R. Roller-Wirnsberger1, S. Lindner1, A. Matijevic1, E. Stolz3, G. Wirnsberger2
1. Medical University of Graz, Department of Internal Medicine, Graz, Austria; 2. Medical University of Graz, Department of Internal Medicine, Division of Nephrology, Graz, Austria; 3. Medical University of Graz, Institute for Social Medicine and Epidemiology, Graz, Austria. Corresponding author: Prof. Regina Roller-Wirnsberger, MD, MME, Department of Internal Medicine, Medical University of Graz, Auenbruggerplatz 15, 8036 Graz, Austria, Phone: +43 316 385 12274, Regina.Roller-Wirnsberger@medunigraz.at
Jour Nursing Home Res 2020;6:50-52
Published online July 6, 2020, http://dx.doi.org/10.14283/jnhrs.2020.14
Austria currently counts 8.84 Million inhabitants, 18.8% of the population being older than 65 years. Given the current demographic trends it is assumed that by 2040 the proportion of citizens older than 65 years will increase to 26.3% and 29.3% by 2080 (1). The population over 85 years is assumed to increase even greater, with a growth by 80.9% (from 225,000 citizens in 2018 to 407,000 citizens in 2040) within the next 20 years, representing 4.3% of the total population (2).
Currently, 947,000 citizens in Austria receive care and social support, the majority (over 80%) of them within the age group older than 60 years (3). 80% of those in need for care live at their private homes. The remaining 20% live in residencies with varying level of support (4). By virtue of prevalent frailty, multimorbidity and disability, care home residents are especially vulnerable to infections (5).
Therefore, it does not seem surprising, that numbers of positive cases and deaths in nursing homes from COVID-19 continue to rise in residential facilities across the world (6, 7). Recognizing the high risk associated with these facilities, the Centers for Disease Control and Prevention (CDC) in the United States has released interim guidance for the prevention and control of COVID-19 (8). In Austria, the first confirmed case of COVID-19 disease was diagnosed in Tyrol on February 25th, 2020. Given the highly contagious nature of the virus, SARS-CoV-2 spread within days, particularly affecting older and frail people in the country. Up to June 12th, 2020 16,868 confirmed cases of COVID-19 are documented in Austria, 22% of which were aged 65 years and over. 94% of the deceased COVID-19 patients were over the age of 65 years. Over the past 3 months, the Austrian public health body detected 355 clusters of disease accumulation, 61 in one of the total 900 Austrian nursing home institutions (22.8% share of total cluster detection) (9). In total, 833 nursing home residents have been tested positive for SARS-CoV-2 infection by real time Polymerase Chain Reaction (rt-PCR) up to this date. 222 of those residents died from COVID-19 in the last weeks.
The Austrian government, together with the Austrian National Institute for Public Health, therefore released recommendations how to best manage prevention, diagnostics and therapy of suspected SARS-Cov-2 positive nursing home residents in Austrian care facilities mid of March 2020. These “Austrian recommendations” were based on advice from the World Health Organization (WHO) as well as the CDC (8, 10).
Following standard operating procedures (SOPs) were recommended: Mandatory symptom and temperature screening together with routine evaluation of mood and behavior of residents. Clients should be informed about threats arising from the SARS-COVID-19 pandemia and safety procedures introduced to protect older people from infection. Social distancing included elimination of group activities and visiting bans for relatives and beloved as well as distancing between staff and residents during routine care procedures if possible. Hygienic measures further included venting the rooms minimum twice daily to protect clients as well as staff. Meal schedules had to be re-organized to enable physical distancing of residents (11).
All single care facilities had to develop SOPs, for handling of residents with suspected or confirmed infectious disease. It is the law in Austria since March 2020, that facilities or separate units with separate staffing for the purpose of containment have to be established in case of COVID-19 positive residents. Every resident tested positively had to be seen by regional health authority or a general practitioner (GP) to decide if he or she needed hospital care or can remain in residence. Contact tracing and social isolation for contact persons of COVID-19 positive patients is obligatory in Austria. All cases have to be reported to the administration to allow monitoring and national surveillance in accordance with the national law on epidemics in Austria (12, 13).
All staff members had to be trained for the SOPs. Furthermore, the national ministry of social and health affairs released a recommendation on basic training content for all staff members in nursing homes. Topics to be included into those trainings are: general information about COVID-19, its threats and clinical signs and symptoms, handling of protective material, handling of suspected cases of COVID-19 in residents and staff and prevention measures in nursing homes and social care. Regular audits by the management of a care facility to monitor adherence to SOPs during the pandemia are mandatory in Austria. Working schedules had to be adapted to needs, securing staffing also in case of illness of staff. Contact tracing aligned with case management of residents and SOPs comparable to those applied in hospitals were introduced for nursing home staff.
During the pandemia there was a general visit ban in all residencies across Austria. This ban was communicated among relatives, caregivers’ and patients’ attorney groups. Exceptions were made for residents terminally ill or in palliative care setting. In these rare cases, visitors were registered upon entry of a care facility, body temperature measured, protective equipment checked by the staff and visitors were instructed about behavior during the visit as well as hygiene measures to be adopted (10).
Critical appraisal of SARS-COVID-19 pandemia in nursing homes in Austria
Nursing homes have been documented as having high transmission rates for infectious diseases for reasons like crowding, sharing facilities, group activities, as well as low preparedness for infection control. In Austria, many care homes are equipped with low-licensed practical nurses or nurse assistants together with trained nursing staff. In general, medical support is provided by GPs. Thus, there may be a large number of GPs caring for residents in one institution, without pre-scheduled visiting times and interprofessional exchange, meaning low integration of processes and knowledge between different groups of professions. The government recommended by law, that each resident suspected to suffer from COVID-19 had to be seen by a medical doctor to ensure medical evaluation of severity of disease (10). Hence, it was interesting that during the COVID-19 crises there was still a focus on admissions to acute care from nursing homes because of lack of resources to manage clinical deterioration. This observation is in line with recently published data (14) and does not seem to reflect a special situation arising from the SARS-COVID-19 pandemia. In Austrian care homes there are no standard specifications for medical cover nor doctors in residence. Despite improvements in GP support associated with a training program delivered by the Austrian Chamber of Medical Doctors (15), the level of medical support remains heterogeneous in our country.
This is also reflected by the relatively low numbers of advanced care plans (ACP) with residents and their relatives in Austrian care facilities. The Austrian Society of Geriatrics and Gerontology clearly expressed the need of ACP measures immediately at the beginning of the COVID-19 crisis (16) as this concept has proven useful to support person centered care especially for nursing home residents (17). It is important to recognize that an ACP, stating the desire to be transferred to hospital in case of clinical worsening provides staff with the capacity to advocate on behalf of the resident and allows person-centered integrated care for chronic as well as acute medical needs.
The SARS-COVID-19 pandemia has taught us that addressing staffing and care models in nursing homes and skilled nursing facilities is a top priority for the future on the national agenda, and that implementation of integrated care models, including also relatives and informal carers, are mandatory on the agenda of providers in the near future. This also includes training standards based upon the special needs of older residents. This aspect of care has also been addressed in the literature recently (18) and has been recommended by the World Health Organization (19) as well as scientific societies worldwide (20-22).
Independent of this structural aspect, staff in the care facilities across Austria did a good job. Mandatory procedures released by the Austrian government were followed and executed in all care facilities. Some of the recommendations put staff under special constraints, such as social distancing and isolation of residents. It has been reported by care organizations continuously during the COVID-19 crises, that psychological and physical harms associated with the recent isolation of residents are significant. Furthermore, lacking therapeutic interventions from physiotherapists and occupational therapists lead to reduced physical capacities and increasing physical instability and tendency to fall. It is important to remember that COVID-19 illness is often atypical in this age group: they may sleep more than usual or stop eating, sometimes seem unusually apathetic or confused, losing orientation to their surroundings. They may become dizzy or simply collapse. Restricting movement for those older people represents a significant loss of autonomy and gives way to behavioral or responsive symptoms associated with dementia or cognitive decline.
Especially older people with reduced mental capacity and the intrinsic need to move suffered from the restraints during social distancing in the COVID-19 crisis in Austria. This is observed in many residents already under regular circumstances (5), however, the SARS-COVID-19 pandemia has put the special needs of nursing residents, particularly those with mental disorders, on Austria’s agenda. Data from nursing home surveys are under way, but not yet published in Austria.
Beyond the issues discussed in this editorial, COVID-19 affects the psychological wellbeing of citizens and health and social care staff all over the country. Staff have providing care, but reported back, that they often felt left behind and not heard. Looking after their residents for years, staff often builds/forms close relationship with them. Managements supported their staff with varying emphasis, mainly focusing on their duty to surveil national recommendations released by the government. Indeed, it is currently not easy to keep staff motivated to stay in their jobs in nursing homes and the number of qualified staff willing to work in this setting is already limited in Austria. Given the current demographic trends for Austria, however, it is clear that the SARS-COVID-19 pandemia has once more highlighted the dilemma of splitting social and health care in Austria, also in the nursing home setting. The difficulties outlined in this article mostly reflect systemic problems in long-term care in Austria: lack of integration of social and health care as well as between the public and private sector, and the failure to integrate needs-based health care paradigms into Austrian nursing homes. The current COVID-19 crisis could make the hard work within the care home sector more visible and put these topics on the agendas of politicians and care providers, also in Austria.
Funding: The authors received no specific funding for this work. The sponsors had no role in the design and conduct of the study; in the collection, analysis, and interpretation of data; in the preparation of the manuscript; or in the review or approval of the manuscript.
Conflict of interests: The authors declare no conflict of interests.
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