key: cord-0832603-dfvyva47 authors: Fallon, Aoife; Dukelow, Tim; Kennelly, Sean P; O’Neill, Desmond title: COVID-19 in Nursing Homes date: 2020-04-20 journal: QJM DOI: 10.1093/qjmed/hcaa136 sha: 0d3d6464fface2f849bdc3689bd0fc2b46c4366f doc_id: 832603 cord_uid: dfvyva47 nan One of the tragic legacies of Hurricane Katrina in public consciousness was the disproportionate loss of life among older nursing home residents 1 . Given the similar lack of preparation and reserves in the nursing home sector in the course of many other natural disasters, the COVID-19 pandemic poses urgent questions as to whether healthcare systems and professionals have learned from these experiences. Older age and the presence of comorbidities are associated with increased risk of mortality in the current pandemic. The high prevalence of functional and cognitive impairment and behavioural symptoms add to the risk posed to nursing home residents 2 , as well as environments which present barriers to infection control 3 . In addition, healthcare professionals globally of all hues have neglected research, recruitment incentivization and quality improvement in nursing home care relative to other areas of clinical practice 4 . This is further reflected by evidence of variable and often inadequate preparation for pandemics in the sector 5, 6 , as well as the absence of infection control from descriptions of the competencies of nurses in care homes 7 . The synergy of these factors is reflected in the first major study of COVID-19 in a nursing home. Nearly two-thirds of residents were infected over a three week period, with a death rate of 33%: fifty staff members and 16 visitors were also infected 8 Spain, it has been reported that a significant proportion of COVID-19 associated deaths have been nursing home residents. There is also a concern that many jurisdictions are not including nursing home deaths in the COVID-19 death toll. Whilst general guidelines emphasise the importance of strict infection control protocols, little acknowledgement is given to the unique challenges faced by nursing homes with significant levels of close-contact physical care. Low staff to resident ratios are further impacted by COVID-19 related sick-leave, quarantine and absconding, threatening the provision of basic care to sick isolated residents. 3 Implementation of isolation procedures and education of residents can be exceptionally complicated for those with significant cognitive impairment and walking with purpose 2 , the person-centred term for wandering. Parallels may be drawn between challenges faced in nursing homes during the current pandemic and those seen in previous infectious outbreaks and epidemics. Following Organisation, the Centers for Disease Control, and the British Geriatrics Society): the latter laudably highlights that residents who 'walk with purpose' will require special consideration [10] [11] [12] . The implementation of these recommendations requires a more clearly developed governance and leadership structure in nursing homes than is often the case currently, such as the medical director role required by law in the USA. A common strand highlighted is the importance of early, collaborative advanced care planning [10] [11] [12] . Provision of decision making support and adequately resourcing facilities to provide good palliative care should also be prioritised 12 Of considerable importance also is the safeguarding of staff mental and physical wellbeing. On a more fundamental level, education of staff, many of whom will lack dedicated gerontological and healthcare training, is essential in order to dispel myths and impart accurate information concerning the pandemic and optimal support of residents. Older people resident in nursing homes are demonstrably the group most at risk of adverse outcomes and mortality during the current pandemic. Early, collaborative advanced care planning, more formalized leadership and governance, and provision of education and support for residents and staff is essential. At a more fundamental level, a radical rethink is needed on how to develop and integrate high quality nursing home care into the canon of core healthcare services, with adequate input from a range of gerontological specialties 13 . A comparison of the nursing home evacuation experience between Hurricanes Katrina (2005) and Gustav Dementia care during COVID-19 Influenza in long-term care facilities. 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