X.J. Walker1,3, D.L. Waters1,2, N. Millar3
1. University of Otago, Department of Medicine, Dunedin, New Zealand; 2. University of Otago, School of Physiotherapy, Dunedin, New Zealand; 3. Southern District Health Board, Dunedin, New Zealand. Corresponding author: Xaviour J. Walker, Consultant Geriatrician, Senior Clinical Lecturer and Associate Dean (Pacific), Department of Medicine University of Otago, PO Box 56, Dunedin 9054, New Zealand, Email: xaviour.walker@otago.ac.nz; Debra L. Waters, Director of Gerontology Research, Department of Medicine| School of Physiotherapy, University of Otago, PO Box 56, Dunedin 9054, New Zealand, Email: debra.waters@otago.ac.nz
Jour Nursing Home Res 2020;6:38-39
Published online July 6, 2020, http://dx.doi.org/10.14283/jnhrs.2020.9
Background of New Zealand
As of the 2018 census, New Zealand has a population of 4.7 million people, with 16.1 percent females and 14.3 percent males aged over 65 years old (1). The majority of New Zealanders over 65 years old are from European descent (87.8 percent), with Māori (5.6 percent), Asian (4.7 percent) and Pacific people (2.4 percent) (2). New Zealand has a predominately general taxation funded health system. The funding body is the local District Health Board (DHB), which provides general hospital care and funds primary and community based services including residents in Nursing Homes (3). New Zealand has 647 registered Nursing Home facilities (called Aged Residential Care (ARC)) with a total of 38,641 available beds at rest home, geriatric medical and dementia care level of care (4).
COVID-19 in New Zealand and national public health measures
The first confirmed case of COVID-19 in New Zealand was 28 February 2020 (5). New Zealand applied initial country entry restrictions from February 3rd then on March 16th applied border restrictions, compulsory self-isolation following travel and cruise ship restrictions. Progressive lockdown from Alert level 2 on March 21 to Alert level 4 (lockdown and greatest restriction) occurred March 25, 2020, which has seen a dramatic reduction to near zero new cases and essentially no community transmission. New Zealand is currently at Alert level 2 (6). As of May 15, 2020, there were 1148 confirmed and 350 probable cases of COVID-19 (7). There have been 290 cases over the age of 60 and 39 cases over the age of 80 years old. Overall there have been 21 deaths, all of which have been for patients over the age of 60 years old (8). There have been 16 COVID-19 significant case clusters, with 5 of them occurring in ARC facilities. The deadliest cluster has occurred at an ARC in Christchurch where 55 people were infected and 10 patients died, eight from Dementia level care and additional two from the hospital-wing (9).
Policies on nursing homes and COVID
The New Zealand Ministry of Health provided national guidelines on their website for ARC providers, with specific guidance documents on personal protective equipment (PPE), patient admission, COVID-19 screening for patient entry, managing staff and residents with COVID-19 infection, controlling outbreaks and for facilities with patients with dementia. Under Alert level 4 and 3 family and friends were not permitted to visit ARC facilities. There is limited exceptions for family visiting on compassionate grounds for end of life or palliative reasons under strict hygiene regulations. Under the current Alert level 2 visiting is allowed under precautions to minimise risk of COVID-19 transmission to residents and staff with health screening, time limits and number of visits, and infection control precautions. Essential outpatient’s appointments only proceed if non-deferrable and cannot be done using telemedicine. Residents should be accepted back to the facility immediately afterwards (10).
Personal protective equipment (PPE)
For ARC residents with COVID-19, PPE requirements included hand hygiene, fluid resistant gown, eye protection (google or face shield) surgical mask and non-sterile gloves. For aerosol generating procedures N95 mask is required. Poster information, instructional videos on how to correctly use PPE and frequently asked questions are available online. The routine use of PPE or routine use of masks has not been mandatory for all staff working with residents. There were some initial supply chain challenges, which were resolved by direct supply to community and residential care providers via the local DHB (11).
Guidance for admissions into Aged Residential Care facilities
ARC services are able to accept admissions from the community if the person had not been overseas in the last 14 days, not had contact with a suspected probable or confirmed COVID-19 case or had any acute respiratory symptoms. If there had been a contact or overseas travel, admission is to be delayed 14 days. Screening done by medical staff can be done virtually. Prospective residents are screened for symptoms using a standard case definition. For admission (transfer) from hospital, patients with concerns for COVID-19 are to be tested but there is no routine testing for COVID-19 prior to return to an ARC facility. For new admissions and hospital transfers, patients are expected to be placed in a single room, with their own bathroom, have meals in the room and not share common spaces for 14 days of isolation after admission and with symptoms monitored. COVID-19 screening forms are to be filled out 2 days prior to admission to ARC facility and are available on the Ministry of Health website (12).
Managing staff and residents with COVID-19 infections in Aged Residential Care facilities
All staff that are unwell, even with mild respiratory symptoms, are required not to come to work and community based testing for COVID-19 is expected and is readily available. Any suspected or probable staff with COVID-19 or with COVID-19 contact are to isolate at home immediately for 14 days. Staff with probable or confirmed COVID-19 are to be managed by the local Public Health Service and cannot be released from isolation until advised, usually at least 10 days since symptoms and at least 48 hours since resolution of symptoms (whichever is longer). All residents with suspected, probable or confirmed COVID-19 should be isolated immediately with standard, contact and droplet precautions taken by staff. If a patient is positive for COVID-19 they do not need hospital transfer, but require daily monitoring to see if they require hospital admission. The ARC facility should liaise with the DHB to ensure they have adequate PPE for patient care. The decision when to release a patient after isolation comes from the local Public Health Service (13).
Managing outbreaks in Aged Residential Care facilities
The local Public Health Service is the lead agency working in close cooperation with the institution and the local DHB. The goals are to stop further spread, and manage residents in situ unless there is a clinical advantage in transfer to hospital. All residents, where possible and reasonable, are tested for COVID-19 along with all staff. Additional clinical support and advice comes from the local DHB. In the case of two outbreaks it proved impossible to continue care in situ, because a large proportion of staff were stood down. Then residents were transferred to defined areas in the local DHB. On one occasion this led to spread amongst nursing staff in the DHB hospital (14, 15).
Advice for aged care providers for residents with dementia
Having adequate staffing, trying to keep the same staff with patients and regular schedules for patients is advised. Clarifying with residents and family about having an Enduring Power of Attorney (EPOA), discussing decisions about hospitalization, life-prolonging interventions and advanced care planning on resuscitation is important (16).
Summary
New Zealand through proactive and coordinated national public health measures has almost eliminated new cases of COVID-19. However, despite these efforts ARC facilities remain the most vulnerable and susceptible that had the highest case cluster of deaths with the majority of deaths occurring in patients over 70 years of age. Spread of COVID-19 into the acute hospital service occurred as a consequence. Current policies with infection control, COVID-19 screening and management of nursing home patients and staff will continue to be paramount even with low levels of COVID-19 cases until a vaccination is available.
Conflict of interest: None of the authors have any financial or personal conflicts of interest to report.
References
1. New Zealand Census Data 2018. Stats NZ Tatauranga Aotearoa. 2020. https://www.stats.govt.nz/tools/2018-census-place-summaries/new-zealand#population-and-dwellings. Accessed May 9, 2020.
2. New Zealand Census Data 2013 – People Aged 65+ in New Zealand. Stats NZ Tatauranga Aotearoa. 2020. https://www.stats.govt.nz/infographics/people-aged-65-plus-living-in-new-zealand. Accessed May 9, 2020.
3. Ministry of Health, New Zealand. Overview of the New Zealand Health System. 2020. https://www.health.govt.nz/new-zealand-health-system/overview-health-system. Accessed May 9, 2020.
4. Ministry of Health, New Zealand. Registered Aged Care Facilities in New Zealand. 2020 https://www.health.govt.nz/your-health/certified-providers/aged-care. Accessed May 9, 2020.
5. Ministry of Health, New Zealand. COVID-19 media release. February 28, 2020. https://www.health.govt.nz/news-media/media-releases/single-case-covid-19-confirmed-new-zealand. Accessed May 9, 2020.
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7. Ministry of Health, New Zealand. COVID-19. 2020 https://www.health.govt.nz/our-work/diseases-and-conditions/covid-19-novel-coronavirus/covid-19-current-situation/covid-19-current-cases#summary. Accessed May 13, 2020.
8. Weekly COVID report. Institute of Environment and Science Research. May 7, 2020. https://www.esr.cri.nz/assets/files/Intel-reports-COVID-19/7-May/7-May-Weekly-Covid-19-report-FINAL.pdf. Accessed May 10, 2020.
9. Ministry of Health, New Zealand. COVID-19 Significant Case Clusters. https://www.health.govt.nz/our-work/diseases-and-conditions/covid-19-novel-coronavirus/covid-19-current-situation/covid-19-current-cases/covid-19-significant-clusters. Accessed May 13, 2020.
10. Ministry of Health. COVID-19: Disability Aged Care and Hospital Providers. 2020. https://www.health.govt.nz/our-work/diseases-and-conditions/covid-19-novel-coronavirus/covid-19-resources-health-professionals/covid-19-disability-aged-care-and-hospice-providers. Accessed May 13, 2020.
11. Ministry of Health. COVID-19: Personal protective equipment for workers. 2020. https://www.health.govt.nz/our-work/diseases-and-conditions/covid-19-novel-coronavirus/covid-19-information-specific-audiences/covid-19-personal-protective-equipment-workers. Accessed May 13, 2020.
12. Ministry of Health. COVID-19 Screening Form: For a person to enter an aged residential care facility. 2020. https://www.health.govt.nz/our-work/diseases-and-conditions/covid-19-novel-coronavirus/covid-19-resources-health-professionals/covid-19-disability-aged-care-and-hospice-providers. Accessed May 13, 2020.
13. Ministry of Health. COVID-19: Guidance for managing staff/residents with COVID-19 infection in aged residential care facilities. 2020. https://www.health.govt.nz/system/files/documents/pages/covid-19-guidance-managing-staff-residents-covid-19-infection-aged-residential-care-facilities-26apr20.pdf . Accessed May 13, 2020.
14. Incident Review Report COVID-19 Staff Infections Waitakere Hospital April. 2020 https://www.waitematadhb.govt.nz/assets/Documents/news/media-releases/2020/Waitemata-DHB-Incident-Review-Report-WTK-Hospital-April-2020.pdf. Accessed May 14, 2020.
15. Health Quality Safety Commission. Guidance for preventing and controlling COVID-19 outbreaks in New Zealand aged residential care facilitieshttps://www.hqsc.govt.nz/our-programmes/aged-residential-care/publications-and-resources/publication/3975/. Accessed May 13, 2020.
16. Ministry of Health. COVID-19: Advice for aged care providers – residents with dementia. 2020. https://www.health.govt.nz/system/files/documents/pages/advice-aged-care-providers-residents-dementia-27apr20.pdf. Accessed May 13, 2020.