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WHILE THE HEALTH AUTHORITIES PREPARED HOSPITALS AND OTHER SECTORS FOR COVID-19, THE VIRUSES WAS SILENTLY DISPOSED THROUGH NURSING HOMES. HOW WAS IRELAND “CAUGHT”?
Sitting in her room at the St. Mary Hospital Nursing Home in Dublin’s Phoenix Park, Rose Hegarty listened to Taoiseach Leo Varadkar’s speech on March 12 announcing the closure of schools and restrictions on public gatherings. This was the first radical attempt by the Government to stop the coronavirus outbreak since the first case had been confirmed in the State 13 days earlier.
For the past week, Hegarty had been taking his own protective steps. The 84-year-old woman had been avoiding the community dining room at home, eating in her room and regularly using hand sanitizer. She knew that her underlying kidney condition was dangerous if the coronavirus reached her.
In the end, she was unable to stop him. This week, Hegarty became one of 23 nursing home residents who died of Covid-19, the disease caused by the virus that has killed more than 230,000 worldwide.
Irish nursing homes, where 25,000 people live and 30,000 employees work, have become ground zero for the coronavirus pandemic in Ireland. The Phoenix Park Nursing Home is one of the hardest hit.
Rose Hegarty, who died at Covid-19 St Mary’s Hospital on Monday, at the age of 84.
By Thursday, April 30, about 735 people in community residential settings had died, accounting for 60 percent of the 1,232 Covid-19 deaths in the state. Nursing homes accounted for 630 deaths, or half of the people who died in the state since the first coronavirus-related death on March 11, 52 days ago.
The elderly are among the most vulnerable to the deadly virus. One in six nursing home residents who hired Covid-19 have died, figures from the Health Department show. This is more than three times the overall death rate among more than 20,000 people infected with the virus in the state.
The vast majority of deaths from the virus from nursing home residents have occurred in nursing homes. Only 16 percent have died in acute hospitals. Of those infected in nursing homes, 3,679 as of Thursday, only 5 percent were hospitalized. Most infected residents recover from the virus.
We have an entire industry in which we have many committed people due to age and past conditions in one area. Essentially, all it takes is a person and a sneeze or cough for the virus to spread.
On March 25, HSE informed nursing homes that Covid-19 patients should be cared for at their facilities and that transfer to the hospital was “only appropriate when this conferred additional benefit.” The HSE says that transfers to hospitals are based on clinical decisions on a case-by-case basis.
“We have an entire industry in which we have many committed people due to age and past conditions in one area. Basically, all it takes is a person and a sneeze or cough for the virus to spread, ”says UCD researcher Karl Conyard, public health advisor for HCA and Carers Ireland, a support network for caregivers and assistants in health. Conyard worked as a nursing home health care assistant for three years.
The magnitude of the death of nursing homes in just seven weeks has left a sector that has suffered years of funding and staffing challenges struggling to cope.
At St Mary’s, there are 150 nursing homes and a separate 48-bed hospital.
As of this week, just under half of the 149 residents between the nursing home and the hospital have contracted the virus or are suspected of having Covid-19, the HSE said.
MARCH 6 St Mary’s, a public facility, banned all visitors, taking the lead on Nursing Homes Ireland (NHI), the body representing the nation’s private nursing home operators. About 75 percent of the country’s 540 nursing homes are privately owned and operated.
Four days later, the state’s chief medical officer, Dr. Tony Holohan, questioned the closure of nursing homes to visitors and the social impact of such restrictions “before they are really necessary.”
“It wasn’t too early,” says Dr. Jack Lambert, an infectious disease specialist at Mater Hospital in Dublin, who has treated Covid-19-infected nursing home patients in their wards.
“That was an absolutely wrong decision, in hindsight,” he says of Dr. Holohan’s consultation. “We did not close the nursing homes in a timely manner. That was an opportunity.
“This is a fast and highly infectious disease. I see people entering the hospital, and in 12 hours they go from zero to dead right in front of my eyes. It is a really terrifying disease. You can die very quickly if you don’t do the right things, “he says.
Dr. Holohan then explained his comments, saying that introducing restrictions “too soon” or “maintaining them for too long” could weaken “public acceptance and understanding” and “greatly increase the risk that those measures will not be effective. “
The National Public Health Emergency Team (NPHET) has produced a graph showing that the sharpest increase in nursing home cases occurred after the 14-day incubation period after the declaration of the Dr. Holohan.
St Mary’s Nursing Home reversed its decision after Dr. Holohan’s comments and, over a period of seven days, allowed visitors in and out.
As staff appealed for PPE on social media, the virus was already spreading silently through the nursing home
It changed its rules again on March 18 in an internal memorandum for staff saying “a no-visit approach will be reintroduced for all residents.”
At this stage, Covid-19 outbreaks, each defined as two or more cases, were reported in just three nursing homes, official figures show.
St Mary’s staff was beginning to voice concerns about the shortage of personal protective equipment (PPE), with some even asking for donations of PPE on social media. At this stage, the virus was already spreading silently through the nursing home.
In an email dated March 26, staff were instructed on the “prudent” rationing of the EPP. “Unnecessary use of PPE will deplete the stocks that will be needed as the number of people with the virus increases,” the email said.
A HSE spokeswoman said St Mary first requested additional PPE on March 19, with a shipment delivered the next day, and that she currently had a “proper” supply.
Staff were reminded that HSE guidelines did not recommend the use of face masks when treating confirmed or suspected Covid-19 cases “in situations other than close contact.”
At that time, a shortage of PPE was felt in other nursing homes.
Tadhg Daly, executive director of Nursing Homes Ireland, said the organization had been searching for PPE for nursing homes since late February and early March. “Begs, borrows and steals, we were trying to find him where we could,” he recalls.
Paul Reid, executive director of HSE, reported to the organization’s board on February 21 that 11,500 PPE “packages” had been issued to general practitioners, after-hours services, primary care facilities, public health physicians, occupational health and even Defense Forces and university services of general medicine. Nursing homes were not mentioned in their report, seen by The Irish Times.
Given the large number of people in the nursing home sector, it is believed that Simon Harris, the Minister of Health, did not even pick up the phone to call us.
Daly, since late February, had unsuccessfully sought help from the sector in the supply of PPE and personnel, as well as guidance from the Government. Frustrated, on March 25 he publicly complained about the failure of Health Minister Simon Harris to meet with his group and at least five unanswered letters or emails.
“Given the large cohort of people in the nursing home sector, it is believed that they have not even picked up the phone to call us,” Daly said that day.
The nursing home group finally met Harris on Monday, March 30. The following weekend, a state aid package for nursing homes was announced.
The group, which represents more than 400 nursing homes, is not yet represented on the National Public Health Emergency Team or its subgroups.
The Health Department says that the regulator of the nursing home sector, the Health Information and Quality Authority (Hiqa), is “very familiar” with the sector, including “the challenges that may exist”, and is “the appropriate agency “to report the NPHET
The department says it has been in “continuous and extensive communication” with the nursing home body and that the HSE has been “regularly engaging” with it since January.
March 29 – the day before the Minister first met with the group of nursing homes – Rose Hegarty’s family was informed that there had been a confirmed case at St Mary’s.
At this stage, the number of Covid-19 groups in nursing homes, mainly in the east of the country, had increased to 24, an increase of six times in just one week, and the number of deaths had increased to 46.
“They contacted my sister to say there was a case, not in her neighborhood,” says Jane Carrigan, recalling the news of the case at her aunt’s nursing home. “It was the other side of the building; we were hoping against hope that it would not catch up, “she says.
Hegarty was transferred to the St Mary’s Oisín ward of the hospital last July after a severe kidney infection. From Finglas, in the north of Dublin, Hegarty was widowed at 40 and never had children, but he was very close to his nieces and nephews.
“She loved Santa Maria and had given her a new lease on life,” says her niece. A nature lover, Hegarty enjoyed gardening around the house. The window of his downstairs bedroom gave him a regular view of the deer roaming the Phoenix Park.
On April 2, the first resident at St Mary’s died of Covid-19.
Two days later, it emerged that there was a positive case in Rose Hegarty’s room. Relatives recalled their premonitions after hearing the news.
“She had said he would come for her,” says Carrigan. “She could be stoic and always be planning the worst possible outcome.”
The penny was falling that we had so many sick people. Covid was in the building
The day the virus hit Hegarty’s ward, Margo Hannon, a health care assistant at the ward for three years, came out of a secluded area and cried.
“The penny was falling and we had so many sick people. Covid was in the building, “says Hannon.
By mid-April, the situation in St. Mary had deteriorated rapidly. An internal memo dated April 13, seen by The Irish Times, says that a fifth of residents in all but one district were confirmed or suspected of Covid-19 cases.
“It is reasonable to assume that transmission is widespread,” says the memo.
The same could have been said for the country as a whole at this time. By April 13, the number of known cases had reached 10,647 and the number of deaths 365, with groups in more than a quarter of nursing homes.
On Tuesday, April 14, Margo Hannon was on leave at home watching online broadcasts of the funerals of two residents. By that Friday, the number of coronavirus deaths at St. Mary’s had reached 11.
Grief is normal for healthcare workers. This is completely different. No matter how old they are, they are all someone’s family. You feel hurt
“Grief is normal for health workers. This is completely different. No matter how old they are, they are all someone’s family. You feel hurt, ”he told The Irish Times.
In an eight-day period, four of the 25 residents in the room died.
“You build a relationship and a relationship. I felt trauma, I still feel it, ”she says.
STAFF AT NURSING HOME across the country they have felt the strain in other ways.
Households have reported a serious shortage of staff due to nurses and health workers taking sick leave due to Covid-19 or having to self-isolate due to exposure. Long delays in Covid-19 test results for staff and residents, the infectious nature of the disease, and dependence on agency staff in a poorly paid and under-resourced sector that has a long history of hardship in the hiring of personnel they have contributed to the growth in outbreaks
“Many nursing homes rely on agency staff, which means you could have a caregiver in seven different nursing homes working seven days a week, so you can imagine the spread from A to B,” says Karl Conyard , the HCA Public Health Advisor and Caregivers of Ireland.
“For a respiratory virus [that] it has such a long incubation phase that it is very, very difficult to stop the outbreaks. “
By Wednesday, April 29, the HSE had reassigned 217 staff members to nursing homes. Surveys by nursing homes Ireland had reported that houses lost considerably more than this. About 85 HSE nurses had been deployed to nursing homes, only one for every five private nursing homes.
“It is a shameful response to an emerging tragedy,” says Dr. Jack Lambert de la Mater.
Co Tipperary nursing home operator Ann Fitzpatrick, owner of St Theresa’s in Thurles, says that the 72,000 applicants for HSE’s “Be On Call for Ireland” initiative with the intention of attracting staff to the health service “do not it has been for Ireland but for HSE ”and this has affected much-needed recruitment in exhausted nursing homes.
The department says the HSE will work with nursing homes “through the critical stages of the outbreaks,” but that the HSE “must also maintain its own services at safe levels of staff.”
If there was a war tomorrow, you could ask who wants to be in the Army, and the next day you would have people lined up. They would have to go to war the next day. But this is a total failure of a dysfunctional system
Dr. Lambert believes that HSE staff should be redistributed from “superfluous” Covid community centers and that even publicly requisitioned and underutilized private hospitals could be used as “intensified” facilities to remove infected residents from nursing homes to keep them free of COVID-19.
“If there was a war tomorrow, you call and say who wants to be drafted to join the Army. Then the next day you would have people lined up; you would have them going to war the next day. This is a total failure of a dysfunctional system, “he says.
A Dublin nursing home fighting a group says Covid-19 has cut them short of essential cleaning staff, catering staff and other underpaid workers “who are afraid to come to work.”
“We and my colleagues across the country need boots on the ground,” says one manager.
In mid-April, PROF DERMOT POWER, A consulting geriatrician at Mater Hospital was hired to help address the group at St Mary’s.
Lack of rapid tests was driving the outbreak, he says. There were delays of up to a week to obtain results, and residents were transferred to “cohorts” within the 25-bed wards, of confirmed cases, suspected cases, and those without symptoms.
“You are trying to isolate the patients as best you can. People moved around a lot, ”he says.
At the same time, a large number of staff was “beginning to decline,” he says.
Delays in testing meant that staff with a cold were unnecessarily waiting for results, while asymptomatic staff with the virus continued to work. It was the “perfect storm,” says Power.
Despite the number of deaths, the house still lived face to face when it came to PPE. “There was always the perception that there was only enough for today, we were surviving on the ‘just in time’ principle, and by some miracle some would come from somewhere,” says Power.
The staff of other nursing homes talk about feeling isolated and without HSE support, or being lost in the system, and questions how the State values life in nursing homes, given the response to its crisis.
All staff now wore surgical masks and “FFP” heavy-duty masks, or filter masks, when caring for residents.
Nursing home sources criticize the slow reaction of the government and state authorities to come to the aid of nursing homes, many of which have had to buy and buy their own personal protective equipment, often dealing with companies that they only supply HSE.
Staff from other nursing homes talk about feeling “isolated” and without HSE support, “lost in the system” and questioning how the State values life in nursing homes, given the response to its crisis.
Outlining its own response, nursing home regulator Hiqa says it ensures that HSE and the department are “fully aware on a daily basis of all identified risks” and of any required “services”.
Hiqa says that on Thursday, April 30, it “escalated” information on 360 nursing homes where there were infections or suspected Covid-19 cases, highlighting 12 “designated centers” that required “specific intervention and risk mitigation.”
The department says the state is providing “an unprecedented level of support to private nursing homes,” and in the past seven days it had delivered almost 3.6 million items of PPE to community residential facilities.
91 YEAR OLD MOTHER OF TONY MURTAGH, Carmel has been at St. Mary’s for four years with advanced dementia. Since the end of March, the family had been asking about the extent of the outbreak.
On April 20, he read in the media that there were 15 Covid-19 deaths in the home. “This was how family members discovered the scope of what was happening,” he says.
Given her dementia, her mother tends to wander. This week Tony Murtagh was told that he had entered another room, which worried him about infection controls at home.
“I have gone far beyond frustration; I am very disappointed, “he says.
Her mother tested negative for coronavirus last week and will now be moved to a separate room with other negative residents. Looking back, he says the nursing home “should never have reopened” to visitors in March.
Rose Hegarty on Christmas Day with her great-niece Freya Fogarty and her nephew Sean Carrigan
IN THE MORNING OF On Sunday April 19, Rose Hegarty began to develop a cough. In the middle of the afternoon, she was breathing with an oxygen mask. The next day, all St Mary’s residents and staff were evaluated in an effort to map the extent of the housing cluster.
At the same time, Mater’s infectious disease consultants were on-site to establish rapid and continuous testing for the facility.
Professor Power says that this near real-time test was the “key” to dealing with the outbreak. It has enabled St Mary’s to segregate residents into positive and negative Covid-19 rooms this week, and to ensure that staff do not unknowingly carry the virus.
“The rate of returning positive results is falling. I’d like to think we’ve changed it, “he says, but cautions that the possibility of patients becoming infected again is” terrifying. “
On Sunday, April 25, Rose Hegarty tested positive for Covid-19.
That same day, the number of group nursing homes increased to 209, the national death toll reached 1,063, and the number of cases reached 18,561.
“She was so vulnerable with her kidneys that we couldn’t do anything, that was difficult,” says her niece Jane Carrigan. “I’m not sure how conscious he was in the last week of his life, he was sleeping a lot,” she says.
In the days leading up to Rose Hegarty’s death, her family was allowed to see her from outside through the window of her downstairs bedroom, the window from which she had seen the Phoenix Park deer.
Cathy Carrigan, another niece and goddaughter, was allowed to enter the room with all her personal protective equipment to hold her hand for a few minutes.
Rose Hegarty died last Monday, April 27.
The surge that Public health officials feared that the country’s hospitals would hit nursing homes.
Dr. Jack Lambert believes that the pandemic has exposed “two levels of care” in Ireland and that the Covid-19 pandemic has “re-exposed the crisis” in the nursing home sector. He and others say the state was too focused on increasing capacity in state hospitals, following the international experience of the outbreak, particularly in Italy. As a result, some of the people most vulnerable to the disease were lost to nursing homes.
“There was a focus on acute services and little or no focus on residential services until it became clear that this was the main battleground. They were taken by surprise, ”says family doctor Co Clare, Michael Harty.
Harty, a former TD and chair of the Oireachtas health committee, believes responsibility will be sought for how the crisis was handled in nursing homes. “There will be a consultation. I think there will be a lot of questions to answer about how the government responded and did they answer the right question? Did the HSE have the capacity to respond and what were the tensions between the department and the HSE and the government, “he says.
Rose Hegarty’s family believes that the flaws lie at the political level. The frontline staff at St Mary’s in Phoenix Park has been amazing, says her niece Jane Carrigan.
Her aunt tried to protect herself during the pandemic, but there were things she couldn’t control, like PPE for staff and tests. He had taken every precaution to avoid the virus, but to no avail.
“It didn’t make a difference,” says Carrigan.
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