A review of the COVID-19 outbreak at Dorothy Henderson Lodge has concluded that infection control practices should be embedded into the culture of aged care homes, and all aged care staff in Australia should receive nationally consistent infection control training.

Infection prevention and control (IPC) was “often neglected” in aged care homes, said the author of the review, Gwendolyn Gilbert, Clinical Professor, Medicine (Immunology & Infectious Diseases), Westmead Institute for Medical Research, which was published in the Medical Journal of Australia this week.

However, IPC should be an “essential” aspect of training for all aged care staff, not only to help during pandemics, but in daily routine care, she said.

The additional training might add to the cost of delivering aged care, but it would lead to less absenteeism from illness or quarantine, one of the key reasons COVID-19 outbreaks were so devastating in aged care, Professor Gilbert suggested.

She also noted that even outside the pandemic, better IPC in aged care homes would reduce the impacts of seasonal flu outbreaks and antimicrobial resistance – two causes of hospitalisation and added costs in aged care.

In the report, titled ‘COVID-19 in a Sydney nursing home: a case study and lessons learnt’, Professor Gilbert said IPC training should be tailored to aged care staff’s roles, and should be nationally consistent. This recent report published in the MJA is a more detailed version than was released in July 2020.

Modern residential aged care homes are “overcrowded” and have “limited staffing”, making them “not conducive” to either preventing or controlling infectious diseases, Professor Gilbert observed.

Aged care residents 74% of all COVID-19 deaths in Australia

Aged care residents represented 74 per cent of all COVID-19 deaths in Australia, the report noted.

The mortality rate at DHL lodge was 8 per cent, which was relatively low compared with some overseas aged care homes which saw mortality rates of between 25 and 30 per cent.

The attack rate – the number of people in a given population diagnosed with COVID-19, divided by the total of the given population – at DHL was also relatively low at 21 per cent. This compares, for example, with an attack rate of 78 per cent at an aged care home in King County, the United States.

Yet, the case fatality rate (CFR) DHL was relatively high. At DHL the CFR was 38 per cent. In King Country, the CFR was 34 per cent.

Major challenges and lessons learned

The report uncovers the key weaknesses in DHL’s responses to COVID-19, and made several corresponding recommendations.

As well as better IPC training, aged care providers should have “contingency plans” to ensure surge capacity of qualified, experienced aged staff are available when suddenly needed.

Allied health support is also essential to maintaining social connection, mobility and nutrition among aged care residents, and to minimise the risks of residents enduring prolonged periods of isolation.

Hospital admission for RACF residents with COVID-19 should be determined according to medical need, resident preference and facility resources.

A single case of COVID-19 in a resident, staff member or visitor requires an immediate outbreak response, Professor Gilbert recommended.

Barriers to controlling the outbreak

The report provided a timeline of the outbreak, and listed the key barriers that prevented DHL from controlling the outbreak.

Some of the barriers that prevented DHL from being able to control the oubreak included:

  • Carpets, soft furnishings, residents’ personal possessions
  • Intermingling of residents, communal activities
  • Shared rooms and/or bathrooms
  • Crowding
  • Clutter
  • Poor ventilation
  • Porous, difficult-to-clean surfaces
  • Inadequate cleaning of communal areas and residents’ rooms
  • Inadequate staff to resident ratios
  • High proportion of part-time, temporary or agency staff
  • Inadequate or absent staff IPC training
  • Staff moving between residents’ rooms or zones unnecessarily or without the proper IPC precautions 
  • Inadequate isolation, transfer or cohorting of infected residents during an outbreak
  • Failure of staff to observe general outbreak/IPC precautions, for example, failure of staff to stay home when unwell and failure of staff to maintain physical distancing in communal areas or community settings 
  • Failure to promptly identify and isolate an infectious disease case
  • Failure to immediately activate an outbreak response

Preventing further COVID-19 deaths in aged care

In total, 685 aged care residents have died from COVID-19 in Australia. 

DHL was in the unfortunate position of being the first aged care home in Australia to experience an outbreak, due to its location in north-west Sydney, the site of the country’s first COVID-19 cluster. 

The better we understand what went wrong at DHL, and glean lessons from those mistakes, the better prepared aged care homes will be to protect their staff and residents, should the virus strike again.

Just as aged care homes in Asia upped their IPC practices after SARS, Australia must do the same here in the wake of COVID-19.

Image: SheraleeS, iStock.

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