Servicio de Geriatría, Hospital Universitario de Getafe, Getafe, Spain. . Corresponding author: Leocadio Rodríguez-Mañas, Servicio de Geriatría, Hospital Universitario de Getafe, Carretera de Toledo, Km. 12.5, 28905- Getafe, Spain, e-mail: firstname.lastname@example.org, Phone: +34 675836102
Jour Nursing Home Res 2020;6:43-44
Published online July 6, 2020, http://dx.doi.org/10.14283/jnhrs.2020.11
According the official figures released by the Spanish Ministry of Health about covid19 in Spain, dated on 10th May, in Spain there was 31,899 causalities due to coronavirus. 9,642, that is 30.2% of the total, took place in Nursing Homes (1). A figure lower than the one recorded in Belgium, France, Ireland, Canada or Norway, where the percentage of people dying in Nursing Homes exceeded 50% of total deaths, but high enough to be consider a true tragedy.
The first case officially recognized in Spain occurred in January but until 5th of March the health authority did not release its first report containing any rules for the Nursing Homes.
These two facts summarize the main characteristics of the management of covid19 in the Nursing Homes in Spain. Being the place where the pandemic produced the most devastating consequences, it has been the place where the respond to the challenge has been less accurate, less agile and less effective. While the responses in hospitals or in the community were quite appropriate, mainly regarding the adequacy of the hospital structures and organization to the increasing burden of the pandemic, this was not the case in Nursing Homes. Indeed, that first document made a tiny and shy approach to the issue, putting the focus on the workers more than in the residents and with few and not very accurate recommendations about quarantines or measure to avoid the spreading of the infection.
Although several facts can explain the high impact of the pandemic in the residents of Nursing homes, some few of them account for the major part of it. Some of them can be considered common to all the countries, but other can be characteristics of each country. And it is important to recognize them in order to put the focus in the appropriate place if we want to avoid a repetition of the tragedy in future times. In the next lines I will try to briefly describe them, with a special emphasis on those that have been due to the organization of Long-Term Care (LTC), and mainly the institutionalized LTC, in my country, in Spain, but also in my region (Madrid), which has been the most affected region by coronavirus in my country.
1) People living in Nursing Homes form a group of very weak older people. They are not like the other older people who live at home, but sicker and with more disability and dependency. Many of the policy makers, and indeed health managers, are not aware about this fact. They are not living in Nursing Homes because they like to do, but because they are not able of receiving the support they need at home. This fact makes them a specially vulnerable population, with a very low functional and biological reserve. Once the virus is inside the Nursing Home, it is very easy for them to become infected and to suffer the poorest consequences of the infection
2) As it was shown in a very elegant paper published in the New England Journal of Medicine (2) completed by an inspiring editorial (3), the prevalence of asymptomatic infection in Nursing Homes is very high: more than 50% of patients infected remained asymptomatic during a long period of time, although after a week all of them except three in twenty-four had symptoms. This mean than in Nursing Homes periodic, timely routine rRT-PCR for both the workers and the residents without evidence showing that they have passed and cured the disease (using serologic tests or having evidence of rRT-PCR positive that, after a time, become negative) is mandatory to control and prevention of an outbreak. In Spain, still now, the possibility of implementing this strategy is finding many barriers, ranging from problems of supplies to logistic ones.
3) As the virus does not leave in the Nursing Home, someone has entered it: the workers and/or the visitors. Because of that it is necessary to implement very rigorous measures (cleaning the soles of the shoes with liquid containing bleach, hand washing, covering the mouth with surgical masks, use of gloves, use of disposable gowns…) both to visitors and workers. Recent documents from the Spanish Ministry of Health but mainly from the Regional Ministry of Health in Madrid region provide accurate measures about how to proceed. However, we are still putting them in practice, overcoming additional barriers, but the supply of the material, that suffer from big problems in the first weeks, are near to be solved.
4) Once the virus has entered, again the residents are not the responsible of its spreading. Again, rigorous measures to avoid spreading (washing hands each time there is a contact with a resident, “clean” and “dirty¨ or lockdown zones, personnel dedicated to care for covid19-patients and personnel dedicated to non-covid19 residents…) are mandatory. The same documents previously mentioned give instructions about how to make the quarantine, in whom, during what time, the requisites to be met by patients willing to be admitted, measures to be taken with the patients recently, newly admitted, etc. The problem is that many Nursing Homes have difficulties in implementing them because of the absence of enough space or a shortage in personnel. To cope with this issue the Regional Government of Madrid has recently approved an increase in the personnel of public Nursing Homes in addition to a better provision of material, as previously mentioned
5) Some residents would need to be transferred to the hospital. Putting the Nursing Homes in tight connection with the Health System has been a big problem. In the major part of the Spanish Regions Nursing Homes are under the auspices of Social Services and not very fluently connected with the Regional Health Systems. This organization led to severe dysfunctions impeding the admission of older people in hospitals or the development of well-based criteria for transferring the patients from the Nursing Home to the hospital
6) Being the Nursing Homes regulated by the social services system their medical equipment to provide a proper care of the residents, and mainly to those with the highest demands of supportive care, was very scarce. This lack of means generated attention deficit in many residents, including those needed for the care provided at the end of life (opiates, anxiolytics)
In the Region of Madrid there was a reorganization of the administrative dependency of the Nursing Homes, which has come to be shared by the Regional Ministry of Social Services and the Ministry of Health. As a consequence, the regional Ministry of Health has created 70 teams (Family Physician and a nurse) and created geriatric liaison personnel, based in the Geriatric Services and Units of the Hospitals of the Regional Service of Health (SERMAS) in order to guarantee the attention of the Nursing Home residents. This re-organization and empowerment of the resources devoted to provide attention to these weak older persons are very recently designed and it is still being implemented. Hopefully, its generalization and its permanence throughout time will strengthen care for Nursing Homes residents during both covid- and, hopefully, post-covid times. If this happen, something good for the older people in Nursing Homes will have come from this horrible pandemic.
Conflict of Interest: The author declares not having conflict of interest
1. Actualización nº 101. Enfermedad por el coronavirus (COVID-19). Ministerio de Sanidad. España
2. Arons MM, Hatfield KM, Reddy SC, et al. Presymptomatic SARS-CoV-2 infections and transmission in a skilled nursing facility. N Engl J Med. 2020 Apr 24 DOI: 10.1056/NEJMoa2008457.
3. Gandhi M, Yokoe DS, Havlir DV. Asymptomatic Transmission, the Achilles’ Heel of Current Strategies to Control Covid-19. N Engl J Med. 2020 Apr 24. doi: 10.1056/NEJMe2009758.