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GPs call for clarity over recovered COVID patients in aged care


Doug Hendrie


3/09/2020 12:02:18 PM

COVID survivors are now returning from hospital to aged care, but mixed messages could be compromising care.

Aged care resident being transferred to hospital.
Nearly 500 suspected or confirmed COVID cases have been transferred from aged care facilities to hospitals so far. (Image: AAP)

UPDATED

Guidance on long-term care is needed to help residents now returning to aged care facilities around Victoria, prominent aged care GPs have said.
 
More than 450 transfers of suspected or confirmed COVID cases have taken place from aged care to private hospitals and around 40 to public hospitals.
 
Survivors may have long-term health consequences, such as heart, lung or neurological damage.
 
Aged Care GP founder Dr Sachin Patel said an emerging issue is the need for clear guidance on how to care for residents returning after a bout of COVID.
 
‘This is going to be a confusing time for anyone managing the care of residents who are coming back after being moved to hospitals,’ he told newsGP.
 
‘There’s a lack of clarity. There are too many different people, saying too many different things.’  
 
In early August, up to 80 residents not in a critical condition were incrementally returned to St Basil’s Homes for the Aged, the site of Victoria’s second-worst aged care cluster with 203 cases. 
 
That decision was made even though some residents may have still had the virus due to concerns around pressure on hospital beds during the worst of the aged care outbreak, according to The Age. Residents confirmed to have COVID were quarantined within the facility.
 
Dr Ken McCroary, a GP with a special interest in aged care and lecturer, told newsGP clarity is essential but has proved challenging given the newness of the disease.
 
‘Clarity in an evolving pandemic is very difficult to come by,’ he said. ‘The experts are becoming expert in COVID-19. As our expertise develops, we will develop greater clarity on management and care for people post-infections.’
 
In the absence of COVID-specific guidance for this group of patients, Dr McCroary recommends treating residents in a similar way to those discharged after influenza or aspirational pneumonia.
 
‘It’s important patients are managed back in the residential aged care facility [RACF] with a focus on pulmonary rehabilitation and monitoring for other long-term sequelae,’ he said.
 
‘[As is] getting them back to their normal GP who can manage all the risk factors for any comorbidities.’
 
Dr McCroary also stressed the importance of ensuring patients are clear of the virus before returning to their facility in order to avoid ‘total disaster’.
 
‘If people were still infectious after being admitted to hospital – that would be a mistake,’ he said. 
 
In badly hit areas of America, COVID patients were controversially discharged back to aged care while still recovering from the virus to make room for more patients.

The chief clinical advisor to the Federal Government’s aged care watchdog said repatriated residents will need an updated care plan and close attention to their health and social needs.
 
Advisor to the Aged Care Quality and Safety Commission, Dr Melanie Wroth, told newsGP that residents returning from hospital would have been cleared by the hospital or public health.  
 
‘If residents have been “cleared” of COVID-19 they are no longer infectious and can be cared for in the same way as any person returning from hospital after an illness,’ she said.
 
‘Some older people who have recovered from COVID-19 may have been essentially asymptomatic or have minor symptoms, with the predominant effects relating to their experience of multiple changes in a short period, including being moved to another facility and cared for in isolation by unfamiliar staff.
 
‘Other residents may be so severely impacted by the virus that they may return from hospital in poor condition, and their goals of care and care plan may need substantial review.’
 
Dr Wroth said it is likely that many people who have recovered from COVID will have physical deconditioning, be suffering from isolation from their loved ones, and potentially will have lost significant weight due to reduced food intake during hospitalisation.  
 
Dr Wroth said all of these issues need to be addressed with the resident, family or carers and aged care home staff, and reflected in an updated care plan.
 
‘Early engagement of the resident, family and multidisciplinary team should be a priority with the aim being to regain health, function and quality of life as soon as possible,’ she said. 

‘Early access to physiotherapy, lifestyle support, a dietitian and psychological support if indicated is [also] important.
 
‘Emotional experiences related to their own situation need to be understood, including the possibility that upon returning to their aged care home they may find that some of their friends have died and some staff have left.’
 
She adds that return to the facility is a key time to review all medications.
 
‘Any antibiotics or short-term therapies used should have their end date clarified,’ she said.

‘Any ongoing oxygen requirement needs review and clarification. Any medications with sedative effects used temporarily to manage risk of transmission by a COVID-19 positive resident with wandering or other behaviours should be reviewed [and] a withdrawal plan documented.’
 
Dr Wroth believes GPs can play a key role in re-establishing ‘great care’ in the affected facility.
 
‘GPs have a leadership role in supporting staff in residential aged care facilities impacted by an outbreak. These staff may be traumatised due to the stresses and losses encountered, uncertain of their newly acquired PPE skills and fearful for themselves, their families and their residents,’ she said.
 
‘Staff may also have questions about how the outbreak occurred and may wonder whether it will have longer term implications for their work at the facility. 

‘GPs can be a great source of knowledge, reassurance and confidence as trusted advisors in residential aged care, particularly where they have well-developed working relationships with staff.’
  
Newly updated Victorian health guidelines state that COVID cases where hospitalisation was warranted should only be released from isolation after:

  • fourteen days have passed since developing symptoms
  • three days have passed without fever and respiratory symptoms
  • two consecutive negative tests at least a day apart.
The calls come as the devastating aged care crisis in the state shows signs of easing. Only one facility is now categorised as high risk – down from 13 in early August – which the Victorian Aged Care Response Centre (VACRC) considers ‘a significant milestone’ in the stabilisation of aged care facilities.
 
Deaths linked to aged care outbreaks account for 420 of the state’s 570 total deaths, with another 1200 people linked to aged care still fighting the virus, including residents, staff and close contacts.
 
In total, almost 4000 cases have been linked to aged care outbreaks in Victoria, with the majority now recovered.
 
There are 105 aged care outbreaks considered still active, down by 21 over the past week.
 
RACGP Victoria Chair Dr Cameron Loy told newsGP that GPs going into aged care centres remain at risk, given how many infections have occurred amongst staff in Victorian facilities.
 
GPs played an important but underutilised role in dealing with Australia’s deadliest aged care outbreak in the first wave, according to an independent review of the outbreak at Sydney aged care facility Newmarch House, where 19 residents died. 
 
In that outbreak, GPs reported being frustrated by accidentally being denied access to the resident records system, which prevented them from monitoring patients and prescribing medication.
 
‘It was soon recognised that on-site general practitioners would be required but it took some time before locum medical staff could be recruited,’ the review states.
 
newsGP approached the Victorian Department of Health and Human Services for comment.
 
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