You are the emergency physician in charge of an urban ED. You receive a call from a residential aged care facility (RACF) registered nurse advising of the transfer of 88-year-old Iris to the ED with a 2-day history of lethargy and nausea. Iris has a background of mild, early stage dementia, ischemic heart disease and diabetic retinopathy causing blindness. She denies fever, cough, sore throat, rhinorrhoea. She has a temperature of 37.4°C, a pulse rate of 110/min, a blood pressure of 100/60, respiratory rate of 32 and oxygen saturations of 94% on room air. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which manifests clinically as coronavirus disease (COVID-19), has exposed the pre-existing vulnerabilities in healthcare delivery to RACF residents, mostly frail people with atypical disease presentations living amidst staff and resource shortages.1, 2 Mortality from COVID-19 in aged care residents ranges from 5 to 47%,3-9 with the mortality in Australian RACF residents reported at 33%.8 In Australia, in September 2020, 75% of all COVID-19 deaths are in residents of RACFs,8 while across European countries this cohort accounts for 37 to 66% of all COVID-19-related deaths.10 Variance in reported mortality in this population is contributed to by:11, 12 Pre-pandemic, evaluating the risk and benefit of transfer to the ED, including the residents' goals of care and their current acute care need, was a recommended but far from routine strategy for RACF clinicians.13 During the COVID-19 pandemic, both the benefits and risks of transfer are increased (Tables 1 and 2), making such an evaluation even more important. Balancing these risks and benefits requires an assessment and, ideally, shared decision-making involving a hospital-based specialist (e.g. emergency physician or geriatrician), the resident or their substitute health decision maker, the general practitioner (GP) and the RACF clinical manager. Where there is a recognised COVID-19 outbreak in the RACF, public health risk of managing the infected residents in the RACF setting, including infection risk to other residents, staff and the broader community, needs to be considered. Conversely, where there is no known outbreak in the RACF, but high level of community infection, transfer to the ED may increase COVID-19 exposure risk for the residents, particularly in settings of ED overcrowding and ambulance ramping. Many of these issues can be addressed through sound geriatric emergency medicine and infection control practice38 and, where clinically appropriate and respecting resident choice, through use of models of care that deliver acute care in the RACF environment.39, 40 ED-substitution models such as Queensland Health's RACF acute care support services,41 NSW Health's Aged Care Emergency programme42 and telehealth programmes can have a role to play in supporting urgent assessment in the RACF setting.43, 44 Regardless of the models of care available, ethical decision-making about the best site of acute assessment and care should balance: Triage to hospital care, even during high levels of pandemic response where hospital capacity is overwhelmed, should not be based on age or residential address but rather be informed by an individual's capacity to benefit from hospitalisation.45 Symptoms reported at the time of COVID-19 testing of residents in RACF outbreaks are outlined in Table 3. Importantly, 27 to 73% of residents who were SARS-CoV-2 positive were identified to be asymptomatic or pre-symptomatic; 29 to 40% had typical symptoms and 8 to 18% had atypical symptoms.3, 5, 7, 46, 48 In those with atypical symptoms, the most common were malaise, delirium, falls and nausea. Importantly, regardless of symptoms being present or absent, large quantities of viral RNA were detected.46 In determining cohorting strategies, application of PPE and COVID-19 testing, reliance on symptom-based screening alone in this population, may fail to identify 50% or more of residents with COVID-19.46 1.6 to 10.3%5, 7, 46, 47 Consideration of likelihood of COVID-19 in residents of RACFs on ED presentation should further include consideration of: It is important, particularly in settings with identified community transmission of COVID-19, to have a low threshold to test this population for SARS-CoV-2 as reliance on presence of typical symptoms and signs alone may miss a significant proportion of residents with COVID-19.46 ED staff must also understand the inaccuracies of current molecular testing strategies50 and consider this risk for PPE use and for discharge isolation and monitoring recommendations. Advance care planning can guide care planning with residents and, where indicated, with substitute health decision makers. Ideally, RACF providers will collaborate with residents to review and update all their residents' advance care plans in the context of COVID-19, where residents (or their substitute health decision makers) choose to engage in these conversations. A resident's choices in relation to the goals of their healthcare should inform types of treatments offered and optimal site of care. Where ED transfer is clinically indicated and concordant with resident choice, advance care plans should be included in transfer documentation. In ED, treatment options offered should be individualised to whether they can benefit the resident, whether the benefit outweighs the risks of harm both to the individual and to others in the community (including risks of harm to other residents and to staff) and whether such treatments are concordant with resident goals of care. Residents who have had a COVID-19 test performed in the ED should generally not be transferred back to the RACF and instead be managed in a hospital environment until the result of the test is available. Testing turn-around-time for this population should be prioritised in order to allow timely identification of an outbreak.1 Where hospital resources are overwhelmed, an ethical decision-making framework supported by validated assessment tools should be used to determine those with most capacity to benefit from hospitalisation51-53 – such considerations should also encompass risk to others (including other residents and RACF staff if the resident were to be transferred back to the facility). Consideration also needs to be given to the ability of the RACF to manage the resident's clinical and care needs, particularly in the context of potential concurrent outbreak management requirements in the facility. When a resident is discharged from ED, it is critical that there is communication of results of assessment, investigation and requirements for ongoing management and assessment. Communication between the ED provider and facility staff is central to ensuring continuity of care.54 There is some low-quality evidence that such communication may improve patient outcomes.28 Generally, communication between EDs and aged care facilities is poor with only 55% having evidence of adequate communication on ED discharge.30 Discharge communication should occur verbally and in writing to the RACF clinicians and the resident's GP, with particular attention to: Continuity of medication management. Evidence-based approaches to ensuring medication continuity should be implemented including:24, 57 Such attention to continuity of medications is particularly important for a resident who is being returned to the facility for palliation. Residents who are nearing end of life may require prescription and supply of medications to ensure appropriate management of symptoms such as pain, nausea, dyspnoea and agitation. It is critical to ensure that RACF staff have the resources required to ensure resident comfort, including subcutaneous medication administration pump (e.g. NIKI pump) and ability and training to administer restricted medications at all hours. Residents of RACFs who are acutely unwell have the right to assessment and management that is consistent with their goals of care. During the COVID-19 pandemic, additional imperatives include consideration of the potential harm to other residents or RACF staff. Reliance on a screening strategy based on typical symptoms of COVID-19 alone will miss a significant proportion of residents with COVID-19. Reduction of risk to individual residents, fellow residents and healthcare workers across the care continuum requires a risk-based assessment with an appreciation of atypical, asymptomatic and pre-symptomatic presentation in this cohort, a low threshold for testing in areas with documented community transmission, and rigorous infection control procedures. Transitions of care to the RACF require attention to communication to ensure that the GP and RACF clinicians are able to provide optimal ongoing care. None declared. Data sharing not applicable to this article as no datasets were generated or analysed during the current study