Independent Review: Newmarch House COVID-19 Outbreak
Written by Ilsa Bird, Sector Support Coordinator
Newmarch House was one of the first residential aged care providers to experience an outbreak related to COVID-19. Between 11 April and 15 June 2020, 71 COVID-19 cases were diagnosed which included both staff and residents and 19 residents sadly died. Below is a summary of the Newmarch House Independent Review Final Report conducted by Professor Lyn Gilbert AO and Adjunct Professor Alan Lilly, published on 20 August 2020.
The key areas explored included emergency response, leadership and management, communication, staffing, infection prevention and control, medical and clinical care and family experience.
Emergency response and interagency operations were characterised by a lack of clarity in the relationships and chain of command among government health agencies. This resulted in confusion for Anglicare Board and managers, who were unfamiliar with the state agencies and the hierarchy of decision-making in the context of a COVID-19 outbreak.
Leadership and management
Leadership at Newmarch House and in the broader Anglicare organisation, was generally invisible to external parties. The Aged Care Quality and Safety Commission delivered a series of regulatory interventions, which led to the requirement to appoint an independent Adviser.
Communication was consistently highlighted as an issue for families who felt disconnected from their loved ones during the course of the outbreak. This impacted families and increased the feelings of isolation of the residents. Making regular meaningful contact with family members presented numerous challenges and tested the system capacity to its limits.
Staffing during the COVID-19 outbreak was severely diminished as a result of many staff being isolated due to COVID-19 infection or quarantined because of close contact. Staff replacement was not reasonably anticipated and it exceeded the organisation’s planned surge capacity. In many cases, loss of staff was intensified due to poor quality or incorrect use of PPE.
Infection prevention and control (IPAC)
Infection prevention and control was identified as a significant concern and failings were identified early in the outbreak. Routine IPAC practices needed to be upgraded to contain the spread of COVID-19 which required the expertise of an experienced professional. This was further challenged in an environment built and furnished as the residents’ home.
Medical and clinical care
Medical and clinical care was led and delivered by the Hospital-in-the-Home (HITH) program in consultation with the Virtual Aged Care Service (VACS) at Nepean Hospital, GPs, locum medical staff and nursing staff at Newmarch House. The HITH program was compromised by inadequate staffing and residents and their families felt that it often failed to provide care equivalent to that of inpatient hospital care.
There was positive recognition of the tireless efforts of staff, however families expressed significant concerns about poor quality of care of their loved ones. There were numerous instances of missed or delayed care resulting in adverse outcomes for some residents, in addition to abundant issues around communication.
Summary of key learnings
- Problems with management need to be addressed as soon as possible after they are recognised
- To ensure the earliest possible identification of all COVID-19 cases, the immediate and repeated testing of all residents and staff should be implemented as soon as a single case is identified
- At the outset, there must be a clear operating protocol in place, outlining the relevant stakeholders, their respective roles and the hierarchy of decision making, noting that the Approved Provider retains its obligations under the Aged Care Act 1997, unless there is a superordinate provision or order in place. The protocol should also address: meeting agenda, objectives, identification of participants, administration, documentation and meeting etiquette
- (i) the Approved Provider should identify and be ready to deploy its Outbreak Response Team (however titled); (ii) the Approved Provider should designate the leader of its Outbreak Response Team who is duly authorised to lead and make decisions on behalf of the Approved Provider; (iii) the Approved Provider must nominate its clinical leader who will provide clinical leadership and advice to the Approved Provider as part of its Outbreak Response Team
- Access to advocacy services should be a priority during an outbreak. Advocates can assist providers and residents (or their legally appointed representatives) to resolve issues expeditiously
- (i) the Approved Provider should be responsible for maintaining an Emergency Contact Register for each resident. A minimum of three contacts may be registered. These contacts must be confirmed by the resident or their legally appointed representative; (ii) there must be a legally enforceable provision to share this Emergency Contact Register information with the Aged Care Quality and Safety Commission, in the event that this is required to assist with improving emergency management
- Communication is a key priority. A communication protocol should be developed and highlight stakeholders, types of communication and frequency
- (i) Approved Providers should consider surge workforce capacity on the premise that a minimum of 50% of its staff may be furloughed; (ii) The Department of Health should consider expanding its surge workforce capacity providers in order to provide scaled support for individual Approved Providers
- Orientation for all new staff during the course of an outbreak is required and must include practical infection control training, instruction and a competency-based assessment of PPE donning and doffing, on a background of regular infection control training.
- Deconditioning of older people is a known complication of reduced activity and isolation. Approved Providers should consider specialist staffing requirements and activities to specifically address and enable maximum independence and reablement during an outbreak
- Misunderstandings and gaps in information exchange between doctors and patients or their relatives are common. Information often needs to be repeated and/or provided in written form. These misunderstandings are likely to be amplified in the context of an outbreaks crisis and especially when they touch on end-of-life care
- HITH is an attractive model of care for management of a COVID-19 outbreak in an aged care facility but the precondition of resident safety is only likely to be met if the outbreak is limited to a small number of cases in residents and staff
- Decisions about the management of COVID-19 cases should be made by an expert panel. The panel should at minimum include membership from experts in infectious diseases, infection control, geriatric medicine, clinical leadership from the approved provider and a local general practitioner. This panel should consult with the relevant Commonwealth and jurisdictional health agencies, the Aged Care Quality and Safety Commission and the designated representative of the Approved Provider. As the soon as an outbreak is declared: (i) the expert panel should be convened and (ii) residents should be transferred to hospital until the residential aged care facility is deemed safe and appropriate for those residents to return.
- GPs are an underused resource during a COVID-19 outbreak in an aged care facility but their participation (and interaction with families) requires good communication and access to patient information
- Approved Providers should consider the implications of a loss of Electronic Records as part of its Business Continuity Plan. Access and implications for all parties using the electronic records should be considered
- Establishing effective infection prevention and control is time-critical. Lack of consistent expert IPAC guidance at the start of the outbreak led to inconsistent use of PPE and uncertainty about exposure of staff contacts to COVID-19 positive cases
- Providers should develop and be ready deploy a dedicated team of staff to act in the capacity of a Family Support Program (however titled), providing person-centred, structured interactions with family members of residents affected during an outbreak. Protocols should be established to determine the frequency and type of contact with the nominated contact persons. Consideration should be given to the availability of furloughed staff to support this program to provide optimum levels of support to family members
- Residents’ families consistently advocated and endorsed improvements in the number, mix and training of staff, supporting improved delivery of care to residents. The outbreak identified a pressing need to lift the standards of education and training in infection control. This feedback should be considered in light of relevant reviews previously undertaken and those currently underway
- Consideration of how to facilitate improved closer physical contact with family members during end of life care must occur as a priority
- Protocols should be developed to provide an authoritative source of guidance on the storage, decontamination and return of desired personal effects to family members following the death of a loved one.
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