Carole Estabrooks is the scientific director of the Translating Research in Elder Care program and a professor in the Faculty of Nursing at the University of Alberta. Colleen M. Flood is University Research Chair & Director of the Centre for Health Law, Policy and Ethics, University of Ottawa. Sharon Straus is a professor with the Department of Medicine at the University of Toronto.
The majority of COVID-19 deaths to date in Canada have been long-term care (LTC) home residents and workers. Most deaths have been in Quebec and Ontario, although there have been several hotspots across the country. To date, Canada has the highest reported national proportion of COVID-19 deaths for LTC residents in the world, with 85 per cent of total COVID-19 deaths; the majority are women. Other comparable countries report percentages ranging from 29 (Australia) to 35 (U.S.) to 54 (England and Wales. Globally, the fatality rate for people with COVID-19 is estimated at 3.4 per cent. In Canada, it’s 7 per cent, but the fatality rate of LTC residents is as high as 29 per cent.
What have we learned from these events and how can we use these learnings to prepare for what seems to be the inevitable second wave of COVID-19, particularly in Ontario and Quebec? Our decision-makers at all levels must learn from the devastation and death of our vulnerable seniors in LTC settings and ensure there is no repeat performance of these damning statistics. Here are seven things that must happen.
First, all (not just some) LTC, retirement homes and other assisted living places must each have an approved plan for responding to infectious outbreaks, including COVID-19. The plan must specify who is responsible for preventing and managing an outbreak and that person must be on site, with clear and measurable performance metrics. Residents and their families must be consulted in the development of the plan and there must be transparent reporting to the public.
Second, in-person inspection of all homes must occur regularly by the relevant public health unit (and not by an accreditation body) to ensure that plans are being operationalized and that residents and workers are safe. It should go without saying that such inspections cannot be by telephone and that LTC facilities should not be warned ahead of the inspection, which is the practice in some provinces. Results of inspections must be made public and there must be consequences for non-compliance.
Third, provincial governments must manage procurement so that LTC settings are equipped for infection control. All workers or others who come into close contact with residents in LTC settings must be equipped with adequate personal protective equipment (PPE). These same people must have proper education in infection prevention and regular ongoing support and re-education in infection control and proper PPE use and conservation. Also, all LTC homes must adopt and have resources for a “test and trace” strategy for all residents and all workers.
Fourth, LTC workers must have full time work with equitable pay and benefits, including mental health supports for the PTSD many are experiencing due to COVID-19. Many personal support workers work for minimum wage, which is unacceptable normally, given the importance of this work and the expertise required. It’s ridiculous in the face of COVID-19, given the personal risks for workers and their families. Similarly, workers providing essential food, cleaning and laundry services must receive equitable pay. When the military was deployed into LTC homes, in Quebec and Ontario they were paid “danger” pay on top of their relatively robust salaries.
Fifth, jurisdictions must continue the "one site work policy" both for the duration of the pandemic and going forward. Working in two or more settings contributed to COVID-19 spread both in and out of facilities and contributes to the spread of influenza at other times.
Sixth, all LTC homes must either have the capability of properly isolating an individual with COVID-19 or clustering positive residents in one area of the LTC home. If this is not feasible, the patient must be transferred to a hospital or other appropriate setting where isolation of positive cases is possible. No hospital should discharge any suspected or confirmed case of COVID-19 back to an LTC setting until the person’s infection has resolved as evidenced by a negative test or clearance by infection control. Plans for managing COVID-19 must also include access to palliative care if needed, including appropriate medications and pain control.
Seventh, response plans for LTC homes must include measures so that technology and other means are fully employed to connect residents with family and friends and that at least one or two family members can safely visit (with PPE and proper infection control practices and training). Residents are closer to the end of their lives; many have dementia. Familiar voices, support and comfort are essential, and sometimes only a family member or friend can provide that. We cannot permit people to die without care at their end of their lives, whether from COVID-19 or otherwise. Family and friends have in the past helped ensure accountability particularly when a resident is too frail to vocalize concerns or make herself heard and with the significant stresses upon workers and management through COVID-19, this line of accountability is critical.
These are seven non-negotiable things that must happen. Provincial governments must continue to use emergency powers to overcome any barriers to achieving these ends and the federal government must help with funding. Canada’s story of COVID-19 is one littered with the bodies of our most frail and vulnerable, and too many left to die without dignity or care. Ideally, provinces and the federal government would rapidly work together in the next few weeks to agree on national standards for LTC across the country, with the seven elements above. However, if provinces fail to prepare properly, then the federal government must intervene. We cannot sacrifice our elderly on the altar of federalism. The federal government must be ready to use its emergency powers to ensure all of Canada’s LTC settings are ready for the second wave of COVID-19.
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