Dr Cathy Parsons has been working in aged care for the past decade and offers these perspectives on the sector and its readiness for a COVID outbreak.
We are very lucky here in WA. If we had had to deal with community spread of coronavirus in aged care earlier this year, we might have been in just as much trouble as the eastern states. We have had the luxury of watching and learning from their experience. Let’s hope we have learned wisely.
Every Residential Aged Care Facility (RACF) in WA has drawn up a plan for management of the pandemic. There has been extensive consultation with the Health Department. However, it would seem that general practice has been mostly left out of the discussions and planning. It is assumed that GPs will take their part in the overall management of any outbreak, but what would that entail?
Contingency planning for coronavirus in RACFs has shown up some of the cracks in the system. Many staff have traditionally worked in casual positions across numerous facilities, with inadequate financial support to take time off when sick. RACFs must address these problems with the system, to ensure that staff are able to make a living wage without having to compromise their own health and that of the aged residents.
But what of GPs attending RACFs? Are we expected to also restrict ourselves to only attending one RACF? Should we attend a RACF straight from our surgery, possibly carrying infection with us? Who will provide our PPE?
Navigating the system
In our traditional small business model, it would seem that each of us is on our own and must develop our own plans. The RACGP has published and updated guidelines, but coronavirus infection is so new to us all that we must constantly upgrade our knowledge and policies.
I think every GP working in aged care should have a frank discussion with each RACF they visit, and with their colleagues, and decide exactly what they will and will not do once we have community spread.
Some of the issues to consider include:
- Will you attend the RACFs? Will they actually let you in? What will you wear, so that you do not carry infection in? What about fomites on your trusty stethoscope and doctor’s bag?
- Are you in a high-risk group yourself, and if so, who will take on your RACF workload?
- How will you prevent taking COVID home to your family?
- Think about what you can and cannot do via telehealth as a GP. Make sure your technology is up to the task. Can you easily contact the Registered Nurse? Can you access the RACF’s IT system and medication charts? Are your notes adequate if an unfamiliar doctor has to take over from you? Do you have contact details for all your residents’ next of kin?
- Do you have a good working relationship with the pharmacy that supplies the RACF? Is there an imprest system, particularly if antibiotics or opiates are needed at short notice?
- Are you able to socially distance in the workplace? (LOL) Mask wearing is recommended in circumstances where social distancing is impossible. That means when examining patients, and when in the cramped nurses’ office. Consider wearing gloves when using shared equipment such as desktop computers and telephones. Remember that the tea room is the most dangerous place for transmission.
- Think about the practicalities of segregating COVID-positive patients in each RACF. Some facilities are built in such a way as to allow easy separation; many are not. Facilities need to plan for having separate groups of staff caring for positive and negative residents. The latent period between infection and symptoms means that separating positive and negative residents will never be an exact science.
- There needs to be surge planning for staff who have to isolate. And not just the nurses and carers! What about when the chef, cleaner and handyman are sick?
- Managing COVID in the context of dementia and cognitive impairment is extremely challenging. The lack of family contact has a terrible effect on those with dementia, as we have already seen here in WA. In the eastern states there have been instances of people with agitated dementia and COVID having to be admitted to tertiary hospitals and heavily sedated in order to protect other residents at their RACF.
- Supplies of PPE are in a better state now than they were at the outbreak of the pandemic. But in the world of General Practice, it seems to be everyone for themselves. If you don’t have a personal supply of PPE, now is the time to get online and order some. Think about what you will wear for different situations. Think about protecting yourself, and also about preventing spread of the virus to others.
There has been much discussion about where to care for RACF residents with COVID. Moving everyone into a tertiary hospital is simply impractical, not to mention desperately unpleasant for many elderly people who would rather not die in a strange place, surrounded by strange people who cannot touch them.
Stay or leave?
Likewise, keeping everyone in their RACF is also not a viable option. It is unfair to the other residents to expose them to infectious patients, and RACFs do not have the capacity to care for a large cohort of desperately ill patients. RACFs were never designed to be acute hospitals.
An option which has not been fully explored may be to provide facilities which are specifically fitted out to be infectious disease wards to nurse people who have high care needs but who are not in the groups who would benefit from being in an acute tertiary hospital. Decommissioned hospitals or other large community facilities such as sports halls might lend themselves to this purpose.
And a final note: never mind the RACFs, are our General Practices COVID ready?
Are practice owners providing a safe work environment as required by law? Will we have workers’ compensation claims when staff contract COVID-19 in the general practice workplace?
What a brave new world! Are we ready to take it on?
ED: the author wrote this piece when WA had no community spread of COVID-19.