Hospital emergency departments are under intense pressure. What to know before you go

Posted on October 12, 2021 by particularkev

David Caldicott, Australian National UniversityEmergency departments around Australia have experienced COVID in a variety of ways.

From the first quarter of 2020, most if not all have worked hard to plan for an influx of very unwell, highly infectious patients. In the less fortunate of jurisdictions, those apprehensions are being realised — though thankfully not yet to the magnitude seen in some overseas cities.

Hospital emergency departments (EDs) are under intense pressure and there have been calls for the public to carefully weigh up need before presenting there. Don’t come if you don’t need to, they’ve been told. But equally, don’t wait if you need treatment, especially for COVID.

Less staff, more pressure

For all hospitals, COVID planning has involved creating streams of patient flow, to ensure those infected can be treated in addition to and at the same time as those who are not — while preventing the former infecting the latter. This is labour-intensive work, often duplicating patient pathways but without a doubling of staff.

In fact, staff numbers in many EDs are down in Australia, for a variety of reasons. Many smaller rural departments rely on fly-in-fly-out locums, now locked out by lockdowns. At times, doctors and nurses have been furloughed because they have been infected at work or elsewhere, or because they have been close contacts.

Understaffed EDs push on, with the greater burden being carried by fewer health workers, resulting in their subsequent burnout. To that, add the task of working in full personal protective equipment, often for many hours at a time. It is physically demanding, uncomfortable, unpleasant work, in an environment in which both high levels of vigilance to keep staff safe and cognitive skills to manage often complex and rapidly deteriorating patients are required.

Not just COVID patients

Much of the focus in the media on health care in a time of pandemic has understandably been on COVID hospitalisations and subsequent intensive care unit admissions. Less has been said about the impact of COVID on the treatment of other illnesses or injuries.

We are very fortunate in Australia there is still more of “the other” in our EDs than there is COVID. That might change in the run up to Christmas.

The ED is most obviously a place of treatment for acute injuries and illnesses. In addition to that, we treat people with chronic illnesses. The ED can act as a safety net for those who have no one else to turn to and reassure many without affliction. For patients in each of these categories, the experience of ED has changed significantly.

There are great concerns many of those who need immediate medical care are deferring seeking it. They may fear catching COVID or being a burden on a strained system. Many in the latter category are elderly patients and those with probably the most reasonable indications for using our services.

First off, it’s your emergency

So how should we, as a resource-constrained civil society, in the middle of a pandemic, use our EDs?

The first and overriding principle is that any medical emergency is YOUR emergency. If you think you are experiencing a medical emergency — one you cannot see yourself addressing with the resources available to you, at the time you are experiencing it — you should come to ED. It doesn’t matter if it seems trivial to others, it’s your emergency. And we are your emergency department.

If you don’t feel too unwell, and are uncertain where you should go for medical care, there are alternatives to the ED where excellent medical advice and treatment can be found.

Telehealth has been a godsend to both patients and our GP colleagues. There are now also numerous health lines to call. Pharmacists can provide excellent information about medication, as well as now providing COVID vaccinations.

The ED is not the best place to go to have a COVID test. If you are otherwise well, there are many testing locations where you will wait a far shorter time for a test and the results.

Similarly, many concerns about the very rare side effects of COVID vaccination can be addressed with a telehealth consultation and a blood test if required.

Extra precautions, longer waits

If you do come to the ED, try and be patient. There are extra measures in place to keep you safe.

You’ll need to wear a mask and check in with a QR code, use hand sanitiser and physically distance. There are increasingly strict rules about the numbers of visitors.

If that’s a problem, you’re probably going to be asked to leave. It’s nothing personal — we have a duty of responsibility to all our patients.

You might wait longer than expected despite the efforts of medical staff to see everyone as quickly as possible.

EDs treat all comers

Finally, if you’re worried about the consequences of catching COVID, get vaccinated. We treat all comers, with a variety of beliefs about their medical care — all as long as they agree to abide by the rules of “The House”: to be respectful and abide by hospital procedures.

But vaccination will reduce your chance of needing ED attention as a consequence of COVID — and protect you from catching it if you come to ED for another reason.

Working in the ED at the moment isn’t much fun for anyone. We’re all really tired and, for many, that’s even before the ED where we work has become COVID-dominant. We’re looking forward to moving out of this phase of the pandemic, safely. Then we can get back to treating the mishaps of more normal human lifestyles, led to the fullest.

David Caldicott, Senior lecturer, Australian National University

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

We’re seeing more COVID patients in ICU as case numbers rise. That affects the whole hospital

Posted on August 28, 2021 by particularkev

Deb Massey, Southern Cross UniversityRising COVID cases in several Australian states means demand for intensive care unit (ICU) beds and specialist critical nurses will rise.

This increase in demand is on top of the typical workload ICUs might see.

And because of the nature of COVID itself and other factors, this puts pressure on the entire hospital system.

What happens in ICU?

The ICU is where we care for the most critically unwell patients, where treatments are designed to support breathing and circulatory problems affecting the heart, blood, or blood vessels.

The most unstable and sickest ICU patients require airway support in the form ventilation to help them breathe. They also need circulatory support in the form of drugs to improve blood pressure and heart function.

Patients come to ICU as a planned admission (for example, after a complex operation), or as an emergency admission (for example, after a serious car accident).

Patients stay for, on average, three days in ICU before recovering enough to be moved to a ward, or sadly, dying.

Because patients in ICU are unstable and critically unwell, there is usually one nurse to care for each patient. This is a highly skilled job. Most ICU nurses have extra postgraduate qualifications.

COVID changed the type of patients we see

Patients who are critically ill with COVID are often sicker than other ICU patients and may require more support for their breathing and circulation. Often, they need to stay in ICU longer than other patients.

This creates challenges for hospital systems, because beds in ICU become blocked, and planned operations may be cancelled because of the lack of ICU beds.

Once patients with COVID no longer need ventilation or circulatory support, they are transferred to the ward for additional care. They may have experienced painful procedures and have a degree of physical impairment.

They may also have witnessed a number of stressful events in the ICU, such as emergency resuscitation procedures and deaths, which may increase the risk of post-traumatic stress disorder, anxiety, and depression.

Although we don’t have definitive long-term data, patients who have been critically ill from COVID often have a long and difficult journey of recovery and will likely remain dependant on health care services for some time.

COVID changed how we nurse

ICU staff looking after COVID patients have the additional demands of working in full personal protection equipment (PPE), which can be hot and uncomfortable and very challenging to work in.

The need to use PPE correctly, and the constant concern about becoming infected or dying if there’s an infection breach, adds to nurses ongoing stress.

The International Council of Nurses’ latest analysis shows the number of nurses who have died after contracting COVID-19 globally is greater than 2,200 – more than any other health-care worker. This data are from earlier this year, so we expect those figures to have risen since then.

COVID challenges Australia

In Australia, there has been more time to respond to the challenges of COVID. In many states, the numbers of ventilators increased, models of care were developed for COVID-positive patients, and snap lockdowns ensured scarce ICU resources were not overwhelmed.

However, the increasing number of positive cases in New South Wales in particular, coupled with the highly infectious Delta variant, means ICUs risk reaching capacity.

At the time of writing, 109 patients were in Australian ICUs and 37 of these patients required ventilation.

Australia has 191 ICUs with 2,378 beds and the capacity to increase this by by up to 4,258 beds.
But there may not be enough specialised nurses or equipment match this bed increase.

Surge capacity also varies between ICU categories and jurisdictions, with tertiary hospitals reporting more capacity. So deteriorating patients may need to be air-lifted to major metropolitan or regional centres.

What can happen in the future?

Fortunately, public health measures have meant Australia has been spared the horrors of countries that were unable to successfully increase their ICU resources to meet demands, for example, Spain, Italy and the United Kingdom.

Yet, hospitals are still feeling the impact of a rise in critically unwell COVID patients in many ways, and will do so in the future.

Undergraduate student nursing placements, for example, have been delayed and many universities have moved their education online. So student nurses may struggle to achieve the clinical hours required to graduate. This may mean a shortfall of clinically competent and educated ICU nurses in the future.

The best we can do

So the next time you hear the latest number of COVID patients in ICU, think of what’s behind those numbers and what this means for the whole hospital system and its staff.

Protect them, yourself and others by sticking to the public health advice, including getting tested with the mildest of symptoms. Most importantly, get vaccinated. People fully vaccinated against COVID rarely end up in ICU.

Deb Massey, Associate Professor, Chair of Nursing, Faculty of Health, Southern Cross University

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

We studied how to reduce airborne COVID spread in hospitals. Here’s what we learnt

Posted on August 17, 2021 by particularkev

Kirsty Buising, The Peter Doherty Institute for Infection and Immunity; Caroline Marshall, The University of Melbourne; Forbes McGain, The University of Melbourne; Jason Monty, The University of Melbourne; Louis Irving, The University of Melbourne; Marion Kainer, Vanderbilt University, and Robyn Schofield, The University of MelbourneMelbourne’s second wave of COVID-19 last year, which led to a lockdown lasting more than 100 days, provided us with many lessons about controlling transmission. Some of these are pertinent as New South Wales endures its ongoing lockdown.

One feature of Melbourne’s second wave was a disproportionate impact on health-care workers, patients in hospital, and residents in aged-care homes. In response to this, a team of Melbourne-based infectious clinicians, engineers and aerosol scientists came together to learn from each other about how to mitigate the risk of airborne COVID-19 transmission in health care.

We are some members of that team. As we hear about COVID spreading in Sydney hospitals during the current outbreak, we want to share what we learnt about how to potentially minimise airborne COVID-19 spread in the hope it’s helpful to our colleagues.

Importantly, much has improved over the course of the pandemic. Most health-care staff and some of our patients (even if not as many as we would like) are vaccinated against COVID-19, reducing the likelihood of severe illness and death. Appropriate personal protective equipment (PPE) is generally available, including fit-tested N95 masks, and practices such as physical distancing and use of tele-health have been widely adopted.

But aerosol transmission of COVID-19 remains a very real and ongoing problem.

We’ve read recent expert commentaries about dealing with COVID-19 that mention paying attention to indoor ventilation. But rarely do these specify what exactly can and should be done in our existing hospital buildings.

The heating, ventilation and air conditioning systems in hospitals, like most public indoor spaces, are built for comfort and energy efficiency, not for infection control (aside from purpose-built isolation areas).

Clearly, we cannot rebuild all our hospital ventilation systems to cope with the current outbreak.

However, there are tangible things that can be done now and in future.

Our recommendations

We recommend hospitals prioritise the use of negative pressure rooms for COVID-19 infected patients where available. Negative pressure rooms are built specifically for patients with highly infectious diseases. We already use them when caring for hospitalised people with tuberculosis, measles and chickenpox.

These rooms usually have an “anteroom” with a door either side before the patient room. The air pressure is lower in the anteroom than the corridor, and then lower again in the patient room compared to the anteroom. This means potentially contaminated air doesn’t escape outside the patient room when the door is opened.

Images showing air flows in positive and negative pressure rooms — Negative pressure rooms ensure potentially contaminated air doesn’t escape into the corridor.
Shutterstock

However, these rooms are usually in short supply even in larger hospitals, and may not exist in smaller or rural hospitals.

If negative pressure rooms aren’t available, then where possible, COVID-19 patients should be managed in single rooms with doors that close.

Preferably, these should be rooms with a high number of “air exchanges per hour”. This is a measure of the refreshing of air in the room. Six air exchanges per hour has been suggested at a minimum for hospital rooms, but preferably more.

Hospitals need to be aware the air in normal rooms can travel outside into corridors. Some rooms may be positively pressured without being labelled as such, so we recommend having them tested.

Two small air cleaners can clear 99% of infectious aerosols

If patients with COVID-19 are being managed outside negative pressure rooms, then we recommend hospitals consider using portable air cleaners with HEPA filters.

We published a world-first study in June into airflow and the movement of aerosols in a COVID-19 ward, giving us a real insight into how the virus might be transmitted.

We found portable air cleaners are highly effective in increasing the clearance of particles from the air in clinical spaces and reducing their spread to other areas.

Two small domestic air cleaners in a single patient room of a hospital ward could clear 99% of potentially infectious aerosols within 5.5 minutes.

These air cleaners are relatively cheap and commercially available. We believe they could help reduce the risk of health-care workers and other patients acquiring COVID-19 in health care.

We are currently using them at the Royal Melbourne Hospital and Western Health.

Innovations such as personal ventilation hoods can also be extremely useful. Western Health’s intensive care unit, which managed large numbers of patients in Melbourne in 2020, used these hoods to filter air close to COVID-19 positive patients and help protect staff.

It’s also important hospitals perform ventilation assessments of wards to be aware of the pathways of airflow through spaces to help inform where to position patients and staff.

We found minimising the number of infected patients in a given physical space was important as we think this helped to reduce the density of aerosols. When patient numbers are high, hospitals should try to avoid caring for more than one COVID-19 positive patient in a room, if possible, which may mean closing beds.

Clearly, if new COVID-19 case numbers climb, this becomes difficult, and enlisting the help of additional hospitals with suitable facilities to “share the load” will be necessary.

New hospitals must focus on ventilation

We need to focus on practical strategies we can implement right now to retro-fit health-care settings to improve safety for staff and patients.

But we must also plan for the future.

In designing new hospitals, it’s critical to:

keep ventilation front of mind
build enough negative pressure rooms and single patient rooms
add air cleaning and air monitoring to the building operations toolbox.

We will achieve this by designing facilities together with staff.

Vaccinations will help control this current pandemic. But we’ve learnt so much about managing this virus in such a short time. Let’s apply what we’ve learnt about aerosol transmission to make practical changes to improve safety now and into the future.

The authors would like to thank Ashley Stevens, hospital engineer at Royal Melbourne Hospital, for contributing to this article and the research.

Kirsty Buising, Professor, The Peter Doherty Institute for Infection and Immunity; Caroline Marshall, Associate Professor, Infectious Diseases, The University of Melbourne; Forbes McGain, Associate Professor, The University of Melbourne; Jason Monty, Professor and Head of Department, Fluid Mechanics Group, Mechanical Engineering, The University of Melbourne; Louis Irving, Associate Professor of Physiology, The University of Melbourne; Marion Kainer, Adjunct Assistant Professor, Health Policy, Vanderbilt University, and Robyn Schofield, Associate Professor and Associate Dean (Environment and Sustainability), The University of Melbourne

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

Bed rest in hospital can be bad for you. Here’s what nurses say would help get patients moving

Posted on August 15, 2021 by particularkev

Danny Hills, Federation University Australia; Breanne Kunstler, Monash University; Christina Ekegren, Monash University; Nicole Freene, University of Canberra; Tracy Robinson, Charles Sturt University, and Virginia Plummer, Federation University AustraliaIf you or a loved one is unlucky enough to be in hospital, you might think the best thing to do is rest in bed as much as possible. But while rest is important, lying or sitting in bed too much can actually make many conditions worse.

Researchers have developed mobility recommendations for some hospital settings but in practice, most patients still aren’t active enough.

To find out more, we asked 138 nurses from five Australian states about the challenges they face trying to to get patients moving more, and what changes would help. We also did some in-depth interviews with a sample of nurses involved in the study.

Our results, published in the Journal of Clinical Nursing, showed there is much we can do. Managers and team leaders have an important role in empowering nurses because our study found nurses do not always feel able to reduce sedentary behaviour in their patients.

The dangers of sedentary behaviour in hospital

Lying or sitting too much while in hospital can lead to deconditioning (such as loss of strength, joint function and mobility), pressure injuries, blood clots, infections, prolonged hospital stays and unplanned hospital re-admissions.

In rehabilitation settings, where a person is recovering from conditions such as stroke, amputation or arthritis, older adults spend as little as 5% of the day
upright.

In acute settings — where a patient in hospital may require surgery or treatments to repair a fracture, remove a tumour or relieve nerve pain — it can be much worse. Older adults spend a median of just 3% of their day standing or walking.

These are staggering figures but the good news is even small increases in activity and movement can help prevent the rapid loss of muscle mass and strength that comes from lying down or sitting too long in hospital.

Our study found nurses have a key role in supporting patients’ mobility and in reducing their sedentary behaviour.

Nurses in this study told us that workload and lack of time were significant barriers to encouraging reduced sedentary behaviour.
Shutterstock

What are the barriers?

Perhaps unsurprisingly, nurses in this study told us workload and lack of time to encourage reduced sedentary behaviour were significant barriers.

However, they also told us there was a perception among family and sometimes patients themselves that they needed to rest and that older people had earned the right to sit back and relax.

This was especially the case when people were unwell or had complex needs. As one nurse said:

For example, ‘Dad’s in his 80s, does he need to do this?’ It is a common mindset of the family of an older person.

So how much exercise should you get while in hospital? There’s no “one size fits all” answer. For some patients, it might just mean getting out of bed and walking to the bathroom, getting dressed or moving around a room. For others, it might mean walking around hospital hallways or doing more specialised movement programs such as My Therapy.

What would help?

Nurses told us that help from family in getting patients up and moving would be a huge bonus.

Families can also help by providing really comfortable shoes and clothing. We know patients are less likely to participate if they are not comfortable.

Another said:

We involved family members at mealtimes [by walking to] the lounge and it has improved nutritional intake by bringing in [special] food and contributing to the social aspects. One brought Italian food and they loved it.

Some patients, however, have only family members or visitors who are, themselves, older and unable to assist the patient with walking. Or, a patient may have no visitors at all.

Working closely with other members of the care team yields results, with one saying:

Going to a team meeting is good […] they say to the patient, this is what we are aiming for, do you agree that you will sit up for lunch every day […] it’s a team effort.

Another told us:

I like to read the physio notes every day and then just have an idea what their actual functional goals and actual functional levels are like. Encouraging people to achieve those tiny little goals like ‘oh, we walked to the toilet’, ‘oh, we brushed our teeth at the sink’.

A nurse helps an older woman walk down a hospital hallway. — Nurses told us that help from family in getting patients up and moving would be a huge bonus.
Shutterstock

One nurse spoke of the value of interventions aimed at getting patients more active, such as the UK’s End PJ Paralysis program.

[…] although not very well promoted, [it] was a great help. Many resources went
into it. With our model of care, there was a social aspect that was a great success, they started friendship groups, lots of activities, we had the Melbourne Cup down in the lounge, and they watched the tennis together. It’s been so positive. We used to really encourage them to go just once, now they want to go all the time. But some nurses still need to learn it’s not about wheeling people down there.

In other words, it’s about walking, not wheeling.

A nurse leader said:

It’s staggering how much time they [patients] spend alone. There’s a potential connection here. Isolation and boredom is one thing. If we tackle the boredom, we tackle the sedentary behaviour, there is a link, and we will solve the social isolation. Enabling nurses to be the coach for getting people up, and there’s definitely an educational aspect.

Creative and sustainable solutions

Our study shows that reducing sedentary behaviour in hospitals is often complex and there are important roles for nurse leaders and organisations in working together on creative and sustainable solutions.

As influential British doctor, Richard Asher, put it in his oft-quoted poem about the danger of sedentary behaviour in hospitals:

Teach us to live that we may dread;

unnecessary time in bed.

Get people up and we may save;

patients from an early grave.

Danny Hills, Associate Professor, Deputy Dean, Federation University Australia; Breanne Kunstler, Research Fellow, BehaviourWorks Australia, Monash Sustainable Development Institute, Monash University; Christina Ekegren, Senior Research Fellow, Monash University; Nicole Freene, Associate Professor, Physiotherapy, University of Canberra; Tracy Robinson, Senior Lecturer in Nursing, Charles Sturt University, and Virginia Plummer, Professor, Federation University Australia

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

In Victoria, whether you get an ICU bed could depend on the hospital

Posted on August 21, 2020 by particularkev

Lisa Mitchell, Deakin University; Emma Tumilty, Deakin University, and Giuliana Fuscaldo, Monash University

Although most hospitals are coping right now, COVID-19 has brought up many questions about how health-care resources should be rationed during a pandemic.

Ideally, every unwell person should get anything they need to get better. But important resources like medications and hospital beds, including intensive care unit (ICU) beds, can become limited if demand outstrips supply.

We’ve had access to confidential documents outlining how various health services are to make decisions on who gets ICU resources in the event they become overwhelmed.

We found there’s significant variation between hospitals’ procedures on this front. And worryingly, the public doesn’t have access to this information.

Resource allocation in hospitals

Resource allocation procedures or triage plans help to work out who gets that bed, ventilator, or vaccine if and when the system comes under significant strain.

Ideally, these procedures should be created well ahead of when they might be needed, and be underpinned by three factors:

local context — what’s available/possible
medical evidence — what works, and for whom
ethical values — what we consider fair and the right thing to do.

The Victorian Pandemic Plan suggests health services should “adopt a systematic and transparent prioritisation of services as demand for treatment grows”.

It also says:

Triage will be enacted at the same level across the state, to promote equity of access of patients to intensive care.

Safer Care Victoria, the peak state body for quality and safety improvement in health care, had been preparing a document to guide hospitals on ethical resource allocation. But it only released this to the health services a few days ago, and the contents are considered sensitive and not for wider distribution within or outside the health services.

In contrast, Queensland Health released an ethical framework to guide clinical decision-making during COVID-19 in April, that’s available to the public.

Red sign says 'Emergency' with arrow. — If resources are stretched, the hospital you go to could determine whether or not you get an ICU bed.
Shutterstock

Different hospitals, different procedures

In the absence of a statewide approach in Victoria, most health services have developed their own resource allocation documents and triage plans.

To our knowledge, none of these documents are publicly available. But we’ve been able to informally review COVID-19 resource allocation procedures from a number of Victorian hospitals.

We’ve found these procedures vary in how ICU resources would be allocated to sick people (with or without COVID-19) in the event resources were scarce.

Some health services would use a standardised scoring system that predicts short-term survival (that is, the person deemed most likely to live would get the bed). But when they use the scoring system, and what additional criteria they take into account, varies between hospitals.

Some hospitals would use exclusion criteria based on certain health conditions. The types of conditions vary between hospitals. For example, one hospital would use a body mass index (BMI) above 40 to exclude people who are obese, while another would exclude people with alcohol dependency.

In “tie-breaker” situations, when it’s not possible to make a decision based on the scoring system, health conditions, or the severity of illness alone, hospitals may use tie-breaker criteria.

Tie-breaker criteria were also different across different hospitals. Some hospitals would prioritise pregnant people, sole parents, health-care workers, and so on. Others would not.

Several of the hospitals plan to use a team of experienced clinicians not involved in the patient’s care as a triage team. Some hospitals have indicated a lottery is the fairest thing to do in tie-breaker situations.

Hospital x, y or z?

Most hospital patients won’t need ICU-level support. Some people, even if they’re very unwell, may choose not to receive treatment in the ICU. And some people will not benefit from ICU care. But for anyone who might benefit, the different plans could mean different access depending on which hospital they go to.

For example, if you’re pregnant, it would be better to go to hospital x. If you’re a widowed parent with young children, you should go to hospital y. If you’re obese, you should try your luck somewhere other than hospital z.

Again, these resource allocation procedures are not publicly available, so we can’t provide information here to guide you.

Health-care worker wearing yellow PPE attends to unconscious patient. — Medical staff would need to make resource allocation decisions using their hospital’s procedures.
Shutterstock

Variation in procedures across different hospitals is understandable in the face of uncertain medical evidence, or when available resources differ in local contexts, or because local communities have specific health needs. For example, you could reasonably expect variation between a smaller regional hospital and a bigger city hospital.

But where resources are similar — for example in two Melbourne hospitals only a few kilometres from each other, with overlapping catchment areas — plans should essentially be the same. If they’re not the same they should at least be publicly available.

It appears they vary, and the current lack of transparency around these resource allocation procedures means patients have no way of knowing whether they would be better to present at one emergency department over another.

Transparency and equity

The pandemic has highlighted various health inequities. In Victoria, the highest case numbers have occurred in areas with the greatest socioeconomic disadvantage.

Resource allocation is considered fair when processes are accountable, transparent, justifiable, and revisable. Where they’re not, they can further disadvantage people and communities.

If Safer Care Victoria and the individual health services were to make their ethical framework document and resource allocation procedures available to the public, this would allow for discussion and engagement, and where possible, enable people to choose which health service will serve them best.

Lisa Mitchell, Conjoint Clinical Senior Lecturer in the School of Medicine, Faculty of Health, Deakin University; Emma Tumilty, Lecturer, Deakin University, and Giuliana Fuscaldo, Associate professor, Monash University

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

Posted on August 8, 2020 by particularkev

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.

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.

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.

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.

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

Posted on July 19, 2020 by particularkev

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.

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.
Shutterstock

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.

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.

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.

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

Posted on June 27, 2020 by particularkev

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.

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.

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.

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.

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

Posted on April 26, 2020 by particularkev

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.

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.

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.

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

Posted on April 25, 2020 by particularkev

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.

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.

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.

Stephen Duckett, Director, Health Program, Grattan Institute

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

Sharing my thoughts with the world from a Particular Baptist perspective

Less staff, more pressure

Not just COVID patients

First off, it’s your emergency

Extra precautions, longer waits

EDs treat all comers

Share this:

What happens in ICU?

COVID changed the type of patients we see

COVID changed how we nurse

COVID challenges Australia

What can happen in the future?

The best we can do

Share this:

Our recommendations

Two small air cleaners can clear 99% of infectious aerosols

New hospitals must focus on ventilation

Share this:

The dangers of sedentary behaviour in hospital

What are the barriers?

What would help?

Creative and sustainable solutions

Share this:

Resource allocation in hospitals

Different hospitals, different procedures

Hospital x, y or z?

Transparency and equity

Share this:

Different states have different policies

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

What are the disadvantages of hospital transfers?

Respecting autonomy and the right for care

Share this:

Deferring planned procedures is not an easy decision

It’s a staffing issue too

Share this:

Who teaches hospital staff how to handwash?

Three types of handwashers

How to improve things

Share this:

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

Different surgeons can assign patients different categories

How do I know what category I’m in?

Share this:

Rethink priorities

Stop the inconsistencies

Time for change

Private hospitals can help

Share this: