Why do long-term care homes have more coronavirus outbreaks than hospitals?

Despite both being health-care facilities that care for the vulnerable and often have patients in close quarters, hospitals have not seen nearly as many COVID-19 outbreaks as long-term care centres.

The stark difference between conditions in Canadian hospitals and the environment in nursing homes illustrates how one arena in health care is prioritized while another is neglected, experts told Global News.

“We spend a lot of money on our acute care hospitals that are beautiful. They’re also well-designed and really well-run and well-managed. And they spend a lot of money on infection control and keeping people safe,” said Colin Furness, an infection control epidemiologist and assistant professor at the University of Toronto.

READ MORE: Military teams raise concerns about conditions at Ontario care homes

“That is one thing we’re not doing, and have not done very well with long-term care homes,” he said.

In Ontario, there have been a total of 84 outbreaks at hospitals while there have been 298 at long-term care homes ⁠— at least three times more. Currently, there are 50 ongoing outbreaks at hospitals in the province and 199 in long-term care as of May 26.

B.C. has seen four outbreaks at hospitals and 18 outbreaks at long-term care centres based on data per public health unit.

Alberta currently has 42 outbreak sites listed, with most in long-term care. No hospitals are listed as outbreak sites.

Global News has also contacted Quebec for hospital outbreak information but has not yet received this data. News reports out of Montreal discuss outbreaks at six hospitals, while in mid-April, public health officials revealed 75 per cent of Quebec nursing homes had had coronavirus outbreaks.

On May 26, Global News published a report after obtaining documents submitted by military personnel deployed to nursing homes in Ontario to provide relief during the pandemic. The documents included reports of horrific abuse towards seniors including residents left in soiled diapers and not attended to while they cried for help for long periods of time.

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Coronavirus outbreak: Nothing is off the table in solving long-term care home crisis, Trudeau says

“I’m so far beyond appalled. This goes beyond anything I imagined, and I imagined some pretty bad things,” said Furness, in response to the release of the military report.

The severity of the abuse outlined in the military report is one more piece in examining how long-term care homes have failed seniors. When comparing these nursing homes with hospitals, there are some other major differences in how the two institutions operate, said Furness.

Patients in long-term care more frail, and have less space

An acute care hospital has patients who were once healthy and have become sick, while long-term care facilities have solely elderly patients who often have co-morbidities and health conditions like dementia that require them to live away from their families, said Furness.

“The underlying health of the two populations, acute care patients and long-term care residents, is completely different,” he said.

READ MORE: Quebec long-term care homes grappling with major challenges: military report

“So it’s the population and the amount of money that is spent on safety, which includes everything from the design of the building to personal protective equipment,” he said.

Some homes also may not have adequate space in communal areas and may place too many residents in a room, creating conditions for coronavirus to spread, said Furness.

As well, long-term care facilities are not included in the Canada Health Act, which is the country’s legislation around publicly-funded health-care insurance. The act has criteria for insured health services and extended health services in order to receive federal money towards those areas of care.

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Military alleges abuse, neglect at five Ontario long-term care homes

He says tough questions need to be asked about the regulatory framework, as well as compliance and enforcement when it comes to these homes, along with questions around funding.

The regulatory framework between what is required to make a hospital safe, and what is required for long-term care, likely differ, he said.

Under-prepared long-term care facilities

Hospitals were adequately prepared for a coronavirus outbreak, which is important as you want to keep those facilities as safe as possible, said Kerry Bowman, a professor of bioethics and global health at the University of Toronto.

Lessons learned from SARS have been applied to hospitals, which have made them less susceptible to a COVID-19 outbreak, he said.

During SARS, hospitals experienced issues like lack of staff, or too many patients for one nurse to manage which could “lead to transmission,” according to a May 2004 study on hospital preparedness in Toronto.  

READ MORE: Ontario to hold independent commission into long-term care home system

But long-term care homes were completely neglected at the outset of this current pandemic, said Bowman.

“Rolling back in the months of February and into March, we really under-prepared long-term care,” he said.

“Personal protective equipment was only available if there were outbreaks, even though numbers were rising. They did not recommend testing of long-term care residents,” he said. Staff rotation between homes wasn’t ordered to stop in Ontario until April, he added.

The fact that long-term care isn’t under the Canada Health Act, really shows what low value is put on nursing homes, added Bowman.

Hospital workers may have more benefits, agency

Work in hospitals is far from easy, but employees tend to be unionized and have the ability to take paid days off, said Bowman.

“They’ve got a lot of buffer. They’ve got pensions, they’ve got a lot of security and a safety net under them,” he said. “If you contrast that with long-term care, they don’t even want full-time staff, because they do not want to deal with the responsibility of full-time staff, like vacation.”

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After the SARS outbreak in 2003, a lot of lessons were learned for long-term care as well, including that rotating staff between long-term care facilities was a problem, he said. But changes to policy weren’t implemented.

Hospitals also have higher staffing levels and higher levels of training for their staff, said Pat Armstrong, a sociology professor at York University who is one of Canada’s lead researchers examining long-term care. She oversaw a decade-long international project about approaches to care in homes.

There are often fewer people confined to a room in hospitals and they have more equipment available, she said. Looking at the military report, a major issue highlighted is the lack of supplies for these homes. For instance, staff are having to ration adult diapers for the residents, she explained.

Another issue is that in the last 30 years, more people in long-term care require specialized equipment like oxygen or catheters due to increased life expectancy. Training and staffing levels haven’t been matched to meet those residents’ needs, said Armstrong.

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Doug Ford reacts to ‘horrific’ military report on five Ontario long-term care homes

There are skilled and caring individuals who work in long-term care and they want more intensive training on how to do their jobs, as opposed to completing an online tutorial, she said.

While a good portion of long-term care workers are unionized, those who are part-time do have less access to benefits and it creates a situation where you may feel the need to get to work even if you are sick, because you can’t get paid time off, she said.

“We’re seeing significantly high turnover rates and it’s one of the things that this military reports talk about,” she said. This is due to factors like the pay, working conditions, how much autonomy you have and access to equipment, she said.

Being told as an employee that changes cannot be implemented and conditions will remain the same is tough, and can drive people out of the profession, said Armstrong.

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Armstrong also points to the absence of long-term care from the Canada Health Act (CHA), where hospital and doctor care are thoroughly funded.

That act was introduced in 1984 when care used to be done in hospitals, but since then, chronic care hospitals and psychiatric hospitals have been closed and these patients are now in long-term care. But those facilities aren’t eligible for funding under the CHA, said Armstrong.

“We don’t have any kind of national plan. We don’t have explicit federal funding that is conditional,” she said.

An option could be to provide funding if there are sufficient staffing levels and regular in-house training, which should be done, she said.

Looking at reports following the SARS outbreak, the focus was on hospitals because that’s where the outbreaks were at that time, she said. Hospitals were also the primary focus in preparing for this pandemic, she said.

‘They were abandoned’

Hospitals can be rapidly overwhelmed and face challenges in preventing a COVID-19 outbreak from happening in the facility, but they have infinitely more resources in terms of quality of care and human resources, said Dr. Zulfiqar Bhutta, a professor of epidemiology and co-director of the Centre for Global Child Health at the Hospital for Sick Children in Toronto.

“If you have one person, one provider looking after six patients, and in many of these long-term care facilities, these patients are totally dependent upon nursing services,” he said.

Avoiding contact or physically handling residents is difficult, and we haven’t explored whether outbreaks first came about in communal spaces in the homes as opposed to individual quarters, he said. That separation is more available and hospital and is considered more carefully, as there is more space and more staff that have been trained on these concerns, he explained.

Understanding what happened in long-term care homes, particularly in Ontario and Quebec where the brunt of COVID-19-related deaths have occurred, will also involve investigating what was done for those patients before they died, he explained.

READ MORE: How Canada’s nursing homes can be fixed to avoid repeat of COVID-19 outbreak

“The response for the health system and services for the needs of long-term care facilities was slow and maybe inadequate. If it wasn’t, we wouldn’t be seeing [multiple] deaths in each long-term care facility,” he said. “Many of these facilities have been emptied.”

Our system for long-term care that is not only inadequate, but also callus, said Bhutta.

“Many of these people had spent their lives principally bringing up the current generation. And they were abandoned at their time of greatest need,” he said.

“I’m not saying they were abandoned deliberately, but the system failed them and it failed them at various levels by both quality of care, quantity of care, and appropriate timeliness of care,” he said. “All of those factors went into these premature deaths.”

Questions about COVID-19? Here are some things you need to know:

Symptoms can include fever, cough and difficulty breathing — very similar to a cold or flu. Some people can develop a more severe illness. People most at risk of this include older adults and people with severe chronic medical conditions like heart, lung or kidney disease. If you develop symptoms, contact public health authorities.

To prevent the virus from spreading, experts recommend frequent handwashing and coughing into your sleeve. They also recommend minimizing contact with others, staying home as much as possible and maintaining a distance of two metres from other people if you go out. In situations where you can’t keep a safe distance from others, public health officials recommend the use of a non-medical face mask or covering to prevent spreading the respiratory droplets that can carry the virus.

For full COVID-19 coverage from Global News, click here.

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