Inquiry supports hospitalisation of COVID-positive residents

The increasing number of COVID-19 cases among Newmarch House residents and staff “fuelled a vicious cycle” of staff and equipment shortages and poor infection control practices, according to an independent review.

The increasing number of COVID-19 cases among Newmarch House residents and staff throughout April “fuelled a vicious cycle” of staff and protective equipment shortages and poor infection protection and control practices, an independent review has found.

The reviewers identified a pressing need to lift the standards of education and training in infection control among 20 key learnings, which are contained in their final report released by the Federal Government on Monday.

Other learnings include that approved providers consider surge workforce capacity on the assumption that at least half of its staff may be furloughed, and as the soon as an outbreak is declared, residents should be transferred to hospital until the facility is deemed safe for residents to return.

The latter supports the repeated calls of aged care provider peak bodies and individual providers.

The outbreak at Anglicare’s Newmarch House in Caddens in western Sydney commenced on 11 April 2020 and was declared over on 15 June 2020. During this period, 71 residents and staff were diagnosed with COVID-19 and 19 of these residents died.

The Department of Health commissioned Professor Lyn Gilbert and Adjunct Professor Alan Lilly in June 2020 to undertake an independent review into the outbreak to understand what occurred and what could be learned.

“The continued presence of residents with COVID-19 in the home, many of whom required a disproportionate share of limited nursing resources, were an ongoing potential source of infection, especially in the face of faulty [infection protection and control] IPAC practices.

“This could have been mitigated by early advice from an experienced IPAC professional. Outbreak control requires both source and transmission control,” Professor Gilbert and Professor Lilly found.

Their key findings include:

  • an emergency response and interagency operations characterised by a lack of clarity in the relationships and hierarchy among government health agencies, which created confusion for Anglicare’s board and managers
  • shortcomings in leadership and management at Newmarch House and Anglicare, who were initially invisible to external parties interacting with them
  • communication issues including regular contact with family members in a meaningful presenting numerous challenges and testing system capacity to its limits
  • severely depleted staffing due to COVID-19 infection or isolation requirements, which could not have been reasonably anticipated and greatly exceeded the organisation’s planned surge capacity
  • loss of staff to quarantine in some cases exacerbated due to poor quality or incorrect use of personal protective equipment (PPE)
  • shortcomings in IPAC in the early, crucial phases, challenges containing the spread of COVID-19, with IPAC further challenged due to the homelike environment
  • medical and clinical care under the Hospital-in-the-Home program compromised by inadequate staffing and support
  • numerous unsatisfactory experiences for family and instances of missed or delayed care resulting in adverse outcomes for some residents.

Key learnings

The review’s list of learnings to inform future practice directed at governments, health authorities, providers and other stakeholders include the immediate and repeated testing of residents after a postive case is found.

Also among them, providers should identify and be ready to deploy its outbreak response team with a designated leader to lead and make decisions on its behalf and a clinical leader who will provide clinical leadership and advice.

In addition to providers considering surge workforce capacity to replace a minimum of 50 per cent of its staff, the Department of Health should consider expanding its surge workforce capacity to provide scaled support for individual providers, according to the report.

Other learnings providers are advised to heed include:

  • maintaining an emergency contact register for each resident with a minimum of three confirmed contacts that can be shared with the Aged Care Quality and Safety Commission if required to assist with improving emergency management
  • consider the implications of a loss of electronic records as part of its business continuity plan
  • develop and be ready to deploy a dedicated team of staff – with consideration given to furloughed workers – to provide person-centred, structured interactions with family members of residents affected during an outbreak.

Another learning is that the Hospital in the Home model is attractive to manage a COVID-19 outbreak in an aged care facility on the precondition that resident safety is only likely to be met if the outbreak is limited to a small number of cases in residents and staff.

The review recommends that decisions about the management of COVID-19 cases be made by an expert panel who consults with the relevant Commonwealth and jurisdictional health agencies, the Aged Care Quality and Safety Commission and the designated representative of the provider.

As the soon as an outbreak is declared the expert panel should be convened and residents should be transferred to hospital until the residential aged care facility is deemed safe and appropriate for those residents to return, the reviewers said.

Stakeholder responses

Minister for Aged Care Richard Colbeck, who announced the release of the report, said the review was an important resource for all levels of government, which would improve the management of potential future outbreaks and inform advice and guidance to support the aged care sector.

Richard Colbeck

“We continue to integrate the learnings from Newmarch and infections in Victoria into the national response as outbreaks occur,” Mr Colbeck said.

He said changes reflected in the learnings already implemented include early identification of all COVID-19 cases actions to reinforce compromised management and the immediate engagement of advocacy group Older People’s Advocacy Network to ensure services and information are available to providers, residents and their families.

Other implemented initiatives include support from the Victorian Aged Care Response Centre to improve communication, staff and management support, expansion of surge workforce for facilities affected by outbreaks and additional infection control training.

Aged care provider peak body Aged and Community Services Australia said the Newmarch House outbreak highlighted the critical need for the first COVID-19-positive aged care residents to be hospitalised.

Patricia Sparrow

ACSA welcomes the report and supports the majority of the findings and recommendations, said CEO Patricia Sparrow.

“The scale of the outbreak at Newmarch and the sudden depletion of staff were not anticipated in the services’ planning. This is a significant learning that occurred early on in the pandemic and one that must guide future planning,” Ms Sparrow said.

The sector urgently needs all states to follow the lead of Queensland and South Australia where the first COVID positive cases in aged care facilities are transferred to hospital, she said,

“Aged care homes are not hospitals. They aren’t staffed like hospitals. They are not funded like hospitals. They are homes,” Ms Sparrow said.

The report vindicates the Australian Medical Association’s calls for urgent assessments of all aged care homes to manage the pandemic, said AMA President Dr Omar Khorshid.

Dr Omar Khorshid

“We must learn the lessons from Newmarch and the outbreaks in aged care homes in Victoria. These lessons must be applied in the plan that the Government announced last Friday,” Dr Khorshid said.

However, he said sending healthy older people to hospital for isolation was not the solution. “Triggers for transfers will have to be set, along with transfer destinations for each individual aged care home.”

The role of GPs needs to be recognised as crucial in all aspects of care for nursing home residents and the must be involved, Dr Khorshid said.

NSW Health provides additional response

In its response, NSW Health raised concerns its feedback on the draft report was not incorporated into the final version and significant aspects of the management of the outbreak from the perspective of NSW Health were not covered by the reviewers.

Following the outbreak, NSW Health said it took assertive action to clarify responsibilities in conjunction with aged care providers, the Commonwealth Department of Health and the Aged Care Quality and Safety Commission.

It also worked with over 880 residential aged care facilities throughout NSW to improve their level of preparedness and prevent another COVID-19

“To ensure the learnings from the report are taken forward, it will be critically important that the accountabilities and responsibilities of aged care providers and Commonwealth agencies continue to be reinforced and enacted accordingly,” NSW Health said it its response.

Access the final report and NSW Health’s response here.

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