Tracked: How the HSE advice to nursing homes shifted between March and April

SCRUTINY IS GROWING of the government’s response to Covid-19 outbreaks in nursing homes. 

This morning, the HSE said that 17 people were still living in a residential centre in Laois, where eight patients with Covid-19 died over the bank holiday weekend. They will now have their conditions reviewed. 

There have been criticisms and accusations that the government failed to properly prepare nursing homes for the challenge of the virus and ultimately reacted too late. As things stand, over 30% of nursing homes have a confirmed or suspected Covid-19 case. 

In the Dáil today, Taoiseach Leo Varadkar faced questions about the management of nursing homes during the Covid-19 crisis.

Speaking on RTÉ Radio One’s Morning Ireland programme this morning, Dr Siobhan Ni Bhriain, the national lead for integrated care at the HSE, said: “We’re trying to protect people by using the principle of cohorting, where that’s possible. And I really understand that in smaller nursing homes that is not possible.”

“What we have been trying to do from the start is that if we suspected a patient had Covid-19, that they will be isolated from the rest of their patient group,” she said. 

TheJournal.ie has been tracking the advice issued to residential care facilities – including nursing homes – in recent weeks. 

This advice is compiled by the HSE and the HPSC – not by Health Information and Quality Authority (HIQA), which works with nursing homes and residential centres on things like inspections.

A spokesperson for HIQA told TheJournal.ie that the organisation “has been in frequent contact with the providers of the services we regulate and have issued a number of regulatory notices”. 

However, the organisation has not been involved in the development of the HSE guidance. 

Guidance

So far, three versions of HSE guidance – titled ‘Interim Public Health and Infection Prevention Control Guidelines on the Prevention and Management of Covid-19 Cases and Outbreaks in Residential Care Facilities and Similar Units’ – have been issued, with the latest document published on 15 April. 

TheJournal.ie has seen two versions of guidance issued to nursing homes in March, titled: “Preliminary Clinical and Infection Control Guidance for Covid-19 in nurse-led Residential Care Facilities.”

Guidance issued to residential facilities on 17 March already seemed behind that of nursing homes themselves. 

On 6 March, Nursing Homes Ireland introduced strict new visitor restrictions, announcing that visitors should only attend in “urgent circumstances”. It noted that “management reserve the right to impose full restrictions where necessary”. 

But two weeks later, the HSE was advising “visitor notices advising of hand hygiene measures before, during and after visiting”. 

It also called for “visitor notices advising against visitors attending if they have been in contact with Covid-19 cases and if they have fever or symptoms of respiratory tract infection and until at least 48 hours after symptoms have resolved”.  

At this stage in the outbreak, there were 292 cases of Covid-19 in Ireland and two deaths. As a comparison, on the 24 March the Irish Prison Service had introduced strict restrictions on visits – introducing social distancing and limiting visits to one adult per visit.  

On 17 March, HSE guidance did not seem to countenance more extreme restrictions, only calling for “appropriate visitor restrictions in the event of a Covid-19 outbreak”.

If a resident does test positive, the advice stated, “visiting should be restricted to absolute necessity” – it gives the example of end-of-life care. 

Giving the example of a scenario where more than one patient tests positive for Covid-19, the guidance advised that management should only “consider closing the facility to all non-essential visitors”. 

And only after more than one case is confirmed, should management “close the facility to new residents and transfers if possible”. 

Three days later, in advice issued on 20 March, this guidance had not changed. 

By 10 April, that advice had shifted. “Family and friends should be advised that all but essential visiting (for example end of life) is suspended in the interest of protecting residents at this time,” HSE guidance states. 

Family and friends should be informed of the changes, the advice states, and “should be made aware that any visitors with fever or respiratory symptoms will not be admitted”.

As of 15 April, this advice hasn’t been developed or changed. 

Personal Protective Equipment

In guidance issued on 17 March and 20 March, there was little mention of personal protective equipment for staff in residential care settings. 

In the case of a resident testing positive for Covid-19, the HSE guidance stated that “staff members who can avoid physical contact and maintain a distance of at least 1m do not require apron, mask or gloves but should attend to hand hygiene. 

“If care of the resident requires close physical contact… staff members should wear a gown, surgical mask, and gloves and eye protection if there is an assessed risk of splashing of blood or body fluids,” the guidance said. 

In later guidance, there was more detail and guidance on the use of personal protective equipment – but no acknowledgement of the struggle facing some nursing homes and residential care settings in actually acquiring such kit. 

However, early guidance did note that a Covid-19 positive patient “should be encouraged to wear a surgical mask if available or otherwise, if possible, to cover the mouth and nose with a tissue when a staff member is within 1m”.

The use of tissues in this context were not referred to in later advice. However, in advice on managing residents who are “close contacts” of a confirmed case, current HSE guidance states that if entering a shared space is “unavoidable”, the resident should either wear a surgical mask or “cover their mouth and nose with a tissue”.

Ideally, the advice states, a resident who is a close contact should be accommodated in a single room and should avoid communal areas. 

Concern

Throughout the crisis, there has been an acknowledgement that people in residential settings are particularly vulnerable.

The very first line in the HSE advice issued on 17 March states: “Data from international Covid outbreaks has identified significant levels of mortality and morbidity in high-risk groups. Therefore, particular attention is required in RCFs [residential care facilities] where significant numbers of vulnerable people are managed.”

But there was already an awareness that this could prove difficult. A note in early guidance issued on 17 and 20 March warns that “implementing infection prevention and control practice is extraordinarily difficult with residents who are unable to comply with requests from staff.”

“In that setting the only practical approach is to apply the key principles of infection control as much as possible,” the advice says.

By 15 April, the language had changed – but the warning remained the same. “It is recognised however that there can be significant challenges in applying transmission precautions in residential settings which resemble household settings more than acute hospitals,” the HSE guidance notes. 

Some of these concerns have now been realised. 

“I think I think we’re all learning and there’s going to be significant lessons to be learned when this ends,” said Mary Dunnion, the Chief Inspector of Social Services with the Health Information and Quality Authority, told RTÉ Radio One’s Morning Ireland today. 

She acknowledged that not all these supports were in place at the beginning of the crisis. ”The processes that have been put in place are now supporting nursing homes,” she said.