DURING 2020, the Royal Melbourne Hospital (RMH) diagnosed well over 1000 cases of COVID-19 and treated 480 inpatients, the majority during Victoria’s large second wave in July and August 2020. In parallel with these admissions, 271 health care worker infections were detected, a number of which were hospital-acquired. As described in the MJA, the local outbreak was controlled through a multimodal response, and no single solution was responsible for containment.
There are ongoing challenges for Australian hospitals in 2021 with further hospital outbreaks being seen, including at RMH.
RMH has experienced a further COVID-19 outbreak on a specialist surgical ward. At the time of writing, this had affected a visitor, five patients and eight staff members. It occurred after a person who attended the hospital was found to have COVID-19 in spite of detailed admission screening attesting they had no symptoms and no identifiable risk factors (eg, the patient was not a close contact nor had they been at an exposure site) for having acquired COVID-19.
We monitored local, state and national information and trends regarding COVID-19 closely and implemented changes and relevant learnings as they were identified. As we were conscious of increased prevalence at the time, staff were already wearing surgical masks and face shields across all clinical and public facing areas. Local changes, such as staggered breaks to minimise the number of staff in a tea room and bedside handover with a smaller number of staff, were also already in place in the affected ward.
We learned many things from the 2020 outbreak at RMH, which have helped us to initiate key adaptations made when the 2021 outbreak was first identified.
There was a rapid shift of the affected ward to “hot” status. It was closed to new admissions, there was a transition of all staff in the ward to “respiratory precautions plus” personal protective equipment (PPE), and there was a further limitation of attendees to the ward.
We implemented N95 masks and face shields across all clinical and public facing areas. Previously, shields were in use but with surgical masks unless the staff member was treating COVID-19 or suspected COVID-19 patients.
All potentially affected staff were identified using risk stratification. Those identified as primary close contacts were required to do 14 days’ quarantine, and those assessed as low risk were able to attend work while being enrolled in our staff surveillance program.
Staff and patients in affected areas are tested daily. There is also routine testing of all patients requiring admission or invasive procedures.
As the outbreak unfolded, communication about what was a rapidly evolving situation was ramped up to a large number of staff.
Some of the key areas of continued focus for us, in consultation with our public health and department of health colleagues, are as follows:
- how to rapidly but robustly capture, monitor and disseminate data regarding the large cohort of potentially affected staff and determine the appropriate risk mitigation strategies;
- how to manage the tension between furloughing large groups of specialist staff to minimise transmission risk while not creating downstream clinical risk through substantial limits to delivery of clinical care;
- how to factor vaccination into decisions about furlough and quarantine;
- how to ensure we have sufficient testing capacity to manage a very large surveillance program;
- how to keep staff updated and supported, particularly as internal exposure sites evolve rapidly.
This article summarises our emerging understanding of drivers of in-hospital transmission of COVID-19 and possible risk mitigation strategies. It is based on our experience of caring for large numbers of patients with COVID-19 in a setting with significant nosocomial transmission, as well as the evolution in our understanding of how SARS-CoV-2 is transmitted — thought initially to be predominantly droplet and contact spread, to the realisation that airborne spread plays a significant role.
A summary of our learnings about ventilation and mitigation strategies has been published elsewhere.
In the tables below, we consider the following to be key considerations for determining strategies to mitigate against in-hospital transmission risk for COVID-19.
Table 1. Optimising clinical spaces to minimise transmission risk
|· Manage COVID-19 patients in a negative pressure room with an anteroom where available, otherwise where possible, a single room with a door. Use pandemic mode wards (situations where wards are negatively pressured relate to other spaces) if available.|
|· Prioritise access to negative pressure rooms for the “most infectious” patients and those having aerosol-generating procedures or exhibiting aerosol-generating behaviour.|
|· Keep doors to rooms of infected patients closed where possible to minimise airflow to corridors, noting that in some circumstances (eg, frail, confused or distressed patients) this may not be safe to do.|
|· Limit the number of COVID-19-infected patients in a ward with only one patient per room if possible (aiming to have fewer sources of infected aerosols in a given space).|
|· Select wards with larger rooms (higher ceilings, greater volume) to dilute infected aerosols where possible.|
|· Select rooms with high air exchanges per hour and using outside air.|
|· Work with hospital engineers to understand airflow patterns – where air enters, travels and exits a room and the ward. Position patients in rooms with return air vents in them, or shorter distance to return air vents if these are in corridors. Select rooms that are not positively pressured.|
|· Consider use of portable air cleaners: these portable devices with high efficiency particulate air (HEPA) filters can reduce aerosolised particle density and, it is presumed, the potential risk of infection from aerosolised virus, although clinical outcome data are lacking.|
|· Consider use of a personal ventilation hood – these hoods may help protect against droplets and aerosol exposure as air within the hood is rapidly evacuated through a HEPA filter (exchanged 100 times/hour). While not suitable for all patients, they may be useful for some, but more data are needed.|
Table 2: Optimising clinical workflows to mitigate transmission risk
|· Set up specific geographical areas to manage known COVID-19 and suspected COVID-19-infected patients in the emergency department, intensive care unit and wards.|
|· Consider movement of these patients through the hospital (corridors and lifts) and access to areas such as radiology and theatre.|
|· Create models of care using COVID-19 and non-COVID-19 medical and nursing teams.|
|· Ensure every ward has a plan to adapt workflow in the event of an outbreak when the ward may need to “turn hot”.|
|· Ensure the ward layout supports safe donning and doffing processes in dedicated areas with clear signage and PPE spotters, including one-way flow through the ward.|
|· Ensure known risk areas such as break and handover rooms have agreed arrangements to limit staff contact (physical distancing, staggering of breaks, additional break spaces).|
|· Minimise the number of staff and the amount of time staff spend in the room with patients known to have COVID-19 without compromising patient care if possible (eg, smaller medical rounds, use of intercoms, iPads).|
|· Minimise unnecessary physical contact (eg, use a Bluetooth stethoscope, wireless monitoring devices).|
|· Consider physical distancing where possible (eg, avoid standing directly in front of a coughing patient and stand 1.5 m back when conversing with patients).|
|· Consider and define the optimal model of care for caring for patients with COVID-19 patients with other diagnoses (eg, dialysis, stroke, coronary care, trauma, neurosurgery, mental health):|
|o ensure staff in these specialist areas are available and familiar with workflows on COVID-19 wards; and|
|o manage competing risks relating to ensuring patients have optimal access to specialist care and minimising traffic through these wards to reduce transmission.|
|· Develop plans to manage Code Grey and Code Blue interventions requiring intermittent attendance of specialist teams.|
|· Develop models to support aged care homes using residential in-reach where possible.|
|· Develop a model to identify and monitor all staff who care for patients with COVID-19 who must thereafter participate in the asymptomatic staff surveillance program where available.|
|· Make testing readily available to staff with rapid turnaround time so that anyone with symptoms can be tested and rapidly return to work where appropriate after results are available.|
|· Ensure sufficient, appropriate PPE is available.|
|· Implement a respiratory protection program, including fit testing of N95 masks.|
|· Ensure that all staff are trained in safe donning and especially doffing of PPE including just-in-time training and refreshers.|
|· Ensure that clear guidelines are available on PPE use and that timely changes are made when necessary.|
|· Using our Safety Code to encourage staff to speak up if PPE use is incorrect.|
|· Implement a program to support staff who have issues with PPE, such as allergy, dermatitis and pressure areas.|
Table 3: Optimally managing the workforce
|· Maximise vaccination uptake: currently in Victoria, it is not mandatory for health care workers to be vaccinated unless working with known COVID-19 patients. Notwithstanding, our approach locally has been to support and encourage vaccination to the fullest extent possible. This is an evolving situation and may change rapidly over coming weeks.|
|· Consider ways to implement, recruit, onboard and govern new roles (eg, PPE spotters and marshals, staff to test and vaccinate, front entry concierge, wellbeing counsellors):|
|o consider alternative workforces to minimise impact on the nursing workforce;|
|o consider ways to deliver orientation of staff new to COVID-19 areas and upskilling in relevant COVID-19-specific procedures.|
|§ Consider alternative roster models that reduce overlapping break times.|
|§ Consider splitting teams to ensure that if there is an exposure, the whole team is not furloughed.|
|§ Embed use of remote communication techniques for meetings and work from home where possible.|
|§ Develop a business continuity plan for managing staff shortages through furlough or redeployment to other roles.|
|§ Review infection prevention capability to ensure surge capacity and expertise available (including for staff contact tracing).|
|§ Develop plans to redeploy staff who decline vaccination and/or fit testing where appropriate.|
|§ Develop strategies to manage staff with high risk medical conditions (eg, immunosuppression) who may require redeployment to lower risk duties.|
|§ Resource laboratories adequately to manage the very large volumes of tests required with asymptomatic screening.|
Table 4: Management of workforce mobility and job insecurity
|· The issue of casualised, mobile workforces has been felt widely throughout this pandemic and may have been a contributor to the aged care outbreaks. These staff may have several places of work.|
|· Many staff not only work together but they also socialise and live together as well as living with staff from other health care institutions, potentially putting multiple parties at risk of acquiring COVID-19 and spreading to other institutions.|
|· More specifically, related to COVID-19, during the Victorian outbreak in 2020, a large number of staff required furlough. This resulted in staff being redeployed from other areas which likely resulted in transmission across campuses.|
|· At a sectoral level, there is ongoing discussion about the best interventions to manage workforce mobility. Some suggested options include:|
|o reducing the number of staff who work across multiple sites;|
|o temporarily furloughing staff who move between sites where one site has an outbreak;|
|o providing payments to casual staff to stop them from moving between institutions.|
Table 5: Management of staff wellbeing
|· During the pandemic, we developed an integrated model to ensure infection prevention and wellbeing staff regularly liaised with and supported furloughed and COVID-19-positive staff.|
|· Access to “COVID-19-special leave” was provided at a sectoral level and this was communicated widely.|
|· Provide access to hotel accommodation to furloughed staff and maintain communication with these groups.|
|· A post-COVID-19 clinic has been established to support those in the community, including our staff, who are experiencing post-COVID-19 symptoms.|
|· COVID-19 ward rosters were designed based on staff preferences.|
|· There remains further work to be done at a sectoral level regarding burnout and fatigue in the health workforce as this is an emerging issue across Victoria.|
|· Managing and supporting staff experiencing emotional distress after seeing patients die without family support, or hearing about colleagues infected and become unwell.|
|· Provide rapid access to vaccination for staff on site and where possible to their families (for workers in COVID-19 wards).|
Table 6: Communication and clinical information provision
|Data and information:|
|§ We found that we needed to rapidly develop a range of real-time reports to support our decision making.|
|§ We required specialised additional software to support staff contact tracing and follow-up and continue to require improved strategies to manage large volumes of information.|
|§ Ensure a model for frequent, rapid communication to all staff and targeted groups as required. We found that regular (daily) updates by trusted senior staff about case numbers, staff infections, and staff furlough numbers were valued.|
|§ Where possible, have updates able to be viewed on demand by busy staff.|
|§ Ensure opportunities for staff to provide feedback and suggestions as well as opportunities to debrief formally and informally.|
|§ Multiple video conferencing forums with real time questions and answers and follow-up with written answers have been important.|
|§ Using managers to communicate with smaller groups of staff to ensure that local issues are understood|
|Guideline development, review implementation, and dissemination:|
|• Consider and develop a rapid decision making model for development and implementation of clinical guidance involving senior multidisciplinary stakeholders.|
|• Develop a central repository for guidelines:|
|o identify resource and governance for maintenance of updates;|
|o agree and implement a model for dissemination of updates.|
Leadership and governance
All of these adaptations require a rapid, streamlined but effective governance approach and consideration should be given by leaders as to the most effective local model to oversee changes and respond rapidly, cohesively and effectively in a rapidly changing environment.
In our circumstance, an emergency operation command structure was created with identified roles for key hospital leaders involving most departments. They met daily (via video link) to identify issues, potential solutions and address problems in real time with appropriate stakeholder engagement.
Reflection and learning
After the surge in cases in 2020, the organisation took time to speak to staff in small groups and as individuals to seek feedback on concerns, challenges and areas for improvement. We administered anonymous surveys and provided forums for discussion, and questions and answers sessions to consider what worked and what needed improvement for the future. This process continues as new data emerge and new challenges are faced.
We recognise that there is still much to learn and ideas may evolve further over time, but these represent some of our challenges and suggestions.
Dr Cate Kelly is Chief Medical Officer of Royal Melbourne Hospital.
Associate Professor Caroline Marshall is Head of the Infection Prevention and Surveillance Service at Royal Melbourne Hospital.
Professor Kirsty Buising is Deputy Director of the National Centre for Antimicrobial Stewardship.
Associate Professor is Director of the Intensive Care Unit at Royal Melbourne Hospital.
Elizabeth Orr is the Manager of Infection Prevention at Royal Melbourne Hospital and Northwestern Mental Health.
Nicholas Keogh is the Building and Operations Manager for Melbourne Health.
Ashley Stevens is the Manager of Preventative Maintenance at Royal Melbourne Hospital.
The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.