An independent review into the COVID-19 outbreak at Newmarch House, commissioned by the Commonwealth Department of Health, was released yesterday 24 August.
The report, prepared by Professor Lyn Gilbert AO and Adjunct Professor Alan Lilly, analyses the catastrophic impact coronavirus had on Newmarch House, its staff, the residents and their families.
When COVID-19 infiltrated Newmarch House in April earlier this year, no other residential aged care home had experienced an outbreak of such magnitude.
How it happened: Newmarch was prepared for a storm, not a cyclone
Newmarch House, owned and operated by Anglicare Community Services (Anglicare) was opened in 2012 and is located in Western Sydney, around 50km from central Sydney. With 102 aged care places, it has enjoyed an exemplary accreditation history.
In early April, Australia was watching with alarm the tragic outcomes of coronavirus entering residential aged facilities internationally. Planning amongst Australia’s facilities, including Newmarch House, was underway.
On 11 April 2020 when Newmarch House recorded its first case, it thought it was prepared. Previously it had managed outbreaks of influenza and gastroenteritis with success. It had a surge workforce in place. It enacted its action plan and established a Crisis Management Team to provide leadership, oversight and integration of Anglicare’s broader outbreak preparedness planning. This would not be enough.
By 12 April, public health officials from the Nepean Blue Mountains Public Health Unit identified seven staff members who had had close contact with one or both of the first two cases (a resident and a staff member). These seven were advised to home quarantine.
It took until 15 April for all residents and staff at Newmarch to be tested for COVID-19. At this point, nine residents and seven staff were diagnosed with the virus. A further 40 of the 90 staff were ordered to home-isolate or quarantine.
By 18 April, 26 residents and 14 staff had been diagnosed with COVID-19 and 87% of frontline workers (personal carers and nursing staff), including most of the surge team, had been furloughed to isolation or quarantine.
23 April marked the appointment of an external team from BaptistCare.
Case numbers among residents peaked on 30 April with 37 cases, and amongst staff on 12 May with 34 cases.
Between 11 April and 15 June, 71 residents and staff members had tested positive for SARS-CoV-2, the virus that causes COVID-19. Nineteen residents had died, with 17 of the deaths directly attributed to coronavirus, resulting in a mortality rate of 46% of the residents who had tested positive.
The COVID-19 outbreak was formally declared over on Monday 15 June 2020, 65 days after it had begun.
Who was in charge? It seems like no one knew
When coronavirus entered Newmarch House, there was no clear hierarchy between government agencies. Those involved included Nepean Blue Mountains Local Health District, NSW Health, the Commonwealth Department of Health, and the Aged Care Quality and Safety Commission. There was no clear direction as to who was actually in charge.
There was a “lack of clarity” about the function of each agency and “where it sat in the hierarchy” that added confusion and stress and “highlighted the complexity of decision-making”.
Leadership concerns were not just limited to government agencies. Within Newmarch House there were shortcomings in management and it was “often unclear who was in charge”.
“Frequent changes in the management team and the fact that many managers were new to their roles contributed to the impression of instability.”
There was also no designated clinical leadership with Anglicare, concerning enough for the Aged Care Quality and Safety Commission, to deliver a number of regulatory interventions before ultimately appointing an independent advisor.
A team from BaptistCare arrived at Newmarch House on Friday 24 April, creating a “welcome turning point” in the management of the outbreak.
When communication fails
The report drew on many discussions and interviews to determine that “communication was a major challenge” for those involved in the outbreak.
In many cases all attempts by families of residents to communicate with Newmarch House were met with failure.
“Telephone calls, messages and emails simply went unanswered”.
Family members were quick to recognise the demands on Newmarch House staff but revealed “their concerns were dismissed” or they were given information that just wasn’t correct.
Family-to-resident communication was also problematic. “There were delays in reconnecting landline phones to newly allocated rooms” as residents were moved within the facility.
On 30 April, a new crisis team backed by clinical support staff established the Family Support Program. This vastly improved communication experiences for families.
Minimal staff equals minimal care
The report acknowledges that no planning could have anticipated the scale of the outbreak, the severe depletion of regular staff or the difficulty in engaging agency staff.
A surge workforce of 50 was based on a “conservative estimate” of 30-40% attrition of permanent staff due to isolation or quarantine, and was in excess of official advice that suggested that planning for 20-30% attrition would be adequate. By early April, 30 of these staff had been recruited and trained.
But by April 15 with 40 of the 90 regular staff ordered to home-isolate or quarantine, even the surge workforce was ill equipped to fill staff shortages.
By 18 April, 26 residents and 14 staff had been diagnosed with COVID-19 and 87% of frontline staff (personal carers and nursing staff), including most of the surge team were in isolation or quarantine. Inadequate direction PPE usage and failure by staff to maintain physical distancing contributed to the number of workers quarantined, and therefore unable to work.
Some agency staff travelled to and from Newmarch House on buses together or in shared taxis and had to wait in line, side-by-side to receive testing. Meal breaks, meetings, and socialising outside of work meant physically distancing did not happen as it should have.
The staffing crisis reached its pinnacle on 20 April, slowly improving after that with the provision of staff from Mable, Aspen, St Vincent’s Hospital and up to eight other agencies. However the skills of the new staff were “highly variable” and day-to-day numbers “unpredictable”. In some cases, relief staff assigned to Newmarch House were unaware of the COVID-19 outbreak at the facility until they arrived at work (some immediately left).
Indeed many staff were “fearful” of working in a COVID-19 positive workplace, creating “increased absenteeism”.
Agency staff also presented problems. Many did not have the correct credentials and it was reported by Newmarch House management that in one situation of “64 ‘expressions of interest’, there were just four suitable staff”. Many of those sent to help had “little or no experience working in aged care.”
The lack of basic staffing led to a failure in delivering person-centered care. There were almost no staff left who understood the individual needs of the residents. The need to train agency staff severely increased the workload of the few staff that remained.
The food quality was also compromised as agency contractors required permits to enable food deliveries. Agency chefs, unfamiliar with the facility, were brought in to cook. Family expressed concern that residents were given frozen sandwiches and cold and inedible meals that were “served on paper plates…with disposable cutlery”.
Feedback from families suggested that the low levels of staff also contributed to “weight loss, dehydration, pressure sores, increases in urinary tract and skin infections and general deconditioning.”
Many families noted there were staff who rose to the occasion, and helped deliver resident care, even though it was beyond the normal scope of their role. Lifestyle staff and pastoral carers facilitated communication between families and their loved ones.
This, however, was “often outweighed and overshadowed by the emotional enormity of living through the outbreak” and in some instances, the sadness of losing a much loved family member.
Was hospital-in-the-home (HITH) the best solution?
HITH is considered by many to be an appropriate solution for elderly residents. It minimises potentially traumatic effects of patient transfers out of their home and is believed to reduce the risk of further virus spread.
“For frail elderly people, admission to an acute hospital, where most staff have limited experience of their complex care needs, can be extremely distressing”.
Professor James Branley, Director of Infectious Diseases at Nepean Hospital deemed HITH to be the best solution for Newmarch House, despite the Aged Care Quality and Safety Commission’s Chief Medical Advisor recommending that infected residents be moved to another facility.
For HITH to work effectively it must be supported by adequate staffing and support. At Newmarch House this was not the case. Residents and families voiced their concerns that the care delivered was not on par with that which would be received by hospital inpatients and there was “a shortfall in staff familiar with the regular care needs of residents.”
Many contributors to the report voiced their concern with HITH being a viable model for care. “It means that a comfortable, home-like setting has to be temporarily converted into one with hospital-level environmental controls, equipment, IPAC practices, pharmacy services and staff to ensure the safety and adequate care of all residents.”
The report has outlined 20 key learnings for the Newmarch House experience. Senator Colbert has suggested that we need to learn from what went wrong. We can only hope that the time to learn has come.