The Royal Melbourne Hospital (RMH) is now coming into its third week without any healthcare worker infections. While we are very pleased with this, we know it is important to continue to understand why they occurred and what we can do to minimise the likelihood of future infections. Some of our staff have come together to reflect on what we have learnt so far in a new pre-print journal article.
Chief Medical Officer Cate Kelly, Head of the Infection Prevention and Surveillance Service (IPPS) Associate Professor Caroline Marshall and Infectious Diseases Specialist Professor Kirsty Buising are just some of the RMH staff who have joined forces to talk about the unique challenges faced by our hospital, in a paper entitled A hospital-wide response to multiple outbreaks of COVID-19 in Health Care Workers Lessons learned from the field.
The RMH was at the epi-centre of COVID cases in North-West Melbourne in this ‘second wave’ surge. The RMH along with Western and Northern health saw the highest numbers of patient cases and experienced the highest numbers of staff infections in Victoria. At the height of the hospital’s response to the pandemic, on the 5th August 2020, The RMH’s City and Royal Park campuses cared for 99 COVID-19 inpatients.
In the early days of COVID-19, particularly from March to July, considerable planning was undertaken in preparation for possible outbreaks. However, the reality proved that navigating through a novel, highly infectious coronavirus, required quick thinking and constantly adapting processes.
Professor Kirsty Buising said it was quickly identified how ‘real-world’ challenges played a part.
“What we’re all learning is that COVID-19 can transmit quickly in a healthcare setting, and you need to move quickly and implement a number of different strategies to bring it under control,” Prof Buising said.
From the 1st July to 31st August, 262 cases of COVID-19 were identified among staff. The RMH responded rapidly to the rise in cases. A number of strategies were implemented to address the rise in healthcare worker infection rates.
These strategies heavily focused on space, ensuring there was adequate space for staff to safely “don” and “doff” PPE, space for staff to distance on breaks and changing the bed allocation strategy.
During this nine week period, RMH staff were working in an incredibly challenging environment. Many staff went above and beyond, putting in additional hours, while navigating through changes to the way they worked and delivered care on a daily basis. One part of our response was to move patients to two wards at the Royal Park Campus. This saw a reduction in staff infection rates, which was also at a time when patient numbers were decreasing at the campus.
“We were able to clear a number of patients and discharge them back to their normal place of residence, and consolidate patients into the newer wards on the campus,” Cate Kelly said.
The paper recognises that there are no simple answers when it comes to healthcare worker infection rates during COVID-19, and Professor Kirsty Buising reiterates that staff safety was always the number one priority.
“This issue is not simply about types of masks or the fit of masks. Infection prevention needs to be much more comprehensive than that” Prof Buising said.
“When it was in the best interest of the hospital, we moved ahead of the state and Commonwealth guidelines at the time. The RMH introduced the use of N95 masks earlier to staff working in clinical areas.”
Associate Professor Caroline Marshall said the additional contribution of N95 masks over surgical masks is hard to quantify; however, they realised it may have been one of the strategies that helped reduce infections. There have been cases at other health services where there have been increased infections despite the use of N95 masks.
“I know there are very strong opinions around N95 masks and aerosol transmission and I believe there is aerosol transmission of COVID but this doesn’t necessarily mean all healthcare workers should be wearing N95 masks at all times,” A/Prof Marshall said.
RMH staff hope this paper will allow other health services to benefit from our learnings.
“Our response required a series of interventions, there wasn’t a single intervention that we think was responsible for limiting further transmission, it was a series of things that were put in place and refined over time.
We haven’t had a healthcare worker infection in our service in since 25 August, which shows this has been a sustained improvement.” Prof Buising said.
These are some of the things the RMH implemented in its COVID-19 response:
- Regular communications to staff via email, social media, remote meetings by hospital executive and managers to keep them informed
- A wellbeing team to actively support staff who were infected or furloughed
- Ensuring testing was always available for symptomatic staff to identify and isolate cases early
- Rapid turnaround-time for test results for staff and patients
- Frequent testing of staff and patients in wards with outbreaks
- Whole new workflows to separate patients with suspected infection, test and isolate them
- Availability of appropriate dedicated wards for suspected and conformed cases with dedicated medical and nursing teams
- Use of single rooms and negative pressured rooms where needed
- Bed allocation strategies to avoid high density of COVID-19 positive patients (minimize shared rooms)
- Universal mask and face shield use for all staff
- Training (baseline and refreshers) and monitoring of PPE use (spotters on the wards)
- Adequate space for staff to safely don and doff PPE
- Adequate space for staff to distance in breaks
- Improved cleaning and active monitoring of cleaning
- Adopting new ways to care for patients safely eg telehealth