Hard questions over infection control as COVID-19 hits aged care

A number of facilities are failing to safely isolate people with suspected or confirmed cases of coronavirus, according to Dr Sachin Patel, the founder of an aged care GP service.
 
The calls come after GPs repeatedly warned of the risks of poor infection control in residential aged care facilities (RACFs) as early as March.
 
Dr Patel told newsGP that many facilities need to improve their processes on safely managing residents who are in isolation with coronavirus.
 
‘I’m hearing many reports of people being isolated in a room, but that there’s no full PPE [personal protective equipment] being used when someone attends. That makes keeping them isolated irrelevant,’ he said.
 
‘We have written to our facilities again about this today.’  
 
Dr Patel said there has been a ‘significant degree of complacency’ in the aged care sector throughout the entire pandemic.
 
‘People were using language like “when we had the pandemic”, as if it had passed. That wasn’t at all the case,’ he said.
 
‘Against those of us who tried to take the firm line, an equal number thought it was all over.’
 
Since April, the 25 GPs who are part of Dr Patel’s company, Aged Care GP, have worn full PPE for face-to-face care for around 2000 residents living in 70 RACFs across Melbourne.
 
But their approach has not been welcomed in a number of facilities.
 
‘We were given a fair chunk of informal abuse about it,’ Dr Patel said. ‘You stand out as alarmist because you’re wearing the stuff.
 
‘Some facilities said it wasn’t a good look, that it looks bad for them. Our aim was only to be responsible and prevent spread.  
 
‘Our job is to do what’s right, not what’s comfortable. Many people didn’t want to hear that.
 
‘But now suddenly it’s in front of their faces and everyone is panicking. We had ample time to plan and prepare.’
 
Dr Patel said the problem is not restricted to aged care staff, with other healthcare professionals also not wearing adequate PPE.
 
The calls come as a recent MJA Insight pre-print case study found infection control lapses during the Dorothy Henderson Lodge coronavirus cluster in Sydney were ‘unsurprising’ given exhausted staff were using 800 sets of PPE daily.
 
Infection control expert Professor Lyn Gilbert wrote that a key lesson was that ‘optimal infection prevention and control practice cannot be assumed, even among trained healthcare workers, in an outbreak setting’.

Professor Gilbert told newsGP that Australia has, to date, been relatively successful at containing the virus within aged care.
 
‘Aged care is clearly a very dangerous setting for this disease to get into, which is why it’s so important to stop it getting in,’ she said.
 
‘In America and Sweden, they’ve had enormous numbers of cases, where up to 80% of residents became infected and many died. So even the much larger outbreak at Newmarch House [in Sydney] was still relatively small compared to those.
 
‘To me the really important thing is getting really good infection control advice early. That was certainly one of the keys to the relative success of containment at Dorothy Henderson Lodge.
 
‘The other lesson we’ve learned is that as soon as there’s a hint of a case – which usually starts in a staff member – you have to test everyone.
 
‘We don’t usually test without symptoms, but in this setting, we know about the potential for people who are asymptomatic, pre-symptomatic or minimally symptomatic to transmit the infection, especially in that close contact a carer has with a dependent elderly person.’
 
Over the weekend, the Federal Government stepped in to mandate mask-wearing in RACFs. It also banned the widespread practice for the sector’s highly casualised workforce to work across multiple facilities in a bid to end the potential spread of the highly contagious virus to new facilities filled with society’s single most vulnerable group.
 
Victorian GP Dr Joe Garra told newsGP he has also been worried about low rates of mask-wearing among staff in RACFs, with a degree of stigma associated with PPE.
 
‘Nursing home staff told me they didn’t need to wear masks because they didn’t have coronavirus there. I heard all these excuses for not wearing a mask,’ he said. ‘All the cases I’ve heard of have been linked to staff, not to visitors. So this is not unexpected.
 
‘We knew as well from overseas that aged care and confined living quarters were some of the riskiest places for coronavirus.
 
‘[Authorities] should have looked at this two months ago. Alarm bells should have gone off. We knew this was going to happen. This was predictable. We knew we were going to have trouble in nursing homes.
 
‘Infection control is the key issue in nursing homes. Staffing is a challenge, with casuals rocking up who might not know what the individual procedures are [as well as] the staff who work between homes. We had a shortage of masks, but we could have looked at face shields.  
 
‘Any case in a nursing home means infection control has failed. You can’t blame the patient – in most cases, they are not leaving the homes. That means the virus is being brought in.’


Dr Sachin Patel, founder of Aged Care GP, said any GP attending an RACF should do so in PPE – a normal level of PPE for seeing unaffected residents, and full PPE for those in isolation.

Internationally, RACFs have been the sites of some of the most lethal outbreaks of coronavirus.
 
But, to date, the spread of the virus within Victorian facilities has been limited, which Dr Patel attributes to rapid improvement in the response by the Victorian Department of Health and Human Services (DHHS).
 
‘In the eight outbreaks we’ve seen, the spread has not been massive where people have followed protocols,’ he said.
 
‘In Europe, people were going from hospital to nursing homes without being tested. That is more stringent here.
 
‘We’ve been lucky so far – it hasn’t really got away on us yet. But the DHHS will be limited by cases and the workload as this grows.’
 
Of the 40 Melbourne RACFs that are currently affected, only three have seen significant spread to the residents of the facility: Estia RACF Ardeer, with 24 residents infected; Menarock Life RACF Essendon, with 15 cases; and Arcare Craigieburn, with 15 cases.
 
Most of the other facilities only have a single staff member infected.
 
GP and lecturer Dr Ken McCroary works in an emerging coronavirus hotspot in south-western Sydney, close to a number of the venues where clusters have occurred. 
 
He told newsGP the new outbreaks in RACFs are concerning but not surprising, coming after he called for urgent attention to the issue back in March.  
 
‘Unfortunately, this doesn’t surprise me,’ he said. ‘We thought if there was community spread that it would go to residential aged care facilities.
 
‘It’s likely we’ll see higher mortality there, given the age and comorbidities.’
 
Dr McCroary has visited aged care facilities where masks were banned and gloves were kept away from staff and set aside in case of a coronavirus outbreak.
 
‘It’s just ridiculous – to remove gloves from patient rooms to prevent stockpiling in case of a COVID-19 outbreak just doesn’t make sense,’ he said. 
 
Dr McCroary called on GPs to keep up the fight and look to the support of the community.
 
‘There may well be some feelings of demoralisation and being overwhelmed, but the work you are doing is greatly appreciated out there,’ he said.
 
‘The support is there, and everyone is grateful for you working so hard, putting yourself on the line.’
 
Aged and Community Services Australia CEO Patricia Sparrow told newsGP that COVID-19 is ‘a very different beast’ compared to the regular gastro and flu outbreaks that facilities had to deal with regularly.
 
‘Aged care providers manage infections every year, and they do understand and work with infection control,’ she said. ‘But this is very different – the situation is now very serious in Victoria.’
 
Ms Sparrow said the Federal Government’s recent moves to make masks mandatory and stop worker movement between aged care facilities are positive. But she questioned the current case-by-case approach to hospital transfer, and called for an overall workforce strategy to fend off inevitable staff shortages.
 
‘We think transfer to hospitals should happen automatically, especially for index cases, as it offers the best chance of survival as well as limiting the spread in the facility,’ she said.
 
‘We have to ensure we have enough staff for every facility. There is a surge workforce, but as people have to isolate [after potential exposure], that’s another worker out of the system.
 
‘The overall number of workers will become a bigger issue.’  
 
Issues of staffing and quality care have long dogged Australia’s aged care system, with a royal commission last year hearing harrowing testimony from family members and GPs.
 
What should GPs who visit aged care homes do to prepare?
Dr Patel said the role of GPs in coronavirus-hit facilities is turning out to be largely providing reassurance and counselling for unaffected residents, as well as communicating updates to worried family members.
 
‘We remind people that this is very serious, but that there are also many good outcomes,’ he said. ‘There are plenty who recover, so it’s important people hear that message as well.’ 
 
Dr Patel said any GP attending an RACF should do so in PPE – a normal level of PPE for seeing unaffected residents, and full PPE for those in isolation.
 
‘PPE for people in isolation is normally provided by the facility, but you need to bring your own for normal visits,’ he said.
 
‘When COVID comes, be ready to communicate at scale with families to keep them informed. Communicating with families and residents is the major burden on doctors, so you need to have all of that ready to go, whether it’s SMS or webinars.
 
‘These are not normal times and you need to be able to do things fairly fast.
 
‘GPs working solo in facilities need to consider support, as they will otherwise struggle with the workload. You’ll need both admin and peer support.’ 
 
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