COVID represents aged care’s ‘greatest challenge’: Royal commission

Matt Woodley

11/08/2020 4:44:02 PM

A review into the industry’s response to the coronavirus pandemic has revealed major gaps in training, preparedness and infection control.

Aged care patient being transferred to hospital.
The commission was told transferring infected residents to hospitals can help limit the spread of infection within aged care facilities. (Image: AAP)

On the day Australia recorded its first instance of person-to-person transmission of coronavirus, GPs and infectious disease experts warned that aged care urgently needed to improve infection control procedures and standards.
Yet, months later it has emerged that many residential aged care facilities (RACFs) are still not adequately prepared to deal with a potential outbreak – an oversight that has left Australia with one of the highest death rates in RACFs, as a proportion of deaths from COVID-19, in the world.
On the first of three days of hearings delving into aged care’s response to the pandemic, the Senior Counsel assisting the Royal Commission into Aged Care Quality and Safety, Peter Rozen QC, described COVID-19 as the ‘greatest challenge the Australian aged care sector has ever faced’.                                                                                     
Mr Rozen painted a picture of ‘naïve’ RACFs – 99.5% of which believed they were prepared to deal with potential outbreaks – instead discovering the difficulties of responding to a novel, highly infectious virus the likes of which they had not seen in their lifetimes.
‘As well as low staff numbers and a casualised workforce, [submissions] refer to inadequate training on infection control and inadequate access to and training in the proper use of personal protective equipment [PPE],’ he said.
‘Workers have been criticised for doing, they say, the best they can in the most difficult circumstances the aged care sector has confronted.
‘Confusion about, and interpretation of guidelines is another clear theme in the submissions as, too, is the confused and inconsistent messaging from providers, state and federal governments, begging the question, “Who is in charge?”.’
According to Department of Health (DoH) data, more than 1000 aged care residents were diagnosed with COVID-19 between 8 July and 10 August. Of these people, 168 have died, equivalent to 68% of all coronavirus deaths across the country.
Mr Rozen said the dire figures represent the consequences of a ‘shortage of clinical skills in aged care homes’, the result of a system in which ‘providers have the ultimate say concerning the numbers and skill mix of their workforce, and can choose between paying the hourly rate of a university educated nurse and that of a care worker with or without a Certificate III’.
‘The aged care system we have in 2020 is not a system that is failing. It’s the system operating as it was designed to operate,’ he said. ‘We should not be surprised at the results.
‘While there was a great deal done to prepare the Australian health sector more generally for the pandemic, the evidence will reveal that neither the Commonwealth Department of Health nor the aged care regulator developed [a] COVID-19 plan specifically for the aged care sector.’
The lack of such a plan, according to South Australian Chief Public Health Officer Professor Nicola Spurrier, was a major oversight.
‘It’s very important that you have a plan that’s in place way before you need it, and it is agreed by everybody,’ she said.
‘It’s also important that you have opportunity to exercise that plan either on desktop, but preferably by some mock scenarios as well.’
Professor Spurrier said while her state is yet to have an outbreak in an RACF, she is of the opinion that immediate hospitalisation of infected residents can help prevent the disease from spreading further.
‘One of the things when you use personal protective equipment that is always helpful is if you actually understand microbiology and you understand how infections are passed from people, one to another,’ she said.
‘My understanding is that the personal care assistants do not have tertiary qualifications and are often fairly untrained. It’s often a casualised workforce and sometimes of people from non-English speaking backgrounds as well, that don’t necessarily have the training in the use of PPE.
‘If you don’t have that basic understanding, even if you’ve been trained in how to wear a mask and how to put on gloves and suchlike, you’re not always going to be doing that at the same level as people that have that full understanding of infectious diseases.’
University of New South Wales epidemiologist and World Health Organization advisor, Professor Mary-Louise McLaws told the commission RACFs are basically a ‘shared home’ and that ‘none’ are set up with best practice for infection prevention and control.
She also said universal mask use in aged care should have been introduced earlier, adding it was ‘unusual’ that this had not occurred.
‘Masks were universally required in Victoria in the beginning of July, so I am not sure why the residential aged care facilities were considered any different to hospitals, given what we know around the world and what we have known about Newmarch House and anywhere else,’ Professor McLaws said.
‘[People in RACFs] need to really wear a face shield, a face mask or both to ensure that they’re not acquiring it … [or] spreading disease to not just the residents, but also the visitors and other staff members.’

UNSW epidemiologist Mary-Louise McLaws told the commission universal mask use in aged care should have been introduced earlier. (Image: AAP)
It was also revealed that while the Infection Control Expert Group (ICEG), which reports directly to the Australian Health Protection Principal Committee (AHPPC), had prepared some guidelines for RACFs, they were based on basic principles of infection control rather than any specific experience of COVID-19 in aged care facilities.
This resulted in numerous issues, predominantly related to the infectiousness of COVID-19, which meant appropriate infection control procedures were not in place, while the proportion of staff deemed likely to be impacted by self-isolation following an outbreak was widely underestimated.
Despite the experiences of Newmarch House and Dorothy Henderson Lodge – which almost lost its entire workforce within 48 hours of that outbreak – it was not until June that the Commonwealth DoH advised providers that 80–100% of their workforce may need to isolate in a major outbreak.
‘Even then, Commissioners, this information was located on page five of a nine-page document uploaded on 7 July 2020 on the aged care regulator’s website with the intended audience identified as “health sector”,’ Mr Rozen said.
ICEG Chair Professor Lyn Gilbert, who also provided evidence on the first day of hearings, said while routine infection control is ‘most of the time … more or less okay’, a crisis requires the experience and expertise of an accredited infection control professional.
‘In that sort of setting, physical distancing is difficult and just the sort of … environmental cleaning and uncluttering, if you like, that we would expect in hospitals, is not possible or appropriate in an aged care setting,’ she said.
‘You can’t have a credentialled infection control professional, certainly not full-time, in every aged care facility; it would not be cost effective.
‘But to have someone who is a consultant to an aged care facility … whose job is to train a small number of relatively senior staff, one would hope, and permanent, not a transient workforce but people who are likely to stay in the facility, and then be a resource when they need help or when they need refreshers and so on [would be beneficial].’
The commission will continue public hearings into aged care’s coronavirus response until 12 August.
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