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What more could be done to protect aged care residents from COVID? Plenty, it turns out…

The safety of people in residential aged care remains at grave risk, with evidence of wide-ranging failures to protect them from COVID-19, reports Jennifer Doggett in a special Croakey investigation.

The current review of Australia’s COVID response provides an opportunity for driving improvements, and “may be the best chance for residents, families and others to highlight the ongoing failure to protect one of the most at-risk groups in the community”, Doggett writes.


Jennifer Doggett writes:

Since the start of the pandemic in Australia, residential aged care facilties have been the site of some of the most deadly outbreaks of COVID-19. Deaths in aged care account for around 30 percent of all reported COVID-19 deaths in Australia despite the fact that less than one percent of the population lives in permanent or temporary residential aged care.

Older people are already at higher risk from COVID, regardless of their living environment. The COVID-19 Mortality Working Group of the Actuaries Institute found that over the first seven months of 2023, people aged 65-84, experienced significant excess mortality, of which around 40-50 percent could be explained by COVID-19 deaths. In the 85-plus age band, there was a significant excess that is wholly attributable to COVID-19.

Older people living in residential aged care facilities are at even higher risk due to the density of living arrangements and the requirements of many residents for personal assistance and care from aged care workers.

Even with vaccinations and anti-viral treatments, COVID-19 has a mortality rate of just over four percent for residents of aged care facilities, compared with 0.1 percent in the general population. This highlights why it is so important to prevent infections from entering and spreading in aged care facilities in the first place.

This has proven difficult to achieve since the relaxing of public health measures in the broader community. The most recent statistics from the Department of Health and Aged care show that between 5 January and 30 November this year, there have been over 6,000 outbreaks of COVID in aged care facilities, resulting in around five deaths per day of an aged care resident.

From the Department of Health and Ageing: COVID-19 outbreaks in Australian residential aged care facilities 30 November 2023

COVID-19 deaths in aged care facilities are sometimes presented as an inevitability by governments and health authorities. Commonwealth Chief Medical Officer, Professor Paul Kelly, has previously referred to aged care deaths as a “reaping delayed” and recently, in giving evidence to a Senate Estimates Committee, stated that:

“We know from the beginning of [the] COVID period, whenever there are cases in the community and we are continuing to have cases and we’re probably in another wave of Omicron right now, there will be cases in aged care, and that’s the reality of living with COVID.”

However, evidence shows that there is significant variability in outbreak duration, attack rate and case fatality rate across aged care settings and that the mitigations introduced by the facility play a significant role in the impact on residents. In the first wave of the pandemic more than 40 percent of Victorian coronavirus aged-care deaths were residents in just 10 homes.

International data also demonstrates that while older people are over-represented in aged care deaths in all countries, the rate of deaths in Australia’s residential aged care facilities is one of the highest worldwide.

Read the ABC article.

Evidence-based mitigations

We don’t know everything about COVID but there is sufficient evidence to identify some modifiable factors that have increased the mortality rate among aged care residents, including low rates of hospital transfer, poor infection control practices, inadequately trained relief staff and low staffing ratios.

We know that broader population health measures to reduce the spread of COVID-19 have a significant impact on transmission in aged care facilities. This is evident from the sharp rise in death rates since the removal of border controls, quarantine and other mitigations around the end of 2021 and start of 2022 (depending on the jurisdiction). In fact, Department of Health figures show that 87 percent of all the pandemic deaths in aged care facilities have occurred since this time.

There is also robust research supporting the complementary role played by different mitigations in reducing the risk of transmission of COVID in the aged care sector. As every individual intervention has limitations, the optimum results are achieved through implementing a combination of evidence-based measures which together can work to reduce the risk that a failure in one area will result in transmission.

An independent review of COVID outbreaks in residential aged care facilities, commissioned by the Department of Health and conducted in 2021 by Professor Lyn Gilbert AO and Adjunct Professor Alan Lilly, described this as a “Swiss cheese” approach. This concept was developed by virologist Adjunct Professor Ian Mackay, drawing upon work by Professor James Reason in reducing human error.

Official responses

Neither the Department of Health nor the Aged Care Quality and Safety Commission (ACQSC) would provide comments to Croakey on the numbers of COVID deaths in aged care but both described the actions they are taking in response to the ongoing threat posed by the pandemic.

The Department of Health outlined the support it is giving to aged care providers to prepare for, prevent and manage cases and outbreaks of COVID-19 through:

  • access to personal protective equipment (PPE) and rapid antigen tests (RAT) though the National Medical Stockpile
  • a summer deployment of PPE to all aged care homes was completed on 10 November 2023 with 64 percent of services opting in to receive PPE packs.
  • outbreak packs and emergency packs continue to be deployed as needed
  • weekly supply of rapid antigen test (RAT) kits for screening staff and visitors
  • access to a temporary surge workforce to help providers if they are unable to fill critical staff shortages due to COVID-19 and emergency response teams, which can be deployed to assist if there is a significant outbreak in a residential aged care home.
  • access to antiviral medications, through community pharmacy, and from the National Medical Stockpile where homes are unable to access from a pharmacy
  • access to COVID-19 PCR testing through standard Medicare arrangements, where GPs and nurse practitioners directly request from a pathology provider
  • reimbursing providers for the costs associated with managing outbreaks through the COVID grants process
  • delivery of fit-for-purpose IPC education, resources, and communications both sector wide and for targeted provider cohorts.
  • regular updates to the aged care sector, primary care providers and older people on latest COVID information and the importance of boosters, treatments, masks and COVID-19 safe behaviours through webinars, social media, stakeholder networks and newsletters.

The ACQSC said that aged care providers are required by law to provide safe and quality aged care at all times, in accordance with the Aged Care Quality Standards. Infection prevention and control is a vital part of delivering safe and quality care.

“Providers must remain vigilant to the risks that COVID-19 and other infectious diseases present to older people, and be ready to manage outbreaks when they occur,” the spokesperson said.

ACQSC identified the following responsibilities for providers of aged care in relation to COVID prevention and management:

  • maintaining and auditing infection prevention and control practices
  • maintaining up to date information on residents’ vaccination status
  • paying close attention to screening and monitoring of staff and visitors
  • regularly checking staff and residents for clinical symptoms of infection
  • ensuring easy access to doctors for antiviral prescriptions which are effective in reducing severe infection
  • checking that local pharmacies have immediate supplies of antiviral medications
  • confirming sufficient stock on hand of essential supplies including PPE and rapid antigen tests
  • staying up to date with public health requirements and information in their respective state/territory.

The spokesperson said ACQSC supports providers to meet their Infection Prevention and Control (IPC) requirements, citing the specific education programs and resources that are available on the Commission’s website as examples of the support they provide to providers in this area.

ACQSC also undertakes IPC spot checks conducted by the Aged Care Quality and Safety Commission and in-reach IPC appraisals for higher risk residential aged care homes. The 30 November update from the Department of Health and Ageing reports that the Commission has conducted 5,885 spot checks to observe infection control practices and PPE protocols in residential aged care facilities.

Both the Department and the ACQSC referenced sources of advice and information provided by government bodies which highlight the importance of a multi-faceted approach to COVID-19 mitigations for residents of aged care facilities and other groups at high risk.

These include the National Covid-19 Community Protection Framework, the National COVID-19 Health Management Plan for 2023, the Infection Prevention and Control Expert Group (ICEG) advice document, the National Guide for Safe Workplaces – COVID-19 and a range of other information on the Department of Health website.

Implementation failures

The Department and the ACQSC did not comment on why these efforts have not been successful in preventing ongoing COVID outbreaks and deaths in aged care facilities, but some insight were provided by the families of aged care residents and experts interviewed by Croakey.

Family members who contacted Croakey described how guidelines on infection control are not being consistently implemented by providers. This includes inconsistent or non-existent mask wearing, even during COVID outbreaks.

One family member of a vulnerable resident told Croakey that aged care staff had informed her that masks were no longer required, despite a recent social event resulting in an outbreak at their facility, which subsequently resulted in the deaths of two residents.

After complaining to the Aged Care Quality and Safety Commission, she was advised that the facility appeared to be acting within current guidelines. On other occasions she has been told that staff are allowed to remove masks to prioritise their morale, despite putting residents at increased risk.

After repeated incidents where staff members entered her family member’s room without a mask, she said she no longer has any confidence in the ACQSC’s ability to fulfil its stated purpose “to protect and improve the safety, health, wellbeing and quality of life of people receiving Australian funded aged care”.

Croakey interviewed five people with family members in aged care facilities across three states who expressed their concern about the care being provided, including poor infection control practices and difficulties in accessing anti-viral medication once their family member was infected. This reflects concerns raised in the Aged Care Royal Commission Special Report on COVID-19 and reports from consumer organisations and other information sources from the sector.

Used PPE discarded in an open box in a common area of an aged care facility during a COVID outbreak. Photo supplied to Croakey

Part of the problem is that many of the guidelines and expectations provided by government are not mandatory. Even when there are clear regulations in place, it is difficult for authorities to have oversight of how the estimated 2,600 aged care facilities in Australia are interpreting and implementing the required measures.

This is compounded by the fact that it is understandably difficult for many residents to advocate for themselves; as well, families of residents often are not present when potentially risky situations occur, such as staff interacting with residents without appropriate PPE.

Experts and stakeholders interviewed by Croakey have also identified some failures of policy and implementation in key areas, including ventilation, vaccines, treatments and RATS.

Ventilation concerns

Ventilation is one option for mitigation with untapped potential to reduce the spread of COVID-19 in aged care facilities.

This was noted by the Federal Parliament Inquiry into Long COVID and Repeated COVID Infections, which found there was “compelling evidence that poor indoor air quality and ventilation leads to increased risk of COVID-19 infection” and concluded that it was “convinced of the role that good air quality and ventilation play in preventing the transmission of COVID-19, and therefore in preventing long COVID and repeated COVID infections”.

Adjunct Professor Geoff Hanmer, a Director at OzSAGE, described to the Committee the role that poor ventilation played in the 700 deaths in residential aged care during the second wave of the pandemic in Melbourne. He said the number of COVID-19 related deaths in aged care in Australia was unacceptable and suggested that poor ventilation in aged care facilities was playing a part:

“In the cold Melbourne winter, windows were shut, ventilation was minimal and COVID was able to accumulate in the air, a bit like smoke. When an infected person entered a facility it proved impossible to stop the infection spreading.”

Multiple sources of advice and recommendations are now provided to facilities on how to improve air quality and reduce transmission risk (SWA, ACSQHC, APPHC  Protecting Older people C-19 update 3 Feb 2022 Cwth DoH, Aged Care Qual Bulletin 48 Protecting Older people C-19 update 22 Apr 2022 Cwth DoH (air scrubbers), Ventilation strategies reduce C-19 transmission RACFs Vic DoH National Aged Care Design Principles Guidelines). There is also evidence showing that the effectiveness of HEPA air cleaners is significantly enhanced by universal masking.

However, in the absence of mandatory and enforceable standard