Across the world residential care and nursing homes have shown to be highly vulnerable to COVID-19. In Canada, these complexes have seen hundreds of deaths as result of the deadly virus. Here in Nova Scotia, Northwood has faced a significant outbreak of the virus and its impacts have been devastating.
We asked Dr. Kenneth Rockwood why residential care and nursing homes are being so heavily hit by the virus and what can be done to mitigate risks and protect the residents of these facilities.
Why are residential care and nursing homes more vulnerable to COVID-19?
There are a few reasons these places are more vulnerable. The first is that they contain more older people who are at risk. We know that around the world, the people who have been most at risk both to contract illness and to die of it have been older people, and particularly older people living in long-term care. We believe this is due first to their degree of frailty. That is one of the areas we are investigating. The hypothesis is that even though more people who are frail or severely frail will develop the disease, it will not affect everyone with that degree of frailty.
The second risk is that within a nursing home, practices that typically serve everybody well, like having group meals and physical interactions, are not good if you are trying to enforce social distancing. Those practices are generally sound; they are just not good in this circumstance. Related to that is the challenge that some people who are in long-term care have dementia and cannot easily learn the new rules. They find it hard to understand why they should have a face mask or why they cannot touch somebody with a face mask to see if it is them, and so on.
In addition, other factors within a community increase risk. For example, if you have health care workers who have bus schedule changes because of low demand — and they are paid such that they cannot afford anything other than the bus — the bus ride that perhaps took 45-minutes now takes 2-hours. It is easy to see why the workers would decide to carpool together to work.
So, there are practices that extend beyond individual health and the nursing home itself. They have to do with the environment in which nursing home health care is provided. The issue is complex, and people who are riding in with one solution are unlikely to get it right. We have to respect the complexity of the problem.
What can be done to mitigate the risk of COVID-19 entering these buildings?
We know that COVID-19 is a predominantly respiratory illness. It spreads through particles from the respiratory tract of an infected individual; coughing and sneezing are the dominant ways of transmission. It can also be transmitted by touching a contaminated surface and then rubbing the eyes, nose, or mouth. These are efficient ways to infuse the virus into the body, even more efficient than blood. So, we should try to reduce the risk of transmission. For the most part, social distancing and then meticulous handwashing. As I said, those things are challenges in long-term care. However, some nursing homes have successfully managed the situation by quarantining the people who likely have been exposed and isolating those who have the illness.
What can governments, health-care workers and administrators of these homes learn from current practices and experiences to protect residents from COVID-19 and other potential pandemics that could emerge in the future?
We need to recognize that long-term care institutions still might be the main sources of illness in a second wave. For example, at the Nova Scotia Health Authority, we initially decided the best thing to do — for good reasons — was to make sure that we had the hospitals as empty as possible to accommodate the demand that was going to come chiefly from the community. As a consequence, we moved people out of the hospital into long-term care just before the pandemic. However, that made it harder when the pandemic struck to isolate people with COVID-19 in the nursing homes.
It is very challenging to move people in a nursing home. It is not like a hospital where they might have just their suitcase. People in long-term care have a ton of things. I expect that some of these solutions are going to be architectural. For instance, creating a locker that is mobile so that people can easily move from their rooms. Also, we are going to need to look seriously at whether there should be anything other than single rooms in long-term care, including retrofitting existing long-term care facilities.
We are going to need to imagine that if people have to manage in their own room, those rooms will be designed to accommodate that, to make it not as constraining. There’s talk of wall-mounted screens that can be used for more than TV; these screens can be entertaining, calming, and so on. We also need to figure out quickly best transportation for workers. If it turns out that many of the workers are living in one area, we could have school buses, moving people back and forth in a manner that ensures social distancing.
Finally, we should look at the notion that it is hard to get people to work in continuing care. We also know that mostly they are not well paid. As a result, some must work in more than one institution. We need to look seriously into paying them more. I think that we should look at creating a reserve corps (possibly from the hospitality industry) who, in pandemic time would not available to be upskilled and help provide personal care in nursing homes. There are people with skill sets and dispositions that could allow them to take on this additional work.
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