Poor ventilation may be adding to nursing homes’ COVID-19 risks


Geoff Hanmer and Bruce Milthorpe, University of Technology Sydney

Over 2,000 active cases of COVID-19 and 245 resident deaths as of August 19 have been linked to aged care homes in Victoria, spread across over 120 facilities. The St Basil’s cluster alone now involves 191 cases. In New South Wales, 37 residents were infected at Newmarch House, leading to 17 deaths.

Why are so many aged care residents and staff becoming infected with COVID-19? New research suggests poor ventilation may be one of the factors. RMIT researchers are finding levels of carbon dioxide in some nursing homes that are more than three times the recommended level, which points to poor ventilation.

An examination of the design of Newmarch in Sydney and St Basil’s in Melbourne shows residents’ rooms are arranged on both sides of a wide central corridor.

The corridors need to be wide enough for beds to be wheeled in and out of rooms, but this means they enclose a large volume of air. Windows in the residents’ rooms only indirectly ventilate this large interior space. In addition, the wide corridors encourage socialising.

If the windows to residents’ rooms are shut or nearly shut in winter, these buildings are likely to have very low levels of ventilation, which may contribute to the spread of COVID-19. If anyone in the building is infected, the risk of cross-infection may be significant even if personal protective equipment protocols are followed and surfaces are cleaned regularly.

Why does ventilation matter?

Scientists now suspect the virus that causes COVID-19 can be transmitted as an aerosol as well as by droplets. Airborne transmission means poor ventilation is likely to contribute to infections.

A recent article in the journal Nature outlines the state of research:

Converging lines of evidence indicate that SARS-CoV-2, the coronavirus responsible for the COVID-19 pandemic, can pass from person to person in tiny droplets called aerosols that waft through the air and accumulate over time. After months of debate about whether people can transmit the virus through exhaled air, there is growing concern among scientists about this transmission route.




Read more:
Is the airborne route a major source of coronavirus transmission?


Under the National Construction Code (NCC), a building can be either “naturally ventilated” or “mechanically ventilated”.

Natural ventilation requires only that ventilation openings, usually the openable portion of windows, must achieve a set percentage of the floor area. It does not require windows to be open, or even mandate the minimum openable area, or any other measures that would ensure effective ventilation. Air quality tests are not required before or after occupation for a naturally ventilated building.

Nearly all aged care homes are designed to be naturally ventilated with openable windows to each room. In winter most windows are shut to keep residents warm and reduce drafts. This reduces heating costs, so operators have a possible incentive to keep ventilation rates down.

From inspection, many areas of typical nursing homes, including corridors and large common spaces, are not directly ventilated or are very poorly ventilated. The odour sometimes associated with nursing homes, which is a concern for residents and their visitors, is probably linked to poor ventilation.

Carbon dioxide levels sound a warning

Carbon dioxide levels in a building are a close proxy for the effectiveness of ventilation because people breathe out CO₂. The National Construction Code mandates CO₂ levels of less than 850 parts per million (ppm) in the air inside a building averaged over eight hours. A well-ventilated room will be 800ppm or less – 600ppm is regarded as a best practice target. Outside air is just over 400ppm

An RMIT team led by Professor Priya Rajagopalan is researching air quality in Victorian aged care homes. He has provided preliminary data showing peaks of up to 2,000ppm in common areas of some aged care homes.

This figure indicates very poor ventilation. It’s more than twice the maximum permitted by the building code and more than three times the level of best practice.

Research from Europe also indicates ventilation in aged care homes is poor.

Good ventilation has been associated with reduced transmission of pathogens. In 2019, researchers in Taiwan linked a tuberculosis outbreak at a Taipei University with internal CO₂ levels of 3,000ppm. Improving ventilation to reduce CO₂ to 600ppm stopped the outbreak.




Read more:
How to use ventilation and air filtration to prevent the spread of coronavirus indoors


What can homes do to improve ventilation?

Nursing home operators can take simple steps to achieve adequate ventilation. An air quality detector that can reliably measure CO₂ levels costs about A$200.

If levels in an area are significantly above 600ppm over five to ten minutes, there would be a strong case to improve ventilation. At levels over 1,000ppm the need to improve ventilation would be urgent.

Most nursing homes are heated by reverse-cycle split-system air conditioners or warm air heating systems. The vast majority of these units do not introduce fresh air into the spaces they serve.

The first step should be to open windows as much as possible – even though this may make maintaining a comfortable temperature more difficult.




Read more:
Open windows to help stop the spread of coronavirus, advises architectural engineer


Creating a flow of warmed and filtered fresh air from central corridor spaces into rooms and out through windows would be ideal, but would probably require investment in mechanical ventilation.

Temporary solutions could include:

  1. industrial heating fans and flexible ventilation duct from an open window discharging into the central corridor spaces

  2. radiant heaters in rooms, instead of recirculating heat pump air conditioners, and windows opened far enough to lower CO₂ levels consistently below 850ppm in rooms and corridors.

The same type of advice applies to any naturally ventilated buildings, including schools, restaurants, pubs, clubs and small shops. The operators of these venues should ensure ventilation is good and be aware that many air-conditioning and heating units do not introduce fresh air.

People walking into venues might want to turn around and walk out if their nose tells them ventilation is inadequate. We have a highly developed sense of smell for many reasons, and avoiding badly ventilated spaces is one of them.The Conversation

Geoff Hanmer, Adjunct Professor of Architecture and Bruce Milthorpe, Emeritus Professor, Faculty of Science, University of Technology Sydney

This article is republished from The Conversation under a Creative Commons license. Read the original article.

Grattan on Friday: Morrison government needs to improve, rather than defend, its poor COVID aged care performance


Michelle Grattan, University of Canberra

The state of aged care preparation in the era of COVID-19 is, it seems, in the eye of the beholder.

Vastly different claims emerged this week, when the royal commission examining the sector turned its attention to the handling of the pandemic.

According to the senior counsel assisting the commission, Peter Rozen, QC, federal authorities had no COVID-19 plan specifically for aged care, always potentially a major risk area. And, Rozen noted, compared with many countries, residents of facilities form a very high proportion of Australia’s deaths.

The government disputes the lack-of-plan allegation and has a different take on the statistics.

Brendan Murphy, secretary of the health department and until recently Australia’s chief medical officer, appearing before the commission, insisted there had been proper planning, and said the death proportion reflected not a failure in aged care but the low number of fatalities in the general community.

If you were taking a bet on who most people would believe, Rozen would be short odds.

Morrison knows the government is highly vulnerable on the issue. Aged care is a federal responsibility. It affects millions of Australians, counting those with relatives in homes. People’s anger buttons are easily triggered when things go wrong.

Some around the government might like to discount Rozen’s attack as being what counsels-assisting do at royal commissions. But his claims were backed by witnesses, from highly regarded geriatrician Joseph Ibrahim of Monash University to union officials with members on the front line.

They also resonated after the numerous first-hand accounts in the media from families as the virus has ripped through well over 100 facilities in Victoria. Currently, there are more than 1,000 cases among residents and over 1,000 among staff, linked to these homes.

Politicians have been congratulated during the pandemic for listening to experts, but according to Ibrahim, there was not enough aged care expertise applied in the preparations to firewall the sector.

It’s hard if not impossible, anyway, to build adequate safeguards when the structure itself is so compromised, due to bad decisions and neglect over many years.




Read more:
Royal Commission into Aged Care reminds Health Department Secretary Brendan Murphy it sets the rules


A sector operating with low paid, often short term, casuals who pick up work across facilities and often have inadequate English (complicating even basic training) was always inviting disaster.

Health Minister Greg Hunt declared recently, after Victoria Premier Dan Andrews said he wouldn’t want his mother to be in some of these places:

The idea that our carers, that our nurses are not providing that care, I think, is a dangerous statement to make. They are wonderful human beings and I won’t hear a word against them.

This misses the point. No one doubts the commitment the majority of the carers have to their work. But the nature of the workforce brings dangers for residents.

Many facilities run on narrow financial margins. The rules allow them to keep their staffing to a minimum, in terms of numbers and skill.

Nor has regulatory oversight been adequate. Often it is families and the media that have exposed neglect and abuses. Morrison announced the royal commission in September 2018 a day before an ABC Four Corners investigation was to air.

The for-profit system emphasises the idea of facilities being “home-like”, which sounds great but can mean inadequate specialised care and challenges for inflection control.

The word “tragic” is thrown around too much by politicians and media. But what’s happened in aged care during COVID-19 has indeed been a tragedy.

It’s just possible if the pandemic had come two years later, after next year’s final report of the royal commission had forced some reform, that fewer lives would have been lost. But even with the system as it is, the evidence indicates better planning could have saved lives.

That’s certainly Ibrahim’s view. In his precis of evidence, he argued “hundreds of residents will die prematurely because people failed to act”.

We had enough knowledge to do better. We failed because when residents are treated as second class citizens there is an absence of accountability and consequences for those responsible for aged care in Australia.

There was “failure to provide the same health response to residential aged care that was delivered to the rest of Australia.”

The government has been playing catch-up on aged care all through the pandemic. It had to put substantial money in to help with staffing; it was slow to acknowledge the importance of masks; it set up a co-ordinated response in Victoria belatedly; National Cabinet only a week ago stepped up preparations in other parts of the country.

Morrison is now confronted at two levels: there must be root and branch reform after the royal commission, and his government is under immediate pressure over this week’s indictment.

The government’s tactic of inserting Murphy into the commission’s witness list was a miscalculation.

It seemed to assume the commission would defer to Murphy when he sought to make a statement to reject Rozen’s claims. But he was refused permission to commence with the statement (which he delivered at the end of the session) and all his appearance did was highlight the government’s sensitivity.

When he summed up the hearings on Thursday, Rozen did not resile from his initial criticisms. He concluded the problems in aged care had been foreseeable; “not all that could be done was done”; and the challenge remained.

Picking up a recommendation from Ibrahim, Rozen urged an “age-care specific national coordinating body to advise government”. It would bring together expertise in aged care, infection control and emergency preparedness.

With such a body, “a national aged care plan for COVID could still be put in place,” Rozen said.




Read more:
Government rejects Royal Commission’s claim of no aged care plan, as commission set to grill regulator


Although the advisory body is not a formal recommendation, commissioner Tony Pagone endorsed it among “practical things that perhaps should not wait.”

The virus doesn’t wait and nor should the measures that need to be implemented to deal with the virus wait either.

The government, which has previously signalled more assistance for aged care in the budget, should stop insisting it has done everything well and act immediately on this and some of the other suggestions made in the COVID-19 hearings.

Morrison said this week in a Facebook message, “I want to assure that where there are shortcomings in these areas they’ll be acknowledged. And the lessons will be learned.”

The government likes to talk about wanting a reform agenda, but this should not be just an economic one. Aged care must be near the top of any serious “reform” to-do list, and vested interests should not be allowed to limit necessary changes.

In his end-of-year ministerial reshuffle, prompted by Mathias Cormann deciding to quit parliament, Morrison should elevate the aged care portfolio from the outer ministry to cabinet.

Having the post in cabinet would send a positive signal but, more importantly, it would encourage a wider range of ministerial eyes on an issue that’s been mishandled for as long as anyone can remember.

Veterans’ affairs is in cabinet, and most families would think aged care is just as worthy of a place.The Conversation

Michelle Grattan, Professorial Fellow, University of Canberra

This article is republished from The Conversation under a Creative Commons license. Read the original article.

Royal Commission into Aged Care reminds Health Department Secretary Brendan Murphy it sets the rules


Michelle Grattan, University of Canberra

The Royal Commission into Aged Care put the Secretary of the Federal Health Department, Brendan Murphy, firmly in his place when he tried to make an opening statement to attack claims by the senior counsel assisting the commission, Peter Rozen, QC.

Murphy, who became a nationally known figure when as Chief Medical Officer he appeared regularly at Scott Morrison’s news conferences, had not been due to give evidence at the commission’s sittings on COVID this week.

But after Rozen’s Monday statement the federal government, which is increasingly concerned at the criticism it is receiving over inadequate preparation for the pandemic in aged care facilities, asked to have him added to the panel of Commonwealth witnesses who appeared on Wednesday.

As questioning of the panel was about to start Murphy broke in, saying he wanted to make a statement in response to Rozen inaccurately claiming the Commonwealth had not planned for the outbreak in aged care and as a result there had been a high death rate.

But after a brief adjournment for consultations the commission denied his request, although he was allowed to make the statement at the session’s end. As commissioner Tony Pagone put it with the utmost politeness but equal firmness, “We are really in control of the procedure that we have and we just need to continue with that.”

On Wednesday Victoria announced a record 21 deaths from the previous 24 hours, 16 of them linked to aged care.

In a Facebook message Scott Morrison, expressing condolences, referred particularly to the need to protect the vulnerable elderly.

He also said pointedly: “I want to assure that where there are shortcomings in these areas they’ll be acknowledged. And the lessons will be learned.”

He warned there would be more “difficult news” in the days and weeks ahead.

Earlier on Wednesday professor Joseph Ibrahim, a specialist in geriatric medicine from Monash University, told the commission: “This is the worst disaster that is still unfolding before my eyes and it’s the worst in my entire career”.

He said hundreds of aged care residents would die prematurely because people had failed to act.

“There’s a level of apathy, a lack of urgency. There’s an attitude of futility which leads to an absence of action.

“The reliance or promotion of advance care plans as a way to manage the pandemic and the focus on leaving residents in their setting I think is wrong and inappropriate. When I voiced my concerns, I have had comments saying that everything is under control, that I’m simply overreacting and causing panic,” Ibrahim said.

Early in the crisis Ibrahim made representations to state and federal bodies, and to Morrison, health minister Greg Hunt and aged care minister Richard Colbeck.

The tension was evident when the panel of Commonwealth officials gave evidence.

Michael Lye, the health department’s deputy secretary for ageing and aged care, unsuccessfully tried to divert to Murphy a question about Australia faring badly on aged care deaths compared to other countries. Rozen insisted Lye answer, saying sharply, “No, I don’t want professor Murphy to answer the question, Mr Lye. I’m asking you. You told us you were the senior most official with aged care responsibility within the Commonwealth department of health”.

In one embarrassing moment for the federal officials, Rozen drew attention to Murphy prompting Lye when the latter was struggling under the questioning.

Rozen told both Lye and Murphy, as they periodically veered into wider comments, to just answer his questions.

Quizzed about the apparent lateness of a July 13 decision to make masks compulsory for care providers in Victorian homes, Murphy admitted “in hindsight, you could have implemented that earlier”, agreeing it was “possible” it might have reduced the number of infections entering homes.

In his forcefully-delivered statement at the end of the session, Murphy declared: “We reject categorically that the Australian government failed to adequately plan and prepare” for COVID in aged care.

He also strongly rejected that there was anything pejorative in the fact people from aged care formed a high proportion of “an extraordinary low death rate in Australia”. “I would say the contrary is true.” He said across Australia’s aged care facilities 0.1% of residents had succumbed to COVID compared to 5% in the UK with many more not detected.

The fact that two thirds of Australia’s about 350 deaths were from aged care “is really a reflection of the extraordinarily low community death rate,” Murphy said.

Diana Asmar, Victorian secretary of the Health Workers Union, told the commission: “Our members right now feel like they’re on the bottom of the Titanic ship”. They did not have proper access to personal protective equipment, they were suffering from huge staffing pressures, and they were feeling neglected.

“The lack of communication, the lack of training, the lack of staffing and the lack of protection unfortunately has caused a huge concern in the aged care sector,” she said.The Conversation

Michelle Grattan, Professorial Fellow, University of Canberra

This article is republished from The Conversation under a Creative Commons license. Read the original article.

Government rejects Royal Commission’s claim of no aged care plan, as commission set to grill regulator


Michelle Grattan, University of Canberra

The federal government has clashed with the Royal Commission into Aged Care, strongly rejecting the claim by senior counsel assisting the inquiry Peter Rozen that it had no specific COVID-19 plan for the sector.

Aged Care Minister Richard Colbeck told a news conference: “We have had a plan to deal with COVID-19 in residential aged care, going right back to the beginnings of our preparations.

“We’ve been engaged with the sector since late January, and continuously working with the sector to ensure they have all the information they require and the support that they need in the circumstance that they might have an outbreak of COVID-19.”

Acting chief medical officer Paul Kelly said: “We have been planning for our aged population as a vulnerable group since the beginning of our planning in relation to COVID-19”. And there had been “very strong communication with the sector throughout,” he said.

Rozen, in a Monday statement at the opening of this week’s hearings on COVID in the aged care sector, said while much was done to prepare the health sector more generally for the pandemic, “neither the Commonwealth Department of Health nor the aged care regulator developed a COVID-19 plan specifically for the aged care sector”.

The sector had been underprepared, he said.

Asked whether the government’s plan had failed, Colbeck admitted there had been “some circumstances where things haven’t gone as we would like”, saying “the circumstance at St Basil’s [in Melbourne] is one, where we didn’t get it all right”.

On Wednesday the commission will take evidence from Janet Anderson, head of the Commonwealth regulator, the Aged Care Quality and Safety Commission, which Rozen said “did not have an appropriate aged care sector COVID-19 response plan”.

The government has left Anderson out to dry, after it was belatedly discovered her body was told of an outbreak at St Basil’s two days after a staffer was diagnosed, but it failed to pass on the information.

Quizzed about this, Colbeck said under the protocols, “the Commonwealth should have been advised of the outbreak on 9 July by either the Victorian health department or St Basil’s management or both. Instead it was formally informed on July 14.”

But he was also critical of the Quality and Safety Commission which was informed of the outbreak when it was speaking to the home as part of a survey about preparedness and infection control.

“The disappointing thing, from my perspective, is that the information that was gleaned … about a positive outbreak wasn’t passed on to anyone else,” Colbeck said.

“There was an assumption made … that information had already been passed on. It wasn’t.

“The gap in the supply chain, or the information chain, has now been closed. … There should not have been a hole in our systems. That’s been rectified appropriately, as it should have been.”The Conversation

Michelle Grattan, Professorial Fellow, University of Canberra

This article is republished from The Conversation under a Creative Commons license. Read the original article.

Federal departments had no specific COVID plan for aged care: royal commission counsel




Michelle Grattan, University of Canberra

Australia’s aged care sector was “underprepared” to deal with the COVID-19 outbreak and federal authorities had no specific plan for it, according to a stinging indictment from Peter Rozen QC, senior counsel assisting the royal commission into aged care.

In a statement critical of authorities and providers, Rozen said while much was done to prepare the health sector more generally for the pandemic, “neither the Commonwealth Department of Health nor the aged care regulator developed a COVID-19 plan specifically for the aged care sector”.

Rozen was speaking at the start of several days of hearings to look at the sector’s preparations and response to the crisis. The commission will probe the NSW outbreaks in homes but not delve in detail into particular homes in Victoria because the crisis is ongoing there.

Aged care is a Commonwealth responsibility, while the states are responsible for health.

Rozen said on Commonwealth data, more than 1,000 residents had been diagnosed with COVID-19, of whom 168 had died.

The pandemic had “starkly exposed” the flaws in the sector that had been highlighted during the royal commission.

In view of the deficiencies it was “hardly surprising that the aged care sector has struggled to respond to COVID-19”.

He stressed the consequences of the deskilling of the aged care workforce and a shortage of clinical skills in homes.

Rozen quoted health minister Greg Hunt saying on July 29 that “aged care around the country has been immensely prepared”. But, Rozen said, “in a number of important respects, the evidence will demonstrate that the sector has been underprepared”.

“We will be asking if greater attention to preparation may have saved lives and could save lives in the future.”

Rozen said that between June 19 and August 3, a crucial period when new infections in Victoria escalated, there was no updated advice for the aged care sector from the Australian Health Protection Principal Committee – the main source of COVID advice.

“There was no advice about how the sector should respond to the risk posed by aged care workers who may be COVID-19 positive yet asymptomatic, particularly those who work in multiple facilities.”

Rozen was critical of the Commonwealth regulator, the Aged Care Quality and Safety Commission, which oversees the sector.

“The regulator did not have an appropriate aged care sector COVID-19 response plan. Given that it was widely understood that recipients of aged care services were a high risk group, this seems surprising.”

On March 17, the regulator wrote to providers with a survey asking about their preparedness. Overwhelmingly they claimed to be prepared, but evidence would be critical of this survey, Rozen said.

He questioned the late timing of the regulator’s action in relation to the Newmarch House in Sydney and the fact the regulator had not investigated the circumstances of the Dorothy Henderson Lodge and Newmarch House outbreaks.




Read more:
View from The Hill: Aged care crisis reflects poor preparation and a broken system


“We also have concerns about whether the regulator’s powers of investigation are adequate,” Rozen said, adding that comparable regulators in areas such as workplace or airline safety were not as fettered.

There were “notorious problems” in the relationship between the health system run by the states and the Commonwealth aged care sector, Rozen said.

He detailed an argument between federal and NSW authorities about whether residents with COVID should be transferred to hospitals, with the federal authorities wanting transfers and the state official opposing.

“Equal access to the hospital system is the fundamental right of all Australians young or old and regardless of where they live,” Rozen said.

“Many of the residents in aged care homes worked their entire lives to build the world class health system of which Australians are justifiable proud.

“They have the same right to access it in their hour of need as the rest of the community. To put it very directly, older people are no less deserving of care because they are old. Such an approach is ageist”.

Rozen noted the time it took, after experience in Sydney, for the Commonwealth health department to advise providers that 80-100% of their workforce might need to isolate in a major outbreak, and even then it was not highlighted.

“Regulators in other fields such as workplace safety publish page one ‘alerts’ to disseminate promptly via safety information they learn from incident investigations.”

Rozen said masks were not made compulsory for aged care workers until July 13 – two days after the first recorded deaths of an aged care resident in Victoria. On July 13, the number of new Victorian infections was 250.

“Why did authorities wait until after the fir
st death to take what seems the simple and obvious step of making masks compulsory for aged care workers?”

Commonwealth aged care regulator admits it was told of St Basil’s outbreak

The head of the Commonwealth’s Aged Care Quality and Safety Commission, Janet Anderson, has told a Senate inquiry St Basil’s Home for the Aged informed the commission of its COVID outbreak on July 10 – contrary to claims made previously that the Commonwealth was not told until July 14.

In a letter to the Senate committee on COVID-19, Anderson wrote she had become aware that on July 10, during a telephone call responding to the commission’s assessment contact program the St Basil’s representative “provided information that one staff member … was diagnosed with COVID-19 on 8 July 2020 and the Public Health Unit (PHU) had been advised”.

Anderson, the aged care minister, Richard Colbeck, and the secretary of the federal health department Brendan Murphy all told the committee on August 4 the Commonwealth had not been informed about the outbreak until July 14.

That was when the Victorian health and human services department notified it. The time lag has been seen by the Andrews government’s critics as further evidence of its poor administration.

In her letter Anderson said the commission was not the first responder to an outbreak and the phone contact had been part of a commission program to seek assurances from facilities that COVID plans had been developed and were ready to be acted on.

“The regulatory official from the Commission who made the assessment contact referred the service’s responses to the Commission’s COVID-19 Response Team and this information was escalated internally and recorded in the Commission’s daily COVID-19 confirmed case tracker, Anderson wrote.

“The Commission did not escalate the matter externally at the time because the St Basil’s representative had confirmed in the interview that they had advised the PHU [the Victorian Public Health Unit] of the outbreak. The representative also confirmed that they had read the ‘First 24 hours’ document.”

Anderson noted this federal health department document lists four actions to be taken in the first 30 minutes. These steps are: isolate and inform the COVID-19 positive case(s); contact the local Public Health Unit; contact the Commonwealth Health Department; lock down the facility.

Anderson said the commission was later advised about the outbreak by the health department on July 14.

“To manage any risks of provider failure to notify the relevant authorities of a COVID-19 outbreak, the Commission now has arrangements in place to confirm immediately with the Commonwealth Department of Health that they have been directly notified by the affected aged care service of any outbreak at that service that comes to the Commision’s attention by whatever means.”

Asked about the bungle, Scott Morrison was sharp. He said the commission was an independent body that operated formally separate from the government but he was concerned about the breakdown in communication.

He said where there were breakdowns and issues, he wanted to know about them and fix them.

“We will be following [the matter] through with the commissioner. And at the end of the day, they’re an independent statutory office and they know their responsibilities and they need to live up to them.”The Conversation

Michelle Grattan, Professorial Fellow, University of Canberra

This article is republished from The Conversation under a Creative Commons license. Read the original article.

Should all aged-care residents with COVID-19 be moved to hospital? Probably, but there are drawbacks too


Jed Montayre, Western Sydney University and Richard Iain Lindley, University of Sydney

COVID-19 is continuing to devastate Victorian aged-care homes, with 1,435 active cases now linked to the sector, and at least 130 residents having died.

The question of whether to automatically move residents with COVID-19 out of aged-care homes and into hospital has divided public and expert opinion.

There are both advantages and disadvantages to consider.




Read more:
4 steps to avert a full-blown coronavirus disaster in Victoria’s aged care homes


Different states have different policies

South Australia pledges to send any resident who tests positive for COVID-19 to hospital.

In New South Wales, a resident who tests positive is to be immediately assessed by the facility management, public health and local hospital services to plan the initial response — whether that’s a transfer to hospital or remaining at the home.

Victorian policy is similar. The public health officer responding to an outbreak notification will assess the patient and assist with this decision.

As of the beginning of this week, more than 300 Victorian aged-care residents with COVID-19 had been transferred to hospital. But that leaves a similar number remaining at home.

Certainly no other state is facing the pressure Victoria is to get this response right.

Elderly woman lying in hospital bed.
Different states have different policies on whether to move aged-care residents with COVID-19 to hospital.
Shutterstock

What can hospitals offer that aged-care homes can’t?

Specialist treatment

COVID-19 is a serious infection with very high death rates among frail older people.

While aged-care homes can provide a degree of nursing and medical care, hospitals are best positioned to provide specialist treatment and the sophisticated interventions many patients will need.

Better infection control measures

Arguably the key reason to move an infected resident to hospital is to stop COVID-19 spreading to other residents and staff. Aged-care settings are not conducive to infection control in the same way hospitals are.

First, they’re not designed like hospitals. As well as not having the same clinical features, many aged-care facilities follow a “boutique” design with common areas for gatherings and events. Residents and staff can easily congregate in these spaces.

The best efforts to isolate a resident with COVID-19 in aged care could easily be compromised. For example, it’s common for residents with dementia to wander in the corridors. Being contained may exacerbate these sort of behaviours among confused and anxious residents.

More highly trained nurses

Staff shortages in aged care were well documented even before the pandemic. A further depleted workforce during COVID-19 — due to staff off work and restrictions on working across multiple facilities — likely means they’re stretched even thinner. Staff may not always have the capacity to supervise isolated residents or follow infection control procedures.

The much higher ratio of highly trained nursing staff in hospitals should ensure better adherence to the guidelines around proper use of personal protective equipment.

For example, registered nurses in aged-care facilities don’t usually provide direct care to residents. Instead they supervise care provided by unregulated staff often with limited infection control training.




Read more:
View from The Hill: Aged care crisis reflects poor preparation and a broken system


What are the disadvantages of hospital transfers?

Older people benefit from carers who know them

The care people receive in aged-care homes relies significantly on staff knowing the residents’ personal and clinical profiles. Aged-care facilities promote person centred care models, which value residents’ rights while striving to create a home-like environment.

Familiar faces who understand residents’ personal preferences may be particularly valuable during a time when residents aren’t able to see their loved ones.

A nurse and a man with a walking stick are seated on a couch. The nurse is reading.
Residents in aged care develop relationships with staff over time.
Shutterstock

Introducing a completely new environment during an illness, particularly for residents with dementia, may do more harm than good.

Limited knowledge about the resident could lead to unmet needs while in hospital, which could trigger behaviours that are difficult to manage.

For older adults with dementia, the likelihood of incidents like falls and infections increases when they’re admitted to hospital.




Read more:
Social housing, aged care and Black Americans: how coronavirus affects already disadvantaged groups


The hospital perspective

Importantly, hospitals may not be able to cope with such a large influx of aged-care residents at one time. The rising numbers of COVID-19 cases from the general population, including older adults living in the community, have already put the health system under a lot of stress.

So there’s an argument that if COVID-19 cases can be managed within the aged-care home, they should be, to avert pressure from the hospital system.

Worryingly though, we’ve seen reports of the health department denying requests for aged-care residents with COVID-19 to be transferred to hospital.

Respecting autonomy and the right for care

On balance, as much as possible, it’s probably be better to transfer residents to hospital as soon as they test positive to COVID-19. This offers the best chance of preventing widespread infection among other residents and staff, and disease spread from the home into the community.

But we must also respect residents’ autonomy. They might have requested not to be transferred to hospital, even if their illness is life-threatening, by way of an advanced care directive. This might still be their wish, or the preference of their relatives and decision-makers.

Conversely, residents or their surrogate decision-makers might request hospital care, even when care is possible within the home. Again, we argue this is their right.

We should also allow people to change their minds, as these decisions may have been agreed upon before the pandemic.




Read more:
Banning visitors to aged care during coronavirus raises several ethical questions – with no simple answers


The Conversation


Jed Montayre, Senior Lecturer (Nursing), Western Sydney University and Richard Iain Lindley, Professor of Geriatric Medicine, University of Sydney

This article is republished from The Conversation under a Creative Commons license. Read the original article.

View from The Hill: There’s no case for keeping secret any aged care facility’s COVID details


Michelle Grattan, University of Canberra

Should the public know the details of all the Victorian aged care facilities that have had COVID-19 cases?

“Yes” seems the obvious answer. But not according to the Health department or Aged Care Minister Richard Colbeck.

At Tuesday’s hearing of the Senate committee monitoring the government’s responses to the pandemic, Greens senator Rachel Siewert sought this information, asking about providers, residents, cases and deaths.

Health department secretary Brendan Murphy – formerly chief medical officer who in that role was often at Scott Morrison’s side at news conferences – asked to provide the information to the committee “in camera”.

“Some of the facilities don’t want it publicly known that they have outbreaks,” Murphy said.

“Many, many of them have been open about it and it’s in the media. But some of them have just had one staff member and the facility has been locked down and it’s been controlled. And they’re obviously worried about reputational issues.”

When Siewert put it that the public had a right to know, Colbeck said the families with a member in a facility were “aware of what’s happening.

“But I am concerned about the stress that’s placed on facilities by some of the public elements of this process.

“I understand where you’re coming from in one sense, but talking to, particularly some of the smaller facilities, their capacity to deal with a huge influx of, say media inquiry can severely impact on the facility.

“And in the circumstance where they’re doing well, the families are being appropriately advised … I’m reluctant to have a public hit list of facilities that have been unfortunate enough to have an outbreak of COVID within them.”

He and Murphy said facilities with outbreaks are locked down and don’t take new residents.

Victorian premier Daniel Andrews reported on Tuesday that all of the latest 11 deaths were linked to outbreaks in aged care facilities. They are part of a chain of multiple deaths, now announced day after day, from aged care in this Victorian second wave. On Tuesday’s figures, there were 1186 active COVID cases relating to aged care facilities (this includes residents and staff).

The Victorian government provides a list of the facilities that have had the largest outbreaks. State government sources, asked on Tuesday night, said it is not seeking to keep secret the others. It doesn’t provide details of deaths in circumstances where that would identify individuals.

The arguments advanced by Murphy and Colbeck for secrecy are flawed and can give the public little confidence.

These are institutions funded and regulated by the federal government, and provided with a great deal of taxpayers’ money. There should be total transparency about what happens in them.

We know from official and media reports over years, and the experience of many families, that it’s vital to get as much information as possible in real time about what’s going on in aged care.

While facilities that have had minimal COVID cases are not in the same class as those with massive outbreaks, it doesn’t mean the details of those homes and cases should be hidden.

It is understandable facilities do not want “reputational” damage. But the magnitude of what is occurring in the sector in Victoria means we are past that concern. It is now a question of accountability.

Colbeck is worried about “media inquiries” and a “hit list”.

“Media inquiries” refers to journalists asking for facts, questions the public would reasonably want answered. As for a “hit list”: families making decisions in the future about institutions have the right to know how an institution performed in the COVID crisis.

How cases arose in facilities – even a single case – is also relevant to assessing the pandemic across the sector.

Committee chair Katy Gallagher said later on Twitter the committee would consider Murphy’s request for the information to be provided in camera.

But she added it would need to be persuaded “of the public interest test of keeping it secret”. That, one would think, would be very difficult.The Conversation

Michelle Grattan, Professorial Fellow, University of Canberra

This article is republished from The Conversation under a Creative Commons license. Read the original article.

AUSMAT teams start work in aged care homes today. But what does this ‘SAS of the medical world’ actually do?



from www.shutterstock.com

Jamie Ranse, Griffith University

The emergency response to Victoria’s COVID-19 crisis has been ramped up today with AUSMAT teams now working alongside defence force and hospital nurses in aged care homes.

This comes as the total number of active COVID-19 cases linked to aged care in Victoria is now at 913.

Federal health minister Greg Hunt recently said AUSMAT, or Australian medical assistance teams, are:

[…] the best of the best. They are the SAS of the medical world.

But what is an AUSMAT? What can they do? And what do we need to think about when deploying them?




Read more:
View from The Hill: Aged care crisis reflects poor preparation and a broken system


What is a medical assistance team?

A medical assistance team is a group of doctors, nurses and/or paramedics who provide clinical care and health support during a health crisis, as part of a recognised organisation.

Logistics, environmental health and other personnel often support these clinical teams.

Medical assistance teams contribute to a coordinated health response in an attempt to restore and/or maintain the health capacity of a community affected by disaster or public health emergency.

In Australia, a medical assistance team may be a civilian government team (such as AUSMAT), non-government organisations (such as Disaster Relief Australia or St John Ambulance Australia), the Australian Defence Force, or a combination of these.

While an AUSMAT is usually deployed internationally, teams were deployed in Australia during last summer’s bushfires, to help with evacuations from China to Christmas Island at the start of the pandemic, and in April to support COVID-19 efforts in northwest Tasmania.

Who’s in an AUSMAT?

Health-care professionals in an AUSMAT usually work at hospitals, health services or ambulance services in states and territories across Australia.

When required, they are released from their local duties to be deployed as part of an AUSMAT response.

They are often highly experienced and leaders in their disciplines. Members undertake additional education and training to work in disaster environments and to manage the health response.

They are also highly regarded. AUSMAT was one of the first medical assistance teams worldwide to be endorsed by the World Health Organisation.

How have they been deployed internationally?

AUSMATs were set up after the 2002 Bali bombings, then used after the 2004 Indian Ocean tsunami.

Since then, AUSMATs have been used during crises, mainly in South Asia, Southeast Asia and Oceania, including the 2010 Pakistan floods, 2011 Christchurch earthquake and Typhoon Haiyan which hit the Philippines in 2014.

AUSMAT also assisted during last year’s Samoan measles outbreak.




Read more:
Measles in Samoa: how a small island nation found itself in the grips of an outbreak disaster


What are the issues when deploying them during COVID-19?

The role of an AUSMAT team will change over the duration of their deployment. Based on previous experience, AUSMAT members may provide direct patient care, coordination of care, or leadership roles.

There is the risk that temporarily sending health workers to work in Victoria as part of an AUSMAT will leave their existing hospitals and health services short-staffed.

At this stage, this is not thought to be a great concern as areas outside Victoria are not yet so significantly impacted by COVID-19, making it easier that their home states will manage without them.

However, if the situation worsens in other states, it may become harder to convince these states to release staff to support interstate efforts.

We also need to look after the physical and psychological well-being of AUSMAT health-care professionals.

We prepare them to assist with emergency health efforts but we don’t always prepare them to return to their normal roles afterwards. Some find it difficult to adjust.




Read more:
4 steps to avert a full-blown coronavirus disaster in Victoria’s aged care homes


What are the benefits to other states?

As well as directly helping the health response where they are sent, there are other benefits to an AUSMAT deployment.

When health workers from other states, such as South Australia and Queensland, work alongside AUSMAT and defence force teams, they can take that experience back to their home states to better prepare for a local COVID-19 outbreak.




Read more:
Coronavirus pandemic shows it’s time for an Australian Centre for Disease Control – in Darwin


The Conversation


Jamie Ranse, Senior Research Fellow; Emergency Care, Griffith University

This article is republished from The Conversation under a Creative Commons license. Read the original article.

Social housing, aged care and Black Americans: how coronavirus affects already disadvantaged groups


Hassan Vally, La Trobe University

While it’s true anyone is at risk of catching and becoming ill with COVID-19, it’s becoming increasingly clear this virus discriminates.

From early in the pandemic, we’ve seen how COVID-19 disproportionately affects older people and those with other health conditions, who are more likely to develop severe symptoms and die.

But as well as discriminating on the basis of biology, this virus discriminates on the basis of socioeconomic disadvantage. It ruthlessly picks on the most vulnerable in society.




Read more:
Our lives matter – Melbourne public housing residents talk about why COVID-19 hits them hard


The Melbourne tower blocks

The recent COVID-19 cases in social housing, which saw nine public housing towers in Melbourne’s north put into hard lockdown, brought this into sharp focus. These tower blocks accommodate some of the most vulnerable people in our community.

People living in these buildings experience high levels of unemployment and job insecurity, generally exist on low wages, have limited access to education, are often from migrant backgrounds, and in some instances are victims of trauma.

The fact we saw the virus spread through these towers should be no surprise given what we know about how it spreads in crowded conditions and shared spaces. Physical distancing is almost impossible when you have big families living in two-bedroom units.

An elderly person is assisted by a carer.
Aged care residents are at higher risk from COVID-19.
Shutterstock

Importantly, for cultural and language reasons, generic health messaging may miss the mark for these groups.

These factors combine to put social housing residents at increased risk of contracting the virus.

Aged-care facilities

Another group this pandemic disproportionately affects is aged-care residents. In aged-care facilities we have a perfect storm: an environment conducive to virus transmission and residents who are among the most susceptible to serious outcomes from infection.

Add into the equation the well-documented system deficiencies and workforce issues that have plagued Australia’s aged-care sector, and we have another situation in which some of the most vulnerable in our society are disproportionately affected by COVID-19.

We’ve seen this in Australia and around the world. Once you have community transmission of COVID-19 it’s hard to keep it out of aged-care facilities, and once in, outbreaks in this setting can be difficult to stop.




Read more:
4 steps to avert a full-blown coronavirus disaster in Victoria’s aged care homes


African Americans in the United States

The disproportionate effect of the pandemic on the most disadvantaged, vulnerable and marginalised in society is not just evident in Australia, but throughout the world.

There is perhaps no better example than the plight of African Americans in the United States. Figures released in May reported Black Americans were dying at almost three times the rate of white Americans from COVID-19.

One of the main reasons Black Americans face a higher health burden from COVID-19 is their increased rate of accompanying health problems such as heart disease, high blood pressure and diabetes.

This burden is amplified by the fact many are excluded from the basic access to health care we take for granted here in Australia.




Read more:
We could have more coronavirus outbreaks in tower blocks. Here’s how lockdown should work


And it’s not only the health effects of the virus which hit the disadvantaged harder. These people are also much more vulnerable to the indirect economic impacts of the pandemic, by virtue of their lower financial resources to begin with.

Looking across the globe

COVID-19’s discrimination against the vulnerable also extends to entire countries. Poorer and less developed nations, such as in Africa and Latin America, will potentially suffer the most in the immediate and longer term.

With weaker health systems, scarcity of medical resources (less equipment such as ventilators, for example) and large, vulnerable populations, these countries are less able to cope with a crisis of this magnitude.

And beyond the demands placed on their health systems, these countries have less capacity to withstand the economic shocks of the pandemic. Its effects could well catapult them into further crises, such as food insecurity.




Read more:
Coronavirus discriminates against Black lives through surveillance, policing and the absence of health data


We know infectious diseases, like other health conditions, are highly influenced by the social determinants of health. That is, the conditions in which people live, learn and work play a significant role in influencing their health outcomes.

Broadly speaking, the greater a person’s socioeconomic disadvantage, the poorer their health.

In shining a light on these inequities the pandemic also provides an opportunity for us to begin to address them, which will have both short and longer term health benefits.The Conversation

Hassan Vally, Associate Professor, La Trobe University

This article is republished from The Conversation under a Creative Commons license. Read the original article.