# Nursing home questions



## elacsaplau (21 Apr 2020)

I have a few questions regarding nursing homes, as follows:

1. Can someone advise what the key challenges currently facing nursing homes are?

2. At what time should family members remove residents from NHs because the risks of catching Covid-19 are too high relative to the risks of cocooning at home?

3. Has any guidance been issued on this?

4. Should nursing homes be obliged to provide data so the families can appropriately assess the risks?


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## Leo (21 Apr 2020)

1. The significant challenge is the concentration of very vulnerable people in a confined setting coupled with the volume of people coming and going including staff, deliveries, etc., therefore a higher risk of someone introducing the virus to the environment. Some seem to be suffering more than others. 

2. It is impossible for anyone here to suggest when a person should be removed from a home, assuming that family member is there for good reason. Every case would need to be assessed on an individual basis in terms of medical needs and risks of removing them from an environment designed to cope with their needs. We've temporarily lifted the medical discussion restriction to allow COVID-19 topics, but I don't think we can allow remote assessment of the risks of removing someone from full time professional care. 

3. I haven't seen any, and I wouldn't expect to see any. I don't believe many health care professionals would suggest many permanent residents would be better off out of that environment. 

It's a very natural response to want to have loved ones close at times like these, but there's a significant risk of well-intentioned families making the wrong decision. 

I'd suggest anyone with concerns should engage directly with the home in question along with the family member's GP. If considering removing a family member form a home, they should very carefully consider the level of care that will be required and assess whether they really have the time and facilities available to provide that level of care for a prolonged period. Do they have the capacity to allow ~14 days isolation from others in the household, and provide round the clock care now and when restrictions start to be relaxed?


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## elacsaplau (21 Apr 2020)

Thanks Leo.

I'm just trying to grapple with the question.

The IT headline today was that 60% of Covid cases have occurred in NHs. These places are now very, very high risk.

There's loads of reasons why someone is in a NH. Some people are there because the family can not look after the person in the long-term but could reasonably look after the person in the short-term.

My absolute belief is that there must be some people for whom the overall risks of cocooning at "home" for a period are less than the risks of remaining in the NH.

Debating this hypothesis is the essence of my question. As ever, you may well be right!


Just on a point of detail, what exactly do you mean here?



Leo said:


> Do they have the capacity to allow ~14 days isolation from others in the household....



In relation to......


Leo said:


> …...provide round the clock care now and when restrictions start to be relaxed?



…..let's take it as being for a finite period.

*****************************************

Perhaps, maybe best to look at the issue in a different way!

1. Is there a group of NH residents for whom cocooning at home would represent a reduced risk overall to the life and well-being of the person?
2. For this group, is it possible and practical to do this?

*****************************************

Let me elaborate with some back of the envelope stuff:

Assumptions:
1. Total over 70 population is 426,000
2. There are 30,000 people in NHs all over 70
3. 700 have died from Covid - say 350 were in a NH
4. Everyone else who died from Covid is over 70

[None of these assumptions will not be precise - on balance, at a combined level, they are meant to understate the NH risk vs. over 70s outside NHs]

Incidence of death o/s NH = 350/(426,000 - 30,000) = 0.088%
versus
Incidence of death in NH = 350/30,000                     = 1.167%

Otherwise put for every 10,000 people over 70,

In the non-NH environment, c. 9 will die
versus
In the NH environment, c. 117 will die


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## RedOnion (21 Apr 2020)

elacsaplau said:


> The IT headline today was that 60% of Covid cases have occurred in NHs. These places are now very, very high risk.


60% of Covid related deaths. Not 60% of all cases.

There are about 550 nursing homes in Ireland. About 190 of them are included in the 'clusters' reported. Only when the current testing is completed will the real picture be known.

I'm conscious that behind all the statistics published, there are real lives and people affected, so this can be a difficult topic to have a reasoned discussion on.


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## Leo (21 Apr 2020)

elacsaplau said:


> The IT headline today was that 60% of Covid cases have occurred in NHs. These places are now very, very high risk.



60% of deaths rather than cases. Is it the home or the residents underlying heath that is the greatest factor? I don't know, but I understand it must be a very worrying time for anyone with a family member is such a setting. 



elacsaplau said:


> There's loads of reasons why someone is in a NH. Some people are there because the family can not look after the person in the long-term but could reasonably look after the person in the short-term.



What do you consider the short term though? It's clear that this virus will continue to pose a very serious risk to the vulnerable elderly for a considerable time. Some experts seem to believe cocooning will be required until an effective vaccine is available, most put that availability at some time next year with further lead time to scale up production of billions of doses.

How likely is it that a family unable to attend to the needs of a loved one are going to be able to sustain the appropriate level of care over a period of months? What happens if we get to a time when the family is not longer capable, but no residential places are available? 



elacsaplau said:


> My absolute belief is that there must be some people for whom the overall risks of cocooning at "home" for a period are less than the risks of remaining in the NH.



I believe you are right here, but I also believe only someone with a full knowledge and understanding of the medical history, current and future needs and prognosis of each case would be in a position to make such a call on overall risk.



elacsaplau said:


> Just on a point of detail, what exactly do you mean here?



If you take a family member out of a care home, it would be prudent isolate them as much as possible for a period in case they bring the virus into your home.


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## elacsaplau (21 Apr 2020)

Apologies Red Onion and Leo for mixing up cases with deaths.

Point taken Red Onion about the sensitivities in all this. As yee were posting, I was editing my previous post with some numbers. Got to do some work now - but I'll repost these figures again because these guesstimates may have been missed earlier.

I appreciate the other points being made - it's a tricky one. In the words of John Prine…...is it better to talk about it or not talk about it?!

***************************

Let me elaborate with some back of the envelope stuff:

Assumptions:
1. Total over 70 population is 426,000
2. There are 30,000 people in NHs all over 70
3. 700 have died from Covid - say 350 were in a NH
4. Everyone else who died from Covid is over 70

[None of these assumptions will be precise - on balance, at a combined level, they are meant to understate the NH risk vs. over 70s outside NHs]

Incidence of death o/s NH = 350/(426,000 - 30,000) = 0.088%
versus
Incidence of death in NH = 350/30,000                     = 1.167%

Otherwise put for every 10,000 people over 70,

In the non-NH environment, c. 9 will die
versus
In the NH environment, c. 117 will die


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## EmmDee (21 Apr 2020)

elacsaplau said:


> Apologies Red Onion and Leo for mixing up cases with deaths.
> 
> Point taken Red Onion about the sensitivities in all this. As yee were posting, I was editing my previous post with some numbers. Got to do some work now - but I'll repost these figures again because these guesstimates may have been missed earlier.
> 
> ...



Some thoughts;

- For someone looking to discuss a clinical decision, you have a lot of guesswork in there. And understanding data is not an amateur hobby. Be cautious with your back of the envelope calculations

- Even assuming your high level estimates are accurate, that doesn't give you a specific prognosis for a specific case. Each case is best assessed by medical professionals based on the individual factors. Even if there was a 50% risk in a NH, it may still make medical sense to keep someone there. Moving someone from a NH to a house doesn't get rid of risk. It reduces one risk but introduces other risks

- I appreciate you sometimes like to "talk things through" on (almost) a philosophical basis. But a decision on an individual care plan isn't really a philosophical discussion.

If you have a concern - I think you have to have the concrete discussion with the medical and care home professionals


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## elacsaplau (21 Apr 2020)

Concerns noted EmmDee!

On a call - so this may be a bit skewed....

As a general response, in my op, I specifically asked whether any official guidance had been issued?

It is also a bit much to infer that I'm in any way implying that bringing someone home gets rid of risk or that order of magnitude estimates magically give a specific prognosis. That's quality Me Tarzan level inferencing! Everything I have said has been in the spiriting of evaluating the relative risks. Read point 2 of my OP and elsewhere for other specific references - and pretty much everything else for the spirit of my posts!

By the way, the guesstimates were intentionally selected to understate the relative risk - purposely to avoid "back of the envelope have no place whatsoever" vibes!

This is not at all philosophical. I will not make that mistake again!! This is about risk evaluation and minimisation!! People die when mistakes are made in dealing with this virus - look at the UK - remember the early days how it was unpatriotic to question the nonsense being peddled? I really have a strong aversion of attempts to close debate.

Think about it this way. The figures (note: referred to as guesstimates) are simply there to give a very broad order of magnitude. Whatever, the precise level, there will be some nursing homes which are virus free and others where the virus is rampant/where there is difficulty in isolating the residents, etc. - i.e. NHs of especially high risk.

So there must be places where the risk of staying put is much more significant for certain patients than going home. Here's 2 question: how many such cases are there and how many of these cases have the families been advised of the increased risk by medics and discussions had about the relative risks and merits of remaining versus cocooning elsewhere.

My suspicion is that medics don't have the resources to do this proactively and that it's not happening as much as it should because it's falling through the gaps.

Also, this is absolutely nothing to do with me personally.

Even if it had, it can be better to inform yourself/reflect on things sometimes before directly discussing with the relevant professionals. The odd time, interesting stuff does emerge in AAM! And to answer John Prine - yep, it's better to talk about it!!

By the way - you are generally an excellent poster!


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## Duke of Marmalade (21 Apr 2020)

Government study on NH mortality published in 2018 said:
			
		

> Median survival in NH was 2.2 years. Yearly mortality rate throughout the three-year observation period was *31.8%*.


The mortality rate in the general population of over 70s is c. *5%*.


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## elacsaplau (21 Apr 2020)

That's very help, Duke


Duke of Marmalade said:


> The mortality rate in the general population of over 70s is c. *5%*.



It might be even more helpful if you show the mortality rate in the general population of the median age used in this report.

I don't want to get into any more trouble and you know how it goes.....


EmmDee said:


> ……..understanding data is not an amateur hobby. Be cautious with your back of the envelope calculations





úlla 's oráistí, úlla 's oráistí……….


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## Duke of Marmalade (21 Apr 2020)

elacsaplau said:


> That's very help, Duke
> 
> 
> It might be even more helpful if you show the mortality rate in the general population of the median age used in this report.
> ...


Consider your back of an envelope calculation.  If you changed 70 to 20, all other assumptions remain valid but you would conclude that NH Covid mortality is 117 per 10k whilst for the population at large it would be less than 1.
But of course you recognised that this would not be comparing apples with apples.  In chosing 70 as your cut off I presume you were trying to compare like with like i.e. comparing folk who are in general equally vulnerable but only differ as to their residential setting.  That is clearly not the case in general as the 5% vs 31% non Covid mortality testifies.
Indeed the correct cut off point to compare roughly equally vulnerable folk would be 96 for the non NH population.  There were 7,580 in this category at the 2016 census.  For their Covid experience to equal the NH experience it would need only 88 to die from Covid or Covid related illnesses.

Yes, NH provided an additional risk factor to staff and residents alike because of the communal living arrangements and the intense personal care. And it may have been underestimated.  However, I think you will need a bigger envelope to statistically quantify the different causes and effects.


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## elacsaplau (24 Apr 2020)

Do NHs advise families of the numbers of residents who have died or have got the virus and if so, how frequently?


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