How did Royal Melbourne Hospital curb its COVID-19 outbreak?

Royal Melbourne Hospital (RMH) is reported to have endured the largest institutional outbreak of COVID-19 infections in healthcare workers in Australia to date. The hospital’s multidimensional response to the outbreak has been examined in a perspective piece published online by the Medical Journal of Australia.

Beyond a focus on personal protective equipment (PPE), the authors identified a number of key factors that shaped the hospital response, including the use of single rooms wherever possible, rapid testing for staff and employee support programs.

Between 1 July and 31 August 2020, 262 cases of COVID-19 were identified among RMH staff. Fifteen individuals (5.7%) required inpatient care and 13 (4.9%) received care by a hospital in the home service. Two were admitted to the intensive care unit (ICU), none requiring mechanical ventilation, with no deaths. Nurses were most commonly affected, followed by support staff (such as food and cleaning services) and doctors (17/21 of these being doctors-in-training).

“The Royal Park Campus had the highest number of staff with COVID-19, making up 40.8% (n = 107) of healthcare worker infections at the Royal Melbourne Hospital, despite this campus constituting about 10% of the total staff workforce at the hospital,” wrote the authors, led by Professor Kirsty Buising, infectious diseases physician at RMH, the University of Melbourne and the Peter Doherty Institute for Infection and Immunity.

“Between 12 and 18 July, the Royal Park Campus received a large number of patients from external residential aged-care facilities, not affiliated with the Royal Melbourne Hospital, with COVID-19 outbreaks. These residents were COVID-19-positive at admission and were managed with appropriate infection precautions throughout. COVID-19 cases among staff rapidly escalated across all six wards at the campus after 16 July, peaking on 27 July.

“Our response was necessarily iterative and pragmatic and advice often pre-dated formal state and federal recommendations,” Professor Buising and colleagues wrote.

Key factors shaping the RMH response

Critical burden

“We hypothesised that large numbers of patients in confined spaces may have created a high density of droplets, aerosols and environmental contamination,” the authors wrote.

“This triggered a detailed assessment of ward physical layout, including the possible role of patient placement and air circulation. We elected to use single rooms wherever possible and to physically space infected patients by closing beds on the ward.

“The intensity of transmission in some wards led to a decision to close wards and move some patients to other healthcare services.

“Further, we adopted the use of N95 masks for staff working in areas with large numbers of patients with confirmed or suspected COVID-19.”

Testing

“The availability of rapid and accessible testing for staff was critical to informing real-time outbreak management,” the authors wrote.

“Rapid availability of data informed our daily incident management meetings and enabled prompt decision-making using the best possible information.”

Support programs

“The importance of staff communication and wellbeing cannot be understated,” Professor Buising and colleagues wrote.

“Many staff reported physical and mental fatigue and stress during these outbreaks. In addition, workforce shortages meant that staff were taking on extra shifts at short notice and working in unfamiliar roles.

“Accordingly, access to employee support programs was an important element of this response.”

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