Covid in Scotland: Discharge link to outbreaks 'cannot' be ruled out

The size of a care home was the biggest factor in the risk of a Covid outbreak said Public Health Scotland

Public Health Scotland (PHS) has said it "cannot rule out" a link between patients being discharged from hospital and Covid outbreaks in care homes.

It found mortality was high, with Covid associated with 21.6% of deaths within 30 days of discharge to a care home.

Almost 5,000 patients were sent to care homes between 1 March and 31 May last year - many without a test.

This report follows an earlier PHS study that was criticised for not being clear on its findings.

The health body said the size of a care home was still the biggest factor in the risk of an outbreak.

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In its report, it said: "No statistically significant association was found between hospital discharge and the occurrence of a care home outbreak. 

"However, due to the uncertainty observed, we cannot rule out a small effect, particularly for those patients who were discharged untested or discharged positive."

When the findings were first published last October, First Minister Nicola Sturgeon announced that there was "no statistical evidence" that discharges led to care home outbreaks.

However, the UK's statistics watchdog said a different reading of the data would suggest a link.

The Office for Statistics Regulation said that, given public concern about care home outbreaks during the pandemic, the uncertainty around the interpretation of the data could have been made clearer.

The group's director Ed Humpherson said at the time: "We consider there are lessons to be learnt from this case and expect the improvement points to be addressed in the presentation of any future statistical analysis of the care home data."

This time, the report says "we cannot rule out a small effect" rather than emphasising that the case was not proven.

How can the same data justify what look like two different conclusions? Both times, care homes that received discharges were about 20% more likely to see an outbreak.

But, crucially, there is a wide margin of error around that - so you can't be fully sure that discharges raised risk.

That margin of error says that the risk could have been raised by as much as 50% instead of 20% . That rules out a doubling or a tripling in the rate of outbreaks, but can't rule out a small increase.

And that margin of error also says that care homes that received discharges might actually have seen slightly lower rates of outbreaks when you take other factors into account.

Hence not proven, known in the statistical jargon as "no significant evidence".

With a narrower margin of error, we might rule out statistically the idea that risk was lower in care homes that received discharges, but we don't have enough evidence to allow such a conclusion.

This revised PHS report makes clear the difficulties in finding a link between hospitals and care homes, because patients were not routinely tested for Covid until 21 April last year.

The Scottish government introduced a new policy requiring patients to have two negative Covid tests before leaving hospital, and all new care home admissions to be isolated for 14 days.

The new publication also outlines other variables in terms of care home size, the types of services the homes offer, and the limited data that could be examined because of the small number of people who tested positive before an outbreak started.

The Scottish government introduced a policy last April requiring Covid testing before transfer into a care home

It also reported that mortality was high among people discharged to care homes from 1 March to 31 May 2020, with 675 people dying within 30 days. Coronavirus was linked with 21.6% of these deaths.

In the 30 days following discharge, 154 people tested positive for coronavirus.

A Scottish government spokesperson said: "These updated findings give greater insight into the outcomes from hospital discharges to care homes in the early stages of the pandemic.

"As with the last PHS report, we will take forward all of the recommendations in this updated report and we will use the report's findings to better understand all the factors driving outbreaks in care homes.

"Saving people's lives has been and will continue to be our priority throughout the coronavirus pandemic."

'Tragic saga'

The Scottish Conservatives said the report showed care homes "bore the brunt of the pandemic" because of the SNP government.

Party health spokesman Donald Cameron said: "Thousands of families are still grieving the loss of loved ones. They deserve answers from those who decided to discharge Covid patients into our care homes."

Scottish Labour health spokeswoman Jackie Baillie said: "The discharge of Covid patients into care homes fanned the flames of the pandemic and put lives at risk.

"This was a colossal and deadly failure of judgement. Those responsible must be held to account."

Scottish Liberal Democrat leader Willie Rennie said ministers had "sought to minimise their role in the most tragic saga of this sorry year".

He said a forthcoming public inquiry into care homes must ensure nothing like this can ever happen again.

When the report was published in October, the Scottish Greens said "the sheer scale of this scandal is absolutely astonishing".

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