02 July 2020

Hospital patients ‘should go to interim beds before discharge to care homes’

02 July 2020

Hospital patients should not be discharged straight into care homes if a second coronavirus wave hits but should stay in interim beds to avoid infection spread, an expert has said.

Gill Livingston, professor of psychiatry of older people at University College London (UCL), said there must be separate “step-down” beds for elderly patients to help care homes stay free of Covid-19.

Asked if there was one thing she would want to see done differently in a second wave, she said: “I think we cannot discharge people from a hospital to a care home immediately, that we have to have some interim step-down beds, outside of care homes.

“We know that even when they are swabbed that these swabs are by no means perfect, with 70 to 80% sensitivity.

“And so people have to have an interim time before they go to care homes, so that hopefully many of the care homes will remain free of Covid.”

Prof Livingston was speaking in a panel on the impact of coronavirus on elderly people held by the Royal Society of Medicine.

It comes as another panellist said infection control in care homes has been “sub-optimal”, with a lack of guidance on how to safely isolate residents and insufficient testing.

People have to have an interim time before they go to care homes, so that hopefully many of the care homes will remain free of Covid

Adam Gordon, professor of the care of older people at Nottingham University, said there are “a lot of caveats and concerns about whether people can be isolated safely in care homes”, and Scotland and England have formed different opinions.

He said: “It’s very clear early in the pandemic, in fact, as far as early June, we were flying half-blind with regard to the care home sector, and that was no way to manage our highly vulnerable population.”

Care homes were told to group residents with suspected Covid-19 together but were not instructed how to do this, he said – a particular concern regarding patients with dementia.

He continued: “Even now, some three-and-a-half, four months into the pandemic, there is no specific guidance on how to allow people to wander safely through your care home from Government – care homes have had to rely upon guidance from third sector organisations in order to work out how to manage these sorts of residents.

“So there are a lot of ways in which the infection control in care homes was sub-optimal in the pandemic, and I think, really, we could have done a lot better.”

It was also noted that delirium is very common but under-recognised and may be the only presenting sign of Covid-19 in elderly care home residents, a third of which may not display the typical symptoms of the virus.

The most common atypical symptoms of patients with coronavirus are anorexia, which are probably a manifestation of delirium, and confusion, Prof Gordon added.

Prof Livingston said if residents are confined to a room for a period of isolation, they will lose some mobility that they are unlikely to get back, while dementia residents may be distressed and their conditions may worsen because they do not understand what is happening.

She said she has heard, through her clinical work, of people asking about giving residents antipsychotics to stop them moving around, which is dangerous for people with dementia.

Similarly, she said it is “totally inadvisable” to give benzodiazepines to residents who are likely to have a respiratory problem.

While infection control and access to personal protective equipment (PPE) is improving, concerns remain about care home staff spending lots of time in very close proximity to residents who may have coronavirus.

Prof Gordon added the only way signs of a second wave in care homes will be spotted is if regular and widespread testing, as opposed to existing pilots, takes place.

He said: “Because up to a third of care home residents are asymptomatic, the only way we will see the next wave coming in care homes is if we’re doing regular surveying and swabbing, and we quite urgently need some guidance and recommendations and resources from Government to support that.”

Access to oxygen and subcutaneous fluids directly provided by care homes has opened up during the crisis, which has meant residents can still receive active treatment without having to go to hospital.

But Prof Gordon warned that mounting costs alongside a drop in income due to lower than usual bed occupancy rates means some care homes will go bust without Government help, leaving vulnerable residents “homeless”.

A Department of Health and Social Care spokeswoman said: “We have been doing everything we can to ensure care home residents and staff are protected during this unprecedented global pandemic. Every stage of our response has been guided by the latest scientific advice.

“We have made £1.3 billion available, via the NHS, to support the hospital discharge process. This funding can help with the costs of providing alternative accommodation to quarantine and isolating residents, where needed, before they return to their care home from hospital.

“In addition, in May we announced a £600m Infection Control Fund to help adult social care providers to reduce the rate of transmission in and between care homes.

“Our Adult Social Care Action Plan also sets out further measures to support care homes in reducing transmission of the virus. This included a commitment to test all patients prior to discharge to a care home.”

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