It's time: Delivering optimal emergency care of residents of aged care facilities in the era of COVID-19
You are the emergency physician in charge of an urban ED. You receive a call from a residential aged care facility (RACF) registered nurse advising of the transfer of 88-year-old Iris to the ED with a 2-day history of lethargy and nausea. Iris has a background of mild, early stage dementia, ischemic heart disease and diabetic retinopathy causing blindness. She denies fever, cough, sore throat, rhinorrhoea. She has a temperature of 37.4°C, a pulse rate of 110/min, a blood pressure of 100/60, respiratory rate of 32 and oxygen saturations of 94% on room air.
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which manifests clinically as coronavirus disease (COVID-19), has exposed the pre-existing vulnerabilities in healthcare delivery to RACF residents, mostly frail people with atypical disease presentations living amidst staff and resource shortages.1, 2
Mortality from COVID-19 in aged care residents ranges from 5 to 47%,3-9 with the mortality in Australian RACF residents reported at 33%.8 In Australia, in September 2020, 75% of all COVID-19 deaths are in residents of RACFs,8 while across European countries this cohort accounts for 37 to 66% of all COVID-19-related deaths.10 Variance in reported mortality in this population is contributed to by:11, 12
- Differences in resident complexity and frailty across countries.
- Resourcing of the sector and preparedness and training for outbreak management.
- Disparity in testing rates and reporting of COVID-related mortality in this cohort.
- Cultural acceptance of a palliative approach to care.
- Disparities in policies, including those that may restrict access to hospital and life-sustaining care for RACF residents.
RACF residents with acute care needs: is ED always the safest option?
Pre-pandemic, evaluating the risk and benefit of transfer to the ED, including the residents' goals of care and their current acute care need, was a recommended but far from routine strategy for RACF clinicians.13 During the COVID-19 pandemic, both the benefits and risks of transfer are increased (Tables 1 and 2), making such an evaluation even more important.
| Domain | Risks for frail older person | Potential complications |
|---|---|---|
| ED environment | ED design may not allow optimal infection control | Preventable transmission of infectious conditions such as SARS-CoV-2 |
| Noise and associated sleep deprivation | Delirium14 | |
| Lack of diurnal light exposure | ||
| Cluttered corridors15 | Falls16 | |
| Lack of non-slip flooring17 | ||
| High trolleys and use of bed rails18 | ||
| Poor signage15 | ||
| Hard support surfaces | Pressure injury17 | |
| Pain19 | ||
| Processes of care | Exposure to infection | Risks due to procedures (intravenous cannulation, indwelling catheter insertion) and infectious agents, for example SARS-CoV-2 and influenza |
| Increased ramping and ED length of stay20 | Pressure injury, infection risk, potential for preventable morbidity or mortality or preventable suffering/pain through delays to the ED care | |
| Inaccurate medication lists and inappropriate prescribing | Medication error, delays to usual medication administration and medication-related complications21-23 | |
| Lack of appropriately textured food and/or appropriate oral fluid options within ED24 | Dehydration, avoidable IV cannulation, aspiration | |
| Failure to ascertain accurately resident's treatment preferences | Provision of care that is not concordant with residents' treatment preferences25, 26 | |
| Transitional communication | Inadequate communication with RACF and primary care physician on transfer to the ED and on discharge from the ED27 | Suboptimal continuity of care;28-30 potential risk of suboptimal infection control in absence of clear communication in relation to COVID-19 risk assessment and requirement for isolation or testing |
| Risk of 14 days isolation after return to RACF31 | Psychological distress secondary to isolation |
| Domain | Risks for frail older person | Potential complications |
|---|---|---|
| RACF environment | Physical layout of facility may not allow adequate isolation or infection control in a SARS-CoV-2 (or other) outbreak32, 33 | Preventable transmission of infectious conditions such as SARS-CoV-2 |
| Lack of diagnostic testing to allow accurate or timely diagnosis to be arrived at in RACF34 | Delays to diagnosis, delays to appropriate treatment, potential for preventable morbidity or mortality | |
| Lack of monitoring equipment or medications and oxygen required to treat acute care or palliative care need | Preventable morbidity or mortality or preventable suffering or pain | |
| Lack of appropriate personal protective equipment35-37 | Preventable transmission of infectious conditions such as SARS-CoV-2 | |
| RACF staffing | Staffing levels – nursing, medical and allied37 | Delays to identification of deterioration, delivery of personal care, or administration of medications |
| Delay to medical review | ||
| Failure to be able to access allied health | ||
| Insufficient attention to infection control | ||
| Staff lack training in care of acute care needs and/or infection control36 | Preventable morbidity or mortality, preventable suffering or pain and potential for suboptimal infection control |
Balancing these risks and benefits requires an assessment and, ideally, shared decision-making involving a hospital-based specialist (e.g. emergency physician or geriatrician), the resident or their substitute health decision maker, the general practitioner (GP) and the RACF clinical manager. Where there is a recognised COVID-19 outbreak in the RACF, public health risk of managing the infected residents in the RACF setting, including infection risk to other residents, staff and the broader community, needs to be considered. Conversely, where there is no known outbreak in the RACF, but high level of community infection, transfer to the ED may increase COVID-19 exposure risk for the residents, particularly in settings of ED overcrowding and ambulance ramping.
Many of these issues can be addressed through sound geriatric emergency medicine and infection control practice38 and, where clinically appropriate and respecting resident choice, through use of models of care that deliver acute care in the RACF environment.39, 40 ED-substitution models such as Queensland Health's RACF acute care support services,41 NSW Health's Aged Care Emergency programme42 and telehealth programmes can have a role to play in supporting urgent assessment in the RACF setting.43, 44
Regardless of the models of care available, ethical decision-making about the best site of acute assessment and care should balance:
- Capacity of diagnosis to be made and care need to be safely managed in RACFs including the need to consider other care demands in the RACF and, where relevant, the ability to achieve adequate infection control.
- Goals of care of resident and resident choice.
- Beneficence or benefit to the resident, staff and other residents.
- Non-maleficence or minimising potential for harm to the resident, but also to staff and others – this includes avoidance of futile treatments.
Triage to hospital care, even during high levels of pandemic response where hospital capacity is overwhelmed, should not be based on age or residential address but rather be informed by an individual's capacity to benefit from hospitalisation.45
Specific considerations in assessment of RACF residents in ED in the COVID-19 era
Clinical picture
Symptoms reported at the time of COVID-19 testing of residents in RACF outbreaks are outlined in Table 3. Importantly, 27 to 73% of residents who were SARS-CoV-2 positive were identified to be asymptomatic or pre-symptomatic; 29 to 40% had typical symptoms and 8 to 18% had atypical symptoms.3, 5, 7, 46, 48 In those with atypical symptoms, the most common were malaise, delirium, falls and nausea. Importantly, regardless of symptoms being present or absent, large quantities of viral RNA were detected.46 In determining cohorting strategies, application of PPE and COVID-19 testing, reliance on symptom-based screening alone in this population, may fail to identify 50% or more of residents with COVID-19.46
| SARS-CoV-2 test result | Presentation | Proportion of residents with relevant COVID-19 test results | Symptoms | Frequency in residents positive for COVID-19 | Odds ratio |
|---|---|---|---|---|---|
| Positive | Symptomatic: typical | 29 to 40%5, 7, 46 of those testing positive | Fever | 23.8 to 71%5, 7, 47 | 1.6 (95% CI ~0.8–3.7) |
| Cough or shortness of breath | 32.5 to 54%5, 7 | 3.72 (95% CI 1.8–7.8)5 | |||
| Symptomatic: atypical | 8 to 18%5, 7, 46 of those testing positive | Malaise | 17.4 to 42%7, 46 | Not reported | |
| Nausea | 13%7, 46 | Not reported | |||
| New onset anorexia | 27%5 | 3.74 (95% CI 1.5–9.8)5 | |||
| Diarrhoea | 0.81 (95% CI ~0.1–9.0) | ||||
| Delirium or altered behaviour | 4.4 to 39%5, 7, 46, 48, 49 | 1.92 (95% CI ~0.9–4.0) | |||
| Falls or increased risk of falling49 | 27%48 | Not reported | |||
| Functional decline or deterioration in general condition49 | 75%48 | Not reported | |||
| Sore throat | 3.5 to 8.7%46, 47 | Not reported | |||
| Myalgia | 3.5%47 | Not reported | |||
| Headache | 3.5%47 | Not reported | |||
| Loss of taste | 3.5%47 | Not reported | |||
| Asymptomatic†/pre-symptomatic‡ | 27 to 73%5, 7, 46, 48 of those testing positive | Not applicable | |||
| Negative | Symptomatic: typical | 12% of those testing negative (95% CI 8–17)5 | One or more typical COVID-19 symptom during the 2 weeks prior to testing | ||
- † No symptoms or only stable chronic symptoms.
- ‡ Within 7 days of testing positive, 89% of asymptomatic residents were reported to develop symptoms, with median time to symptom onset of 4 days.7
Consideration of likelihood of COVID-19 in residents of RACFs on ED presentation should further include consideration of:
- Assessment of the level of local community transmission of SARS-CoV-2 (and hence, risk of RACF outbreak) through attention to local public health alerts.
- Knowledge of current local RACF policy for COVID-19 prevention such as pre-emptive RACF lockdown and risk-screening of visitors and staff – given the diversity of RACF providers, this may be best regulated and communicated through Aged Care Directions by jurisdictional Chief Health Officers.
- Current suspected or confirmed COVID-19 outbreak at the resident's facility.
- Ability of resident to report symptoms (cognitive impairment, communication limitations).
COVID-19 testing
It is important, particularly in settings with identified community transmission of COVID-19, to have a low threshold to test this population for SARS-CoV-2 as reliance on presence of typical symptoms and signs alone may miss a significant proportion of residents with COVID-19.46 ED staff must also understand the inaccuracies of current molecular testing strategies50 and consider this risk for PPE use and for discharge isolation and monitoring recommendations.
Goals of care
Advance care planning can guide care planning with residents and, where indicated, with substitute health decision makers. Ideally, RACF providers will collaborate with residents to review and update all their residents' advance care plans in the context of COVID-19, where residents (or their substitute health decision makers) choose to engage in these conversations. A resident's choices in relation to the goals of their healthcare should inform types of treatments offered and optimal site of care. Where ED transfer is clinically indicated and concordant with resident choice, advance care plans should be included in transfer documentation. In ED, treatment options offered should be individualised to whether they can benefit the resident, whether the benefit outweighs the risks of harm both to the individual and to others in the community (including risks of harm to other residents and to staff) and whether such treatments are concordant with resident goals of care.
Disposition
Residents who have had a COVID-19 test performed in the ED should generally not be transferred back to the RACF and instead be managed in a hospital environment until the result of the test is available. Testing turn-around-time for this population should be prioritised in order to allow timely identification of an outbreak.1 Where hospital resources are overwhelmed, an ethical decision-making framework supported by validated assessment tools should be used to determine those with most capacity to benefit from hospitalisation51-53 – such considerations should also encompass risk to others (including other residents and RACF staff if the resident were to be transferred back to the facility). Consideration also needs to be given to the ability of the RACF to manage the resident's clinical and care needs, particularly in the context of potential concurrent outbreak management requirements in the facility.
Transitional communication
When a resident is discharged from ED, it is critical that there is communication of results of assessment, investigation and requirements for ongoing management and assessment. Communication between the ED provider and facility staff is central to ensuring continuity of care.54 There is some low-quality evidence that such communication may improve patient outcomes.28 Generally, communication between EDs and aged care facilities is poor with only 55% having evidence of adequate communication on ED discharge.30 Discharge communication should occur verbally and in writing to the RACF clinicians and the resident's GP, with particular attention to:
- Results of assessment, investigations and requirements for ongoing management.
- COVID-19 risk assessment, test result and isolation requirements. Where a resident has presented to the ED, prior to transfer to the ward or discharge to the facility, the resident should be risk stratified for COVID risk and transfer/discharge should be accompanied by communication of this risk and by instruction on requirements for isolation, monitoring or need for follow up. In those residents who test negative but who have a high pre-test probability for COVID-19, isolation, regular observations and repeat COVID-19 testing may be indicated since the sensitivity of recombinant reverse transcriptase polymerase chain reaction increases from 78% with a single test to 86% with a second test and 98% with five tests.55, 56
-
Continuity of medication management. Evidence-based approaches to ensuring medication continuity should be implemented including:24, 57
- Results of assessment of a multidisciplinary team including where indicated, a pharmacist-led medication reconciliation.
- ED medication discharge information including a record of medications administered in ED, new medications including indication and intended duration, changed medications or any medications that can be ceased.
- An interim order for new medications, to facilitate safe administration by RACF registered nurses in the interim to GP review.
- An interim supply of medication or confirmation that the facility will be able to source medications in a timely fashion.
Such attention to continuity of medications is particularly important for a resident who is being returned to the facility for palliation. Residents who are nearing end of life may require prescription and supply of medications to ensure appropriate management of symptoms such as pain, nausea, dyspnoea and agitation. It is critical to ensure that RACF staff have the resources required to ensure resident comfort, including subcutaneous medication administration pump (e.g. NIKI pump) and ability and training to administer restricted medications at all hours.
Conclusion
Residents of RACFs who are acutely unwell have the right to assessment and management that is consistent with their goals of care. During the COVID-19 pandemic, additional imperatives include consideration of the potential harm to other residents or RACF staff. Reliance on a screening strategy based on typical symptoms of COVID-19 alone will miss a significant proportion of residents with COVID-19. Reduction of risk to individual residents, fellow residents and healthcare workers across the care continuum requires a risk-based assessment with an appreciation of atypical, asymptomatic and pre-symptomatic presentation in this cohort, a low threshold for testing in areas with documented community transmission, and rigorous infection control procedures. Transitions of care to the RACF require attention to communication to ensure that the GP and RACF clinicians are able to provide optimal ongoing care.
Competing interests
None declared.
Open Research
DATA AVAILABILITY STATEMENT
Data sharing not applicable to this article as no datasets were generated or analysed during the current study
