Oct 01, 2020

“For cases to continue, lessons haven’t been learnt,” says Epidemiologist Mary-Louise McLaws

Victoria’s active cases have dipped below 300 for the first time since June this week, and there is a sense the state is emerging from the crisis.

Whilst the numbers are improving there are still 79 active cases in aged care homes across the state – that’s 27 per cent of active cases.

New cases are still being identified in aged care homes every day. But when you consider there are tens of thousands of residents living in care in Victoria this number puts it in perspective. 

Despite this there has been intense scrutiny of the sector and extensive examination of serious outbreaks.

The Royal Commission into Aged Care Quality and Safety has conducted hearings into what went wrong in the way aged care homes responded to COVID-19 and has handed its findings to the government. 

There was also an in-depth study of what occurred at Newmarch House, released only a month ago.

With so much analysis of what went wrong, what are the learnings that can be shared to minimise the impact and hopefully prevent further deaths?

We spoke to two experts in the field to hear their views, epidemiologist Professor Mary-Louise McLaws, and Dr Rodney Jilek, managing director, Aged Care Consulting and Advisory Services Australasia. 

So many reasons…

Dr Jilek has just returned from a month helping aged care homes in Victoria cope with COVID-19 outbreaks. He listed the “many reasons” Victorian aged care homes have not been able to prevent the spread of COVID-19. 

“The fact there are so many people living on top of each other, the use of insufficient or incorrect personal protective equipment, the lack of clear guidance on hospital transfers, poor and inconstant cohorting of positive residents, agency nursing staff allowed to move freely from one site to another, and guidelines being repeatedly revised and reissued, often without notifying the aged care services,” he noted.

The combination of these factors contributed to an overall “lack of control”, Dr Jilek said. “It appeared from early on that decisions were being made on the hop and consistency was a real issue.”

“Managing at the front line” became “extremely difficult”, he said.

The coordination of operational support was “dysfunctional” and infections were still being passed within and between aged care homes. 

Decision paralysis

With the Quality & Safety Commission, The Commonwealth Department of Health, The Victorian Department of Health, the Victorian Aged Care Response team, the Public Health Unit and local health services all playing a role in coordination, the outcome for those on the front line was “chaotic”. 

“Nobody was able to make a decision,” Dr Jilek said. “Requests for assistance and advice were “eternally escalated” with little coordination between the various parties. Some key agencies attended just 2 of 26 daily meetings over a month, even when the outbreak was at its worst, he said.

There was no clear chain of command and providers were having to liaise with vast bureaucratic organisations in an attempt to navigate an ever-changing environment. Every agency provided ‘advice’ with slightly different interpretations and expectations, Dr Jilek explained.

“You have non-clinicians sitting in offices as far away as Sydney telling clinicians on the front line what to do, insisting on things like daily weights, oblivious to the infection control risks this poses. 

“You have a continued focus on paperwork and ticking boxes instead of ensuring good practice,” Dr Jilek said. 

Stronger regulation could have reduced case numbers

“Many of the issues faced were the result of a lack of clinical expertise and operational experience within the regulator and a reflection of the broken aged care accreditation system,” Dr Jilek said.

“Homes don’t go from full compliance one minute to systemic non-compliance the next. These [problems] have been evident for some time and should have been identified months, if not years ago. 

“If the regulatory process was effective, many of these outbreaks would have either not occurred or could have been easily minimised.”

As for how the residents are faring, Dr Jilek said many are still “stuck at home” on emergency leave, unable to return to their aged care home. Others remain in hospital. Many are fed up and morale is low. They are “over it”, he said. 

Residents with the virus should be taken to hospital

“For cases to continue says lessons haven’t been learnt,” said Professor McLaws, noting that 73 aged care homes have had outbreaks of five or more cases.

The main reason aged care residents continue to contract COVID-19 is that they are not being taken to hospital, she believes. 

“That’s the reason,” she told HelloCare. “Hospitals are built for infection prevention. They are staffed by experts. Our healthcare staff are some of the best in the world,” she said.

It “beggars belief” that residents are remaining in aged care homes. 

“It may be the place to keep them happy because they are at home, but it is not the place to keep everybody else safe. Surely we have a moral obligation to the other residents of this shared accommodation to keep them safe from COVID-19.”

Aged care homes are not built to prevent the spread of highly contagious diseases, she said. 

COVID-19 can be spread through airborne particles, so high rates of ‘airflow change’ are needed to prevent its spread. Aged care homes are simply not built to these specifications.

“On a COVID-19 ward, you need 60 to 80 litres per second [of air] per patient. In most residential aged care facilities… it wouldn’t be anywhere near that,” Professor McLaws said.

“You can’t expect an environment that was never built to cater for a highly infectious disease to be able to manage an outbreak,” she said. 

“It doesn’t surprise me we are continuing to get infections within institutions,” she said, but what is “disconcerting” is that there hasn’t been more of a change in direction.

Residents who contract the virus are still often not being taken to hospital.

The only alternative to hospital would be where a resident could live in an on-site ‘pod’, which is essentially a pop-up intensive care unit, separate structurally from the home, and with separate entrances, exits, cutlery, and even air. But of course, pods are not appropriate, or even possible, for all homes.

Aged care residents offered a lower standard of care

The policy of caring for residents with COVID-19 within aged care homes came as a “surprise” to Professor McLaws. 

“It suggested there were two levels of care given to the elderly. One for those who live at home [who could go to hospital], and one for those who live in a residential aged care facility.”

The argument that residents wished to remain at the aged care home should carry little weight in these circumstances, Professor McLaws says, because they are putting the health of the majority at risk.

Similarly, concerns about older people with COVID-19 becoming disoriented in hospital and that those living with dementia trying to walk around their environment are not valid. In these extreme times, it has been known for patients to be “locked down”. “It has been done overseas. It has been done before,” Professor McLaws said.

Australia has also been “slow” to have dedicated staff for COVID-19 patients, and was “slow” to wearing masks. Victorians didn’t start wearing masks until July, a month after the World Health Organisation recommended the wearing of masks when prevalence was high in the community.

At one point in conversation, Professor McLaws sounded exasperated. “How many more lessons do we need?” she asked. “I don’t understand how 73 learning opportunities haven’t been taken up in residential aged care.”

Image: Wanderluster, iStock.

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