2. Measures to prevent and prepare for infection in residents
COVID-19 should be suspected in residents with influenza-like illness such as a fever of at least 37.8°C and at least one of: new persistent cough, hoarseness, nasal discharge or congestion, shortness of breath, sore throat, wheezing or sneezing.
To support diagnosis in residents, it is important that care home staff take residents temperature and where necessary are supported to take other vital signs including blood pressure, heart rate, pulse oximetry and respiratory rate. This will enable external healthcare staff to triage and prioritise support of residents according to need.
While such monitoring will be helpful for diagnosis, it is important to note that for many older people living with frailty, their presentation when unwell may be very different to younger people. They may not have a cough and a temperature but may have a decline in function, falls or increased confusion as a symptom that they are unwell. Staff and family members will often be able to provide information on changes of health, behaviour or mood. The most important thing is simply to be vigilant that someone who is frail may experience health challenges in a different way and being aware of that may provide an opportunity to flag up when someone needs medical or nursing assessment.
2.2. Social distancing and shielding
Long term care facilities be subject to ‘social distancing’ and ‘shielding’ to reduce the risk of infecting residents and their carers.
Social Distancing: This measure reduces social interaction between people in order to reduce the transmission of the virus. It is intended for those situations where people are living in their own homes with or without additional support from friends, family or carers.
Shielding: This is for people (inc. children) who are at very high risk of severe illness from COVID-1 when an extremely vulnerable person is living in their own home, with or without additional support and those in long term care settings. The aim of shielding is to minimise interaction between individuals and others to protect them from coming into contact with the virus, thereby aiming to reduce mortality in this group. Information on which people are in this category and what to do are on the NHS Inform website
Within a long term care setting, this needs to operate at two levels:
- Routing visiting should be suspended – Only essential visitors permitted in line with HPS guidance. Local risk assessment and practical management should be considered, ensuring a pragmatic and proportionate response. Visits from appropriate health and care staff would be classed as essential. For family and friends, visits should be restricted to end of life care situations or people with dementia who are distressed. In such instances there should be a named contact for visiting, and ideally visits should involve one person at a time; no children should be permitted. These visitors must not visit any other care areas or facilities. Where a resident has COVID-19, it will be appropriate for visitors to wear PPE in order to be able to spend time with them. Visitors should also be asked about symptoms on arrival; symptomatic people should stay away. A log of all visitors should be kept. Consideration should be given to alternative measures of communication including phoning or face-time. Visiting may be suspended if considered appropriate.
- Residents to remain in rooms as far as possible - There is a high risk within a long term care facility that infections are spread between residents through communal areas such as lounges and dining areas. Residents should stay within their rooms as far as possible. Meals should be served in residents rooms where possible and communal sitting areas avoided. It may be practical to stagger meal times to allow staff to manage this and to allow adequate time for cleaning. If a communal area does have to be used on occasions, then it is advised that the distance between residents should be approximately two metres where possible. Where a home has people with infections, communal activities should be avoided.
2.3 Handwashing between contacts should be maximised and the regular use of liquid soap and paper towels (see hand washing advice in appendix 2 of HPS guidance).
2.4 Appropriate Personal protective equipment (PPE) should be used for positive cases and long term facilities should ensure that they have access to adequate stock and that they know where to access additional supplies if needed. Advice on what to wear and how to don the PPE is available in Appendix 3 of the HPS guidance and all staff must be made aware of it. This includes the disposal of the equipment. All staff (of any grade) must be made aware of the guidance.
2.5 Anticipatory Care Plans (ACP) should be in place for as many residents as possible (and ideally all residents) in these settings. Clear documentation of ‘What matters to me’ is helpful in the event of changing circumstances. In many cases the staff in the care home settings are able to start these conversations with involvement of families. Healthcare Improvement Scotland are adapting ACP documentation to a 1-2 page summary tailored to dealing with the current situation. Do Not Resuscitate paperwork should be in place where appropriate and discussed appropriately with residents or carers. It may be judicious to ensure that just-in-case medication is prescribed for high risk residents. Similarly verification of death paperwork for appropriate ill residents may help staff to anticipate and manage death and minimise clinician contacts.
2.6. NHS Near Me video consulting (powered by Attend Anywhere) can be used to reduce exposure to coronavirus. It provides care homes with access to GPs, community teams and clinicians to help to reduce the number of visits whilst providing access to support and occasional clinical opinions. Scenarios where video consulting may be beneficial in homes include:
- to protect residents from potential exposure to coronavirus from visiting clinicians in situations where non hands-on care can be given.
- to avoid transporting residents to hospital for outpatient type clinic appointments.
- to maximise clinician capacity by avoiding travel time.
2.7 Cleaning of communal areas - there should be vigilance around cleaning in communal areas, particularly of frequently touched areas such as door handles, light switches and chairs arms where the virus can persist for up to 72 hours.
2.8 Staffing levels need to be considered in relation to higher dependency of residents and care provision in the isolation of their own room coupled with higher staff sickness levels. This will need to be considered in the context of business continuity planning of NHS Board’s and Health and Social Care Partnerships where staff may need to be deployed to support care homes.