On 21 December 2020, the Commonwealth Department of Health (DoH) released an independent report commissioned by the DoH conducted by Professor Lyn Gilbert AO and Adjunct Professor Alan Lilly. It inquired into the COVID-19 outbreaks at St Basil's Home for the Aged (St Basils) and Heritage Care Epping Gardens (Epping Gardens) in Victoria (together, the Facilities) (Report).

At a high level, the Report found that managing COVID-19 outbreaks in the early stages of Victoria's second wave of COVID-19 infections was complicated by a range of factors including difficulties in emergency planning and preparedness. DoH and interagency support and communications were also lacking, as was communication with families and residents. Proactive planning in relation to infection prevention and control (IPC) and surge workforce also contributed to the severity of the outbreak given the Facilities were ill prepared for such a severe outbreak of COVID-19.

Although the Report notes that over the last quarter of 2020, 'systemic improvements have been implemented' in the Victorian aged care sector, the Report details the lessons learned and impediments in managing this COVID-19 outbreak. While not making any explicit recommendations, the Report details several findings, learnings and considerations to understand the elements that led to the outbreak of COVID-19 at the Facilities. As a coronial inquest is currently examining the deaths at St Basils, and legal proceedings are currently underway at both Facilities, the Review did not have the benefit of engaging with some officials, staff and families.

The Report catalogues the events at Epping Gardens and St Basils and, although there are some distinctions between the events and circumstances of the two Facilities, the themes from the learning and considerations are shared.

Leadership and management

A key concern highlighted by the Report is that management at the Facilities was often lacking a 'command and control structure'. The Report notes that the St Basils and Epping Gardens were issued with a Notice to Agree (NTA) on 26 July and 28 July respectively, with the condition that an independent advisor be appointed and a requirement to comply with advice provided by the advisor. Although the Report comments that an NTA 'seems an unlikely tool with which to fix an escalating crisis', it nevertheless 'functions as a circuit breaker'. Whilst not explicitly classing it as a recommendation for Government to adopt in the future, the Report does note that the roles and responsibilities of Approved Providers in leading the response to a COVID-19 outbreaks should be 'clearly defined'. Further, open dialogue between the Approved Provider and regulators may limit the need for NTAs.

Effective communication

The Report finds that communication with consumers was often lacking and inadequate. It was found that residents and their families were often inadequately informed as to the implications of outbreaks in the Facilities, with the communications often being disjointed and confusing. From an interagency perspective, although the role of Victorian Aged Care Response Centre (VACRC) assisted in driving effective interagency communication, in the early stages of the outbreak, the quality of interagency communication was poor. Accordingly, the Report notes that the VACRC (and equivalent agencies in other jurisdictions) should continue and advice to Approved Providers should also be streamlined.

Planning and preparation

The Report also found that poor planning and preparations, including outbreak management plans at the Facilities contributed to the severity of the outbreak. Site-specific outbreak management plans should be developed, updated and tested regularly by Approved Providers. The Report also considered the issue of transfer of residents to hospital – concluding there should be no restriction on such transfers on the basis of clinical need, while transfers in other circumstances should take place on an as required basis, depending on local circumstances.

Infection prevention and control

Pre-COVID-19 IPC administrative and environmental arrangements were examined by the Report. The importance of routine IPC education, training and practice in aged care facilities was stressed by the Report – noting that IPC training and resourcing requirements should also be incorporated into an outbreak preparedness plan. While aged care facilities are now required to employ an 'IPC clinical lead', who has completed a recommended IPC course, the Report notes that roles and responsibilities of the IPC lead need to be fully defined and IPC guidelines, standards and assessment criteria need to be developed.

Emergency management

The Review determined that the preparedness, resilience and self-sufficiency of the Facilities was low before and during the outbreak of COVID-19. For example, the lack of business continuity plans and handover once the entire St Basil's workforce was furloughed, significantly affected outbreak management. The Report recommended the development of handover and business continuity plans to ensure the Approved Provider maintains operational control and supports replacement staff. This must extend to providing assistance in orientating replacement staff, including making available resident care and clinical records to ensure the safety of residents.

Pathology testing

Delayed pathology testing, contact tracing and cohorting of residents and staff had an adverse impact upon the workforce and outbreak control. The Report notes that aged care facilities should be aware of notification requirements for an index case and should maintain resident information in a format that is compatible with laboratory requirements. Medical practitioners ordering pathology tests should also ensure results are passed to facility managers and individual members of staff for prompt distribution to residents or their nominated representatives.

Workforce

Noting that there was a 'lack of surge workforce planning', the Report concludes that this factor limited the Facilities' capacity to manage and contain the outbreak without external assistance. The Report advocates for the introduction and use of innovative roles that may include 'Residential Aged Care Nutrition Assistant' or other roles focusing on resident safety and wellbeing. These roles would be resourced by people who are unable to undertake their substantive roles in other industries during an outbreak, and may include resident family members, or students to participate in the workforce of a facility during an outbreak. Further, the Report encourages further consideration of alternative models of aged care surge workforce support, such as an 'aged care reserve' - a volunteer or standby workforce trained in aged care to provide surge capacity.

Key takeaways

The Report provides some key takeaways for Approved Providers for managing and containing a significant outbreak. The Report uses the metaphor of several slices of 'Swiss Cheese' vertically and parallel placed with each slice containing randomly placed holes to illustrate that the alignment of 'imperfections in multiple slices' created the circumstances for the outbreak at the Facilities. Put another way, it was the cumulative impact of the factors identified above that contributed to the severity of the outbreak at the Facilities. The Review concludes by noting that the observations and learnings contained in the Review should be a catalyst for further review and improvement of aged care providers and the aged care system as a whole in Australia.