How the COVID-19 crisis in Quebec's nursing homes unfolded

The first health-care worker at a Quebec long-term care home to test positive for COVID-19 had, like thousands of other Quebecers, recently returned from a trip abroad duringthe province's early March break.

Her case was reported March 14 by the health board for the Lanaudire region, just northeast ofMontreal. In retrospect, itwas a warning of how easily the coronavirus could enter seniors' residential institutions, known in the province as CHSLDs.

One day before, in what had seemed like an harsh measure to some, Premier Franois Legault had banned visits to all seniors' homeswhen he declared a public health emergency.

It was already too late.

Outbreaks were reported at a number of residences in the following days. On March 18, Mariette Tremblay, 82, a resident of a private seniors' home in the sameLanaudire region, died of COVID-19 and became Quebec's first known victim of the pandemic.She had had avisitfroma family member back from a trip.

Infection spread through a Sherbrooke seniors' home, too, after a family reunion.

Vectors of the coronavirus family and health-care staff returning from abroad had entered the CHSLDs, home to the province's most vulnerable to the disease, long before Legault called for an end to visits.

But a failure to respond quickly and effectively in the weeks since has allowed COVID-19to spread almost unhindered in dozens of homes, according to interviews with health-care workers, union representatives and a review of documents that demonstrate a lack of clear directives.

Workers on the front lines describechaos inside the homes as increasing numbers of staff and residents fell sick, including a lack of protective equipment for themselves and residents who had not yet caught the disease.

They also say whatever measures were in place to prevent spread of the virus weren't fully respected. Some workers who tested positive say they were ordered to return work before the end of their quarantine.

Nowresidents of those homes account for the vast majority of the COVID-19 death toll in Quebec. Of the 1,340 deadtallied so far in Quebec, 1,057 were seniors in care.

The crisis is far from over.More than 80 homes considered "critical" by the province, a number that has doubled in the past week.

At least 4,000 health-care workers have tested positive for COVID-19 and another 5,500 are absent from work, making it difficult for many CHSLDs to provide the most basic care.

One emergency room doctor at Montreal's Jewish General Hospital hasdescribed how patients are being wheeled into the ER, not sick from COVID-19, but because they are dehydrated and malnourished.

Slow to adaptafter focus on hospitals

When a woman who had been travelling inIran was reported to be the first case in the province Feb. 28, the province said the threat was still minimal and the focus was on preparing hospitals.

"All the measures that are necessary to protect the population, to protect the workers and take care of the patients, if it occurs, are there," Danielle McCann, the provincial health minister, said at the time.

Butas it became clear the bigger threat was in long-term care homes and other kinds of seniors' residences, the province was critcized forbeing slow to reallocate resources and staff.

Alain Croteau, a union president representing workers at the Centre-Sud-de-l'le-de-Montral health agency, described the response as "very chaotic, very disorganized."

By March 30, two weeks after the ban onvisits to hospitals and seniors' homes, the province announced the number of cases had surpassed 3,000.

That day, it announced $133 million in emergency funding for CHSLDs and other kinds of seniors' establishments.

"We will be able to hire more staff, buy more protective equipment and more disinfectant," said Quebec's minister for seniors, Marguerite Blais.

In the weeks that followed, however, it became clear many residences were still operating without enough gloves, masks or gowns.

Workers in Laurentians bought their own, for instance. So did nurses in Laval, fundraising with colleagues on social media and buying N95 masks and Bauer visors from friends of friends.

Directives published March 25 by Laval's health board stated staff in CHSLDs don'thave to wear N95s, even when treating COVID-positive patients, unless the patientsare on oxygen machines.

"The reason for that remains nebulous to me," said Jessika Ct, an emergency room nurse in Laval. She wasreassignedto work at a hard-hit seniors' residence,CHSLD Sainte-Dorothe, where at least 74 patients have died and more than 90 per cent of residents have tested positive.

Mixed messages

Even before the pandemic, CHSLDs across the province struggled to recruit enough nurses and patient attendantsto provide quality care. Recognizing that poor pay could trigger absenteeism and make a chronic staffing shortage even worse, on April 1, the Quebec governmentboosted wagesby eight per cent in public CHSLDs, and by $4 an hour in private long-term care homes.

But as conditions grew worse and more and more health-care workers started getting sick,workers who had tested positive forCOVID-19 were ordered toreturn to CHSLDs before the end of a normally compulsory 14-day quarantine.

At CHSLD Laflche, a long-term care home in Shawinigan, for instance, workers who had been exposed to COVID-19 were told to leave isolation early because there was no staff to replace them.

In early April, McCann defended the decision, saying it was "exceptional" and based on "scientific advice" provided by Quebec's public health institute.

"Leaving people all by themselves without services we cannot do that," she said.

The government still has not banned outright the practice of health-care workers putting in shifts at more than one nursing home, despite warnings from workers of the increased risk of spreading the virus.

Ct, the ER nurse, believes there would be thousands fewer health-care workers absent or sick today if the province had provided workers with the right equipment and clearer directives.

When she arrived at CHSLD Sainte-Dorotheon April 3, Ct said managers didn't even know she was coming and didn't give her any training.

She was sent to one of the home's hot zones, where she scrambled to provide residents a minimum of care.

Ct says the CHSLD only provided a surgical face mask, a gown and a pair of gloves.

In the days that followed, she observed staff circulating between cold and hot zones without changing gowns a major potential vector for the virus, she said.

Instead of changing gloves, many would simply wash or sanitize them, she said.

Ct said the circumstancesonly got worse in the days that followed a heavier workload, more deaths, and COVID-positive patients being transferred back into areas where some hadn't yet caught the disease.

"They said that since most of the CHSLD was contaminated anyway, there was no point having designated zones," Ct said.

Ctsaid she and her colleagues cried every day.

"The co-ordinator would go from nurse to nurse, and we would all be in tears because we just couldn't anymore," she said.

Of the 25 ER nurses who were sent to work in Laval CHSLDs,Ct said, ninehave since caught the coronavirus.

Ctis one of them.

As awful as COVID-19 can be, Ct said, it was a relief when she received her positive result over a week ago.

"I love my work, so I don't like saying this, but it finally gave me a break," she said. In a few days, she'll be going back to Sainte-Dorothe, where she's heard things are a little better.

Offers of help, unheeded

In recent weeks, as the crisis has become even more acute, Legault has repeatedly called on health-care workers to help staff the besieged nursing homes.

But many say they put their names forward early in the pandemicbut weren't able to securea position, with the hiring bureaucracy overwhelmed.

Natalie Stake-Doucet, the president of Quebec's nurses association, said she tried for weeks to offer her assistance at a CHSLD.

"It took, finally, talking directly to someone who I know who happens to be a manager and got me a job," she said.

"When I got there, it was devastation. I've never seen anything like it. It was shocking and sad and overwhelming," she said.

Stake-Doucet, now a PhD candidate and nursing instructor at theUniversit de Montral, stopped working full-time as a nurse two yearsago, in part out of frustration overthe impact of cuts to the health-care networkon patient care.

She blames health reforms imposed by theprevious Liberal government onthe breakdown incommunication between health authorities and health-care workers on the front lines. She saidthe chronicstaff shortages in the CHSLDs prior to the crisis havemade the problem even worse.

In his daily briefings, Legault has said repeatedlythat the time will come to examine all that went wrong.In a strikingly frank mea culpa a week ago, the premier said he takes"full responsibility" and is filled withremorse that "we didn't better care for the elderly, the most vulnerable."

On Friday, he said he is "not excluding"the possibility of taking over all private seniors' homes and creating a network of more spacious, better-staffed and more home-likeresidencesfor the aged across the province.

He said he'd learned "a big lesson" about the need for less crowdingand more staff.

The outbreak of COVID-19 in Quebec's long-term care institutions, Legault said, hasbeenlike setting fire to hay.

"Everything burns rapidly," he said.