Confidential document reveals healthcare outbreaks
As Victoria battles the stubborn tail of its second wave of Covid-19, a confidential government document obtained by The Saturday Paper reveals that outbreaks of the virus have been reported in at least eight hospitals in the past 10 days.
These figures show that hospitals have become a key risk area in this phase of the pandemic. Staff at some of these hospitals have not been told about the transmissions happening in their workplaces and are not being offered extra protection.
Outbreaks were reported at Western Health in Footscray, Eastern Health in Box Hill, Northern Health in Epping, St Vincent’s Private Hospital in East Melbourne, Knox Private Hospital in Wantirna, Royal Children’s Hospital and Melbourne Private Hospital in Parkville, and Dandenong Hospital, as well as in a number of allied health and other primary health services.
A spokesperson for Healthscope confirmed the cases at Knox Private Hospital and Melbourne Private Hospital, adding that there had been no cases reported at either site since September 10.
Doctors and nurses working on the Covid-19 front line have been calling for a full breakdown of cases in healthcare settings to be released by the Department of Health and Human Services, but the data has been released only sporadically. Some of the outbreaks have not been publicly disclosed by DHHS in the past week and are being reported here for the first time.
“There’s a lack of transparency with what’s actually going on in healthcare facilities,” one doctor told The Saturday Paper. “We need more transparency because I think if you knew that your hospital was responsible for 25 per cent of the current infections at the moment, then there’s more pressure on the hospitals to be providing enough PPE, improving social distancing and taking other steps to protect staff.”
It is unclear how many individual cases have occurred at each hospital that has reported an outbreak. Only some hospitals are choosing to share that information with their staff.
“The morale of healthcare workers who work at hospitals where figures are being shared with staff is much better,” says Dr Sarah Whitelaw, who represents emergency physicians to the Australian Medical Association.
The proportion of new Covid-19 cases made up by healthcare workers has been steadily growing for months, even as overall case numbers in Victoria have fallen.
In the week leading up to August 5, healthcare workers were only 11 per cent of new infections. By September 16, they made up 37 per cent of new cases.
In the week to September 16, healthcare workers, aged-care residents and their close contacts made up 69 per cent of all new cases. The numbers highlight that even as stage-four lockdown measures have worked to blunt community transmission, they haven’t been enough to snuff out the virus in essential and high-risk settings.
Victorian Premier Daniel Andrews has accepted the persistence of the virus in healthcare settings is a problem, but some doctors have been frustrated by the state government’s insistence that the high case numbers “speak to how infectious this virus is” rather than the need for better infection control and personal protective equipment, and more transparency about outbreaks in healthcare environments.
“It’s defeatist and basically throwing healthcare workers to the wolves,” says Dr Mukesh Haikerwal, the chair of the Australian Medical Association’s Victorian taskforce on Covid-19.
Doctors who spoke to The Saturday Paper also disputed the premier’s claim that controlling hospital outbreaks earlier wouldn’t have decreased case numbers among healthcare workers.
“If we could have prevented those infections, there’d be overall less cases, less transfer of those workers back into their homes and less spread into the community,” says Dr Alicia Dennis, an associate professor at the University of Melbourne.
According to the latest DHHS figures, 3408 healthcare workers have been diagnosed with Covid-19 in Victoria since the start of the pandemic and 72 per cent acquired the virus in the workplace.
Exactly how Covid-19 was able to spread in Victorian healthcare settings has been documented by infectious disease researchers who studied outbreaks at the Royal Melbourne Hospital in July and August.
In July, geriatric wards at the hospital received an influx of Covid-19 positive patients from aged-care facilities. Despite the availability of PPE, the researchers noted that cases in hospital staff “rapidly escalated” across all six geriatric wards immediately after the aged-care patients arrived.
The size of the wards and the lack of adequate ventilation was identified as a key issue. Many patients were in multi-bed wards where they couldn’t be adequately distanced from one another. Some patients experienced delirium, which led to wandering, shouting and other behaviours that increased the risk of transmission. “Staff noted that particular behaviours in infected patients appeared to be linked to transmission events (distressed patients shouting, vigorous coughing),” the report says.
As case numbers rose among Royal Melbourne Hospital staff, more and more workers were furloughed. The remaining staff became overwhelmed and most wards were closed, with patients moved to other hospitals.
“The infrastructure on most of our wards was never set up to care for Covid-19 positive patients,” the hospital’s divisional director of medicine and community care told staff at the time.
The researchers ultimately found that “many staff reported physical and mental fatigue and stress during these outbreaks” and that “workforce shortages meant that staff were taking on extra shifts at short notice and working in unfamiliar roles”. These factors exacerbated the outbreaks, and the hospital was not equipped to deal with them. After patients were moved and healthcare workers switched from surgical masks to more expensive N95 masks, the spread of virus at Royal Melbourne slowed.
At the time these outbreaks were occurring in hospitals, the Victorian government was downplaying the risk for doctors and nurses at work. On August 11, Victorian Health Minister Jenny Mikakos told a parliamentary committee that only 10 to 15 per cent of healthcare worker Covid-19 cases were being acquired in the workplace.
Healthcare workers were shocked by that analysis. The case numbers showed that the rate of infection among healthcare workers was double that for the rest of the population. If Mikakos’s numbers were right, it meant front-line healthcare workers were socialising and breaking the lockdown rules at a higher rate than the rest of the population. But doctors and nurses were seeing firsthand how the virus was spreading, and it was happening in the workplace. Two weeks later, the Victorian government reversed its position. It released a report showing that 86 per cent of healthcare worker infections in the second wave had occurred in the workplace.
Each day in August, while the government was still claiming the infections were occurring in the community, an average of 34 healthcare workers were being diagnosed with coronavirus. Once the Andrews government accepted that healthcare staff were acquiring Covid-19 at work, it sought the advice of a healthcare infection prevention and wellbeing taskforce to bring together knowledge and experience from those on the front line, and announced a series of measures designed to bring infection numbers under control.
Hospitals and other healthcare settings would be required to develop Covid-safe plans to ensure staff were socially distancing in break rooms. More PPE would be rolled out, along with additional training for hospital staff on infection control. But nearly a month on from that announcement, cases are still emerging in healthcare sites and doctors say the government isn’t acting fast enough.
“The way you mitigate it is not just saying wash your hands,” says Mukesh Haikerwal. “It’s not just saying keep your distance. We’re doing all that. It’s actually making sure that the workplace that you’re working in is as safe as it can be.”
According to Sarah Whitelaw, keeping healthcare workers safe involves “looking at this not just from an infectious disease perspective, but looking at it from an occupational medicine perspective, from an engineering perspective, from a systems flow perspective for patients and for staff”.
“We have guidelines that are being put out that are being misinterpreted as best practice when, in fact, the people deciding them also have in the back of their mind: what resources do we have?” she says.
A key issue is the rollout of N95 masks. Even now there is no mandate to use the masks in all Covid-19 settings.
“If you’re a nurse and you’re in a room looking after a known Covid-19 patient, both the national guidance and state guidelines don’t require you to wear N95,” says Alicia Dennis.
The Victorian government ramped up its rollout of N95 masks at the end of August, but to work effectively they need to fit properly. Different makes have different sizes, and if they’re too big they don’t prevent the spread of particulates.
“These masks weren’t being fit-tested,” says Dennis. “If you don’t have a mask that fits you properly, it’s not going to protect you properly.”
While the Andrews government announced a trial to ensure the masks were “fit-tested”, that has only taken place at Northern Health in Epping. Doctors say they don’t understand why fit-testing isn’t being rolled out everywhere in Victoria, as soon as possible, given it is already mandated in Western Australia and in all public hospitals in New South Wales.
“There is no time line,” says Whitelaw. “And there is a real concern amongst healthcare staff that that will not happen quickly enough.”
“We’re not doing enough to give reassurance that we’re trying to do absolutely everything we can to keep our people safe,” says Haikerwal. “That’s about getting hold of proper PPE, which includes proper gowns, not plastic pinnies that you wouldn’t even bake in.”
Meanwhile, healthcare workers also have been asking for more transparency on where exactly the virus is spreading. In August, the government promised it would release data to show “where and, to the extent possible, how healthcare workers are contracting the virus”.
The government has started to release information about healthcare workers who are Covid-19 positive, showing a breakdown by discipline, but no full list of healthcare environments with outbreaks has been publicly released. This stands in contrast to aged care, with data released every day showing the number of cases and their location.
“There’s individual listing of aged-care settings and the names of all the aged-care facilities that have had outbreaks,” says Dennis. “But what we’re not seeing with any clarity is the hospital outbreaks.”
As Melbourne hit the benchmark on Wednesday for the next easing of restrictions, with a 14-day average of fewer than 50 new cases daily, the question remains whether numbers will continue to drop or plateau as a result of persistent healthcare worker and aged-care infections.
The biggest contribution to that highly watched average number is now healthcare workers, residents in aged care and their close contacts. Remove those cases from the calculations and Wednesday’s figure drops to an average of 20 cases a day.
“If we don’t get the healthcare worker infections under control, we were never going to get the numbers of new cases a day down fast enough,” says Dennis.
A number of doctors involved in testing and contact tracing told The Saturday Paper they were concerned that outbreaks were disproportionately occurring among migrant workers and international students who are working as nurses and cleaners in aged-care facilities. Those employees are unable to access government support measures, leaving them vulnerable and financially desperate. Many live in overcrowded accommodation with shared bathrooms, creating a risk for coronavirus to spread.
The way the infections can continue to bounce between people in high-risk settings was highlighted this week when The New Daily reported that a resident of the Estia Health Keilor aged-care facility had contracted Covid-19 during a hospital stay unrelated to coronavirus. The resident tested positive for the virus after he had returned to the facility, and it was discovered he had shared a hospital room with a patient who has also tested positive. The government did not release information about this outbreak until nine days later.
Following advice from DHHS, Estia Health Keilor had eased its PPE requirements on September 5, so staff were no longer wearing head-to-toe PPE during their shifts. There are now 10 active coronavirus cases at the aged-care facility, including four staff.
A spokesperson for Estia Health told The Saturday Paper: "Where a home has been cleared by DHHS, the department directs that staff are to wear masks and face shields. In addition, Estia Health directs staff to also wear gowns and gloves when coming into close contact with residents."
“There’s this anticipation because we don’t know what’s going to happen next,” says Sarah Whitelaw. “What is going to hold us up [from reopening], apart from contact tracing, once we get our healthcare worker infections and staff furlough numbers down, is the capacity in the health system.
“And that’s something that all of us, particularly in the emergency department, are really worried about, because our capacity on a good day, with no Covid, is very little. We already run pretty much at 100 per cent or over all of the time.”
Clarification: This article has been updated to more accurately reflect, at the time of online publication, the period within which the eight hospitals reported cases to the Victorian government.
This article was first published in the print edition of The Saturday Paper on Sep 19, 2020 as "Confidential document reveals healthcare outbreaks".
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