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Clinical governance, risk and duty of care for aged care providers in times of COVID-19: a look at CPR

Dr Melanie Tan, Anita Courtney, Victor Harcourt and Johanna Heaven

The additional scrutiny on aged care as a result of COVID-19 draws particular attention to issues such as infection control and workforce management. While these domains represent individual components of the Aged Care Quality Standards (ACQS) respectively, organisational governance (as espoused in Standard 8), including clinical governance, is the ‘overarching’ standard that must support all others under the ACQS.

Clinical governance in aged care

Particularly in this pandemic, we suggest clinical governance is key and foundational to other obligations in aged care, including a provider’s duty of care. Also crucial is training to ensure aged care staff are familiar with, and understand, their employer’s policies and procedures - this is essential to their implementation.

As with any situation, effective clinical governance within the unpredictably dynamic environment presented by the COVID-19 pandemic requires aged care providers to consider their individual circumstances and seek contemporaneous clinical input. However, contemporaneous guidance is also relevant and it is important for aged care providers to keep abreast of emerging literature.

In this vein, a recent consensus statement published in the Medical Journal of Australia[1] (consensus statement), addressing the management of cardiac arrest in pre-hospital settings and associated risk to healthcare workers, offers a useful approach to CPR in aged care. However, as with any other guidance, it should not be considered in isolation. 

CPR during the COVID-19 pandemic

Central to the consensus statement is the basic principal of resuscitation that chest compressions and defibrillation save lives. It is significant that at the time the consensus statement was written, community transmission in Australia was low[2]. As such, its recommendations were made in the context that cardiac arrest was unlikely to be the result of COVID-19. It was recognised that where there is significant community transmission, it may be reasonable to assume all critically ill patients with undifferentiated presentations have COVID-19. This is relevant to the decision-making algorithm in the event resuscitation is required. 

Despite the increase in community transmission in some states since its publication, the consensus statement offers a useful framework within which residential aged care providers might consider their clinical governance policies and procedures.

Ethical considerations

The first question to ask in any given situation, regardless of the level of community transmission, is whether CPR is appropriate for the particular resident. This includes considering the following:

  • The resident’s goals of care, including any advance care directive or other statement of wishes.This should be clarified as early as possible and is a requirement of Standard 2 of the ACQS.
  • The likely benefit of CPR for the particular resident and the risk of harm, such as neurological damage.
  • The risk of infection to other residents and staff.

    The consensus statement recommends an ethical framework to establish treatment goals in the context of COVID-19 which may be applied within a clinical governance structure. This framework includes:

    • assessing the likely cause of a resident’s illness;
    • their mortality risk (eg. based on acute illness severity, premorbid frailty and likely success of treatment options); and
    • risk to staff and other residents.

      Resident and/or family wishes are also central to this framework in determining the appropriate treatment pathway (ie. life-saving or supportive) – this is in line with the consumer being at the heart of the ACQS.

      Clinical governance and CPR

      CPR has the potential to generate aerosols, risking viral transmission through expulsion of infected droplets from a patient’s airway.[3] Clinical governance necessarily concerns management of risk, the profile of which will vary across organisations due to factors such as resident and community demography. 

      Clinical governance frameworks around resuscitation in aged care should consider risk in the context of availability of personal protective equipment (PPE) to first responders. This risk should be balanced against the life-saving potential of basic life support.

      Policies and procedures should also be regularly reviewed and take into account prevalence of COVID-19 in the community generally, and within the facility’s specific demographic. 

      Finally, an effective clinical governance framework must include systems to enable prompt recognition of clinical deterioration, and when intervention is required.

      According to evidence at the time the consensus statement was written, defibrillation is not an aerosol-generating procedure , whereas weak evidence suggests chest compressions may carry a low risk of droplet transmission. Nevertheless the consensus statement considers it reasonable to commence compression-only CPR, provided adequate PPE is available (ie. eye protection, gloves and a surgical mask)[4].

      Recommendations – consensus statement

      The key recommendation in the consensus statement is that what interventions may be safely implemented should be determined by the level of PPE available. It had previously been recommended that chest compressions should only commence once staff have appropriate PPE (which should be readily accessible)[5]

      In addition, one person should be designated responsibility to ensure all staff involved in resuscitation are using PPE safely. The number of staff intervening should be kept to a minimum, and no one should be permitted in the room without appropriate PPE.[6]

      The consensus statement recommends modifications to existing advanced life support protocols. In the context of aged care, similar modifications to basic life support should be considered such as:

      • palpating for chest movements to assess for breathing, rather than listening or feeling for it (ie. avoid close contact with the patient’s airway);
      • placing a standard oxygen mask (if available) over the patient’s mouth and nose with an oxygen flow of up to 10 L/min;
      • covering the oxygen mask, or patient’s mouth and nose, with a towel, cloth, surgical mask or clear plastic sheet (while regularly checking the airway for vomitus or other secretions).[7] 

      Of course, an ambulance should always be immediately called. 

      Summary

      In dynamic times and a pandemic which continues to evolve, robust governance provides a framework within which providers and their workforce can operate, offering some degree of certainty within a world of uncertainty.

      It is a role of clinical governance in aged care to actively consider risks so that providers can balance these against other obligations in the ACQS and their duty of care to residents, staff and families. As such, aged care providers should be cautious in taking a blinkered or blanket approach to governance, especially where such policies are solely reactive to the risk environment. 

      While contemporaneous literature can assist in framing an approach to clinical governance, aged care providers must always consider their individual circumstances and seek appropriate clinical input.  And, as always, if in doubt seek advice.

      How we can help

      If you require any further information please contact Dr Melanie Tan, Anita Courtney or Victor Harcourt from our expert Aged Care team.

      If you would like to keep in touch with Alerts, events and Insights from our expert Aged Care team, you can subscribe to our mailing list here.

      [1] Craig S et al, ‘Management of adult cardiac arrest in the COVID-19 era: consensus statement from the Australasian College for Emergency Medicine’. Medical Journal of Australia, Volume 213, Issue 3.  Published 3 August 2020:  doi:10.5694/mja2.50699. This should be read together with the following: Brewster DJ et al, ‘Consensus statement: Safe Airway Society principles of airway management and tracheal intubation specific to the COVID-19 adult patient group.Medical Journal of Australia, Volume 212, Issue 10..  Published 5 May 2020. doi: 10.5694/mja2.50598

      [2] The consensus statement was published on 12 July 2020; Victoria’s Stage 4 lockdown commenced on 2 August 2020.  This Alert was written on 25 August 2020.

      [3] Brewster, D et al.  ‘Consensus Statement: Safe Airway Society principles of airway management and tracheal intubation specific to the COVID-19 adult patient group’.  Medical Journal of Australia 2020; 212 (10); 472-481. Published online 5 May 2020, doi: 10.5694/mja2.50598.

      [4] The consensus statement has adopted a conservative approach and that their recommendations are based on weak evidence.  As such they are subject to the outcome of further research.

      [6] Brewster DJ et al, ‘Consensus statement: Safe Airway Society principles of airway management and tracheal intubation specific to the COVID-19 adult patient group.’ Medical Journal of Australia, 2020.  First published 16 March 2020. https://www.mja.com.au/journal/2020/consensus-statement-safe-airway-society-principles-airway-management-and-tracheal

      [7] This article does not substitute the need for specific clinical input.

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