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Wairarapa District Health Board July 2020

AGENDAHeld on Thursday 16 July 2020Lecture room, CSSB, Wairarapa DHB 9.00am

COMMUNITY AND PUBLIC HEALTH ADVISORY COMMITTEE

PUBLIC SESSION

Item Action Presenter Min Time

1. PROCEDURAL BUSINESS

Karakia 9.00am

1.1 Apologies ACCEPT 15mins

1.2 Continuous Disclosure1.2.1 Interest Register1.2.2 Conflict of Interest

CONFIRM / ACCEPT

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1.3 Minutes of Previous meeting APPROVE “

1.4 Schedule of Action Points NOTE “

1.4.1 Work Programme NOTE “

2. DECISION

2.1 Maori Health ENDORSE Daniel KawanaService Development Manager,Planning & Performance

30mins 9.15am

3. DISCUSSION

3.1 Regional Public Health (RPH) update

NOTE Peter Gush, General Manager, RPH 15mins 9.45am

3.2 COVID-19 Report and Wairarapa Age Residential Care

NOTE Joanne EdwardsService Development Manager, Planning & Performance

15mins 10.00am

4. INFORMATION

4.1 Clinical Services Plan NOTE Sandra Williams, Executive Leader, Planning & Performance

10mins 10.15am

4.2 Testing Strategy NOTE Sandra Williams, Executive Leader, Planning & Performance

10mins 10.25am

5. OTHER

5.1 General Business

CPHAC - PUBLIC MEETING - Agenda

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Wairarapa Community and Public Health Advisory Committee (CPHAC)INTEREST REGISTERAS AT 15 MAY 2020

INTEREST REGISTER

Name Interest

Dr Tony BeckerDeputy Board Chair

∑ Shareholder and Director (Clinical) Masterton Medical Limited∑ Shareholder and Director Wairarapa Skin Clinic∑ Wife contracts to Wairarapa District Health Board∑ Trustee, Hau Kainga∑ Member Alliance Leadership Team

Helen PocknallBoard Member

∑ Contractor with Ministry of Health

Joy CooperBoard Member

∑ Chairperson Wharekaka Trust Board Incorporated

Jill StringerBoard Member

∑ Director, Touchwood Services Limited∑ Husband employed by Rigg-Zschokke Ltd

Yvette GraceBoard Member

∑ General Manager, Rangitāne Tu Mai Rā Treaty Settlement Trust ∑ Member, Hutt Valley District Health Board ∑ Husband is a Family Violence Intervention Coordinator at Wairarapa District Health Board ∑ Sister-in-law is a Nurse at Hutt Hospital∑ Sister-in-law is a Private Physiotherapist in Upper Hutt

Dr Stephen PalmerRegional Public Health Clinical representative

∑ Employee of Hutt Valley DHB as Medical Office of Health in Regional Public Health∑ Member of the Policy Committee of NZ College of Public Health Medicine

Limone KellyPacific representative

∑ Works at Lyndale Rest Home

Justine ThorpeTu Ora Compass Health Wairarapa representative

∑ Tū Ora Compass Health is Deputy CEO, General Manager for Equity, Population Health and Wairarapa

∑ Member of Primary Care Alliance Trust ∑ Member of Papakanui Iwi Land Trust∑ Member of South Waiarapa District Council Water Race Management Committee )

Annie LincolnPrimary Care Clinician

∑ Director Carterton Medical Centre

Wairarapa DHB Executive Leadership Team - Interest Register

Name Interest

Dale OliffChief ExecutiveWairarapa DHB

∑ No interests declared

Sandra WilliamsExecutive Leader Planning & Performance

∑ No interests declared

Jason KerehiDirector Maori Health

∑ Negotiator – Rangitane Settlement Negotiations Trust∑ Trustees – Rangitane Tu Mai Ra – Post Settlement Governance Entity∑ Partner is employed as a school nurse by Compass

CPHAC - PUBLIC MEETING - PROCEDURAL BUSINESS

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COMMUNITY & PUBLIC HEALTH ADVISORY COMMITTEE PUBLIC

Wairarapa District Health Board June 2020

MINUTESHeld on Thursday 18 June 2020CSSB Lecture roomWairarapa District Health Board9.00am

COMMUNITY & PUBLIC HEALTH ADVISORY COMMITTEE PUBLIC SECTION

PRESENTJoy Cooper MemberHelen Pocknall Acting ChairJill Stringer MemberYvette Grace MemberAnnie Lincoln Member (Primary Care Clinical Representative)Justine Thorpe Member (Primary Care Representative)Dr Stephen Palmer Member (Regional Public Health (RPH) Clinical Representative)

ATTENDANCEDale Oliff Chief Executive, Wairarapa District Health Board (CE)Sandra Williams Executive Leader Planning & Performance (ELP&P)Tofa Suafole Gush Director, Pacific HealthDaniel Kawana Service Development Manager, Planning & PerformanceJaneen Cross Māori Health Coordinator, Māori HealthJen Bergantino Minute taker, Planning & Performance

1.0 PROCEDURAL BUSINESS

1.1 APOLOGIESAn apologies were received from Limone Kelly (Member) and Dr Tony Becker (Chair). Helen Pocknall was the acting Chair for this meeting.

1.2 CONTINUOUS DISCLOSURE

1.3 CONFIRMATION OF MINUTES

1.4 WORK PROGRAMME

RESOLVED MOVED Joy Cooper SECONDED Justine ThorpeCARRIED

2.0 DECISION

2.1 PACIFIC HEALTH AND WELLBEING STRATEGIC PLAN FOR THE GREATER WELLINGTON REGION, 2020-2025

Points noted were:

NOTED that this was the final draft before it is signed off by the three Boards.

NOTED that a second round of consultation has taken place. Feedback has been received from the community and there has been internal consultation with DHB staff.


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NOTED that the document has six priority areas including three national priorities set by the Minister and is a five year plan. This plan will form the direction of work to be undertaken over the next five years.

NOTED that the specialist mental health services and cardiovascular disease data (Pg 59) were around the wrong way.

NOTED that the implementation plan has just been completed and will be released when the Pacific Health and Wellbeing Strategic Plan is launched. The Committee would like to see a Wairarapa specific part in the implementation plan.

NOTED that the following recommendation is to be added to the Board report –NOTE that the Implementation plan will be available when the Pacific Health and Wellbeing Strategic Plan is launched.

RESOLVED that the Community and Public Health Advisory Committee

a. Notes the contents of this report

b. Notes the Pacific Health and Wellbeing Strategic Plan for the Greater Wellington region, 2020-2025 is one of the key supporting plans for the Wairarapa strategic direction and transformation change work being undertaken

c. Agrees to recommend to the Board that it endorse the Pacific Health and Wellbeing Strategic Plan 2020-2025

MOVED Jill Stringer SECONDED Yvette GraceCARRIED

2.2 STRATEGIC DIRECTIONPoints noted were:

NOTED that once the plan is ready to be published the final version will be available on the DHB website. A printable version and a short version of the Strategic Direction document will be made also be available.

NOTED that the DHB’s Chief Executive acknowledged the work undertaken by Daniel Kawana, Service Development Manager for Planning and Performance team.

NOTED that this document should be presented at the Clinical Society meeting.

9.55am Stephen Palmer arrived

RESOLVED that the Community and Public Health Advisory Committee

1. Notes the draft Hauora Mō Tātou – We Are Wairarapa 2020-2030.

2. Notes the timeframes to completion.

3. Endorses to the Board the draft Hauora Mō Tātou – We Are Wairarapa 2020-2030 noting further editing is expected.

MOVED Jill Stringer SECONDED Yvette GraceCARRIED

3.0 DISCUSSION

3.1 EQUITY INITIATIVESPoints noted were:


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NOTED that these equity actions form part of and are included throughout the DHB’s Annual Plan

NOTED that most of these projects span 1 – 2 years.

NOTED that the Maori Strategic Plan which will pull some of this work together.

RESOLVED that the Community and Public Health Advisory CommitteeNotes this summary of the Wairarapa DHB Equity Initiatives planned for in the 2020/21 year.

MOVED Yvette Grace SECONDED Jill StringerCARRIED

4.0 INFORMATION

4.1 HOSPITAL AT HOMENOTED that an update on the Hospital at Home model will be provided to the Committee in August 2020.

MEETING CLOSED AT: 10.45AM

Date of next meeting: 16 July 2020

CONFIRMED that these minutes constitute a true and accurate record of the proceedings of the meeting.DATED this day of 2020

Helen PocknallActing Chair, Community & Public Health Advisory Committee (CPHAC)Wairarapa District Health Board

Resolution to move to Public Excluded meetingRESOLVED MOVED Joy Cooper SECONDED Jill StringerCARRIED


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WAIRARAPA DISTRICT HEALTH BOARD PUBLIC CPHACSchedule of Actions

Meeting Date Action Person Responsible Status18 February 2020 Prepare a dashboard of statistical data and services in Wairarapa for Maori Health

which will be brought back to CPHAC in May. Executive Leader Planning & Performance

This will be available in July which will fit in with the work programme around equity.

20 May 2020 Oral health for children to be considered with next report on children Executive Leader Planning & Performance

This will now be included under the report back on Primary and Community - child health in September.


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Community and Public Health Advisory Committee Work ProgrammeThis programme will continue to be updated in line with the new Strategic Direction work

February March April May June July August September October NovemberSystem and service planning

-Annual Plan -Strategic Direction

-Strategic Direction

-Mental Health and Addictions

-Strategic Direction-Final Pacific Health Plan-Equity Initiatives -Annual Plan, and System Level

Improvement Plan

-Maori Health Plan update and Maori Health Dashboard/ Performance development approach-Digital Strategy-Clinical services plan update

- Planned Care 3 Year Plan - Implementation Plan for the Pacific Health & Wellbeing Strategic Plan

-Clinical Services Plan update- Draft Maori Health Plan-Mental Health and Addictions

-Community Services Integration- Final Maori Health PlanUpdate-Long Term Conditions and Wellbeing Plan

-Annual Plan Process-Clinical Services Plan draft

System & provider performance

-Health of Older People

- Primary and Community-community pharmacy and youth health- Palliative Care

- Primary and Community includes oral health-child and youth- SLM reporting

-Hospital @Home Update

-Regional Public Health-COVID-19 & ARC report-Testing Strategy-COVID 19

-Alliance and SLM reporting- Hospital @ Home update

-Primary and Community-child health-Health of Older Peopledashboard

- Primary and Community-Alliance & SLM reporting

- Mental Health and Addictions)

Investment and prioritisation

-Investment & Prioritisation

-Investment & prioritisation


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Wairarapa District Health Board

DECISION PAPER

Date: 9 July 2020

Presented By Sandra Williams, Executive Leader Planning and Performance

Author Daniel Kawana, Principal Advisor Māori Health Planning and Performance

Endorsed By Dale Oliff, Chief Executive

Jason Kerehi, Executive Leader Māori Health

Subject Māori Health

RECOMMENDATION

It is recommended that the Board:

a. Notes the broad approach of delivering a Māori Health Plan for Wairarapa DHB.

b. Notes the focus on Māori health within the Wairarapa DHB equity projects.

c. Notes the future of Māori health within the Wairarapa DHB region through inquiry and reconfiguration.

d. Notes the formation of an analytical arm of Māori health to provide expert advice to operationalise changes in the Wairarapa DHB region.

e. Notes the creation of a ‘fit for purpose’ Māori health dashboard to monitor change.

f. Endorse an inquiry and reconfiguration of Māori health service delivery within Wairarapa DHB.

APPENDICES:

1. Māori Health Plan timeframes

2. Draft Terms of Reference [Tūhono Māori Health]

1 PURPOSE

This paper presents five key actions for improving service delivery within Māori Health. These are short term actions (next 2 years) focussed on driving Māori health into the future and bring to life the aims of Hauora Mō Tātou - Strategic Direction 2020-2030. Rather than a piecemeal approach, this is part of a comprehensive plan for change. We want and expect to see improvements in the health status of whānau Māori. The actions are:

a) the completion of a comprehensive Māori Health Plan for delivery over the next 5 years; b) an approach to inequities that prioritises Māori health in its design and delivery; c) an inquiry into the delivery of Māori health across WrDHB;d) the formation of an expert analytical arm focussed on analytics and insights for Māori health;

ANDe) a fit for purpose Māori health dashboard.

CPHAC - PUBLIC MEETING - DECISION

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The Māori Health Plan will complement and align with the recently released Hauora Mō Tātou -Strategic Direction 2020-2030, the Māori Health Plan is:

- A five year plan of action;- Considers current recommendations from local reviews and needs analysis;- Recognises the needs and obligations of and to Māori as separate and distinct; - Understands the position of Iwi Māori in relationship to the Crown;- Recognises the Treaty of Waitangi; - Considers current shifts in knowledge specifically concerning health outcomes and its

relationship to institutional racism and unconscious bias; - Review of recommendations from other sources, such as: WAI2575, He Korowai Oranga –

Māori Health Strategy 2000, The New Zealand Health and Disability System Review 2020 and others;

- Will collate and consider feedback from local communities and blend these perspectives; - Reconfirms that whānau are the logical start point for any change or approach.

In general the layout will follow the common conventions of generic planning documents, drawing particular attention to the key actions for change. This document will focus on actions that provide real change and work toward better results for whānau Māori. Some actions will be structural, some will be process based and others around commissioning.

These equity projects are currently being undertaken or in the process of contract negotiation and the focus is primarily on whānau Māori:

- Kura Pounamu, Antenatal education [Māori maternal health 0 – 3 years] - Hapūtanga, Antenatal education [Māori maternal health 0 – 3 years]- Tāringa Whakarongo, Micro suctioning of ears [Māori & Pacific ear health under 18 years] - Niho Taniwha, Surgical dentistry [Māori oral health surgical procedures under 18 years] - Kāinga Ora, Warm and dry homes [Māori, Pacific, Low Socioeconomic whānau] - Mate Patupaiarehe, Measles immunisations [Māori & Pacific 15-29 years] - Tapū Te Hā, Smokefree [Māori, Wāhine Māori, Māori Youth]- Kaumātuatanga, Advanced Care Planning [Māori & Pacific 55+ years] - Te Whakauruora, Suicide Prevention and Postvention [Men, Māori, Rural all ages]- Te Kawai Whakaeke, Heart Health [Men, Māori, Rural 40+]

This is not a small piece of work and it is a vital piece of work, we will define and undertake an inquiry into Māori health providership and service delivery directly to whānau Māori. The initial focus is on those providers deemed Māori health providers or kaupapa Māori providers or Māori focussed groups, roles or positions. Secondly a general overview of the quality of delivery of services to Māori within our other generic service providers in the DHB itself. This review will be a mixture of paper based analysis, documentary analysis, key informant interviews and group feedback sessions. The main thrust of this inquiry is understand the current ‘state of play’ of service delivery to Māori within Wairarapa and to provide a small number of key recommendations for transforming/reconfiguring the local system to address inequities that may exist within that service delivery.

2 SUMMARY

The headline actions include –a) The Māori Health Plan 2020-2025

b) Projects focussing on inequities in Māori health

c) Māori Health Inquiry


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A Māori health dashboard is currently under investigation with the insights and analytics team at Hutt Valley DHB. Information that is fit for purpose depends on the audience more often than not we are scrambling to understand the rationale behind our decisions and this approach means often we don’t make the most robust, precise or directive decisions. This action is connected to the formation of Tūhono Māori Health which is linked to better, more useful, user friendly analytics and insights.

Reporting directly to the Chief Executive, Tūhono Māori Health will provide insights and tactical recommendations to the Wairarapa District Health Board focussed on smart commissioning and local delivery of healthcare services to Māori. A key function of the group is to ensure adherence to the Wairarapa DHB Māori Health Plan and our Kaupapa Māori Framework.

d) Māori Health Analytics and Insights

e) A ‘fit for purpose’ Māori health dashboard

3 BACKGROUND

The need for a comprehensive approach to addressing the unacceptable inequities that exist in health, specifically for Māori - is uncontested. Part of the problem with addressing these longstanding needs is that they are usually ‘small parts of the whole’ and the much more influential factors such as the configuration of services are never addressed or they are worked on incrementally. The methodology espoused in this paper looks at Māori health as a subset of service delivery across the health continuum or health system, a system which influences the way we deliver services to Māori (and others). In short this programme of action is seeking to provide real world solutions.

The equity projects are currently being funded or in the process of being contracted out, they provide us with current, real world situations in which to work alongside whānau and understand the issues or pressures facing them. The equity projects also play a vital role in filling a number of known gaps in our service provision. The equity projects themselves may not be the ultimate answer but they are a solid barometer in terms of understanding what service delivery looks like for Māori and they give us an opportunity to work alongside new providers such as the Māori Women’s Welfare League.

The Māori Health Plan is the catalyst for change and will be the guidance tool that provides the fundamental direction for Māori health and provides ‘real world’ recommendations that are smart, informed and achievable. The Māori Health Plan is also intimately connected to our Strategic Direction and seeks to achieve the aims of this direction.

The review of Maori health service delivery is a game-changer, not only does it serve us in terms of understanding what’s going in this space, it also will provide new potential configurations to consider. The review is about taking command of our future and not passively waiting for the future to unfold. The analytical support and the Māori health dashboard can become the monitor to change and provide valuable insight into the subtleties we sometimes miss in the rush of our work programme. Over the next two years the way that health services are delivered by, with and for Māori will need to change in order to be more effective in addressing inequities for Māori.


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4 CONCLUSION

In order of sequence the actions will be:

Action Start Date Completion Date Contract for services focussed on whānau Māori with an emphasis on child and youth to address known equity issues.

31 July 2020 30 June 2022

Form the Tūhono Māori Health group to undertake analytics and insights in Māori Health.

18 September 2020 n/a

Discuss and define the Māori Health Dashboard with Tūhono Māori Health, HVDHB analysts and Tū Ora Compass Health analysts.

18 September 2020 n/a

Start and complete the Maori Health Plan. 20 July 2020 09 December 2020Start and complete the Māori Health Inquiry. 18 January 2021 31 May 2021


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APPENDIX 1Māori Health Plan timeframes

KEY TASKS Y/N RESPONSIBILITY Date

Decide on the parameters and secure the funding for delivery of a Māori Health Plan

Y Exec. Māori Health/ Prin. Māori Health

20 July 2020

Secure expertise for design and development of a Māori Health Plan

Y Exec. Māori Health/ Prin. Māori Health

20 July 2020

Map out the engagement with key stakeholders N Māori Health Directorate/ Prin. Māori health

31 July 2020

Complete Communications Plan, make bookings, promote hui

N Māori Health Directorate/ Prin. Māori Health

31 July 2020

Start and complete hui sessions with key stakeholders

N Iwi Māori Iwi Kainga Māori Womens Welfare League Exec. Māori Health Māori Health DirectoratePrin. Māori Health

18 September 2020

Collate feedback, provide analysis N Exec. Māori Health/ Prin. Māori Health

5 October 2020

Write first draft, provide for feedback, undertake iterative process, alignment to WrDHB key documents, policies etc.., incorporation of known data analytics and health sector movements.

N Exec. Māori Health/ Prin. Māori Health

30 October 2020

Finalise document, design and incorporation of feedback, organise communications for a launch

N Exec. Māori Health/ Prin. Māori Health

6 November 2020

Launch document N Māori Health Directorate 9 December 2020 TBC may align with another December event?


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APPENDIX 2

TERMS OF REFERENCETŪHONO MĀORI HEALTH

Introduction Reporting directly to the Chief Executive’s Office, Tūhono Māori Health will provide insights and tactical recommendations to the Wairarapa District Health Board [WrDHB] focussed on smart commissioning and local delivery of healthcare services to Māori. A key function of the caucus is to ensure adherence to the WrDHB Kaupapa Māori Framework.

Purpose / Scope1. To provide insight to the Chief Executive’s Office. 2. To give analytical rigor to decisions affecting Māori. 3. To provide tactical leadership in matters relating to Māori Health.4. To ensure health services within WrDHB are safe, rational and cost effective 5. To ensure health services within WrDHB are compliant with tikanga, policy and best practice. 6. To monitor WrDHB progress against timeframes and indices for Māori health. 7. To provide mentoring and peer support.

Objectives1. Be the operational body for Wairarapa DHB with reference to:

- Data, analytics and insights for Māori Health - Monitor Māori specific outcomes - Monitoring adherence to Māori health deliverables - Provide feedback on Māori health equity

2. To provide WrDHB with robust advice on Māori health:- Re-designing service delivery of Māori health - Planning and commissioning of Māori health

3. Measure compliance against Māori health: - Compliance against the WrDHB Kaupapa Māori Framework- Compliance against the WrDHB Te Tiriti o Waitangi policy - Design and guide Māori health planning

MembershipShall include a maximum of 7 members with expertise in Māori health, data, analytics, policy and insights. Members will be selected to ensure breadth of experience across Te Ao Māori. Quorum – minimum of 3 members.


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Frequency of MeetingsOne meeting lastly 2 full days will be held every two months.

Relationships (External and Internal)Linkages will be maintained with the following: - Māori Community - Te Iwi Kainga Chair - Iwi/Māori Chairs - Māori Health Providers - Interagency Māori Stakeholders - Executive Leader Māori health

Accountability and ReportingThe caucus is directly accountable to the Chief Executive Officer WrDHB, with the Executive Leader Planning and Performance as the shadow. Minutes will be available on the Māori Health SharePoint site.

Review PeriodThe terms of reference for Tūhono Māori Health will be reviewed annually.


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Community & Public Health Advisory Committee July 2020 1

COMMUNITY & PUBLIC HEALTH ADVISORY COMMITTEE

Date: 6 July 2020

Author Peter Gush, General Manager, Regional Public Health

Dr Craig Thornley, Clinical Head of Department, Regional Public Health

Subject Regional Public Health activity throughout the Wairarapa region

RECOMMENDATION

It is recommended that the Community & Public Health Advisory Committee

Receives this report.

1 SUMMARY

In response to your request, this paper provides an overview of the services Regional Public Health (RPH) provides in the Wairarapa DHB district. For the March to May 2020 period all of our efforts were focussed on the public health response to COVID-19. A copy of the organisation chart for RPH is included as Appendix 1 for your information.

2 PUBLIC HEALTH NURSES

The Public Health Nurses deliver services to children and young people in schools and early childhood centres. The focus of this service is based on the identified needs of children, and the level of intensity of service provision being higher to those ECCs and schools with the lowest decile rating.

Public Health Nurses work in Schools, ECC and Kohanga settings to: ∑ Support children referred by parents/caregivers or schools∑ Assess, advocate and refer to hospital, outpatients, specialists or education services∑ Support access to health care∑ Provide health education and promotion∑ Link children and families with community and social services

The nurses also provide school based immunisations with offering two vaccines, (1) Tdap vaccine boosts the protection children receive as babies against tetanus, diphtheria and whooping cough and (2) the HPV vaccine which protects against four strains of human papillomavirus responsible for cervical, some other cancers, and genital warts. The BCG vaccine is offered from birth to 6 months for babies who are eligible.

Through the work our Vision and Hearing Technicians undertake we aim to improve the hearing and vision of children through the implementation of the Ministry of Health National Vision and Hearing Screening Protocols 2014. This includes:

• Mass screening of 4 and 11 year old children• Initial screening for new entrants and new immigrants• Screening for those children with hearing concerns

3 COMMUNICABLE DISEASE AND HOUSING TEAM

The Communicable Disease and Housing Team conduct disease surveillance across the 3DHBs, in which disease data is systematically collected, analysed, interpreted and acted upon, for the purpose of preventing, identifying and responding to emerging communicable disease issues. This team respond promptly to cases

CPHAC - PUBLIC MEETING - DISCUSSION

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and outbreaks of notifiable communicable, waterborne and foodborne diseases (of note: 2019 nationwide measles outbreak and 2020 the COVID-19 pandemic).

The team maintains a working relationship with the manager of the Wairarapa needle exchange service, to facilitate an annual review of their service, ensuring the service is operating in accordance with their authorisation documentation.

Post June 2020, we will support the resettlement of UN Quota Refugees into the Wairarapa district. RPH will ensure a continuum of care approach is delivered to refugee communities through networking, developing partnerships and providing training for health practitioners.

The Well Homes Programme has trained and supported Whaiora Whanui staff to complete housing assessments in the Wairarapa region in 2019/2020.

4 HEALTH PROTECTION OFFICERS

Health Protection Officers work in support of healthy environments across a wide range of activities. These include: assessment and audits to provide assurance that council and private drinking water supplies are safe to drink, emergency response in relation to hazardous chemicals and natural events (earthquakes/floods/pandemics), health approval to the application of poisons to land (possum control operations), resource consent applications which may impact public health, public health risk communication supporting bathing water monitoring and assisting with the resolution of situations of infirm and neglect (persons living in insanitary conditions).

Specific examples include: working with Wellington Water to ensure public health is at the forefront of resolving the recent Featherston drinking water outage, assessing annual compliance of drinking water supplies against legislation and Standards, ensuring conditions in the permit to undertake possum control in the vicinity of the Pukaha/Mt Bruce wildlife sanctuary protect public health, and assessing the public health impact of discharge to air of chemicals from a spray paint premises.

RPH was involved with the Greater Wellington Regional Council and the Masterton District Council when the Masterton Air Quality Plan was established. The main issue being the poor quality of discharge to air from open fires and older wood burners. At the moment, RPH maintains a watching brief rather than active involvement. During the last Calendar year September to August in the Masterton township air shed there has been 17 exceedance’s of the WHO guidelines for PM2.5 (Particulate matter less than 2.5 microns which isthe main constituent of wood smoke).

5 ALCOHOL REGULATORY AND HEALTH PROMOTION

The Medical Officer of Health is required under the Sale and Supply of Alcohol Act to inquire into and report on liquor licence applications received from the three Councils situated in the Wairarapa. This includes off-, on-, club, and where appropriate, special licences (clubs, cafes, restaurants, bars, supermarkets, grocery stores, bottle stores and may include special events).

Assessment includes inquiring into amenity and good order. This is to say that “regards must be had to current and possible future levels of noise, nuisance and vandalism; the number of existing premises that hold on-licences in the locality; and the extent to which the purposes for which land near the premises concerned issued are compatible with the purposes for which those premises will be used if the licence is issued.” (www.alcohol.org.nz ).

In the assessment of alcohol licences, there is an emphasis on staff training procedures, host responsibility procedures, understanding what the signs of intoxication are and what policies or procedures are in place to deal with intoxication etc.

Wairarapa Local Alcohol Policy came into force on 1 November 2018, and the next review will be in 2021.


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http://www.alcohol.org.nz/

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In collaboration with NZ Police, RPH test licensee’s compliance with the Sale and Supply of Alcohol Act (2012) by conducting controlled purchase operations utilising underage volunteers. If alcohol is successfully purchased, or a premise does not have adequate food available, the premises operator, manager or licensee is liable for prosecution or other sanctions via the Alcohol Regulatory and Licensing Authority.

RPH continues to support Tu Ora Compass Health (Tu Ora) by providing funding for the What About You? Wairarapa Community Alcohol Campaign. RPH is also a campaign partner and member of the steering group. An evaluation was completed in December 2019 on the first phase of the project. New resources have been developed that focus on alcohol and mental wellness. The platform for the website is hosted through Wairarapa DHB. The next phase of the campaign is in partnership with Wairarapa Bush Rugby Union lead by Tu Ora. This initiative has two main focuses which are:

∑ Raise awareness of responsible alcohol consumption within Wairarapa Rugby clubs and amongst their supporters.

∑ Raise awareness of mental health and wellness services and contacts for help in the Wairarapa.

This phase of the initiative was kicked off in February 2020 by the launch of the Wairarapa Bush’s Code of Conduct which outlines the expectations of things like acceptable side-line behaviour, fair play, and guidelines around alcohol use.

6 HEALTH PROMOTION – PUBLIC HEALTH ADVISORS

The promotion and development of consistent breastfeeding information continues through the forum of Pēpe Ora (The Website) and presentations to Lead Maternity Carers, GPs and other health providers. RPH uses the key messaging flip chart resource for presentations and has noticed an increase in confidence bythose who have received this messaging. The purpose of the flip chart is to highlight up to date information and direct people to the Website using an interactive tool. The intended audience for the flip chart ismidwives and mums.

The most recent development is the broadening of the Website into a regional landing page where each DHB’s population would have links to their local support services. This is underway and RPH is looking forward to launching this soon. RPH continues to improve and innovate off Pepe Ora with planning going into the design of an App and breastfeeding video.

Wairarapa DHB is leading the way with the alignment to the Ministry of Health: National Healthy Food and Drink Policy. WrDHB is aligned with the policy and with support from RPH is writing up a case study to share with other DHB’s.

RPH recently employed a Public Health Advisor (PHA) to support Healthy Active Learning. Our PHA will be working alongside another of our PHA’s based in the Wairarapa to support Early Learning Services and Secondary Schools to encourage students to drink more water and consider better food options including growing their own. One of our PHA’s has been working with schools on water-only for a year which has resulted in 80 per cent of Wairarapa Schools striving to be water-only schools. Healthy Active Learning will provide the boost and support with healthy food, drinking water and physical activity to strengthen learning.

The partnership of RPH, Sport Wellington and Ministry of Education is looking to collaborate not duplicate with each focusing on education age groups; RPH 0-4 and 13-18 year olds, Sport Wellington 5 – 12 year olds and Ministry of Education 5 – 15 year olds.

Although COVID-19 has slowed down RPH’s progress with water-only schools RPH has collaborated with Refill NZ to place two water dispensers in the Wairarapa. One at the Featherston Community Centre and one at Wairarapa Connecting Communities and there are discussions underway to have a community based hydration station available.


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7 ANALYTICAL AND POLICY TEAM

In partnership with others, we aim to achieve equitable population health outcomes across localities, settings and systems. Approximately 10 per cent of all team services are intended to contribute to WrDHB population health outcomes.

The services we deliver are: ∑ Health in All Policies (e.g. influencing local council policy development)∑ Public health intelligence (e.g. analysis, evaluation, data management)∑ Communication (e.g. media responses, RPH website)∑ Public health planning, accountability and infrastructure functions (e.g. contractual plans and

reports)

RPH’s activity is included in the WrDHB Draft Annual Plan – particularly in the ‘Improving Wellbeing Through Prevention’ section, under;

a) Environmental and Border Healthb) Healthy Food & Drinkc) Smokefree 2025d) Reducing Alcohol Related Harme) Communicable Diseasef) Cross Sectoral Collaboration including Health in All Policies

8 BUSINESS SUPPORT TEAM

RPH distributes health education resources on behalf of the Ministry of Health and the Health Promotion Agency. Orders from organisations, community groups and individuals are placed via the HealthEd website, packed and delivered to the customer by the Business Support team.

9 MEDICAL TEAM

The RPH Medical team has four Medical Officers of Health, a Medical Officer and a Public Health Registrar who provide input, oversight and leadership to the work undertaken across the wider service. In addition, the Medical Officers of Health hold statutory designations that enable functions under a range of legislation to protect public health – these functions include the ability to make enquiries, to report and to take actions to counter public health risks in specific circumstances.


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Appendix 1.

Regional Public Health Organisational Chart


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CPHAC DISCUSSION PAPER

Date: July 2020

From Sandra Williams, Executive Leader, Planning and Performance

Author Joanne Edwards, Service Development Manager


Subject COVID-19 Report and Wairarapa Aged Residential Care

RECOMMENDATION

It is recommended that the Community and Public Health Advisory Committee (CPHAC):

1. Notes the recommendations of the independent review of COVID-19 Clusters in Aged Residential Care (ARC) Facilities in NZ which has been recently published by the Ministry of Health.

2. Notes that there were no cases of COVID-19 associated with any ARC facilities in Wairarapa.3. Notes the Wairarapa ARC response to COVID-19 and related lessons.4. Discusses and notes the recommended actions for further development.

ADDENDUMSAppendix 1 - Independent Review of COVID-19 Clusters in Aged Residential Care Facilities. Appendix 2 - WrDHB IMT Residential Care Facility COVID-19 Outbreak Response Plan – DRAFT.Appendix 3 - Residential Care Facility Incident Management Team (IMT) Actions for Consideration.

1. PURPOSE

The purpose of this paper is to present reflections of the Wairarapa response to COVID-19 with regard to ARC in the context of the independent review, which was commissioned by the Director General of Health1. Using the structure of the review report, it provides summary comment from the Wairarapa perspective and local recommended actions.

2. SUMMARY

The COVID-19 pandemic is a unique and unprecedented event in New Zealand. As it unfolded, it soon became apparent from overseas experience and emerging NZ experience that the elderly frail residents in ARC were particularly at risk. From 11 March to 28 March in NZ there were outbreaks of five ARC clusters2 which resulted in 39 residents being infected, 78 health care workers and 36 others associated with health care workers.

The independent review presents findings relating to these ARC clusters and provides a framework for wider reflection across the health sector. Some recommendations included in the report relate to the need for national and regional action and Wairarapa DHB will be participating in addressing these recommendations. Although there were no cases of COVID-19 associated with any ARC facilities in Wairarapa, a number of findings in the report also reflect local experience of COVID-19 recommendations are very pertinent to the Wairarapa.

1 29 May 2020, “A Review of Independent Review of Covid-19 Clusters in Aged Residential Care Facilities”, Ministry of Health2 Defines a facility where there are 10 or more confirmed cases of COVID-19.


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3. DETAILS

3.1 Preparedness

Prior to lockdown at Alert Level 4, The DHB had recognised the need to work with ARC providers on site to consider their pandemic preparedness, address staff training and review PPE supply.

‘Partner providers’ were identified for small stand-alone facilities and the larger ARC providers shared their planning resources.

Additional DHB staffing resource was provided by the Planning & Performance Department to assist ARC preparedness and helped establish coved-related communication channels for rapidly addressing issues as they arose. This supportive approach was translated into a more formal review of ARC readiness. These reviews were in response to the request from the Director General of Health and included disability residential care in the community. Although there were some minor adjustments to be made, no findings of concern were identified across ARC facilities. However, at that stage, the reality of what an outbreak in an ARC facility might be like was not apparent until the NZ ARC clusters occurred.

Although all ARC providers were able to describe their mitigation strategies for a reduction of staff, most of these depended on extension of hours of current part time staff and use of volunteers in non-clinical activities. However, the demand on ARC managers was considerable to manage their staffing levels through uncharted times. While vulnerable staff were removed from the workforce, others posed unacceptable risks through breaking lock-down rules. Staff issues which would have normally be dealt with through usual Human Resource (HR) processes created disproportional stress on some managers and therefore impacted on their ability to address the range of COVID-19 related issues which had arisen. The DHB was able to offer specific support to a small facility with staffing issues of an experienced ARC manager from their Workforce pool. This arrangement worked well, and also resulted in a number of quality improvements.

3.2 IPC Policy and Procedures

Although all ARC providers had infection control policies some smaller stand-alone facilities struggled with planning for the potential impact of a positive COVID-19 case. Generally there was clear continuity planning for staff reduction for up to 40% of staff, but not large scale stand down of staff (which was required by the cluster ARC facilities in the review).

ARC providers continued early emphasis on staff training for infection control procedures as the pandemic unfolded. However, the connection between the DHB infection Prevention and Control (IPC) staff and Wairarapa ARC facilities was minimal. This would have been particularly useful for the smaller stand-alone facilities who did not have the planning and training resources of the larger national providers. The DHB IPC team was not very visible in the ARC sector and it was the Older People Nurse Specialist who took the clinical lead for the preparedness assessments (in both ARC and Disability community homes).

3.3 Ability to isolate

As noted in the ARC cluster review, the practicality of establishing areas for isolation was easier for the more modern layouts with en-suites than for the more traditional older ARC design such as the rest-home only facilities which needed to be treated as one isolation bubble.

Dementia areas were particularly challenging in the ARC cluster review. During this time, Wairarapa was fortunate to have two available dementia wings (8 – 10 beds each, in South Wairarapa and Masterton) which could be allocated for isolation purposes if the need arose. Fortunately the need for such arrangements did not arise, but if it had, staffing capacity and dementia-specific capability would have been a major challenge.


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3.4 Lockdown and COVID-19

Most facilities were implementing restrictions on access prior to lockdown (e.g. day care) and a number reported a ‘rush’ of family visiting residents prior to Alert Level 4. At least two residents left their facilities to spend their lock down period with their families.

Most Wairarapa ARC providers enabled access for compassionate reasons through strict IPC measures. There was at least one instance where a family member moved into the facility to be with her mother.

ARC providers with villages on the same grounds extended their control over access. In some instances this created tension between those living in villages (living independently in the community) and the ARC providers who were taking their responsibility for welfare of all their clients seriously. This limitation of access also had an impact for usual provision of home and community support (HCSS) for people living in a village with access being blocked by the ARC provider and provided by the facility. Decisions made at the time have led at least one village provider to reconsider its model for support of village residents.

Wairarapa ARC providers have identified that Alert Level 4 was the easiest of all the pandemic alert levels. The rules were clear and the doors were shut, creating their own bubble. Levels three and two were more stressful for ARC providers. They resulted in some confusion and changing rules/guidance from the Ministry were slower to be published than the national ARC organisation which created some dissonance for ARC providers.

While residents and their families accepted the lockdown rules, there were occasions when ARC providers needed to deal with staff who broke those rules. The DHB provided management and HR assistance to one provider to deal with this situation.

Beyond these exceptions, it was notable that ARC staff and management frequently went well beyond the normal call of duty. Reassurance of staff and frequent communications (e.g. daily short meetings) reinforced that national message that we were “all one team’”.

3.5 Psycho-social environment

Wairarapa was fortunate that ARC facilities were not the focus of media attention as were the cluster ARCs. With one notable exception (which was following their national office directions), the ARC facilities tended to refer to the Ministry advice as their ‘one true source’. Such advice was sometimes contrary to advice from their national organisation and included level of access, IPC management (including testingand isolation) and PPE. They shared this advice with residents and families which enabled consistent messaging.

As for the ARC cluster group, all facilities showed additional effort to address the psycho-social needs of their residents. All facilities organised regular contact between residents and whānau/family. A number of facilities employed additional staff hours to ensure that their residents maintained communication with their families (e.g. video calls) and were provided with additional diversional activity (e.g. participating in creating video entertainment for families and others).

3.6 Communication Channels and relationships with the DHB and Public Health

As one ARC provider summarised (in an understatement), “It seems that things in the pandemic world move very fast!”

Like the cluster ARCs, Wairarapa providers felt ‘bombarded’ by communications from the Older People’s team in the Ministry, HealthCERT, Public Health, and regional DHB services as well as their national organisation. All advice received from the Ministry was forwarded to ARC providers by the DHB and most of them used this advice as their ‘source of truth’.


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Not all the messages were aligned and it sometimes wasn’t clear if a message was coming from the Ministry for the Disability Sector (DSS) or ARC. As these two groups are distinctly different not all the DSS messages were transferable.

ARC providers indicated that the role of Public Health and its relationship with the DHB was unclear within the total system. Later as the alert levels reduced, Regional Public Health seemed to engage more with ARC providers. There was a risk of repetitive surveys and the DHB was able to provide Public Health with the information they were seeking about ARC in Wairarapa.

The 3 DHB teams for ARC met virtually on a frequent basis to ensure sub-regional consistency. However it wasn’t always clear when a 3DHB communication/arrangement became a 2DHB one (CCDHB & Hutt) and often the 2DHB messaging was not appropriate for the Wairarapa situation (e.g. processes, names and contact details).

To reduce the confusion and ensure consistency of appropriate messaging to ARC, a single portal through Planning Performance was used for all ARC. Once established as the preferred communication route, this arrangement worked well (for most agencies). All queries from ARC providers about local arrangements also came through this office. An early education forum was organised by this office and provided by a medical specialist in infectious disease. It was held for ARC providers (as well as primary care) and helped inform, dispel myths and calm the situation.

Prompt response to queries was given priority as it was recognised that ARC providers were under considerable stress. If there hadn’t been a recent call from an ARC provider, the DHB office called them to check briefly that they were coping. Minor issues were then able to be dealt with before they escalated and ARC providers expressed appreciation of that support. Also acknowledged and appreciated were the calls provided by the CEO to each ARC provider to reassure them that the DHB was supporting them. Spontaneous positive feedback has since been received from ARC providers for the DHB support they received.

3.7 Communication Channels and relationships with Primary Care, Medical Supplies and the Hospital

A number of ARC providers reported that their usual suppliers of PPE were unable to fill orders, with the earliest date estimated to be September. Once their supplies were depleted, they were therefore very reliant on the DHB.

Although a supply chain was quickly developed for PPE across the sub region, some frustration became apparent initially when providers sought supplies from the hospital rather than the PPE supply centre. Unfortunately, change to a generic e-mail address during the lockdown period resulted in more confusion for some ARC providers and resulted in delayed deliveries.

As reported in the ARC cluster review, ARC practice for wearing of PPE did not necessarily reflect Ministry advice, resulting in a higher than expected use of PPE. Early instances of theft of PPE also accounted for some disappearing stock. This in turn resulted in some tension between the PPE Supply centre and ARC providers seeking more supplies. These tensions were further exacerbated when the need for PPE to meet the clinical needs of a very dependent resident in isolation was disputed (needed for two staff every two hours). Similar to the findings of the ARC cluster review, provision of PPE stocks in Wairarapa ARC facilities would not have been sufficient for an outbreak.

Some ARC providers noted that their PPE was limited by their storage capacity. It appeared that modelling of PPE demand for ARC would have been greatly challenged if a positive case of COVID-19 had occurred in Wairarapa.


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Virtual primary care clinics in ARC were established and the usual electronic access to pharmacies by ARC providers assisted in management of residents’ clinical needs.

Wairarapa did not experience the problem of ARC insisting on testing asymptomatic residents prior to transfer from hospital to the same extent as other areas around New Zealand. Once protocols had been clarified and established pathways reconfirmed, most patients were able to be transferred to ARC from hospital (new or returning residents) without undue delay. This seemed to reflect the decision of most ARC providers to follow Ministry guidelines as mentioned above.

Although a number of ARC providers accepted the DHB offer of training for their RNs to provide testing if needed, the provision of this service by the Community Nursing mobile testing team was appreciated and enabled timely testing of residents displaying symptoms of COVID-19. These residents were isolated whilst waiting for results and none tested positive.

The speed of case recognition and notification of outbreak was identified as an important consideration for management of the ARC clusters. It is not known whether local ARC facilities would have identified this risk any earlier than the cluster ARCs. Although they have experience of identifying and notifying norovirus, delayed notification of COVID-19 symptoms may arise from psychological discomfort about the possibility of COVID-19 infection.

4. ARC REVIEW AND LOCAL RECOMMENDATIONS

The following table highlights recommendations from the independent ARC Cluster Review and also recommendations specifically relating to the Wairarapa ARC experience. It is not an exhaustive list, but contains the more obvious actions that need to be addressed.

Whilst Wairarapa DHB will be participating in national and regional actions to address the ARC Cluster Review recommendations, there are also a number of local actions, which will need to be taken.


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Recommendation from ARC Cluster Review Wairarapa DHB Action Comment

Highly Recommended

1Acknowledgement by the Ministry of the substantive work done by the ARC sector to prevent and manage the COVID-19 cluster outbreaks.

Publicly acknowledge the work done by Wairarapa ARC providers to keep their residents safe during the COVID-19 pandemic.

Previous acknowledgement of ARC by the DHB was well received.

2

ARC, DHB, and PHU to develop a national outbreak management policy with leadership roles, reporting processes and communication channels, and including policy on, IPC strategies, case recognition, staff and resident management and support, supply and use of PPE, testing, screening, isolation, lockdown, and resident transfers and admissions.

Participate in policy development as appropriate.

Strengthen relationship with Regional Public Health Unit.

Ensure support for ARC from IPC staff.

Develop Wairarapa ARC outbreak plan.

Share small DHB perspective.

Local outbreak management policy needs to include RPH and IPC involvement for ARC

This is already in progress and is aligned regionally.

3

The development of protocols for the rapid formation of a regional ARC IMT, which includes representation and decision-making capability from both the ARC sector, PHU, DHB and relevant specialist units, and the training and practise scenarios that are undertaken to sustain this capacity on agreed occasions.

Participate in policy development as appropriate.

Seek Public Health leadership in developing local protocols

Local IMT work is required. A regional ARC /DHB IMT will be clumsy and time consuming to set up.

Local outbreak plan developed.

4

Identify and provide psychosocial support for staff wellbeing during a stand down and in the period after, taking into account the unique circumstances of the individual including accommodation, whānau/family, and community.

Include ARC staff in provision for workforce wellbeing related to a pandemic (& pathway to access that support).

5

Identify and provide psychosocial support for residents’ wellbeing during and after outbreaks including alternatives to visitation during lockdown, taking into account the unique circumstances and identity of the resident.

DHB to continue to endorse ARC providers’ psychosocial support of residents – share examples of excellence.

This also contributes to reassurance for families and the general public.

6 Review IPC standards and develop a national IPC strategy as it relates to the ARC sector. This should then be applied regionally and locally.

Participate as appropriate. New IPC standards will be applied through the ARC certification/ contract audit process.


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This should be done with a working group consisting of representatives from the ARC sector, DHBs, and the Ministry.

7That protocols clarify case recognition to identify infections early and the place of surveillance during a pandemic in high risk environments.

Participate in developing sub regional protocols relating to early identification and surveillance in ARC during a pandemic.

8A pandemic management workbook relevant to the ARC sector is developed through collaboration between the ARC sector, PHUs, DHBs, IPC, and the Ministry.

Promote use of the workbook and actively support ARC providers to adopt it.

This is likely to be a welcome development by ARC.

9Further consideration be given to the reputational consequences for ARC facilities and stigmatisation of ARC staff, for example reconsider method for naming outbreaks.

Adopt national protocols as appropriate.

Apply these protocols to DHB communications with local media and DHB departments (e.g. Hospital, Community Nursing and FOCUS).

Align with national messaging and clarify pandemic terms: e.g. “at risk”, “suspected”, ‘Probable”, “confirmed”, residents in care or “cluster”.

10Reporting requirement to PHUs, DHBs, and others need simplification and streamlining including appropriate software, spreadsheets, and documentation to improve this.

Participate as appropriate. Maintain DHB communication portal for all pandemic reporting.

Planning & Funding reporting portal has been established

Recommended

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Clarify and reinforce strong communication channels between DHB, PHUs and DHB IPC teams. Work together to establish protocols for cooperative and mutually respectful alliances to manage similar situations in the future. Incident and emergency management could provide a useful framework and scenario exercises could be helpful.

Participate in development of protocols.

Strengthen DHB IPC role with regard to ARC. Need for increased IPC FTE for ARC during a pandemic.

Communication channels and alliances are included in the Wairarapa ARC outbreak plan -currently being drafted.

12

Explore options for familiarising the broader workforce with the aged care environment (such as through clinical rotations or supported placements) to enable a well-prepared surge workforce. Incident and emergency management could provide a useful framework and scenario exercises could be helpful.

Increase in dementia education for hospital and community health staff.

Ongoing DHB register for voluntary workforce –check every new employee’s willingness to participate in register.

Consider providing an ARC experience module in education programme for DHB staff.

Strengthen surge workforce skills and knowledge in dementia to reduce adverse impact for residents.

13 A review is undertaken as part of the national annual review of the ARRC services agreement between DHBs and ARC providers to ensure



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alignment and consistency with Health and Disability Services Standards (NZS 8134) and Ministry pandemic plans.

14Reinforce PPE supply, storage, stock management, utilisation advice and “outbreak” kits in collaboration with relevant sector representatives.

Develop sub regional PPE protocols for supply, storage and stock management, including provision of outbreak kits.

Develop and test ARC PPE modelling assumptions.

Sub regional work with CCDHB continuing to take the lead for PPE for ARC.

15 Provision of support for localising pandemic planning, policies, and procedures especially standalone units.

Continue to share pandemic planning examples.

Involvement of ICT in this work.

Larger ARC providers are willing to share their planning resources.

16 Develop pathways for de-escalation, means to avoid complacency, and acknowledgement of successes and champions.

Maintain DHB-ARC communication portal.Maintain consistent messaging during de-escalation (locally & regionally).

DHB public acknowledgement of ARC.

There is a need for national messaging to be timely and consistent.

17

As part of the ongoing review of the Health and Disability Services Standards (NZS 8134:2008), strengthen the IPC standard or guideline, as deemed appropriate, concerning pandemic planning. This may include evidence of relationship between PHU, DHB, and IPC experts.


18Give consideration to timing of infection surveillance of health of residents and staff, reporting to PHU it is a notifiable disease or discussion with DHB infection control.

Develop sub regional protocols relating to early identification and surveillance in ARC during a pandemic.

Wairarapa ARC providers already use an established protocol for notification to PHU of notifiable disease.

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Establish a continuous learning/quality cycle with regional networks. For smaller/standalone ARC providers, without a central office, establish local networks with assistance of DHB, to identify potential networks to link with.

Maintain established local networks for Wairarapa ARC providers.


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Appendix 1

Independent Review of COVID-19 Clusters in Aged Residential Care Facilities

29 May 2020

Review panel members

Tanya Jackways, Infection Prevention and Control Practitioner

Riana Manuel, Chair, Te Apārangi and Manukura Hauora CEO, Te Korowai Hauora o Hauraki

Dr Phil Wood, Geriatrician, Waitemata DHB and Chief Advisor, Healthy Aging, Ministry of Health

Dr Peter Moodie, General Practitioner

Dr John Holmes, Public Health Physician and Honorary Clinical Senior Lecturer, Department of

Preventative and Social Medicine, University of Otago

Dr Frances Hughes, Chair, Nurses Leadership Group, New Zealand Aged Care Association and General

Manager, Oceania Health Care


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Acknowledgements

“This is not BAU, this is something ARC has to deal with. ARC has learned some lessons

and forged more positive relationships with agencies … We have done a pretty good job:

1% of ARC were affected, overseas 30% or more. We should pat ourselves on our back.

We have protected our residents under most difficult circumstances. It has been a

journey that I’m sure each and every one of us will take something from.”

Anonymous, ARC Facility

The panel would like to acknowledge the small number of ARC facilities involved in this review as well

as the generosity of staff who gave their time for further discussion.

The panel would like to thank E Tū and the New Zealand Nurses Organisation for extending the panel’s

opportunity to interview additional nurses and caregivers.

The panel would also like to thank ESR for providing additional data to give a clearer description of the

COVID-19 ARC clusters.


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Contents

Acknowledgements.......................................................................................................................... ii

Glossary ........................................................................................................................................... iv

Executive Summary ......................................................................................................................... 1

Context and Purpose ................................................................................................................. 1

Methodology and Sampling ...................................................................................................... 1

Findings ...................................................................................................................................... 2

Summary of Key Recommendations ......................................................................................... 3

Highly Recommended .......................................................................................................... 3

Introduction .................................................................................................................................... 4

Background and Context to the Review .................................................................................... 4

COVID-19 Clusters in ARC .......................................................................................................... 4

Methods .................................................................................................................................... 5

Limitations ................................................................................................................................. 5

Findings ........................................................................................................................................... 6

Preparedness ............................................................................................................................. 6

IPC Policy and Procedures .................................................................................................... 6

PPE Stock .............................................................................................................................. 7

Previous Experience with Outbreaks ................................................................................... 7

Ability to Isolate ................................................................................................................... 7

Lockdown and COVID-19 ...................................................................................................... 7

Psychosocial Environment of COVID-19 Alert Level 4 for ARC Sector ....................................... 9

ARC Provider Internal Relationships .................................................................................... 9

Communication Channels and Relationships with External Agencies ............................... 12

Recommendations ........................................................................................................................ 14

Highly recommended .............................................................................................................. 14

Recommended ........................................................................................................................ 15

Appendix A: COVID-19 ARC Clusters in Aotearoa New Zealand ................................................... 17

Appendix B: Overseas Experiences ............................................................................................... 22


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Glossary

Alert Level 4 The highest level of alert of New Zealand’s COVID-19 four-level alert system

ARC Aged Residential Care

ARRC agreement Age-Related Residential Care agreement

Bubble This term was used by the NZ Government to communicate the social distancing requirements of Alert Level 4. A bubble in an ARC setting is made up of all the people in the ARC facility at lockdown. This includes ARC staff and residents.

CDC Centers for Disease Control and Prevention

COVID-19 Coronavirus infection 2019. For the purposes of consistency with wider NZ Government communications, this term is used to also mean SARS-CoV-2 where applicable.

Clusters Defines a facility where there are 10 or more confirmed cases of COVID-19.

DHB District Health Board

ESR Institute of Environmental Science and Research Te Whare Manaaki Tangata, Taiao hoki

GP General Practitioner

HCA Health Care Assistant

HCP Health Care Personnel

ID Infectious Diseases

IMT Incident Management Team

InterRAI International Resident Assessment Instrument

IPC Infection Prevention and Control

Lockdown Refers to the period of time when New Zealand was at Alert Level 4. This required ARC facilities to severely restrict and monitor the visitors, services, admissions and staff movements.

the Ministry The Ministry of Health

NRHCC Northern Region Coordination Centre

NZ New Zealand

NZACA

Outbreak

New Zealand Aged Care Association

Defines a facility where there are two or more confirmed cases

PHO Primary Health Organisation

PHU Public Health Unit

PPE Personal Protective Equipment

SARS-CoV-2 The virus causing SARS-COV-2

Whānau Family or family-of-choice of an ARC resident

WHO World Health Organisation


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Executive Summary

Context and Purpose

The COVID-19 pandemic is a unique and unprecedented event in Aotearoa New Zealand. A huge

amount of rapidly changing information and advice filtered through to the public and health sector via

both formal and informal channels. Variation in opinions between ‘experts’ was highly newsworthy.

International experience noted that many of the deaths attributable to COVID-19 were older residents

with multiple comorbidities, and many lived in long term care facilities. In Aotearoa New Zealand, the

ARC sector consists of over 650 providers, and over 38,000 beds. This sector became very vigilant and

naturally concerned about the potential impact. Much of the early clinical and pandemic planning by

DHBs focused on hospital/secondary care management. Early on in Aotearoa New Zealand’s COVID-19

response, a difference in perspective between the ARC sector and the hospital care health system

became apparent. This difference was highlighted by the ARC sector wanting a negative COVID-19 test

prior to admission, in addition to the Ministry’s requirement that all admissions be placed in 14-day

isolation.

Following the classification of five clusters of COVID-19 in ARC facilities, the Director-General of

Health, Dr Ashley Bloomfield, commissioned this review to quickly learn what was effective and what

needs to be improved in order to avoid or better manage any similar events in the future. All the initial

infections came from outside the facilities and two were associated with overseas travel. The ESR data

shows three out of five facilities had staff cases first.

Methodology and Sampling

The sample included five facilities known to have clusters of COVID-19, an ARC facility with a contained

single case of COVID-19 and an equal number of comparable facilities (balanced for size, management,

and location) without an outbreak. One ARC facility had predominantly Māori residents. Included ARC

facilities were informed of the review and permission sought for interview with the panel. All

interviews followed a semi-structured questionnaire and were done via Zoom video conferencing.

Paired members of the panel usually met with individual staff of the facility, occasionally small groups

or pairs of senior management, registered nurses, residential care assistants and senior corporate

staff. A total of 12 facilities were involved. Interviews were also conducted with key staff members of

the PHUs and DHBs associated with the major clusters. Limitations are noted in the Introduction

section of the full report.


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Findings

Few facilities had fully comprehended the impact a probable case would have on their facility, or the

impact of one member of staff becoming symptomatic with COVID-19 (and test positive). The most

notable adverse impact of a staff member’s positive test was the stand down of a high proportion of

the ARC facility’s staff, and the limited prospects of backfilling these. All facilities which experienced a

COVID-19 outbreak, and more notably those with a cluster, reported a number of staff who suffered

considerable stress. This stress was attributed partly to the extra vigilance and longer working hours,

and partly due to considerable external pressures from community misinformation, isolation from

their families, and having their accommodation threatened by fearful landlords or housemates. This

was accentuated by adverse social and conventional media reporting. In addition, while some ARC

staff reported COVID-19 swab testing processes of staff was very thorough and well-managed, others

reported they were left in an uncertain state: feeling pressure to decide either to continue to work or

to have no contact with family. News of “silent spreaders” occupied their thoughts. A number of ARC

providers reported they felt they were under pressure from all sides. Those that experienced a

COVID-19 outbreak, cited concerns for their reputation and their standing in the community. Whether

they had one case or many they were all “tarred with the same brush”, which highlighted the

stigmatisation of the disease and pandemic anxieties.

Amongst the difficulties reported, some ARC management and staff conveyed an increased level of

camaraderie and pride at work. Staff turnover dropped during the four weeks of lockdown, as did

sickness and absenteeism. ARC providers said they increased wellness initiatives for their staff,

recognising the effects of the pandemic on their workload and wellbeing. In some instances, this

extended to financial compensation.

Communications and resources provided to ARC providers and management were at times confusing

and not always clear or consistent. Some noted a lack of available PPE leading into the pandemic

contributed to an inability to practice wearing PPE in some facilities. Relationships with the local DHB

infection prevention and control staff were variable. Concepts such as outbreaks, clusters, probable

versus proven cases, and other epidemiological terminology, are not part of ARC provider day-to-day

discourse and there needed to be better socialisation of the information. The panel found the

perspectives of ARC providers and various “expert opinions” became divided. ARC facilities who

experienced a COVID-19 cluster reported they felt there was a “takeover” by PHUs and/or DHB IPC

experts who had little understanding of the work required in an ARC setting. In contrast, interviewed

PHU staff said they were focused on supporting ARC facilities they understood to be overwhelmed by

the public health requirements to contain the spread of COVID-19.

ARC providers and staff interviewed reported they had up-to-date IPC documentation and procedures

that they had adapted for the COVID-19 pandemic. Refresher training on hand hygiene and PPE use

was undertaken. Many ARC facilities elected to encourage surgical masks be worn even if that was not

required or advised by the Ministry. Several interviewees felt this was associated with minimising

transmission for their ARC facility.

The effect on ARC resident’s whānau/family was noted by staff, especially just prior and in the early

stages of lockdown. Prior to lockdown, several ARC facilities reported a spike in visiting whānau/family,

which contributed to their decision to go into lockdown sooner than the official advice. Virtual visits

using platforms such as Zoom and WhatsApp were commonplace. Visiting a resident receiving


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palliative care was managed on a case-by-case basis in some imaginative ways. Complaints and

criticism were not common and attempts to explain and find alternatives were generally successful.

Summary of Key Recommendations

The panel has the recommendations in two gradings: highly recommended and recommended. The

recommendations included in the executive summary are those graded “highly recommended”, and

have been prioritised in order of importance below. Greater detail is included in the

Recommendations section of this report.

Highly Recommended

1. Acknowledgement by the Ministry of the substantive work done by the ARC sector to prevent

and manage the COVID-19 cluster outbreaks.

2. ARC, DHB, and PHU to develop a national outbreak management policy with leadership roles,

reporting processes and communication channels, and including policy on, IPC strategies, case

recognition, staff and resident management and support, supply and use of PPE, testing,

screening, isolation, lockdown, and resident transfers and admissions.

3. The development of protocols for the rapid formation of a regional ARC IMT, which includes

representation and decision-making capability from both the ARC sector, PHU, DHB and

relevant specialist units, and the training and practise scenarios that are undertaken to sustain

this capacity on agreed occasions.

4. Identify and provide psychosocial support for staff wellbeing during a stand down and in the

period after, taking into account the unique circumstances of the individual including

accommodation, whānau/family, and community.

5. Identify and provide psychosocial support for residents’ wellbeing during and after outbreaks

including alternatives to visitation during lockdown, taking into account the unique

circumstances and identity of the resident.

6. Review IPC standards and develop a national IPC strategy as it relates to the ARC sector. This

should then be applied regionally and locally. This should be done with a working group

consisting of representatives from the ARC sector, DHBs, and the Ministry.

7. That protocols clarify case recognition to identify infections early and the place of surveillance

during a pandemic in high risk environments.

8. A pandemic management workbook relevant to the ARC sector is developed through

collaboration between the ARC sector, PHUs, DHBs, IPC, and the Ministry.

9. Further consideration be given to the reputational consequences for ARC facilities and

stigmatisation of ARC staff, for example reconsider method for naming outbreaks.

10. Reporting requirement to PHUs, DHBs, and others need simplification and streamlining

including appropriate software, spreadsheets, and documentation to improve this.


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Introduction

Background and Context to the Review

The COVID-19 pandemic is a unique and unprecedented event in Aotearoa New Zealand. A huge

amount of rapidly changing information and advice filtered through to the public and health sector via

both formal and informal channels. Almost all deaths attributable to COVID-19 were ARC residents.

Aotearoa New Zealand has (at the time of writing this report) five significant COVID-19 clusters in ARC

facilities; two in Christchurch, two in Auckland, and one in Waikato. ARC residents are particularly

vulnerable to the complications of COVID-19 infections.

The Ministry has prioritised action in this sector and worked closely with DHBs and the NZACA since

early in the evolution of the COVID-19 pandemic. NZACA represents over 90% of ARC providers and

during this time they provided detailed proactive advice to their members, some of which were

experiencing COVID-19 clusters.

Three other reviews of ARC facilities are being completed in response to the COVID-19 pandemic:

1. DHB Readiness Assessments: at the start of April, Director-General of Health, Dr Ashley

Bloomfield, asked DHBs to systematically assess the readiness of ARC providers in their area and

to provide support and assistance as necessary. DHBs looked at each ARC facility’s IPC policies

and practices to ensure the safety and wellbeing of residents. This included an assessment of

PPE stocks and supply.

2. Chief Ombudsman inspection of secure ARC facilities in response to the COVID-19 pandemic.

using The Optional Protocol to the Convention against Torture to inform the inspection. The

goal of the Ombudsman inspection is to provide an independent assessment of how the sector

is responding to COVID-19, including a specific focus on standards of care for those in locked

facilities such as dementia care units and psychogeriatric facilities.

3. The Auditor-General is undertaking an independent review for the public and Parliament of the

Ministry’s management of PPE required for the COVID-19 response.

Early overseas reports identified aged and frail individuals and long-term care facilities as high-risk

groups. These reports highlighted other risk areas which included health care workers who worked

when unwell and across multiple facilities (See Appendix B: Overseas Experiences and Table 1 in

Appendix A: COVID-19 Cases in Aotearoa New Zealand).

COVID-19 Clusters in ARC

In the five clusters, all the initial infections came from outside the facilities and two were associated

with overseas travel. The ESR data (figures 1-5 in appendix A) shows three out of five facility’s had staff

cases first. In some cases, recognition of an outbreak was relatively delayed which accelerated

internal facility transmission.


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Onset dates ranged from 11 March 2020 through to 28 March 2020 with further outbreak reports

ranging from 24 March 2020 through to 10 April 2020 and associated secondary cases have

continued to present through to mid-May 2020.

The clusters reflected the peak period of incidence throughout New Zealand.

The definition of a cluster meant that it could include both residents/staff but also outside

contacts. A total of 39 cases occurred in residents out of a total of 428 “beds”, with cluster size

totalling 153.

The most common vector of COVID-19 to facilities was a staff member, although in one case the

source has not been formally identified.

For details of the COVID-19 disease and the SARS-CoV-2 virus refer to Appendix A: COVID-19 Cases in

Aotearoa New Zealand.

Methods

In keeping with the terms of reference,1 the sample included the five ARC facilities with COVID-19

clusters, one ARC facility with a single case of COVID-19, and six comparable facilities with no clusters

(balanced for size, management, location). One of these facilities had predominantly Māori residents.

Those on the contact list were informed of the review, and permission sought for interviews. A total of

12 facilities were involved. Interviews were also conducted with key staff members of PHUs and DHBs

associated with the major clusters.

A semi-structured questionnaire was designed and used as a basis for conducting the interviews, each

of which was done by video conferencing and varied in duration from 30 minutes to two hours. Each

of the ARC facilities were encouraged to include staff (nursing, caregivers and support) and

management in the interview process. Where possible, staff were interviewed separately from

management. The panel further requested whether there would be any residents who would be

available for a conversation. This offer was not taken up by any residents and is an acknowledged

limitation of this report. The panel worked in pairs to conduct the interviews which were then collated

into this final report.

The interviews were designed to be qualitative and sought to understand what happened during the

COVID-19 pandemic. Multiple interviews occurred within facility clusters with staff to validate findings.

Limitations

The panel acknowledges the limitations of this review. Due to the travel restrictions of Alert Level 4

and Alert Level 3, the panel was unable to visit the ARC facilities included in this review. Whilst ARC

staff and residents were provided with the opportunity to meet with the panel, the virtual nature of

the review may have been a key barrier. The review panel did not interview residents or

whānau/family who may have offered additional perspective. Whilst some ARC staff were interviewed,

it is possible some residents and more staff would have been available for a conversation if panel

members were on site.

1 https://www.health.govt.nz/system/files/documents/media/23_april_-_irccarc_tor_final.pdf


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Findings

Preparedness

During February and March 2020 New Zealand’s preparation for COVID-19 focused mainly on

hospital/secondary care management and the sector working on pandemic planning. The potential

impact on the community and ARC sector was increasingly realised through March and April 2020; the

DHB Readiness Assessments were carried out during this interval.

Whilst the review panel did not critically examine contracts, standards and pandemic plans, it was

noted that alignment of these crucial agreements and process in relation to managing pandemic

response was lacking. Inconsistencies between the ARRC service agreement,2 expectations of PHU,

and DHB pandemic response were noted.

IPC Policy and Procedures

All ARC providers interviewed reported up to date and compliant infection control policies in place

which were reviewed annually. While all anticipated the impact of a pandemic in general, no facilities

were prepared for the impact of a positive case, let alone an outbreak/cluster. ARC facilities which

were part of larger organisations had detailed pandemic plans developed prior to the Aotearoa New

Zealand outbreaks.

Few ARC facilities or DHBs had ever coped with a large scale stand down of staff, as was the case for

ARC facilities with clusters. Clear continuity planning for staff backfilling was limited to reduction in

20%, 40% or 50% of staff, but did not require continuity planning for up to 100% staff reduction of

staff and was not stress tested. The impact on ARC residents being looked after by backfilled staff,

unfamiliar to both the functioning of ARC and their individual residents, was considered by

interviewees but felt a lack of involvement in the decision making process meant no reasonable

alternatives were further identified.

Senior ARC staff said that they had a very good understanding of

infection control and so were able to implement the plans

quickly. All ARC facilities had an IPC Lead on-site. This person

generally had good links to the IPC team within DHBs and were

able to discuss their policies and plans as required.

Subsequently, it was found that the ARC facility’s preparedness,

in terms of policy and procedures, did consider the magnitude of

the events that could occur due to COVID-19. However, the extent of the impact COVID-19 had on ARC

facilities far exceeded the expectation of all ARC providers, even with plans in place.

2 https://www.health.govt.nz/our-work/life-stages/health-older-people/long-term-residential-care/age-related-

residential-care-services-agreement

“We worked together, non-stop, in PPE. We worked out it was 64 shifts in a row with PPE.”

ARC STAFF


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PPE Stock

Most ARC providers had a two-week minimum supply of PPE in advance of the lockdown. Most ARC

providers had access to PPE through the DHB, although there was initially some difficulty obtaining

stocks from them. While all ARC providers insisted on minimum standards, most allowed staff to wear

the PPE gear which made them feel safe. Clarity around why this view was held or who was being

protected was unclear. The panel is of the opinion there may be a misperception that PPE was

equivalent to IPC.

Through March 2020 to early April 2020, provision of PPE stocks in many ARC facilities would not have

been sufficient for an outbreak, and many facilities were reliant on their regular supply of PPE, most

notably masks and facial shields/goggles. These supplies were obtained from a variety of sources

including commercial suppliers, DHBs, and sometimes from other ARC providers. Access to sufficient

supplies was challenging. This improved following the development of a national supply chain and

improved central purchasing arrangements.

Previous Experience with Outbreaks

Most ARC providers had previous experience with outbreaks of

norovirus, influenza, and/or measles. During these outbreaks, the

facilities would go into lockdown. Several ARC providers noted that

it was their first experience of one of a virus outbreak which

prompted a review of IPC policies, best practice, and PPE supply.

Ability to Isolate

All interviewed ARC facilities had the ability to isolate people if

required in rooms or bubbles. In some cases, isolation zones were

prepared before any cases were reported, based on independent

access and infrastructure. The practicality of establishing areas for

isolation was linked to the age of the building. Some providers

acknowledged that should an outbreak occur they could have only

done what was possible. Dementia areas were particularly challenging as residents within a dementia

unit are treated as one isolation bubble. Some ARC facilities reported that DHBs were inconsistent in

their understanding of the challenges of applying isolation in these environments.

Lockdown and COVID-19

As the pandemic unfolded, all interviewed ARC providers developed detailed plans involving possible

isolation of infected patients, and commenced additional staff training activities. Those facilities

belonging to larger corporate organisations reported they were able to draw on their national and

trans-Tasman experience and expertise.

A poignant quote provided to the ARC management by the whānau/family of an ARC resident who passed away during lockdown was “our loved one died of loneliness.”

RESIDENTS AND WHĀNAU/FAMILY


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Most ARCs instituted lockdown procedures before this was officially mandated. One ARC provider who

experienced a COVID-19 cluster waited until the official lockdown and explained they were hesitant to

“jump the gun” and go against the advice of their local DHB. This was something that they regretted

later.

The ARC providers and their staff felt significantly more secure in lockdown and most wished they had

locked down sooner than they did.

Following lockdown, one ARC facility described how they worked from the “outside to the inside” in

cleaning their facility. They first ensured the facility’s physical perimeters were cleaned and then

progressively moved the cleaning process into the building. This facility highlighted that contamination

came from the without, rather than from within. This provider believes this was an essential measure

to contain the spread.

Staff

ARC providers reported they proactively worked with their staff to monitor their health status,

including temperature checks, declaration of health status and PPE checks at the start of shifts. ARC

providers developed resources to increase staff awareness of IPC protocol, transmission risks, and

appropriate use of PPE. ARC staff interviewed separately confirmed there was an increase in and

reported they were motivated to learn what would help keep the ARC residents safe.

Some ARC providers provided online training for Alert Levels 3 and 4, which included reading material.

For some essential training, staff were expected to confirm they had received, read and understood

the training via an emailed response. These were sent to personal emails. ARC staff were able to do

this if they had time while rostered, however, otherwise this was on their own time so not necessarily

paid.

Residents

ARC management and staff had conversations with residents to explain the ongoing pandemic, the

lockdown, and what this meant for them. Residents reported feeling sad they would be unable to have

visitors but understood why this was not possible. ARC staff reported residents managed well but that

they were “obviously unhappy” at the loss of visiting by relatives.

All ARC providers created cohorts for meals and daily activities. One provider played the WHO video

on COVID-19 at the start of each daily activity to remind residents of the importance of lockdown. One

provider held daily afternoon meetings for residents at which they would provide COVID-19 updates.

Whānau and Family

Just prior to lockdown, several ARC providers reported an increase in the number of visits from

whānau/family and in, some instances, this influx prompted an earlier lockdown.

In the first few days of lockdown, most ARC providers were overwhelmed by phone calls and emails

from residents’ whānau/family. However, these lessened once communication channels were

established.


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Overall, those interviewed reported resident’s whānau/family were supportive of ARC provider’s

decision to go into lockdown. Whānau/family visits were allowed if the resident was in palliative care.

One ARC provider allowed a visit as the resident was experiencing severe depression. In all instances of

visiting, whānau/family understood and adhered to the strict PPE and IPC measures that were in place.

Psychosocial Environment of COVID-19 Alert Level 4 for

ARC Sector

ARC Provider Internal Relationships

Relationships with Residents and Whānau/Families

In the early stages of COVID-19 before national lockdown,

relationships with some residents’ whānau/family became

strained. ARC providers reported the initial strain was likely

fuelled by media who were referring to “illegally locked in”

whānau/family in their coverage. These articles were often

published without consulting the ARC facilities they were

reporting. The ARC facilities advocated for the safety of

residents. Eventually, and following government

announcements, whānau/family concerns decreased.

All facilities organised regular contact between residents and

whānau/family. This included: setting up a regular email

newsletter, increased phone access, and setting up Facebook

pages and WhatsApp for their residents. All ARC providers

increased their assistance in organising video calls, such as Zoom, with one ARC provider putting on an

extra staff member specifically for this. One facility made a video for relatives. Some relatives were

able to communicate through closed windows.

ARC staff worked particularly hard to maintain and strengthen communication between residents and

whānau/family, frequently allowing consideration of visits on a case-by-case basis. Interviewees

reported whānau/family have overall been quite positive about ARC providers response during Alert

Level 4 and, in particular, when there were clusters.

Despite the best efforts of ARC staff, there was general feedback regarding the decline in the quality of

life of residents during the lockdown. This was often attributed to the visiting restrictions.

The psychological wellbeing of residents and whānau/family in the context of a pandemic requires

further consideration by ARC providers, DHBs, PHUs and the Ministry.

At the end of isolation, one ARC resident, who had been attended by staff in full PPE for a number of weeks said, in good humour:

“Look, I want to see your face. Who are you? I wouldn’t recognise you in the street, yet you’ve looked after me in the shower, toilet and at

bedtime.”

ARC RESIDENTS AND STAFF


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ARC Provider and Staff Members

At the start, there was tension and stress placed on ARC staff. Both management and staff described

an atmosphere of fear. Initially, there was a perception that the Ministry, DHBs, and PHUs were unsure

what to do and all were making high-level decisions without considering the context of the ARC sector.

All interviewed felt ARC staff should have been provided prioritised access to COVID-19 testing at a

much earlier stage.

There was a significant psychological burden placed on staff. It was not uncommon to hear that staff

members were threatened with eviction from their accommodation by their landlords or housemates

if they continued to work for the facility. Some staff reported they were “treated like lepers in our

society” and the facilities were also the subject of online attacks. One person posted on an ARC

facility’s social media page that the ARC facility should be “burnt to the ground.” Staff at one facility

were subject to irate neighbours due to large amount of DHB yellow laundry bags being left on the

street. Neighbours abused staff on entry and exit for “exposing them to COVID-19.” ARC staff were

concerned about the effects of this type of aggression going forward.

Generally, the relationship between ARC management and staff has strengthened during the last few

weeks. ARC management reported learning more about their staff and their personal life as part of

their transmission risk assessments. Some ARC providers created new systems in relation to knowing

their staff, where they lived and who with. Where staff members were identified as vulnerable, it was

decided that they would not work near infected patients if this were to occur. In most cases where

housing was an issue, ARC staff were supported with accommodation either using spare beds at the

ARC facility, staying in a nearby hotel and/or a rented caravan. Some ARC providers made the decision

to provide a temporary wage increase in recognition of the extra workload and risk involved in the

pandemic response.

Some ARC staff worked across a number of ARC facilities, in some cases this was against their

employer’s guidance and ARC staff had not always informed their employer. Uncovering this caused

tension for the ARC staff and their employer(s).

Frequent communication and check-ins with ARC staff greatly impacted the perceived quality of the

ARC provider’s response to COVID-19. The majority of ARC providers established a practice of daily

short meetings (in some instances twice-daily) with ARC staff.

Interviewed facilities felt the general atmosphere, once the ARC staff were reassured, was good.

Across the board, staff members were quite close and part of established work environments with

strong community, compassion and camaraderie. All ARC staff and management handled the situation

in a professional and compassionate manner, frequently going well beyond the normal call of duty.

Relationships within Management and to Board / Central Office / Owner

Some ARC facility managers had regular meetings with their board, head office or regional group.

These were considered essential to ensuring correct information flow and providing reassurance from

the top-down. These took the form of daily briefings, presentations on policies, and/or quick check-ins.

Where appropriate, meeting frequency was reduced to remain proportional to the risk of

transmission. Some regional ARC providers set up short-cycle quality improvement loops to learn from

their various facilities.


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ARC providers found great success with solutions tailored to their local environment. One ARC

provider reported that preparation for COVID-19 was at a local community level, referring to the Iwi-

based roadblocks set up by a resident to prevent road travel and

prevent people from travelling in/out of the local area. The

roadblocks greatly increased community awareness to the risk of

COVID-19, which simplified the work of the ARC provider in

instituting lockdown and IPC measures.

ARC providers reported feeling “bombarded” by communications

from the Ministry, the DHB and PHU, which were not always

relevant to the ARC sector. The panel noted that during this time

the Office of the Ombudsman was undertaking inspections of

dementia facilitates, which added further concern for ARC sector.

ARC facilities who were part of larger organisations found benefit

in having a centralised office to collate the published information

and resources, which were often not in concert and often a day or

two late for correspondence that was sent to residents

whānau/family. A few interviewees reported the delays caused by

Ministry internal sign-off on needed documents was a repeated

frustration.

Relationships with Local Primary Care Support and Medical Suppliers

Clinical assistance at a distance from ARC providers primary care support and usual medical suppliers

worked very well, and some had software which allowed the doctors to be able to look at the case

notes and nursing notes. Likewise they had electronic access to pharmacies.

ARC facilities who had primary care support as staff or through external contracts were largely

unaffected by Alert Level 4 isolation. Where possible, appointments were conducted via video

conferencing or telephone. Sometimes primary care professionals worked across multiple ARC

facilities and some ARC facilities use multiple primary care professionals.

ARC facilities who used the local primary care support sometimes found it difficult to manage primary

care support visits, in light of PPE and isolation requirements, and that sometime access to primary

care was not always readily available.

ARC facilities with staff that required COVID-19 testing had difficulty getting advice from Healthline.

Lag times and provision of results was variable, and not well communicated through to the ARC

facility. ARC management reported this complicated rostering and communications to their staff.

In some instances, ARC staff members were refused a test by their GP if they were asymptomatic.

They were not aware that testing of asymptomatic people was discouraged in protocols from the

Ministry. This was not helped by the changing advice as more information known about the virus and

testing capacity increased.

“The relationship between ARC and funder has improved and there has been a lot of development. We would like to see those relationships continue to be built on. We are looking after New Zealand’s greatest treasures.”

ARC FACILITY STAFF MEMBER


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Communication Channels and Relationships with

External Agencies

ARC Providers and DHBs

The majority of ARC providers were complimentary about their

interactions with their local DHBs, who were helpful in providing

PPE and kept in regular contact with ARC providers. This included

brief conversations over the phone during which ARC providers

were able to get advice and support on an array of issues.

However, ARC providers reported there was variation in DHB

response which signalled not all ARC-DHB and/or PHU

relationships are strong. ARC providers observed that the

personality of their DHB and/or PHU contact was very important.

One ARC provider, who had experienced a cluster, wished the DHB

had offered nursing staff to help manage the extra workload in the

ARC sector in light of the fact that non-acute services within the

DHB had been cancelled.

ARC management spoke complimentarily about those DHBs who set up crisis units to manage the

situation. Despite the initial loss of ARC staff, a number of other ARC staff members actively

volunteered to work in the isolation unit and others agreed to work 12-hour shifts so that the

increased workload was covered.

Although there was significant variation in the types of responses by DHBs, their work was appreciated

by the affected facilities. In addition, one of the unaffected ARC facilities was being effectively

managed by the DHB due to a significant and acute loss of staff prior to the pandemic.

One DHB, when confronted with the reality that patients may have to be moved to the public hospital,

rose to the occasion and became involved at a detailed level and indeed helped to find staff for

specific shifts.

When decisions were made to transfer residents from certain ARC facilities, there was insufficient IPC

guidance requested on appropriate IPC protocols for ARC providers and DHBs to follow. There needs

to be a clear escalation process agreed by key parties (such as ARC, PHU, DHB IPC) prior to any

resident being moved out of their environment. Sudden movements create stress on vulnerable

groups.

ARC Providers and other External Services

Those ARC providers looking after COVID-19 residents were broadly critical of their interactions with

external services such as PHUs and DHB IMT teams. Many ARC providers reported they did not have

access or involvement with the IMTs to allow the ability to contribute to decisions. ARC providers

concerns were exacerbated by ineffective and/or inconsistent communication from the PHU, which

they perceived had poor links with their local DHBs.

“We arrived and it was chaotic. Everyone was new. We had no idea of the work routine, nothing got documented, we couldn’t work the hoist, and all we could do was feed, keep people clean, toilet, and ready at bedtime.”

DHB STAFF COVERING ARC

SHIFTS


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Once an outbreak was identified, management of staff was critical. Within 48 hours, ARC providers

with a cluster reported at least 40% of their staff chose not to work because they feared infection, or

because the PHU had contacted and informed the staff they were either suspected or close contacts

and not to return to work. Often ARC staff received the instruction from the PHU that they were to be

stood down either just prior to or in the middle of a shift. ARC facilities were generally not given prior

warning, which could have assisted with staff planning. Some staff stopped working because of age or

significant co-morbidities. The sudden loss of staff caused the ARC provider to turn to casual and

agency staff, which also resulted in increasing the risk of infection. This period was described as

“complete chaos” and was highly stressful for all concerned.

Some DHBs provided staffing support to ARC facilities. These posts were voluntary, and DHB staff who

accepted these roles were assured of appropriate PPE and protocols at the ARC facility. DHB staff, ARC

management, and staff highlighted that the DHB staff were not adequately briefed on what to expect

when working in the ARC setting. Primarily, the differences in the way care is provided in an acute

setting versus a resident’s home setting. DHB staff were not told to expect a different RN-resident

ratio, different PPE, or briefed in the nature of work required. DHB staff were faced with very

unfamiliar territory, processes, recordkeeping, and pharmaceutical management technology. Existing

ARC staff and those familiar with old and frail people put considerable effort into educating and

training the DHB staff and other replacements.

From the PHU perspective, ARC staff with multiple contacts and working at multiple facilities did

complicate contract tracing. There were difficulties accessing reliable contact details, accurate rosters,

details of “work bubbles” in some cases. One ARC facility reported their PHU asked ARC staff to

shorten their time with residents to 15 minutes or less, which the ARC staff found an untenable option

in light of their duties to taking care of residents (showering, toileting, feeding, etc).

ARC Providers and Media

Media reports were a significant distraction for ARC providers, who were aggrieved they were not

given meaningful warning of media releases. One ARC provider was given 10 minutes warning that

they were about to be named as a COVID-19 cluster on television. The media report resulted in a

storm of anxious and confused correspondence from worried whānau/family who had previously been

told that everything was under control.

ARC providers that were part of a national group or chain appeared to have had greater support

because their national offices fielded questions and developed communication responses which took

the “heat off the facility”.

ARC providers had difficulty understanding reported size and timing of the clusters. For example, one

ARC facility was reported by the PHU as having 15 cases. This ARC facility had just three residents with

COVID-19. The PHU had included all people who were suspect or confirmed cases of COVID-19 as part

of the cluster. This included household contacts of the ARC staff member. This led to a

misunderstanding of the meaning of “cluster”, which had a devastating effect on the whānau/family’s

confidence in the ARC providers.


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Recommendations

Highly recommended

1. Acknowledgement by the Ministry of the substantive work done by the ARC sector to prevent

and manage the COVID-19 cluster outbreaks.

2. ARC, DHB, and PHU to develop a national outbreak management policy with leadership roles,

reporting processes and communication channels, and including policy on, IPC strategies, case

recognition, staff and resident management and support, supply and use of PPE, testing,

screening, isolation, lockdown, and resident transfers and admissions.

3. The development of protocols for the rapid formation of a regional ARC IMT, which includes

representation and decision-making capability from both the ARC sector, PHU, DHB and

relevant specialist units, and the training and practise scenarios that are undertaken to sustain

this capacity on agreed occasions.

4. Identify and provide psychosocial support for staff wellbeing during a stand down and in the

period after, taking into account the unique circumstances of the individual including

accommodation, whānau/family, and community.

5. Identify and provide psychosocial support for residents’ wellbeing during and after outbreaks

including alternatives to visitation during lockdown, taking into account the unique

circumstances and identity of the resident.

6. Review IPC standards and develop a national IPC strategy as it relates to the ARC sector. This

should then be applied regionally and locally. This should be done with a working group

consisting of representatives from the ARC sector, DHBs, and the Ministry.

An effective IPC strategy needs to address environmental, organisational, and individual barriers

to adherence. Intervention programmes need strong leadership and the involvement of staff at

all levels. Infection prevention does not rely solely on a functional infection control team, but

also depends on facility organisation, bed occupancy, staffing, and workload.

7. That protocols clarify case recognition to identify infections early and the place of surveillance

during a pandemic in high risk environments.

8. A pandemic management workbook relevant to the ARC sector is developed through

collaboration between the ARC sector, PHUs, DHBs, IPC, and the Ministry. The workbook should

include:

a. early establishment of an ARC facility IMT, which includes representation and decision-

making capability from the ARC sector, DHB, PHU, IPC and any relevant specialist units

(these may be tailored depending on the nature of the outbreak)

b. essential responsibilities of the executive management team

c. the communication strategy, including internal communication, newsletters to

whānau/family, local community, PHU, DHB, etc

d. staffing opportunities and resources including accommodation, travel, and wellbeing

support


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e. developing cohorts/bubbles within facilities (to be localised to the facility)

f. pre-shift screening and testing thresholds for staff

g. staff contacts, rosters, living situation, and membership of a “bubble”

h. staff support chain, agreement about test result dissemination

i. clear processes and procedures for when a staff member develops symptoms at home, or

during a shift

j. PPE supply, storage, and access, which reflects the perceived threat/risk

k. better resident identification and technology to enable backfill staff to provide safe and

efficient care

l. wellbeing support for residents including technology, visiting opportunities, and end-of-

life support

m. decision point for transfer from residential facility to DHB, required briefing material, and

up-to-date resident identification information

n. decision point for DHB staffing assistance to residential facility, required briefing

material, and up-to-date resident identification information

o. routine simulation exercises for isolating units of an ARC facility and/or isolation of staff

members as part of IPC plan.

9. Further consideration be given to the reputational consequences for ARC facilities and

stigmatisation of ARC staff, for example reconsider method for naming outbreaks.

10. Reporting requirement to PHUs, DHBs, and others need simplification and streamlining

including appropriate software, spreadsheet, etc documentation to improve this.

Recommended

11. Clarify and reinforce strong communication channels between DHB, PHUs and DHB IPC teams.

Work together to establish protocols for cooperative and mutually respectful alliances to

manage similar situations in the future. Incident and emergency management could provide a

useful framework and scenario exercises could be helpful.

12. Explore options for familiarising the broader workforce with the aged care environment (such as

through clinical rotations or supported placements) to enable a well-prepared surge workforce.

Incident and emergency management could provide a useful framework and scenario exercises

could be helpful.

13. A review is undertaken as part of the national annual review of the ARRC services agreement

between DHBs and ARC providers to ensure alignment and consistency with Health and

Disability Services Standards (NZS 8134) and Ministry pandemic plans.

14. Reinforce PPE supply, storage, stock management, utilisation advice and “outbreak” kits in

collaboration with relevant sector representatives.

15. Provision of support for localising pandemic planning, policies, and procedures especially

standalone units.


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16. Develop pathways for de-escalation, means to avoid complacency, and acknowledgement of

successes and champions.

17. As part of the ongoing review of the Health and Disability Services Standards (NZS 8134:2008),

strengthen the IPC standard or guideline, as deemed appropriate, concerning pandemic

planning. This may include evidence of relationship between PHU, DHB, and IPC experts.

18. Give consideration to timing of infection surveillance of health of residents and staff, reporting

to PHU it is a notifiable disease or discussion with DHB infection control.

19. Establish a continuous learning/quality cycle with regional networks. For smaller/standalone

ARC providers, without a central office, establish local networks with assistance of DHB, to

identify potential networks to link with.


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Appendix A: COVID-19 ARC Clusters in

Aotearoa New Zealand

As at 9:00am on 24 May 2020, there had been 1,154 confirmed cases of COVID-19, 350 probable cases

and 21 deaths since the first case was identified on 26 February 2020.3 Five clusters of COVID-19 were

identified within ARC facilities by 10 April 2020, shortly before the establishment of the Independent

Review.

Table 1 shows the rate of COVID-19 is low in the population aged over 70 in Aotearoa New Zealand.

Table 1: Aged distribution of COVID-19 cases in New Zealand4

The Weekly COVID-19 Report5 for the week ending 15 May 2020 showed that five ARC clusters were

associated with 153 cases linked to ARC facilities out of a total of 1,504 cases nationally at 24 May

2020 (10.2% of all cases). Table 2 shows that for the five clusters, a total of 39 residents were infected

and there were 78 health care workers and 36 others associated with health care workers infected.

The rate of infection in residents was considerably lower than that of health care workers or their

close associates. The onset dates of the outbreak cluster cases range from 11 March 2020 until 28

March 2020 which coincides with the peak in national notifications. The timing of the onset of

infection in residents, health care workers and others associated with the various facilities is shown in

the Epidemic Curves6 of Figures 1 to 5.7,8

3 https://nzcoviddashboard.esr.cri.nz\#!404 (accessed 24 May 2020). All data used in this appendix is based on an extract

of data performed by ESR and provided to the panel on 24 May 2020. 4 Data extracted from the Ministry website https://www.health.govt.nz/ (accessed 21 May 2020). 5 This report was prepared for the Ministry by ESR and is available from https://www.esr.cri.nz/. 6 An Epidemic curve for an outbreak shows the number of cases of a specific disease occurring at specified intervals during

the entire outbreak. 7 In Figures 1 to 5 the numbers are colour-coded to show residents, staff and others. 8 All detailed data used in this report is based on an extract of data performed by ESR and provided to the panel on 18 May

2020.

Age Group Confirmed Probable Grand TotalRate pr

100,000

<1 1 3 4 6.7

1 to 4 5 13 18 7.3

5 to 9 3 11 14 4.3

10 to 14 28 18 46 14.2

15 to 19 54 21 75 23.8

20 to 29 284 74 358 51.3

30 to 39 175 54 229 35.2

40 to 49 173 47 220 35.4

50 to 59 186 60 246 39.1

60 to 69 152 26 178 34.3

70+ 93 23 116 22.0

Grand Total 1,154 350 1,504 30.6


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https://nzcoviddashboard.esr.cri.nz/#!404

https://www.health.govt.nz/

https://www.esr.cri.nz/

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Table 2: Summary of COVID-19 outbreak clusters related to ARC facilities

In cluster outbreaks 2 and 3, residents appear to have been the first to show infection, but in cluster 3

a resident and a health care worker developed signs of infection simultaneously. The source(s) of their

infections are unknown.

It is noteworthy that, according to the data from ESR, for three of the outbreaks, notification to the

PHU was late in the outbreak. On reviewing the data in retrospect, it appears that more than half of

the people had developed symptoms of illness before the outbreak was notified. This delay makes

contact tracing very difficult due to people being unable to remember details and contacts many days

earlier.

This can be seen in Figure 1, the outbreak cluster 1 was reported on 24 March 2020 when 13 people

had been identified as being infected of the 15 cases who subsequently developed symptoms (all staff

or others associated with the staff).

Figure 2 shows outbreak cluster 2 with a notification date of 1 April 2020 at which time 12 of the 19

cases (including 5residents) had become ill. The timing of the onset of first symptoms, upon which the

graph is based, becomes clear when the case is investigated by the PHU. Sometimes the timings as

reported may differ from their recognition by clinicians.

More detailed studies based on gathering information about the sickness experience and behaviours

of individuals within the facility is required when trying to determine the risk factors for people

becoming ill. Such studies require considerable resources and much planning and are not appropriate

in outbreaks such as seen in the ARC facilities.

Epidemic curves for the individual facility outbreaks do not show the temporal overlap of clusters in

two centres when the PHUs were each experiencing two outbreaks. These are incorporated into

Figure 6. Figure 6 shows the distribution of confirmed and probable cases and the relationship of the

outbreak clusters to the national picture. It can be appreciated that there would be significant

workload for staff in the PHUs involved in contact tracing but also a very high demand for health care

workers in the ARC facilities to replace those who were sick leave or had been put into 14 days

isolation.

It is important to note that some symptoms shown in the graphs below were identified retrospectively

and occurred prior to recognition of the outbreak by the PHUs.

Outbreak Number

Number of

cases

linked

(EpiSurv)

Cases in

Residents

Bed

numbers

Attack

rate (cases

/ 100 beds)

Outbreak

report date

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of earliest

case

Most recent

onset date

International

travel link

Outbreak Cluster 1 15 3 87 3.4 24/03/20 12/03/20 1/04/20 Yes

Outbreak Cluster 2 19 5 89 5.6 1/04/20 11/03/20 6/04/20 No



Outbreak Cluster 5 13 5 97 5.2 10/04/20 18/03/20 16/04/20 Yes

Total 153 39 428 9.1


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Figure 1: Epidemic curve for COVID-19 outbreak “Cluster 1”9

Figure 2: Epidemic curve for COVID-19 outbreak “Cluster 2”


9 Data from ESR extracted for period to 14 May 2020.

Notification of Outbreak




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Figure 6: Covid-19 cases and outbreak clusters by ARC facility

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sCovid-19 cases and Outbreak Clusters

ESR Confirmed cases ESR Probable cases Outbreak 1 Outbreak 2 Outbreak 3 Outbreak 4 Outbreak 5

BR

L2 L3 L4 L3 L2

BR - Border Restrictions 16 Mar 2020 L2 - Covid Level 2 21 Mar 2020 L3 - Covid Level 3 23 Mar 2020 L4 - Covid Level 4 25 March 2020 L3 - Covid Level 3 28 Apr 2020 L2 - Covid Level 2 14 May 2020


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Appendix B: Overseas Experiences

A report from the CDC described the experience of COVID-19 in the United States between

12 February and 9 April 2020.10 In that period, 315,531 COVID-19 cases were reported to CDC, 49,370

(16%), and of those 9,282 (19%) were identified as HCP. The article concluded: “These preliminary

findings highlight that whether HCP acquire infection at work or in the community, it is necessary to

protect the health and safety of this essential national workforce”.

One of the first clinical reports from the United States described an outbreak of COVID-19 cases

among 89 residents in a “skilled nursing facility” in King County, Washington State.11 This resulted from

a HCP working for two shifts (26 and 28 February) whilst symptomatic and in the early stages of

infection. They tested COVID-19 positive on 1 March. On 2 March a resident in the unit became unwell

and tested positive on 3 March. In all, 76 residents were tested between 10 and 26 March and

48 (64%) tested positive for COVID-19.12 Seventeen (35%) of these residents described typical

COVID-19 symptoms, four (8%) had atypical symptoms, and 27 (56%) reported no symptoms at all. The

authors estimated the doubling time for cases in the facility to be 3.4 days (95% confidence interval

[CI] 2.5 to 5.3). They concluded that there was poor correlation between symptom onset and viral

shedding and recommended, “Consideration should be given to test-based strategies for identifying

residents and staff with COVID-19 infection for the purpose of excluding infected staff and cohorting

residents, either in designated units within a facility or in a separate facility designated for residents

with COVID-19”.

The detection of cases of COVID-19 in ARC facilities depends on the recognition of symptoms, but this

can be difficult when many residents may have dementia, a history of strokes, or other health issues

that may mask manifestations of COVID-19 infection. All health care workers in ARC facilities need to

follow the ABCD:13

“Awareness of potential key clinical differences of COVID-19 in this population; quickly

initiating appropriate behaviours to manage the infection clinically in ARCs;14

implementing containment strategies to disrupt further spread of the virus, as well as

preventive interventions in an ARC; and being knowledgeable about the decisions being

made at the local, regional, and national level will help achieve this goal.”

The authors conclude with: “... this article is intended to help ... healthcare providers understand the

ABCDs of the COVID-19 pandemic. We recognize that the situation is fluid as new information and

recommendations are released almost hourly”.

10 CDC COVID-19 Response Team. 2020. Characteristics of Health Care Personnel with COVID-19 – United States, February

12-April 9, 2020. Morbidity and Mortality Weekly Report 69(15), 477–481. https://doi.org/10.15585/mmwr.mm6915e6 (accessed May 2020).

11 Kimball A, Hatfield KM, Arons M, et al. 2020. Asymptomatic and Presymptomatic SARS-CoV-2 Infections in Residents of a Long-Term Care Skilled Nursing Facility – King County, Washington, March 2020. Morbidity and Mortality Weekly Report 69:377–381. DOI: http://dx.doi.org/10.15585/mmwr.mm6913e1 (accessed May 2020).

12 The paper refers Kimball A et al. Refer to SARS-CoV-2, but the virus had been renamed by WHO on 11 February 2020. 13 D’Adamo H, Yoshikawa T, Ouslander JG. 2020. Coronavirus Disease 2019 in Geriatrics and Long-Term Care: The ABCDs of

COVID-19. J Am Geriatr Soc 68(5): 912–917. doi:10.1111/jgs.16445 (accessed May 2020). 14 Terminology has been adapted for the Aotearoa New Zealand context. Original text uses the term: “long term care” which

is equivalent in Aotearoa New Zealand to ARC.


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Post-containment management of ARC facilities will require a combination of medical, psychological,

political and economic resources. “Until a proper management plan is drafted, ARC15 residents are in

for a lonely journey.”16

The American Geriatrics Society noted challenges and opportunities that will impact on the availability

and expertise of the workforce in the ARC facilities.17 These include paid leave, screening, training, and

staff availability.

A study of 224 staff in Dunedin Hospital in 2008 looked at “sickness presenteeism”.18 It found that

about 50% of hospital staff had worked when unwell during the preceding 12 months. Twenty-eight

percent of staff reported working when they had symptoms of influenza and 78% said they would

work when they had symptoms of “common cold virus”. These symptoms are all recognised in

assessing COVID-19 and so it should not come as surprising that the HCP in Washington State worked

for two shifts. The main reason given for continuing to work was: “Did not want to increase workload

of others (53.5%)”. Thirty-one percent reported “There would not have been a replacement available”

and 22% reported “Pressure from work” as reasons for not taking sick leave.

15 Terminology has been adapted for the Aotearoa New Zealand context. Original text uses the term: “nursing home” which

is equivalent in Aotearoa New Zealand to ARC. 16 Boucaud-Maitre D, Roxane M, Maturin V, Villeneuve R, Tabue-Teguo TM. Post-containment management of nursing

 homes: a new public health concern. [Published online ahead of print, 13 May 2020]. Eur Geriatr Med [Internet]. 2020 (0123456789). Available from: https://doi.org/10.1007/s41999-020-00328-9. This French article refers to “nursing homes” but it applies to ARC in the New Zealand context. 2020 1–2. doi:10.1007/s41999-020-00328-9 (accessed May 2020).

17 American Geriatrics Society (AGS). 2020. American Geriatrics Society Policy Brief: COVID-19 and Nursing Homes. J Am Geriatr Soc 68(5): 908–11.–911. doi:10.1111/jgs.16477 (accessed May 2020).

18 Bracewell LM, Campbell DI, Faure PR, Giblin ER, Morris TA, Satterthwaite LB, Simmers DA, Ulrich CM, Holmes JD, et al. Sickness presenteeism in a New Zealand hospital. NZ Med J [Internet] 2010; 123(1314): 30–41. Available from: 31–42. Published 14 May 2010. http://www.nzma.org.nz/journal/123-1314/4106 (accessed May 2020).


54

https://doi.org/10.1007/s41999-020-00328-9

Appendix 2

PURPOSE

This document sets out the approach of the Incident Management Team (IMT) in supporting the management of a COVID-19 outbreak in a residential care facility (RCF).

RCF include:

∑ Aged Residential Care facilities∑ Disability Support Sector facilities

ACKNOWLEDGEMENT

It is acknowledged that all parties to this Outbreak Response Plan are separate entities operating within differing business models and/or funding streams representing both public and private healthcare.

The existence of this plan is an acknowledgement of the unique nature of an outbreak of this nature and the shared responsibility to collectively ensure the health and wellbeing of RCF residents and the broader community is preserved to the greatest extent possible.

OUTBREAK DEFINITION

An outbreak is described as one or more confirmed positive cases of COVID-19 amongst residents or staff at an RCF.

SCOPE

This document focusses on the response processes that the IMT will work through in the event of an outbreak at an RCF. The roles and responsibilities of agencies central to the response are described.

OVERVIEW OF ROLES AND RESPONSIBILITIES

PHO

∑ Provide clinical support to outbreak management in partnership with DHB o Consider utilising a small group of clinicians (well-equipped / trained in ICP) to

review any residents suspected of having COVID-19 across the Wairarapa

∑ Provide advice and support as required


55

RCF

∑ Manage outbreak in accordance with facility outbreak plan

∑ Stand down impacted staff as required

∑ Isolate residents as required

∑ Review advanced care planning arrangements

∑ Ensure appropriate PPE available for staff caring for suspected or confirmed residents

∑ Ensure safe staffing levels

∑ Orientate and support additional staff

∑ Work in partnership with DHB & RPH on:o Communicationo Additional IPC & infectious disease supporto Additional staffo External movement of residents

∑ Complete daily illness log & monitoring of residents

∑ Inform DHB Incident Controller

∑ Obtain pre-completed facility audit

∑ Notify MOH

∑ Initiate case investigation

∑ Support case isolation management

∑ Support daily monitoring of cases

∑ Complete contact tracing plan

∑ Contact identification follow up, education, and advice

∑ Provide support in partnership with DHB & PHO staff

RPH

FOCUS (NASC Agency)∑ Identify support requirements for individuals

∑ Service allocation to meet assessed support needs

∑ Facilitate transfer allocation of residents if needed

∑ Ensure RCF residents’ rights and protections are assured in the process of decision-making regarding welfare


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NOTIFICATION OF AN OUTBREAK

Regional Public Health will follow these steps:

1. Contact facility to notify outbreak and ascertain scale (initial estimate of numbers of residents and staff potentially exposed).

2. Ensure the facility can immediately and safely isolate confirmed and suspected cases3. Notify the DHB Duty Nurse Manager (who will notify the Duty ELT member).4. Notify the Ministry of Health.5. Obtain the pre-completed facility audit.6. Commence detailed case investigation.

IMMEDIATE ACTIONS

RECEIVE INITIAL REPORT FROM RPH

RPH will contact the Incident Controller or Duty Executive Leadership Team Member to provide an initial assessment of:

∑ The potential size of the outbreak.∑ The ability of the facility to immediately isolate confirmed and suspected cases.

∑ Stand up Incident Management Team

∑ Identify Incident Controller

∑ Provide support to outbreak management through Incident Management Team

∑ Ensure clear lines of communication exist or are quickly established with all parties involved in the response

∑ Identify additional support requirements to ensure care is provided to all residents

∑ Work in partnership with RCF, RPH, & PHO on:o IPC education / supporto Specialist clinical support (Geriatrician / Infectious Disease Specialist / Mental

Health)o Additional staffo PPE supplies / supporto Sourcing alternative locations of care if requiredo Isolation requirementso Communicationo 3DHB & MOH liaison

∑ Work in partnership with FOCUS on:o Support requirements for individualso Service allocation to meet assessed support needs

DHB


57

∑ The number of staff likely to be stood down.

CALL TOGETHER IMT AND DESIGNATE A LEAD CONTACT FOR RCF

The Incident Controller will call an urgent meeting of the IMT and designate a lead point of contact between the RCF and the IMT. Inclusion of PHO manager and/or GP liaison is important.

IMT to review additional expertise or potential support requirements and include additional representatives / experts in support planning. Additional support may include:

∑ Lead point of contacto Lead point of contact will generally be a member of the Planning & Performance

team routinely involved in RCF liaison∑ RCF Manager∑ Infection Control / Infectious Disease Specialist∑ Occupational Health∑ Psycho-Geriatrician∑ Mental Health∑ FOCUS (NASC)

An outline agenda for the first meeting is included as Appendix 1.

ACCESS RCF INFORMATION AND ESTABLISH LINE OF COMMUNICATION

The lead point of contact and RCF manager will:

∑ Review the pre-completed facility audit for the RCF and provide advice to the IMT.∑ Establish line of communication with the RCF and all supporting parties in preparation for

support activity.

SUPPORTING APPROPRIATE CARE AND MANAGEMENT OF RESIDENTS

PRINCIPLES

1. The DHB will provide support to the delivery of outbreak plans and procedures that the RCF has in place.

2. Where appropriate, all residents will have advanced care plans, health passports, and/or enduring powers of attorney in place.

3. Where possible, all residents (COVID-19 positive, suspected, and negative) will continue to be cared for within the RCF.

a. Enhancing familiarity for both residents and staff within dementia or high dependency areas will be key to compliance, safety and care. Where possible these areas should continue to be staffed by RCF staff familiar with the residents and work area.

b. Additional non-RCF staff should be rostered to work in non-COVID-19 areas of the RCF if possible.

4. Residents will only be moved if it is essential to ensure that they will receive the care that they need.


58

5. Residents will not be admitted to the acute hospital environment for medical management unless it is appropriate to do so or there are no alternatives to ensuring they will receive the care that they need.

DECISION-MAKING FRAMEWORK

The type and extent of support will vary depending on the type of outbreak and the capacity of the RCF. The factors that will dictate the amount of support that the RCF may need include:

Factor Variables Impact

Size & location of outbreak

How many residents confirmed/suspected?

In one part or spread throughout RCF?

How many residents in shared wings with confirmed/suspected residents?

How many residents have been in contact with confirmed/suspected staff?

Some RCF have large wings with many residents, increasing the number of suspected cases requiring isolation and testing.

Number of rooms with en-suite bathrooms.

Ability to effectively isolate residents.

Type of RCF Size of RCF and usual care ratios. Number of residents and staff likely to be impacted.

Additional staffing support requirements.

Is the RCF part of a larger regional or national organisation?

Yes – will have plans in place for additional support.

No – May require more support.

Levels of Care Is the outbreak in a dementia or high dependency unit?

Isolation will be more difficult. There will be behavioural challenges and it will be difficult confining residents to their room. May need to designate a ‘COVID wing’ as an alternative.

RCF preparedness

As per pre-completed facility audit. Variations in preparedness and capacity to manage will affect support requirements.

Size of workforce requiring to be stood down

Numbers.

Type (management, nursing, carers, cleaners etc)

Will inform the number and type of workforce required to support ongoing care requirements.


59

DECISIONS

The flow chart below guides key decisions for the IMT.

Can residents who are positive/suspected be

appropriately isolated & managed?

Are there sufficient staff to provide 24 hour care?

Consider transferring COVID positive/suspected residents

to another location

Yes No

RCF continues to deliver care to all residents on site

Work with RCF to determine number & types of staff

required

NoYes

Can sufficient & appropriate staff be

sourced to safely provide 24 hour care?

Consider transferring some residents to alternative

location/s

RCF continues to deliver care to all residents on site

Yes No


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OPTIONS

A range of options for workforce (see Appendix 2) and facilities may be available for consideration. These options include:

1. Additional staff support:a. Other residential care facilitiesb. Temporary workforce agenciesc. DHB workforce office

2. Alternative locations for care delivery:a. Other residential care facilitiesb. Empty residential care facilitiesc. DHB (option of last resort)

INFECTION PREVENTION AND CONTROL

All facilities have enough contact and droplet PPE on site to manage during the early response to a suspected or confirmed COVID-19 case. An early action point for the IMT will be establishing additional and ongoing PPE support requirements to ensure adequate on site supply.

A key support focus will be ensuring initial and ongoing competence as well as confidence of all staff with IPC procedures – particularly the donning and doffing of PPE. Incorporating a buddy system into standard practice will assist in ensuring staff safety.

TESTING

A mobile testing unit will be able to be provided at relatively short notice to assist with swabbing residents and staff.

This can be organised through the Planning and Performance team / PHO / RPH if required.

STAFF ACCOMMODATION

Staff involved in or impacted by the outbreak may require support in regard to accommodation and/or welfare. Options to consider:

∑ RCF on-site options ∑ Supported self-isolation∑ National staff accommodation support

COMMUNICATION

There will be significant community and media interest in any positive COVID-19 case linked to a RCF.


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The IMT will coordinate support to the management of communications through the WrDHB Communications Team.

APPENDIX 1: INCIDENT MANAGEMENT TEAM RCF OUTBREAK MEETINGTEMPLATE

Meeting Date & TimeAttendees

ROLES AND RESPONSIBILITIES

Confirm roles and responsibilities of all agencies in supporting outbreak management.

OUTBREAK SUMMARY

Location of outbreakNumber of suspected resident cases (contacts)Number of confirmed resident casesNumber of suspected staff cases (contacts)Number of confirmed staff cases

OUTBREAK MANAGEMENT – INFORMATION TO SUPPORT ACTION DEVELOPMENT

Principle: Provide support to enable RCF to isolate and care for impacted residents on site. RCF manager will lead outbreak response with support from the IMT.

Notifications

- Notifications made to various agencies?

Infection Prevention and Control

- Is adequate isolation achievable?- Are there sufficient PPE supplies for 48-72 hours?- Any additional ICP staff support requirements?- Cleaning support adequate?

Staffing

- Is RCF able to cover staffing requirements?- What are the available options for additional support?- Are there any alternative accommodation requirements?

Client Deterioration

- Are care needs able to be met?- Arrangements for GP support to the provision of care.- Advanced care plans in place for impacted residents?

Facility Management

- Logistic support adequate (food, cleaning supplies etc)?


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Communications

- What immediate communication requirements are there?

Whanau / Support

- Whanau information / support requirements.

APPENDIX 2: OPTIONS TO SUPPORT RCF

WORKFORCE SUPPORT

It is likely that some staff will need to be stood down immediately. It is also likely that additional support will be required to continue to care for non-COVID residents while safely isolating and caring for suspected or confirmed residents.

These conditions will apply to all elements of the RCF workforce including clinical, non-clinical, management, and administrative support staff.

There is likely to be an urgent need for a short term solution, followed by longer term capacity sustainment due to the likely time period of isolation and potential transmission between residents.

Options to work through in providing workforce support include (in descending order of priority):

1. Re-configurement of RCF staff / rosters.2. Usual RCF mechanisms for sourcing additional staff (agency etc).3. Support from parent organisation or partner RCF.4. Broader community workforce (PHO, DHB etc).5. DHB hospital workforce.6. External volunteers managed through local, regional, and national workforce

streams.


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Appendix 3

Residential Care Facility IMT Actions for Consideration

Action: Establish clear lines of regular communication with all parties who will be involved in RCF outbreak response. Transparent communication will be a pivotal enabler to ensuring an effective response an ensuring the right support is made available at the right time for the RCF.

Action: Ensure all residents have advanced care plans in place and accurate EPOA, resuscitationorders etc. This will help avoid any controversy regarding inappropriate transfer to hospital etc. This is generally considered best practice as part of ARC BAU. Conversations with GPs need to be formalised as advanced care plans as much as possible.

∑ There is good 3DHB guidance available on healthcare pathways (regionalised national guidance) – 3d.healthpathways.org.nz

Action: Younger disabled folk may have health passports which will assist in planning their care in the event of an outbreak in a DSS facility. Ensure those who would benefit from a health passport have (an up to date) one as much as possible.

Action: Explore possibility of mirroring hospital COVID-19 ‘streaming’ of patients within GP practices to reduce the possibility of cross-contamination within waiting areas etc. Flows into workforce management – the same staff review and assess potential COVID-19 patients during an RCF outbreak. Will become more important as swabbing clinics are stood down in coming weeks.

Action: In an outbreak situation, have a small group of clinicians (well-equipped and trained in ICP) review any residents suspected of having COVID-19. Enhances safety of GPs; reduces risk of further spread; ensures a consistent approach to assessment and clinical decision-making. (Reflected in outbreak management plan).

∑ Explore synergies with the Hospital@Home programme and opportunities for integration in providing outbreak support

Lack of staff prepared to volunteer to help during an outbreak has been identified as a key factor in the need to transfer RCF residents to the in-hospital environment in order to meet care requirements. This was highlighted in the review of the response to the St Margaret’s ARC Facility COVID-19 outbreak in West Auckland.

Action: Care of cognitively impaired people, or disabled people in RCF requires specific skillsets and knowledge. Introduce as much care of the elderly as well as cognitively impaired as possible into regular professional development for DHB staff and any areas likely to provide additional support to RCF in an emergency. Could include short term placements or secondments for those willing to helpduring an outbreak.

Action: Confirm processes for safely redeploying staff to assist in an RCF in an outbreak situation.Plan in the first instance would be for additional staff to assist in non-COVID areas of the facility.

o Make up of extra staff will be defined on a case by case basis as each situation will be unique


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o May include non-clinical as well as clinical staffo Staff will need to be enabled to add value – training / experience, orientation etco Most of the caring undertaken in RCF facilities is completed by care workers (HCA level, not

RN) – may require more additional care workers than RNso An additional nurse manager may be required to coordinate / manage additional staff, assist

in response administration etc

Action: DHB staff recruitment should include the redeployment data form so that staff can volunteer early for redeployment in an emergency. This allows data to be held with potential staff for redeployment and personalised professional development as preparation.

Action: Appropriate pre-determined additional PPE supplies to assist in the initial response should be ‘pushed’ forward. List of PPE to be determined.

o Facilities hold their own emergency supply of PPE for the first couple of days


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CPHAC INFORMATION PAPER

Date: 9 July 2020

Author Sandra Williams, Executive Leader Planning & Performance


Subject Clinical Services Plan Update

RECOMMENDATION

It is recommended that the Community Public Health Advisory Committee:

NOTES the approach and timelines for the Clinical Services Plan

1 PURPOSE

The purpose of this paper is to inform the Community and Public Health Advisory Committee on the work commencing on the Clinical Services Plan and the timeline and activity for the completion of the work.

2 CLINICAL SERVICES PLAN APPROACH

At the end of 2019, Wairarapa DHB undertook a process to develop a common sense of purpose and direction for health services in Wairarapa. Hauora Mō Tātou | Strategic Direction 2020–2030. This document identifies eight broad areas of activity in which change is needed to shift to a responsive, effective health system that achieves equitable outcomes for all people in our communities:∑ Integrating health and social services∑ Strengthening primary care∑ Excellence in older persons’ services∑ Improving access to health and disability services∑ Close connections between primary and secondary care∑ A fit for purpose hospital∑ Building a sustainable workforce∑ Tamariki-mokopuna our children and young people are our future

Clinical services planning is the next level of more detailed planning in some of the areas identified above, that will determine the clinical services and models of care required and guide investment over the coming years.

This project will develop a clinical services plan that deliberately focuses on three pressing issues:

1. The future configuration of hospital services and the model for how services will be delivered at Masterton Hospital

2. Access to urgent care across the Wairarapa district

3. Delivery of services with better geographical reach and community focus across the Wairarapa district

It is acknowledged that we can’t do everything at once—the targeted nature of the plan gives us the best chance to make measurable progress in high priority clinical service areas. Subsequent planning work will be conducted to address other elements of service provision in 2021.

CPHAC - PUBLIC MEETING - INFORMATION

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3 TIMELINES AND ACTIVITY

Timeframe Work Timeframe

Establishment – confirm scope, approach and timelines Early July 2020

Brief interviews with key stakeholders July 2020

Community engagement – initial engagement with consumer groups and iwi to inform them about the work and to seek their input into identifying examples of service models or priorities for consideration

July/August 2020

Desktop review – research service models (including review of relevant peer reviewed or grey literature), conduct high level analysis of models and describe their potential application to the Wairarapa context.

August 2020

Workshop options – up to three workshops involving both clinical and community participants to review options for service models and agree a preferred direction

September 2020

Analysis and reporting – additional analysis on preferred options, modelling potential workforce and cost implications to be included in a final report with recommendations

October 2020

Draft Report November 2020

Finalise Report December 2020


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CPHAC INFORMATION PAPER

Date: 9 July 2020

Author Sandra Williams, Executive Leader Planning & Performance


Subject COVID 19 Testing Strategy

RECOMMENDATION

It is recommended that the Community and Public Health Advisory committee:

NOTES the update on the Wairarapa DHB COVID 19 testing strategy

1 APPENDIX: NEW ZEALAND’S NATIONAL TESTING STRATEGY FOR COVID-19 FOR JUNE TO AUGUST 2020

2 APPENDIX 2 CASE DEFINITION PUBLISHED 24 JUNE 2020

1. PURPOSE

The purpose of this paper is to update the Community and Public Health Advisory Committee (CPHAC) on the COVID 19 Surveillance Plan and Testing Strategy.

2. BACKGROUND

The Government's overall public health strategy for COVID-19 is elimination. That is, to apply a range of control measures in order to stop the transmission of COVID-19 in Aotearoa New Zealand.

Elimination does not mean eradicating the virus permanently from New Zealand; rather it is being confident we have eliminated chains of transmission in our community and can effectively contain any future imported cases from overseas.

It is accepted that this approach will be needed in the long term ie, for many months or longer, depending on the emerging epidemiology and evidence around the disease and its management and progress with developing safe and effective treatments and/or vaccines.

There are four key pillars of the elimination strategy-

1. Border controls are a key tool for stopping the introduction and spread of new cases from overseas

2. Robust case detection and surveillance allows us to identify new cases quickly and take appropriate action

3. Effective contact tracing and quarantine is an essential part of controlling transmission of the virus


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4. Strong community support of control measures. The most important measures to restrict the spread will remain physical distancing, good hygiene, staying home if sick and effective use of PPE when required.

3. EARLY DETECTION AND SURVEILLANCE TESTING

The new testing approach aims to keep COVID-19 out of our communities by finding any new cases arriving at our borders and stamping the disease out as quickly as possible before it has a chance to spread further. The Ministry of Health (MOH) Testing Strategy is attached as Appendix One.

3.1 Why the testing strategy is changing

Under Alert Levels 3 and 2, while we were working towards eliminating COVID-19 in New Zealand, the testing strategy focussed on two areas:

1) diagnosing cases from people with clinical symptoms and tracking down and testing the people close to them, and

2) finding out if there were people in high-risk groups that were infected but not showing any symptoms. This second area was focussed on ensuring that COVID-19 was not widespread in our communities.

Now that there are so few cases of COVID-19 within New Zealand, the second approach is unlikely to uncover any new cases. Future sampling and testing effort is better targeted where new cases are most likely to arise, i.e. at the border (the highest risk originating from overseas travellers, air and maritime crew and border workers, depending on where they have travelled from).

At the same time, our system must allow the detection of early warning signs should a new outbreak occur within New Zealand and should be flexible enough to respond: deploying resources to where they are needed to contain any emerging situation.

This means implementing a new system including: targeted testing, use of existing surveillance systems for other respiratory illnesses, and the timely capture and sharing of information to inform rapid action at local and national level, as soon as it is needed. Testing availability must be equitable –for Māori and Pacific people and other priority groups, as well as across the country.

We also need to ensure that testing is proportionate to the assessed risk and does not unduly impact on health care and timely access to health services more generally, especially during the winter months when there is a seasonal increase in respiratory illness. Over time, the strategy for testing will continue to evolve as the situation changes in New Zealand and internationally, and if new testing methods become available.

3.2 Testing in the Wairarapa Area

The MOH is asking Wairarapa DHB to support the implementation of the testing Strategy through ongoing COVID-19 testing at the border, and in primary care and community-based settings. Funding has been made available for the period up to 30 September 2020. Further advice from the MOH is expected in September. The testing strategy and case definition continues to be subject to change as circumstances change.

As at 23 June 2020 eligible groups for testing include people who have clinical symptoms consistent with COVID 19, with priority for people who meet the new high index of suspicion (HIS) criteria, thorough testing around confirmed case, people arriving at the border or work at the border. See Appendix 2 for the case definition.


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Currently Wairarapa DHB has not been identified as a site for a managed isolation and/ or quarantine facility.

Our testing plan has been developed with Tu Ora Compass and relies on testing in our primary care general practices supported by our DHB run mobile swabbing unit. Our designated swabbing practices are outlined below- Kuripuni refers to Masterton Medical:

Type Location Address Opening Hours Days

Designated Practice Masterton Medical Centre 4 Colombo Road, Masterton 0800-1800 7 Days

Designated Practice Whaiora Masterton 394 Queen Street, Masterton 0830-1700 5 days

Designated Practice Carterton Medical 163 High St South, Carterton 0800-1700 3 days

Designated Practice Greytown Medical Centre186 East Street, Greytown 0800-1700 5 days

Designated PracticeFeatherston Medical Centre

14 Wakefield Street Featherston 0800-1700 5 days

Designated PracticeMartinborough Health Service

5 Oxford Street, Martinborough 0800-1700 5 days

Mobile Wairarapa Mobile Arranged by GP 0800-4:30pm 5 days

Masterton Medical remains our 7 days a week testing site with the ability to increase levels of testing if required. The mobile swabbing team can be accessed through general practice when required for people who are not able to access general practice or where we might need to test in the community.These sites also have the capacity in conjunction with the mobile swabbing team to increase access to population groups if this is required to ensure we have good testing levels -including equity considerations.

Testing Capability - Ensure good access and coverage across the region; - Ensure application of case criteria – recognising we have low rates of transmission;- A focus on priority populations (Māori, Pacific, Residential Care) and those under-represented;- Capability to stand up responses urgently and immediately; and- Community assessment through mobile teams and designated practices.


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New Zealand’s national testing strategy for COVID-19 for June to August 2020June 2020

ContentsNew Zealand’s national testing strategy for COVID-19 for June to August 2020.....................................................1

Summary............................................................................................................................................................................................2

Overall goal.......................................................................................................................................................................................2

Why the testing strategy is changing.....................................................................................................................................2

The five interconnected parts of the new testing strategy ............................................................................................3

Parts 1, 2 and 3 Activities within New Zealand...................................................................................................................4

Part 1 Test people presenting to primary and secondary care with relevant symptoms ......................4

Part 2 Contact tracing and testing around identified cases...............................................................................4

Part 3 Monitor trends in diseases with similar symptoms ..................................................................................5

Part 4 COVID-19 management at the border....................................................................................................................6

Parts 5a and 5bInformation gathering, decision-making, support and guidance................................................6

Part 5a Information gathering..........................................................................................................................................6

Part 5b Information gathering..........................................................................................................................................7


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SummaryWe have reached a new stage in the management of COVID-19: maintaining the elimination of the disease in our country. To remain effective, our surveillance and testing strategy across the country and at the borders must evolve. To do this, we’re implementing an integrated, five-part national system which will adapt and respond rapidly to manage any new outbreaks, should they arise. We’ll explain this new system here, and what it means in practical terms for frontline health workers.

Overall goalThe new testing approach aims to keep COVID-19 out of our communities by finding any new cases arriving at our borders and stamping the disease out as quickly as possible before it has a chance to spread widely.

Why the testing strategy is changingUnder Alert Levels 3 and 2, while we were working towards eliminating COVID-19 in New Zealand, the testing strategy focussed on two areas: (1) diagnosing cases from people with clinical symptoms and tracking down and testing the people close to them, and (2) finding out if there were people in high-risk groups that were infected but not showing any symptoms. This second area was focussed on ensuring that COVID-19 was not widespread in our communities.

Now that there are so few cases of COVID-19 within New Zealand, the second approach is unlikely to uncover any new cases. Future sampling and testing effort is better targeted where new cases are most likely to arise, i.e. at the border (the highest risk originating from overseas travellers, air and maritime crew and border workers, depending on where they have travelled from).

At the same time, our system must allow the detection of early warning signs should a new outbreak occur within New Zealand and should be flexible enough to respond: deploying resources to where they are needed to contain any emerging situation.

This means implementing a new system including: targeted testing, use of existing surveillance systems for other respiratory illnesses, and the timely capture and sharing of information to inform rapid action at local and national level, as soon as it is needed. And we must also continue to ensure that access to testing is equitable – for Māori and Pacific people and other priority groups, as well as across the country.

We also need to ensure that testing is proportionate to the assessed risk and does not unduly impact on health care and timely access to health services more generally, especially during the winter months when there is a seasonal increase in respiratory illness.

Over time, the strategy for testing will continue to evolve as the situation changes in New Zealand and internationally, and if new testing methods become available.


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The five interconnected parts of the new testing strategy

Figure 1 Objectives of the new testing system and supporting activities (five parts)

Objectives Supporting activities

Ensu

re e

quita

ble

acce

ss to

test

ing

Identify new cases as soon as possible

Part 1

Test people with relevant symptoms

Part 2

Contact tracing and testing as appropriate around identified cases

Part 4

Management at the border

Evidence for unknown clusters of cases

Part 3

Monitor trends in diseases that have similar symptoms to COVID-19

High-level crisis management

Part 5a

Information gathering: in-country data, situational awareness, local and international research findings

Part 5b

Decision-making, support and guidance to in response to new situations arising

Note:

∑ The list of symptoms for COVID-19 remains the same: any acute respiratory infection with or without fever, with at least one of the following symptoms: new or worsening cough, sore throat, shortness of breath, coryza (runny nose, sneezing etc), or anosmia (loss of sense of smell).

∑ At present, all testing will focus on detecting the presence of viral RNA. Serology tests to detect antibodies will be implemented in the longer term, once these tests become available and can produce reliable results.


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Parts 1, 2 and 3 Activities within New ZealandPart 1 Test people presenting to primary and secondary care1 with

relevant symptoms Any person presenting to primary or secondary care1 must be sampled and tested if:

∑ their symptoms include a new or worsening cough, sore throat, shortness of breath, coryza (runny nose, sneezing etc), or anosmia (loss of sense of smell), and

∑ if they are at a higher risk2 of exposure to the virus through: recent contact with a confirmed or probable case, recent overseas travel, direct contact with overseas travellers (e.g. staff working at the borders and in managed isolation facilities), worked on an aircraft or vessel on international routes, or cleaned at an international airport or port in areas visited by people arriving from abroad.

If a patient has the relevant symptoms and is at a higher risk of exposure (as above), or if they are a confirmed or probable case of COVID-19, the doctor or nurse treating them must notify their local Medical Officer of Health. Laboratories must also notify the local Medical Officer of Health immediately of any confirmed cases. All people with any of the symptoms above, and who are at a higher risk of exposure for the reasons above (i.e. they meet the HIS criteria2), must self-isolate while awaiting their COVID-19 test results.

The testing and reporting combined are crucial because the results will be analysed regularly by regional and national decision-makers (part 5b).

It remains important to ensure that people have access to testing if they are symptomatic but not in a higher-risk group for exposure to COVID-19 (i.e. they do not meet the HIS criteria2), and on advice from a clinician.

People who have existing access issues to primary health care (e.g. Māori, Pacific Peoples, and people with disabilities) may need a more proactive approach outside of community-based testing centres and designated GP practices on the advice from the Ministry's routine analysis of surveillance information. This will ensure that these people have access to testing if they meet the clinical criteria.

People with symptoms but are not at a high risk of exposure to COVID-19 (i.e. they do not meet the HIS criteria2) do not need to self-isolate while awaiting test results.

Part 2 Contact tracing and testing around identified casesThis activity has been in place throughout the COVID-19 response. If a person tests positive for COVID-19, the local Medical Officer of Health is informed and the details are added to official records, so that investigation and contact tracing can be undertaken immediately to identify the source of infection (if possible) and to limit the forward spread. Where the source of infection is unknown, close contacts must be tested and any contacts with negative test results but who later develop symptoms must be retested.

1 Explanation for non-health professionals using this document:Primary care: first and most generalised level of patient care, e.g. GP or nurseSecondary care: medical specialist, patient is generally referred by a GP or other primary healthcare provider

2 The criteria for this Higher Index of Suspicion (HIS) are defined in the COVID-19 case definition


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When a person is tested based on their symptoms and history, a decision may be made to start contact tracing immediately (before the test result is confirmed), if there is a high risk that they could have COVID-193.

Testing casual contacts depends on the circumstances; this may be considered in high-risk situations or where no source has been identified. In some cases, repeat testing may be needed. And as the investigation progresses, Medical Officers of Health may recommend additional screening in other at-risk groups or underrepresented demographics, if the situation warrants it.

Part 3 Monitor trends in diseases with similar symptomsNow that there are minimal cases of COVID-19 in New Zealand, random testing of people without COVID-19 symptoms is unlikely to uncover unknown cases in our communities. Instead, the existing surveillance streams for influenza-like illnesses (ILIs) will provide signals that could be interpreted as early warnings of the presence of the disease (Table 1).

This allows constraints to be set for the testing system, to safeguard against any future supply chain issues, or a severe influenza season. So, it is important to keep reporting into these systems.

Any increase of cases reported into the ILI surveillance systems will initially be considered as a cue for discussion, rather than for immediate action. The Ministry of Health will analyse the information (along with all other available information) and present findings to a national working group of technical advisors (the role of this working group is explained in Part 5b below).

The working group will then discuss and clarify the observations with the DHB or PHU concerned and establish the best surveillance approach for the community.

Table 1: Existing and planned ILI surveillance systems in New Zealand and the organisations responsible for analysing information and advising on deploying risk-based or stratified random surveillance

Surveillance system Description

Healthline Patients self-identify over the phone

FluTracker Online survey of ~60,000 weekly participants reporting on influenza like illnesses (ILIs)

Healthstat Data from 380 participating GP practices tracking ILIs

GP sentinel surveillance Annual participation from ~90 GP practices to collect samples from ILI-presenting patients

HealthLink form for mild respiratory illness

Enrol practices to collect information that would not be flagged on other ILI systems

Testing people with mild respiratory illnesses

A planned collection from a subset of people with mild acute respiratory illness

Text mining Application rolled out over primary healthcare providers to monitor the number of mild and acute respiratory conditions and ILIs presented in the primary healthcare system

3 Use the decision tree in the clinical algorithm to determine high-risk scenarios


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Part 4 COVID-19 management at the borderA main objective of the new system is to ensure that the virus is contained at our borders and does not enter the New Zealand community. Procedures to manage COVID-19 at our borders are designed for the following groups of people:

∑ passengers arriving from overseas (by air and sea), including people on pleasure craft or yachts∑ air and maritime crew, and ∑ people who work at the border (frontline contact roles for international arrivals, customs,

biosecurity, aviation staff, shipping and port staff, people working in managed facilities where arriving travellers are housed, cleaners of vessels and areas frequented by overseas travellers).

Passengers arriving from overseas by air will stay in managed facilities for a set period of time and will be swabbed and tested. Passengers arriving by sea will be isolated onboard the vessel they arrived on, or in managed onshore facilities. Some people may be given an exemption on compassionate grounds and allowed to self-isolate elsewhere, if their application for an exemption is approved.

Air and maritime crew will be tested if they have symptoms consistent with COVID-19. If they are considered at high risk of exposure, they will be requested to isolate themselves until a test result is confirmed.

People who work at the border will be strongly encouraged to seek testing if they experience symptoms (however mild), and airports and ports must ensure that there are no disincentives to test.

In addition, testing of asymptomatic people who have been potentially exposed to COVID-19 infection through their work will be available.

Parts 5a and 5b Information gathering, decision-making, support and guidance

Information gathering is a key part of any surveillance and testing system, to feedback and allow rapid public heath action, adaptation, and redeployment of resources (if needed) following a change in the ongoing situation.

A COVID-19 expert working group is responsible for providing support and guidance to the DHBs/PHUs on situations as they arise. Their guidance is based on all available information.

Part 5a Information gatheringThe whole system relies on analysis of data gathered locally and nationally from:

∑ the testing and activities outlined above in parts 1 to 4 of the system ∑ supplementary data attached to the test results∑ rapid and comprehensive investigations of a new outbreak, including lessons learned from

operational performance locally and nationally, and details of active clusters and activity at the border

∑ a thorough understanding of the individual circumstances at the DHB/PHU level, and∑ integration of one-off findings from local and international research and experience, and

emerging evidence


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∑ information from new COVID-19 testing methods as they become available, such as serology tests and detecting SARS-CoV-2 in wastewater

∑ interpretation of modelling of disease spread, and∑ the results of intermittent surveys on attitudes towards health services.

Part 5b Information gatheringThe COVID-19 expert working group is a team of technical experts drawn from ESR and teams from the Ministry of Health. This working group will work closely with other related advisory groups and stakeholders as appropriate.

Regular data and information are gathered and supplied to the working group about active clusters, investigations, observed symptoms, border activity, testing and other pertinent information to inform next steps.


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COVID-19 criteria and case definitions24 June 2020

The Ministry of Health has developed the following criteria and case definitions for COVID-19 based on expert advice from our Technical Advisory Group. The criteria take into account New Zealand’s current COVID-19 status. We are currently in a position where people with an acute respiratory infection are not automatically considered a suspect case, so we have removed the term suspect case.

We have introduced “Higher Index of Suspicion” (HIS) criteria as, at this stage, our greatest risk of re-introduction of COVID-19 and spread is via our border. All people meeting the HIS criteria who have symptoms consistent with COVID-19 should be tested for COVID-19 and self-isolate while awaiting test results to reduce the risk to others.

Other conditions that require urgent assessment and management should always be considered alongside COVID-19.

The Ministry has also developed a Testing Strategy. The Testing Strategy outlines additional testing being undertaken to support early detection of COVID-19 at the border, and surveillance testing of people with symptoms consistent with COVID-19 who present to primary and secondary care to ensure that there is no community transmission.

Case definitionsClinical criteria

The following symptoms are consistent with COVID-19:Any acute respiratory infection with at least one of the following symptoms: new or worsening cough, sore throat, shortness of breath, coryza1, anosmia2 with or without fever.

Some people may present with symptoms such as only: fever, diarrhoea, headache, myalgia, nausea/vomiting, or confusion/irritability. If there is not another likely diagnosis, and they meet the HIScriteria then test.

Higher Index of Suspicion (HIS) criteria

Either, in the 14 days prior to illness onset have:∑ had contact3 with a confirmed or probable case∑ had international travel ∑ had direct contact with a person4 who has travelled overseas (eg Customs and Immigration staff,

staff at quarantine/isolation facilities)∑ worked on an international aircraft or shipping vessel

1 Coryza – head cold e.g. runny nose, sneezing, post-nasal drip.2 Anosmia – loss of sense of smell.3 Refer Advice for Health Professionals for close contact criteria

(https://www.health.govt.nz/system/files/documents/pages/updated-advice-health-professionals-22may20.pdf)4 Excludes household and community contacts of aircrew


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https://www.health.govt.nz/system/files/documents/pages/updated-advice-health-professionals-22may20.pdf

∑ cleaned at an international airport or maritime port in areas/conveniences visited by international arrivals, or

∑ any other criteria requested by the local Medical Officer of Health

Case classification

Under investigation caseA case that has been notified where information is not yet available to classify it as confirmed, probable or not a case.

Probable case

∑ A close contact of a confirmed case that has a high exposure history, meets the clinical criteria and for whom testing cannot be performed, or

∑ A close contact of a confirmed case that has a high exposure history, meets the clinical criteria, and has a negative PCR result but it has been more than 7 days since symptom onset before their first negative PCR test was taken.

Confirmed caseA case that has laboratory definitive evidence. Laboratory definitive evidence requires at least one of the following:

∑ detection of SARS-CoV-2 from a clinical specimen using a validated NAAT (PCR) ∑ detection of coronavirus from a clinical specimen using pan-coronavirus NAAT (PCR) and

confirmation as SARS-CoV-2 by sequencing∑ significant rise in IgG antibody level to SARS-CoV-2 between paired sera (when serological testing

becomes available).

Not a caseAn ‘under investigation’ case who has a negative test and has been assessed as not a case.

Notification procedure

Laboratories must immediately notify the local medical officer of health of any confirmed cases.Attending medical practitioners must notify any confirmed (or probable cases) AND anyone who meets both the clinical and HIS criteria.


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