Care Homes - Testing is a Red Herring

[StuartO]

Care Homes contain vulnerable residents so the requirement, if they were to protected from the virus reliably, was always to set up and maintain a reliable barrier against infection - which always meant reorganising the running of the place to keep staff who were to be in contact with residents inside the barrier - i.e. become resident too.  It was never going to be enough to ban visitors, although of course most Care Homes did that promptly because it was an easy, no-cost option, because the likely route of infection into the Home was always going to be the staff coming and going from home  and some of them working in more than one Care Home.

In-contact staff would have to live on site and remain within the infection barrier, there would be no other reliable way.  Other "non-contact" staff (such as perhaps catering staff who can stay within the kitchen) could stay outside this infection barrier, continue to come and go and therefore live at home.  If new residents were to be admitted at all they would need to be quaranteened in isolation (with dedicated quaranteen staff using PPE) before they entered the virus-free zone.  This would not be easy to organise but if the infection was to be excluded, it was necessary regardless of whether testing was also being done.

Testing of residents and staff, which is now being demanded, could therefore never have helped to keep the Care Home virus-free without the establishment of a robust infection control barrier as described above.  Testing doesn't detect someone who is incubating the virus and might start shedding it almost immediately after the test.  A postive test merely shows that someone is already likely to have spread the infection within the Care Home - so testing is useful only for big-picture epidemiological purposes and not at all for keeping residents of Care Homes safe.

Care Homes are private or corporate businesses run for profit or local authority homes and they are inspected regularly by local authorities (the enforcement authorities) and the Care Quality Commission.  Infection control is an important part of these inspections and care homes are expected to have comprehensive written policies and contingency arrangements.  I don't know whether this requirement included contingency plans for a pandemic but they should have done and Care Home should have been given guidance on this too.  Making these arrangements work is the responsibility of the Care Home owners and they should not be trying to blame the Government for not supplying them with PPE.  Care Homes all have a retained doctor and they would also have access to guidance from Public Health England.  PHE advice is said to have been changing rapidly in the early stages of the outbreak as they mounted their learning curve but generally speaking care homes will have had a reasonable opportunity to get their  act together in time.

Unfortunately many, perhaps all Care Homes have failed to grasp the nettle, do the work and spend the necessary money to achieve reliable infection control whilst the opportunity was still available.  Once inside a Care Home the virus is very likely to make the rounds regardless of using PPE (because the types of PPE and the staff training to barrier nurse effectively will be inadequate regardless of adequate suplies) and kill a high proportion of residents.  Care Homes will therefore lose many if not most of their paying customers and suffer the financial penalties.

That won't stop the Care Home owners trying to pass the buck, as they are now doing by claiming that lack of testing and the NHS's failure to provide them with PPE as a priority too.  We should not be deceived.

[John52]

Your capacity to ignore the obvious when it doesn't suit your prejudice never ceases to amaze me.

:-S

My Apologies to everyone whose intelligence I am insulting by stating the obvious here - Testing wouldn't pick up every carrier, but it would identify most, and isolating them would reduce the spread of the disease.

[StuartO]

John52 - 2020-04-30 8:55 AMYour capacity to ignore the obvious when it doesn't suit your prejudice never ceases to amaze me. :-S My Apologies to everyone whose intelligence I am insulting by stating the obvious here - Testing wouldn't pick up every carrier, but it would identify most, and isolating them would reduce the spread of the disease.

Testing everyone every day or maybe even more than once per day might help to stop the leaks but as I explained in terms which open-minded people would understand, reliable infection control to protect highly vulnerable residents of Care Homes would depend above all on the effectiveness of their infection barrier.  Testing for the virus is most useful in the workplace for getting people who have had symptoms or family illness back to work after their period of self-isolation.

I'm afraid it's your own intelligence, or relative lack of it, which you are displaying John52.

[John52]

StuartO - 2020-04-30 9:04 AM

 

to protect highly vulnerable residents of Care Homes would depend above all on the effectiveness of their infection barrier. 

 

Correct 8-) (was it a mistake ;-) )

But its not practical to maintain such a barrier between everybody

So if you know who is most likely to be infected, you can have the barrier where its most effective.

[StuartO]

No the barrier is established around the residents as a group and the staff who look after them would also remain within this perimeter, a bit the "green zones" or "virus-free" hospital units being maintained in hospitals. I know they use testing but they also have a clear infection-control perimeter. Doing this in a care Home would allow those inside the infection perimeter to be cared for more easily as a group and require less use of PPE because the staff would also be "clean" all the time. This is just one way of doing things but I suggest it because it allows a relatively normal internal and social care regime - at the price of having to establish and maintain the perimeter.

 

But the points I made about the limits of what testing alone can do for a care home are also noteworthy. As well as limitations of sensititvity and specificity, which every test has, there is the problem of current testing being merely a snapshot view of whether the virus is detected as present in the subject's body at the time of testing - and a negative result doesn't guarantee that the individual isn't already infected, is incubating the virus and will therefore become a source of contagion soon.

 

I have a bit of a conscience about suggesting you have limited intelligence and I apologise because it was not necessary for the purpose of the post, even though you had implied gratuitous insult to me. I think of you as a stubborn person of fixed ideas, a closed mind and enormous prejudice rather someone who is necessarily stupid. I attribute your charactaristics to a big chip on your shoulder stemming from your struggling or failed early years in education but I might be wrong.

[John52]

StuartO - 2020-04-30 1:40 PM

 

No the barrier is established around the residents as a group and the staff who look after them would also remain within this perimeter, a bit the "green zones" or "virus-free" hospital units being maintained in hospitals. I know they use testing but they also have a clear infection-control perimeter. Doing this in a care Home would allow those inside the infection perimeter to be cared for more easily as a group and require less use of PPE because the staff would also be "clean" all the time. This is just one way of doing things but I suggest it because it allows a relatively normal internal and social care regime - at the price of having to establish and maintain the perimeter.

 

.

 

So if one has got the virus they all get it.

Wheras testing might have identified them before they infected everyone else.

 

[StuartO]

John52 - 2020-04-30 3:44 PM So if one has got the virus they all get it.

 

Wheras testing might have identified them before they infected everyone else.

 

Yes, if you allow the barrier to be penetrated there would then be a high risk of them all getting infected - which is why you prevent the barrier from being penetrated by keeping all the carers inside all the time. You also take care to prevent other ways in which the virus get in, for example by ensuring their food, crockery and cutlery doesn't bring it in. All of which is achievable because the hard bit was prevemting staff bringing it in.

 

Testing might have identified bringers-in of infection but it wouldn't detect all of them reliably all of the time (and thereby maintain the barrier) because the testing is intermittent and doesn't exclude incomers who are incubating the virus undetectably.

 

If you don't get this then I give up.

[Brian Kirby]

The testing is only required to verify if the infection is, actually, Covid-19, so that accurate records of the scale of infection are maintained, and if admitted to hospital, what threat the patient presents.

 

Since the tests apparently take on average 2 days to provide results, and since the number of tests necessary were not available on an "on demand" basis, testing on the scale implied would have been of little use in preventing the spread into, and within, care homes IMO and, even had they been available, due to that delay in getting results, plus the acknowledged incidence of false negatives, the virus would, sooner or later, have got in. What then?

 

I think Stuart is right, and the establishment of a rigorously maintained cordon sanitaire would have been ideal. But, whether a regime of that severity could have been installed in the large number and variety of homes at short notice, I somehow doubt. I think that would require purpose designed and built homes, with pandemic control always in mind.

 

In some homes, I'm sure it might be possible, but it would require those carers working inside the cordon to take up permanent residence within the homes, which implies sufficient accommodation for them to be, and remain, available for the duration of the threat. That implies the carers needed to be in place and "locked in" from about the end of January, meaning in turn that the cordon would need to have been planned for, and installed, before that date.

 

It also assumes that the owners/managers of all homes, large and small, had the knowledge and resources to implement such measures, which, having seen some of them interviewed, I doubt. This says nothing of the willingness for the relatively low paid carers to accept that, for an unknown period, possibly six months or more, they would be incarcerated in the place in which they worked. Some might; indeed, I understand a few have volunteered to do this, but all? What of their families? Would they be so nobly sanguine?

 

This also omits that hospitals were transferring patients into care homes to free up hospital beds, and that people from care homes also become ill for reasons other than Covid, with some needing hospital treatment. It is notable that even those working in hospital ICUs go home, and then have to adopt stringent anti-infection measures before entering their workplaces. This proposal imposes a far more demanding regime on the largely unqualified carehome work force. I really don't see how it could have been made to work, or how it could, under real world conditions as they were, have achieved better outcomes that we presently have.

 

I have had the misfortune to have visited a carehome years back, populated largely by mostly infirm elderly ladies, in varying stages of dementia, with a few prone to spontaneous aggression, and I cannot imagine how such a group could be managed safely even with the kind of PPE that should have been available from the outset, even allowing that the staff would have needed training in its effective use.

 

There is no ideal, "get out of jail free" solution here but, from my perspective, the ready distribution of appropriate PPE to, and within, the homes, with appropriate instruction on its use, was the least-worst pragmatic solution that might have ben achieved - had that actually been possible. It places the barrier between anyone who may be infected, so that even if they are, they do not infect others. But I have to say, the idea that those demented, unpredictable, ladies could ever have been relied upon to use PPE themselves had they become infected is for the birds. Some would just have removed it and tried to eat it. Any who became infected would have to have been confined to their rooms, and the consequences of that, given the incidence of incontinence (including double incontinence) and the lack of "en-suite" facilities, hardly bears thinking about.

[John52]

I can see how difficult it is once the Government has let the virus on to our island, wasting the huge advantage we have of being surrounded by sea, by failing to test and quarantine at the borders they have been so obsessed with 'taking back control' of.

But that opportunity has been lost whilst BoJo was more concerned with preventing his Brexit deadline being extended.

The next best thing - a timely lockdown before the virus got established, has been wasted too.

Now they have let it in and the god-given opportunity to keep it out has been wasted and lost for good, and the best chance of damage limitation by an early lockdown has been wasted too, its a case of limiting further damage as best we can.

But, if you could test those going into care homes, including the carers, it might pick out some carriers before they infected others.

What we do now is going to be far more difficult and far less effective than what we could have done whilst BoJo was only concerned with forcing through his Brexit deadline.

A little damage limitation is the best we can hope for now BoJo has wasted all our opportunities to do better :-(

[StuartO]

Brian Kirby - 2020-04-30 7:13 PM ....

I think Stuart is right, and the establishment of a rigorously maintained cordon sanitaire would have been ideal. But, whether a regime of that severity could have been installed in the large number and variety of homes at short notice, I somehow doubt. I think that would require purpose designed and built homes, with pandemic control always in mind.

 

In some homes, I'm sure it might be possible, but it would require those carers working inside the cordon to take up permanent residence within the homes, which implies sufficient accommodation for them to be, and remain, available for the duration of the threat. That implies the carers needed to be in place and "locked in" from about the end of January, meaning in turn that the cordon would need to have been planned for, and installed, before that date.

 

It also assumes that the owners/managers of all homes, large and small, had the knowledge and resources to implement such measures, which, having seen some of them interviewed, I doubt. .....

 

Clearly it would be more difficult for some Care Homes than others but my granddaughter works in a Care Home for residents with dementia (which I have visited) and they would be able to establish an effective infection barrier - and in their case still would be able to do so because (in rural Suffolk) they have so far remained non-infected. But the owners haven't tried to establish a barrier beyond banning visits and requiring more careful staff proceedures; I don't know why. They are a married couple of London barristers and they own two homes in Suffolk and employ managers but retaining all the purse strings themselves and visiting once per week at most. They seem to be waiting until they have a case or two, then they'll do something I suppose. I suspect that many Care Homes are owned by non-expert people who are investing their wealth. If it was my Care Home I would have done it a while ago - although I don't think it would have been essential to have established the barrier as early as January.

[StuartO]

John52 - 2020-05-01 5:01 AM

 

I can see how difficult it is once the Government has let the virus on to our island, wasting the huge advantage we have of being surrounded by sea, by failing to test and quarantine at the borders ....

 

GIven the numbers of people flying internationally I would think (with the benefit of hindsight) that the virus was pretty much in every developed country from December onwards and lots of developing countries too, certainly in ours although we didn't know it, starting to spread in the community. But faster and firmer action at an early stage would have made a difference to the speed of spread in UK, including an earlier lockdown.

[Brian Kirby]

StuartO - 2020-05-01 8:07 AM...……………….. If it was my Care Home I would have done it a while ago - although I don't think it would have been essential to have established the barrier as early as January.

But that would depend on the layout of each home, and how readily that facilitated the introduction of such barriers, bearing in mind the requirements, for example, for emergency escape and fire resistance. Unless those aspects of the building had first been assessed, and the measures (if any) necessary to meet the various requirements considered, no-one would be able to say whether any given premises could easily be adapted, whether construction work of whatever type would be necessary, and how long that might take while working within a functioning care home and observing safe working including - social distancing. Consider also, what then happens if any of the "over 11,000" registered care and nursing homes across the UK are judged unsuitable for adaptation. Do they close down, or what? Who pays?

 

It is in any case far too late now to switch horses, but in view of the growing evidence that the particular circumstances of care homes were overlooked while the government's was prioritising the re-organisation of hospitals to cope with estimated potential numbers, and that the earlier epidemic/pandemic planning reports had been shelved/forgotten (in either event, not enacted), I can't see much chance that any degree of swift response being feasible. For a rapid response to the declaration of a pandemic each care home would have needed an up to date, individually tailored, plan that could be immediately put in train.

 

Once disaster strikes one is reduced to fire fighting, not fire planning. What you are proposing first required fire planning.

[laimeduck]

Interesting thread for me as I have first hand experience.

 

My mother aged 99, who is virtually blind, whose one hundredth birthday is in August (hopefully?) is in a care home, paying close on £4000 per month.

The care home is smallish, 30 residents, cared for by about 30 staff and a few staff of other types - managers, maintenance etc. The residents are mainly old ladies, many with dementia. Most of these care staff are local, part time, married ladies with families. One, the cook is now a live in.

 

I had the misfortune to have visited many carehomes about 25 years ago to sell them my service and can confirm Brian's experience in some of them. Disgusting, demeaning places that should have been closed down. I was fortunate that I could pick and chose which homes to work for, so I did. We chose my mother's home based on my experience, they thought they were interviewing us, whereas in reality, we were interviewing them.

 

In my mother's case, the home first restricted visitors to visit by appointment, and visitors were questioned about movements before entry and required to wash hands before entering.

After about a week this changed to no visits at all.

My mother then developed a chesty cough, so was locked down in her room and carers had to gown up with full PPE to enter. (It was bronchitis, cured by antibiotics)

After about another week, all residents went into lockdown in their rooms as another resident had a cough.

Now, the residents have their temperatures taken x 2 per day, and by and large are contained in their rooms - not a problem for my mother as that's what she did anyway, being blind.

 

I too have listened to care home owners complaining on the news about PPE - this is garbage - at £4000 per month they have the money and with a bit of foresight and planning they had the opportunity to prepare - albeit in a rush. Fortunately ours did.

 

I think the management of many carehomes are ignorant (used in the true sense of the word). They are simply hoteliers with limited knowledge of infection control, some with a genuine compassion, who want to look after old people while making a very good living. In a normal world this worked, but Covid has changed all that - they are now on a steep learning curve - some will learn, others will fall by the wayside as their residents die.

 

No-one could have planned a concerted action plan for carehomes - they have simply had to individually, adapt, adopt and improve. The good ones have, the bad ones will fail.

 

As for a cordon sanitaire? It would be pie in the sky to expect the carers to live in - not at all practical or realistic.

 

So they are doing what they can. Politics really doesn't come into the situation

 

It strikes me as obvious that testing residents en mass is a waste - the only people who perhaps should be tested are the carers and ancillary staff who go from outside to inside the home, and that will only tell you if they've got it at the time of the test which is almost certainly too late. Testing is also simply a snapshot of the state of the individual at the time of the test - they could contract the virus the next day!

 

So they will continue to muddle through some better than others - so far, my mother's is better than others, lets keep everything crossed for her sake!

[StuartO]

Brian Kirby - 2020-05-01 10:48 AM But that would depend on the layout of each home .....It is in any case far too late now to switch horses ....

 

To a limited extent yes it would but it would usually be possible, for example to make the whole Care Home the protected zone, accommodating staff inside or in adjacent temporary accommodation such as portakabins, providing services such as catering if necessary from outside. The key requirement would be to accommodate staff inside the perimeter. It's not too late to do it now, especially if the Care Home's residents are currently virus-free. I haven't thought about who pays but I don't see it as inevitably, outrageously expensive.

[John52]

Brian Kirby - 2020-05-01 10:48 AM

care homes were overlooked while the government's was prioritising the re-organisation of hospitals to cope with estimated potential numbers

The whole Covid19 Crisis was overlooked whilst BoJo was obsessed with passing a law to force Brexit through whatever the circumstances - he didn't even bother to attend the Cobra meetings.

But we are where we are - the only opportunities to stop it have been wasted, and our only options now are catastrophically expensive things like economic shutdown which only delay the spread of the virus - testing people before they enter care homes would be no more wasteful than that.

[StuartO]

laimeduck - 2020-05-01 11:25 AM ....I had the misfortune to have visited many carehomes about 25 years ago .... Disgusting, demeaning places that should have been closed down....I too have listened to care home owners complaining on the news about PPE - this is garbage - at £4000 per month they have the money and with a bit of foresight and planning they had the opportunity to prepare....I think the management of many carehomes are ..... simply hoteliers with limited knowledge of infection control, some with a genuine compassion, who want to look after old people while making a very good living. ....as for a cordon sanitaire? It would be pie in the sky to expect the carers to live in - not at all practical or realistic.

 

Care Homes are inspected by both CQC and their local authority, annually in the case of any that are assessed as less than "Good". There's a lot of emphasis on having all the polies etc written up properly. 25 years ago it was probably very different.

[Brian Kirby]

StuartO - 2020-05-01 12:27 PM

 

Brian Kirby - 2020-05-01 10:48 AM But that would depend on the layout of each home .....It is in any case far too late now to switch horses ....

 

To a limited extent yes it would but it would usually be possible, for example to make the whole Care Home the protected zone, accommodating staff inside or in adjacent temporary accommodation such as portakabins, providing services such as catering if necessary from outside. The key requirement would be to accommodate staff inside the perimeter. It's not too late to do it now, especially if the Care Home's residents are currently virus-free. I haven't thought about who pays but I don't see it as inevitably, outrageously expensive.

I'm with Jeremy, I think abruptly insisting that staff live live-in would be, for a substantial proportion of them, a non-runner. So then the home has to recruit, at short notice, replacements willing to live in - whether or not in portacabins. It may be a comforting thought that this could be done, but I really don't think, under present circumstances, that it could be achieved. What we have is the consequence in part of an absence of considered pre-planning, and in part of ignoring the pre-planning that had been done. I don't lay all the blame for this at the door of the present government, the lack of adequate planning, and the ignoring of what had been planned, lies mostly with previous administrations. It's just a shame for the present incumbents that those previous administrations were of the same political party.

 

That is the only area where I think the politics becomes relevant. Corners have been cut.

[StuartO]

Well, none of us runs a Care Home, so what does it matter what we think?

[Guest pelmetman]

John52 - 2020-04-30 8:55 AM

 

Your capacity to ignore the obvious when it doesn't suit your prejudice never ceases to amaze me.

:-S

My Apologies to everyone whose intelligence I am insulting by stating the obvious here - Testing wouldn't pick up every carrier, but it would identify most, and isolating them would reduce the spread of the disease.

 

Do you have any recent experience of care homes? :-| .........

 

High death rates in care homes was sadly inevitable.........

 

For our resident Loser brigade to make polictical capital out of it......was also inevitable *-) ...........

 

 

[laimeduck]

StuartO - 2020-05-01 2:38 PM

 

Well, none of us runs a Care Home, so what does it matter what we think?

It matters to me because of my mother Stuart.

[StuartO]

laimeduck - 2020-05-01 3:02 PM

 

StuartO - 2020-05-01 2:38 PM

 

Well, none of us runs a Care Home, so what does it matter what we think?

It matters to me because of my mother Stuart.

 

Quite, I hope she is comfortable and has no exposure to COVID-19.

[thebishbus]

It seems that some homes can cope with the virus.Thursday there was an article the Express about one,

Five residents had tested positive and eight more were showing symptoms. The head nurse stepped in. She was a specialist in advanced forms of life support and had worked in a Hospital at the time of the swine flu outbreak. She turned a communal lounge into a ward, and isolated all 13 together with round the clock care from four staffers- until everyone was better. they all survived .

Brian B.

[John52]

pelmetman - 2020-05-01 2:55 PM

 

 

our resident Loser brigade

 

 

If you won't tell us who this 'Loser brigade' is, we won't know who you are talking about (as usual)

[Guest pelmetman]

John52 - 2020-05-01 5:05 PM

 

pelmetman - 2020-05-01 2:55 PM

 

 

our resident Loser brigade

 

 

If you won't tell us who this 'Loser brigade' is, we won't know who you are talking about (as usual)

 

You Losers know who YOU are :D ..........

 

You're the ones who lost a referendum and 2 elections ;-) .........

 

Your rather good at losing (lol) .........

 

 

[Guest rael]

With reference to the OP

 

Just a couple of points. Not all care home are 'for profit' as you implied.

 

In terms of PPE, then yes, I agree, care homes should have been stockpiling, however, government has not exactly set a good example in this area. My mums care home has struggled to source suitable PPE, and although I'm not a big fan of charity, I have made face shields for them and provided surplus safety glasses from work. What choice do I have?

 

I'm certainly not defending 'for profit' care homes. In my opinion the care crisis has been dodged by all political parties. In my opinion its easily solved, however, subsequent governments are reluctant to grasp the nettle.