A Perfect Storm
COVID-19 made its international debut in the early weeks of 2020. First impressions can be powerful, and North America’s initial sense of the mysterious new coronavirus came by way of images half a world away. They depicted hospitals utterly overwhelmed – infected patients clogging emergency departments, filling intensive care units, forcing health officials to find ever more beds to treat the sick. In Wuhan, China, where the pathogen first emerged, cameras captured the rapid construction of a hospital in just 10 days in January. In Italy, northern area hospitals ran out of beds, life-saving medical equipment and morgue space to house the dead.
From Milan to Madrid, and then from Manhattan, pictures told the chilling story of a crisis to come and indelibly shaped Canada’s pandemic response. Coast to coast, the Canadian health system rallied and reorganized to preserve the capacity of its hospitals. It cancelled elective surgeries, sequestered personal protective gear for hospital staff, stockpiled ventilators for hospital patients, emptied wards and waited in fear for a crush of patients. But the crush never materialized – at least not in the hospitals.
While efforts had been singularly focused on preparing hospitals for the worst, the virus was silently spreading unchecked through Canada’s long term care and retirement homes, where deaths among seniors would dwarf mortality in the rest of the Canadian population.
According to the National Institute on Ageing, between March and September, COVID-19 killed more than 7,000 seniors living in long term care homes and retirement residences, accounting for nearly 80 per cent of the country’s deaths – a proportion far higher than other wealthy nations in the Organisation for Economic Co-operation and Development. During the pandemic’s first wave, 16 long term care staff members also lost their lives.
The catastrophic toll has sparked a national reckoning on the state of long term care in Canada, driven in part by the pressing need to understand all that went wrong. Why was it that the frail elderly, some of society’s most vulnerable members, were least protected? Why were long term care residents and staff so hard hit by this terrible contagion?
In an effort to answer these questions, Revera Inc. – one of the country’s major operators of long term care homes and retirement residences, a company privately owned by a federal public service pension plan – assembled an independent panel to investigate the circumstances that led to the COVID-19 crisis in its long term care homes, most of them in Ontario. With unusual access to the company’s internal data and public health information, the 10-member panel – made up of experts in geriatrics, public health, infectious disease, infection control, labour relations, architecture, health care policy and health care design – found that the contributing factors are highly complex.
Well before the pandemic struck, families of long term care residents, unions and industry associations across the country had been advocating for more funding to address staffing and infrastructure challenges in long term care. But long term care in Canada is not a sector that can operate in a silo. Home operators – private, not-for-profit and municipal – must rely on critical investment, input and co-operation from across the health system to function well. COVID-19 not only exposed cracks within the sector, but also the broken links between it and the system as a whole.
This translated into a series of systemic breakdowns that allowed the virus to flourish in long term care. Among these breakdowns was a sector-wide shortage of personal protective equipment to shield staff and residents from transmitting and contracting infection, along with a woeful lack of laboratory testing throughout the pandemic’s first wave to identify those who were infected. At the outset, it was also not understood that people without symptoms could spread the disease, and that symptoms could vary so dramatically. Managing outbreaks within residences was further complicated by inconsistent and sometimes conflicting instructions from public health authorities.
The pandemic also exacerbated the sector’s pre-existing problems and historic challenges. Among them are the outdated long term care facilities with multi-bed shared rooms and communal bathrooms that fuelled the spread of COVID-19. As the pandemic stretched on, the sector’s shortages of personal support workers and nurses intensified and challenged the industry’s efforts to contain the spread of the virus. No-visitor policies also contributed to residents’ overall physical and psychological decline. In many homes, doctors who had been contracted to care for residents were often absent, while health authorities in various regions discouraged the transfer of infected residents to emergency departments so local hospitals could maintain their capacity to admit COVID patients from the community. Yet it was well known from the outset that seniors, with their advanced age and likelihood of having other conditions, were at high risk of the worst outcomes.
Together, these circumstances combined to create a perfect storm of sickness and death in nearly a quarter of Canada’s long term care and retirement residences, amounting to outbreaks in 1,287 sites, with the majority of these in long term care, across 10 provinces in the spring first wave.
If there is anything to be gained from this tragedy, it is the opportunity to learn from the forces that shaped it. Affecting meaningful change will not only require reform within the long term care sector, it will demand closer collaboration across the broader system – between home operators, local and provincial governments, public health units, hospitals, physicians and their governing bodies, health care and personal support workers, their unions, and the families who have entrusted the care of their loved ones to long term care.
The sector is currently home to more than 425,000 seniors at 5,800 sites across Canada, a number poised to rise substantially as the country’s older population is expected to increase by nearly 70 per cent over the next two decades. As COVID-19 so ruthlessly demonstrated, the need for change – not least to shore up public confidence in long term care – has never been more urgent. The next wave, the next pathogen, or the next pandemic may be just a breath away.
When the first known case of COVID-19 reached Canada on January 25, the national stockpile of personal protective equipment, or PPE, was dwindling. Canada was hardly alone. Several countries discovered the cupboards were nearly bare, that their supplies of medical-grade masks, face shields, gowns and gloves could not keep pace with the expected demands of a highly contagious new virus.
The global shortage resulted in overburdened supply chains, lengthy back orders, and rationing. As doctors, nurses and other healthcare workers scrambled to fashion their own protective gear, federal officials in Canada made it clear that whatever PPE was available would be prioritized and reserved for frontline healthcare workers in hospitals.
But in the pandemic’s early days, the broad need for personal protection was misunderstood: Specifically, masks were considered unnecessary for people without symptoms of COVID-19. Echoing the stance of the World Health Organization, Canada’s chief medical officer of health recommended on March 30 that masks be worn only by the sick, or those caring for them. The rationale offered was that masks do little to prevent transmission from asymptomatic people and might actually increase the risk of infection if they are used improperly, or induce people to be careless or complacent. That advice contributed to the early view by health officials in Canada that it was unnecessary for seemingly healthy staff members in some long term care settings to wear masks.
Science, however, is an ever-evolving field, and just one week later the federal government reversed its guidelines on masks. Enough research had accumulated to prove that asymptomatic people could indeed transmit the novel coronavirus, and – based on studies of the major outbreak aboard the Diamond Princess cruise ship – could spread it with startling frequency. That knowledge eventually expanded to include evidence that pre-symptomatic people could also pass on the virus, and that while symptoms may involve coughing, sneezing and fever, they might also present as stomach upset, headache, a loss of taste or smell, or even blackened toes – a list so varied that a number of COVID-19 cases likely went undetected early on.
On April 6, Canada’s chief medical officer issued the new recommendation that everyone should wear non-medical face masks in public spaces and wherever social distancing was not possible, again safeguarding medical-grade PPE for frontline health workers. On April 8, the Public Health Agency of Canada issued a recommendation that all staff working in long term care settings be universally masking as well. However, earlier decisions to prioritize the protection of in-hospital staff would prove disastrous for long term care and retirement residences, which generally only keep a three-day PPE supply on hand as the pandemic preparedness legislation requires. Yet efforts to secure more, in anticipation of COVID-19, were unsuccessful. Revera, for example, heard from vendors and health officials as far back as February that PPE stock was reserved for hospitals and would be made available to a long term care home only if it was already experiencing an outbreak.
While universal masking became mandatory in Ontario long term care homes on April 8, the actual same-day delivery of PPE to long term care homes did not take effect until April 13, five days later. By then, COVID-19 had gained a strong and stubborn foothold in long term care homes across the country.
Revera’s data shows that 97 per cent of its residents’ infections – or 844 of its 873 cases in long term care, which was much more severely impacted than the company’s retirement residences – could be traced back to outbreaks that occurred during the week of April 13 or earlier. The same timeline applies to 90 per cent of infections among its staff: 398 of the company’s 442 employee cases owed to outbreaks that started before mid-April.
The numbers add up to a sobering conclusion. Since only essential caregivers were permitted at long term residences after March 9, the Revera Expert Advisory Panel found that the virus was most likely introduced into homes by staff members or essential caregivers who had contracted the infection in their communities (an issue further explored in Chapter 2). But in March, infected staff members without symptoms, or those who were pre-symptomatic, had little reason to suspect they were carriers and appropriately went to work –- often unprotected – to care for the elderly.
Meanwhile, the decision of public health authorities not to prioritize long term care residents and staff members for COVID-19 testing in March and April marked another missed opportunity to contain the virus. Additionally, when the world learned the virus spread asymptomatically, only one province where Revera operates, Ontario, heeded the industry’s calls for surveillance testing every two weeks for all staff (not just staff in homes in outbreak).
The drastic move became necessary in part because the loss of staff in long term care homes rose steadily as the pandemic stretched on. Some employee absences were due to infections among staff, and quarantines. Others missed work for the same reasons that kept employees home across the country, as children no longer in school were in need of supervision, or staff with underlying conditions felt they could not take the risk of catching COVID-19. But in a sector where recruiting and retaining staff have been longstanding challenges (an issue covered further in Chapter 4), the impact of losing personal support workers, nurses, cooks, cleaners and other crucial employees during outbreaks and lockdowns is difficult to overstate.
With the growing case counts in long term care through the spring, various levels of government ministries, bodies, public health units, hospitals, long term care agencies and doctors issued advice, instructions, orders and recommendations in a bid to keep the crisis in check. But often the input was inconsistent and contradictory, triggering rounds of confusion that may have increased the risk of transmission.
Different residences in the same province, for instance, received different instructions from local public health units as to how long a staff member should be quarantined following a potential exposure to the virus. In Ontario, which has 35 public health units, a 14-day quarantine was recommended by one unit, while another suggested quarantining an exposed staff member for 28 days.
Similarly, conflicting instructions emerged around infection prevention and control practices. Staff at one Revera home, for example, received training from the region’s emergency medical services personnel, only to be told a day later by the local public health unit that the instructions were incorrect and staff had to be re-trained according to its procedures.
One of the most critical and controversial areas of advice, however, involved efforts to create cohorts of residents. The aim was to separate the healthy from the sick and those suspected of being infected. But there was little consensus among public health units as to how Revera, as well as other operators, could achieve this, particularly in homes with few spare rooms, and homes with shared rooms that accommodated as many as four residents. The clashing instructions from various public health authorities resulted in multiple moves that increased the risk of spreading the virus and also contributed to residents’ decline. An estimated 90 per cent of long term care residents have cognitive impairment, and changes to their environment – seeing personal belongings packed away, for example – were often traumatic.
At the same time, enforcing rules around physical distancing, isolation, and infection control measures among residents with dementia – who are prone to wander, and unlikely to adhere to masking or strict hygiene practices – also highlights a fundamental gap in understanding the characteristics of long term care residents.
Managing outbreaks was further complicated by the scarcity of doctors at a time when residents most needed medical care.
Is There a Doctor in the House?
The pandemic altered the practice of medicine across the country, as online and telephone appointments between doctors and patients became common. The College of Physicians and Surgeons of Ontario, for example, recommended that family doctors deliver virtual care as much as possible to minimize the risk of spreading the virus and to conserve thin supplies of PPE. The College of Physicians and Surgeons of Alberta made a similar recommendation, advising its members to conduct physical examinations only when absolutely necessary, and to follow those exams with self-isolation if required.
Other provincial colleges governing family physicians took the same tack, and since most long term care doctors are family doctors, they tended to follow the advice. The Ontario Long Term Care Clinicians, a professional and advocacy organization whose members include medical directors and attending physicians in the province’s long term care residences, also recommended that care to residents only be provided virtually. All this had a profound effect in limiting the availability of in-person doctor visits at long term care homes, where residents faced both the highest needs for medical care and the highest risk from COVID-19 infections.
Often, attending physicians under contract with homes to provide medical care did not visit, despite repeated requests that they do so, and their capacity to provide care virtually was often hampered by other factors. Some doctors, for instance, were unfamiliar with the online platforms needed to run appointments remotely. Elderly residents, meanwhile, found it difficult to participate in virtual consultations, especially when they were ailing and as staffing shortages grew more severe. Yet most long term care homes where physician attention fell short had little recourse to remedy the situation.
In Ontario, for example, the Long-Term Care Homes Act clearly spells out that each residence must have a medical director, and it details the duties and obligations of that position. This includes development, implementation and evaluation of medical services for residents, advising on clinical policies and procedures, after-hours care and on-call coverage, and communicating these expectations to attending physicians. But nothing in the Act cements the obligations of attending physicians, beyond the need for them to be available 24 hours a day either in person or by telephone. Neither are attending physicians required to have training or experience in geriatrics, palliative care, or infection prevention and control procedures, such as the safe use of personal protective equipment. The pandemic pushed these issues to the forefront.
When attending physicians explained why they would not visit their long term care homes in person, they cited fear as a major reason. Doctors felt they had inadequate training in infection control and in the use of personal protective equipment, and also offered a range of personal reasons. A significant portion of long term care physicians are themselves elderly, having retired from their own family medicine practices, and they worried their advanced age, or an underlying condition, would increase their risk of serious infection. Some mentioned that they had an immune-compromised family member, which made them reluctant to enter a high-risk residence.
Meanwhile, some long term care home supervisors expressed concerns that physicians working at multiple homes might spread the virus from one affected site to another that had been COVID-free. Indeed, there are no limits on the number of homes or residents for whom an attending physician can provide care, how visits should be organized, or when or whether families should be included in care discussions. Approaches can vary from province to province, and even from home to home. At some sites, the medical director is the only physician on staff; at others, attending teams of 10 doctors or more provide rotating care or after-hours services. Retirement residences have even fewer requirements when it pertains to medical care; neither do they have any obligation to provide after-hours service.
For long term care homes struggling to contain an outbreak, the absence of doctors was compounded by the lack of treatment options for sick residents. Several hospitals and regional health networks discouraged long term care homes from sending infected seniors to hospital, especially if they were frail, suffered from dementia or were deemed unlikely to survive. This left many residents to battle the disease in locked-down homes that were never designed to provide acute care, which meant going without the medications, oxygen and ventilators that might have eased their suffering or saved their lives.
An Epidemic of Loneliness
An unfortunate result of the sector’s efforts to contain the virus by restricting visitors was the separation of long term care residents from their loved ones – husbands, wives, children, grandchildren, friends. Restricting all visitors, including essential family caregivers, was the earliest measure undertaken to safeguard long term care residents from infection. It was a restriction that applied to all homes, regardless of whether or not they had an outbreak, and it occurred at a time when the familiar faces of staff were also disappearing, along with employees in general.
It did not take long before loneliness and feelings of isolation and depression took their own toll. Experts note that the mental health effects of the extended lockdowns have proven to be as damaging as the virus.
Family members also endured considerable turmoil in not being able to see their loved ones or care for them, particularly if the loved one had become ill. They expressed understandable frustration and early in the pandemic’s first wave, many began considering options to withdraw their loved ones from long term care and retirement homes. Since many Canadians were working reduced hours or not working at all, some families did opt to temporarily bring their loved one home, particularly as governments relaxed rules around discharge policies and long term absences during the pandemic. But most Canadians recognized that the needs of their aged family member remained too complex for them to manage outside of an assisted-living or long term care setting.
Yet, in retrospect, it may be that a critical level of attention was lost with the prohibition of family visits. Family caregivers might have been able to detect minimal or atypical symptoms of COVID-19 in their loved one early enough to manage the resident’s disease sooner and more effectively. At the same time, it might well have prevented the physical, cognitive and psychological decline of seniors essentially shut away from the people who brought them joy.
1) A several-day supply of PPE must be maintained at every long term care home. Central regional inventories should be established to provide supplementary supplies for homes that require extra supplies during an outbreak.
Revera Response: Recommendation already implemented.
Early on in the pandemic, Revera was a contributor to and a founding member of the Canadian Alliance to Protect and Equip Seniors Living (CAPES), a volunteer-based initiative that sources, supplies and shares PPE across the seniors’ living sector in response to the urgent need during the COVID-19 pandemic. Moreover, Revera actively engaged in a vigorous purchasing strategy to secure PPE from local, national and international suppliers with an expenditure commitment of $15.5M to date, with further continuous investments contemplated. Revera warehouses a minimum six-month supply of PPE, reviews thresholds and makes adjustments as needed. Additionally, Revera utilized government supply during outbreaks. In Ontario, each long term care home also has an eight-week supply from the government stock.
2) Consistent provincial public health standards and directives should be established for each provincial health system. Ontario in particular must align the varied approaches taken by its 35 individual public health units. The varying messages received from the various units resulted in confusion in the Ontario long term care sector.
Revera Response: Recommendation is directed at the broader system rather than Revera.
While this recommendation is not under Revera’s control, Revera continues, at the regional and provincial levels, to discuss and clarify the messaging and varied approaches that are creating confusion in the sector.
3) Each province should establish a regional network for its long term care sector with established relationships between the region’s hospitals and long term care homes. A closer relationship should allow for infection control consultation to be provided by hospitals to long term care homes. It would also allow for regular consultation from long term care homes for hospital specialists (see below).
Revera Response: Implementation of recommendation is in progress.
Long term care homes have been paired up with hospital supports in Ontario as part of the pandemic plan. Revera’s internally developed Pandemic Playbook directs homes to reach out and plan with their local hospital partner during the pandemic.
4) Each long term care home should have an established medical leader who will attend at the home on a regular basis and when requested by the home’s staff. Consideration should also be given to establishing a nurse practitioner role in the home to collaborate with the physician in ensuring an on-site clinical resource for patient assessment. Appropriate PPE must be maintained for clinical use. It should be evident to clinical leaders that virtual patient assessment cannot entirely replace in-person assessment of older residents with acute respiratory illness.
Revera Response: Implementation of recommendation is in progress.
Each home in Ontario is required by the Long-Term Care Homes Act (LTCHA) to have medical leadership in the form of a medical director. The role of the medical director is clearly outlined in the Act and includes oversight of the attending physicians. Physicians must attend the home weekly, as per their service agreements with Revera. Physician services must be available 24 hours/day. Revera’s chief medical officer is establishing expectations for in-person assessments, as appropriate, during outbreaks.
5) The relationship between regional hospitals and long term care homes should establish availability of the hospital’s medical and surgical specialists to support the home’s clinical teams in managing residents. These residents may be transported to the hospital for assessment, may be assessed virtually while in the home or may be seen in consultation by hospital specialists visiting the long term care home.
Revera Response: Recommendation is directed at the broader system rather than Revera.
As part of a broader strategy, some regions are developing “hub and spoke” models of care that provide hospital support to long term care homes/retirement residences, including access to specialists such as geriatrics and palliative care. This will be an ongoing strategy that will require provincial processes to establish a consistent approach.
6) Four-bed resident rooms in long term care homes must be eliminated. Shared bathrooms must receive special attention in infection control and cleaning.
Revera Response: Aspects of this recommendation are not practical in the short term.
The recommendation related to shared resident rooms is in progress as we have been eliminating four-bed ward rooms allowing for more physical space and better distancing protocols. However, it is not possible to eliminate shared bathrooms in our existing older long term care homes. While we can eliminate shared bathrooms in redeveloped long term care homes (this issue does not apply to retirement residences, where all residents have private bathrooms), we are ensuring that shared bathrooms receive enhanced cleaning in all settings to reduce the infection risks.
7) Designated family members and/or friends should be recognized as “essential caregivers” with the same virus screening protocols and testing used for staff. These essential caregivers must also receive IPAC (infection prevention and control) training.
Revera Response: Implementation of recommendation is in progress.
We have recognized essential caregivers in all provinces and our sites have reached out to family members who are interested in becoming designated as essential caregivers. All visitors and essential caregivers go through our screening protocols. We are about to direct homes to ensure that the designated essential caregivers receive IPAC training (this is now a requirement in Ontario). In Ontario, all family visitors, essential family caregivers and agency staff will now require proof of a recent negative COVID-19 test result in order to enter our buildings.
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This report is dedicated to Revera’s employees, residents, their families, and all those on the front lines of the senior living sector who are working through the worst pandemic in living history.
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