Virus experts criticise "superficial" report on hospital discharges and Covid-19 in care homes

Residents being relocated from Clifton Nursing Home after a Covid-19 outbreak. Photo taken in May 2020 by Declan Roughan, Press Eye.

Residents being relocated from Clifton Nursing Home after a Covid-19 outbreak. Photo taken in May 2020 by Declan Roughan, Press Eye.

A report which found no correlation between hospital discharges of patients into care homes and Covid-19 outbreaks in care homes, in Northern Ireland, has been criticised by experts.

The Detail teamed up with VIEW magazine to assess the Department of Health (DoH)-commissioned report, produced by Dr Niall Herity – a Belfast-based consultant cardiologist.

Dr Herity sought to establish “if there was any correlation between hospital discharges (especially discharges in the absence of testing in early stage of pandemic) and subsequent care home outbreaks”, but he did not find any.

His research, published last November, doesn’t “support a hypothesis” that discharges from hospitals into care homes were a “substantial cause” of Covid-19 outbreaks in care homes in Northern Ireland.

In the last 12 months in Northern Ireland, more than 1,000 care home residents’ deaths have involved Covid-19, leading to calls for a public inquiry.

A DoH spokesperson said Dr Herity’s research “looked at data for discharges, as well as considering if there was any correlation between discharges from hospitals and infection rates in care homes” and that “the work could not identify any such correlation”.

However, Dr Connor Bamford, an expert in virology and antiviral immunity at Queen's University Belfast (QUB), said the report appears to be a “superficial analysis and needs to be followed up”.

He also told us that after “looking at what analysis was done” he was not surprised it took a “short time” – eight weeks or under – to complete.

Dr Bamford said: “I would have thought this would take time and a lot of effort on the part of numerous individuals with different expertise, such as clinicians, infectious disease experts, public health doctors, epidemiologists and people who run care homes.

“I am concerned that there appears to be a lack of expertise required to look at this properly, so I do not think the analysis is as good as it could be.”

Another QUB academic, Dr Lindsay Broadbent, who specialises in respiratory viruses, also criticised the report.

She said that “data is taken at face value” without consideration of “other virology or epidemiology knowledge” of the virus that causes Covid-19.

Dr Broadbent said: “The author infers that the peak of discharges into care homes doesn’t correspond to the peak in care home outbreaks and that there is, therefore, no connection.

“However, this does not consider the delay that would occur due to the virus incubation period. The peak of discharge into care homes was week 10-13 and the rate of outbreaks increased sharply from week 13.”

Dr Bamford added that the report’s format meant it could not establish “whether discharges from hospitals into care homes of an infectious individual then brought Covid-19 into care homes”.

He said: “You would need to do an in-depth analysis of discharges, likelihood that individuals being discharged had Covid-19 or not and care home outbreaks – all in the context of virus levels in the community."

Dr Bamford also said that the “size and duration” of Covid-19 outbreaks in care homes would also need “to be looked at”, but that this was not done for the report.

He added: “You could compare care homes or linked care homes (staffed by the same people) who accepted infectious discharges versus those who did not.

“You would also have to take into account availability of PPE for staff in care homes, that could exacerbate outbreaks. In my opinion this has not been done and has barely been attempted.”

Dr Herity’s report also sought to consider the “relationship (or otherwise) between departmental guidance” and the “clinical decision-making process in relation to discharges”.

The report concludes that “extensive communication was circulated” by both Health Minister Robin Swann and the DoH throughout the pandemic and that “subjectively, consultants indicated that departmental guidance had minimal or no impact on their discharge decisions”.

This conclusion was drawn after an anonymous “short survey” was addressed to 130 consultants in the Belfast Trust. Under one quarter of these consultants, 31 in total, responded.

The report says consultants were asked to consider the impacts of letters from the DoH on their decisions to discharge patients.

Dr Herity’s report concludes that of the 31 respondents, 14 consultants said “letters such as this have a minor impact" on their clinical decisions to discharge patients while 11 respondents said “letters such as this have no impact” on their decisions to discharge patients.

However, virus expert, Dr Broadbent, said: “The author does not state the responses from the other six respondents. I would wonder about the distribution of discharges among these respondents.”

Permanent Secretary for the DoH, Richard Pengelly, sent correspondence – referenced in Dr Herity’s report – to each health trust chief executive on March 26, 2020.

The correspondence highlights the importance of hospitals implementing “effective discharge arrangements for patients as soon as they are well enough to leave hospital in order to release beds for newly-admitted patients”.

Mr Pengelly added that families would have to “accept that patients may be discharged to a nursing home that would not be their first choice”.

QUB’s Dr Broadbent referenced how “the sharpest decline in median length of hospital stay” was immediately after Mr Pengelly directed this.

She added: “It is unknown what the median length of hospital stay would have been without the impact of the letter.”

In addition, further correspondence sent by Mr Pengelly in late April 2020, states that while patients should have been tested – “ideally” 48 hours prior to their discharge back into a care home – the results of these tests were not relevant to whether discharges should or shouldn’t take place.

This correspondence was also sent to each health trust chief executive in Northern Ireland, as well as the Regulation and Quality Improvement Authority (RQIA), Chief Medical Officer Dr Michael McBride and Chief Nursing Officer Professor Charlotte McArdle.

The correspondence says: “This testing requirement must not hold up a timely discharge.”

Unlike Mr Pengelly’s March 26, 2020 correspondence, his late April correspondence is not referenced in Dr Herity’s report.

While the report was produced “at the request” of Health Minister Robin Swann, Mr Pengelly was to be provided with updates on the progress of Dr Herity’s work “as and when requested”.

Given the contents of both his March and April pieces of correspondence, we asked the DoH if there was any conflict of interest in Mr Pengelly being informed of Dr Herity’s progress in this way, but the department did not respond to this.

The report also does not mention if the survey, sent to the consultants, made specific reference to Mr Pengelly’s correspondence from either March or April 2020.

Dr Herity previously faced scrutiny for a review he conducted into cardiac services in University Hospital Waterford.

The cardiologist defended this review before an Oireachtas committee, despite former Waterford TD, John Halligan, calling elements of it “outrageous” and “fundamentally flawed”.

The DoH also said that Dr Herity has previously done other “statistical analysis” for the department on elective care across Northern Ireland.

However, Dr Broadbent told us, Dr Herity carrying out this review, “seems like a conflict of interest” given he is responsible for discharging patients.

She said: “This report should have ideally been undertaken by someone that had no role in discharging patients or any role in hospital administration.”

We questioned the DoH about this and also asked whether a virologist, epidemiologist or infectious disease expert would have been more suitably placed, than a cardiologist, to produce this report, but the department did not respond.

Dr Herity also declined to be interviewed for this article.

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