The conclusions of a much-awaited report into discharges of patients from hospitals to care homes should be treated with care. It shows that the risk of a care home outbreak is more clearly related to the size of the care home (larger more likely to have an outbreak) than by the extent of hospital discharge into a care home, which was not “statistically significant”.
Not “statistically significant” should not be mistaken for meaning that hospital discharges did not play a role in spreading covid-19, indeed the report finds that “hospital discharge is associated with an increased risk of an outbreak when considered on its own”. It’s simply not possible for Public Health Scotland to evidence a strong statistical link, especially after accounting for the stronger correlation between size of care home and outbreaks.
Finding that size of the care home correlates more with outbreaks does not tell you what the likely source of the outbreak is. The report did not have data on staff testing and thus the impact of covid-19 positive staff on care home outbreaks was not included in the analysis. There are no conclusions drawn from this report about the cause of outbreaks in care homes, only that there is insufficient data evidence to finger hospital discharge as the cause. It’s very important to recognise the difference between correlation and causation in a study of this kind.
“These data are observational, meaning they can tell us what appeared to happen, but do not tell us what the direct cause was,” the report states.
Public Health Scotland do argue that the estimated risk from hospital discharges to care homes rises if a person has been untested (a 27 per cent increase) or if they had tested positive (a 45 per cent increase). But because the number of positive test discharges is a relatively small number as compared to care home outbreaks, there is a low-level of statistical confidence in linking the two. The report does however say that “we therefore cannot exclude a moderate to large excess risk from a care home receiving a discharge where the last test was positive”.
Given this, we should not lose sight of the headline findings of this report on hospital discharges into care homes, or assume that they are no longer important because no strong statistical evidence was found between these discharges and outbreaks. From 1 March to 21 April there were 3,599 hospital discharges into care homes, 81.9 per cent of which were untested. Of the 650 who were tested and were discharged, 78 had received a positive test result. From 22 April to 31 May, after the guidance had changed, there were 1,605 discharges from hospitals to care homes, 93 per cent of those were tested, with 278 testing positive, though 233 of those had one negative test result prior to discharge.
The justification for hospital discharges of positive tested patients after 21 April is the following: “There is recognition that changes in policy and guidance require time for implementation in clinical practice and this was reflected in the feedback from NHS Boards. Feedback received provided several reasons for not being able to complete negative testing prior to discharge, including: unable to swab (clinically inappropriate due to end of life care or distress to person), clinical decision based on symptoms and duration since first swab, and that the individual was returning to a care home with a known outbreak.”
So take from that what you will. It would be totally wrong to conclude from this report that it was okay to send patients untested or with positive test results into care homes. That was clearly a very bad mistake, which took far too long to rectify, and when the guidance was changed, compliance was not uniform. But what we can say from this report is that hospital discharge cannot be isolated as the sole or main reason for care home outbreaks. There was other problems in the system, most obviously that care home staff were not being routinely tested at the height of the outbreak, and that larger care homes which tend to be run by private providers – with big staff-to-resident ratios, high levels of staff turnover and chronic low pay – were particularly vulnerable.
So far from this report closing the book on the care homes scandal, if anything it generates more questions about what went wrong, and how structural faults in the sector are going to be addressed over the long-term.
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