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COVID-19’s remorseless advance through the Northwood facility in Halifax this spring caused 53 deaths, and exposed gaps in a system which is supposed to protect our most vulnerable citizens. In the wake of those events, the province will spend $26 million over the next year, and $11 million over the following two years, to improve infection control at 133 nursing homes and residential care facilities.
The expenditures are in response to two reports commissioned by the Department of Health to guide its actions in preventing additional deaths during a potential second wave of COVID as well as during annual influenza outbreaks.
The reports’ findings underscored many issues which were already well-known.
Dr. Chris Lata, an infectious disease doctor in Sydney, and Dr. Lynn Stevenson, a former associate deputy health minister in B.C., were hired to review what happened at Northwood in Halifax under the Quality Improvement and Information Protection Act. This means their interviews remain secret and only their recommendations — which are non-binding — become public.
One reason for this is because the provincial government and Northwood Group Inc. have been named in a class action lawsuit launched by a number of families who lost loved ones during the COVID outbreak of April 5–May 26. Although there were outbreaks and a handful of deaths at eight or nine other nursing homes in the province, the scale at Northwood was unprecedented.
“Northwood did do quite a bit of preparation, given what everybody knew prior to March 15,” said Lata. “Unfortunately, the sheer amount of spread and the high percentage of asymptomatic transmission of this virus really impacted Northwood’s ability to respond — given its incredibly high occupancy — in a way that would have quelled this outbreak quickly.”
Northwood is the largest nursing home in Atlantic Canada and bigger than the Cape Breton Regional Hospital. In a briefing with journalists today, Lata noted the “sheer size” of Northwood, with its 485 frail elderly residents housed in mostly shared rooms built over 50 years ago, was a major factor in the spread of the disease. In total, 360 residents and staff tested positive during the outbreak. By contrast, the smaller, newer Northwood campus in Bedford with single rooms and no shared bathrooms did not report a single positive case.
Unsurprisingly, the Northwood Review Panel is recommending the government reduce the number of people housed at Northwood in Halifax but has left the final number up to the Department of Health. The Review says:
Reduce occupancy on a permanent basis to reduce density. Additional empty space should be set aside to cohort infected persons should future outbreaks occur. Develop an Infection Prevention Control Plan that considers shared bathrooms and ventilation.
Asked about this specific recommendation, Health minister Randy Delorey said a final occupancy target for Northwood has not been determined, but the facility is being allowed to keep 90 rooms vacant as a means to improve infection control in the future.
“We have received and look forward to reviewing the recommendations of the government-commissioned review of the COVID-19 outbreak at Northwood,” said Murray Stenton, spokesperson for Northwood Group Inc. in an emailed statement. “We will take the opportunity to review the recommendations before speaking further or in any detail about the report findings. Before the pandemic our occupancy at the Halifax Campus was at 485 residents. Currently, our occupancy is at 375 with 16 residents in double accommodations. We will maintain some shared accommodations for scenarios such as couples who want to live together, or those who prefer to have a roommate.”
Shared Rooms Will Continue
The province is committing to eliminate “triple bunking” (rooms with three or more people) that continues in 30 situations around the province.
A second report that reviewed Infection Prevention and Control (IPAC) procedures and staffing for 8,000 people at 133 long-term care facilities found that just over half the homes (58%) had single rooms. That means 42% of homes with disabled or elderly residents will continue to allow shared rooms and bathrooms until the Department of Health opens new facilities with single rooms.
Doing so would meet standards established back in 2007. Funding and construction of approximately 300 new rooms is underway but will still fall woefully short of ensuring every resident has their own room. Both PC and NDP leaders say they would commit hundreds of millions of dollars towards this goal if their party forms the next government.
The Second Review
Policies and procedures designed to control outbreaks of flu and COVID-19 are handicapped by the design of older group homes and nursing homes. At least that’s the conclusion of a literature review of other outbreaks in Canadian nursing homes undertaken by registered nurses and infectious disease specialists Patsy Rawding and Shelley Jones, who work for the Nova Scotia Health Authority. They note:
A significant amount of research exists on the disproportionate burden of COVID-19 related mortality among LTC (long-term care) residents… Findings highlight that current IPAC protocols and practices are designed for ideal environments and are not representative of the actual environment and infrastructure of many LTC facilities in Canada, consisting of shared resident rooms, large communal spaces, and shared bathrooms, which make it difficult for staff to implement best IPAC practices.
Another major shortcoming noted in the IPAC report is the need for more training and support for the nurse or caregiver who is the designated “infection prevention” person at each long-term care home.
The report surveyed all 133 homes and found 72% of these front-line workers had not received accredited training and were also carrying out other duties and responsibilities.
Of the designated infection control people, 25% did not have access to computers to keep in-the-loop during this dynamic period of crisis.
The IPAC report states many of these front-line staff were frustrated in their dealings with Public Health which they described as “inconsistent” and which tended to send out directives late on Friday afternoons. Compounding the problem, according to the IPAC report, were a number of retirements among infection control staff just as the pandemic hit in April.
In response to these findings, Health Minister Delorey has committed to hiring an infection prevention and control resource person in each of the four health care zones dedicated to help long-term care homes. As recommended by both reports, the province will also establish one mobile infection prevention and control response team in every zone to support facilities facing outbreaks.
Not enough caregivers, still
The first recommendation made by the Northwood Review team of Lata and Stevenson identifies inadequate staffing once staff and residents began testing positive during the April outbreak. It’s known that workers who weren’t showing symptoms of COVID brought the virus into the Northwood facility sometime in mid-to-late March. The first positive cases were reported April 5-7, and by April 10, Northwood had 131 staff off work and self-isolating while they waited several days for test results or were afraid to come to work.
Recommendation 1 says:
Critical staff loss numbers should be a surveillance priority. A set point should be defined at which to contact Department of Health and Wellness for staffing support.
Lata says that number would be different for each facility depending on its size, but that number should be defined before another infectious disease erupts.
In Northwood’s case, the number of residents and staff testing positive for COVID-19 continued to grow, registering 68 cases by April 16. But it wasn’t until the deaths of three residents on April 18 — 12 days after the first case appeared — that the Department of Health and Nova Scotia Health Authority responded by sending in 40 nurses from the Halifax Infirmary, paramedics, VON, and volunteers from other nursing homes. The NSGEU complained its nurses found the facility unsanitary and many residents who needed immediate attention.
The review noted that although Northwood replaced cleaning staff who were off work, not enough cleaners were hired to carry out the “enhanced cleaning” and “removal of used PPE” and garbage during the outbreak.
“Did Northwood and/or the Department of Health that licenses long-term care facilities wait too long to bring in replacement staff?” asked The Halifax Examiner.
“Yes, the directive (from the Department of Health that sent in the Emergency Response team) occurred later than would have been desired, but there were reasons for that, “said Lata. “It wasn’t that people were not paying attention. They were responding to a crisis and their focus was on making sure their residents were safe in a staff loss situation.”
More money for cleaners
Interestingly, the province will use some of the recently announced Safe ReStart federal funding ($19 million) so that all long-term care facilities can hire more cleaners (immediately) and to “fund staff who can be deployed as needed to manage outbreaks.”
“As needed” is the key phrase. What Health Minister Randy Delorey would not promise is to hire more frontline staff, such as continuing care assistants and nurses for long-term care homes. This was another recommendation from the Northwood Review Panel. This recommendation mirrors one made by the Nova Scotia Nurses Union five-and-a-half years ago. The Northwood Review Panel urges the province to “set and fund minimum care hours based on the complexity of residents’ needs.”
Delorey said “work is underway” (through the Centre for Aging at Mount Saint Vincent University) to identify the appropriate mix and ratio of staff to long-term care residents. This phrase sounds quite threadbare, considering the numerous published studies in North America and Europe which offer models for an improved level of care beyond the staffing standards legislated in this province 30 years ago.
PC leader Tim Houston says the lack of funding and the lack of a public inquiry are proof that seniors’ issues are not a priority for this government. “Our plan will ensure dignity for seniors and will address long overdue problems such as staffing and single rooms,” says Houston. “Under a PC government you will see at least 2,500 new single rooms in long-term care and the hiring of 2,000 health professionals.”
NDP leader Gary Burrill commented, “Today’s reviews add to the pile of reports calling on the Liberal government to make the changes needed to staffing and care levels in long-term care facilities. A room in long-term care is a person’s home and we should make sure that people are able to live a safe and healthy life when they are living in the nursing homes of Nova Scotia.”
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