In the early days of the pandemic the wider societal and political concern was the risk that the NHS acute sector would not be able to deal with a massive increase in patients requiring treatment for COVID19. It was at this time that there was a concerted focus on creating capacity within NHS hospitals by ceasing routine non-essential treatments, by maximising the availability of respirators, etc. At the same time there was a push to discharge individuals who were fit for discharge either to their own homes or to care homes.
In ordinary circumstances an individual is discharged when they are clinically fit. Before Covid-19 this was often a process which was delayed as a result of the non-availability of care home beds. This was not because the beds were not available but because funding from public authorities was not sufficient to enable these transfers to take place.
Even before Covid-19 there were circumstances where the eagerness to discharge from hospital in some locations had led to a strain or breakdown in relationships with the care home sector. The most commonly cited instance for these tensions was where a clinician considered someone capable of being supported in residential care, whereas after they were discharged it became clear to care staff that they required nursing and not residential care.
Before the pandemic, therefore, the process of clinical discharge into care homes was one which was not always smooth and frequently problematic. As a result, there was often a local distrust in the discharge system and process.
This level of challenge was reflected in the Clinical Guidance issued by the Scottish Government on 13thMarch which stated:
‘Transitions from hospital.
There are situations where long term care facilities have expressed concern about the risk of admissions from a hospital setting. In the early stages where the priority is maximising hospital capacity, steps should be taken to ensure that patients are screened clinically to ensure that people at risk are not transferred inappropriately but also that flows out from acute hospital are not hindered and where appropriate are expedited.’ (page 4)
Because individuals were not routinely tested at the point of discharge at this stage of the pandemic, despite the requests of the care home sector at the time, there was a real concern that people who entered care homes might be infectious. It should also be noted that the Guidance from Health Protection Scotland issued on 12th March made no reference to any process to be undertaken during admission from hospital.
Scottish Care’s CEO, Dr Donald Macaskill held a meeting on the 18th March with the Cabinet Secretary for Health and Sport and highlighted that care home providers were expressing concern over discharge procedures and that some were refusing to admit new residents. During the meeting he stated that the previous relationships between the acute and care home sector had sometimes not been as good as they might have been. As a positive result of the meeting the Clinical Guidance was revised and re-issued on 26th March.
This Guidance made the process of admission much clearer. It states:
‘4.2 Admissions/transfer from hospital to care home facilities
HPS updated guidance states that if the individual is deemed clinically well and suitable for discharge from hospital, they can be admitted to the facility after:
- appropriate clinical plan.
- risk assessment of their facility environment and provision of advice about self-
- isolation as appropriate (See NHS Inform for details). (page 4)
- there are arrangements in place to get return them to the facility
Decisions about any follow-up will be on a case by case basis.
If a patient being discharged from hospital is known to have had contact with other COVID-19 cases and is not displaying symptoms, secondary care staff must inform the receiving facility of the exposure and the receiving facility should ensure the exposed individual is isolated for 14 days following exposure to minimise the risk of a subsequent outbreak within the receiving facility.
Individuals being discharged from hospital do not routinely need confirmation of a negative COVID test. Facilities will be advised of recommended infection prevention and control measures on discharge. It is recommended that this includes a documented clinical risk assessment for COVID-19.’ (pages 4-5)
This general approach was followed which meant that there was a presumption that it was not necessary to test an individual prior to them being discharged and admitted to a care home. This is stated clearly in the Health Protection Scotland Guidance of 17th April:
‘As part of the national effort, the health and care sector plays a vital role in accepting individuals who have COVID-19. Such individuals can be safely cared for in a health and care facility, if this guidance is followed.
Individuals who have been confirmed as having had COVID-19 but no longer have symptoms and have completed their isolation period prior to arrival, whilst still in hospital, home or another facility, can have care provided as normal.’
Scottish Care during this period continued to call for mandatory testing of individuals at the point of discharge whilst at the same time recognising the importance of residents returning to their care home and the strategic need to ensure that people were not unnecessarily delayed in hospital.
We further recognise that from 21st April it became a requirement for all patients being transferred from hospital to receive a negative test. Before this date, no such requirement was in place.
Before 21st April it is impossible to determine the extent to which care providers were made aware of the testing status of individuals upon admission to care homes.
Today’s report is an extremely thorough statistical analysis based on a diverse set of data and a triangulation exercise and presents a conclusion that hospital discharges per se were not a significant factor in outbreaks in a care home. It does state that the admission of some residents in some instances would statistically increase the risk especially if they had been untested.
More reassuring is the analysis that the use of testing reduces the risk of an outbreak in a care home. The report’s recommendation on the importance of discharge planning involving the person themselves, their families and care homes as partners, and on the need for clear communication of an individual’s testing status, is welcome.
More work needs to be undertaken to better understand the reasons why the size of a care home is proving to be a factor in relation to outbreaks, including what particular factors relating to size have an impact.
Dr Donald Macaskill, the CEO of Scottish Care states:
“Today’s report makes for detailed and robust reading and yet it is only part of the story. The statistical analysis is thorough and highlights that the risks to care homes in terms of outbreaks are related to the size of a care home. This is because larger care homes tend to be nursing homes, dealing with more frail residents and those living with dementia; they have larger numbers of staff members and environmentally because of size present greater IPC risks.
What is missing amongst all the data and statistics, the numbers and charts, is the story of those who cared for residents in our care homes. Their experience of discharge, of residents arriving home or coming for the first time to the care home, is missing and requires to be told. Some of our members and staff who work in care homes in a few cases believe that Covid-19 was introduced into their care home community as a result of discharges. I hope the researchers can take some time to listen to the experience of staff in care homes where there have been significant outbreaks. At the moment we have one side of the story, what is missing is the frontline experience of our care sector and its staff, the voices of those who received care and their families.
At the start of the pandemic all the emphasis was on the preservation of the NHS. Our politicians and medical advisors stood in front of posters which read ‘Protect the NHS’. The care home sector and its workforce played its part in that protection, and can be assured that in the majority of instances that support through enabling people to come home or be admitted, was not a significant risk factor for outbreaks. However, we need to ensure that where people are convinced there was a direct relationship between discharge and outbreak that this belief needs to be investigated.
We should have initiated testing for all discharges much earlier than we did. The report makes it clear that there are real benefits from this testing process.
We know those of older age, the very frail and those living with multiple co-morbidities remain at particular risk – we all of us need to do everything we can to protect our most vulnerable, regardless of where the live or are cared for.
We expected and still do expect that care homes, which are places of contact and community, become isolation units for those leaving hospital or coming in from the community, almost to become specialist infection control environments against the most virulent disease we have witnessed in decades. Care homes, regardless of the sacrificial dedication and skill of staff, cannot completely protect against the virus. It is quite clear that during the summer we had virtually no outbreaks but as transmission rates increased in the community, then the risk of asymptomatic spread into our care homes has increased at a disturbing level.
The report is a reminder of the pain we have all endured. Its insight should become the energy to ensure that the whole health and care system really does support the care home sector in the weeks ahead, that it becomes each of our responsibilities to protect by our everyday action, putting the needs of the residents rather than the protection of any system or organisation at the heart of that shared focus.”
Public Health Scotland has published its findings on discharges from hospitals to care homes during the COVID-19 pandemic. The report is split into two sections: one presents statistics on people aged 18 and over who were discharged from a hospital to a care home between 1 March and 31 May 2020, while the other defines and describes care home outbreaks of COVID-19 with an analysis of the factors associated with those outbreaks, specifically including hospital discharges.
Last Updated on 4th November 2020 by Shanice