Calls for wider changes as healthcare worker COVID cases drop

UPDATED 

Doctors and health advocates warn that relief over lower coronavirus case numbers could mean hard-fought concessions – such as the newly announced respiratory protection program and N95 respirator fit-testing, advocacy around the potential risk of higher aerosol spread, and changes to ventilation and infrastructure – could lose momentum or return to the too-hard basket.
 
The concerns come as daily healthcare worker cases continue to decline, down to 12 as of 9 September, after running as high as 130 cases on 4 August.
 
Health authority data shows coronavirus infections among healthcare workers accounted for 65% of Victoria’s new cases at the end of August, rising as a proportion even as community caseload fell. The 3408 overall healthcare worker cases – largely hospital nurses and aged care workers – account for 17% of the state’s total caseload.
 
The downwards trend may put to rest the fears of experts like Melbourne University epidemiologist Professor Tony Blakely, who three weeks ago warned ‘stubbornly high’ healthcare worker infections could see the state’s long lockdown extended.

‘While it’s pleasing to see the rate of healthcare worker infections trending down, we will do everything we can to prevent any healthcare worker from contracting coronavirus at work,’ a Department of Health and Human Services (DHHS) spokesperson told newsGP. 

‘That’s why we have made N95 masks mandatory in high-risk wards and we’re working with hospitals to improve infection control practices.

‘We have also provided hospitals with guidance to reduce staff-to-staff transmission in tea rooms and meeting areas and trained PPE spotters to be a second pair of eyes and make sure their colleagues are putting on their PPE correctly and not rushing when they take it off.

‘All Victorian healthcare workers are receiving the recommended PPE and are trained in the correct donning and doffing to minimise infection.’   
 
But some have warned of the risks of complacency and called for sustained action to prepare for any further outbreaks.
 
Healthcare worker advocate Dr Benjamin Veness told newsGP a connection between declining case numbers in the community and declining infections in healthcare was to be expected, especially when combined with increased availability of N95 respirators.
 
But Dr Veness warns that as the issue loses urgency, harder decisions could be at risk of being put off.
 
These include a push for elastomeric respirators, which are more expensive per unit but can offer better protection, can be reused and tend to pass fit-testing more readily, as well as infrastructure changes to ventilation and common spaces such as break rooms and elevators.
 
‘My hope is that if we have a lull in infections, the opportunity is taken to roll out changes properly so we’re in a much better starting point if we have to face a third wave,’ Dr Veness said.
 
Dr Veness said complacency is common on issues like fit-testing, pointing out only South Australia has a statewide fit-testing program in place, while other states have not yet followed suit.
 
‘The real risk is if we don’t use this as an opportunity to change the culture in health and aged care to properly consider risks to staff as well as patients,’ he said.
 
‘This is a wake-up call for Australia – we need to treat health and aged care as dangerous workplaces and work closely with occupational hygienists and occupational health and safety experts.’
 
Echoing Dr Veness’ concerns is Victorian Allied Health Professionals Association assistant secretary Andrew Hewat, who sits on the state’s Healthcare Worker Infection Prevention and Wellbeing Taskforce.
 
‘Our biggest problem now that numbers are coming down is that we relax and get complacent,’ he said.
 
‘The taskforce will keep working, but there’s less urgency and less pressure to then make the significant changes that need to be made if there’s another wave – or a different virus.’ 
 
Mr Hewat said the changes required include ensuring adequate personal protective equipment (PPE) supply chains, workflow practices, and pandemic-compliant facilities, ranging from break rooms to bathrooms.
 
‘There’s no silver bullet. All of this takes planning, designing, implementing and money,’ he said. 
 
Mr Hewat told newsGP that hospitals and aged care have become the ‘new Ruby Princess’.
 
‘My concern is that [the Government] has relied on the overall numbers to come down to bring healthcare worker numbers down, rather than actively addressing [the issue],’ he said. ‘Infections have been prolonged because of healthcare workers and aged care.’
 
A prominent Melbourne specialist, who did not want to be named, told newsGP that healthcare worker infections as a proportion of overall cases are still high, suggesting most of the decline had been due to lower community transmission.
 
But the specialist said the Royal Melbourne Hospital’s response to its outbreak – the largest healthcare cluster to date, with 262 healthcare worker infections from July to August – demonstrates that health service interventions could work, ranging from moving COVID patients out of older wards with bad ventilation, a rapid shift to N95 respirators, and a focus on break rooms and common areas where workers might let down their guard. 
 
‘PPE guidance was changed to increase use of aerosol precautions on high-risk patients,’ they said. ‘[This] may have helped reduce healthcare worker infections in hospitals such as Royal Melbourne, where staff would have been adequately trained in its use.
 
‘But in other areas where institutional infection control and protection isn’t available, such as residential aged care facilities, it may not have as much impact.’  
 
The Royal Melbourne Hospital response – captured in a pre-print study – also included at least weekly asymptomatic testing of staff members working on ‘hot wards’ where confirmed or suspected COVID patients were present.
 
Victorian GP Dr Bernard Shiu, who is an adviser to Safer Care Victoria, told newsGP that while PPE availability has been a problem, preventing infection is a broader issue.
 
‘Healthcare worker infections are not just about PPE, but about the use of PPE and the donning and doffing. That’s as important as availability,’ he said.
 
‘Many infections were detected in an environment where staff were provided with adequate PPE. The infections may have come from taking off PPE, or in common areas such as elevators, staff rooms and changing rooms. 
 
‘There has not been a time we had to put any healthcare workers at risk by not providing enough PPE in hospital.’
 
Dr Shiu acknowledged that Victoria’s PPE stockpile has run low, but stressed that the critical threshold had never been reached.
 
‘There was a danger, but we never ran out,’ he said. ‘Accessing supplies has been difficult, but that’s a worldwide problem.’

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