The inquiry into how seven nurses were infected with Covid-19 in a hospital blames use and types of personal protective gear but makes no recommendation on moving staff between Covid and non-Covid wards.
A Waitakere Hospital incident report into an outbreak of Covid-19 among nurses shows the hospital was underprepared for an influx of Covid-positive patients.
The report has implications for all DHBs and the potential level of exposure to the virus faced by in-patients and medical staff as the country moves into winter and Level 2 begins.
Since April 27, seven nurses and four of their household contacts have tested positive or are probable.
The hospital had been preparing for a wave of Covid patients with specially prepared areas, yet the report makes it clear it was quickly overwhelmed when six CHT St Margaret’s Hospital and Rest Home residents were transferred in mid-April.
Stretched staffing resources and problems with the types of PPE available and their usability are thought to be contributing factors in the outbreak.
One of the report’s five key findings was also the lack of time between the decision to transfer the St Margaret’s residents and their arrival at the hospital, with staff given “a short time to plan and respond putting together a Covid-ready ward.”
This is despite the fact the ward the patients were sent to being specifically set up for Covid-positive patients. Questions remain about why a ward that was set up specifically for Covid-positive patients did not have ways for staff to communicate with other staff outside patients’ rooms, which “increased the frequency of donning and doffing PPE,” a known factor for increasing risk of infection.
Kate Weston, the acting associate professional services manager of the NZ Nurses Organisation, is pleased with how thorough the report is and how quickly it was carried out, but warns if the lessons aren’t implemented in all DHBs we could see further Covid spikes.
“We’re not out of the woods yet, as we come out of Level 3 into Level 2 and into winter, people are going to be sick with respiratory issues and we won’t know if they’re Covid-positive or not until they’re properly diagnosed, and we need to be able to manage that challenge. There could be more Covid spikes and we have to ensure the lessons we’ve learnt from this get applied.”
Weston also says the report highlights issues within private aged care institutions.
“It’s put the spotlight on issues in aged care around how prepared they were, and it’s actually raised a much deeper conversation around how they’re being funded, how they’re being staffed and how they’re able to be prepared for something as significant as this if they’re already working in a way that they’re already stretched. Certainly the preparedness has been very variable through an aged care facility – they are our most vulnerable population.”
The report noted there “was no back-up plan by St Margaret’s management for how patients should be managed if it became unsafe to manage the patients in the facility.”
As a result, the decision to transfer the residents had to be made quickly on a Friday, with staff given just three hours to prepare for the residents’ arrival in Ward A.
The report goes on to say: “The need to support an aged residential care facility was unexpected, unprecedented, and challenging. It required the DHB to provide a lot of support and resources to the facility over more than two weeks.” This included sending up to 27 health care assistants to help at St Margaret’s on one day alone.
The deputy CEO of Waitemata DHB, Dr Andrew Brant, has apologised to staff for the outbreak saying the DHB was “deeply sorry”.
“We are deeply saddened that these nurses became infected with COVID-19,” he said. “They were being selfless in caring for others in the middle of a difficult, evolving and intense situation at St Margaret’s.”
“We recognise their professionalism in caring for patients from St Margaret’s and we regret that they became ill in the course of their work.”
Despite full PPE being made available at all times for staff treating the Covid-positive patients, problems with the personal protective equipment were apparent from the time the St Margaret’s residents arrived in the ward. These ranged from ill-fitting and malfunctioning items, changes in the supply of PPE and the need for staff members to remove their PPE up to eight times in a single shift, all of which created stress for staff.
“There were problems with the usability of the PPE equipment that was regionally supplied: the gowns’ velcro tabs loosened easily creating gaps at the back. The initial eyewear provided was a frame with removable lens. The lens was a hard plastic that could flick when removed. Initially the eyewear lens needed to be cleaned, with alternate eyewear provided some days later that contained a disposable lens. The eyewear was changed to goggles that didn’t fit some staff with staff using a tie to hold the goggles in place.
“Nursing staff were also concerned about the exposure of their hair and shoes as these areas were not required to be covered.”
The report noted it was only due to the continued advocacy from the charge nurse manager that a consistent supply of high quality PPE was provided. Before that, it was not considered a priority to provide another supply of N95 masks that staff had been fitted for because the ward was “considered to be low risk.”
There was also no way for nursing staff to communicate with staff outside the patients’ rooms which increased the frequency of donning and doffing PPE, which can increase exposure to infection.
“The nursing staff described having to leave patients’ rooms several times per shift in order to telephone and speak to the geriatrician.”
Lack of preparedness
As part of Waitakere Hospital’s preparation for the intake of covid-positive patients under Level 4, two wards were readied, one of which was Ward A, where the St Margaret’s residents were installed.
“The charge nurse manager worked with senior managers to ensure the wards were ready to take Covid-19 patients. Planning was detailed and included renovations, ensuring equipment, including personal protective equipment as per the policy for a Covid responsive ward, was stocked and available, ready to be used.”
The report also says when three other Covid-19 patients were admitted to the hospital in late March and early April, they were “managed, without incident and in accordance with the plans.”
When the residents from St Margaret’s arrived they were not acutely unwell – instead they had been transferred in order to ease a staffing shortage at the rest home.
“However, this rationale was not clear to staff; it was confusing and stressful for staff with rosters having to be made very quickly, pulling staff from different wards to work together for the first time. In fact, the patients deteriorated quickly and required fully nursing care. Earlier back-up planning could have helped manage this situation.”
Despite the preparations the hospital had made for an intake of covid-positive patients, it struggled with the level of planning and care these six patients required.
Crossing wards still fine
Repeated staff concerns and calls from the NZNO were made from the beginning of the St Margaret’s patients’ arrival that staff be kept in ward ‘bubbles’ and not move between Covid and non-Covid wards as an additional protection for staff and patients beyond PPE.
“Some senior medical staff and nursing staff raised concerns about the rostering of nursing staff to work between wards. This was reviewed by incident management team clinical leaders who advised that it was acceptable for staff to work between wards so long as they remained on the ward with the Covid-19 patients for the entire shift, only working on a different ward on another shift; they maintained procedures for ‘dirty’ (PPE) and ‘clean’ (non-PPE) areas; they observed hand hygiene, wore scrubs, showered before leaving work, and left scrubs at work to be laundered.”
The report also says “it was not possible with the available nursing staff to create a ‘nursing bubble’ roster with the staff working only on the Covid-19 cohort ward.”
The day after Newsroom’s revelation that nurses had been working between wards, the hospital instituted ward ‘bubbles’, but only temporarily.
The report does not make any recommendations around changing this practice.
Instead, it points to guidance published by the Northern Region Health Coordination Centre that reinforces advice that it “was acceptable for staff to work between wards so long as they remained on the ward with the Covid-19 patients for the entire shift, only working on a different ward on another shift.”
Weston says it was a huge concern for the NZNO that nurses were still moving between wards when “they didn’t want to be”.
“I think we need to be hot on this – why wouldn’t a bubble be set up in a way that minimises exposure for staff and patients? I recognise there is going to be pressure on staff but there needs to be a way of making it imperative to minimise or eliminating the risk whilst ensuring staffing. Because it comes back to the conversations about PPE – obviously with this report we still have issues and we still haven’t nailed it, so there needs to be other strategies and not just reliance on PPE.”
Key findings of the report
The nursing staff provided exemplary care to the six patients on the ward; they were compassionate, professional and worked to ensure the patients were provided with the best care possible.
The decision to transfer the residents was made quickly on a Friday, and staff had a short time to plan and respond putting together a COVID-ready ward.
The patients required full nursing care and deteriorated relatively quickly. Consequently, nurses needed to spend long periods of time at the patients’ bedsides.
There was no way for nursing staff to communicate with staff outside the patients’ rooms which increased the frequency of donning and doffing PPE.
Full PPE was available to staff at all times. However, there were problems with the usability of the PPE and changes in types of PPE provided, which was stressful for staff.
Ensure a plan is in place to support aged residential care facilities during the Covid-19 pandemic. This is a national and regional issue and will need leadership and support from the Ministry of Health and the Northern Regions’ DHBs.
Develop a plan for managing a cohort(s) of Covid-19 patients transferred from aged residential care facilities to Waitakere Hospital and North Shore Hospital.
Consideration be given to PPE procurement and supply chains to ensure that PPE is available in a variety of sizes and styles to suit individual needs; PPE is prioritised for high risk areas; there is consistency of style of PPE equipment and clinical expert advice is sought about what PPE is used.
Identify and implement ways to minimise donning and doffing PPE and ensure PPE training. Make communication and provision of information to staff that is timely, clear, and consistent, a priority.
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