Conclusion OVV: the nursing home sector was unable to participate

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Every crisis has its own vulnerabilities. And those vulnerable to seeDoing your utmost to protect those people, that is the government’s task.

Those who were looking for the most vulnerable in the first months of the corona crisis found them mainly in nursing homes. According to the Dutch Safety Board, a ‘silent disaster’ took place there. Or more precisely: a disaster that received too little attention in the fight against it.

On Wednesday, the council presented the first part of three reports on tackling the coronavirus crisis. The council reconstructs the first months of the crisis in 2020 and devotes an important part of the report to the ‘hard-hit’ nursing homes. Of the first ten thousand corona deaths, half died in a nursing home. They often died alone. Family members were not allowed to visit, or were afraid to do so because of the risk of contamination.

And when it comes to those sick and deceased residents, the Dutch Safety Board’s judgment is sharp. The council establishes a direct link between the high number of sick and dead and the approach taken by the cabinet, among others. “As vulnerable elderly people, the residents of nursing homes are susceptible to the virus,” the council writes, “but the focus of the crisis approach has also contributed to this.”

Shortage of everything

In the first months of the crisis, the focus is mainly on acute care and care in hospitals. There, patients and staff are tested for the virus. There, doctors and nurses wear masks, glasses and aprons during their work.

In the meantime, there is a shortage of everything in nursing homes: of testing, of protective equipment, of clear guidelines. Staff often work unprotected, while keeping their distance is complicated here. Residents with dementia, for example, cannot be instructed. The council quotes a nurse as saying: “They don’t stay in place, grab you and cough you full in the face from close by.” Because there is little testing, and employees with minor complaints continue to work, there is hardly any insight into the spread of the virus in those first weeks.

Employees are scared and concerned – some are even shunned by their families. What if they are sick? What if they infect the elderly? They struggle with the shortage of protective equipment and the guidelines that are constantly changing: first they must wear FFP2 masks, then only a surgical mouth mask, or no mask at all. Arms should be covered, and later exposed. And shaking up a pillow: is that ‘fleeting contact’ or not?

The management of healthcare institutions hastily arrange their own protective equipment. From asbestos suits to fireworks glasses, everything is tackled. Wim Martens is a director of care institution WZU Veluwe. He spends “a fortune” on it in those first months, he says over the phone. The institution has five locations, four hundred residents and 1,300 employees. “Five hundred aprons went through in one weekend. But whatever we asked, we got nothing.”

Also read the interview with OVV chairman Jeroen Dijsselbloem: ‘You cannot speak as firmly as you have done about a virus that you do not know’

Because nursing homes are not allowed to test employees and residents on a large scale at the GGD, the institution is setting up a test street itself. Martens thinks the conclusion that the sector was behind when it came to resources is an understatement. “In the first wave, we had to give up how large our stock of aprons, goggles and mouth masks was. They then asked us to give some to the hospitals, because the materials were badly needed there.” Martin refused. “Naturally! We had our hands in the hair ourselves.”

This policy creates an ‘increased chance’ that the residents will become infected, the Dutch Safety Board concludes. This ultimately results in an emergency measure: nursing homes close their doors on March 20. There will be a nationwide ban on visiting. Family members, carers, they are no longer allowed to visit the residents.

Professor of geriatric medicine Cees Hertogh, who was involved in the advice on this as a member of the Outbreak Management Team, calls it “more than regrettable” that it has come to this. A visitation ban was the only instrument, he says. And here Hertogh becomes firm: “If we had had the mouth caps, if we could test, then this measure would never, never have been necessary.”

From a medical point of view, the measure is a success, the number of infections is decreasing. In the meantime, however, the well-being of many residents is under pressure. They feel lonely and locked up, the council writes. Martens: “In such a crisis, a medical approach prevails. That seems logical at first, but later we had a lot of discussion about it. Is the detention of people in their last phase of life justified?”

Also read: When the tests finally came, half the nursing home was infected

He remembers the desperation of outbreaks. Two years ago, 88 people died of Covid-19 in the five houses of WZU Veluwe (400 residents). “Everything was lacking: protection, personnel. We cannot scale down care like hospitals do. Residents here must always be looked after, taken out of bed, with help to the toilet.”

Not everywhere at the table

How could it be that the most vulnerable were not heard? The council concluded because they were unable to participate. The nursing home sector was far from everywhere at the table. Not where the protective equipment was distributed, not where measures were considered. Nursing homes lack a clear figurehead. The OMT consists of “mainly experts in the fields of virology, microbiology, epidemiology and acute care”. It takes almost two months (until March 17) for an expert elderly care to join the OMT. And even after that, the council writes, nursing homes don’t always feel heard.

Photo Olivier Middendorp

Professor of geriatric medicine Jos Schols recognizes this image, although he also thinks that the sector should look at itself: they should organize themselves better, seek contact with each other. “And we really need our own Ernst Kuipers.”

Martens saw the importance of media attention. “I called Hugo de Jonge in mid-April. After that I was also allowed to visit On 1† He talked about the shortages of masks and glasses and about the lack of testing capacity at the GGD. Coincidence or not: „Na On 1 everything went better.”

Professor Cees Hertogh, who as a source was interviewed for hours by the Dutch Safety Board, sees another explanation for the fact that nursing homes have long been ignored: socially little attention is paid to the vulnerable. He recalls the “dry wood discussion” that left “a crack” in society after the first wave. “It was about how much we are willing to give up to protect vulnerable people in society.” Hertogh would like to have that discussion now. He would like to give one “point of attention”: “Someday we will all be vulnerable.”

The OVV criticizes…

1… The too limited testing policy

The OVV is critical of the limited testing policy in the first months. In March, the WHO is calling for as much testing as possible in the event of complaints, but this will only be possible from 1 June. Until then, shortages meant that only healthcare personnel and hospital patients could be tested. “The government is letting go of the aim of limiting the number of cases through testing and source and contact investigations.”

While officials and the OMT discussed the best ways to distribute the limited number of tests, they should have put effort into increasing capacity. Because little test material was purchased, suppliers shifted their stocks elsewhere. “The policy of taking into account scarce testing capacity is counterproductive in obtaining materials to expand capacity.”

Partly due to the ‘restrictive testing policy’, many vulnerable elderly people were quarantined untested and it was unclear how many victims the virus caused in the nursing homes. This was also due to the ‘narrow case definition’ of the OMT. Fever was a requirement for a test, while an increase in the elderly is more difficult to determine due to a lower body temperature. “For example, a national picture of the real number of infections has been missing for a long time.”

Due to major shortages of test materials, large-scale testing was impossible in those first months. Nevertheless, the Netherlands could have arranged more capacity in order to gain a better insight into the spread.

2… The open doubts about the usefulness of face masks

According to the OVV, the open doubts of OMT chairman Jaap van Dissel about the functioning of mouth masks have affected the support for the measure. “These statements have undermined government policy by advisers from that same government.”

Van Dissel has always doubted the usefulness of the mouth masks – there was no scientific consensus about this at the time, he also said on Tuesday after the technical briefing. He did not call the introduction of a mask obligation a scientific, but a political choice that could lead to a false sense of safety.

In May of 2020, the cabinet nevertheless introduced a mouth cap obligation in public transport. Public interior spaces followed later.

In the crisis, the government relied heavily on the scientific expertise and hard figures of the OMT and the RIVM, the OVV noted. Officials who had to test the OMT advice for practical and political feasibility, ‘in the majority of cases’ adopted the advice unchanged.

In the case of “the hot topic” of the mask obligation, the OVV suggests that the OMT could have been questioned more critically. At the time, the OMT said that the basic principle was that people with complaints should stay at home, while it was already clear that some of the people went outside anyway. That ‘optimistic assumption’ of the OMT was nevertheless not called into question.

3… The flawed ability to anticipate

After the first wave, the infections decrease. The government would then like to treat the pandemic less as an acute health crisis and pay more attention to the socio-economic effects of the restrictive measures. A regional approach is proposed: security regions and the GGDs must ‘kick out’ local outbreaks as much as possible themselves.

That approach did not work out well, writes the OVV. “Because the crisis structure disappeared, this led to a lack of clarity among security regions and ministries about the division of roles, tasks and responsibilities.” As a result, as the infection rates rose in the run-up to the second wave, it was not clear who should intervene next. Measures were taken ‘delayed’.

The local approach is “not realistic,” writes the OVV. “This is partly caused by shortages in test capacity, but also because possible regional measures, such as possible closures of catering, shops or cultural activities, have a waterbed effect.”

Information from the corona dashboard, just new that summer, should help prevent the second wave. However, although the signal values ​​are exceeded, no action is taken. Only when the hospital figures also start to rise will the cabinet intervene. For example, policymakers ‘once again showed a lack of ability to anticipate the situation’, concludes the OVV.

A version of this article also appeared in NRC on the morning of February 17, 2022

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