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Concerns over personal protective equipment have been raised at another rest home where residents died after contracting Covid-19, amid calls for greater oversight of a sector that looks after our most vulnerable. Nicholas Jones reports.
There was a reluctance to volunteer to work in the coronavirus-stricken rest home, and some staff who stepped up were soon concerned for their safety.
CHT St Margaret's residential aged-care home in Te Atatu recorded its first Covid-19 case on April 4 and was soon overwhelmed by an outbreak that turned deadly.
Residents and staff alike got infected and others went into precautionary isolation. The local DHB, Waitematā, sent in nurses and healthcare assistants.
The Weekend Herald has confirmed some of those DHB staff raised concerns about personal protective equipment (PPE), a term for gear like face masks and gloves used to shield against possible infection.
St Margaret's was following PPE practices recommended by the Ministry of Health for aged-care facilities, on the advice of regional health authorities and the DHB.
However, those weren't as stringent as the newly arrived staff were used to within hospitals, or guidelines the NZ Aged Care Association gave members, including St Margaret's.
NZ Nurses Organisation kaiwhakahaere Kerri Nuku said nurses spoke up because they needed to feel safe.
"It certainly was different from the gear our nurses were used to using inside DHBs," she said of the situation at St Margaret's. "There should be some consistency in the type of PPE gear [used], in accessibility, the appropriateness and the training.
"If you get put in somewhere unfamiliar and you are using gear that is perhaps of a lower standard, then you need to be safe and feel safe. And the nurses were concerned about the level of quality [of the] PPE gear."
The aged-care facility has resident suites and a dementia unit and is run by CHT Healthcare Trust, a charity with 16 aged-care facilities across the upper North Island.
CHT chief executive Max Robins said all its facilities had strictly adhered to ministry guidelines for PPE and infection control. Contact tracing immediately began after confirmation of the first case, and Auckland Regional Public Health Service (ARPHS) advised who to isolate.
"PPE has been available before the first positive case was confirmed and continually available with support from the DHB to ensure our stock levels were adequate. We have consistently adhered to the MOH [Ministry of Health] guidelines for PPE use when working with people who either did or did not have symptoms."
The NZ Aged Care Association, which represents more than 90 per cent of the sector, recommends staff in facilities with suspected, probable or confirmed Covid-19 use an N-95 face mask (designed to fit tight and prevent inhalation of small airborne particles), fluid-resistant gowns and protective goggles.
That goes further than ministry advice that N-95 masks aren't needed except for procedures that cause airborne particles or respiratory droplets, and that only a surgical mask and hand washing can be enough when treating patients who don't have symptoms and aren't suspected cases, depending on risk of exposure to bodily fluids.
Robins, who is on the board of the NZ Aged Care Association, said he was aware of the difference in guidelines.
"While we were aware of the NZACA advice, the Waitematā DHB and APRHS both advised us to strictly follow the MOH guidelines, which we did, as well as providing us with PPE advice when required."
A Waitematā DHB spokeswoman said its staff had requested the PPE they were familiar with at their usual workplace, and this was immediately provided. Further questions including how this gear differed and when it was supplied weren't answered by deadline.
A crisis builds
St Margaret's closed to visitors from March 23. Its first case was confirmed on April 4, and three days later the DHB was told of an outbreak.
Wider communication was lacking; the family of one resident were only officially told there was Covid in the facility on April 16 and after making inquiries themselves following media reports naming St Margaret's.
The DHB eventually had to cover up to 85 per cent of the facility's staffing, but was relying on staff to volunteer to go - and many were reluctant.
Despite daily meetings between the rest home and the health board's incident management team, there had been little discussion of what would happen if it became unsafe to manage the residents at the facility.
That point was reached as staffing issues grew, and groups were urgently moved by ambulance to hospitals on April 17.
The transfers were because of staffing problems not for health reasons, but the residents quickly deteriorated, with all confined to their beds, incontinent, coughing and unable to follow instructions. Over the following week, three died.
Concerns have now been raised about PPE use at the two rest homes that have lost residents to Covid-19. The Herald previously revealed the coronavirus outbreak at Rosewood rest home in Christchurch spread so rapidly that there were "safe practice" issues, including the way PPE was used.
Twelve Rosewood residents have died, and the toll from the Rosewood and St Margaret's outbreaks account for 15 of the country's 21 deaths.
PPE has been a hotly debated issue both here and overseas. The Nurses Organisation and some frontline workers have criticised the availability and guidelines, at times running up against expert clinical advice and evidence about what gear will actually make a difference to safety.
The ministry PPE guidelines followed by St Margaret's were drawn up after clinical advice, for example, and experts say properly using and removing (doffing) PPE can be as critical as the type worn.
After concerns voiced by some nurses on a ward with transferred Rosewood residents Canterbury DHB made visors and N-95 masks available - but stressed this wasn't needed for clinical reasons.
"Evidence shows that during the Ebola outbreak, a common cause of healthcare workers contracting the disease was by self-contamination when removing their PPE, which is why more is not always better," the DHB's clinical director of microbiology, Dr Josh Freeman, said in a media release at the time.
Some nurses working on the Waitākere Hospital ward with six St Margaret's Covid-19 patients caught the virus themselves, creating new chains of transmission and despite wearing full hospital-level PPE (gloves, fluid-repellent gowns, eye protection and an N-95 mask).
An urgent review ordered after those infections was released this week, and found there were problems with usability of some PPE, and information about expected practice wasn't always consistent, including because the ward with St Margaret's patients was wrongly considered low-risk.
Rostering pressures meant nurses who got infected worked on other Covid-free wards despite concerns from some senior medical and nursing staff. Some DHB staff sent to work at St Margaret's also worked hospital shifts.
Six rest homes have had Covid-19 cases, and some successfully ended transmission after quick action. Atawhai Assisi Rest Home and Hospital, just south of Hamilton, sent large numbers of staff home and isolated all residents after its first positive result, with remaining staff staying in designated areas and entering and exiting through separate kiosks. Infrared temperature equipment was brought in, as were motorhomes and caravans for some staff to live onsite.
Director-general of health Dr Ashley Bloomfield noted the differing results among affected rest homes when announcing a review into "what has worked well, and what could be improved", saying in some facilities "we have seen just how tricky this virus is".
'We will continue to fail the vulnerable without adequate oversight'
Waitematā DHB chair Judy McGregor called for change in the aged-care sector in an opinion piece published in the Herald after the transfer of St Margaret's patients and subsequent deaths.
Professor McGregor, the head of the school of social sciences and public policy at AUT, didn't mention individual facilities but said Covid-19 had "critically exposed the frailties of our regulatory and oversight systems surrounding aged care".
"DHBs found in Covid-19 that they had limited jurisdiction over privately-owned facilities ... we will continue to fail the vulnerable without adequate oversight."
In 2012, McGregor - who declined to be interviewed - released a landmark report into the aged-care sector, as Equal Employment Opportunities Commissioner and after going undercover as a rest home worker.
Recommendations including making voluntary safe staffing guidelines mandatory and establishing an aged care/older people commissioner haven't been implemented, despite Labour promising a commissioner would be provided for in its first Budget in Government and support from Age Concern, Grey Power and unions.
After a Herald investigation found a third of the country's 650-plus aged-care facilities had recent shortcomings related to resident care, Associate Health Minister Jenny Salesa in September 2018 said she'd asked for advice on establishing a commissioner.
There's been no progress, which McGregor noted in her opinion piece: "If polling was undertaken today, I predict there would be support for a commissioner ... the Covid-19 aged-care crisis shows we can't wait."
The Greens previously campaigned on creating such a watchdog, and NZ First policy is to set-up a commissioner for seniors, with its own ministry.
"It has to be like the Children's Commissioner, where it actually has a bit of teeth," said NZ First MP Jenny Marcroft, who last year presented a 13,000-strong petition calling for change and following a case where a South Auckland rest home resident had maggots hatch in his open wounds after poor care.
Salesa said creating an aged-care commissioner remained under "active consideration".
"Older New Zealanders should be able to speak up and be heard ... while our aged-care facilities, and health and disability system in general, has responded well to Covid-19, this pandemic has underscored the importance of having quality and consistent aged care across the country as a frontline health defence."
Are audits robust?
Rest homes are regularly audited against standards and criteria, and those only partially attained are graded by potential risk and corrective actions ordered.
One in five aged-care facilities in greater Auckland had shortcomings related to staffing levels, staff training or infection control procedures, a Weekend Herald review of records for all 179 homes found.
Problems included inadequate laundry and handwashing facilities, a lack of PPE, no working sluice area and overflowing bins. Some facilities didn't have enough staffing, with one care assistant in charge of 15 hospital-level residents.
The E tū union believes audits don't provide a true picture of problems, because inspectors don't interview workers in a way that protects them from any employer blowback.
"We think it is a crucial missing link," said director Sam Jones. "Our members tell us that some facilities staff up before an audit - they fill the rosters, the place looks great, the systems look wonderful. And then the audit people leave and they revert back to dangerous staffing - and that has a direct impact on resident care and shortfalls.
"I've even heard stories about people being put on rosters who aren't working, in the worst cases."
Jones said the union was worried the current review of Covid-19 and aged care would be similarly compromised because of a lack of worker involvement.
Longer term, E tū, the nurses organisation and others want action over staff-to-resident ratios - saying Ministry guidelines should be updated to reflect the fact residents need more care because the average age and need has increased, and made mandatory.
Having strong infection control measures and enough time to follow them is crucial, even in non-Covid times; the latest available figures show there were 86 norovirus outbreaks in aged care facilities in 2018, causing 2365 cases and four deaths. That compares to 24 outbreaks, 272 cases and no deaths in hospitals.
Long road ahead for rest homes
Simon Wallace, chief executive of the NZ Aged Care Association, said the sector's Covid-19 response was a success story - taking action before officials in areas including PPE guidelines, closing facilities to visitors, testing and isolating admissions and readmissions.
"We have got 665 rest homes in New Zealand, we have sadly had deaths at two rest homes and we have had outbreaks at five in total, which is a very, very small number compared to what's happened overseas.
"The Government is to be commended for going early, but we went early in terms of our preparation also. You can't gloss over that."
The major hiccup of the government's Covid-19 response had been PPE, Wallace said, particularly distribution to aged-care facilities.
"The distribution chain just was not working. We had numerous members having to purchase their own PPE before anything came from the government's stocks, at considerable cost."
Judy McGregor's opinion piece "really does make a giant leap in terms of her call for a commissioner", Wallace said, and there was adequate and strong oversight of the sector.
The debate about staffing numbers was like that about school class sizes, he said - "it is not about the numbers; it is about having experienced, trained staff". To that end, an emergency step to extend visas by a year for temporary migrants was a "huge relief", given half of the 5000 nurses in aged-care are from overseas.
The association has released level 2 guidelines recommending rest homes put restrictions around visitors, including agreed-upon visiting times, with physical distancing and contact allowed only on compassionate grounds. Similar measures could remain until any rollout of a vaccine - something that could be years away.
"Operationally, I think we will be the last sector to come out of it ... this is a very aggressive and tricky virus, and the average age of our people is 85. We have to be doing this, and this is not necessarily going to be popular with families."
Some St Margaret's residents with Covid-19 remain in hospital, but other residents who were moved out of the facility have returned, as have nearly all staff.
The wider "cluster" of connected cases that some St Margaret's residents were part of now numbers 50 (confirmed and probable), with 27 recovered.
It peaked in mid-April with the onset of six cases in one day. Ages of those affected range from 7 to 99, with the median age 35.5. Seven people infected were older than 65. Three DHBs are involved.
Wallace said he couldn't comment on St Margaret's, as he didn't know any details about what happened. The association would watch with interest an ongoing review of the ministry's management of PPE (findings pushed out to June), and the review of aged-care clusters announced by Bloomfield.
"He talked about deficiencies in rest homes. The review will ascertain whether that was the case or not. We need to wait for that process to run. But the review will also be looking at the role of the DHBs, and their support and engagement with rest homes."
Kerri Nuku, of the nurses organisation, said urgency remained along with the threat of the virus, despite new cases falling away for now.
"As we go down [levels] there is always going to be that increased risk - we have got to get on top of the things that we should have been on top of five weeks ago."