Covid-19: the precarious position of Spain’s nursing homesBMJ 2020; 369 doi: https://doi.org/10.1136/bmj.m1554 (Published 20 April 2020) Cite this as: BMJ 2020;369:m1554
More than 10 000 older people in Spain have died in the covid-19 pandemic, while thousands of others remain isolated—and this is a best estimate, as experts suspect that the true figure is worse. As official statistics on cases and deaths continue to climb at an alarming rate, nursing homes have been a blind spot for a country that ranks third in the world for covid-19 deaths.
Spain lacks precise data from its autonomous administrative communities. Official numbers of cases and deaths do not always include people who were suspected of having the infection before death but were not tested. This includes those who died in health facilities or at home, as well as the vast majority of those who perished in nursing homes.1
Radiotelevisión Española (RTVE), the state owned public Spanish radio and television corporation, estimates that at least 10 719 people have died as of 16 April with covid-19 or similar symptoms in nursing homes throughout Spain, equal to half of the country’s official death toll. Most of these have been in nursing homes in the autonomous communities of Madrid, Catalonia, and Castile and León.2
The branch of the Spanish armed forces responsible for providing disaster relief (Unidad Militar de Emergencias; UME) has been drafted in to help disinfect residential nursing homes. The defence minister, Margarita Robles, said at a press conference that the UME had found “seniors in a state of complete abandonment, when not directly dead in their beds.” In several regions prosecutors have opened investigations looking for evidence of negligence.
Pere Godoy, president of the Spanish Society of Epidemiology, told The BMJ that nursing homes had been insufficiently prepared, given the concentration of high risk groups in enclosed spaces. He says, “It is not the time to place blame, but the competing administrations must provide nursing homes with adequate protective equipment and ensure the adequate training of their personnel.”
A precarious system of healthcare
The current pandemic has revealed the “precariousness of nursing homes,” says Pilar Rodríguez Rodríguez, president of the Fundación Pilares para la Autonomía Personal (Pillars for Personal Autonomy Foundation). Rodríguez is one of many who had been advocating for a major change to the nursing care model long before the coronavirus crisis.
“The public healthcare system acts as if this group of very old and vulnerable people do not exist,” she told The BMJ. Although public healthcare is free in Spain, she says, the “lack of political and social consideration” for nursing care means that these residents often cannot access adequate healthcare, amounting to age related discrimination.
Spain had 5417 nursing homes as of 2019. Of those, 3844 (71%) were privately run, housing 271 696 residents.3 Rodriguez says that large business groups have been buying nursing homes. Such a system “lacks adequate control” by public administrations, she warns, and staff are insufficiently trained, low in numbers, and on poor wages. She calls it a “precarious parallel system of healthcare, without [proper] human or technical resources.” Covid-19 has magnified these issues.
In the Community of Madrid from 8 March to 14 April almost 5000 older people died in nursing homes, either with confirmed coronavirus (781) or with compatible symptoms (4172). By comparison, 900 elderly residents died in nursing homes from any cause in March 2019. And even this may be an underestimate, says Ignacio Aguado, the region’s vice president and a member of the national-liberal Ciudadanos (Citizens Party). “The actual figures [of deaths] are much more dramatic than the ones appearing on the news,” he told the local public broadcaster, TeleMadrid.4
The regional government of Catalonia—the community with the most nursing homes and nursing home residents in Spain—says that from 15 March to 15 April some 1810 people died with confirmed coronavirus infection in the region’s nursing homes. Another 3920 remained under treatment in isolation with confirmed covid-19 infection. A further 1214 others had been admitted to hospital, and 5755 nursing home workers were in isolation or had confirmed symptoms.
In other autonomous communities, Castile La Mancha has reported 636 covid-19 deaths, the Valencian Community 323, Aragon 364, Extremadura 287, the Basque Country 269, and Andalusia 300.
As part of the state of emergency declared on 14 March,5 private nursing homes were put under public authority. But the effectiveness of this is still not clear.6 In a public nursing home in the Madrid district of Usera, the bodies of two nursing home residents who had died with the virus were left in their rooms for almost an entire day before being collected.
Not all nursing homes have doctors or nurses on their staff. By mid-March the Community of Madrid announced that public healthcare workers, including doctors, would be sent into nursing homes to help treat elderly residents on site and prevent a further influx of patients to hospitals already buckling under the strain. However, relatives and professionals have highlighted that the medical care available is limited and does not include intensive care treatment.
Media reports cite instructions given to emergency services to avoid transferring patients to hospitals, almost all of which have a shortage of intensive care beds and ventilators.78 Guidelines sent to nursing homes by Madrid’s department of health during the week of 16 March state that residents showing symptoms of respiratory infection who either cannot move independently, have a severe intellectual disability, or have a severe comorbidity should not be sent to hospital.9
“We are transferring almost no one, but we are not abandoning anyone,” Davíd Pérez told The BMJ. Pérez is a physician working at the emergency department of the Puerta de Hierro University Hospital in the Madrid municipality of Majadahonda, which provides medical care for over 60 nursing homes and 6600 residents. He says that almost all older people in his area who are treated in situ have a severe cognitive and functional impairment and would not benefit from transfer to hospital. He adds that it is normal practice to avoid unnecessary suffering.
Trapped without testing or PPE
As of 26 March at least 15 000 nursing home residents remained in isolation, a third with covid-19 compatible symptoms. An ongoing investigation, opened on 19 March by regional inspectors, is attempting to confirm how many of these residents may be infected.
Covid-19 tests are not commonly or consistently conducted at nursing homes, primarily because of a nationwide shortage of testing kits. Spain’s minister of health, Salvador Illa, announced on 5 April that a million rapid diagnostic tests would be distributed among autonomous communities to tackle the problem.
Visitors are currently prohibited in all nursing homes nationwide, but staff fear that their own movements could transmit the disease. At the private Catalan Centre Geriàtric Lleida, 24 workers agreed to isolate with their 89 residents, not leaving the building since 13 March. So far they have not had a single case of covid-19.
Workers in nursing homes are generally continuing to work unless symptoms appear. The BMJ spoke to two nursing home workers who continued working in Madrid even though they had relatives in the same house presenting covid-19 symptoms.
A guideline for nursing homes published on 24 March by the Ministry of Health states that “the risk should be individually assessed, but in general the usual work activity will continue and surveillance will be carried out to detect the early onset of symptoms.”10 Madrid’s own regional guideline for all healthcare workers, updated on 3 April, states that any worker who has had “a high risk exposure” to possible or confirmed cases of covid-19 without wearing personal protective equipment (PPE) “may work as long as [he or she] is asymptomatic and wears a surgical mask and gloves,” with daily active monitoring of symptoms.11The BMJ contacted the Government of Madrid to request comment but has yet to receive a reply.
Staff are fearful of the lack of testing but also, more urgently, the lack of PPE. In the autonomous community of Castile and León, 1802 older people have died in nursing homes in the past month. Raul Tardón, a primary care nurse in the region’s municipality of Valladolid, answered a call for volunteer assistance from the private Casa de la Beneficencia nursing home. To date, 30 of its residents have died and half of its staff have been in isolation, having tested positive for covid-19.12
“Even though the management try to hire staff, people are afraid,” Tardón told The BMJ. Although they finally received more supplies about a week before, the lack of PPE has been “extremely intense,” he says, adding that private nursing homes have had much more trouble than public ones in obtaining PPE.
Rodríguez, president of the Pillars for Personal Autonomy Foundation, concludes that the “lack of social recognition” for nursing homes has contributed to the shortage of testing kits and PPE. But she sees an opportunity for reform once the pandemic is over.
“We must change to a model of integrated and person centred care,” she says. “Nursing homes should not be a mortuary where people are waiting to die, but spaces to continue living.”
Competing interests: I have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.
Provenance and peer review: Commissioned; not externally peer reviewed.
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