*** This article was updated on 21 May with additional commentary ***
Health, aged care, and disability services across Australia are being urged to interrogate their infection control processes in the wake of devastating COVID-19 outbreaks in North West Tasmania and at the Newmarch House aged care facility in Sydney.
The calls come as health authorities in Victoria have this week locked down four aged care facilities under a new COVID-19 policy where “one case equals an outbreak”.
Many other underlying issues must also be addressed to keep coronavirus out of critical settings like hospitals and aged care homes, including precarious casualisation of the workforce and the changing profile and risk of aged care residents, as Marie McInerney reports below.
Marie McInerney writes:
Early investigations into North West Tasmania’s recent devastating coronavirus outbreak did not have to dig too deeply to identify how it spread so rapidly – most likely from one or two patients who had been on board the Ruby Princess.
By late April, 114 people had been infected, including 72 local health care staff and 22 patients. Two hospitals were shut down, and thousands of health care workers and their households were quarantined.
In an interim report released last month, Tasmanian Public Health Services found there had been “multiple potential chains” of direct person-to-person transmission, “between staff, or between staff and patients (in both directions)”.
“The local Coles store was doing better social distancing” was the informal verdict given by a senior Tasmanian health official during a recent national webinar briefing, attended by Croakey.
In Tasmania, many health workers and administrators have been personally vilified over such outbreaks, reporting that they have copped abuse, in person and on social media, including for an unfounded rumour – subsequently repeated by the Australian Government’s Chief Medical Officer Professor Brendan Murphy – that the outbreak began with an “illegal dinner party”.
But experts stress the importance also of examining the systemic issues involved in breakdowns in infection control.
Future inquiries in Tasmania and nationally are being urged to dig deeper into underlying causes for both the North West Tasmanian outbreak and the more deadly outbreak at Sydney’s Newmarch House aged care facility, which this week claimed its 19th coronavirus death, and Australia’s 100th.
For North West Tasmania, there are ongoing questions about supply and use of personal protective equipment (PPE), whether staff and patients are confident the risks are now under control, and whether unwell staff were in the past pressured by the hospitals to ‘soldier on’.
As well, there are deeper issues around chronic underfunding, system fragmentation, crippling workforce shortages, low pay, increasing casualisation of the workforce, and a lack of specialist skills to manage the complexity of conditions and co-morbidities now prevalent in aged care homes.
Presenting the interim report to the Tasmanian Health Minister, the COVID-19 State Health Commander Kathrine Morgan-Wicks said that “in a matter of days”, Tasmanian Health Services had “rapidly stood up to face an unprecedented pandemic, of a size, scale, speed and devastating mortal impact that we are now witnessing globally.”
“As a jurisdiction we are not alone in falling victim to a devastating hospital outbreak, and we certainly did not foresee one of the size and magnitude that has occurred in North-West Tasmania,” she wrote.
Tasmania has been mostly praised for its swift and dramatic Easter Monday shutdown of the co-located North West Regional and North West Private hospitals in regional Burnie and for its rapid investigation into the causes of the outbreak which reported two weeks later.
The 28-page report is in two sections: the first is an epidemiological review by the state’s Public Health director Dr Mark Veitch and deputy director Dr Scott McKeown; the second includes 17 recommendations, adopted in full by the Government, by Tasmanian chief medical officer Professor Tony Lawler.
Health experts say it sounds the alarm for hospitals and health services across Australia, particularly in regional areas, if they don’t recognise and address the contributing factors it identifies.
Days after the North West Tasmanian shutdown was ordered, Newmarch House was placed in lockdown after a staff member who tested positive to coronavirus worked six shifts while showing symptoms.
Meanwhile, Queensland Health recently reported that a nurse, who sparked a lockdown at the North Rockhampton Nursing Centre, had been sent for coronavirus testing after showing symptoms, but went back to her workplace before the positive test result was returned.
The Tasmanian report details how the coronavirus spread among nursing, medical, psychiatric, allied health and other teams in the two hospitals, onto wards, into the Emergency Department and operating theatres. Affected staff worked in many areas, including pathology collection and outpatient facilities in the co-located medical precinct, the Mersey Community Hospital in nearby Latrobe, and in aged care facilities in the Northwest Region.
In very cautious language, the report suggests that – despite Australia being on high pandemic alert in the weeks leading up to Easter – hospital staff continued to meet at close quarters for meal breaks, meetings, ward rounds, and handovers. “A high attack rate was associated with meetings with staff in confined spaces, such as nursing handovers and discharge planning,” it said.
There was high movement of staff between the hospitals and other services, as well as the transfer of “undiagnosed infectious or incubating patients” between facilities.
Of the 73 infected staff members, the report found that most (77 percent) attended work during their infectious period, half of them while symptomatic, including around 15 who worked for up to six days with symptoms that they attributed to other respiratory conditions.
“Several clusters” of COVID-19 were identified among attendees of regular meetings, such as administrative or clinical planning, and included senior clinicians.
Contact tracing efforts missed contacts or were slow because of having to locate and interrogate multiple ICT systems, data bases and paper records, including rosters.
One doctor was advised they did not meet the definition of a close contact of a newly diagnosed case in a patient and could continue to work. They chose to self-isolate despite the advice and tested positive. Another was missed because, as a relief staff member, they were not named on the roster.
The situation was escalated just before Easter when the hospitals were advised that national guidelines relating to the definition of a close contact had been reinterpreted to 15 minutes cumulative rather than continuous face-to-face contact, “dramatically impacting the number of close contacts captured in tracing for notified cases”.
Calls for action
The report’s recommendations include:
- strengthen the culture of safety re infection control
- stronger social distancing in the workplace (including for handovers)
- address the drivers of presenteeism
- better contact tracing that is rapidly scalable
- cut back movement between facilities for both patients and staff
- establish dedicated teams for outbreak control skilled especially for contact tracing.
The report does not provide evidence of specific infection control breaches nor does it interrogate reported concerns that health workers were asked to ration or re-use PPE concerns. On PPE, it notes that strong investment in PPE in the facility was “not always visible to ‘frontline workers’ and urges regular communications and better PPE training in future.
Rather than apportion individual blame, the report goes to pains to praise staff for their diligence professionalism, and commitment.
That’s a cop out, according to Tasmanian health policy analyst Martyn Goddard who wrote of the outbreak as a “tragic and utterly avoidable farce” where “nobody has to take responsibility”.
“This is a catalogue of inept management, poor policy, inadequate training, failure to give crucial protection to staff and patients, insufficient resourcing, and a lack of basic preparedness,” he wrote in an opinion piece in Hobart’s newspaper, The Mercury, republished here on his blog.
Others are more forgiving, including Phil Russo, President of the Australasian College for Infection Prevention and Control (ACIPC), who says the pandemic is something very new for health services.
However, Russo says both the North West Tasmania and Newmarch House outbreaks underscore the need for a national Centre of Disease Control to coordinate and centralise responses in times of pandemics and emerging antimicrobial resistant infections, including for supply and proper use of PPE.
“We’re obviously seeing pretty good leadership [from the Australian Health Protection Principal Committee] but we are seeing states and territories doing slightly different things, [and] the various colleges, associations and societies coming out with their own version or interpretation of [infection control] guidelines,” he told Croakey.
“As a whole as a country, we have responded reasonably well, but I think we could have done better and acted more quickly if we did have a national centre.”
Annie Butler, national secretary of the Australian Nurses and Midwives Federation, said the union’s Tasmanian branch had been raising concerns about the North West region for weeks, particularly about supplies and use of PPE. These were ignored by the Government and health authorities.
“They hear the union calling and go ‘they’re just making trouble’, but no we were not, we were saying ‘there’s a problem’, because there was a problem,” she said, adding that for local nurses, it felt like the region “was always just one step behind the guidance”.
The unfolding crisis was a “torrid and difficult” time particularly for nurses who, she said, bore the brunt of much social media abuse that was blaming health workers for the outbreak.
Butler and local independent MP Ruth Forrest, a former nurse and midwife, defend heath care workers who went to work with mild symptoms, not knowing they might have COVID-19 and welcomed the report’s recommendation for Government to investigate the drivers of “presenteeism”.
Forrest says she knows what it feels like to get the call, when you’re tired or not well, to come and help relieve pressure on stressed colleagues or care for patients you know need more support.
She believes chronic underfunding of health, the fragmentation of health in Tasmania into three regions, interactions between public and private hospitals, and a reliance on locums also all played a role that needs closer examination.
For Butler, an additional problem is that health work has been increasingly casualised in a region “that is not the most flush in economic terms” and at a time of unprecedented economic uncertainty.
“People have been put out of work, a lot of nurses find themselves being in the position of the only breadwinner, they may feel compelled to work,” she said.
That’s even more of a concern for low paid aged care workers amid the still unfolding tragedy at Newmarch House, which is now subject to regulatory action from the Aged Care Quality and Safety Commission and ongoing investigations of the Royal Commission into Aged Care Quality and Safety.
Like others, Butler compares the slower response and worse toll in the Newmarch House outbreak to the dramatic action in North West Tasmania, where Australian Defence Force and AUSMAT teams were brought in to oversee deep cleaning and early emergency responses.
Asked why, she says her worry is maybe our systems “just don’t care as much” about the elderly residents of a nursing home.
For Ian Yates, head of the Council of the Ageing (COTA), that’s an important question right now. Thankfully, he says the positions of some economists, politicians and protesters, who ask whether we are paying too high an economic price to keep vulnerable older people alive, have been “largely quashed” by the Prime Minister and within the health sector.
But he was still surprised at the slow response to Newmarch, once it was known that a staff member had worked for six days while infected so it was likely to be a “significant outbreak”.
He wants to know why someone with crisis management skills was not brought in earlier to coordinate the efforts of the home and, like the Ruby Princess, multiple levels of federal and state governance involved.
Yates also nominates staffing as a crucial issue, not just staff coming to work sick, but the costs too of “significant understaffing due to absenteeism”, amid preliminary reports from Europe that many people who died in aged care did not die of COVID-19 but of “neglect”, including being abandoned.
His message to aged care providers is:
Do you have your infection prevention protocols and practices strongly enough in place?
And, if you think you do, revisit them, and then have someone more experienced than you come in and ask the questions again.”
No time for complacency
Despite these outbreaks, the consensus is that Australia has done very well in the pandemic, not just in managing overall cases but particularly keeping the coronavirus out of high risk settings such as nursing homes, which internationally have accounted for up to half of all deaths from COVID-19.
But COVID-19 is also exacerbating and emphasising long-term health and social issues that had not been addressed before the pandemic, says Alison Verhoeven, Chief Executive of the Australian Healthcare and Hospitals Association.
Like Annie Butler, she told Croakey it is simplistic to declare that staff should not go to work when they’re sick, given many don’t have enough or any leave available. Services may need to consider paying these workers to take sick leave, at least in the pandemic.
Verhoeven says the pandemic is also shining a light on unresolved issues in aged care, now that most residents have more complex conditions and comorbidities than their counterparts 20 years ago. We need to think about whether they are hospitals or homes, and how therefore we should staff and run them, she says.
For the moment, though, she says, it is crucial that all health, aged care and disability service leaders learn the immediate infection control lessons of North West Tasmania and Newmarch House.
“It’s absolutely incumbent on them to see where things have gone wrong, to analyse why, to look at lessons learnt and what needs to be implemented in their own facilities,” she said.
“This is no time for complacency.”
Update on 21 May
These comments were supplied after the article above was published, and Croakey judged they would be of interest/use to our readers:
Leading Age Services Australia (LASA) provided the following comments from CEO Sean Rooney:
Every situation is unique and there have been comprehensive and constructive learnings from all major Australian outbreaks in aged care, that have assisted the sector, health authorities and the Government.
These experiences have been broadcast widely to aged care providers, with people directly involved presenting to national webinars coordinated by Leading Age Services Australia (LASA) and the Department of Health. They have been viewed by thousands of providers and their staff.
Earlier, LASA also hosted popular webinars involving overseas providers from the United States and Ireland, to help Australian aged care be better prepared for COVID-19. Over the longer term, the Aged Care Royal Commission and a Senate Select Committee are investigating COVID-19 responses.
Learnings have included:
- clear and timely communications with residents, staff and families
- repeated training of staff in preparation for an outbreak;
- having a specialist response team within aged care homes;
- having adequate PPE on hand
- immediate and extensive COVID-19 testing following an outbreak
- immediate access to an experienced surge workforce for a long period
- careful communication of options for the moving of healthy residents during a major outbreak
- maintaining close relationships with state and federal health authorities.
Resourcing of PPE, staff and testing has greatly improved and the approach to the recent Rockhampton case exemplifies lessons learned, with blanket COVID-19 tests at the home, PPE and an emergency responses team guaranteed and vulnerable residents moved into private hospitals.
Constant education is the key to staff, contractors and visitors complying with Federal Government regulations on not attending aged care homes with flu-like symptoms.
They must understand that it is extremely disappointing and potentially deadly, if they do not follow the rules.