomeproactivelyimplementedpreventivemeasures

includingsendingletterstovisitorsandshorteningthevisitingperiod.Tofurther

alleviatetheworryandfearofthestaff,especiallythehealthcareassistantsand

domesticstaff,inserviceworkshopsandseminarsareindicated,andmorechannels

forcommunicationandsupporttoallstaffarerecommended.


Table4S

Out

com

es re

late

d to

faci

lities

StudyID

Country

Setting

Population

Describe/typeof

intervention

Outcomemeasures

Outcomes

Abra

ms

et

al(2020)

USA

All n

ursin

g el

igib

le

hom

es

Facilities

Descriptionof

facilitiesincluding:

Nursinghomesize,

owne

rshi

p, c

hain

m

embe

rshi

p, h

igh

med

icai

d sh

are,

high%ofAfrican

Amer

ican

resid

ents

, urbanlocation,

CMSoverall5star

rating,priorinfection

violation,state

Likelihoodofhavinga

COVID-19case.Logistic

regressiontoestimate

Oddsratioofeach

characteristiconthe

likel

ihoo

d of

hav

ing

a documentCOVID-19

case

2949of9395NH(31.4%)hadCOVID-19case;averagenumberofcaseswas19.8.

Largerfacilitysize(OR=6.52forlargevssmall,OR=2.63formediumvssmall),urban

location(OR=3.22Vrural),greater%AfricanAmericanresidents(OR=2.05Vlow%),

non-chainstatus(OR=0.89forchainvsnon-chainstatus),andstateweresignificantly

relatedwithprobabilityofhavingCOVID-19case.Outbreaksizesignificantly

associatedwithfacilitysize(large=-15.88,medium=-10.8,smallisreferencei.e.

smallergreateroutbreaksize),for-profitstatus(=1.88vsnon-profit),andstate.

Medicaiddependency,ownershipoffive-starratingandpriorinfectionviolationwere

notsignificantlyrelatedtoCOVID-19cases.Averagenumberofcaseswas19.8per

facility.NewJersey(88.6%,OR7.16)andMassachusetts(78%,OR4.36)havehighest

numberofaffectedfacilities.Georgia(61,5%,OR1,98),Connecticut68.1%,OR2.62)

Maryland(63.9%,OR1.57).

Amer

ican

Geriatrics

Soci

ety

PolicyBrief:

COVID-19

and

Nursing

Homes

USA

NHand

LTCFs

Workers,

resid

ents

an

d facilities

None,reporting

recommendations

CM

S ha

s ro

lled

out

seve

ral p

olic

y ch

ange

s to

sup

port

hea

lthca

re

prof

essio

nals

and

syst

ems

on th

e fr

ontli

ne o

f car

ing

for i

ndiv

idua

ls w

ith

COVID-19.



settings.NHs,LTCFs,othercongregatelivingsettings(eg,assistedliving),andhome









theresident(s)separatelyfromtherestofthecommunityandprovidededicated

staffforpeoplewithCOVID-19inlinewithCDCguidance.NHsandhospitalsto

createtheirowntransferpolicies,whichmayrequirefrequentadjustmentbasedon

localconditionsandbasedonhospitalresources.Hospitaldischargealsoplaysan

importantroleinCOVID-19planninganduseoftelemedicine.Workforceplanning

includingexpertise,trainingandsupports,ratios.Considerationoftaxreliefsand

payments.

Lynchetal

(2020)

USA

Long-

term

car

e facilities

Facilities

Five

Ste

ps to

Mod

ify

PatientRoomsto

NegativePressure

Recommendations.

Inacutecarefacilities,airborneinfectionisolation(AII)roomsaredesignedto

beunderaslightnegativepressurewithrespecttoadjacentroomsandhallways.

Thisreducesthepotentialforairbornerespiratorydropletstobecarriedonair

currentsfromthepatientintohallways.EstimateTotalRoomVolume,Ventilation,

andDifferentialPressure.Step2:InstallSupplementalExhaustVentilationThrough

DedicatedExhaustPortals.Step3:IncreaseEfficiencyofFiltration.Step4:Keep

DoorstoHallwaysClosed.Step5:FollowInfectiousDiseasePreventionGuidelines

forHealthCareWorkers.

Rios

et a

l (2020)

Can

ada

Long-

term

car

e facilities

Facilities

None

The17clinicalpractice

guidelinesjudgedtobeof

verylowquality.

Preventionstrategieswerehandhygiene,wearingPPE,socialdistancing,isolation,

disinfectingsurfaces,policiesforstaff,residentsandvisiting,cough,managing

respiratoryillness.Guidelinesarebasedonexpertopinions.Noneaddressedresident

issuesincludingfrailty,comorbiditiesandrespiratoryillness.

182

Table4S

Out

com

es re

late

d to

faci

lities

StudyID

Country

Setting

Population

Describe/typeof

intervention

Outcomemeasures

Outcomes

Stal

l et a

l (2020)

Ontario,

Can

ada

Nursing

hom

esFacilities,

resid

ents

Weobtainedall

data

for t

his

stud

y fromtheOntario

MinistriesofHealth

andLong-Term

Car

e as

par

t of

the

prov

ince

’s em

erge

ncy

“modelingtable”.

This

incl

uded

nur

sing

hom

e le

vel d

ata

from

theLong-TermCare

InspectionsBranch

onthecumulative

num

ber o

f res

iden

t COVID-19casesand

deaths.Additional

nurs

ing

hom

e le

vel

data

obt

aine

d fr

om

theOntarioMinistry

ofLong-TermCare

Theprimaryexposureof

inte

rest

was

the

nurs

ing

homeprofitstatus

(for-profit,non-profit

ormunicipal).Themain

outc

omes

of i

nter

est

were:nursinghome

COVID-19outbreaks(at

leastoneresidentcase),

COVID-19outbreaksizes

Of623Ontarionursinghomes360(57.7%)wereforprofit,162(26.0%)were

non-profit,and101(16.2%)weremunicipalhomes.Therewere190/623(30.5%)

COVID-19nursinghomeoutbreaksinvolving5218residents(meanof27.5±41.3

residentsperhome),resultingin1452deaths(meanof7.6±12.7residentsperhome)

withanoverallcasefatalityrateof27.8%.TheoddsofaCOVID-19outbreakwas

associatedwiththeincidenceofCOVID-19inthehealthregionsurroundinganursing

home(adjustedoddsratio[aOR],1.94;95%confidenceinterval[CI]1.23-3.09)and

numberofbeds(aOR,1.40;95%CI1.20-1.63),butnotprofitstatus.For-profitstatus

wasassociatedwithboththesizeofanursinghomeoutbreak(adjustedriskratio

[aRR],1.96;95%CI1.26-3.05)andthenumberofresidentdeaths(aRR,1.78;95%CI

1.03-3.07),comparedtonon-profithomes.Theseassociationsmediatedbyahigher

prevalenceofoldernursinghomedesignstandardsinfor-profithomes.For-profit

statusisassociatedwiththesizeofaCOVID-19nursinghomeoutbreakandthe

numberofresidentdeaths,butnotthelikelihoodofoutbreaksrooms.Overall,the

crudeincidenceofCOVID-19nursinghomeoutbreakswas85.1perthousandamong

for-profithomes,61.4perthousandamongnon-profithomes,and23.4perthousand

amongmunicipalhomes.ThecruderateofCOVID-19nursinghomeresidentdeaths

was23.4perthousandamongfor-profithomes,18.2perthousandamongnon-profit

homes,and5.8perthousandamongmunicipalhomes.Thecase-fatalityrateamong

nursinghomeresidentswas27.5%amongfor-profithomes,29.7%amongnon-profit

homes,and25.0%amongmunicipalhomes.

Wasserman

etal(2020)

USA

Nursing

Facilities

Facilities

Recommendations

frommodifiedDelphiConsensuswith6

scenariosfromexperts

OnApril19,2020posedthefollowingquestion:“Asymptomaticstaffcanbe

contagious.Whywouldn’twewanttoidentifystaffwhowillbecomethevectorfor

transmission?Whatisthedownsidetowidespreadtestingofstaffinnursinghomes.

ThesecommunicationsbeganthefirststageofthemodifiedDelphiprocess.The

singlemostimportantfindingfromthisDelphipanelisthatitsmembersconsistently

supportpointprevalencefacilitywidetesting,withnodissent,ofallstaffand

residentswhentestingisreadilyavailable.Thepanelfeelsstronglythatlongtermcare

providers,aswellasfederal,state,andlocalofficialsshouldlistentoexperienced

healthprofessionalsonthefrontlines,fightingthispandemic,whenmakingpolicy

decisions.Thepanelfavorstestingevery1to2weeksbasedonthefactthatthe

incubationperiodfordevelopingsymptomsvariesfrom3-5daysupto2weeks.

Thefrequencycanbereducedtoeverymonthascommunityprevalencedeclines.

TheotherimportantconclusionfromthepanelrelatestotheavailabilityofPPE.The

idealsituationforprotectingbothresidentsandstaffisaggressiveuseoftesting,

intensiveinfectioncontrolprocedures,andPPE.Unanimousagreementthatresidents

whotestpositiveand/orhavebothtypicalandatypicalsymptomsshouldbeisolated.

StaffinthesecircumstancesshouldfullytakeadvantageofPPEandbetrainedin

itsproperuse.TherearedifferingopinionsinthescenariowithlimitedPPEand/or

limitedtesting.Thereverystrongconsensusaroundisolatingresidentswithtypical

oratypicalsymptoms.Theonlyscenariowithoutaclearconsensusistheoptionof

isolatingallresidentswhenthereisabundantPPEandlimitedtesting.


Table4S

Out

com

es re

late

d to

faci

lities

StudyID

Country

Setting

Population

Describe/typeof

intervention

Outcomemeasures

Outcomes

Zazzaraet

al(2020)

London,

Engl

and

Hospital

(and

com

mun

ity

base

d co

hort

Resid

ents

/ Facilities

Asse

ssm

ent o

f frailty.Weusepoint-

of-caredatafrom

patientsadmittedto

a la

rge

UK

hosp

ital

trus

t, su

ppor

ted

bycommunity-

basedCOVID-19

Sym

ptom

Stu

dy

mobileapplication

(“app”)data,to

asse

ss h

ow fr

ailty

affectspresentation

ofconfirmed+ve

COVID-19infection

inolderadults.

Multivariatelogistic

regr

essio

n an

alys

is performedonage-

mat

ched

sam

ples

fr

om h

ospi

tal a

nd

community-based

coho

rts

to a

scer

tain

associationoffrailty

with

sym

ptom

s ofconfirmed

COVID-19.

Frai

lty

Hospitalcohort:significantlyhigherprevalenceofdeliriuminthefrailsample,withno

differenceinfeverorcough.Frailtysignificantlypredicteddelirium(p=0.013,OR(95%

CI)=3.22(1.44,7.21).Community-basedcohort:significantlyhigherprevalence

ofprobabledeliriuminfrailer,olderadults,andfatigueandshortnessofbreath.

Frailtysignificantlypredicteddelirium.Frailtyfoundtopredictdelirium(p=0.038,

OR(95%)=2.29(1.33,4.0).Frailtypredictedfatigue(p=0.038,OR=2.23(1.27,3.96);

SOB(p=0.043,OR=2.0(1.19,3.39)).Thisisthefirststudydemonstratinghigher

prevalenceofdeliriumasaCOVID-19symptominolderadultswithfrailtycompared

tootherolderadults.Thisemphasisesneedforsystematicfrailtyassessment

andscreeningfordeliriuminacutelyillolderpatientsinhospitalandcommunity

settings.CliniciansshouldsuspectCOVID-19infrailadultswithdelirium.After

age-matching,deliriumwasreportedin40(38%)offrailand13(12%)ofnon-frail

patientswithCOVID-19.Frailtywasfoundtosignificantlypredictdelirium(P-value:

0.013;OddsRatio(OR)(95%ConfidenceInterval(CI))=3.22(1.44,7.21).There

werenosignificantdifferencesbetweenfrailandnotfrailforothersymptoms

(fever(temperature≥37.5C)andcough).Afterage-matching,frailtywasfoundto

significantlypredictdelirium(P-value0.038;OR(95%CI)=2.29(1.33,4.00)).Frailty

alsopredictedfatigue(P-value:0.038;OR=2.23(1.27,3.96))andshortnessof

breath(P-value:0.043;OR=2.00(1.19,3.39)).Therewerenodifferencesbetween

frailandnotfrailfortheother11symptomsanalysed.

184

Table5SO

utco

mes

for V

isito

rsStudyID

Country

Setting

Population

Describe/typeof

intervention

Outcomemeasures

Outcomes

Dor

a et

al

(2020)

Cal

iforn

ia,

USA

Skill

ed

nurs

ing

faci

lity

USA

Resid

ents

, staffand

visit

ors

AllSNFresidents,

rega

rdle

ss o

f sy

mpt

oms,

unde

rwen

t ser

ial

approximately

weekly)

naso

phar

ynge

al

SARS-CoV-2RT-PCR

testing,


betweenMarch29and

April23(after3+V2


betweenMarch28-29),


29-April10.Testingofall

visitorsMarch6th.March

17thallvisitorsprohibited

frombuildings.


cont

rol p

roce

dure

s an

d st

rate

gies

for c

ase





revi

ewed

and

mon

itore

d useofPPEwithaSNF

staffmembers.PPE

prot

ocol

s un

chan

ged


screened.








ofresidentswhowereCOVID-19positivetoreducetransmissioninthefacility.






136staffmemberstestedand6%infectionsidentified-allworkedinwardsAandC.



Hoet

al.,(2003)

HongKong

A nu

rsin

g ho

me

in

HongKong

Resid

ents

andstaff

and

visit

ors

Com

mun

ity b

ased

outreachteamsincl.

geria

tric

ians

, nur

ses,

mob

ilise

d to

clo

sely

m

onito

r nur

sing

hom

e re

siden

ts

disc

harg

ed fr

om

hospital.

Revi

ew o

f out

brea







Table5SO

utco

mes

for V

isito

rsStudyID

Country

Setting

Population

Describe/typeof

intervention

Outcomemeasures

Outcomes

McM

icha

el

etal(2020)

King

Cou

nty,

Washington,

USA

Skill

ed

nurs

ing

faci

lity

in K

ing

Cou

nty,

Washington

Resid

ents

, staffand

visit

ors

Reportingeventof

outb

reak

OnFebruary28,2020,

fourcasesofCOVID-19

confirmedamong

resid

ents

of K

ing

Cou

nty;

1personhadpresumed

travel-relatedexposure,

and3wereidentified




pneumonia)andwho

hadtestednegative



Oneofthesewasthe


A; o

ne w

as a

Fac

ility

A

staffmember.Whenthe



45residentsandstaff

disp

erse

d ac

ross

Fac

ility

A

had

sym

ptom

s of


wasnotifiedofthis

incr

ease

by

the

faci

lity

onFebruary27.Asof

March18,atotalof167

personswithCOVID-19

that

was

epi

dem

iolo

gica

lly

linke

d to

Fac

ility

A h

ad


resid

ents

of K

ing

Cou

nty

and23wereresidents

March18,atotalof167confirmedcasesofCOVID-19affecting101residents.

MostcasesamongresidentsincludedrespiratoryillnessconsistentwithCOVID-19;

however,in7residentsnosymptomsweredocumented.Hospitalizationratesfor

facilityresidentswere54.5%.Thecasefatalityrateforresidentswas33.7%(34

of101).AsofMarch18,atotalof30long-termcarefacilitieswithatleastone

confirmedcaseofCOVID-19hadbeenidentifiedinKingCounty.Amongfacility

residents,118weretested;101resultswerepositiveand17negative.Mostaffected

personshadrespiratoryillness,chartreviewoffacilityresidentsfoundthatin7

casesnosymptomshadbeendocumented.Clinicalpresentationrangedfrommild

(nohospitalization)tosevere,including35deathsbyMarch18.Reporteddates

ofsymptomonsetrangedfromFebruary15toMarch13.Themedianageofthe

patientswas83years(range,51to100)amongfacilityresidents,62.5years(range,

52to88)amongvisitors,and43.5years(range,21to79)amongfacilitypersonnel;

112patients(67.1%)werewomenMost(94.1%of101)facilityresidentshad

chronicunderlyinghealthconditions,withhypertension(67.3%),cardiacdisease








pathologist,environmentalcare(housekeeping,maintenance),nurse,certifiednursing

assistant,healthinformationofficer,physician,andcasemanager.16visitorspositive.

Hospitalizationratesforfacilityvisitorswere50.0%.

OnMarch10,2020,thegovernorofWashingtonimplementedmandatoryscreening

ofhealthcareworkersandvisitorrestrictionsMonitoringofstaffabsences.

186

Table5SO

utco

mes

for V

isito

rsStudyID

Country

Setting

Population

Describe/typeof

intervention

Outcomemeasures

Outcomes

McM

icha

el

etal(2020)

King

Cou

nty,

Washington,

USA

Long-Term

Car

e Sk

illed

Nursing

Faci

lity

Resid

ents

, staffand

visit

ors

Repo

rt o

f out

brea







County(17staffand1visitor).Symptoms16thFebto5thMarch.Medianage81years.

(range54-100)residents;42.5(22-79)staff,62.5years(52-88)visitors.65.1%


residents27.2%andvisitors7.1%.Nodeathsreport-edforstaff.Underlyinghealth


obesity33.3%,pulmonarydis-ease32.1%.At9thMarchatleast8otherout-breaks

report-ed.Contributingtotransmission=staffworkingwhilesymptomatic,staff





Table6S. F

ocus

sed

resid

ent o

utco

mes

from

stu

dies

exa

min

ing

COV

ID-1

9 in

resid

entia

l car

e ho

mes

Study

Samplesize

Age

Outcomes

Abra

ms

et a

l (2020)

N=9395nursing

hom

esLikelihoodofhavingaCOVID-19case:

Facilitysize:(largevssmall)OR=6.52

Location(urbanvsrural)OR=3.22,

Greater%AfricanAmericanresidents,OR=2.05vslow%),

Non-chainstatus(OR=0.89forchainvsnon-chainstatus),

StateweresignificantlyrelatedwithprobabilityofhavingCOVID-19case.

Outbreaksizesignificantlyassociatedwithfacilitysize(large=-15.88,medium=-10.8,smallisreferencei.e.smallergreater

outbreaksize),

For-profitstatus(OR=1.88vsnon-profit),

State.

Aron

s et

al

(2020)

N=89residentsin

faci

lity

N=76infirstpoint-

prev

alen

ce s

urve

yN=49insecondpoint-

prev

alen

ce s

urve

y

Positiveresidents=

78.6±9.5

Negativeresidents=

73.8±11.5

57of89(64%)residentstestedpositivebetween13March(survey1)and26March(survey2).

23/76residentstestedpositiveinsurvey1(1asymptomatic,11presymptomatic,11symptomaticofwhich9typical

symptoms,2atypicalsymptoms).

24/49testedpositiveinsurvey2(2asymptomatic,13presymptomatic,9symptomaticofwhich7hadtypicalsymptoms,2

hadatypicalsymptoms).

48/76(63%)ofresidentswhoparticipatedinfirstsurveytestedpositiveineitherinitialorsubsequentpoint-prevalencesurvey

(including1residentwhohadpreviouslytestedpositivebuttestednegativeduringthetwopoint-prevalencesurveys).

Doublingtimeestimatedat3.4days.Mortality26%(15of57).

Brainardetal

(2020)

Carehomes,n=248

SpreadofCOVID-19regressioncoefficients:eyeprotection(B=1.66),facemask(B=1.2),countofcareworkersemployed

(B=1.04),countofnursesemployed(B=1.18)

Hazardratioofoutbreakoccurring:(onlynon-careworkernumbersignificant)-<10workersHR=1.0,

11-20workersHR=6.502,

21-30workers

HR=9.87,

>30workersHR=18.927

188

Table6S. F

ocus

sed

resid

ent o

utco

mes

from

stu

dies

exa

min

ing

COV

ID-1

9 in

resid

entia

l car

e ho

mes

Study

Samplesize

Age

Outcomes

Dor

a et

al

(2020)

N=96

WardA,n=30

WardB,n=30

WardC,n=36

Positiveresidents=75

(66-85)

19/96residentsintotaltestedpositive.5/19symptomatic,8/19presymptomatic,6/19asymptomatic.1/19died.

Initialtesting(29-31March):

WardA–4/30(13%),WardB–0/30,WardC-10/36(28%).

Secondroundtesting(April6):2/28wardCtestedpositive

Thirdroundtesting(13April):0/27positive

Fism

an e

t al

(2020)

N=627LTCfacilities

Totalresidentsn=

79498

272/627(43.4%)eitherconfirmedorsuspectedCOVID-19infectioninresidentsorstaff.

IncidencerateratioofdeathinLTCcomparedtocommunity:

residentsaged>59=23.1,

aged>69=13.1,

aged>79=7.6,

allages=90.4.

Infectedstaffata2-daylag:relativeincreaseinresidentdeathperinfectedstaffmember=20%(95%CI14-26%);

6daylag=17%95CI11-26%.

Grahametal

(2020)

N=394residentstotal

N=313residents

test

ed

126/313(40%)residentstestedpositiveforCOVID-19(54asymptomatic,72symptomatic,ofwhich50typicaland22

atypicalsymptoms).

5/173(4%)negativeresidentstestedpositiveonre-test1weeklater

53/103(54%)deathsconfirmedorsuspectedCOVID-19

Handetal

(2018)

N=130residents

Medianage82(range

66-96)ofcasepatients

20/130residentssuspectedascases(between1-18November).13/20suspectedcasesweretested,ofwhich7/13(54%)

werepositiveforHCoV-NL63.

Nonewcasesamongresidentsafter18November

Heungetal

(2006)

N=67residents

participated

65-75years:n=7

76-85:n=32

>85years:n=28

Female:n=53

0/67residentswerepositiveforantibodies

Hoetal

(2003)

N=3infectedresidents

3infectedresi-dents

aged81,87,93.

Singleresidentinfectedduringhospitalstay,returnedandthevirusspreadto6people(3residents,1staff,3visitors)

2/3residentsdied


Table6S. F

ocus

sed

resid

ent o

utco

mes

from

stu

dies

exa

min

ing

COV

ID-1

9 in

resid

entia

l car

e ho

mes

Study

Samplesize

Age

Outcomes

Kenn

elly

et a

l (2020)

N=2043residents

N=24nursinghomes,

21ofwhichhad

outb

reak

710/1741residentswerepositiveacross21NHs.54/1741suspected.764intotal.193/710confirmedcaseswere

asymptomatic.

Casefatalityrate25.8%inresidentswithconfirmedCOVID-19.27.6%whensuspectedresidentswereincluded.

Significantcorrelationbetweenproportionofsymptomaticstaffandnumberofresidentswithconfirmed/suspectedCOVID-19

(Spearman'srho=0.81).

NocorrelationbetweenasymptomaticstaffandresidentswithCOVID-19.

Kim(2020)

N=142residentsin

faci

lity

Nomoreinfectedpersons.Allpatientstestednegative14daysfromstartofquarantine.

Kim

ball

(2020)

N=76residentstested

(ofthe82residentsin

facility)

Femalen=48

Positiveresidents=

75.1±10.9

Negativeresidents=

80.7±8.4

23/76(30.3%)testedresidentswerepositive.

10(43.5%)weresymptomatic(8/10typicalsymptoms,2/10atypicalsymptoms),and13(56.5%)wereasymptomatic(10of

whichlaterredefinedaspresymptomatic).

Themeanintervalfromtestingtosymptomonsetinthepresymptomaticresidentswas3days.

Thirteen(24.5%)residentswhohadnegativetestresultsalsoreportedtypicalandatypicalCOVID-19symptomsduringthe14

daysprecedingtesting

Leeetal

(2020)

N=189residents

adm

inist

ered

trea

tmen

t0/189residentstestedpositiveatconclusionofthe14-dayintervention.

Treatmentwasdiscontinuedin5patientsduetogastrointestinalupset(n=2),bradycardia(n=2),needforfasting(n=1).

McM

icha

el

(2020)

N=118residents

test

ed

69femalespositive

Positiveresidents:

Median=83(range

51-100)

101residentspositive(118weretested).

Casefatalityrate33/7%(34/101residents)

Officeof

National

Statistics

(2020)

N=293301(95%C.I.

293168–294434)

N=9081nursing

hom

es

10.7%(95%C.I.10.1-11.3%)ofresidentspositive.15606deathsofresidentsacrossallhomesduetoCOVID-19.

Residentinfectionincreased:witheachadditionalinfectedstaffworking(OR1.11,95%C.I.1.1-1.11);inhomesusingbank/

agencynurses/carersmostoreveryday(OR1.58,95%C.I.1.5-1.65).

Residentinfectiondecreased:inhomeswherestaffreceivesickpay(OR0.82-0.93,95%C.I.7-18%).

Roxbyetal

(2020)

N=80residentstested

62femalestested

Mean=86(range

69-102)

3/80residents(3.8%)testedpositive.

Re-testingconducted1weeklater,1newpositivetest(asymptomatic).

Allresidentswereclinicallystable14daysafterthesecondtest,afterremaininginisolation.

Onday21,allcasescontinuedtoexhibittheirusualstateofhealth,andnonewcasesofCOVID-19werefoundamong

resid

ents

190

Table6S. F

ocus

sed

resid

ent o

utco

mes

from

stu

dies

exa

min

ing

COV

ID-1

9 in

resid

entia

l car

e ho

mes

Study

Samplesize

Age

Outcomes

Stal

l et a

l (2020)

N=623nursinghomes

Casefatalityrate27.8%(1452/5218)

TheoddsofaCOVID-19outbreakwasassociatedwiththeincidenceofCOVID-19inthehealthregionsurroundinganursing

home(adjustedoddsratio[aOR],1.94;95%confidenceinterval[CI]1.23-3.09)andnumberofbeds(aOR,1.40;95%CI1.20-

1.63),butnotprofitstatus.

For-profitstatuswasassociatedwithboththesizeofanursinghomeoutbreak(adjustedriskratio[aRR],1.96;95%CI1.26-

3.05)andthenumberofresidentdeaths(aRR,1.78;95%CI1.03-3.07),comparedtonon-profithomes.

Stow

et a

l (2020)

N=6464residents

2007men,3373

women,1086missing

gend

erN=460carehome

units

Menage=80.1±12.6

Womenage=

83.0±12.9

Between23/3/2020and10/5/2020therewere1532COVID-19relateddeaths.

Theproportionofabove-baselineNEW

Sincreasedfrom16/03/2020andcloselyfollowedtheriseandfallinCOVID-19

deathsoverthestudyperiod.Theproportionofabove-baselineoxygensaturation,respiratoryrateandtemperature

measurementsalsoincreasedapproximatelytwoweeksbeforepeaksincarehomedeaths

Thehighestcorrelationwasobservedforatwo-weeklag(r=0.82,p<0.05

Tse(2003)

N=40(33female)

resid

ents

Range65-82

ThoseresidentswiththeleastknowledgeaboutSARSalsohadtheleastconcernsaboutcontractingthedisease.

Zazzaraetal

(2020)

N=322(hospital

patients)

N=210afterage-

matching(82female)

N=535(community

patients)

N=238afterage-

matching(82female)

Hospital:all

participants,mean=

78.58±7.93

Age-matched,mean=

77.9±6.83

Community:age-

matched,mean=

73.0±5.86

Hospitalcohort:significantlyhigherprevalenceofdeliriuminthefrailsample

Frailtysignificantlypredicteddelirium(p=0.013,OR(95%CI)=3.22(1.44,7.21).

Communitycohort:

Frailtyfoundtopredictdelirium(p=0.038,OR(95%)=2.29(1.33,4.0).Frailtypredictedfatigue(p=0.038,OR=2.23(1.27,3.96);

SOB(p=0.043,OR=2.0(1.19,3.39))

Afterage-matching,deliriumwasreportedin40(38%)offrailand13(12%)ofnon-frailpatientswithCOVID-19.


Table7S.FocusedworkeroutcomesfromstudiesexaminingCOVID-19inresidentialcarehomes

Study

Samplesize

Age

Outcomes

Aronsetal(2020)

N=138facilityworkers

tota

lN=51workerstested

11of138fulltimestaffpositiveatfirstsurvey.ByMarch26,55reportedsymptoms,51weretested,26werepositive

Doraetal(2020)

N=136staff,alltested

8/136stafftestedpositive(4symptomatic)

Geuryetal(2020)

N=136staffmembers

(112female)

Median=39(range

27-48.5)

3/136(2.2%)stafftestedpositive.1presymptomatic(symptomsdeveloped24hoursaftertesting),1wasasymptomatic.

Attimeoftesting,98staffwereasymptomatic(72%).

Grahametal

(2020)

N=70tested

(N=596workers

in to

tal a

cros

s th

e facilities)

3/70(4%)stafftestedpositive

Handetal(2018)

Nostaffreportedrespiratorysymptomsduringoutbreak.

Heungetal(2006)N=26tested(22

female)

(N=32workersin

facility)

Aged31-50:n=18

Aged>50:n=8

0/26staffwerepositiveforantibodies

Hoetal(2003)

N=1infectedstaff

mem

ber

Staffaged65

1/1infectedstaffdied

Kenn

elly

et a

l (2020)

N=1392staff

members(across12

nursinghomesreporting

totalstaffnumbers)

675staffpositive,across24/28NHs.

Significantcorrelationbetweenproportionofsymptomaticstaffandnumberofresidentswithconfirmed/suspected

COVID-19(Spearman'srho=0.81).

NocorrelationbetweenasymptomaticstaffandCOVID-19residents.

Almostaquarter(23.6%,159/675)wereasymptomatic,identifiedbymasspoint-prevalencetesting.

Kimetal(2020)

N=85

Nomoreinfectedpersons.Allemployeestestednegative14daysfromstartofquarantine.

Leeetal(2020)

N=22careworkers

adm

inist

ered

trea

tmen

t0/22stafftestedpositiveatconclusionof14-daytreatmentperiod.

McMichael(2020)

N=170facilitystaff

N=50positivehealth

care

wor

kers

(38females)

Median=43.5(range

21-79)

50healthcarepersonnelpositive

192

Table7S.FocusedworkeroutcomesfromstudiesexaminingCOVID-19inresidentialcarehomes

Study

Samplesize

Age

Outcomes

OfficeofNational

Statistics(2020)

N=441,498(95%C.I.

441,240-441,756)

staff

4.0%(95%C.I.3.6-4.4%)staffpositive.

Staffinfectionincreased:foreachadditionalinfectedresident(OR1.04);inhomeswherebank/agencystaffworkmostor

everyday(OR1.88,95%C.I.1.77-2.0);homeswherestaffregularlyworkelsewhere(OR2.4,95%C.I.1.92-3.0).Staffat

homesoutsideLondonhadhigheroddsofinfection.

Quickeetal(2020)N=454workers

N=5facilities

StaffatSiteAremaineduninfectedthroughouttheentiresix-weekstudyperiod.

22.5%ofworkersatsiteDhadprevalentinfectionsatthestartofthestudyandincidencewashighinitially(12.2per100

workersperweek),decliningovertime.

AtsiteC,initialinfectionprevalencewaslower(6.9%)andtheincidencedeclinedtozerobyweek3.

Twofacilitieswithlowprevalenceinweek1(sitesBandE)sawanincreaseincases–including,atsiteB,incident

infectionsdetectedafterfourweeksofnoinfections.Infectionswereobservedinworkersacrossalljobtypes

Sixindividualsexhibitedtwopositivetests,separatedbyaperiodofnegativetests

Roxbyetal(2020)

N=62(42females)

40.0±15

2/62(3.2%)stafftestedpositive,bothsymptomatic.


Table8S. F

ocus

sed

resid

ent o

utco

mes

from

stu

dies

exa

min

ing

COV

ID-1

9 in

resid

entia

l car

e ho

mes

Study

Samplesize

Age

Outcomes

Hoetal

(2003)

3visitorspositive

Aged27,28,88

0/3infectedvisitorsdied

McM

icha

el e

t al(2020)

16visitors

epid

emio

logi

cally

link

ed

to th

e fa

cilit

y(5femalespositive)

Positivesage:median=

62.5(52-88)

16visitorspositive

194

30. ReferenceList1ReviewofPolicies June2020–HIQ-RapidReviewofPublichealthGuidanceforResidentialCare

Available:https://www.hiqa.ie/reports-and-publications/health-technology-assessment/rapid-review-public-health-guidance

March2020-TILDA-TILDAreporttoinformdemographicsforover50sinIrelandforCOVID-19crisis Available:https://tilda.tcd.ie/publications/reports/Covid19Demographics/

May2020-TILDA-TILDAnursinghomedata:AshortreporttoinformCOVID-19responsesforourmostvulnerable2020 Available:https://tilda.tcd.ie/publications/reports/Covid19NursingHomes/index.php

May2020-HIQA-AnalysisofNF01andNF02notificationstoHIQA*

May2020-TheInternationalLongTermCarePolicyNetwork-InternationalexamplesofmeasurestopreventandmanageCOVID-19outbreaksinresidentialcareandnursinghomesettings Available:https://ltccovid.org/wp-content/uploads/2020/05/International-measures-to-prevent-and-manage-COVID19-infections-in-care-homes-11-May-2.pdf

May2020-TheEuropeanCentreforDiseasePreventionandControl-SurveillanceofCOVID-19atlong-termcarefacilitiesintheEU/EEA Available:https://www.ecdc.europa.eu/en/publications-data/surveillance-COVID-19-long-term-care-facilities-EU-EEA

March2020-TheWorldHealthOrganisation-InfectionPreventionandControlguidanceforLong-TermCareFacilitiesinthecontextofCOVID-19 Available:https://apps.who.int/iris/bitstream/handle/10665/331508/WHO-2019-nCoV-IPC_long_term_care-2020.1-eng.pdf

March2020-ECDCTechnicalReport-InfectionpreventionandcontrolforCOVID-19inhealthcaresettings-firstupdate Available:https://www.ecdc.europa.eu/sites/default/files/documents/COVID-19-infection-prevention-and-control-healthcare-settings-march-2020.pdf

May2020-TheInternationalLongTermCarePolicyNetwork-MortalityassociatedwithCOVID-19outbreaksincarehomes:earlyinternationalevidence Available:https://ltccovid.org/wp-content/uploads/2020/06/Mortality-associated-with-COVID-21-May.pdf

InternationalLongTermCarePolicyNetwork-Countryreports:COVID-19andLong-TermCare-Examplesof9countrieslistedinthisreport Available:https://ltccovid.org/country-reports-on-covid-19-and-long-term-care/

*Could not find on HIQA website – was given by DoH


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32. AppendixExampleofSearchStrategy

Pubmed Search#1 “Residentialfacilit*”OR“Residentialagedcare”ORConvalescenthome*OR“NursingHome*”OR“Homesfortheaged”OR“Housingfortheelderly”OR“Skillednursingfacilit*”OR“longtermcare”OR“Longtermcare”ORHome*fortheagedOR“OldAgeHome*”OR“long-termcare”OR"NursingHomes"[Mesh]OR“long-termcare”[MeSH]OR"ResidentialFacilities"[Mesh]OR"HousingfortheElderly"[Mesh]

213,035Results

Intervention Search#2 (“Infectioncontrol”ORInfectionpreventionandcontrol*OR“PatientSafety”OR“Patientharm”OR“Patientrisk”OR“HealthcareDelivery”ORtransmissionORbodysubstanceisolation*ORphysicalbarrier*ORphysicalintervention*ORphysicalprotection*ORpersonalprotection*ORpersonprotection*ORBSIORIPCORN95ORffp1ORffp3ORffp2ORtransmission*ORcontamination*ORsheddingORfomite*ORgap*ORnon-pharmintervention*ORnon-pharmaceuticalintervention*ORShieldORN99ORN97ORVentilator*ORSpaceORspacingorseparationOR“CommunicableDiseaseControl”OR"PrimaryPrevention"ORfacemask*ORfacemask*ORface-mask*OR"DeliveryofHealthCare"OR“Diseasetransmission”OR“InfectiousDiseaseTransmission”ORPPEOR“PersonalProtectiveEquipment”ORmask*ORvirucide*ORantivirusagent*ORHandwashingOR“Handwashing”OR“HandDisinfection”OR“handhygiene”ORdistancingORdistancesORaerosol-generatingprocedure*ORpatientisolation*ORpatientisolator*ORpersonisolator*OR“individualisolation”ORindividualisolator*ORfilteringfacepiece*ORfaceprotection*ORfaceshield*ORfaceprotectivedevice*ORfaceprotectivegear*OReyeprotection*OReyeshield*OReyeprotectivedevice*OReyeprotectivegear*OREyemask*ORairborneprecaution*ORdropletprecaution*ORsafetysupplyORsafetysupplies*ORsafetydevice*ORsafetyequipment*ORsafetymeasure*ORsafetygear*ORprotectivesupply*ORprotectivesupplies*ORprotectivedevice*ORprotectiveequipment*ORprotectivemeasure*ORprotectivegear*OR“personalisolation”ORrespirator*ORrespiratoryprotection*ORrespiratoryprotectivedevice*OR“respiratoryprotectivesupply”OR“respiratoryprotectivesupplies”OR“respiratoryprotectiveequipment”OR“respiratoryprotectivegear”OR“safelyequipped”ORmeterORmetreORfootORfeetORmetersORmetresORheadcover*ORfacecover*OReyecover*ORgoggle*ORprotectiveclothing*OR"InfectionControl"[Mesh]OR"PersonalProtectiveEquipment"[Mesh]OR"HandDisinfection"[Mesh]OR"CommunicableDiseaseControl"[Mesh:NoExp]OR"DiseaseTransmission,Infectious"[Mesh]OR"PrimaryPrevention"[Mesh]OR"DeliveryofHealthCare"[Mesh:NoExp]OR"Fomites"[Mesh]OR"Ventilators,Mechanical"[Mesh]OR"CommunicableDiseaseControl"[Mesh]OR"PrimaryPrevention"[Mesh]OR"DeliveryofHealthCare"[Mesh]OR"PatientIsolation"[Mesh]OR"PatientSafety"[Mesh]OR"PatientHarm"[Mesh]) 5,741,706results

200

And

Search#3 (Coronavirus*OR“Coronavirus”ORBetacoronavirusorBeta-coronavirusORCorona*ORcoronaviralORcoronavirdaeORcoronaviridaORcoronaviridaeORcoronavirideaORcoronaviridiaeORcoronavirinaeORcoronavirionORcoronavirionsORcoronavirosesORcoronavirousORcoronaviruesORcoronaviruscpeORcoronaviruseORcoronavirusesORcoronaviruslikeORcoronaviserORcoronaviursORcoronaviusesORcoronavriusORcoronavvirusORCOVIDORSARSORSARS-CoVOR“MiddleEastrespiratorysyndrome”ORMERSORMERS-CoVOR“SevereAcuteRespiratorySyndrome”OR“severeacuterespiratorypneumoniaoutbreak”OR2019-nCoVORnCoVORCOVID-2019OR“COVID2019”ORcov2ORCovid19ORCOVID-19ORCOVID19ORSARS-CoV*ORcoronaviridaeOR"coronavirus"OR"SARS-CoV-2"OR"sarscov2"OR"SARS-CoV-19"OR2019nCoVOR"SARS-CoV"ORSARSCOV2OR"2019coronavirus"OR"SARS2"OR"2019coronavirus"ORcovid19OR"novelcoronavirus"OR"newcoronavirus"OR"novelcoronavirus"OR"newcoronavirus"OR“coronavirusinfection”OR"nouveaucoronavirus"OR"COVID-19"[SupplementaryConcept]OR"severeacuterespiratorysyndromecoronavirus2"[SupplementaryConcept]OR"CoronavirusInfections"[Mesh]OR"Coronavirus"[Mesh]OR"MiddleEastRespiratorySyndromeCoronavirus"[Mesh]OR"CoronavirusInfections"[Mesh]OR"SARSVirus"[Mesh]OR"Betacoronavirus"[Mesh]) 595,661results Search#4=#2AND#3116,217results Outcomes Search#5 MortalityOR“Deathrate*”OR“MortalityRate*”ORMorbidityOR“RiskofInfection”OR“infectionrisk”OR"Mortality"[Mesh:NoExp]OR"Morbidity"[Mesh] 3,204,107results

Search#6=#1AND#4AND#5593results

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COVID-19 Nursing HomesExpert PanelExamination of Measuresto 2021Report to the Minister for Health

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