Volume 214 Issue 1

Recommendations to guide residential aged care facilities in preparing for and managing infectious disease outbreaks

Georgia E Aitken · Alice L Holmes · Joseph E Ibrahim

Peer support initiatives can help health professionals experiencing mental health and wellbeing challenges during the COVID-19 pandemic and beyond

Tahnee L Bridson · Kym Jenkins · Kieran G Allen · Brett M McDermott

Controlling the exit from work and accumulating multiple resources early predict adjustment to retirement The traditional approach to leaving a career in medicine has been informal. The fact that about 10% of medical practitioners in Australia are aged 65 years or over1 — a seemingly natural consequence of increased life expectancy, improved quality of life and fluctuations in financial markets — highlights the need for a more methodical process for leaving medicine. The final transition in a medical career is one that the profession has largely ignored, thereby risking unplanned departures that affect succession planning for practices, continuity of care for patients, and the wellbeing of the practitioner. The eventual introduction of proposed mandatory health checks for practitioners aged 70 years and over in Australia2 may hasten the retirement of some, which only increases the urgency of retirement planning becoming a routine task for all practitioners. The aim of this article is to describe a framework that examines how this transition may be achieved, so that practitioner wellbeing and adjustment to retirement are enhanced. For all the changes in medical culture that must occur — and to which the colleges, employers and other professional organisations must contribute — the individual practitioner ultimately remains responsible for their own welfare across the career cycle. While this article is aimed mainly at clinicians, its principles remain pertinent to other medical practitioners. Understanding the process of retirement Retirement is not a lone event. It is better understood as a longitudinal process that comprises three phases that may overlap.3 In the “pre‐retirement” phase, the practitioner continues to work but may anticipate and prepare for retirement. In the “transition” phase, decisions are made about how and when the practitioner should approach stopping work. The final phase of “adaptation” may involve some paid work but the practitioner is principally retired. Each phase is considered a critical turning point, in which action or neglect can influence the outcome of subsequent phases. Some practitioners may chart a non‐linear transition, moving in and out of work. Any approach to determining the optimal time to transition out of a career in medicine must consider individual motivation as well as other competing factors. The first is the right of all and the desire of some older practitioners to continue working versus the extrinsic demands of family expectations or life events, such as illness in a loved one. The second is the continued provision of clinical services by senior medical practitioners, usually within well established patient relationships, versus the right of patients to receive the highest level of care possible. In this regard, older practitioners are at increased risk of physical and cognitive changes that may potentially affect practice, such as poorer patient outcomes,4 and may lead to being the subject of a complaint to a regulatory authority.5 Why retirement planning may be hard When the transition away from work should start is an individual decision. Yet a cross‐sectional survey found that more than one‐third of older practitioners working in Australia had failed to even reach the pre‐retirement phase, as they reported no intention of retiring or were unsure about doing so.6 Moreover, not intending to retire was an occupational factor that predicted practitioners’ perceptions of ageing successfully.7 This suggests that even considering leaving work may be viewed as a sign of personal weakness. Financial factors related to inadequate superannuation funds, continuing debt, or other commitments have been found to prevent retirement planning.8 Several other reasons for continued practice and delayed retirement, however, reflect more intrinsic difficulties in detaching from medicine. These include a feeling of responsibility for patients, a lack of interests outside of medicine, and a fear of potential changes in their relationship with a spouse.8 These factors may be the result of a lifetime of work centrality whereby medicine takes precedence over other life roles.6 For many doctors, self‐identity is bound up in their work and the drive to further their careers. A study of academics suggested that work–life balance was more nebulous because outside interests, including family, were considered an inconvenient distraction.9 Conversely, emotional connections towards a workplace or institution may strengthen. Prioritising work limits social connections and creative pursuits, thereby perpetuating a reluctance to retire. A structured transition to retirement plan The purpose of adequate retirement planning is to enhance wellbeing after ceasing work. Pre‐retirement planning is a long term goal‐oriented behaviour that has been associated with retirement satisfaction.10 In addition, retirement adjustment is predicted by the conditions of exit — namely, control over how and when one leaves work11 — and resource acquisition in multiple domains.12 While the elements of planning should occur throughout the career cycle, we recognise that it is not a compelling consideration for many practitioners. We would still propose that all practitioners formally write an initial transition to retirement plan by the age of 55 at the latest, review it regularly, and the intervals between reviews should become more frequent with time (Box). The proposed introduction of the mandatory health check for practitioners aged 70 years or over should be an important incentive for self‐care. Traditional pre‐retirement planning has tended to consist only of financial advice such as wealth creation, tax optimisation, and estate planning. This is an essential task as people tend to underestimate how much money will be required in retirement, but should not be used as the sole criterion of fitness for retirement. The more pertinent questions are how time in retirement will be spent and how much it will cost to support, rather than a pre‐determined goal of wealth accumulation. Resource accumulation While adequate financial resources do contribute to retirement adjustment, so do adequate physical health, social engagement and emotional resources.12 This means a much broader spectrum of planning that uses advice from multiple professionals is required. Methods for optimising financial, physical and leisure resources are relatively easily sourced. What may be more difficult to manage, however, are the emotional resources needed to navigate the transition to retirement. In particular, the inevitable loss of self‐identity may lead to anticipatory grief and bereavement.13 That intending to retire is viewed as a mark of ageing less well by practitioners not only poses a considerable challenge for their retirement planning, but highlights the importance of understanding successful ageing in any discussion of transitioning away from full‐time work in medicine. Successful ageing is a concept that has evolved from a biomedical model, requiring an absence of physical disease and good physical functioning, to a more subjective notion that emphasises adaptation and autonomy.14 A sense of engagement, a prominent feature of self‐rated successful ageing, is inherent in the work of medical practitioners and is reflected in the pursuit of continued stimulation and learning, a sense of purpose and utility to society.15 Successful occupational ageing is based on insight into personal strengths, a dynamic process of goal setting, generativity (guiding and mentoring the next generation), and self‐care.14 There are a number of areas that are important for self‐reflection, such as the original motivations for training in medicine, the reasons for continuing to work, the anticipatory grief of the loss of identity and role, and the fear of ageing.14 Not every practitioner will be capable of self‐reflection, so that professional help may be required via a career development counsellor or vocational psychologist. While many practitioners will set a pre‐determined age or personal milestone at which to retire, others may continue to work indefinitely, thereby increasing the risk of practising with an impairment. This may be prevented by incorporating a professional advance care plan16 that outlines a set of premorbid views about ongoing practice in the event that capacity to practise is impaired. Permission would be given to one or more people, such as a spouse, friend or colleague, to monitor fitness to practise and to provide regular feedback. “Red flags” to stop working may include physical illness or concern from a trusted source about deterioration in cognition or procedural or clinical skills. Developing an encore career Developing an encore career is the final aspect of the transition plan that allows the use of skills and experience developed over a career, and helps maintain meaning and engagement. Giving consideration to the encore career while still working enables the practitioner to better position themselves to access greater opportunities. Up until this point, the practitioner may have found integrating different life roles challenging and pursuing outside interests unnecessary. An encore career can lead to feeling purposeful, provide goals to strive towards, and opportunities for intellectual and social pursuits. For example, a general practitioner keen to maintain patient contact but reduce caseload may want to specialise in an area of medicine (eg, mental health). Some may investigate governance roles with accrediting bodies, sit on guardianship or mental health review tribunals, or take up committee membership. Others may wish to provide leadership through directorships or management roles in hospitals or medical services. Others may wish to apply their lifetime of insights to teaching or research pursuits. Examples include teaching medical students, mentoring trainees, writing research grants and articles. It might be worthwhile revisiting those businesses or volunteering opportunities that were set aside before a medical career became the sole focus. Conclusion Retirement should not be viewed as a single endpoint but as an anticipatory process that involves the accumulation of social, emotional, financial and other resources. Active participation in retirement planning is essential to ease the transition, gain a better sense of control and enhance emotional adaptation. Encore careers provide the opportunity to capitalise on a lifetime of accumulated wisdom by integrating training, experience, interests and strengths. Given medicine’s long‐standing neglect of retirement planning, there is also a need for professional bodies to provide education about the transition process and for practitioners themselves to share stories of encore careers and inspire peers to explore avenues for transition. Box – My plan for transitioning to retirement I will accumulate the following resources: Physical resources ► What am I doing to take care of my health (diet, exercise, adherence with medications)? ► How often am I seeking independent health care, including consulting my general practitioner? Financial resources ► How do I optimise my finances (reduce debt, maintain income)? ► Who is my professional adviser? How often do I consult with them? Emotional resources ► Who are the people I can connect with for emotional support? Who do I support in return? ► Who do I know who has aged well and transitioned well? What can they share? ► What types of professional assistance do I need to support the transition? Social resources ► How do I maintain healthy relationships (spouse, children, family and friends)? ► Who can provide professional support to help me manage these relationships now and when I am not working? ► What relationships have lapsed that I want to re‐initiate? ► What interests can I develop or revisit? Cognitive resources ► What intellectual pursuits outside medicine can I follow? ► How do l want to learn, develop and grow? ► What creative pursuits do I want to develop? ► What courses or training might help to reposition me for an encore career? My professional advance care plan I will discuss the timing of transition and retirement with my peers and loved ones I will engage my junior colleagues in a discussion about succession planning I will reduce my hours, stop procedural work etc, at age X or if the following health or practice problems occur … I will stop working at age X or if the following health or practice problems occur … I will set up a peer mentoring system with close colleagues so that we can provide each other with feedback on professional issues and review skill levels. Encore career What are some professional aspirations I can pursue given greater time availability? How do I convert my passions and interests into pursuits? Do I want to focus on areas of expertise, governance, leadership or teaching and research? Was there a business opportunity I considered before my medical career that I want to revisit? What other career options have people who have successfully transitioned considered?

Chanaka Wijeratne · Joanne Earl

A 75-year-old man was referred to our centre with a history of sudden onset painless loss of vision in the right eye, on a background of recent jaw claudication and weight loss

Khizar Rana · Carmen Oakley · David M Ross · Sumu Simon

A 64-year-old man with underlying hypertension and hyperlipidaemia presented with abdominal distension, vomiting and no bowel movement for 2 days

Assyifaa Nik Mazian · Siti Soraya Ab Rahman

Kanjanapan Y, Yip D. Considerations for cancer immunotherapy during the COVID‐19 pandemic. Med J Aust 2020; 213: 390‐392. https://doi.org/10.5694/mja2.50805 In this Perspective, on page 391, the sentence “Current guidelines recommend ICI monotherapy to be delivered at increased dosing intervals, such as nivolumab four times per week and pembrolizumab six times per week” is incorrect. It should read: “Current guidelines recommend ICI monotherapy to be delivered at increased dosing intervals, such as nivolumab every four weeks and pembrolizumab every six weeks”.

The MJA aims to be an outstanding general medical journal, broadly relevant to all specialties in medicine and health, with a national and global focus, a journal that influences policy and practice

Nicholas J Talley

Adequate capacity — beds, equipment, consumables, and, crucially, trained personnel — is needed to cope with a surge of critically ill patients

Mervyn Singer

Inappropriate behaviour harms health workers and patients, and evidence-based solutions are needed

Anthony Scott · Danny Hills

The prognosis may not be as poor as overseas, but the intensive care resource burden may be greater

Aidan JC Burrell · Breanna Pellegrini · Farhad Salimi · Husna Begum · Tessa Broadley · Lewis T Campbell · Allen C Cheng · Winston Cheung · D James Cooper · Arul Earnest · Simon J Erickson · Craig J French · John M Kaldor · Edward Litton · Srinivas Murthy · Richard E McAllister · Alistair D Nichol · Annamaria Palermo · Mark P Plummer · Mahesh Ramanan · Benjamin AJ Reddi · Claire Reynolds · Tony Trapani · Steve A Webb · Andrew A Udy

Objective: To identify individual and organisational factors associated with the prevalence, type and impact of unprofessional behaviours among hospital employees. Design, setting, participants: Staff in seven metropolitan tertiary hospitals operated by one health care provider in three states were surveyed (Dec 2017 – Nov 2018) about their experience of unprofessional behaviours — 21 classified as incivility or bullying and five as extreme unprofessional behaviour (eg, sexual or physical assault) — and their perceived impact on personal wellbeing, teamwork and care quality, as well as about their speaking‐up skills. Main outcome measures: Frequency of experiencing 26 unprofessional behaviours during the preceding 12 months; factors associated with experiencing unprofessional behaviour and its impact, including self‐reported speaking‐up skills. Results: Valid surveys (more than 60% of questions answered) were submitted by 5178 of an estimated 15 213 staff members (response rate, 34.0%). 4846 respondents (93.6%; 95% CI, 92.9–94.2%) reported experiencing at least one unprofessional behaviour during the preceding year, including 2009 (38.8%; 95% CI, 37.5–40.1%) who reported weekly or more frequent incivility or bullying; 753 (14.5%; 95% CI, 13.6–15.5%) reported extreme unprofessional behaviour. Nurses and non‐clinical staff members aged 25–34 years reported incivility/bullying and extreme behaviour more often than other staff and age groups respectively. Staff with self‐reported speaking‐up skills experienced less incivility/bullying (odds ratio [OR], 0.53; 95% CI, 0.46–0.61) and extreme behaviour (OR, 0.80; 95% CI, 0.67–0.97), and also less frequently an impact on their personal wellbeing (OR, 0.44; 95% CI, 0.38–0.51). Conclusions: Unprofessional behaviour is common among hospital workers. Tolerance for low level poor behaviour may be an enabler for more serious misbehaviour that endangers staff wellbeing and patient safety. Training staff about speaking up is required, together with organisational processes for effectively eliminating unprofessional behaviour.

Johanna Westbrook · Neroli Sunderland · Ling Li · Alain Koyama · Ryan McMullan · Rachel Urwin · Kate Churruca · Melissa T Baysari · Catherine Jones · Erwin Loh · Elizabeth C McInnes · Sandy Middleton · Jeffrey Braithwaite

Switching trauma specialist services to pandemic management would be unwarranted

Teagan L Way · Seth M Tarrant · Zsolt J Balogh

Introduction: Coronavirus disease 2019 (COVID‐19) is a contagious disease that is caused by the severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2). Health care workers are at risk of infection from aerosolisation of respiratory secretions, droplet and contact spread. There are a number of procedures that represent a high risk of aerosol generation during cardiothoracic surgery. It is important that adequate training, equipment and procedures are in place to reduce that risk. Recommendations: We provide a number of key recommendations, which reduce the risk of aerosol generation during cardiothoracic surgery and help protect patients and staff. These include general measures such as patient risk stratification, appropriate use of personal protective equipment, consideration to delay surgery in positive patients, and careful attention to theatre planning and preparation. There are also recommended procedural interventions during airway management, transoesophageal echocardiography, cardiopulmonary bypass, chest drain management and specific cardiothoracic surgical procedures. Controversies exist regarding the management of low risk patients undergoing procedures at high risk of aerosol generation, and recommendations for these patients will change depending on the regional prevalence, risk of community transmission and the potential for asymptomatic patients attending for these procedures. Changes in management as a result of this statement: This statement reflects changes in management based on expert opinion, national guidelines and available evidence. Our knowledge with regard to COVID‐19 continues to evolve and with this, guidance may change and develop. Our colleagues are urged to follow national guidelines and institutional recommendations regarding best practices to protect their patients and themselves. Endorsed by: Australian and New Zealand Society of Cardiac and Thoracic Surgeons and the Anaesthetic Continuing Education Cardiac Thoracic Vascular and Perfusion Special Interest Group.

Joanne F Irons · Warren Pavey · Jayme S Bennetts · Emily Granger · Elli Tutungi · Aubrey Almeida

To the Editor: We write in reference to the recommendations published by Brewster and colleagues1 to report our centre’s experience with tracheal intubation in adults with coronavirus disease 2019 (COVID‐19) in Australia. Intubating patients with COVID‐19 requires careful balance between providing adequate pre‐oxygenation while concurrently maintaining staff safety through minimising aerosolisation. Guidelines from the Safe Airway Society (SAS),1 the Australian and New Zealand Intensive Care Society,2 and overseas3 emphasised rapid sequence induction techniques with the minimisation of bag valve mask ventilation. Our institution developed a specific tracheal intubation protocol for the intubation of patients with suspected or confirmed COVID‐19 incorporating the recommendations of the SAS.1 Eight patients with confirmed COVID‐19 have been intubated in our intensive care unit. The demographic characteristics of these patients are similar to those reported internationally,4,5 with a male predominance (seven out of eight) and a mean age of 69 years (range, 52–77 years). Before intubation, each patient was receiving high flow nasal oxygenation, with flow rates of 15–50 L/min and fraction of inspired oxygen (Fio2) 60–100%. All patients were pre‐oxygenated via bag valve mask with a positive end expiratory pressure valve in the assembly, as per the SAS recommended circuit set‐up.1 Video laryngoscopy with indirect view was used and a full view of the glottis was established for six of the eight patients; in the other two patients only the epiglottis was seen. All patients were intubated successfully on the first attempt with a bougie. During intubation, desaturation to peripheral capillary oxygen saturation (Spo2) 70% or less occurred in six of the eight patients, although the Spo2 recovered to more than 90% within one minute of being connected to the ventilator in five patients and within several minutes in the remaining patient. No patient received manual ventilation, and none of the patients developed haemodynamic instability during the intubation period. Our centre’s experience, while modest in number, highlights the significant risk of desaturation during intubation for patients with respiratory failure and COVID‐19 using a conservative approach to pre‐oxygenation and apnoeic oxygenation that minimises aerosolisation. We note the now updated SAS statement saying that “patients with severe disease are likely to require manual ventilation to prevent profound oxygen desaturation”.1 Whether manual ventilation, alternative pre‐oxygenation methods, or other strategies, such as potentially tolerating desaturation as transient and expected, is the most suitable method for patients with COVID‐19 remains to be determined.

Katherine E Triplett · Luke W Collett

To the Editor: The New South Wales Department of Health has taken necessarily stringent steps to reduce the risk of workplace outbreaks during the coronavirus disease 2019 (COVID‐19) pandemic. Currently, two nasopharyngeal samples, analysed by polymerase chain reaction (PCR), negative for severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) are required before asymptomatic individuals can return to high risk workplaces (eg, hospitals, schools and prisons) or close proximity living arrangements (eg, residential aged care facilities, military barracks, and group homes).1,2,3 In Newcastle, existent hospital in the home services have been redeployed as part of a tiered pandemic response under the banner “COVID Care at Home”. COVID Care at Home offers daily telehealth monitoring and efficient clearance certification for patients in isolation or excluded from workplaces. In our experience with 45 patients with COVID‐19 admitted to COVID Care at Home, increased PCR surveillance also uncovered cases of prolonged RNA detection. One passenger from the vessel Ruby Princess tested positive for COVID‐19 52 days after the initial swab and more than 60 days after the first day of symptoms. A review of international data showed that PCR positivity usually persists for 20–30 days regardless of symptomology.4 Cases of SARS‐CoV‐2 RNA detection persisting for 60 or even 80 days have been recorded in the literature.5,6 In the case of our patient, the ongoing exclusion from the workplace created significant psychological and financial burden due to lack of leave entitlement. Similar policies in countries with less worker security are likely to have even greater workforce impact. To tackle the issue of prolonged positivity, we have convened a panel of clinicians in the disciplines of infectious diseases, population health, and microbiology to make informed decisions about patients with prolonged viral RNA detection in regard to their ongoing need for isolation and exclusion from high risk environments. PCR positivity is not synonymous with infectivity.7,8 Regardless, to maintain the good results Australia has enjoyed thus far, we will need to persevere with a high level of vigilance. Making informed and safe decisions about clearance for high risk environments and supporting patients with prolonged exclusions from their workplace will be an ongoing challenge for Australian clinicians during the COVID‐19 pandemic.

Eliza Jane T Milliken · Sarah Browning · Danielle A Rohl

In reply

David J Brewster · Christopher J Groombridge · Jonathan J Gatward