NSW Health notes the work undertaken by the independent review into the Newmarch House COVID-19 Outbreak and the publication of its final report.
NSW Health sincerely acknowledges the significant impact of the outbreak in Newmarch House on residents and their families; not only in terms of the 19 resident lives sadly lost, but also for other residents and the staff involved in delivering care. NSW Health accepts there are learnings from the experience which can assist in the prevention of future events.
NSW Health is concerned its feedback on the draft report was not incorporated into the final version and significant aspects of the management of the outbreak, from the perspective of NSW Health, were not covered by the reviewers; in particular, some positive outcomes achieved.
There are several key issues concerning the review that warrant specific mention:
As covered in the report, the responsibility for managing an outbreak of COVID-19 or other viral and bacterial infections in an aged care facility such as Newmarch lies principally with the residential care facility’s operators, as per the National Guidelines.
The National Guidelines state ‘the primary responsibility of managing COVID-19 outbreaks lies with the Residential Care Facility (RCF), within their responsibilities for resident care and infection control. All RCF should have in-house (or access to) infection control expertise, and outbreak management plans in place’.
Operators of facilities have been required by the Commonwealth Government to prepare their staff and facilities to meet the risks of COVID-19 in line with specific Commonwealth Government guidelines entitled National Guidelines for the Prevention, Control and Public Health Management of COVID-19 Outbreaks in Residential Care Facilities in Australia. These guidelines were developed in consultation with the aged care sector.
The Commonwealth requires all operators to have robust plans in place to manage the care of residents affected by the virus and to infection control measures to protect staff and other residents from transmission. It is the expectation of the Commonwealth that operators have in-house infection control expertise or access to infection control expertise to guide local outbreak management plans.
Further, the National Guidelines state:
Special considerations in the management of residents with suspected or confirmed COVID-19 in an RCF include:
- immediately isolate ill residents and minimise interaction with other residents
- if COVID-19 is suspected, have a low threshold for requesting medical review and testing
- transfer residents to hospital only if their condition warrants. If transfer is required, advise the transport service provider and hospital, in advance, that the resident is being transferred from a facility where there are potential or confirmed cases of COVID-19.
The NSW Health response was prompt, both in terms of its public health responsibilities and in the provision of clinical staff from Nepean Blue Mountains Local Health District (NBMLHD). The NSW Health response was delivered in the absence of an assertive response from Newmarch House or Anglicare management.
The NSW Health log of events records the following:
On 11 April (Easter Saturday) – Newmarch House was informed of a confirmed case in a staff member by the NBMLHD Public Health Unit (PHU) and the facility was advised to:
- lockdown the facility
- inform staff who have worked with the case to self-isolate
- treat all residents as COVID-19 cases with staff to use personal protective equipment (PPE) when providing care
- arrange COVID-19 testing for any close contacts who are symptomatic
- provide rosters of staff to the PHU
- attend a teleconference with the PHU and NSW Ministry of Health the next morning.
On April 12 (Easter Sunday)
- Teleconference held at 10.30am between Newmarch House, PHU and Public Health Emergency Operations Centre (PHEOC) representatives.
- Infectious diseases expert Dr James Branley (Head of Infectious Diseases, Nepean Hospital, NBMLHD) attended the facility to advise on testing and infection control measures.
- Contact numbers for Anglicare’s senior staff were not available. There was no response to a message left on Anglicare’s contact number.
On April 13 (Easter Monday)
- On-site support was provided by an NBMLHD infection control Clinical Nurse Consultant (CNC).
- Feedback was provided by Dr Branley – hopefully the spread should be contained within the facility given three weeks of reduced visiting and compliance with the instructions given. PPE was confirmed to be in place for staff. No requests for further assistance were made.
On April 14
- All 100 residents across the three buildings (Blaxland, Wentworth and Lawson) were swabbed for COVID-19 by Dr Branley.
- The facility was visited by Dr Bradley Forssman, Director Public Health NBMLHD.
- Unsuccessful attempts to contact Anglicare’s chief executive continued to be made.
- Still no requests were made by Newmarch House for further assistance.
The challenges faced in the staffing of Newmarch by Anglicare were well documented in the review with a 25% reduction in rostered shifts worked in the first five days and increased acuity of residents and workload. The reluctance of General Practitioners to continue supporting the clinical care of residents further exacerbated the situation. This was despite the Commonwealth expanding Medicare-subsidised telehealth services for General Practitioners and other health practitioners from 30 March.
With the failure of Anglicare Executive to ensure adequate General Practitioners and adequate registered nurses and care staff to support medical and clinical care of residents, NSW Health
put in a team of highly-skilled specialists in infectious diseases, geriatrics, palliative care and intensive care from NBMLHD. This team provided round-the-clock care on-site and also through a dedicated 24-hour advice line for Newmarch staff. NSW Health believes this clinical team was best positioned to understand the clinical needs of the residents as they were personally assessing patients. They assisted in the ongoing management of the outbreak in the absence of a durable response from Anglicare to provide a stable and expert workforce.
This outreach model of Rapid Enhanced Aged Care Hospital in the Home (REACH) is consistent with the models put in place for many other residential aged care outbreaks. There have now been 17 outbreaks in residential aged care facilities in NSW, including at Dorothy Henderson Lodge. The outreach model is designed to allow the residents to be cared for in the facility, which is their home, supported by carers familiar to them. However, as identified in the report, the capacity of Newmarch House to provide staffing to the facility was problematic.
Hospital care was always available, and is always available, to residents who require more complex clinical support and want to be transferred to an inpatient setting. During the outbreak, seven residents were transferred from Newmarch House to Nepean Hospital for treatment.
NSW Health considers decisions on the best care settings should always be made by the treating clinicians with residents and their families, rather than generic guidelines. NSW Health sees no justification for the recommendation HITH is only suitable in outbreak is limited to a small number of cases and residents and staff. NSW Health considers a scalable response of outreach to aged care facilities is desirable and appropriate and should be assessed on a case by case basis.
NSW Health rejects the comments attributed to Dr James Branley regarding the options put forward by Commission’s medical advisor for the management of the residents in a private hospital or other aged care facility. They reflect opinion rather than fact. The reality was that neither the Commonwealth nor Anglicare Executive had an operational plan for how the residents should be managed.
Personal Protective Equipment
The national guidelines require an RCF to have adequate PPE. Supplies of PPE would normally be obtained by the RCF through its own suppliers, but facilities also have access to the Commonwealth Government’s medical stockpile.
The report identifies Anglicare had difficulty acquiring adequate supplies from the Commonwealth Government medical stockpile.
Although the provision of PPE is the responsibility of the Commonwealth Government, NSW Health stepped in to provide this equipment due to the urgency of the situation and continued to provide PPE throughout the course of the outbreak to ensure the safety of staff and residents.
On the evening of Friday 17 April, when NSW Health was advised of a potential PPE shortage, NSW Health requested the necessary supplies from NBMLHD and HealthShare NSW be sent to Newmarch House.
NSW Health supplied significant quantities of PPE during the Newmarch outbreak, including 90,450 gowns, 125,000 gloves, 17,100 P2 masks, 9,400 aprons and 6,500 surgical masks.
The review also recognises the support of NSW Health in providing infection control expertise to Newmarch House through the Clinical Excellence Commission (CEC).
NSW Health clinical staff were aware of the concerns and frustrations expressed by the residents’ families, carers and support people about the absence of timely communication with them. These concerns were escalated to the most senior levels of government and Anglicare to resolve.
In response to these concerns, NSW Health set up a support van outside the facility, with NSW health staff working to improve communication between residents and their families, and to provide a more appropriate and comfortable place for concerned family members to gather, with tea, coffee and refreshments provided.
After the outbreak
Due to some of the challenges experienced by NBMLHD clinical staff supporting Newmarch House during the outbreak. NSW Health took assertive action to clarify responsibilities.
NSW Health worked with aged care providers, the Commonwealth Department of Health and the Aged Care Quality and Safety Commission to develop the Protocol to support the joint management of a COVID-19 outbreak in a Residential Aged Care Facility in NSW. This protocol can be found at: https://www.health.nsw.gov.au/Infectious/covid-19/Pages/racf-outbreak-management.aspx.
The protocol sets out responsibilities between providers, the Commonwealth Department of Health, NSW Health and local health district clinicians. The protocol also clarifies leadership and management roles.
The apparent lack of preparedness of residential aged care facilities, highlighted by events at Newmarch House and subsequently in Victoria, has prompted NSW Health to step in and ensure that aged care facilities can demonstrate they have progressed comprehensive planning for outbreaks as required by the Commonwealth. NSW has worked with over 880 residential aged care facilities throughout NSW to improve their level of preparedness and prevent another COVID-19 outbreak in this vulnerable setting.
Critical work led by NSW Health to support the preparedness of residential aged care facilities includes:
- the need to ensure aged care staff are well trained in infection control and prevention, and have an infection control lead or champion at each facility
- that individual facilities hold suitable levels of PPE and know how to use it
- that scenario exercises are conducted to test outbreak management plans in the local setting.
NSW Health remains committed to supporting aged care providers in caring for their vulnerable residents during the COVID-19 pandemic.
To ensure the learnings from the report are taken forward, it will be critically important that the accountabilities and responsibilities of aged care providers and Commonwealth agencies continue to be reinforced and enacted accordingly.