How we are dealing with Covid-19 in care homes

14 May 2020

Care homes for older people are most at risk of Covid-19 deaths. We have seen this in Europe and North America. In one widely publicised case, 34 out of 101 infected residents in an American care home died.

In Cape Town you may have read about outbreaks at Highlands House and Nazareth House. Almost every facility in the city must by now have staff or residents who are Covid-positive, though this may not be known, because they have not been tested.

I have been assisting care facilities in the Cape Metro, including Highlands House. Extraordinary measures have been taken to reduce the risk of Covid-19 infections but more can be done to help.

At the outset, though, it’s important to temper expectations and accept a grim truth. No matter what we do, there will be Covid-19 outbreaks in care homes and people will die. Data from across the world show that the overwhelming number of deaths have occurred in people over the age of 60. Once infections get into a care home, it’s likely that within a few weeks, most of the residents will be infected. All we can do is try to reduce the risk and reduce the number of deaths.

Care facilities cannot be isolated from the outside world. Staff have to come in daily from their communities, where there may be many infections. We have restricted access to family members visiting their loved ones, but this is difficult psychologically both for residents and for their regular visitors. The life of residents in care facilities has been immeasurably changed by Covid-19, because they are now no longer able to socialise with friends as they used to.

At Highlands House on 18 March, nine days before the official lockdown began, we implemented our own lockdown. Daily, staff entering the facility have their temperatures taken and are screened for symptoms. Staff have been trained to use personal protection equipment (PPE). They were issued with face masks in mid-April, both for travelling to and from work, and for use in the facility.

Food is no longer served in communal rooms. All residents who needed hospitalisation, had medical appointments, or had to leave the facility for urgent matters, were placed in two-week quarantine.

Despite these measures, Covid-19 has entered the facility. Most people with the coronavirus are asymptomatic, or mildly symptomatic, for several days. So there is almost no way to prevent the infection from entering a facility.

Many residents who live in care facilities are highly dependent on close contact with staff who have to wash, dress, and feed them, brush their teeth and hair, and assist them with the toilet and walking.

Many residents have dementia and behavioural disturbances, which need further close contact with staff. These residents may wander in corridors and are difficult to isolate in their rooms. They are often frightened when they see staff wearing masks, and this causes further behavioural disturbance. Many residents often need two caregivers to assist with their tasks of daily living.

Providing care in a facility is complex. There are also cooks, drivers, laundry and general maintenance people on site. There are challenging logistics of providing food and other services in the context of Covid-19.

On the day a resident at Highlands House became ill, a Covid-19 test was done. Unfortunately the resident died, within 48 hours.

Within 24 hours of getting the result showing that the resident had Covid-19, we implemented a strategy to test all residents who were known to have been in contact with the deceased, and all staff members. Thirty tests were done on residents and staff. Fourteen staff were advised to immediately quarantine at their homes.

The next day it was decided to test all staff and residents. More than 460 tests were done over a period of 48 hours. This was a mammoth undertaking, unprecedented, as far as we know, in any care facility worldwide. The tests were done by private labs and all results were received within 48 hours.

It was this strategy that allowed us to rapidly identify 12 positive residents and 26 positive staff. To date all residents remain stable (one of whom is in hospital). More than eight days since the last test date, we have not had further deaths. Of course we cannot be at all sure that it will remain this way. About 185 residents are currently quarantined in their rooms (which is very difficult for them), and 40 out of 280 staff are either quarantined or in isolation at home.

All positive residents are seen daily by a doctor. All residents are being monitored for symptoms. Those that have tested negative but present with symptoms will be retested.

Had these measures not been taken, instead of 12 positive residents, we might have had many more. While we have had one death, we believe we have, at least for now, averted many further deaths.

Despite this enormous effort the facility still had a Covid-19 outbreak, and there will likely be more. And what Highlands House has done is not easily replicable elsewhere; the facility is relatively well-resourced.

Yet the strategy needs to be emulated as much as possible elsewhere because care homes are not only where large outbreaks occur; staff travel patterns can spread the virus into and out of facilities. If we aggressively test and quarantine, we can reduce infections across the city.

Care facilities fall under the Department of Social Development (DSD). The department needs to be more energetic in assisting those that provide services to state-funded residents. These facilities lack resources and staff. They cannot fund the services required to reduce the risk of outbreaks.

Staff members working in facilities are fearful. They have received minimal training and support from the DSD. Facilities have never been given the capacity to deal with an epidemic like this.

The government’s mass screening and testing programme is well-intentioned and at first it seemed like the way to go. But it is causing problems and needs to be reassessed. Because of the scale of the screening and testing programming, there is a huge backlog of tests at the state-run National Health Laboratory Service. It’s taking over a week to get results (which is why Highlands House used private labs). In a country with our limited resources, it makes more sense to do the bulk of testing at high-risk facilities or in areas where there are outbreaks.

The cost of testing and PPE is far too high. A private lab test costs about R850, the price of hand sanitisers has increased from about R25 per 500ml a couple of months ago to over R85, and a mask costs R15.

Also, it’s understandable that people are anxious about their family members in care facilities. They may want to lash out and blame the staff at facilities when their family members become sick or die, but it’s profoundly unhelpful, stressful and disrespectful to those of us doing our very best to protect the residents. One only has to look at what is happening in care homes in the richest countries to see how difficult this is.

These are unprecedented circumstances. Over time, there will be information as to how best to manage this crisis. However, it is in everyone’s interest to support the staff in facilities, who are trying their hardest and working under extreme stress, often putting their own health in jeopardy, to try and provide effective care.

The author is a general practitioner with a particular interest in care for the elderly.
Disclosure: The author is related to GroundUp’s editor.

Views expressed are not necessarily GroundUp’s.