Covid 19 coronavirus: Rest home review finds confusion and lack of PPE as virus struck

Three ambulances leave CHT St Margaret's rest home in Te Atatu. Photo / Sylvie Whinray

A review into how rest homes hit by Covid-19 outbreaks responded has found personal protective equipment (PPE) wasn't available in some facilities and communications and support by health authorities was at times "confusing and not always clear or consistent".

The panel report also confirmed that infections were introduced to the facilities by staff or visitors, and "in some cases, recognition of an outbreak was relatively delayed which accelerated internal facility transmission".

For three of the outbreaks, "it appears that more than half of the people had developed symptoms of illness before the outbreak was notified" and "this delay makes contact tracing very difficult due to people being unable to remember details and contacts many days earlier".

Reviewers noted feedback from family of residents, including whanau of a resident who died during lockdown. "Our loved one died of loneliness," the family concluded.

Rest home staff described an atmosphere of fear, with some being threatened with eviction by landlords or housemates if they kept working for a facility.

"Some staff reported they were "treated like lepers in our society" and the facilities were also the subject of online attacks," the report noted.

Most facilities lockdown and kept visitors away before this was officially required. One that waited until the official lockdown later had an outbreak, and told reviewers they were hesitant to "jump the gun" and go against advice given by their local DHB. "This was something that they regretted later."

Communications and resources provided to aged residential care (ARC) facilities "were at times confusing and not always clear or consistent," the review found.

"Some noted a lack of available PPE leading into the pandemic contributed to an inability to practice wearing PPE in some facilities. Relationships with the local DHB infection prevention and control staff were variable."

Six rest homes have had Covid-19 cases, and some successfully ended transmission quickly. Two others - Rosewood and CHT St Margaret's residential aged-care home in Auckland's Te Atatu - account for 16 of New Zealand's 22 Covid-linked deaths.

Director general of health Dr Ashley Bloomfield noted the differing results when announcing the review today, saying it was meant to find out "what has worked well, and what could be improved".

An unprecedented crisis

The review found all facilities had compliant infection control policies, but none were prepared for the impact of a positive case "let alone an outbreak/cluster".

"Few ARC facilities or DHBs had ever coped with a large scale stand down of staff, as was the case for ARC facilities with clusters. Clear continuity planning for staff backfilling was limited to reduction in 20 per cent, 40 per cent or 50 per cent of staff, but did not require continuity planning for up to 100 per cent staff reduction of staff and was not stress tested.

"The extent of the impact COVID-19 had on ARC facilities far exceeded the expectation of all ARC providers, even with plans in place."

Staff describe 'atmosphere of fear', confusion about testing

Staff working in aged care and their managers described an "atmosphere of fear", and an initial perception that the Ministry, DHBs and public health units were unsure of what to do, and made decisions without talking to the sector.

"All interviewed felt ARC staff should have been provided prioritised access to COVID-19 testing at a much earlier stage."

Some rest home staff worked in other facilities, in some cases without an employer's knowledge and against their guidance. That complicated contact tracing.

There was confusion around testing, with "lag times and provision of results variable and not well communicated through to the ARC facility", which made rostering difficult.

"In some instances, ARC staff members were refused a test by their GP if they were asymptomatic. They were not aware that testing of asymptomatic people was discouraged in protocols from the Ministry. This was not helped by the changing advice as more information known about the virus and testing capacity increased."

Covid-hit facilities unhappy with support from DHBs, one reports 'complete chaos'

Facilities with Covid-19 cases were "broadly critical" of their interactions with services such as public health units (PHUs) and DHB incident management teams, with many saying they weren't involved enough with the latter.

"Providers' concerns were exacerbated by ineffective and/or inconsistent communication from the PHU, which they perceived had poor links with their local DHBs."

PHUs sometimes told rest home staff they were suspected or close contacts and not to return to work when they were in the middle of a shift, and without telling the facility.

"The sudden loss of staff caused the ARC provider to turn to casual and agency staff, which also resulted in increasing the risk of infection. This period was described as 'complete chaos' and was highly stressful for all concerned."

DHB staff who volunteered to help at Covid-hit homes weren't properly supported or briefed. One told reviewers of arriving to chaos: "Everyone was new. We had no idea of the work routine, nothing got documented, we couldn't work the hoist, and all we could do was feed, keep people clean, toilet, and ready at bedtime."

Media reports were a distraction and source of anxiety for staff and residents' families. One facility was given 10 minutes warning that they were about to be named on television as a cluster.

Recommendations and sector response

The review's recommendations include developing a national infection prevention and control (IPC) strategy for the aged care sector.

Another is to clarify "case recognition to identify infections early", and how surveillance testing might be used. The Herald has previously reported on how residents at St Margaret's rest home in West Auckland were only swabbed 11 days after a staffer tested positive - turning up undetected cases, two of whom later died.

The Aged Care Association has said those dangerous testing gaps were despite the efforts of rest homes and his association to have more residents swabbed. The Ministry of Health had "held on to their case definition and would not test".

Chief executive Simon Wallace welcomed today's report, saying many recommendations picked up on what the association had called for, including better access to PPE and testing.

"As the review points out, the MOH's initial focus with the pandemic was on hospitals rather than aged residential care. In the absence of that early support we had to take a strong leadership role and believe it is important that the MOH continues to work closely with us.

"A source of stress for staff was uncertainty around knowing who had the virus, and we repeatedly called for testing of all staff and residents to address this, which was denied by the Ministry."

Problems revealed at both homes where residents died

The review's release came after documents obtained by the Herald revealed Canterbury DHB took over Rosewood Rest Home after concerns about its response to what became NZ's deadliest cluster, with 12 lives lost.

A lack of available staff meant the facility breached its contract obligations in multiple areas including cleaning, food and laundry services and emergency provision of supplies.

An apparent lack of contact from Rosewood's owner also exasperated health authorities, and the DHB wasn't able to confirm if there was an emergency health plan in place as required.

Documents obtained by the Herald have also revealed concerns about PPE use at St Margaret's rest home, including a lack of bins for safe disposal.

Today's review did not name specific facilities.