Two Victorian aged care facilities that experienced COVID-19 outbreaks leading to the deaths of 83 residents were insufficiently prepared for emergencies with surge workforces “inadequate to manage the scale of the outbreak”, an independent review has found.
The independent review released in mid-December was commissioned by the Department of Health to look into the events surrounding the COVID outbreaks at St Basil’s Home for the Aged in Fawkner and Heritage Care’s Epping Gardens Aged Care in Epping in September.
The reviewers Professor Lyn Gilbert and Adjunct Professor Alan Lilly, who also undertook independent reviews into the COVID-19 outbreaks at Dorothy Henderson Lodge and Newmarch House in New South Wales in early 2020, identified that emergency planning and preparation was untested and reactive at both facilities.
“Despite numerous guidelines, frameworks and directions provided by the government agencies and Aged Care Quality and Safety Commission, site-specific outbreak management plans had not been developed and trialled in either facility under review,” Professor Gilbert and Professor Lilly found.
“Surge workforce planning at each of the facilities was inadequate to manage the scale of the outbreak. This was exacerbated by the growing demand for staff, across the aged and health care sectors, at that time,” they found.
Frontline agency staff hired to replace regular staff were generally “young and inexperienced,” Professor Gilbert and Professor Lilly also found.
“Most had little experience in aged care, and many only spoke basic English. With little preparation or supervision, it is not surprising that many did not stay and those who did, were quite likely traumatised.”
Other key findings across both facilities include:
- suboptimal infection prevention and control capacity and capability
- failures in leadership and effective management
- delayed pathology testing
- ongoing challenges across the health department and interagency support and communications , but the reviewers note significant improvement and streamlining of communication
- largely unsatisfactory experiences among family and residents, most significantly due communication and care delivery.
St Basil’s reported its first case of COVID-19 on 8 July, however the health department was not alerted until six days later. During the outbreak, the facility reported 188 residents and staff members diagnosed with COVID-19, including 94 residents, of whom 45 died.
Epping Gardens reported its first case on 20 July and went on to experience 189 cases among staff residents, including 103 positive residents and 38 subsequent deaths.
“These stark numbers do not begin to convey the trauma and grief suffered by all residents, whether or not they developed COVID-19, and the enormous impact on their families,” Professor Gilbert and Professor Lilly said in the report.
The review identified the need for improved communication between aged care facilities and residents and relatives, as residents and their families were often the last informed about the progress and implications of the outbreaks.
It also highlighted that effective leadership in any crisis required an understanding of the leader’s role and a defined command and control structure.
Other findings and learnings included:
- routine infection prevention and control and education, training and practice in the two facilities was variable in general but often basic
- planning and preparedness determines the extent to which a facility will be reliant upon external resources
- factors contributing to delays in specimen collection and results reporting included:
- delays in appropriate notification of an index case
- documentation required for efficient specimen registration, scheduling and reporting was unavailable or in the wrong format
- unprecedented demand for laboratory testing
- concerns for the safety of collection staff due to conditions at the facilities
- failures to pass on results to workforce managers.
The reviewers, which built on the findings of the previous Dorothy Henderson Lodge and Newmarch House reviews, highlighted several factors at play in managing COVID-19 outbreaks.
“Whilst improvements have been observed and new lessons identified, there is an ongoing challenge to drive and embed consistent improvement across the aged care sector,” the reviewers said.
“The sector is always learning, and resources are constantly being reviewed, updated and disseminated. However, this review clearly identifies how easily things can go awry and that the preparations needed for such major outbreaks are often significantly underestimated. It also identifies learnings for improvement at a local and sector level.”
Review highlights important lessons
At the time of the report’s release, Minister for Aged Care Services Richard Colbeck said the government has been adapting the National Response Plan for COVID-19 in aged care since early 2020 and incorporating lessons learned nationally and from overseas.
“It’s important we understand what occurred and what can be learned to make sure we can prevent similar outbreaks now and into the future,” Mr Colbeck said.
Minster for Health and Aged Care Greg Hunt said the report served as a platform for understanding and action.