4/21/20, “The Anti-lockdown Strategy,“ Dr. Malcolm Kendrick. Scottish Doctor, author
“Lockdown has two main purposes. One, to limit the spread of the virus. Two, and most important, to protect the elderly and infirm from infection – as these are the people most likely to become very ill, end up in hospital, and often die. [In my view, if we had any sense, we would lockdown/protect the elderly, and let everyone else get on with their lives].
However, the hospitals themselves have another policy. Which is to discharge the elderly unwell patients with COVID directly back into the community, and care homes.
Where they can spread the virus widely amongst the most vulnerable. This, believe it or not, is NHS policy. Still.
Yes, you did just read that. COVID-19 patients, even those with symptoms, are still to be discharged back home, or into care homes– unless unwell enough to require hospital care e.g. oxygen, fluids and suchlike….
In fact, it does seem to be policy, although the guidance from the UK Government is virtually incomprehensible1. I have read it a few times and I fail to fully understand it – or partially understand it….
I wrote about this situation in my last blog [post, 4/17, posted below], as the impact of COVID of care homes was becoming apparent – even to politicians. I thought that someone, somewhere, might have realised the policy of flinging COVID positive patients – or patients who may have COVID – out of hospital, and into care homes, might prove a complete and utter disaster.
I now call care homes COVID incubators. Places where the disease can grow and multiply, happily finding new host after new host. Not so happily for the residents.
Equally, sending people home is further complete madness. Sending them home to somewhere that, very often, contains another elderly and frail person. Normally a husband or a wife.
Did anyone think through the consequences of this? Clearly not. Do you think the other person in the house may be at risk?…
If there is not another elderly partner in the house, there will usually be carers who come in to look after the freshly discharged COVID positive patients. These carers will have almost no protective equipment. Even if they do, they will be lifting and moving the patient around, washing them, taking them to the toilet… in very close proximity. The chances of getting infected are very, very, high.
These carers will then go and visit other elderly, vulnerable patients scattered around the community. They become the perfect vectors to spread the virus far and wide, amongst the exact group of people that we are trying to protect….
The hospital trusts appear incapable of understanding the argument. ‘Clear the hospital, clear the hospital’… are the only words they seem capable of uttering.
The hospitals, I point out repeatedly, have been cleared. Wards are standing empty, corridors echoing. The first peak has also been passed – even if no-one dares admit it. So why are we continuing to fling COVID positive patients out into the community?
‘Because it is national policy’….‘Because it is national policy’….
The entire nation has been locked down. Do not travel, stay two meters apart, do not go outside blah, blah….
If you wanted to create a system most perfectly designed to spread COVID amongst the vulnerable elderly population, you may well have come up with the current one. Infect people with COVID in hospital, and then scatter them into care homes and the rest of the community. Making sure that you infect all the carers on the way.”...
1: https://www.gov.uk/government/publications/COVID-19-guidance-for-stepdown-of-infection-control-precautions-within-hospitals-and-discharging-COVID-19-patients-from-hospital-to-home-settings/guidance-for-stepdown-of-infection-control-precautions-and-discharging-COVID-19-patients
………………………………………………
Added: “The actions taken, so far, have made the problem far, far, worse. All the thinking and resources have been directed to the NHS. Meanwhile, the residents and the staff of nursing homes have been, effectively, thrown in front of a bus. [Ed. note: Death by government-no gun needed]. The focus, the entire focus, has been to clear patients out of hospitals, waiting for the deluge of patients. This has been so effective that, in my area of Cheshire, the local hospitals have never been so empty. There are wards with no patients in them. The shiny new Nightingale hospital in London, with four thousand beds, apparently had, so I am informed, just nineteen patients in it last weekend. Yet still the pressure still comes down: get patients out of hospital and back into care homes.”
4/17/20, “Care homes and COVID19,“ Dr. Malcolm Kendrick. Scottish Doctor, author
“The government’s disregard of care home residents – old, sick people, acutely vulnerable to COVID19 – has been scandalous.
As a GP, I regularly visit care homes. At one I visit, they recently had eight residents who died in a week, probably from coronavirus. But there’s no testing, so who could possibly know…
When COVID struck, many things were not known, and could not possibly have been predicted. The transmission rate, the case fatality rate, the best way to treat those infected.
However, it was very clear, very early on, that COVID was killing the elderly in far greater numbers than anyone else. In Italy, the early figures released revealed that the average age of death was seventy-nine. The figures were slightly higher in Germany, and around eighty years old in pretty much every other country.
Equally, it was known that amongst the elderly who were dying, almost all of them had other serious medical conditions. Heart disease, high blood pressure, diabetes, chronic pulmonary disease and suchlike. This is often known in my line of work as “multimorbidity.”
In a world of uncertainty, one thing stood out. Which is that the unwell elderly were the ones who were most likely to die. Equally, they were the ones most likely to end up in hospital, potentially overwhelming the health services. As happened in Italy and Spain.
Ergo, you would think that someone, somewhere in the UK government, would have asked the obvious question. Where do we have the greatest concentrations of elderly, frail, people with multimorbidity? Could it possibly be that they are being looked after in care homes around the country?
Nursing homes, residential homes, care homes. They are all pretty much the same thing nowadays. Nursing homes tend to look after those with greater health needs, and they must have registered nurses looking after patients, but the distinctions have become blurred.
Many care homes are also specialised in looking after the elderly with dementia. In the UK, they are called EMI units [elderly mentally infirm]. These represent a particular problem in that residents tend to wander about from room to room.
So, in care homes we potentially had the perfect storm for the pandemic. They are full of elderly and infirm and highly vulnerable people. Environments where it is often impossible to isolate residents, and staff who have never been adequately trained in isolation measures. Equally, whilst relatives cannot visit hospitals, care homes [in the UK] have been continuing to allow them in. It is not as if the warning signs were not there, flashing red. [Ed. note: In the US, I’m absolutely prohibited from visiting my 95 year old mother in a long term care facility in New Jersey. The facility employs caregivers who leave the building after their shift, go home or to the grocery store where other people may be present, and return to my mother the next day. “Care” facilities in the US have limited test supplies if they have any at all. This is a private facility considered top of the line but obviously now very short of staff. No staff have died, they’re just not allowed in the building if they have symptoms or test positive. The management keeps us informed which is nice, but we’re not allowed to see our mother who requires 24 hour attention due to dementia issues. She’s still able to enjoy conversation with people, but now she can’t even do that because they keep all the seniors isolated in their rooms].
What was the government’s strategy for dealing with nursing homes? It has been, up until the last couple of days, to make things even worse. The instructions from the Dept of Health have been to send patients diagnosed with COVID out of hospital, and back into care homes, with instructions to “barrier nurse” them, a term for a set of stringent infection control techniques. Care homes were informed that they could not refuse to take the residents back.
All of which means that the staff end up attempting to barrier nurse COVID positive patients with flimsy surgical masks, no eye protection, no gowns and gloves that, in my case, disintegrate rapidly and are almost completely useless. Until very recently, nursing home staff, in many homes, were told not to wear masks, and this was true even when there were COVID positive patients in the home.
The focus, the entire focus, has been to clear patients out of hospitals, waiting for the deluge of patients. This has been so effective that, in my area of Cheshire, the local hospitals have never been so empty.
There are wards with no patients in them. The shiny new Nightingale hospital in London, with four thousand beds, apparently had, so I am informed, just nineteen patients in it last weekend. Yet still the pressure still comes down: get patients out of hospital and back into care homes.
At the same time, all the effective personal protective equipment (PPE) has been directed to hospitals and hospital wards. Care homes have been almost unable to access anything. I scavenge what I can before I visit. I keep being told that things have improved. By those who haven’t seen a patient – or the inside of a care home – for years.
I have also watched patients go down very rapidly and die. COVID is a strange disease that kills people in a way that I have never witnessed before. In some cases, very quickly. I have tried to suggest that hospitals are the best place to look after potentially infectious people, not care homes. No-one has been interested.
Now, of course, the disaster is unfolding. The entirely predictable disaster. Here, from The Guardian:
“Care home leaders have accused the government of vastly underestimating the deaths of elderly people from coronavirus, as they warned the disease may be circulating in more than 50% of nursing homes and mortality is significantly higher than official figures. [Per AP, nearly 40% of US virus deaths occur at nursing homes]
Operators of several large care providers accused the government of not paying enough attention to the tragedy unfolding in residential settings across England, as figures from three of the largest chains show 620 deaths from COVID-19 in recent weeks.”
As I mentioned earlier, in one care home that I visit, they recently had eight deaths in seven days. Were these COVID deaths? Who knows for sure. No-one was tested. No-one is tested. The staff are not tested. I have patients who have died quickly. What do I put on the death certificate? COVID? Well I cannot, not really, because I have no idea if they had COVID or not.
It seems clear that many, many, COVID deaths in care homes will not even be registered as COVID deaths, so the figures are almost certainly worse here than are being reported.
I think we all recognise that the COVID pandemic has hit the country with great force, and that the Government has had to react at great speed. You can agree or disagree with some of the actions.
However, one thing that stands out is that complete and utter abject failure to grasp the impact of COVID on care homes.
The actions taken, so far, have made the problem far, far, worse. All the thinking and resources have been directed to the NHS. Meanwhile, the residents and the staff of nursing homes have been, effectively, thrown in front of a bus. [Ed. note: ie, murdered]. On Thursdays, while others have been clapping the NHS, I have been clapping for the unsung heroes of this epidemic. The care home staff.”
Added: “The actions taken, so far, have made the problem far, far, worse. All the thinking and resources have been directed to the NHS. Meanwhile, the residents and the staff of nursing homes have been, effectively, thrown in front of a bus. [Ed. note: Death by government-no gun needed]. The focus, the entire focus, has been to clear patients out of hospitals, waiting for the deluge of patients. This has been so effective that, in my area of Cheshire, the local hospitals have never been so empty. There are wards with no patients in them. The shiny new Nightingale hospital in London, with four thousand beds, apparently had, so I am informed, just nineteen patients in it last weekend. Yet still the pressure still comes down: get patients out of hospital and back into care homes.”
4/17/20, “Care homes and COVID19,“ Dr. Malcolm Kendrick. Scottish Doctor, author
“The government’s disregard of care home residents – old, sick people, acutely vulnerable to COVID19 – has been scandalous.
As a GP, I regularly visit care homes. At one I visit, they recently had eight residents who died in a week, probably from coronavirus. But there’s no testing, so who could possibly know…
When COVID struck, many things were not known, and could not possibly have been predicted. The transmission rate, the case fatality rate, the best way to treat those infected.
However, it was very clear, very early on, that COVID was killing the elderly in far greater numbers than anyone else. In Italy, the early figures released revealed that the average age of death was seventy-nine. The figures were slightly higher in Germany, and around eighty years old in pretty much every other country.
Equally, it was known that amongst the elderly who were dying, almost all of them had other serious medical conditions. Heart disease, high blood pressure, diabetes, chronic pulmonary disease and suchlike. This is often known in my line of work as “multimorbidity.”
In a world of uncertainty, one thing stood out. Which is that the unwell elderly were the ones who were most likely to die. Equally, they were the ones most likely to end up in hospital, potentially overwhelming the health services. As happened in Italy and Spain.
Ergo, you would think that someone, somewhere in the UK government, would have asked the obvious question. Where do we have the greatest concentrations of elderly, frail, people with multimorbidity? Could it possibly be that they are being looked after in care homes around the country?
Nursing homes, residential homes, care homes. They are all pretty much the same thing nowadays. Nursing homes tend to look after those with greater health needs, and they must have registered nurses looking after patients, but the distinctions have become blurred.
Many care homes are also specialised in looking after the elderly with dementia. In the UK, they are called EMI units [elderly mentally infirm]. These represent a particular problem in that residents tend to wander about from room to room.
So, in care homes we potentially had the perfect storm for the pandemic. They are full of elderly and infirm and highly vulnerable people. Environments where it is often impossible to isolate residents, and staff who have never been adequately trained in isolation measures. Equally, whilst relatives cannot visit hospitals, care homes [in the UK] have been continuing to allow them in. It is not as if the warning signs were not there, flashing red. [Ed. note: In the US, I’m absolutely prohibited from visiting my 95 year old mother in a long term care facility in New Jersey. The facility employs caregivers who leave the building after their shift, go home or to the grocery store where other people may be present, and return to my mother the next day. “Care” facilities in the US have limited test supplies if they have any at all. This is a private facility considered top of the line but obviously now very short of staff. No staff have died, they’re just not allowed in the building if they have symptoms or test positive. The management keeps us informed which is nice, but we’re not allowed to see our mother who requires 24 hour attention due to dementia issues. She’s still able to enjoy conversation with people, but now she can’t even do that because they keep all the seniors isolated in their rooms].
What was the government’s strategy for dealing with nursing homes? It has been, up until the last couple of days, to make things even worse. The instructions from the Dept of Health have been to send patients diagnosed with COVID out of hospital, and back into care homes, with instructions to “barrier nurse” them, a term for a set of stringent infection control techniques. Care homes were informed that they could not refuse to take the residents back.
All of which means that the staff end up attempting to barrier nurse COVID positive patients with flimsy surgical masks, no eye protection, no gowns and gloves that, in my case, disintegrate rapidly and are almost completely useless. Until very recently, nursing home staff, in many homes, were told not to wear masks, and this was true even when there were COVID positive patients in the home.
The focus, the entire focus, has been to clear patients out of hospitals, waiting for the deluge of patients. This has been so effective that, in my area of Cheshire, the local hospitals have never been so empty.
There are wards with no patients in them. The shiny new Nightingale hospital in London, with four thousand beds, apparently had, so I am informed, just nineteen patients in it last weekend. Yet still the pressure still comes down: get patients out of hospital and back into care homes.
At the same time, all the effective personal protective equipment (PPE) has been directed to hospitals and hospital wards. Care homes have been almost unable to access anything. I scavenge what I can before I visit. I keep being told that things have improved. By those who haven’t seen a patient – or the inside of a care home – for years.
I have also watched patients go down very rapidly and die. COVID is a strange disease that kills people in a way that I have never witnessed before. In some cases, very quickly. I have tried to suggest that hospitals are the best place to look after potentially infectious people, not care homes. No-one has been interested.
Now, of course, the disaster is unfolding. The entirely predictable disaster. Here, from The Guardian:
“Care home leaders have accused the government of vastly underestimating the deaths of elderly people from coronavirus, as they warned the disease may be circulating in more than 50% of nursing homes and mortality is significantly higher than official figures. [Per AP, nearly 40% of US virus deaths occur at nursing homes]
Operators of several large care providers accused the government of not paying enough attention to the tragedy unfolding in residential settings across England, as figures from three of the largest chains show 620 deaths from COVID-19 in recent weeks.”
As I mentioned earlier, in one care home that I visit, they recently had eight deaths in seven days. Were these COVID deaths? Who knows for sure. No-one was tested. No-one is tested. The staff are not tested. I have patients who have died quickly. What do I put on the death certificate? COVID? Well I cannot, not really, because I have no idea if they had COVID or not.
It seems clear that many, many, COVID deaths in care homes will not even be registered as COVID deaths, so the figures are almost certainly worse here than are being reported.
I think we all recognise that the COVID pandemic has hit the country with great force, and that the Government has had to react at great speed. You can agree or disagree with some of the actions.
However, one thing that stands out is that complete and utter abject failure to grasp the impact of COVID on care homes.
The actions taken, so far, have made the problem far, far, worse. All the thinking and resources have been directed to the NHS. Meanwhile, the residents and the staff of nursing homes have been, effectively, thrown in front of a bus. [Ed. note: ie, murdered]. On Thursdays, while others have been clapping the NHS, I have been clapping for the unsung heroes of this epidemic. The care home staff.”
………………………………………..
Added: Nearly 40% of US virus deaths occur at nursing homes, per AP. New York State by far leads the nation in nursing home deaths:
4/17/20, “‘Heartbreaking’ report shows virus ravaging NY nursing homes,” AP
“New York, by far the nation’s leader in coronavirus nursing home deaths, released details Friday on outbreaks in individual facilities after weeks of refusing, revealing one home in Brooklyn where 55 people died and four others with at least 40 deaths….
The state’s accounting of multiple deaths at 68 nursing homes was based on a survey and is substantially incomplete. It accounted for less than half of the 2,690 nursing home deaths that have been reported in the state. It also didn’t include people who got sick in nursing homes, but then died at hospitals.
But it was the first time the state provided any information about homes that, according to an Associated Press tally, account for nearly 40% of the nation’s 6,912 deaths in such facilities.
At the top of the list with 55 deaths was Cobble Hill Health Center, a 300-bed facility in a 19th-century former hospital in a tony section of Brooklyn.
Four ambulances arrived within an hour at the facility Friday, underscoring the ongoing crisis. Police showed up to assist with the removal of bodies, including one that was wheeled out the front door.
The Cobble Hill home said in a statement that the deaths it reported were “based on the possibility of COVID-19 being a factor,” adding testing in nursing homes remains “extremely difficult to obtain.”
“Although we’ve had an increase in deaths during the past few weeks, we have not been able to confirm that the deaths are specifically related to COVID-19,” the statement said.
A total of 19 homes in New York’s report listed 20 deaths or more.
The survey’s release came a day after New York Gov. Andrew Cuomo’s administration reversed course and promised transparency about the worst outbreaks, after previously saying residents at the hardest-hit homes deserved privacy. Few states have released such information.
Cuomo did not respond directly when asked at his daily coronavirus briefing why his administration had not alerted the public about the outbreaks sooner.
“We’ve been talking about nursing homes every day for the past 30 days,” Cuomo said….
The state’s list omitted homes with fewer than five deaths.
Connecticut released a similar list Thursday, reporting that eight nursing homes had at least 10 residents die. In Connecticut, nursing home residents account for 375 of the state’s 971 virus deaths [about 39%].
Officials at several of the nursing homes on the list said they were doing their best, and attributed the high number of deaths to the fragility of their patients and difficulty in keeping the virus out, rather than substandard care….
Scacco said the facility, whose residents include war veterans and Holocaust survivors was ravaged despite having infection control practices that exceed CDC and health department regulations and guidelines….
Stephen Hanse, president and CEO of the New York State Health Facilities Association and the New York State Center for Assisted Living, said the figures reflect the fact that those facilities are dealing with extremely vulnerable patients.
“Outbreaks are not the result of inattentiveness or a shortcoming in our facilities,” he wrote in a statement. “The very nature of long-term care is a high touch environment where social distancing is not an option. Staff are helping residents with bathing, dressing, eating and other personal daily needs.”
He also blamed the [New York] state health department for worsening the situation by barring nursing homes from denying admission to patients with COVID-19 if they were medically stable.
Nursing homes have been known since the earliest days of the outbreak as a likely trouble spot….
Yet even with that early warning, many nursing homes remained without adequate supplies of personal protective equipment. Testing for residents and staff remains spotty, at best.
Federal officials in mid-March banned visitors, halted group activities and ordered mandatory screening of workers for respiratory symptoms, but by then the virus had quietly spread widely….
Many nursing home administrators also previously declined to release information, leading Cuomo to say this week that the state would begin requiring homes to inform patients and their families within 24 hours if a resident got the virus or died.
Chris Laxton, executive director of the The Society for Post-Acute and Long-Term Care Medicine, applauded the state for releasing the data. But he said facilities still desperately need the state’s help.
“We continue to be in urgent need of PPE, especially gowns, test kits, and surge staff, to limit staff from traveling between buildings and risking additional spread,’ Laxton said.
Some nursing homes have disclosed information voluntarily that differed from the numbers put out by the state Friday.
The state survey listed 10 deaths at the Montgomery Nursing and Rehabilitation Center, about 50 miles north of New York City, but facility Vice President Vincent Maniscalco said 21 residents have died recently. Eight of those patients, he said, had symptoms consistent with the virus but died prior to being tested….
An Associated Press report found infections were continuing to find their way into nursing homes because screening staff for a fever or questioning them about symptoms didn’t catch people who were infected but asymptomatic.”
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Added: Nearly 40% of US virus deaths occur at nursing homes, per AP. New York State by far leads the nation in nursing home deaths:
4/17/20, “‘Heartbreaking’ report shows virus ravaging NY nursing homes,” AP
“New York, by far the nation’s leader in coronavirus nursing home deaths, released details Friday on outbreaks in individual facilities after weeks of refusing, revealing one home in Brooklyn where 55 people died and four others with at least 40 deaths….
The state’s accounting of multiple deaths at 68 nursing homes was based on a survey and is substantially incomplete. It accounted for less than half of the 2,690 nursing home deaths that have been reported in the state. It also didn’t include people who got sick in nursing homes, but then died at hospitals.
But it was the first time the state provided any information about homes that, according to an Associated Press tally, account for nearly 40% of the nation’s 6,912 deaths in such facilities.
At the top of the list with 55 deaths was Cobble Hill Health Center, a 300-bed facility in a 19th-century former hospital in a tony section of Brooklyn.
Four ambulances arrived within an hour at the facility Friday, underscoring the ongoing crisis. Police showed up to assist with the removal of bodies, including one that was wheeled out the front door.
The Cobble Hill home said in a statement that the deaths it reported were “based on the possibility of COVID-19 being a factor,” adding testing in nursing homes remains “extremely difficult to obtain.”
“Although we’ve had an increase in deaths during the past few weeks, we have not been able to confirm that the deaths are specifically related to COVID-19,” the statement said.
A total of 19 homes in New York’s report listed 20 deaths or more.
The survey’s release came a day after New York Gov. Andrew Cuomo’s administration reversed course and promised transparency about the worst outbreaks, after previously saying residents at the hardest-hit homes deserved privacy. Few states have released such information.
Cuomo did not respond directly when asked at his daily coronavirus briefing why his administration had not alerted the public about the outbreaks sooner.
“We’ve been talking about nursing homes every day for the past 30 days,” Cuomo said….
The state’s list omitted homes with fewer than five deaths.
Connecticut released a similar list Thursday, reporting that eight nursing homes had at least 10 residents die. In Connecticut, nursing home residents account for 375 of the state’s 971 virus deaths [about 39%].
Officials at several of the nursing homes on the list said they were doing their best, and attributed the high number of deaths to the fragility of their patients and difficulty in keeping the virus out, rather than substandard care….
Scacco said the facility, whose residents include war veterans and Holocaust survivors was ravaged despite having infection control practices that exceed CDC and health department regulations and guidelines….
Stephen Hanse, president and CEO of the New York State Health Facilities Association and the New York State Center for Assisted Living, said the figures reflect the fact that those facilities are dealing with extremely vulnerable patients.
“Outbreaks are not the result of inattentiveness or a shortcoming in our facilities,” he wrote in a statement. “The very nature of long-term care is a high touch environment where social distancing is not an option. Staff are helping residents with bathing, dressing, eating and other personal daily needs.”
He also blamed the [New York] state health department for worsening the situation by barring nursing homes from denying admission to patients with COVID-19 if they were medically stable.
Nursing homes have been known since the earliest days of the outbreak as a likely trouble spot….
Yet even with that early warning, many nursing homes remained without adequate supplies of personal protective equipment. Testing for residents and staff remains spotty, at best.
Federal officials in mid-March banned visitors, halted group activities and ordered mandatory screening of workers for respiratory symptoms, but by then the virus had quietly spread widely….
Many nursing home administrators also previously declined to release information, leading Cuomo to say this week that the state would begin requiring homes to inform patients and their families within 24 hours if a resident got the virus or died.
Chris Laxton, executive director of the The Society for Post-Acute and Long-Term Care Medicine, applauded the state for releasing the data. But he said facilities still desperately need the state’s help.
“We continue to be in urgent need of PPE, especially gowns, test kits, and surge staff, to limit staff from traveling between buildings and risking additional spread,’ Laxton said.
Some nursing homes have disclosed information voluntarily that differed from the numbers put out by the state Friday.
The state survey listed 10 deaths at the Montgomery Nursing and Rehabilitation Center, about 50 miles north of New York City, but facility Vice President Vincent Maniscalco said 21 residents have died recently. Eight of those patients, he said, had symptoms consistent with the virus but died prior to being tested….
An Associated Press report found infections were continuing to find their way into nursing homes because screening staff for a fever or questioning them about symptoms didn’t catch people who were infected but asymptomatic.”
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