COVID‐19 in a Sydney nursing home: a case study and lessons learnt

Lessons learnt from COVID‐19 outbreaks in residential aged care facilities could limit future impacts

Infectious disease outbreaks are a hazard of communal living in places such as military barracks, boarding schools, prisons and residential care homes. The risks are exacerbated when residents are vulnerable because of advanced age, comorbidities and frailty, or there are too few or inadequately trained staff. The home‐like setting of modern residential aged care facilities (RACFs), and the overcrowding and limited staffing that are features of many, are not conducive to prevention or control of infectious diseases.1,2,3

Early in the coronavirus disease 2019 (COVID‐19) pandemic it was clear that age would be a risk factor.4,5 Internationally, age‐stratified case fatality rates (CFRs) have been an estimated three times higher in people aged over 60 years (4.5%) than in those aged under 60 years (1.4%).6 In Australia, the overall CFR from COVID‐19 is about 3%.7 The majority of deaths have occurred in people over 70 years of age. At 14 September 2020, there were 1995 COVID‐19 cases among residents of government‐subsidised RACFs, of whom 604 (30%) died. This is in contrast to a CFR of 8.5% (7/82) among recipients of government‐subsidised domiciliary aged care services. Residents of RACFs represent 74% (602/816) of all COVID‐19 deaths in Australia to date.7

Comorbidities associated with an increased risk of severe COVID‐19, including diabetes, chronic kidney and cardiovascular disease, are more common among RACF residents.8 Transmission of COVID‐19 can spread silently within an RACF from someone with asymptomatic or presymptomatic infection, or atypical symptoms.9,10,11 Outbreaks in RACFs, with high attack rates and CFRs, have been reported in many countries.9,10,12,13,14

An outbreak of COVID‐19 in a Sydney nursing home

The first major RACF outbreak in Australia was at Dorothy Henderson Lodge, an 80‐bed nursing home which is part of a BaptistCare‐operated retirement living complex in a northern suburb of Sydney (Box 1). When the outbreak began on 3 March 2020, Dorothy Henderson Lodge had 76 residents. The first case was a longstanding personal carer who developed mild respiratory symptoms and sought testing for COVID‐19. She had no history of COVID‐19 contact or recent travel and had not worked while unwell. A crisis team, comprising Lodge managers and Northern Sydney Local Health District senior public health and infection prevention and control (IPC) staff, was formed immediately. Residents in the wing where the carer had worked were isolated and IPC precautions were implemented. The next day, an IPC specialist from the NSW Clinical Excellence Commission took charge of IPC. Standard precautions were introduced for everyone entering the facility, along with additional contact and droplet precautions for staff in close contact with residents.

Over the next 2 days, all residents were confined to their rooms and all personal care staff were furloughed to home quarantine; two additional staff members and four residents were diagnosed with COVID‐19 (Box 1), including two residents who were already in hospital with hitherto undiagnosed illnesses. A skeleton staff of BaptistCare managers and other volunteer staff, who had not had close contact with residents, provided care for several days until agency staff could be engaged. Enhanced cleaning, laundry and waste collection and food delivery practices were introduced. Symptomatic residents and staff were tested. Between 9 and 19 March, COVID‐19 was diagnosed in another four residents and one staff member. All 12 cases diagnosed until then had probably been infected before, or in the few days after, IPC precautions were introduced. An agency nurse who worked at Dorothy Henderson Lodge only from 8 to 12 March was diagnosed with COVID‐19 on 20 March.

By 20 March, three of the 76 residents had died from COVID‐19, five were in hospital, and the remaining 68 had been confined to their rooms for 17 days. They were becoming increasingly distressed by isolation and immobility, and a few with dementia repeatedly wandered from their rooms. Clearly, there was some urgency to provide relief. Although they had no acute symptoms, all were tested for COVID‐19, with a view to allowing them brief periods of supervised exercise outside their rooms if test results were negative. Unexpectedly, five were positive. Review of their records showed that two had had mild symptoms a few days before being tested. They, and two others who remained asymptomatic, remained at Dorothy Henderson Lodge. The fifth, who was asymptomatic when tested, later deteriorated and died in hospital. Ten days later, three more residents developed symptoms of COVID‐19 and two died. Altogether, 16 of 76 (21%) residents developed COVID‐19; 12 were admitted to hospital, of whom six recovered and six died, including one who returned to Dorothy Henderson Lodge for palliation. All four residents who remained at the Lodge recovered.

By mid‐April, about 80% of permanent staff had returned to the Lodge and the previous team‐based care of residents in each zone was restored, with ongoing support from agency staff. Residents had been confined to their rooms for more than 6 weeks, with serious adverse effects on mental and physical wellbeing, despite efforts by staff to mitigate them. Strict IPC precautions remained in place, but quarantine was cautiously eased, by allowing residents short, supervised walks outside their rooms, and later to spend time with fellow residents in the same wing. The outbreak was declared over on 7 May 2020, which was more than two incubation periods since the last case.

The COVID‐19 outbreak at Dorothy Henderson Lodge occurred at a time when community transmission and experience with control were limited. The source of the outbreak was not specifically identified but whole genome sequencing15 showed it was part of a community outbreak that also involved a nearby hospital, school and day care centre. The outbreak was limited (21% attack rate) compared with reported RACF outbreaks overseas. For example, in a contemporaneous outbreak in King County, Washington, 101 of 130 (78%) residents were infected and 34 died (CFR, 34%; 26% of all residents).12 The CFR at Dorothy Henderson Lodge was similar (6/16; 38%) but the overall mortality (6/76; 8%) was lower than in many RACF outbreaks overseas (25–30%)9,10 and elsewhere in Australia. Nevertheless, it was inevitably associated with great physical and emotional cost to residents, families and staff, and financial cost to the organisation.

Major challenges and lessons learnt

The Dorothy Henderson Lodge COVID‐19 outbreak presented a number of major challenges, and the lessons learnt could limit future COVID‐19 impacts on RACFs (Box 2).

Staffing, infection prevention and control, and medical support

From the start, Dorothy Henderson Lodge was supported by experienced IPC professionals and medical practitioners who were crucial to the outbreak response. Strict IPC precautions were consistent with national guidelines and, while necessary, were also costly and burdensome. The considerable financial costs of the COVID‐19 outbreak were due to the need to replace quarantined staff with agency staff, and acquisition and disposal of personal protective equipment (PPE). More than the usual complement of frontline staff and a higher proportion of registered nurses were needed because of the extra workload due to the increased acuity of care. The estimated 800 sets of PPE used each day were disposed of as clinical waste, requiring collection by a licensed contractor. The unfamiliar working conditions for agency staff, many of whom had not worked in an aged care facility before, were stressful and tiring; they were understandably fearful of COVID‐19 and unused to the discomfort of continuous PPE use. It was therefore unsurprising that a Clinical Excellence Commission review of IPC in April found a number of breaches.16 Compliance improved after additional training.

Effects on residents and relatives

The long period of quarantine was distressing for residents and relatives. Dorothy Henderson Lodge staff facilitated contact by phone, video, text messaging, voicemail, or in‐person contact with physical distancing from a balcony or behind a transparent barrier. Nevertheless, the lack of physical contact, exercise and fresh air seriously affected residents’ mental and physical health. Some became depressed, withdrawn or physically deconditioned and refused to eat or, when later given the opportunity, leave their rooms. This highlights the importance of mobilisation and resuming family contacts as soon as possible.

Hospital admission

Admission of residents with COVID‐19 to hospital was appropriate early in the outbreak, before its extent was known and staff numbers and IPC were stabilised. Admission to hospital can be confusing and frightening, especially for residents with dementia. Later in the outbreak, it was possible for residents with COVID‐19 to be safely cared for in the home, as most preferred, including at least one who received end‐of‐life palliative care. Decisions about hospital transfer of aged care residents should consider their medical needs and preferences and the facility's capacity to care for them safely.

Testing and case detection

Clinical indicators are an unreliable guide to COVID‐19 testing in high risk settings such as RACFs. When this outbreak began, asymptomatic testing was not recommended, even in the setting of community transmission, and early case detection relied on active screening for acute symptoms or fever. It is now recognised that a single case in a high risk setting such as an RACF should prompt immediate testing of all residents and staff, irrespective of symptoms. Testing should be repeated in the early stages of an outbreak; how frequently depends on the duration and extent of unrecognised spread and how rapidly IPC measures are implemented.

Embedding infection prevention and control practices into RACF culture

Prevention and control of infection, including COVID‐19, in residential care settings, depends on a hierarchy of measures encompassing environmental, administrative and staffing factors (Box 3), which are at least as important as standard and transmission‐based IPC precautions. However, IPC training is essential — but often neglected — for protection of staff and residents, not only during a pandemic but also for routine care. IPC training should be tailored to the educational levels and roles of staff; be nationally consistent, to avoid confusion when they move between workplaces; and involve all aged care workers, including personal care, nursing, agency and support staff. IPC training requires additional resources but, if successful, the benefits should include less absenteeism among staff (from illness or quarantine), which has been a major contributor to high COVID‐19 attack and fatality rates among RACF residents.17 In the long term, improved prevention and control of infection in RACFs should contribute to reducing the impacts of seasonal influenza and antimicrobial resistance,18,19 which are important causes of avoidable hospitalisation and cost in aged care.