2. Key decisions and actions to manage the outbreak

2. Key decisions and actions to manage the outbreak

COVID-19 is an unprecedented global pandemic and has presented extraordinary challenges for health systems around the world. Tasmania’s health system, like others globally, has been required to learn in real time how to best detect, contain and manage the virus and its consequences. In responding to the COVID-19 outbreak that occurred at the NWRH in April 2020, it is acknowledged that unprecedented measures were required to contain the outbreak, protect healthcare workers and the community, and support health service viability and capacity.

In making these decisions, recognising the high-risk hospital setting and the rapidly evolving nature of the outbreak, the key principles underlying DoH’s response were to be proactive and to act quickly and decisively, with the ever-present priorities of protecting the patients, the staff, and the community. While recognising the unprecedented nature of the COVID-19 pandemic, the DoH was able to draw upon the key preparedness strategies and actions outlined above in Section 1 in order to respond to the outbreak.

It was necessary to balance the often competing priorities of outbreak management and containment with continuity of service delivery, and the DoH sought to take pre-emptive action throughout the outbreak to support a planned and staged approach that minimised risk to our staff, patients and the community. While this ultimately necessitated intense interventions to provide a ‘hard reset’, these were undertaken with the intention of providing the greatest chance of controlling the outbreak and restoring sustainable service functionality in the North West within the shortest timeframe possible, rather than an urgent, uncontrolled and potentially longer disruption of services.

As discussed in section 1 of this submission, the planning and preparedness work undertaken during March 2020 provided the strong basis for management of the North West outbreak. Escalation Management Plans had been developed for each region with specific outlined roles and responsibilities and detailed command, control and coordination arrangements for COVID-19, and these helped to guide the level of response required as the outbreak escalated. The governance structures put in place in March 2020 comprising the Health ECC, PHEOC, AT EOC, THS EOC and three RHEMTs provided a balance of regional level management and coordination with the capacity to draw upon statewide resources and strategic oversight. The North West was also augmented with specific incident management resources and teams to directly manage the outbreak, including an Outbreak Management Team (OMT) and contact tracing capability.

Responding to the outbreak was a whole-of-government effort, and the DoH was also able to draw upon the support and expertise of other government agencies and partners through the Interoperability Arrangements to support more timely and effective management of the outbreak. Whilst this submission details the health response during the North West outbreak, the SCC led a critical range of support, compliance and recovery activities in the North West to support the health response.

The number of cases and dates outlined below have been drawn from daily internal reporting, which informed decision making in the lead up to, and during, the outbreak. It is also important to note PHS has subsequently undertaken further investigative work relating to the outbreak cases, which has led to some minor adjustments to case numbers on particular dates (reflected via the footnotes below).

2.1 Initial entry and spread of the virus in North West Tasmania

The first COVID-19 positive case in North West Tasmania was notified to PHS on 21 March 2020. The patient had been a passenger on the Ruby Princess cruise ship and had been admitted to the NWRH and tested for COVID-19 the previous day (20 March). The patient was subsequently transferred to an isolation room in the NWRH.

In the following days to 31 March, 11 additional overseas acquired cases were identified, all of whom were residents of the North West. In addition to the original positive case hospitalised on 20 March, two further cases associated with cruise ships were hospitalised, one of whom was linked to the subsequent NWRH outbreak. The second patient linked to the NWRH outbreak had also been a passenger on the Ruby Princess ship and was admitted to the NWRH on 26 March.[1]

One healthcare worker from the MCH tested positive to COVID-19 on 27 March 2020. The healthcare worker did not have close contact with patients, and the THS and PHS commenced investigations to attempt to identify possible sources of infection. The THS identified five close contacts of the healthcare worker, who were directed to self-isolate and were actively monitored, and 18 casual contacts were identified and advised to contact PHS if they experienced symptoms.

Following investigations by PHS, it was determined the MCH healthcare worker was not epidemiologically linked to the subsequent NWRH outbreak as they had not worked there prior to diagnosis. Their source of infection was not able to be determined through case interviews and exposure history.

2.2 Additional governance arrangements and resources in response to the initial North West Regional Hospital cases

Two cases of COVID-19 in healthcare workers at the NWRH were notified to PHS late on Friday 3 April. The source of infection was most likely to have been one (or both) of the two inpatients who were admitted to the NWRH with COVID-19 acquired on the Ruby Princess ship. Of the initial cases amongst NWRH staff, at least one was a healthcare worker who had provided care directly to one of these patients.

The same day these two cases were notified, the State Health Commander established an IMT within the THS. The IMT was initially led by the CMO and included local North West senior medical and nursing clinical and operational leads, reporting to the THS EOC. An additional case in a NWRH healthcare worker was notified to PHS on Saturday 4 April, and the State Health Commander gave further instructions to establish the OMT to report to the IMT. As noted above, governance arrangements to allow this to occur were activated in early March 2020 as part of the Level 2 response including activation of the THS EOC.

2.3 Service reconfigurations to support ongoing service delivery and patient care

Recognising the impact of the evolving outbreak on staffing levels, service reconfigurations were made on Monday 6 April to minimise disruption to normal hospital operations and help reduce the workload on the NWRH whilst staff managed the outbreak, namely:

• AT presentations from Devonport eastwards would be transported directly to the LGH from 8:00PM onwards; and
• in accordance with the THS North West Escalation Management Plan, visitor access to the NWRH and the MCH ceased from 6:00PM onwards.

Visitor restrictions to hospitals and aged care facilities were extended statewide on 7 April via Directions under the Public Health Act.By the morning of Wednesday 8 April, 12 healthcare workers had tested positive for COVID-19 and a further 47 staff who had been identified as close contacts were in self-isolation. Balancing the continued viability of full-service provision at NWRH with necessary outbreak management and containment required constant monitoring by senior management, and constant liaison between local senior management and members of the ECC centrally. In light of the rapidly evolving situation, THS North West was approved to move to Level 3 of its COVID-19 Escalation Management Plan, leading to the following service changes:

• The MCH being closed to admissions with the exception of internal transfers from the LGH, NWRH and RHH, and its Emergency Department operating on reduced hours (closed between 10:00PM and 8:00AM).
• The NWRH medical and surgical wards being closed to new admissions with the exception of COVID-19 positive patients, or those suspected of having COVID-19, and uncomplicated low-risk surgical patients admitted to theatre at NWRH and transferred to the NWPH for recovery. The NWRH remained able to accept patients transferred back from the RHH and LGH.
• AT following new transport boundaries, in which emergency calls for patients east of Ulverstone (from Queen Bridge) were sent to the LGH, and patients treated west of Ulverstone sent to NWRH.

These decisions were critical at this stage of the outbreak to support ongoing service delivery and ensure patients continued to receive a high level of care, while also seeking to contain further transmission of the virus.

2.4 Closing the North West Regional Hospital and North West Private Hospital

On Thursday 9 April 2020, the SoNG definition of “close contact” was clarified by CDNA with the OMT as part of a nationally determined update as comprising cumulative (rather than continuous) exposure time of up to 15 minutes face‑to-face.  This increased the number of close contacts related to notified cases.

While this would have consequences for prospective contact tracing, it would also have a significant impact on the contact tracing that had already occurred. This is because the nature of the questioning that had been undertaken to date on contact tracing was predicated on the prior definition, and there would need to be an entirely new set of interviews undertaken with those who had already been interviewed to apply the new definition.

In discussions with PHS, it was advised that the most appropriate application of the new definition would be to:

• apply the new definition prospectively (that is, for contact tracing of cases identified after the new definition),
• only apply the new definition retrospectively to those who were identified as high risk – noting, and as explained above, the classification of individuals as low or high risk was not possible given the application of a different definition in earlier interviews, and
• do not apply retrospectively otherwise.

At this point, in recognition of the significant time and resources required to retrospectively assess all medical and surgical ward staff for contact status and compounding the risk of further infections, it was recommended by the CMO and the North West Regional Health Commander that a proactive decision be taken to direct all these staff to self-isolate. In essence, rather than undertaking extensive and time-critical contact tracing when there was growing concern that the level of risk was such that the numbers of staff affected would inevitably disrupt safe service provision, the decision was taken to regard all staff from these wards as “not being able to be excluded as close contacts”.

Accordingly, on Friday 10 April the State Health Commander approved THS North West to move to Level 4 of its COVID-19 Escalation Management Plan, leading to:

• Closure of the MCH Emergency Department and Close Observation Unit to allow staff to be transferred to the NWRH to support service delivery, and consolidating rehabilitation patients into the medical ward to release staff to assist at the NWRH.
• NWRH medical and surgical ward staff being directed to self-isolate for 14 days, and closure of these wards to new admissions. Patients requiring medical or surgical admissions from the Emergency Department were transferred to the LGH, while patient transfers to NWPH ceased.
• AT following new transport boundaries where:
• emergency calls for patients east of Penguin were transferred to the LGH if transport to an emergency department was required; and
• emergency calls for patients west of Penguin were initially taken to the NWRH Emergency Department; however, if admission was deemed necessary, these patients were transferred to the LGH.

The DoH also assumed operational control of the NWPH on 10 April for the purposes of managing the outbreak. The employment and movement of staff across both sites meant staffing levels and service delivery at the NWPH had been similarly impacted by the escalating outbreak. The DoH assuming operational control of the NWPH at this point allowed the expansion of the OMT to deal with the situation across the NWRH and NWPH as a single site. These decisions were publicly communicated in media releases from the CMO and Minister for Health on 10 April.

A further 10 cases relating to the outbreak were notified on the evening of Friday 10 April. On 11 April, the State Health Commander worked together with the CMO and Incident Controller to review the sustainability of safe services at the NWRH given the outbreak’s significant impacts on staffing. Advice from the CMO indicated the likely trajectory of the outbreak was that significant disruption to safe service delivery was inevitable and, as a result, recommended to “undertake the planned closure and staged reopening of the North West Private and North West Regional Hospitals in order to address the outbreak, protect staff and patients, and markedly reduce the likelihood of a community outbreak of COVID-19”.

A plan was developed to close the NWRH and NWPH sites, transfer patients to other facilities, and mitigate risk for specific clinical disciplines, including but not limited to emergency medicine services, maternity services, cancer services, inpatient and ICU services, and mental health services. It also outlined the need for a deep clean of both facilities and a quarantine execution plan.

While recognising the magnitude of the decision to close the hospital sites, it was the view of the ECC, the THS EOC, the OMT and members of the senior clinical and executive staff of the NWRH that, without such significant action, the outbreak would extend to the point where continued hospital operations were impossible, and an outbreak into the community would become inevitable. As such, it was the CMO’s view the orderly and staged closure and reopening of the NWRH and NWPH at this point presented the best opportunity to control the outbreak, protect staff and patients, and restore sustainable services.

Later that day, the State Health Commander convened a meeting with key clinical leaders to test and confirm the following proposals:

• all patients be transferred out of the NWRH and NWPH to close the hospital sites from 7:00AM Monday 13 April, with:
• patients discharged to the community for home quarantine where safe to do;
• other patients transferred to receive care at the MCH, and managed on the basis of assumed positive for COVID-19; and
• patients only to be transferred out of the North West region if their clinical condition absolutely required it.
• a comprehensive deep clean be conducted across the NWRH and NWPH sites;
• the quarantining of all NWRH and NWPH staff, patients and contractors (including their household members) to occur from 13 April 2020 (approximately 4 000 people);
• maintain support for emergency care in the region, including additional ambulance and aeromedical support and Primary Health Tasmania to provide an incentive payment to general practices in the region to open for patients on the public holiday of 13 April; and
• progressively restart services with COVID-19 clear staff over a 14-day period, starting with the Emergency Department, Maternity Services, Cancer Services, Paediatrics and the ICU.

This approach was further discussed with the DPH and Deputy DPH, State Controller and Deputy State Controller. The DPH advised, following the continuing increase in cases in the North West related to the NWRH, that this was an appropriate response for controlling and containing the spread of the virus.

The State Health Commander and CMO briefed the Premier and Health Minister and senior personnel late on 11 April 2020. The State Health Commander made the decision to close, deep clean and restart the NWRH and NWPH on 11 April 2020 and called in all available senior health resources to prepare on Sunday 12 April (Easter Sunday)

To allow these actions to be implemented, on Sunday 12 April several further directions were issued under the Public Health Act, namely:

• ‘Gatherings (North-West Region) - No. 1’, which required closure of non-essential businesses in the North West region;
• ‘Mersey Community Hospital – No. 1’, which required MCH staff to self-isolate when not at work; and
• ‘Quarantine (North-Western Region) - No. 2’, which required all NWRH and NWPH staff and patients discharged from 27 March, and their household contacts, to self-isolate for 14 days.

The State Controller also issued a Direction on 12 April under the Emergency Management Act to assume control of the NWPH site from its private operator from 7:00AM the following day.

In light of all NWRH and NWPH staff being required to quarantine from 13 April, the CMO and State Health Commander consulted with the State Controller on 11 April regarding deployment of an Australian Defence Force (ADF) health response team to staff the NWRH Emergency Department following completion of the deep clean. A request for Australian Government assistance to support provision of emergency department care in the North West was subsequently submitted by the Department of Police, Fire and Emergency Management through national mechanisms on 12 April. The Health Minister also engaged with the Federal Health Minister on this matter.

The decision to close the two hospitals and related services and place all staff who had worked at these sites since 27 March and their households into quarantine for 14 days was communicated to staff and publicly announced during the afternoon of Sunday 12 April. Additionally, the Premier announced the following day that ADF and Australian Medical Assistance Team (AUSMAT) staff had been secured to provide additional resources to ensure emergency services at the NWRH were able to be re‑established following the deep clean of the area, while local staff were completing quarantine.

The decision to close the NWRH and NWPH was unprecedented and difficult, and impacted other public and private health facilities. However, appropriate planning (including the establishment of surge plans with escalation triggers and identification of additional bed capacity in March 2020) and existing strong networks and relationships across the private and public health sectors meant the DoH was able to leverage other resources (particularly those in other hospitals) and patients were still able to be cared for in appropriate and safe clinical settings. The DoH bolstered ambulance capacity in the North West (including additional aeromedical support), and worked closely with local GPs to deliver increased primary care capacity wherever possible, including providing funding for practices to support increased hours. Pharmacists also provided increased coverage during this time.  The MCH, LGH and Calvary North assisted with the care of patients following the closure of the NWRH and NWPH, including the relocation of maternity services from the North West to Launceston.

It is the view of the DoH the swift decision and execution of the closure of the NWRH and NWPH, together with strict quarantine measures and retail restrictions, were the significant causative factors in ultimately controlling the North West outbreak.

2.5 Recommissioning the North West Regional Hospital and North West Private Hospital

With the agreed course of action to close, empty, clean and progressively reopen the hospital sites in place, the DoH’s execution of this plan was guided by a strong precautionary approach. Extensive planning accompanied the recommissioning process, which included a staged approach to ensure services were ready and safe to operate before reopening, and a comprehensive return to work program for all staff exiting quarantine to ensure safety of staff, patients and the community. Cross-agency collaboration and the Interoperability Arrangements were key to timely and efficient execution of the recommissioning plan.

From 7:00AM on Monday 13 April, AT commenced the transfer of appropriate patients from the NWRH and NWPH to the MCH. The full transfer of 28 patients from both hospitals was completed during the course of the day, and contract cleaners were secured to undertake a deep clean of the NWRH.

In readiness to staff the Emergency Department following the deep clean, the ADF and AUSMAT teams arrived in the North West on 14 April. Cleaning teams were contracted and trained in infection control, process and PPE donning and doffing. As part of the cleaning process, expert advice and direction was sought from an Infectious Diseases Physician, Microbiologist and Clinical Nurse Consultant – Infection Prevention and Control. Police Forensic Services also provided assistance to verify the clean environment was contaminant free.

The NWRH Emergency Department was recommissioned at 2:00PM on Friday 17 April following approval of the State Health Commander. As noted above, the Emergency Department was initially staffed by ADF personnel under the leadership of AUSMAT, with formal handback occurring after sufficient NWRH staff could return to work following their period of quarantine. The ADF and AUSMAT team handed over operation of the Emergency Department to the THS at 7:00AM on Wednesday 29 April as the first group of NWRH staff returned to work at the hospital having satisfied the return to work requirements outlined below.

Following the progressive reopening of individual services from late April and early May, the full recommissioning of the NWRH was completed on Thursday 14 May, one month after its closure due to the outbreak. The recommissioning process included:

• A terminal clean of the entire NWRH site, which was guided by infection control experts. Each clean was reported on separately to the THS EOC and State Health Commander.
• Following the cleaning process, each work area was required to undertake a recommissioning process including reconfiguration of the work area and checking all related areas, services and equipment. The process covered areas such as:
• facilities and engineering;
• equipment and zone set up;
• rostering and staffing levels;
• social distancing protocols;
• PPE; and
• related support services.
• As part of the recommissioning of the NWRH, a MCH Reset Plan was developed to gradually restore the MCH to normal operations and allow a rebalancing of patient load across the hospitals. The MCH Emergency Department remains challenged in the face of significant national workforce impacts.

2.6 Return to Work Program

To support the effectiveness of the quarantine measures, a comprehensive Return to Work Program was developed to prepare returning staff and minimise the likelihood of outbreak recurrence. The State Health Commander determined that all quarantined staff were required to be tested for COVID-19 and return a negative test prior to returning to work, with staff who had previously tested positive required to have two consecutive negative tests at least 24 hours apart. Staff were also required to complete a questionnaire to identify if they had developed any symptoms while in quarantine.

The Return to Work Program also included online and face-to-face learning and/or reskilling in infection control and the use of PPE. The online learning included a COVID-19 Infection Control Training eLearning module, a National Hand Hygiene training video, videos about PPE and infection prevention and control, and reference to the Infection and Prevention Protocols. Staff were required to provide a certificate of completion to their manager and were not permitted to return to the workplace until the requirements of the Return to Work Program had been completed, including testing.

Additional measures were implemented to ensure staff were appropriately trained and requirements were being adhered to. Upon return to the workplace, prior to starting their rostered shift, clinical staff were required to complete face-to-face training including demonstrating their understanding of the infection prevention and control precautions, and further training in the appropriate use of PPE. Random internal audits of these training requirements were conducted and showed a high percentage of accurate completion. Screening was also implemented for all staff at the beginning of each shift before they could begin duties.

The transition of staff back to the workplace was also supported by unit managers who undertook a return to work coordination role, with assistance from additional administration staff and clinical coordinators on the ground who coordinated the return to work testing and training requirements. Staff were contacted individually to discuss the process and confirm when each staff member was able to return to the workplace. A number of staff were also nominated to act as ‘PPE Guardians’, acting as contact points for work areas about appropriate use of PPE and provided an escalation point about PPE related issues and concerns.

To support the wellbeing of staff transitioning back to work and their families, a comprehensive support package was also developed. This included an online selfcare, resilience and wellbeing program, which provided individualised selfcare plans to prepare quarantining staff to return to the workplace. In addition to providing online programs, a peer support network with training and ongoing mentoring has also been developed. More generally, staff were reminded they could contact the Employee Assistance Program to access counselling services delivered by a team of qualified psychologists and social workers.

Following confirmation that all NWPH staff had completed the same Return to Work requirements as NWRH staff, the State Controller revoked the Order taking control of the NWPH on 9 May on the advice of the State Health Commander.

The DoH remains committed to supporting staff that continue to recover from post COVID-19 infection complications. The DoH accepted a number of claims for workers compensation associated with the North West outbreak, and our claims managers continue to prepare individual return to work assessments and packages to allow our staff to safely return to duty when appropriate.

2.7 Genomics analysis

By 6 May 2020, a total of 138 people had acquired COVID-19 associated with the North West outbreak, comprising 80 staff, 25 patients and 33 others including household contacts.[2] This number includes the positive cases directly linked with the hospital outbreak including the NWRH, NWPH and MCH as well as a linked community cluster, but does not include all cases who reside in the North West or cases linked to cruise ships or overseas travel.

All 226 Tasmanian COVID-19 positive samples, including those from the North West outbreak, were sent to the Microbiological Diagnostic Unit at the Doherty Institute in Melbourne for genomic sequencing to identify genetic clusters of the virus that might help improve the understanding of the observed or suspected epidemiological links and clusters in Tasmania.

Nine distinct genomic clusters were identified from 217 of the 226 SARS-CoV-2 positive samples (96%) that were successfully sequenced. The largest cluster in Tasmania, Cluster A, was associated with infections originally acquired on the Ruby Princess cruise ship. This cluster has two sub-groups. Cluster A1 had a total of 29 cases comprising several returned Ruby Princess passengers including one of the two index cases in the NWRH, four healthcare workers from that hospital and seven of their household contacts. Cluster A2 had 120 cases including 119 of the 138 cases associated with the North West outbreak. This group included the other Ruby Princess index case who was admitted to the NWRH, all cases in the NWPH and associated facilities, the MCH, the Melaleuca Residential Aged Care Facility, and all cases linked with the North West community cluster.

The remaining genetic clusters ranged in size from two to 17 people and largely corresponded well with identified epidemiological links to specific sources such as other specific cruise ships, or among travelling companions who had recently returned from interstate or overseas.

The genomic sequencing was consistent with the epidemiological evidence that two returned passengers from the Ruby Princess were the index cases for the outbreak. It also demonstrated that transmission of SARS-CoV-2 to staff occurred from both patients.

Apart from the North West outbreak, there was no evidence of sustained transmission from other cases imported to Tasmania. This suggests that quarantine, contact tracing and testing procedures within the state were effective.

2.8 Conclusion

As highlighted throughout this section, responding to the North West outbreak required challenging and unprecedented decisions and actions.

At all times, the DoH sought to take proactive action to best manage the frequently competing priorities of ongoing service delivery and infection control and management. When the outbreak reached a point where this became unachievable, the DoH was prepared to take decisive action to close the NWRH and NWPH to bring the outbreak under control in the shortest time possible, avoiding the risk of an uncontrolled and potentially longer disruption of services. Through the cooperation and support of healthcare workers, government agencies and partners, and the wider North West community, the outbreak was able to be brought under control and the number of new infections slowed through late April before ceasing in early May.

The planning and governance arrangements that had been put in place in March 2020 provided a framework for action and escalation and supported decision making during the outbreak. Most importantly, the resilience, professionalism and dedication of all staff involved was unwavering throughout the outbreak, and they should be incredibly proud of the service provided under extraordinary circumstances. However, many learnings and improvements were also identified, as outlined in the North West Regional Hospital Outbreak Interim Report (the Interim Report).