NSW looking to ban e-cigarettes from smoke-free areas. What’s the big deal?

Once touted as a traditional cigarette replacement on the road to quitting the nicotine habit ‘electronic cigarettes’ or e-cigarettes as they are more commonly known has developed  a bad reputation.  ABC news reported on Thursday that support is growing for New South Wales to join five other Australian states (ACT, Queensland, Victoria, Tasmania and South Australia) in banning the use of e-cigarettes in smoke-free public areas where currently only traditional burned cigarettes are outlawed. So what are e-cigarettes and are they as harmful to the user and bystanders as traditional cigarettes?

What are e-cigarettes

Both traditional cigarettes and e-cigarettes do share one very common trait, the heating of the consumed material to make either smoke or vapor. E-cigarettes, instead of using smoldering or fire to burn the solid material implement an electronic heating element within  the device to vaporize a liquid thereby allowing that liquid to enter the user’s lungs much the same as traditional tobacco smoke. Proponents say that e-cigarettes are less harmful to both the user by eliminating the secondary chemicals normally found in traditional cigarettes and to those affected by traditionally passive smoke as the e-cigarette is less likely to transmit harmful chemicals throughout a space. The latter fact is what is being debated regarding the smoke-free e-cigarette ban.

Traditional cigarette risks versus e-cigarettes

Traditionally burned cigarettes have been widely studied and their harmful health effects well known. The American Cancer Society warns that there could be as many as 70 harmful chemicals in cigarettes which could lead to cancer when burned and inhaled. The same site does state that there are chemicals known to be contained in e-cigarettes which could contribute to cancer formation, however the biggest risk in e-cigarettes is the current lack of regulation and control on the ingredients, both type and quantity, which means that it is difficult to quantify their effects. A publication by New South Wales Health agrees with the American Cancer Society that there are a wide variety of levels of harmful chemicals, including nicotine, in unregulated levels within various e-cigarettes without accurate labeling. Additionally, e-cigarettes could also contain other by-products such as heavy metals which are used in the heating elements of the device. The take-home message for users of e-cigarettes is that there is an inherent danger as the e-cigarette market is mostly unregulated allowing for a range of chemicals, both listed and unlisted, to be included in the liquid active ingredients. This range of chemicals could lead to both short and long-term health effects.

The New South Wales Health fact sheet also state that there is a risk of exposure for people in the immediate vicinity of users of e-cigarettes, known as exposure to second-hand smoke. Again research into second-hand smoke with traditional cigarettes have been widely studied; and this has led to the smoke-free bans seen here in Australia and world-wide to protect non-smokers from the effects. The study into second-hand smoke amongst e-cigarettes and the effect on those around smokers is not as clear cut.

Second-hand e-cigarette smoke research and opinion

A systematic review of the effects of second-hand smoke from e-cigarettes was published by the Public Health Research and Practice group in 2016. The review looked at scholarly articles published between 1996 and 2015 regarding the study of this subject. The results showed that there were particles of nicotine, harmful chemicals similar to traditional cigarettes and heavy metals found within the vicinity of the e-cigarettes. However, the levels of these chemicals were much less. Additionally, the spread of these chemicals was overall less as the authors concluded the exhalation of traditional cigarette smoke could spread the airborne chemicals further than e-cigarettes. However, this study concluded similar results to those listed above that regulation of e-cigarette ingredients and concentrations of those ingredients have led to poor research outcomes.

The ‘vaping’ community has weighed in on this topic. The website “Vaped: by Totally Wicked” has stated:

Though studies are still ongoing on this topic, those that have been done so far strongly indicate that passive vaping poses little danger, if any. In fact, what they have managed to show thus far is that passive vaping is a non-existent problem, with ‘no apparent risk to human health from e-cigarette emissions based on the compounds analysed.’

The study linked to this statement was published in 2012 by the journal Inhaled Toxicology. While I did not have access to the article the synopsis did state that

For all byproducts measured, electronic cigarettes produce very small exposures relative to tobacco cigarettes. The study indicates no apparent risk to human health from e-cigarette emissions based on the compounds analyzed.

The issue is that the study used four e-cigarette liquids and compared to traditionally burned cigarettes. As the discussion has indicated previously there is widespread variation in chemical inclusions and concentrations as well as a lack of clear labelling which makes any comparison impossible. Therefore, research into the effects of passive smoke cannot be generalized at this point.

Another blog site, Vaping 360, lists a 2016 report prepared by the Royal College of Physicians entitled “Nicotine without smoke Tobacco harm reduction” which discussed the use of e-cigarettes as nicotine-replacement- alternatives and how traditional tobacco companies were attempting to gain ground in this market within the UK. The Vaping 360 cite quoted:

Users of e-cigarettes exhale the vapour, which may therefore be inhaled by others, leading to passive exposure to nicotine. There is, so far, no direct evidence that such passive exposure is likely to cause significant harm, although one study has reported levels of polycyclic aromatic hydrocarbons that were outside defined safe-exposure limits. It is clear that passive exposure will vary according to fluid, device and the manner in which it is used. Nicotine from exhaled vapour can be deposited on surfaces, but at such low levels that there is no plausible mechanism by which such deposits could enter the body at doses that would cause physical harm.

Nicotine-replacement legislation in Australia

But the debate over second-hand smoke and e-cigarettes could be moot here in Australia. According to the Royal Australian College of General Practitioners (RACGP) the use of e-cigarettes for nicotine-replacement are illegal.

In all Australian states and territories, it is an offence to manufacture, sell or supply nicotine as an S7 poison without a licence or specific authorisation. This means e-cigarettes containing nicotine cannot be sold in any Australian state or territory. There are several reported instances where individuals have been charged with the illegal supply of liquid nicotine for use in e-cigarettes in Queensland.16,17

A recent clarification from the Federal Department of Health has advised that nicotine can be imported by an individual for use as an unapproved therapeutic good (eg a smoking cessation aid), but the importer must hold a prescription from an Australian registered medical practitioner and only import 3 months’ supply at any one time. The total quantity imported in 12 months cannot exceed 15 months’ supply of the product at the maximum dose recommended by the manufacturer.18 Most current consumers are unlikely to visit medical practitioners for a prescription of products that are readily available over the internet. The purchase and possession of nicotine by individuals are not regulated by Commonwealth legislation except for importation as allowed under Commonwealth law.

Non-nicotine e-cigarettes are not regulated, according to the RACGP site, however if they are not specifically for nicotine-replacement therapy then their use is purely recreational and should be subject to concerns raised by state governments and health authorities as to the additive chemicals and the effects of those chemicals on non-users within the immediate vicinity. Therefore, with no specific medical need for e-cigarettes the health concerns of second-hand smoke should outweigh the desire to have a cigarette-substitute in public and should be banned.

What does all of this mean for e-cigarette use in public?

So what does this mean for Australia, and specifically New South Wales, in the debate over e-cigarettes? The debate, to me, is quite simple. E-cigarettes in Australia at this point cannot contain nicotine as per Commonwealth law. Therefore, they cannot be considered as a replacement to traditional cigarettes as has been touted elsewhere in the world. That also means they have no medical necessity to users. Non-nicotine e-cigarettes at this point are legal, however there are a number of chemicals used in various e-cigarettes which can be as harmful as in traditional cigarettes to individuals standing within close proximity to the user. Additionally, chemicals used in e-cigarettes are not regulated so the quantities and types of chemicals contained do not need to be listed. While e-cigarettes are less harmful than traditional cigarettes there is still a risk of passive second-hand exposure. So there seems to be no reason why the state government should not join the five other states in outlawing e-cigarette use in smoke-free locations throughout the state.

Your thoughts? Until next time,

Ray

 

 

References

ABC News- E-cigarette ban in smoke-free areas of NSW attracts Government support

http://www.abc.net.au/news/2017-11-02/fight-to-ban-e-cigarettes-in-smoke-free-areas-of-nsw/9109858?pfmredir=sm

Web MD- The Vape Debate: What You Need to Know

https://www.webmd.com/smoking-cessation/features/vape-debate-electronic-cigarettes#2

American Cancer Society- Harmful Chemicals in Tobacco Products

https://www.cancer.org/cancer/cancer-causes/tobacco-and-cancer/carcinogens-found-in-tobacco-products.html

New South Wales- Are electronic cigarettes and e-liquids safe?http://www.health.nsw.gov.au/tobacco/Factsheets/e-cigs-are-they-safe.pdf

Centers for Disease Control- Secondhand Smoke (SHS) Facts

https://www.cdc.gov/tobacco/data_statistics/fact_sheets/secondhand_smoke/general_facts/index.htm

Public Health Research and Practice- A systematic review of the health risks from passive exposure to electronic cigarette vapour

http://www.phrp.com.au/issues/april-2016-volume-26-issue-2/a-systematic-review-of-the-health-risks-from-passive-exposure-to-electronic-cigarette-vapour/

Vaped: by Totally Wicked- SHOULD YOU WORRY ABOUT PASSIVE VAPING?http://www.totallywicked-eliquid.co.uk/vaped/passive-vaping/

Inhaled Toxicology- Comparison of the effects of e-cigarette vapor and cigarette smoke on indoor air quality.

https://www.ncbi.nlm.nih.gov/pubmed/23033998

Vaping 360- Is second hand vapor harmful?

http://vaping360.com/is-second-hand-vapor-harmful/

Royal College of Physicians- Nicotine without smoke: Tobacco harm reduction

https://www.rcplondon.ac.uk/projects/outputs/nicotine-without-smoke-tobacco-harm-reduction-0

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Look out! Record-breaking mosquito outbreak coming to Sydney

The daily mail has reported that experts are warning that a high number of mosquitos. Dr Cameron Webb, Medical Entomologist at University of Sydney and NSW Health Pathology is warning that this year will be the worst on record for mosquitos in Sydney.

To minimize the chances of being bitten experts advise:

  • Stay indoors at dawn and dusk.
  • Use fans to disrupt the mosquito’s flight path.
  • wear light-coloured clothing. Mosquitos are attracted to dark colours.
  • Avoid smelly feet and eating strong cheeses due to their smell.
  • Stay away from standing bodies of water.

Until next time,

Ray

The Daily Mail- Worst mosquito outbreak EVER expected as sweltering weather brings bloodsuckers out in record numbers – so here’s how you can avoid them= http://www.dailymail.co.uk/news/article-5037709/Worst-mosquito-outbreak-hit-Sydney-summer.html?ito=email_share_article-aboverelatedarticles

 

2017 worst influenza season in Australia since 2012 with New South Wales hit the hardest

Quick facts

  • Influenza is a very contagious respiratory virus which is spread by sneezing or coughing commonly.
  • There are two strains of influenza with many variations due to proteins within the DNA. This allows continual mutations from year to year.
  • Worldwide 3-5 million people become infected every year with 250,000 to 500,000 deaths annually.
  • In Australia approximately 18,000 people are hospitalized each year with 3,500 deaths.
  • The World Health Organization has been monitoring and producing vaccines for influenza since 1952 with 142 monitoring centres in 112 countries.
  • Five international centres produce the vaccines used every year, including one in Melbourne.
  • While criticism of the level of outbreak for 2017 in Australia is mixed statistics showed that there were more reported cases this year than at any point since 2012
  • Of the 217,559 cases of influenza reported in Australia up to October 2017 over half (101,793) were reported in New South Wales.
  • Officials recognize an issue with how the influenza outbreak was handled in Australia this year, however they are divided on possible solutions to prevent a repeat in years to come.

 

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With 2017 thought to have been a horror year for influenza in Australia, I thought I would  research where our flu vaccines come from, how are they chosen and why has this year in particular been so bad?

A little about influenza

Flu, or more correctly known as influenza, is a respiratory virus which has similar symptoms to that of a common cold. The difference is the severity and quality of those symptoms. Surprisingly there are only two strains of influenza: A and B. However, within those two strains are combinations with varying protein chains of H and N. This is what gives the influenza virus the ability to mutate and evade eradication. Influenza can strike at any time of the year; however the colder months are more likely to see the spread of the virus. One possible explanation I heard a few years ago is that during the colder months people are more likely to congregate together indoors which would allow influenza to spread more readily. This could be due to the fact that influenza transmits via airborne means such as sneezing and coughing.

Globally the World Health Organization (WHO) estimates that between three to five million cases of severe influenza occur each year worldwide and of those 250,000 to 500,000 cases result in deaths. Australia specifically sees 18,000 hospitalizations for influenza annually with an average of 3,500 deaths. Influenza is also estimated to account for 10% of all yearly workplace absenteeism in Australia.

Worldwide vaccine efforts

As a virus you cannot cure it with antibiotics; once infected all you can do is wait it out. However, vaccines work by introducing a weak or dead strain of the virus into the body where antibodies can be produced which when confronted with the influenza virus will kill the virus before it takes hold of the host’s body and produce debilitating symptoms. The production of antibodies can take three to four months before fully effective so experts recommend having the flu vaccine early in the season to allow for immunity to develop.

Logo-WHO

The WHO has been responsible since 1952 for the monitoring of influenza and vaccine research through their Global Influenza Surveillance and Response System. Different influenza strains become more prominent from year to year, and strains can mutate. Therefore the WHO runs 142 monitoring centres in 112 countries. Five of those centres host World Health Organization Collaborating Centers for Reference and Research on Influenza:

  • Atlanta, Georgia, USA (Centers for Disease Control and Prevention, CDC);
  • London, United Kingdom (The Francis Crick Institute);
  • Melbourne, Australia (Victoria Infectious Diseases Reference Laboratory);
  • Tokyo, Japan (National Institute for Infectious Diseases); and
  • Beijing, China (National Institute for Viral Disease Control and Prevention)

These five centres are also produce vaccines for the different influenza strains. Monitoring of influenza occurs year-round, however production of vaccines takes approximately six months and therefore decisions on which strains (usually three to four) are included are made half a year before the major flu season starts. The actual vaccine doses are then manufactured by private companies with the strains produced by the centres above.

The 2017 influenza season

So with all of the knowledge of influenza and the work of the WHO and CDC along with other scientific groups, what happened this year? Well that depends on who you ask. According to the Australian Department of Health the peak of the influenza season was mid-August of this year. The department did state that there appeared to be higher-than-usual numbers of cases being reported, however mitigated that fact by saying that testing was more readily used and could have contributed to the larger number of reports. Influenza A seems to be the dominant culprit this past season. The department’s report also goes on to say that they number of hospital admissions this season were ‘moderate’ compared to previous years, and that the vaccines given seem to have had a good effect.

NSW health minister Brad Hazzard would disagree with the federal department of health report. According to Minister Hazzard “I think at this stage what we got unfortunately was a vaccine, with the benefit of hindsight — and hindsight is a wonderful thing — that wasn’t quite up to it.” Peter Collingnon, executive director of ACT Pathology and a physician at the Canberra Hospital Infectious Diseases, went onto say that he felt the vaccine this year had very low efficacy for the A H(3) strain responsible for so many hospitalizations and deaths. Although the vaccine supplied to Australians was up to the global standard many patients were being seen by GPs with influenza despite being vaccinated.

According to the Immunisation Coalition in Australia as of the 24th of October 2017 there were 217,559 cases of influenza confirmed.  Of those cases over half (101,793) were reported in New South Wales. The next highest rate was Queensland which only had 53,487. So in my state of New South Wales was by far the worst hit this past season. The reported number of cases nationwide, according to the Immunisation Coalition, in 2017 were significantly higher nationwide than at any point in the last five years.

The future?

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So is this a trend, or just a one-off event?  That is very hard to know. According to the information I read the experts are mixed. One possible suggestion is that our vaccine processes are out-dated and we need to re-think how vaccines are produced. Additionally, community hygiene practices could be reviewed to limit spread of influenza, particularly in peak times. What we do know is that influenza won’t be going away anytime soon. And at least for 2017 New South Wales bore the brunt of the outbreak.

As a member of the acute healthcare team I applaud every member of healthcare for their work and dedication during this flu season. Ask any person working in this industry, particularly in New South Wales, and they will tell you it was a very busy and trying time.

Until next time,

Ray

 

National Centre for Immunisation Research and Surveillance- Influenza fact sheet= http://www.ncirs.edu.au/assets/provider_resources/fact-sheets/influenza-FAQs.pdf

Centers for Disease Control and Prevention- CDC’s World Health Organization (WHO) Collaborating Center for Surveillance, Epidemiology and Control of Influenza= https://www.cdc.gov/flu/weekly/who-collaboration.htm

Centers for Disease Control and Prevention- Selecting Viruses for the Seasonal Influenza Vaccine= https://www.cdc.gov/flu/about/season/vaccine-selection.htm

World Health Organisation- Influenza (Seasonal) Fact sheet= http://www.who.int/mediacentre/factsheets/fs211/en/

Influenza Specialist Group- Influenza Fast Facts= http://www.isg.org.au/index.php/clinical-information/influenza-fast-facts-/

Australian Department of Health- Australian Influenza Surveillance Report and Activity Updates= http://www.health.gov.au/flureport

ABC news- Influenza: NSW Health Minister says current vaccine ‘not up to the job’ after deadly flu season= http://www.abc.net.au/news/2017-10-30/influenza-australia-deadly-year-prompts-calls-for-new-vaccine/9098598

Immunisation Coalition- Influenza Activity Surveillance 2017= http://www.immunisationcoalition.org.au/news-media/2017-statistics/

Drug resistant staph infections more common in the community

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An article in Business Insider Australia has highlighted that drug resistant staph infections are now more commonly acquired in the community than in hospital. In the report Dr. Agostino, a researcher from ANU medical school, stated that upwards of 60% of these staph infections are picked up in the community. This is a marked change from the early 2000s in which most infections originated from hospitals.

But, as the report suggests, effort now needs to focus on community education and proper drug use. Hospitals have implemented policies such as the “Five moments of hand hygiene” and regularly conduct hand washing audits on wards. Protocols for antibiotic use are much more prevalent and help to control the spread of these infections.

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What needs to be done to rid the community of these problematic infections which can be lethal to the elderly, young or pregnant women? With the increased co-mingling of individuals and lack of rigor towards hygiene procedures the infectious disease community will need to re-think its approach to dealing with the spread of infections outside of the hospital setting.

Business Insider Australia- Drug-resistant staph infections have escaped from Australia’s hospitals

AHPRA recognition for paramedicine one step closer

In a tweet by the Australian Health Practioners Regulatory Agency (AHPRA) Paul Fisher has been named as the new Executive Officer for the new Paramedicine board of AHPRA. This furthers the progress of creating national recognition of paramedics and a register of qualified paramedics.

I think this is a step who’s time has well and truely come. The UK has already created a national body and registration for paramedics. Australian states regulate paramedics within their borders, however as registered nurses know moving from state to state brought about logistical and clinical differences which caused unnecessary delay and red tape. Having a national paramedicine register through AHPRA will provide important benefits for paramedics, employers and the general public.

  • A universal code of standards will more clearly define the paramedic’s role.
  • Entry educational requirements will be universal. Meaning a paramedic could train in one state and obtain a position in another.
  • Paramedics in general will have less difficulty obtaining positions in other states. Employers as well will have a central repository for validating a potential paramedic’s qualifications.
  • The term ‘paramedic’ will nationally become a protected title.
  • Those not qualified to be paramedics would have difficulty decieving employers in other states.

As an emergency department registered nurse I see first-hand the great work paramedics do in stabilizing patients before arriving to our department. Giving them the national recognition that AHPRA provides will ensure universal quality throughout Australia. It will also standardize the care given to patients throughout Australia.

What do you think?

Until next time.

Ray

AHPRA- National regulation of paramedicine moves a step closer

HCPC- UK listing of paramedics

Where do doctor’s prescriptions end and pharmacists dispensing begin?

An article in news.com.au on Tuesday ( the 24th) has brought up an interesting question in my mind, where does the line exist between pharmacy dispensing of medications and requiring a doctor’s prescription?

The article describes the debate over restricting medications containing codeine to prescription-only, requiring patients wanting these medications to see their doctor’s first before obtaining the drug. The Thearputic Goods Administration was indicating a change in codeine-related products from pharmacy-dispensed to prescription in 2016, although debate over the issue is heading up as the deadline for the change is February next year.

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Pharmacy representatives state this would affect the quality of analgesic care for patients by requiring them to see their doctor first. Physician groups are stating that low-dose codeine found in these medications show on therapeutic benefit, and the restriction would prevent misuse. Politicians are stuck in the middle in wanting to satisfy both sides.

So what is the issue with codeine? It is addictive and potentially harmful in high doses. Codeine is an opiate, an analgesic similar to Morphine. Therefore, its properties of pain relief can lead to addiction if misused. The Sydney Morning Herald stated that 12% of Australians surveyed exceeded the recommended daily dose of analgesic medications containing codeine. While the codeine dose is quite small the issue with this worrying fact is the potential for overdosing on paracetamol and ibuprofen; both have potentially toxic effects if too much is in the human body. An article by NPS Medwise has shown that when codeine has been consumed to lethal levels, although being accidental in nature, the number of deaths are double that of deaths related to stronger prescription medication such as morphine.

So why take it away from pharmacists hands? Simply control and monitoring. Even in my role within a public hospital I see frequently patients who travel from one hospital to another asking for pain relief, sometimes discharging and presenting to multiple hospitals in the course of a day. I am sure that most pharmacists are very conscientious and ethically-responsible people. However, a patient could approach one pharmacy let’s say in the morning and buy a codeine-related product, and then travel to a completely different area in the afternoon approach another for more product. This individual may not even intend to do this, instead they may work in the city and travel from home in a completely different area by public transport. The second pharmacist would not have knowledge of the previous purchase and therefore would not question the transaction.

A doctor’s prescription requires individuals to physically see a doctor. A record of the prescriptions would exist and could be tracked. Additionally, higher consumption could trigger the doctor to investigate the reasons for the increased usage and try to eliminate the cause of pain in the first place.

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 While I have no issue with pharmacists as I think they are very competent and ethical practitioners I do support the moving the responsibility of codeine release from pharmacists to doctors.  Codeine is an opiate, and most opiates (along with other analgesics of similar strength) are classified as schedule eight restricted due to their addictive properties. The low doses of codeine and the toxic properties of the main ingredients (paracetamol and ibuprofen) mean that overdosing on these over-the-counter medications can lead to serious health consequences. Finally, as I stated above requiring a prescription can then lead a doctor to investigate, and hopefully treat, the source of pain rather than continuing to mask it through analgesics.

What do you think of codeine-related products requiring a prescription? Does it even matter to you?

Until next time,

Ray

News.com.au- MPs push to water down ban on codeine sales without prescription

New Scientist- Australia bans non-prescription codeine to fight opioid crisis

Therapeutic Goods Administration- Update on the proposal for the rescheduling of codeine products

Sydney Morning Herald- More than 2 million Australians exceeding recommended medicine dosage, worrying doctors

NPS Medwise- Codeine-related deaths: a cause for concern

Another wake-up call to revamp the aged care sector

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The Australian newspaper has reported that federal aged care minister Ken Wyatt has released several recommendations from an independent review into aged care facilities which, if implemented, may lead to changes within the Residential Aged Care Facilities (RACF) community.

In a side note from minister Wyatt he stated in a speech to the National Press Club that up to 40% of aged care residents never receive visitors. While I cannot say I agree with that high figure I will agree that there are a significant number of residents who do not receive any visits from friends or family. This may be simply due to family and friends dying out, as does happen with age, or to family dynamics. But it does create a lonely environment for those residents. The advantage of aged care facilities for these residents is the social atmosphere of other residents and staff. In all of the aged care homes I have worked in and visited I can say emphatically that the care staff do interact and provide social connection with the residents.

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While all of the recommendations from minister Wyatt were not laid out in the article one particular recommendation was worthy of note to prompt me in writing this post. Minister Wyatt has called for annual re-accreditation to be conducted spontaneously without prior notice given to aged care facilities or their parent companies. To me if this is done effectively it could serve to lead to increased compliance and overall adherence to the governing federal policies for RACFs.

Currently, when a facility is nearing the end of their accreditation period the governing agency, the Australian Aged Care Quality Agency, will usually notify the RACF of the date of their re-accreditation visit with several weeks notice. This starts a chain of events where numerous corporate representatives invade the facility and start pouring through the documentation and policies ensuring that the facility meets the four standards required for re-accreditation. Oftentimes this process sees months and sometimes years of inaction or bending of rules suddenly become corrected. Resources are brought in to ensure compliance. Documentation is mulled over and errors corrected. On the day everything is perfect. The accreditors are treated like royalty for their two or three day visits, and once passed the same routine resumes.

But an unannounced visit would change this. Facilities would not be aware in advance of a visit, as the current unannounced visits are conducted. But unlike unannounced visits the re-accreditation looks closely at all standards. Facilities would need to enact processes and procedures which would require ongoing compliance, not just rushing in and fixing everything up just before they show up at the door. While it may not fix all of the issues and solve all of the complaints in RACFs it would at least serve as a start to ensuring that facilities RUN as they should, not to just look good on paper once every three years.

Until next time.

Ray

The Australian- Crisis in aged-care industry prompts wave of reform

The Aged Care Quality Agency website