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.




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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.

Victoria’s latest elective surgery slowdown is painful but necessary



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Stephen Duckett, Grattan Institute

Just weeks after allowing public hospitals to restart elective surgeries, the Victorian government has ordered Melbourne hospitals to defer category 3 procedures again.

Category 3 procedures include hip and knee replacements and cataract procedures. Category 3 patients are the easiest to defer because they have been assessed as not requiring treatment within three months.

Elective surgery will also be reduced to no more than 50% of usual activity across all public hospitals and 75% in private hospitals.

Whether further reductions in planned surgery will be necessary — such as limiting category 2 patients — will depend on the trajectory of the pandemic, and the extent of competing demands from other emergency patients.




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The coronavirus ban on elective surgeries might show us many people can avoid going under the knife


Deferring planned procedures is not an easy decision

Although some surgery is of limited value to the patient, and some problems would be better treated in other ways, in most cases the surgery is necessary to reduce pain and enable people to go about their day-to-day lives.

But as Victoria’s second wave reaches concerning heights, the Victorian government has to make difficult decisions.

The latest pause on elective surgeries affects hospitals in metropolitan Melbourne.
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Hospital beds, including intensive care beds, are used both for planned procedures and for emergency treatment — and that includes patients infected with COVID-19.

As the number of people infected in Victoria has increased, so too has the demand for beds. To avoid a situation in which people need to be turned away by hospitals or denied effective treatment, the proper course for government is to order hospitals to reschedule lower-priority planned procedures.




Read more:
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It’s a staffing issue too

The pressure on the system is exacerbated when the number of available hospital staff falls. We’re currently seeing high numbers of COVID-19 cases among health workers, meaning they — and any fellow staff they’ve been in contact with — are having to stay home to avoid infecting others.

Victoria has mandated minimum staffing ratios so when the number of available hospital staff falls, the supply of staffed beds also falls. This double whammy of increased demand and reduced supply makes it even more important for the government to make this choice.




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Rising coronavirus cases among Victorian health workers could threaten our pandemic response


This new deferral will be hard for patients whose procedures were deferred during the first wave of the pandemic. Some will have just been given a new date for their deferred surgery, but now face a further wait.

Unfortunately, there’s no way of knowing how long the deferral will be. Today has seen 428 new cases recorded in Victoria, and it’s still too early in the second lockdown to assess whether we’ve been able to bring the virus under control again.The Conversation

Stephen Duckett, Director, Health Program, Grattan Institute

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

From hospitals to households, we can all be better at remembering to wash our hands



F. Cary Snyder/Unsplash, CC BY

Debbi Long, RMIT University

While Australia gradually opens up from COVID-19 lockdown, Victoria is still struggling to contain the outbreak. The Black Lives Matter protest in Melbourne on June 6, which attracted thousands of face-masked and hand-sanitised protesters, did not prove to be the public health nightmare many commentators (particularly politically conservative ones) had predicted. But Melbourne is nevertheless contending with a worrying spike in case numbers arising from infection clusters around staff working in quarantine sites and extended family gatherings.

From the beginning of the COVID-19 pandemic, we were told two behaviours were crucial to keeping us safe: social distancing and handwashing. The coronavirus crisis has brought the mundane act of washing our hands into public discussion, and the internet is now awash (ahem) with advice, from the practical to the surreal.

Judi Dench on hand with some helpful, if mildly unsettling, advice.

If there’s one place where you would expect hand cleanliness to be beyond reproach, it’s hospitals. But this isn’t necessarily the case.

Surprisingly, hand hygiene is a vexing issue in hospitals all over the world. Repeated studies have shown it is common for hospital staff to follow hand hygiene protocols less than 50% of the time. This is as true in Australia and New Zealand-Aotearoa as it is globally. As any infection control nurse will tell you, specialist doctors are often among the worst offenders.

Who teaches hospital staff how to handwash?

Like most Western-style hospitals, all Australian hospitals have infection control experts, typically nurses, whose job is to educate, advise and monitor compliance on infection control protocols among hospital workers. This is lifesaving work, because hospitals are prime breeding grounds for deadly antibiotic-resistant bacterial strains.




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Washing our hands of responsibility for hospital infections


The main line of defence in hospitals against these potentially fatal infections is prevention, hence the strict protocols around hand hygiene, and widespread use of gloves, robes, masks and safety googles.

Proper hospital hand hygiene involves using gloves, hand sanitiser, and frequent handwashing. Protocols dictate that gloves should be used in situations where health workers might expect to come into contact with blood, bodily fluids or other contaminants. Staff should wash or sanitise their hands before and after every patient contact, and in all situations where there has been contact with potentially contaminated material.

Infection control nurses undertake routine hand hygiene audits, and hospital staff can be disciplined if they fail to comply with the protocols.

Three types of handwashers

What makes hospital staff more or less likely to comply? It turns out there are different categories of handwasher, and therefore different ways to help people remember to do it.

While working on a project looking at communication in a multidisciplinary hospital team, infection control education became one of the areas of interest. Part of the study focused on the hand hygiene habits of hospital staff in a ward with particularly high infection risks.

Based on observations, interviews and informal conversations, we discovered nursing staff tended to fall into one of three broad categories: “hero healthworkers”, “family members”, and those who were “working for the whitegoods”.

Overall, most health-care workers practised good hand hygiene most of the time. But when there was time pressure — such as during short-staffed shifts, or when multiple patients were in particular need at the same time — nearly everyone had moments of non-compliance. But, fascinatingly, there were patterns to this non-compliance.


Kelly Sikkema/Unsplash, CC BY

No matter how busy things were, “hero healthworkers” always practised hand hygiene before approaching a patient’s bed. But if time was short, sometimes they did not wash or sanitise their hands on leaving the patient. Nurses (and doctors) who exhibited this behaviour tended to make comments suggesting they valued patients’ health above their own.

“Family members” always practised good hand hygiene when leaving a patient, but sometimes missed out on washing or sanitising before interacting with a new one. In each case, these staff members had vulnerable people in their household – mostly young children, and in a couple of cases older relatives. Interviews and informal discussions revealed deep concern around infection risks and “taking something home”.

The third group was mostly meticulous in their practice when observed by a superior, but much less conscientious when only peers were around. Nurses who fitted this pattern tended to be disparaged by their colleagues as “working for the whitegoods” – treating nursing less as a professional vocation and more as “just” a job to earn money.

These patterns were observed — sometimes with minor variations — in more than a dozen wards over three different hospital sites during subsequent research projects.

How to improve things

None of these behaviours appear to have been conscious, even among the least conscientious “whitegoods” group. Many staff recognised their own behaviour patterns when they were pointed out, but said they had not been explicitly aware of them.

Identifying these characteristic behaviour patterns allowed the infection control educator to target education efforts more effectively. “Hero healthworkers” were educated on the risks to other staff by potentially transmitting infection to work surfaces and other places in the hospital by not handwashing after seeing a patient. “Family members” were reminded of the risks to patients of transmitting infections in the opposite direction. And those who only complied when being directly supervised were counselled on the need to have high standards at all times.

This shift in education strategy was employed along with a number of other infection control interventions, resulting in a significant reduction in multidrug-resistant infections.




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How clean is your hospital room? To reduce the spread of infections, it could probably be cleaner


One insight we can take from this for our day-to-day realities in the middle of COVID-19 is to be reflective about our own handwashing practices. When are we conscientious, and when do we let our standards slip? Is there a pattern in our own behaviours that we can identify, and what are the subconscious beliefs driving those practices? Can we use that knowledge to change our behaviours?

The simple act of handwashing is perhaps more complex than we realise. But it is one of the things that will determine how well we fare in the current pandemic.The Conversation

Debbi Long, Senior Research Fellow, RMIT University

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

What elective surgery will be allowed now the coronavirus situation has improved? It’s up to your surgeon or hospital



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Stephen Duckett, Grattan Institute

Australian Prime Minister Scott Morrison has announced some elective surgery can start again in private hospitals, as it becomes clear the health system will cope with the additional coronavirus demand.

He said this week “all Category 2 or equivalent procedures in the private sector, and selected Category 3 and other procedures, which includes all IVF” can restart.

What’s this mean for you? It all depends on which category you are in – and what your surgeon has decided about how urgently your surgery is needed.

It also depends on whether you are a patient in a private hospital or public hospital. If it’s the latter, you can expect to wait a while until the hospital can tell you exactly when your surgery will happen.




Read more:
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Category 1, Category 2, Category 3: what’s the difference?

Private hospitals have not had elective surgery waiting lists in the past and so have not categorised patients for elective surgery. So it’s no surprise this announcement has created enormous confusion.

States have not yet announced their plans for restarting elective surgery.

Elective procedures are categorised into three categories based on urgency:

  • Category 1, the most urgent, is where patients should be seen within 30 days
  • Category 2 patients should be seen within 90 days
  • Category 3 patients should be seen within 365 days.

Categorisation is done by the surgeon and takes into account the specific circumstances of the patient. For example, they would consider the extent of the pain and mobility loss, and the impact on the work or education if the surgery was delayed.

Different surgeons can assign patients different categories

Unfortunately, different surgeons seeing the same patient may make different assessments of what category they should be in. This policy issue needs to be addressed.




Read more:
Elective surgery’s due to restart next week so now’s the time to fix waiting lists once and for all


There is no fixed rule about whether a particular procedure is always in a specific category.

However, generally cardiac surgery, such as a heart bypass, will be classified as Category 1. More than half of all patients awaiting this procedure are treated within three weeks.

A patient waiting for a hip replacement, on the other hand, will be typically categorised as Category 2 or 3. In fact, half the patients waiting for that procedure had to wait up to four months.

Waiting times for public hospital treatment is longer in some states and others. Data for elective surgery waiting times it is published by the Australian Institute of Health and Welfare.

Categorisation is done by the surgeon and takes into account the specific circumstances of the patient.
http://www.shutterstock.com

How do I know what category I’m in?

If you are scheduled for an operation in a private hospital, either the hospital or the surgeon will contact you.

They will let you know if your surgery is now going ahead, and discuss with you appropriate timing. Elective surgery will commence over the next week, so private hospital patients should hear from the hospital surgery within the next fortnight or so.

Because states haven’t yet revealed their strategies for restarting elective surgery, public hospital patients should not expect to hear from the public hospital until those announcements have been made.The Conversation

Stephen Duckett, Director, Health Program, Grattan Institute

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

Elective surgery’s due to restart next week so now’s the time to fix waiting lists once and for all



Monkey Business Images/Shutterstock

Stephen Duckett, Grattan Institute

The near-total shutdown of elective surgery across Australia will end soon, following National Cabinet consideration on Tuesday.

The shutdown was imposed to ensure there would be enough personal protective equipment (PPE) for doctors and nurses to manage a projected tsunami of COVID-19 patients in our hospitals.

But now there is a big backlog of Australians waiting for elective procedures.




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Good news on elective surgery, but dire warning on the economy


Elective surgery waiting times are the bane of every state health minister’s life. Better ways to manage such procedures could be a major benefit from the shutdown and restart.

But we have to act quickly if we are to change how we manage these wait lists, as federal Health Minister Greg Hunt wants a staged reintroduction to begin on April 27.

Rethink priorities

Currently, elective surgery is classified as urgent (category 1), semi-urgent (category 2) and non-urgent (category 3). But different hospitals and different surgeons actually classify patients in different ways.

What’s worse is that some procedures are undoubtedly unnecessary, such as spinal fusion or removing healthy ovaries during a hysterectomy, and would provide no value for the patient, as Adam Elshaug and I have argued before.

Of course, not all of the backlog is low-value procedures. As states consider how to recommence elective surgery, they should seize this opportunity to introduce new systems, especially in metropolitan areas.

A properly managed elective procedures system should have three key elements:

  • there should be a consistent process for assessing a patient’s need for the procedure, and ranking that patient’s priority against others

  • the team performing the procedure, and caring for the patient afterwards, should be highly experienced in the procedure

  • the procedure should be performed at an efficient hospital or other facility, so the cost to the health system is as low as possible.

Unfortunately, Australia sometimes fails on all three measures.

Stop the inconsistencies

There is no consistent assessment process across hospitals. Even different surgeons in the same hospital seeing the same patient sometimes make different recommendations about the need for a procedure.

This means a patient lucky enough to be seen at hospital A may be assigned to category 2, but the same patient seen at hospital B might be assigned to category 3 and so have to wait longer.

Patient characteristics, such as gender or level of education, also seem to inappropriately affect categorisation decisions.

High-volume hospitals and other facilities generally have better outcomes for a given procedure than low-volume centres. And they are more efficient.

Yet most states ignore these facts. They have done little to rationalise services for the benefit of both the patient and the taxpayer.

Time for change

The large backlog of demand creates the opportunity for a new way of doing things. States should develop agreed assessment processes for high-volume procedures, such as knee and hip replacements and cataract operations, and reassess all patients on hospital waiting lists.

Reassessment could be done remotely using telehealth. Specialists in each area should be invited to develop evidence-based criteria for setting priorities. Where appropriate, patients should be diverted to treatment options other than surgery.

Private health insurers should be empowered to participate in funding diversion options so patients are able to have their rehabilitation at home rather than in a hospital bed.

A new, coordinated, single waiting list priority system in each state would enable all patients to know where they stand. A patient on the top of the list would be offered the first available place, regardless of whether it was closest to their home.

They could refuse the offer, without losing their place in the queue, if they wanted to wait for a closer location.

The health minister says it’s up to hospitals to decide which patients get to undergo elective surgery.
Roman Zaiets/Shutterstock

The single waiting list should include both regional and metropolitan patients, to ensure as much as possible that city patients do not get faster treatment than people in regional and remote area.

Patients with private health insurance can opt to be treated as a private patient in a public hospital. So the waiting list should include public and private patients, to prevent private patients gaining faster admission to public hospitals.

The system should be further centralised in metropolitan areas. The full range of elective procedures should not be re-established in every hospital. Some surgeons would need to be offered new appointments if elective surgery in their specialty was no longer being performed at the hospital where they previously had their main appointment.

Private hospitals can help

The private hospital system has taken a battering during the pandemic. Private hospitals have effectively been closed, and their viability may be under pressure.

States should consider signing contracts with private hospitals, at or below the public hospital efficient price, for elective procedures to be performed in these hospitals to help clear the elective surgery backlog.




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As part of the new service model, states should bolster their hospital-in-the-home systems. For many patients, rehabilitation at home or as an outpatient can produce better outcomes than in-hospital rehabilitation.

The pandemic is not over yet and policymakers are right to be turning their minds to the transition back to something approaching business as usual. But the new, post-pandemic normal should be nothing like the old.

Physical distancing seems to be beating the virus, but the second victim might be health reform. Not wasting the crisis is the cliché on everyone’s lips. Australia has the chance to improve our elective surgery system. For the sake of taxpayers and patients, we should grasp it.The Conversation

Stephen Duckett, Director, Health Program, Grattan Institute

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

Good news on elective surgery, but dire warning on the economy


Michelle Grattan, University of Canberra

Restrictions are to be eased on elective surgery, enabling a “gradual restart” to procedures next week.

But as national cabinet took early baby steps towards restoring normality, Reserve Bank Governor Phil Lowe warned the first half of this year would likely see the biggest contraction in Australia’s national output and income since the 1930s depression.

After Tuesday’s national cabinet meeting, Scott Morrison announced that from Monday, category 2 and some important category 3 procedures can restart in public and private hospitals. These were earlier suspended amid uncertainty about how hard COVID-19 would hit the hospital system.




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Category 2 covers cases needing treatment within 90 days; category 3 are ones that require treatment in the next year.

The easing will cover:

  • IVF

  • screening programs (cancer and other diseases)

  • post cancer reconstruction procedures (such as breast reconstruction)

  • procedures for children under 18 years of age

  • joint replacements (incl knees, hips, shoulders)

  • cataracts and eye procedures

  • endoscopy and colonoscopy procedures.

More dentistry services will also be available.

The elective surgery easing has been facilitated by the extra availability of protective equipment; also, the low number of COVID-19 cases has meant the pandemic has not placed as much demand on beds as had been feared.

It is estimated the announced easing will lead to reopening about 25% of the elective surgery activity that had been closed in private and public hospitals.

Morrison said the situation would be reviewed on May 11 to decide whether all surgeries and procedures could recommence more broadly.

Clinical decisions will determine the priority given to cases.

The Prime Minister said the easing “is an important decision because it marks another step on the way back. There is a road back”.

On aged care, national cabinet was concerned some nursing homes are being too extreme, with full lockdowns that do not allow residents to have any visitors.

People in nursing homes are particularly vulnerable to the coronavirus and there have been outbreaks and deaths in the sector.

But “there is great concern that the isolation of elderly people in residential care facilities, where they have been prevented from having any visits … is not good for their well-being, is not good for their health,” Morrison said.

The national cabinet gave a “strong reminder” that its earlier decision was “not to shut people off or to lock them away in their rooms.”

This decision was to allow a maximum of two visitors at one time a day, with the visit taking place in the resident’s room. Apart from that, residents should be able to move around the facility.




Read more:
Hospitals have stopped unnecessary elective surgeries – and shouldn’t restart them after the pandemic


Further restrictions would apply where there was an outbreak in a facility, or in the area.

On the economic front, in an indication of the devastating job losses that have already occurred, Morrison said since March 16, 517,000 JobSeeker claims had been processed. JobSeeker used to known as Newstart.

“By the end of this week we will have processed as many JobSeeker claims in six weeks [as] we would normally do in the entirety of the year,” he said.

In a speech at the Reserve Bank Lowe said it was difficult to be precise about the size of the contraction underway.

But on the bank’s current thinking:

  • national output was likely to fall by about 10% over the first half of 2020, with most of the decline in the June quarter

  • total hours worked were likely to decline by about 20% in the first half of the year

  • unemployment was likely to be about 10% by June, “although I am hopeful that it might be lower than this if businesses are able to retain their employees on lower hours.”

Lowe predicted inflation would turn negative in the June quarter, and it was likely prices would turn out to have fallen over the entirety of this financial year, the first time that had happened in 60 years

Lowe expressed confidence the economy would “bounce back”, but stressed the recovery’s timing and pace would depend on “how long we need to restrict our economic activities, which in turn depends on how effectively we contain the virus”.

“One plausible scenario is that the various restrictions begin to be progressively lessened as we get closer to the middle of the year, and are mostly removed by late in the year, except perhaps the restrictions on international travel.

“Under this scenario we could expect the economy to begin its bounce-back in the September quarter and for that bounce-back to strengthen from there.

“If this is how things play out, the economy could be expected to grow very strongly next year, with GDP growth of perhaps 6–7%, after a fall of around 6% this year,” Lowe said.

He said unemployment was likely to remain above 6% over the next couple of years.

“Whatever the timing of the recovery, when it does come, we should not be expecting that we will return quickly to business as usual.”

“It is highly probable that the severe shocks we are now experiencing will change the mindsets of some people and businesses. Even after the restrictions are lifted, it is likely that some of the precautionary behaviour will persist.

“And in the months ahead, we are likely to lose some businesses, despite best efforts, and some of these businesses will not reopen. There will also be a higher level of debt and some households might revaluate the risks of having highly leveraged balance sheets.

“It is also probable that there will be structural changes in the economy. We are all learning to work, shop and travel differently. Some of these changes will probably stay with us, requiring a rethinking of business models. So the crisis will have reverberations through our economy for some time to come.”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.

Hospitals have stopped unnecessary elective surgeries – and shouldn’t restart them after the pandemic



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Adam Elshaug, University of Sydney and Stephen Duckett, Grattan Institute

Part of Australia’s response to the coronavirus pandemic was a severe reduction in elective surgery, and so private hospitals have stood almost empty for a month now.

People who might otherwise have had a procedure are experiencing “watchful waiting”, where their condition is monitored to assess how it develops rather than having a surgical procedure.

The big question is whether all those procedures which didn’t happen were even necessary. There has now been a steady stream of work which suggests many procedures don’t provide any benefits to patients at all – so called low- or no-value care.




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Bringing about change in health policy is usually difficult (or slow, at best) because it’s like turning a big ship around. But in the past six weeks that ship has made a sudden about-turn.

Australia’s elective procedure system after the pandemic should be different from before the pandemic. We should dramatically reduce the number of low- or no-value procedures.

What is low- or no-value health care?

Low- or no-value health care mean the intervention provides no or very little benefit to patients, or where the risk of harm exceeds the likely benefit.

Reducing such “care” will improve both health outcomes for patients and the efficiency of the health system.

Research in New South Wales public hospitals showed up to 9,000 low-value operations were performed in just one year, and these consumed almost 30,000 hospital bed days that could have been used for high-value care.

One example of low-value care is spinal fusion surgery for low back pain. This is a procedure on the small bones in the spine, essentially welding them together. The alternative is pain management, physiotherapy and exercise.

Spinal fusion for low back pain is an example of low-value care.
Shutterstock

The NSW analysis revealed up to 31% of all spinal fusions were inappropriate. But even this figure is likely an underestimate.




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Needless treatments: spinal fusion surgery for lower back pain is costly and there’s little evidence it’ll work


Other examples include:

  • vertebroplasty for osteoporotic spinal fractures: surgery to fill a backbone (vertebrae) with cement

  • knee arthroscopy for osteoarthritis: inserting a tube to remove tissue

  • laparoscopic uterine nerve ablation for chronic pelvic pain: surgery to destroy a ligament that contains nerve fibres

  • removing healthy ovaries during a hysterectomy

  • hyperbaric oxygen therapy (breathing pure oxygen in a pressurised room) for a range of conditions including osteomyelitis (inflammation of the bone), cancer, and non-diabetic wounds and ulcers.

Low-value care can harm patients because of the risks inherent in any procedure. If a patient having a low-value procedure gets even one complication, the time they spend in hospital doubles, on average.

For some patients, the hospital stay can be much longer. For example, a low-value knee arthroscopy with no complications consumes one bed day. If a complication occurs, that length of stay increases to 11 days, on average.




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Needless procedures: knee arthroscopy is one of the most common but least effective surgeries


For most low-value procedures, the most common complication is infection.

The situation is even worse in private hospitals, where a much greater proportion of elective procedures are low value.

Prioritise treatments that work

Most state health departments and private insurers now know the size of the low-value care problem and which hospitals are providing that “care”.

Due to the COVID-19 response, the tap for these procedures has been turned down for some and off for others. This is a risk for some patients, but others will benefit from not having the surgery. We must grasp the opportunity to learn from this enforced break.




Read more:
The coronavirus ban on elective surgeries might show us many people can avoid going under the knife


One of the challenges for policymakers in the past in controlling low-value care has been difficulty in ratcheting down supply by reducing or redirecting a hospital’s surgical capacity and staff.

In many ways, the COVID-19 response has done this for them. After the pandemic, we can reassess and reorient to high-value care.

Some people will need catch-up surgeries after the pandemic, but some won’t.
Shutterstock

This does not necessarily mean reducing capacity. Some people aren’t currently getting the care they need. When the tap comes back on, this unmet backlog of care must be performed.

But this needn’t detract from a focused effort to keep the low-value care from re-emerging. The last thing we need is for low-value care to take the place of high-value care that has been delayed because of the COVID-19 response.

So how do you do it?

Australia should take three immediate steps to ensure we don’t return to the bad old days of open slather.

First, states should start reporting the rates of low-value care, using established measures. This reporting should identify every relevant hospital – public and private – and it should be retrospective, showing rates for the past few years.




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Second, states should require all public hospitals to take steps to limit low-value care – and hospitals that don’t comply should be called to account.

States have the insights and data necessary to do this.

Hospital strategies might include requiring a second opinion from another specialist before a procedure identified as low-value care is scheduled for surgery, or a retrospective review of decisions to perform such surgery.

Hospitals could require second opinions before scheduling low-value procedures.
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In the post-pandemic world, states should also consolidate elective surgery, so the number of centres performing elective procedures in metropolitan areas is reduced, with decision-making tools to highlight downsides of low-value care and the alternatives.

Third, private insurers know low-value care is provided in private hospitals, but currently have fewer levers at their disposal to reduce such care. The Commonwealth government should legislate to empower funds to address this issue. Given the Commonwealth government is providing financial support to the private hospitals during their downturn, perhaps a requirement should be that they work with the insurers and Medicare to police the re-emergence of low-value care.

It would be a dreadful shame to waste this unprecedented opportunity, and revert to the old status quo of low- and no-value care.The Conversation

Adam Elshaug, HCF Research Foundation Professorial Fellow, Professor in Health Policy and Co-Director, Menzies Centre for Health Policy, University of Sydney and Stephen Duckett, Director, Health Program, Grattan Institute

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

A coronavirus spike may put ICU beds in short supply. But that doesn’t mean the elderly shouldn’t get them



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Paul Komesaroff, Monash University; George Skowronski, and Ian Kerridge, University of Sydney

Although recent encouraging news suggests the rate of new coronavirus cases in Australia is slowing, our medical facilities could still be overwhelmed at some point.

One modelling study has suggested that, if public health measures are not observed or do not work, demand for the existing 2,200 intensive care unit (ICU) beds in Australia will be exceeded within a few weeks. More optimistic views of our achievable ICU capacity would merely delay this event for a few weeks.

Critical shortages of ICU beds and other medical resources overseas have resulted in large numbers of deaths. In these countries there have been vigorous debates about which of many eligible patients should be given access to care facilities in short supply.

This discussion is now underway in Australia.

For many clinicians, the question of who has access to limited ICU beds presents disturbing challenges, especially in view of a widely disseminated proposal that has gained particular support in Italy. This bases decisions about who is granted access to ICU beds on calculations of the future years of life that could potentially be achieved through treatment (or, in some proposals, “quality adjusted” years of life).

This would deny access to people above a certain age as well as to people with disabilities and certain medical conditions.




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What is a person worth?

This approach is deeply problematic.

It has taken many years for us to move away from judging the value or worth of a person by their age, race, sexual preference, physical ability, religion or other personal characteristics.

The worst outrages of the 20th century resulted directly from such approaches, which were often claimed at the time to be supported by “ethical” justifications.

Decisions should not be made based on calculations about how many years a person has to live.
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There has also never been a public discussion, and certainly there is no agreement, about whether the “ethical value” of a person can be calculated mathematically on the basis of the total number of years he or she might live.




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The alternative, which has been developed and routinely employed in hospitals around Australia for years, applies a process of rigorous discussion about the potential benefits and burdens of treatments proposed for every individual patient, taking into account all relevant clinical features and whether acute problems can be overcome.

It entails a detailed analysis of technical issues and results. It involves open discussion with the patient, medical carers, family members, and expert ICU staff, about medical, social, emotional and ethical issues.

It embraces flexibility and a readiness to adapt and change protocols with changing circumstances. It takes into account the specific circumstances of individual patients’ lives, including their personal preferences and religious and cultural beliefs.

It leaves aside personal characteristics not relevant to the medical decision at hand, such as race, gender, sexual preference and ethnicity.

Age can be relevant

This is not to say that age can never be a relevant consideration. Indeed, in some conditions, advanced age is closely linked with the likelihood of a poorer response to a treatment.

Sometimes this is because increasing age is directly linked to age-related diseases that reduce the likelihood of a successful outcome from treatment, such as certain types of cancer.

Sometimes age can be a factor but it’s more of a signifier of other considerations.
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At other times, for reasons that are much less clear, age itself appears to predict poor outcomes of treatment, leading to its inclusion in many scoring systems for predicting outcomes of treatment, including in intensive care and cancer care.

In both cases it is valid that age be taken into account in decision-making. It is also possible that age may be relevant to more philosophical considerations, for example, whether older people consider themselves to have already lived a “fair innings” or whether young people should be given the opportunity to live a life and gain their potential.




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While these may also be relevant considerations, and be accepted by many, including sometimes by older people themselves, they are much less clear and much more contested, and require ongoing debate.

The key point is that, even in these cases, age is never taken as a defining quality or characteristic of a person but rather as a potential signifier of other relevant characteristics or risk factors. Its relevance is linked to what it implies for the particular person, not to an assumption that old people have diminished value and are less worthy of treatment.

In extreme settings, time and resource constraints may add greatly to pressures on the decision-making process but the same principles still apply. In fact, it is exactly in these contexts that it is most important to resist resorting to criteria that are not founded on evidence or valid ethical arguments.

How do we respond?

The ethical strength of a society is revealed in how it responds to serious challenges. If we have values worth defending, this is the time to fight for them.

Most of us do not want to move to a society based on the arbitrary imposition of measures that discriminate against people on the basis of ethically or medically irrelevant personal characteristics.

Future generations will judge us on how we respond to this crisis and whether we have been able to defend our core values. This is the time, perhaps more than any other, when we have to keep our ethical nerve.




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The Conversation


Paul Komesaroff, Professor of Medicine, Monash University; George Skowronski, Research Affiliate, Sydney Health Ethics, School of Public Health, University of Sydney, and Ian Kerridge, Professor of Bioethics & Medicine, Sydney Health Ethics, Haematologist/BMT Physician, Royal North Shore Hospital and Director, Praxis Australia, University of Sydney

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

Federal government gets private hospital resources for COVID-19 fight in exchange for funding support


Michelle Grattan, University of Canberra

Private hospitals will be on the frontline in the coronavirus battle, under an arrangement with the federal government that makes available the sector’s more than 30,000 beds and 105,000 workforce, including more than 57,000 nursing staff.

The government will offer agreements to Australia’s 657 private and not-for-profit hospitals “to ensure their viability, in return for maintenance and capacity” during the COVID-19 crisis.

The agreement makes available more resources to meet the virus crisis, preserves the private hospital workforce, and is designed to allow a speedy resumption of non-urgent elective surgery and other normal activity when the crisis has passed.

The states will complete “private hospital COVID-19 partnership agreements”, with the Commonwealth paying half the cost.

“In an unprecedented move, private hospitals, including both overnight and day hospitals, will integrate with state and territory health systems in the COVID-19 response,” the government said in a Tuesday statement.

These hospitals “will be required to make infrastructure, essential equipment (including ventilators), supplies (including personal protective equipment), workforce and additional resources fully available to the state and territory hospital system or the Australian government”.

Private hospitals will support the COVID-19 response through:

  • Hospital services for public patients – both positive and negative for COVID 19

  • Category 1 (urgent) elective surgery

  • Use of wards and theatres to expand ICU capacity

  • Accommodation for quarantine and isolation cases where necessary, and safety procedures and training are in place, including:

    • Cruise and flight COVID-19 passengers
    • Quarantine of vulnerable members of the community
    • Isolation of infected vulnerable COVID-19 patients.

The cost of the move is estimated at $1.3 billion.

Last week the government announced a ban on non-urgent elective surgery. While this freed up beds and staff, it would also strip the hospitals of core income and threaten the collapse of some hospitals without government action.

Health Minister Greg Hunt said the agreement dramatically expanded the capacity of the Australian hospitals system to deal with COVID-19, at the same time as the curve of new cases showed early signs of being flattened.

The private hospitals “are available as an extension now of the public hospital system in Australia. So, whilst we’re not taking ownership, we have struck a partnership, where in return for the state agreements and the commonwealth guarantee, they will be fully integrated within the public hospital system”.

Hunt said the $1.3 billion estimated cost was not capped. “If more is required, more will be provided. If it turns out that it’s not that expensive, then those funds will be available for other activities. That takes our total additional investment to over $5.4 billion within the health sector.”

In a letter to private hospital providers, Hunt stressed: “A fundamental principle of this agreement is that it contributes towards to your ongoing viability, not profits or loan/debt repayments”.

Commonwealth deputy chief medical officer, Nick Coatsworth said intense efforts were being made to ramp up rapidly the number of ventilators.

He said there were some 2,200 ventilated intensive care beds in Australia. Currently just over 20 were being used for COVID-19 patients.

With immediate expansion, including repurposing and use of the private sector, this could be increased to 4,400.

“Our target capacity for ventilated intensive care beds in Australia currently stands at 7,500.

“We are working around the clock to procure ventilators,” he said. “Locally, we will have 500 intensive care ventilators fabricated by ResMed, backed up by 5,000 non-invasive ventilators, with full delivery expected by the end of April.”

The Australian Healthcare and Hospitals Association welcomed the “ground-breaking agreement” with private hospitals for ensuring both the best use of resources and the stability of the health system for the future.

The Australian tally of cases as of Tuesday afternoon was 4557, with 19 deaths; 244,000 tests had been completed.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.

What steps hospitals can take if coronavirus leads to a shortage of beds


Gerard Fitzgerald, Queensland University of Technology

The number of COVID-19 cases in Australian continues to grow with new cases confirmed each day.

Of those who get ill, about 20% will have moderate or severe illness that requires hospitalisation.

Based on experience in China, of those admitted, about 26% will require a stay in an intensive care unit (ICU) and 17% mechanical ventilation.




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So what happens if we run out of hospital beds for patients with COVID-19?

Overwhelmed health systems

The epidemic is currently under control in Hubei but continuing to expand rapidly in Italy which is currently overwhelmed by this disease and its health system floundering.

A report this month in the New England Journal of Medicine describes the impact of this outbreak in Italy: operating rooms turned into ICUs, patients admitted for other reasons contracting the disease and health workers falling ill.

In Australia, as of this morning there were more than 1,800 confirmed cases of COVID-19, with 344 new cases since 6am yesterday.

We have an extensive health capability in Australia with around 94,000 hospital beds (61,000 in public hospitals) including 2,200 ICU beds. We also have about 800,000 people working in health services including 350,000 nurses and 90,000 doctors.

At present in Australia, the number of cases is not at a level that would challenge our health treatment capability.

But health personnel are stretched undertaking contact tracing to understand how the infection is spreading, data collection and analysis, and implementing enhanced infection control procedures.

Similarly the laboratory system is being challenged by increased testing rates and primary care services are likely to be stretched by responding to considerable community concern.




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So, if demand continues to increase, what can our health system do to surge the response?

As the numbers grow

The surge requirements are not one-dimensional. People often speak about the capacity of the system to surge the amount of space, staff and stuff. Each of these has limitations.

The space must be appropriate to need.

The surge in staff must take into consideration the impact this event has on staff availability and the risk they are taking on.

Surging consumables and equipment depends on supply chains. The domains are complementary. Increasing ventilators alone without having sufficient staff to operate them is futile.

In addition, people will continue to get sick from other causes. Indeed, there is often a danger in disaster response in which all of the attention is focused on those with the disease and other patients including some who are serious and critically ill are relatively ignored.

A four tier response

Health system responses will escalate as demands increase and may be broadly categorised into four tiers.

The first tier is when there is a relatively small epidemic. Health systems will seek to concentrate the care into a small number of facilities, thus concentrating the expertise and maximising the infection control. This is what is happening now.

The second level of response occurs when health facilities need to create additional internal capacity or to refocus existing capacity. Common strategies involve cancelling elective surgery, early discharge and relocation of patients to other facilities.

The third tier of response occurs when additional capacity has to be created. Options include recommissioning purpose-built facilities (closed hospitals) or by taking over suitable alternatives such as hotels.

Hotels can be useful for recuperating patients who require mainly observation and support. They are facilities that can be easily and rapidly converted to include appropriate levels of infection control.

Victoria has announced funding for an extra 269 hospital beds, including 84 at Melbourne’s old Peter Mac Hospital, and the former Baxter House Hospital in Geelong will be recommissioned.

In South Australia, new facilities will be set up at the recently decommissioned ECH College Grove and Wakefield hospitals providing an extra 188 beds.

Additional space and equipment is one thing, but not helpful as we need people to care for the patients and run the ventilators. We need to protect the existing staff wherever possible.

Additional staff can be found among recently retired practitioners and students, and by redirecting personnel from other (particularly non-clinical) areas.

But a word of caution. This is not a time to learn new skills. Familiarity leads to efficiency and so unfamiliar staff can be best used to help and support and to undertake non-technical roles.

Hard decisions at tier four

The fourth tier occurs when a system is overwhelmed, as in Italy and other European countries at present. This is when the demand for care exceeds any possibility of providing that care equally to all.

In this case, very difficult decisions have to be made involving triage of patients and the allocation of resources.

We have not had to implement such responses in this country since perhaps the Spanish Flu pandemic of 1918/1919. But such decisions based on risk and possible benefit are not unusual.




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Decisions about whether to resuscitate or operate are made commonly but mostly focused on the likely benefit to the individual and are made in partnership with the patient and their carers.

In this circumstance, very hard decisions will have to made about relative benefit to preserve the health system’s capacity for people who are more likely to survive.

To support this, we would need to identify and communicate what is known as “Crisis standards of care” so that there is a consistent, system-wide approach. The legal and ethical aspects of this will need agreement not only by medical authorities but more broadly in the community.




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The Conversation


Gerard Fitzgerald, Emeritus Professor, School of Public Health, Queensland University of Technology

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