Older person-specific recommendations

All older persons, in addition to the principles outlined in ACEM’s P51 Policy on the care of older persons in the emergency department [Link], we recommend:

1. Vaccination of all older persons for COVID-19 and influenza  (where there is no medial contra-indication and where the person consents)
2.  Beyond standard case-definitions, emergency clinicians should also consider the following in screening of older persons for potential COVID-19:

• Acute respiratory illness (ARI) may present with atypical symptoms in older persons, including, for example, functional decline, delirium (which may manifest as hypoactive, hyperactive or mixed on the basis of psychomotor behaviour), exacerbation of underlying chronic conditions, falls, loss of appetite/nausea, malaise, diarrhoea and myalgia. Emergency Department triage screening tools should flag the potential for atypical symptoms in older persons.
• Although fever is the most common sign in the population overall, it is not a sensitive sign in older persons.
• Emergency clinicians should take care to avoid anchoring onto a diagnosis of COVID-19 and consider broad differential diagnoses where older persons present with atypical symptoms.
• Reliance on symptom-based screening alone in the frail, older population may fail to identify 50% or more of those with COVID-19.

3. Prediction of probability of mortality in all persons (irrespective of age) should incorporate use of objective evidence-based multi-dimensional tools (for example, use of age combined with clinical frailty scale together with a measure of acute illness severity e.g. SOFA or qSOFA).
4. Where feasible, emergency departments prioritise flow of older persons to inpatient wards when admission is indicated.
5. Emergency physicians recognise and provide support to older persons and their carers for psychological distress and stress that is likely to result from the pandemic situation. 

We do not recommend limitations on treatment based solely on age or place of residence.

For RACFs and RACF residents we recommend:

1. All RACFs adhere to the Communicable Diseases Network Australia (CDNA) National Guidelines for the Prevention, Control and Public Health Management of COVID-19 Outbreaks in Residential Care Facilities in Australia [Link], and comply with all advice, notices and directives made in relation to Federal and state legislation and policy in relation to ensuring safety of residents in RACFs.
2. RACFs undertake stringent infection control processes recommended in Australian Guidelines for the Prevention and Control of Infection in Healthcare (2019) [Link].
3. Disaster plans at all jurisdictional levels, from local to national,  to incorporate cross-sector support for RACFs and General Practitioners (GPs).
4. Pre-hospital triage of RACF residents (with COVID-19 and with non-COVID-19 presentations) during this pandemic response is critical to minimising harm to residents and achieving sustainability of acute health service delivery. Decisions to transfer RACF residents to hospital should include assessment of: 

• Public health and infection control imperatives.
• Advance care planning.
• Acute care need including consideration of:

            o Frailty and comorbid illness
            o Risks of transfer and potential benefits

• RACF capability and capacity to attend to care needs.
• Reliance on symptom-based screening alone in the frail, older population may fail to identify 50% or more of those with COVID-19.

This telephone triage assessment may be supported by telehealth utilising RACF support services e.g. Connecting Care. 

Where a resident is clinically stable, consideration should be made for a planned and controlled admission, direct to the inpatient ward, bypassing the Emergency Department (ED).

5. All hospital systems implement or expand specialist-led telehealth and mobile assessment services to support RACFs and GPs or RACF acute care support services (RaSS).
6. RACFs implement systems to ensure up-to-date influenza and COVID-19 vaccination for residents and staff (contracted and visiting) in accordance with national immunisation recommendations and jurisdictional legislative requirements.
7. RACFs and GPs, with health service support where necessary, prioritise advance care planning with residents and their health decision makers.
8. RACFs and GPs proactively change residents on nebulisers to metred aerosols with spacers where  clinically appropriate. Residents receiving non-invasive ventilation should have a plan developed in consultation with their respiratory or sleep physician, of how to manage this in the context of suspected or confirmed COVID-19.
9. Where RACF residents require transfer to hospital, ED physicians recognise that 43 to 73% of residents testing positive for COVID-19 in RACF outbreaks are asymptomatic or presymptomatic at the time of testing and a higher proportion present with atypical symptoms than in the general population. Any  resident presenting to ED from a RACF with a current COVID-19 outbreak should be managed with airborne and contact precautions in a single room regardless of symptoms.
10. Where RACF residents are tested for COVID-19 in the ED and considered suitable clinically for discharge, the result must be available before they are transferred back to the facility. ED transitional communication will provide COVID test results and clear guidance as to isolation, infection control and follow-up requirements specific to the RACF setting.

If the result is positive, ensure public health has been notified by phone and consulted in relation to disposition. If the case represents an index case, there will need to be activation of the RACF’s outbreak  management plan and activation of Commonwealth, state and local health district response teams.

We advocate for:

1. That the Commonwealth strengthen RACF surge workforce planning, early warning systems and response to business continuity failure either as a direct or indirect result of COVID outbreaks.  Evacuation of RACF residents to hospitals in the context of RACF business continuity failure in the absence of clinical indications for hospital admission contributes to avoidable risk to residents.
2. Development and implementation of a collaborative community strategy for care and support of community-dwelling frail older persons, including increased access to transition support and home care packages.
3. Adequate access of RACF staff and GPs to recommended PPE, fit-testing, and training for donning and doffing and fit-checking.
4. Honesty with patients and relatives, and transparency of process in resource allocation decisions.
5. Increased funding and medical and nursing support provision to RACFs.
6. Improved access of GPs and RACFs to telehealth support and hospital-delivered clinical support in the RACF environment, 24 hours per day.
7. Every jurisdiction to have clearly defined clinical governance for management of COVID-19 outbreaks in residential aged care facilities

We align with:

• CDNA National Guidelines for the Prevention, Control and Public Health Management of COVID-19 Outbreaks in Residential Care Facilities in Australia. [Link]
• Infection control processes relevant to RACFs recommended in NHMRC, Australian Guidelines for the Prevention and Control of Infection in Healthcare (2021). [Link]
• QLD Health, Checklist for Residential Aged Care Facility (RACF) preparation for COVID-19 prevention and outbreak management [Link]
   

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