Uncertainty and fear: aged care in a time of COVID-19

“The most vulnerable people in the community are looked after by GPs …”

Ten years change in ten days: how COVID-19 accelerated change in general practice. An address to colleagues, University of Melbourne, 20 October 2020, by Professor Michael Kidd

ON 30 March 2020, two GPs who attended a local aged care facility had a telephone conversation. A nurse at an aged care facility they both visited regularly had just reported that a female resident had developed a dry cough but remained afebrile, with minimal right basal crepitations heard on auscultation. The resident had returned from 5 days’ community leave from the facility on 21 March. She spent her period of leave undergoing elective treatment in a local private hospital and recuperating at her family’s home.

At that time, nasopharyngeal swabs to detect COVID-19 via polymerase chain reaction (PCR) were in short supply. Given the resident’s mild symptoms, she did not meet the testing criteria at the time. After weighing the risks of undetected COVID-19 posed in an aged care facility, the GPs decided to proceed with testing.

The following day the swab was reported as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) DETECTED (Case 1). The result was notified to the Victorian Department of Health and Human Services (DHHS) and all 48 residents on two open floors were placed into lockdown. Case 1 resided in a room on the upper floor.

Initially, instructions from the DHHS were to continue to isolate Case 1 with strict infection control measures (including wearing personal protective equipment [PPE]) and to quarantine all other residents in their rooms. Following a deep cleaning process directed by the DHHS, all upper floor residents were confined in quarantine in their rooms. Ground floor residents were permitted to move about freely. Communal areas were open to ground floor residents, but physical distancing rules were mandated. All staff were considered close contacts and were told to quarantine at home. Only two of the quarantined staff members developed mild symptoms (headache, nasal congestion, and sore throat) within a few days, but both returned a negative COVID-19 swab result.

The DHHS instructed the isolation of Case 1 for 14 days from the onset of respiratory symptoms. Release from isolation was planned on 11 April. Quarantine for all upper floor residents was planned to conclude on the same day. At the time, DHHS guidelines did not include recommendations on retesting before release from isolation. However, after a discussion between the nurses, GPs and facility owner, a repeat swab was taken of Case 1 on 14 April (delayed due to a public holiday). The result was reported as negative next day.

Another upper floor resident was also swabbed on 14 April after developing a cough. This resident, and her husband, remained in quarantine for a further 24 hours. Her swab returned a negative result on 16 April. The isolation period for Case 1 – and quarantine of upper floor residents – concluded on 16 April.

Some of the residents’ families were upset. They frequently rang the nurses to ask about their family member’s wellbeing and were stressed because they could not see them. Some of the themes were accelerated deterioration of cognitive impairment without family support; others were frustrated about the lack of state and federal government support in aged care during these uncertain times. They all wanted to know when the DHHS would let them see their loved ones once again.

The potential outbreak of COVID-19 at this facility terrified the owner and its staff. The media shaming and opprobrium heaped upon management and staff at Newmarch House in Sydney following their outbreak was fresh in their minds. Political leaders were publicly stating that it was time to open the doors to aged care facilities. Meanwhile, facilities were struggling to understand exactly how they could safely reintroduce family visits. The guidance was perceived as opaque. Uncertainty among residents’ families translated into anger that, in some cases, was directed at staff. This further added to the psychological distress upon the staff.

On 24 April, 24 days after Case 1 returned a positive test, and 8 days after the end of isolation for that resident and quarantine for other upper floor residents, a ground floor resident developed a new cough and sore throat. She had no fever. She was isolated. On 28 April, the swab returned a SARS-CoV-2 DETECTED result (Case 2). DHHS instructed ongoing isolation for Case 2 and room quarantine for all residents. Staff were again considered close contacts and quarantined at home for 14 days, some doing so for the second time.

Uncertainty and confusion around this second transmission added to the staff anxiety and fear. At the time, the global situation painted a frightening picture: 97 500 daily new cases of COVID-19 were reported worldwide and 47 500 people had already died from COVID-19 in the US alone. Predictions were dire. Nationally, Australia saw a sustained plateauing of the epidemic curve with 20 new daily cases reported compared with 288 new daily cases a month prior. Only 56 cases of COVID-19 from residential care had been reported to date in Australia, mostly from New South Wales.

At the facility, a critical conversation took place. Should we swab everyone? Residents, GPs, nurses, carers and staff — everyone. The Victorian guidelines published on 25 April 2020 stated that asymptomatic people should not be tested except in special circumstances, such as recovered cases wishing to return to work in a health care or aged are facility or as part of outbreak management or enhanced surveillance. Clear direction regarding COVID-19 outbreak management in aged care facilities had yet to be published. However, there were some published reports of rapid transmission and asymptomatic infection in nursing facilities internationally (here and here).

There was concern among the GPs about asymptomatic or pre-symptomatic transmission and a rapidly developing outbreak. It seemed highly likely that there were more cases within the facility and the risk of missing these cases was too high. Families were faced with the awful dilemma of weighing up the risk of keeping their loved one in the facility or removing them to the community. That risk could not be quantified without testing and, if residents were taken out of the facility into the community without testing, another layer of risk of spread would be added.

So, the GPs acted – DHHS said it was not a decision for them to make at the time – and the testing went ahead.

A newly launched public–private collaborative testing service in Victoria was engaged and, on 28 April, a team of pathology collectors from Sonic Healthcare undertook a facility-wide testing of all residents, staff and visiting doctors. Quarantined staff were tested in the facility car park with physical distancing.

The main challenges at the time of performing point prevalence testing of COVID-19 in an aged care facility included sourcing swabs, training collectors, acquiring PPE and collecting samples from residents with cognitive impairment. Logistical challenges (such as sample delivery to the laboratory) also presented. The public–private collaborative testing service proved to be highly efficient. Their involvement provided a welcome psychological boost for residents, their families, and the facility team. Their efficiency and competence helped to restore a degree of trust and confidence.

Seventy-nine residents and staff members were swabbed, two residents (Case 3 and Case 4) and one non-clinical staff member (Case 5) returned SARS-CoV-2 DETECTED results. All new cases were afebrile. On retrospective review, Case 3 had complained of nausea 4 days before testing. Case 4 remained asymptomatic throughout. Case 5 had presented to a GP with a sore throat 2 weeks earlier but was not tested for COVID-19. Enquiry suggested this was due to “the shortage of PPE and testing equipment, and uncertainty about guidance”. They were also asymptomatic at the time of testing.

These results were notified to the DHHS and the guidance still did not recommend re-testing before ending quarantine. After some internal discussion, it was decided to retest all residents and staff as a proactive precautionary measure. Facility-wide testing was undertaken again on 12 May 2020. Staff in quarantine at home were tested at off-site testing centres. No new cases were identified.

Instructions from DHHS were to retest Cases 2, 3 and 4 at day 10 after symptom onset. Criteria for ending isolation were: being 10 days after symptom onset with noted improvement in symptoms, 72 hours free of fever, and two SARS-CoV-2 NOT DETECTED results at least 24 hours apart. Case 2 returned a positive swab result on day 12 and negative results on days 16 and 19. Case 3 returned positive swab results on day 11 and 18, negative results on day 15, 22 and 32, with an “INDETERMINATE” result on day 25. Her clinical presentation had included nausea, cough, sore throat, lethargy, and loss of sense of taste and smell. Case 4 returned a negative swab result on days 10 and 11 and was asymptomatic throughout her isolation period. Case 5 (non-clinical staff member) was not followed by the authors.

None of the resident cases recorded a fever or developed pneumonia during their illness/isolation period. None of the resident cases required escalation such as hospital admission.

Reflecting on this first-hand experience of an outbreak of COVID-19 in a residential aged care facility, we make the following practical suggestions to our colleagues:

1. Test any symptomatic resident patient for COVID-19, even if only mild, non-respiratory but infectious symptoms exist.
2. When a positive case of COVID-19 is identified, institute full facility lockdown and quarantine of all residents and staff early.
3. Consider how staff will be quarantined.
4. Anticipate and plan for the effects on staffing from quarantine.
5. Ensure early communication with the DHHS (or equivalent) and the diagnostic pathology provider to coordinate the outbreak response and testing.
6. Regular and consistent communication should be established with families and staff that sets out the plan if a case arises.
7. Plan for the enormous psychological impact of an outbreak on residents, their families and the facility team and their families.
8. Consider early contact with any hospital or palliative care services/resources to discuss service capacity and pathways for communication during the outbreak.
9. Plan for psychological and physical rehabilitation of residents after isolation or quarantine.

Communication challenges risk losing the trust of families. Demonstrating that testing is being undertaken and providing information builds trust. SMS and video updates also help to disseminate information and provide reassurance. To further complicate the situation, key team members are lost due to illness and quarantine. Families become angry due to their anxiety. Reduced or new staff and increased family anxiety can prevent effective handover and feedback, especially if new staff are unfamiliar with residents. Telehealth continues to provide a valuable means of reviewing residents and supporting staff while reducing the risk of COVID-19 transmission into aged care facilities through health professional visits. If visiting the facility, medical practitioners need to have a clear understanding of the facility infection control plan (eg, where to don and doff PPE) and resident isolation status, to keep visits efficient, and to avoid any inadvertent PPE breaches.

Consider further communication with residents on an individual basis. Written care-needs updates placed in resident’s rooms – provided regularly by this facility – helped orientate residents’ carers and increase their understanding. For positive cases, the written plans provided reassurance, and an outline of testing and timeframe during the particularly challenging period of isolation. It took some pressure off facility staff and families who were receiving regular telephone calls from the isolated residents. It also helped shorten GP visits.

The first positive case of COVID-19 in an aged care facility brings fear and uncertainty to everyone – residents, families, staff, and the medical staff. Advice from DHHS (or equivalent) can be fluid and change regularly, especially when mixed with federal agency involvement. We recommend a more cautious approach with all decision making when doubt or significant concern arise.

Associate Professor Malcolm Clark is an Inaugural Member of the Academy of Clinical Teachers at Melbourne Medical School; Honorary Associate Professor, Department of General Practice, University of Melbourne; Member of the VicREN Committee, NPS MedicineInsight data governance board and Eastern Melbourne Primary Health Network clinical council; Consultant Clinical Director, Sonic Clinical Trials & Medical Director, IPN Medical Centres, Victoria.

Associate Professor David Brewster is a practicing anaesthetist and intensive care physician at Cabrini Hospital, a medical educator and a passionate advocate for kindness in healthcare.

Dr Laura Jones is a Melbourne-based GP with a specialist interest in aged care. 

Dr Jagdeesh Singh Dhaliwal is a Melbourne GP with a special interest in aged care. He has experience of working in corporate and clinical management, education, medical indemnity and strategy. He has lectured widely in the UK, US, Latin America and Asia and his particular interests lie in healthcare leadership and supporting new technologies and innovation.

Dr Jasmine Teng is a medical microbiologist at Melbourne Pathology. She is passionate about the diagnosis and management of infectious diseases, teaching and hopes to pursue her research interest in medical mycology.

The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.