Frontline Letters

FRONTLINE LETTERS

The sharing of information in a fast moving emergency is critical. Victoria became the canary in the coalmine during the COVID-19 resurgence and first responders assumed that the Victorian experience was being disseminated throughout Australia. In fact, the reverse appears to have occurred. Hard borders between states and territories have thankfully kept the rest of Australia safe but this has had the unintended effect of turning the flow of operational information between states into a trickle. Anecdotally, news feeds in non-surge areas within Australia have reverted to local issues. Existing structures at national, state and service levels have not filled this gap either. In a rapidly evolving emergency the frontline needs to share lessons because we recognise that all types of information are valuable to decision making. Boots-on-the-ground knowledge complements the evidence-based medicine edifice. We encourage healthcare workers from all disciplines to share their informal reflections for the benefit of our colleagues around Australia-Dr Michelle Ananda-Rajah.

Lessons from Victoria
By Dr Sarah Whitelaw, Emergency Medicine physician and AMAV Board member , VIC

12 September, 2020

Acute Care

Optimise home base care

Ensure your options for treatment in the community are optimized and presume that similar monitoring and community care pathways  will need to be available for discharge in terms of handover from hospital teams to GPs. The exponential increase in COVID-19 case numbers occurs so quickly that you absolutely cannot afford to have patients with mild symptoms turning up to ED.

Preserve Trauma units (staff and beds)

Despite lock down we did not see any reduction in trauma presentations. Delivery vehicles and trucks and more relaxed restrictions in regional areas meant that our state volume and severity of trauma presentations did not decrease – there were still lots of high speed motor vehicle accidents, falls and household accidents including burns.

Vulnerable groups

It is important to identify care pathways for patients with drug and alcohol issues, who are homeless or otherwise vulnerable and are COVID-19 positive. Where do they or their close contacts go? What if they don’t want to go to the facilities provided? Who ensures they comply? Who do staff call? Should staff try and stop these patients from leaving? These issues will arise and it is important for health services to have policies in place to address them.

Expect an increased demand of acutely unwell mental health patients. We are still experiencing this in Victoria but have very little mental health surge capacity resulting in patients waiting over 2 days for admission in multiple emergency departments. We can not get unwell patients with mental health issues into acute care beds. These patients are remaining in the ED and getting repeated chemical sedation because there are no fit for purpose rooms left-all the single rooms are kept for COVID-19 patients. There is significant increased stress on staff and patients and increased occupational violence risk. Ensure surge capacity in both community and acute mental health services, and in security staff trained in infection control procedures and PPE. There appears to be no surge capacity in mental health staff even if we had more beds. It’s important to start training more staff now (along with aged care workers)-none of them will be wasted.

Challenging behaviours

It is important for the health service to have policies in place for patients who refuse to comply with masks, testing, isolation, or who wish to discharge against medical advice if they are COVID-19 suspected or confirmed. What processes should staff follow? Who should be notified? Police? State health department? If the patient presents a risk to others because of mask non-compliance, can hospital security remove the patient and if so to where? For agitated patients, ensure that security staff are adequately protected.

Communication and culture

Develop optimal checklist for Health services to ensure governance systems are adapted for pandemic eg daily dashboard of patient and staff infection, multimodal communication re what’s being done to address issues, transparency, obtaining feedback from staff, install clinical staff on all levels of hospital decision making groups. Seeking and acting upon input from staff on the ground has been key to preventing infection spread within the hospitals. This checklist should be audited to ensure compliance. Areas of poor governance have led to significantly increased staff stress and anxiety.

Establish a mechanism to allow the sharing of resources between health services that are not necessarily within the same pandemic response cluster. It is possible that all hospitals in one cluster will be under strain. Access assistance (eg transfer of patients if over capacity, equipment sharing, additional PPE) from those able to give it

State health department communication and transparency has been a huge issue. Design mechanisms to improve the bidirectional flow of information between health services and the state health department.

With respect to organizational culture, ensure that the identification of problems, insight/recognition of limitations, seeking of help and additional resources are REWARDED and not punished. Ensure that the appropriate expertise is sought and utilized. This may mean inviting disaster medicine and systems experts.

Aged Care

Establish a combined federal state taskforce immediately; it is likely impossible to prevent infection spreading to residential aged care facilities. You need to have plan in place now. The taskforce should have multiagency representation from state, federal, public and private facilities, primary care, acute health services, pre-hospital care. It requires a systems approach. Consider seeking and utilizing all available disaster medicine expertise e.g. AUSMAT, multidisciplinary teams; who’ve undertaken all aspects of mass evacuation of nursing homes in previous disasters.

Plans should be developed for residential aged care facilities based on individual risk assessments of each facility regarding the care of residents who test positive and triggers for transfer. Incorporate capacity for surveillance screening.

Increase aged care staffing now. This is required so that staff can work in PPE, work under infection control systems, to accommodate potential HCW infections and staff furloughing or the need for more staff when necessarily working with unfamiliar staff.

Invest in PPE and training and infection control systems NOW.

Address and anticipate industrial relation issues. These include pandemic leave, consolidation of HCWs into single facilities and compensation for loss of other jobs. This is important in order to reduce the movement of HCWs between facilities.
Audit the care homes  to ensure compliance.

Support GPs to provide care to residential aged care patients in every way. This includes telehealth, face to face care. Provide PPE and training. Use GPs to ensure Advanced Care Plans up to date and utilize the GPs in communication with families.

Incorporate GPs into hospital InReach teams that go out to support aged care homes. GPs can help scale up capacity of inreach teams which ideally should be available 24/7.

Ensure that a crisis response team is available 24/7. Decompensation of residential aged care facilities (RACFs) can be precipitous and often occurs after hours resulting in the sudden decision to transfer large numbers of patients to the nearest emergency department. A plan needs to be in place to address this. We have seen this again and again. The contributing factors being HCW infection, staff shortages, unfamiliar inexperienced staff who are brought in, associated with critical concern reached by staff often after hours.  Staff may be unable to manage dementia patients or don’t know if patients are more unwell than usual. Suddenly the system decompensates and all patients are sent to hospital.

Develop a plan now when the first resident tests positive. Most RACFs will need positive residents moved out ASAP – optimally within 30 mins (that quick) to minimize spread of infection. Where will the well negative patients go when a threshold point of positive patients in the facility is reached? Try to avoid transfers to acute health services if at all possible as they will quickly be overwhelmed. Bear in mind that patients will likely require quarantine for weeks and will have further impacts being in an unfamiliar acute care environment. Identify subacute facilities, consider cohorting into positive and negative RACFs.

Transport logistics needs planning. How will residents be transported as there is a risk of overburdening the acute ambulance service. Communication with families and interpreter services are vital. Essentially none of this was done in Victoria. The plan was “prevent infection” then “deal with positive patients on a case by case basis”. It failed.

Rinse and repeat the above for the disability sector. Do not allow the NDIS/state divide to prevent development of a coherent approach.

Prepare the community for 30% and above mortality rates in aged care residents irrespective of treatment. Do not leave this to the treating teams to break to families.

Do not neglect communication pathways for feedback.

There should be central oversight and coordination. This should not be left solely to individual acute health services who will already be under strain in the same geographic area.

Workforce

Planning

Develop workforce plans to address shortages secondary to physical and mental exhaustion. Workforce shortages have been far more important than ICU beds and ventilators in determining health service capacity in Victoria. Ensure ALL barriers to health services reporting problems to state health departments are removed. Anticipated workforce issues need to be actively monitored particularly by medical workforce. There is a tendency for health services to avoid admitting to the state health department they need assistance. Why this has occurred is unclear. Possible reasons may be a lack of faith in state health department workforce plans or contracted supplier of additional staff or a preference for the health service to use its “own staff”. There may be potential concerns around the associated cost of acquiring more staff.

Address barriers to health services escalating medical workforce shortages to state health departments. If this does not occur, the state department will not be aware of the extent of the crisis. Hence the need for ACTIVE monitoring by state health departments (i.e. increase the frequency of scheduled check-ins, consider expanding state databases and investing in national databases)

Moving staff from nearby facilities is not the solution. This may exacerbate the spread of infection. It is better to minimise HCW movement across multiple sites if possible.

Post COVID HCW workforce – anticipate exhaustion, Mental health issues, trauma – shortages due to complications post COVID infection – develop plan NOW

Work health and safety

Look at all infrastructure upgrades required and implement them now. These should  not be restricted to patient care areas such as negative pressure rooms. How will you create safe spaces for staff in offices and tea rooms? What tracking systems (eg QR codes) and contact tracing systems will you use for staff? What flow/system changes will be implemented regarding staggered break times etc. Look at temporary structures like tents with good ventilation.

Develop best practice regarding communication, transparency and integration of clinical staff in all decision making processes and audit this to ensure compliance. Poor governance will result in massive anxiety and fixation of staff on specific issues that may not be beneficial to overall response.

Recognise and monitor impending workforce issues to avoid a crisis.  This includes mental and physical exhaustion associated with PPE, working with unfamiliar staff, working within infection control restraints, the emotional impact of death and palliation, patients with visitor restrictions, communication difficulties, being unable to debrief in the usual ways at work, and the impact of current community restrictions on staff. The latter take their toll on staff in the same way that they do on the rest of the community.

Staff exhaustion will require careful workforce planning for the future (needs to start now) and the impact of medical complications from staff COVID-19 infection on workforce numbers is unknown – plan for medium and long term shortages.

Community

Avoid “blaming” community for spreading virus/ not complying with advice and restrictions

Enquire why they aren’t and address all issues (e.g. delayed test results, difficulty in accessing screening, pandemic leave etc). Is in home screening needed? This backfires when the community see government also making mistakes (which are inevitable) and it may deter testing. It ensures that any HCW who are told they contracted COVID19 in community and brought it to work will be ashamed and angry. In other words, a different messaging is required to ensure HCW are tested and stay home when symptomatic.

Contact tracing

Ensure screening clinics are collecting standardized data including GP details and ensure GPs are notified automatically if their patients test positive. Advise patients to contact a GP as soon as they test positive. Ensure GPs are utilized/trained/equipped to monitor patients and that they integrate with health service outreach teams. We have had a number of patients that have deteriorated to the point of being too unwell to call 000 at home, and some died at home. They need active monitoring.

Optimise community care for COVID-19 positive patients

Involve GP monitoring, telemedicine and face to face consultation, virtual monitoring, integration with hospital outreach services and acute health services.