Most people living in care homes in England are over the age of 80, have multiple long-term health conditions, and the majority are affected by physical disability and/or cognitive impairment. These factors explain, in part, the vulnerability to COVID-19 of older people living in care homes. For example, during the first wave of the pandemic between mid March to mid June 2021, there were 19,286 deaths of residents of care homes where the virus was mentioned on the death certificate, accounting for 40% of all COVID deaths registered in that period.1
Monitoring and caring for residents with COVID-19, is made difficult by the complexity of care residents require, regional disparities in integrated working with NHS staff alongside primary, community and secondary care teams, and an over-stretched workforce. Challenges when treating residents with COVID-19 are further exacerbated if clear and consistent guidance, which can be read and digested quickly, is absent. For instance, early in this pandemic there was a paucity of such guidance for care homes.2
There is emerging evidence that using pulse oximetry, a non-invasive and painless test that measures a person’s oxygen saturation level, in community settings may help to more accurately predict outcomes for individuals who have tested positive for COVID-19, with regard to mortality and intensive care unit (ICU) admission. Models of care using pulse oximetry with people in their own homes were set up and implemented across primary and secondary care in England during the first wave of the pandemic (April to September 2020), which led to the national roll-out of COVID Oximetry @home; a service that involves pulse oximetry and the remote monitoring of patients with coronavirus symptoms. A mixed-methods evaluation of that COVID Oximetry @home programme has been undertaken by the BRACE and RSET evaluation centres.
However, little is known about the use of pulse oximetry and remote monitoring with regard to COVID-19 specifically in care homes. In response, researchers working across two NIHR-funded rapid evaluation centres, BRACE (Birmingham, RAND and Cambridge Evaluation) and RSET (Rapid Service Evaluation Team), and the Institute of Global Health Innovation at Imperial College London, completed two independent evaluations:
Study 1: a collaboration between NIHR BRACE and NIHR RSET
- To explore the views of care home staff, and NHS staff they interact with, about the use of pulse oximetry with residents when managing COVID-19 in the care home environment.
Study 2: Institute of Global Health Innovation, NIHR Imperial Patient Safety Translational Research Centre, Imperial College London
- To describe the number and characteristics of care home residents onboarded to COVID Oximetry at home (CO@h) pathways across England and their rates of mortality and hospital admission.
- To analyse the characteristics of care home residents with a positive COVID-19 test that are associated with being onboarded to the CO@h pathway.
Using online surveys sent to care homes, interviews with care home and related NHS staff, and analysis of all care home residents with either an onboarding or offboarding event to the CO@h programme using data from 70 Clinical Commissioning Groups (CCGs) in England, researchers collectively uncovered key lessons which have been summarised in a short slide deck. First, pulse oximeters were used with residents in many, but not all, responding care homes before the pandemic and their use widened during the pandemic. Using pulse oximeters was usually not challenging for staff and did not add to staff workload or stress levels. Additional support provided through the NHS COVID Oximetry at Home programme was welcomed at the care homes receiving it, but over half of survey respondents (care home managers) from Study 1 were unaware of the programme. In some cases, support from the NHS, including training, was sought but was not always available. Analysis of data collated by the 70 CCGs, shows that 29,606 care home residents had a positive COVID-19 test after the local implementation date of the CO@h programme. 812 (2.7%) of these were recorded as onboarded onto a CO@h programme within seven days before and 28 days after a positive COVID-19 test.
Given the small sample sizes across both evaluations, lessons drawn should be interpreted with caution. Yet, the evidence generated across our two evaluations points to a simple and yet critical message for the role of pulse oximetry for care homes. Thus, the use of pulse oximeters can be beneficial to care home residents. Continued development and awareness of the NHS COVID Oximetry @home programme amongst the care home sector needs to managed carefully. However, if developed and promoted with the support of local NHS infrastructures the programme could provide much needed help for staff and managers. For that to happen, primary care and other health care services need to be more consistent and clear in how they respond to and support care homes.
This article was written in collaboration with and reviewed by Jon Sussex, Robin Miller, Naomi Fulop, Thomas Beaney, Ana Luisa Neves and Jonathan Clarke.
References
1 Curry N (2021) “Beyond Covid-19 wave two: what now for care homes?”, Nuffield Trust comment.
2 Gordon A & Goodman C (2020) “Tackling the Covid-19 outbreak in care homes: messages from a geriatrician and a health service researcher about how the NHS can help”, King’s Fund comment.