‘Unclear processes’ led to days of delay for critical asymptomatic testing at long-term care homes

Mixed messaging, confusion and unclear processes led to days of delay for critical asymptomatic testing to be arranged and deployed at Alberta continuing care homes with an outbreak.

Premier Jason Kenney announced the asymptomatic testing for residents and staff of these facilities on April 17. At the time, he said the testing would start “in the coming days.”

However, one operator tells Global News that testing did not begin there until April 29, 12 days after the announcement.

At the time, 32 of Alberta’s 50 deaths were in long-term care sites. As of Nov. 9, 236 of the province’s 369 deaths were linked to these facilities. In both instances, that’s 64 per cent.

Lack of a coherent plan

Documents obtained by Global News from Alberta Health Services through a Freedom of Information request reveal, for the first time, what happened behind-the-scenes as the health authority scrambled to implement the testing and that questions about how to execute the testing persisted up to seven days after the announcement.

On April 17, Chief Medical Officer of Health Dr. Deena Hinshaw sent an email to high-ranking officials in Alberta Health and AHS medical officers of health stating that this type of asymptomatic testing had helped with early detection of cases and outbreak control in B.C. This email then cascaded down to AHS staff.

The next day, a member of the communicable disease unit sends the following email: “Please be advised that a COVID-19 outbreak has been declared for Swan Evergreen Village…NP swabs to be collected: any staff member or residents that develops symptoms.”

A specialist with integrated supportive and facility living with AHS then responds saying, “the messaging in these outbreak notices does not align with Dr. Hinshaw’s latest direction per email.”

On April 20, a director with integrated supportive and facility living writes that she has not heard of any plan for swabbing residents.

“(I) am waiting for something more official than just the transcript of Dr. Hinshaw’s talk on Friday,” the email reads.

The documents also indicate uncertainty and ambiguity around the processes to start the asymptomatic testing.

“I am not sure if we have clarification from (Alberta Health) on whether this applies to a unit or full site — I have asked for further clarification on this announcement,” writes an executive director of palliative and continuing care on April 21.

“My understanding at this point is that decisions about which asymptomatic staff and residents get swabbed is in the hands of physicians at the facility,” writes a medical officer of health the same day in response to inquiries for testing from the president of the Brenda Strafford Foundation — an organization that provides seniors care at several locations in Calgary and Okotoks.

“Asymptomatic swabbing: we should have more direction after our (medical officer of health) meeting tomorrow,” writes an acting zone lead medical officer of health also on April 21.

Five days after the announcement, there is still confusion.

“Can we as nurses in Calgary operationalize this recommendation, or would you like each request to be run by the (medical officer of health) group?” writes a member of the communicable disease unit.

“We are just sorting out today what to tell the sites so for now you can refer any questions about the asymptomatic swabbing to say discussion/planning around that issue will be done during the facility outbreak meetings,” reads an email from a medical officer of health in response.

Nearly a week after the announcement was made, the protocols around who will conduct the swabbing remain hazy.

“One possible twist on approach is to work with the facility first to determine their capacity to do the swabbing themselves before calling in a swabbing team,” writes a medical officer of health on April 23 as conversations continue about staffing protocols.

Protocols ‘a bit undefined’

Dr. Craig Jenne, an infectious disease researcher at the University of Calgary, said COVID-19 spreads easily through long-term care facilities due to tight quarters and healthcare staff who see multiple patients.

“Once coronavirus gets into one of these facilities, we tend to have really bad outcomes,” he said.

The emails reveal an acknowledgement within the health authority that the procedures are vague.

“I now understand that we don’t have good processes developed for asymptomatic swabbing when a site goes on outbreak…thinking we should have a brief chat to try to sort out what we need to do?” writes a provincial medical director of seniors health on April 22.

“Yes it is a bit undefined currently,” reads a response from a medical officer of health.

Indifference and incompetence, family says

David Cowling’s younger brother Donald has been a resident at Clifton Manor in Calgary, which is run by the Brenda Strafford Foundation, for approximately one year. At the time of the April 17 announcement, an outbreak had already been declared at the facility.

Donald, 51, suffers from a condition that affects his mobility and has had a history of pneumonia and lung issues, David said, meaning he may be more vulnerable to COVID-19.

Early on in the pandemic, David was among a growing call for asymptomatic testing at continuing care facilities so he was pleased when the announcement was made on April 17.

“Obviously that was a step in the right direction, albeit extremely belatedly,” he said.

In response to the documents released to Global News, David said they reveal ineptitude on the part of the health authority.

“The indifference that’s demonstrated by the emails you found is just entirely frustrating,” he said.

“They demonstrated utter incompetence in terms of rolling out this process.”

The emails also reveal frustration boiling over from facility operators.

“(There has been) no forward movement on testing for all staff and residents…The press and the community at large are demanding answers from us about testing all residents and staff…

“It is becoming increasingly difficult to say we are ‘waiting on MOH directives’ when the premier and CMO have already given the order,” writes Mike Lavallee, CEO of Seasons Retirement Communities on April 22.

On April 23, almost a week after the premier’s announcement, Hinshaw steps in to reiterate the importance of the testing.

“This is an important intervention to move forward on, and I need your support to make this work,” reads an email by Hinshaw to a group including medical officers of health and high-ranking officials in Alberta Health.

On April 24, AHS holds a meeting about COVID-19 and continuing care.

“We need to spend some time sorting out the asymptomatic swabbing processes for outbreak sites. Logistics need to be determined…There is pressure to get this done today,” writes a provincial medical director of seniors health.

‘It’s very risky’

Colin Furness, an infection control epidemiologist at the University of Toronto, said the change in testing procedures was a shift from previous testing protocols and notes that health care workers were trying to do their best, but he stopped short when asked whether the delays were acceptable.

“It’s hard to imagine it’s going to go smoothly, but to have done this and the have several delays just around uncertainty or confusion, it’s very risky,” Furness said.

A week after the premier spoke, the president and CEO of the Brenda Strafford Foundation, Mike Conroy, sends strong words to an executive director of palliative and continuing care. The Brenda Strafford Foundation oversees the facility that Donald Cowling lives in.

“Last week the Premier spoke of putting ‘a wall of defence around our seniors.’ We welcomed this intent but we have yet to see substance supporting this statement. The actions to date on asymptomatic testing seems to run counter to this objective,” he wrote in an email.

A response from a provincial medical director of seniors health states a standardized process is being finalized to be out the door April 27, 10 days after the initial announcement.

In an interview with Global News, Conroy said the foundation took it upon itself to swab residents at one site on April 18 while another site started testing seven to 10 days later.

“We, as a provider, we would have interpreted everybody was on the same page and ready to act very quickly. And that became apparent that that was not the case,” he said.

Jenne said he could not comment specifically on whether the process outlined in the emails was chaotic or confusing but noted there are logistics ranging from swabs to testing capacity to the transport of swabs for analysis.

“There’s a lot of moving parts. Ideally these would all be worked out before we launch a program,” Jenne said.

Response from AHS, Alberta Health

No one from Alberta Health Services was made available for an interview.

In a statement to Global News, AHS said it moved “as quickly as possible to implement asymptomatic testing” at the facilities, however the health authority also noted testing was one of several tools to protect residents and staff, citing visitor restrictions, mandatory screening and enhanced cleaning.

“We did face some challenges in the timely implementation of this initiative,” reads the statement, in part.

“We acknowledge that operators were anxious to get this testing underway as soon as possible, however we needed to ensure all of the required processes to support it were first in place; some of which required provincial coordination and others zone support.”

Alberta Health spokesperson Tom McMillan said the government department knew there could be some “temporary challenges” in changing testing procedures “so quickly.”

“These challenges were addressed by clarifying processes and working closely with AHS to implement the testing as soon as possible,” McMillan said in a statement to Global News.

“We have done our best to learn from this challenge by giving implementation time frames for changes, such as the two-week notice provided when licensed supportive living and long-term care standards changed in September. This allowed clarity around what was needed to make changes, and gave operators time to implement.”

Experts said it will be important to look at the lessons learned during the pandemic.

“I do think it’s critical we learn from our experience now and develop an improved strategy for the next potential pandemic or outbreak,” Jenne said.