Oct 22, 2020

“Prepare – I mean really prepare”: An insider’s advice from the COVID-19 front line

Last month, Dr Rodney Jilek, managing director of Aged Care Consulting and Advisory Services, spent four weeks in Melbourne assisting aged care homes battle outbreaks of COVID-19.

Without hesitation, he and his team made the commute to Melbourne to help his colleagues during the unprecedented crisis. He missed spending Father’s Day and his 50th birthday with his family and was away for the final weeks of his wife’s pregnancy. His team remains in Melbourne where they have been since 17 August.

During the peak of the pandemic, Dr Jilek shared his insights and advice in regular social media posts giving us all a glimpse of what it was like for those on the frontline.

We are republishing his comments in the hope they will provide useful guidance to others.

Though case numbers are down, there are still active cases in nursing homes, and future outbreaks can not be ruled out.

Preparation is key

Prepare – I mean really prepare. Not tell the Commission over the phone you are prepared, actually have a plan and resources available.

Plan for significant staff losses. Our home lost 90+% of staff including the director of nursing, all three maintenance men, 70% of all RNs, all but one cleaner, all laundry staff and all activity staff. You are likely not to know the virus is present in your home at the initial stages because many can be positive but asymptomatic.

Due to increased care needs, isolation of everyone, increase in daily communication with families, rostering, making signage, listing of cases and the enormous task of donning and doffing and cleaning your workforce, needs will escalate dramatically.

For just 65 beds we are running 8-10 RN, 15-20 PCA – per shift!

We have additional staff as: 

  • door monitors, 
  • PPE spotters, 
  • 4 x liaison staff to contact all relatives and ring hospitals every single day and run iPad visits, 
  • extra admin to collect the endless data for govt departments, 
  • 2 x Physiotherapists to provide 1:1 treatments 
  • 3 x activity staff to provide 1:1 every day 
  • cleaners & laundry staff by the dozen. 

There is huge maintenance pressure as things still break down and no one will visit a COVID site.

Where are you going to get your staff from? Plan now.

Sign up for nursing agencies now. Sign up to lots. There is lots of paperwork so sign up proactively.

Put in place additional supply arrangements. Supply companies require financial information and contracts. It all takes precious time. Do it now.

Think about where you will buy disposable products from – plates, cups, cutlery, wash bowls … and PC thickened fluids, drinks, single use wound care supplies etc.

Prepare waste management – alginate bags, clinical waste bags – we are using a 6m x 2m x 2m skip bin as a clinical waste bin and filling it every two days.

Infection control

Cohort early and fast to minimise the spread.

Train your staff in personal protective equipment use over and over and over again.

If you have an outbreak, call in AUSMAT to help you set everything up and zone your home.

Lock away all your vinyl gloves and normal (non N95) face masks.

Buy zip lock bags to put mobile phones in.

Make sure you have extra equipment – BP, Pulse Ox, Thermometers, Glucometers so you don’t have to share across so many residents.

Buy an extra medication trolley so you can put just positive residents meds inside.

Pack away as much furniture as possible – less makes cleaning easier.

Make sure you have paper, printer cartridges, laminating pouches and a laminator (all signs need to be laminated).

Admin can work offsite for some things but it makes things much harder.

Check your PPE stocks – N95 mask, face shield, full arm length gown, nitrile gloves.

Check your masks fit your staff properly. Many Asian staff find the standard N95 masks are too big to seal properly. 3M makes a mask that is smaller and fits well for smaller people. The best are the orange duck billed masks but they are near impossible to get.

Do NOT use plastic gowns (the ones we usually use for showering) – they increase transmission risk and do not provide protection.

Do NOT use normal surgical masks.

Do NOT use booties (shoe covers) – they increase transmission risk. You need a disinfectant spray to spray shoes upon leaving the premises.

Do NOT use full body HAZMAT suits – they increase transmission risk

Hair nets / Hats are NOT necessary – IF you wash your hair daily.

Ideally, staff should come to work in their own clothes, change into work clothes at work, change out of work clothes when leaving, wash everything as soon as you get home and shower / bath including washing your hair.

Take care finding staff, despite the urgency

Make sure that your processes are not person dependent and clear process instructions are available to fill in – across all roles.

Agencies are stretched to the limit. Some are sending anyone with a pulse. Students, IT people, unemployed – no qualifications, no experience, no training. All passed off as ‘nurses/carers’.

I have had people turn up expecting to do ‘on the job training’. One today had never fed anyone. Often, they have never seen a lifter. 

You need to vet everyone walking in your door and ask them key questions to determine their skill level.

Some agencies such as Mable are now like Uber Nursing. They have no staff. They just link you to independent workers. You then need to negotiate wages, times, shifts. Many will only come if you let them do double shifts and/or work seven days a week or both. Some want weekend rates during the week. They can name their price. Mable takes no responsibility because they are ‘not their staff’. Be aware that as desperate as you may be, bending to these demands puts you, your workers and your residents at risk.

Emergency leave

Under the changes to Aged Care Act, residents are able to take emergency leave and return to their family. This leave is additional to the normal social leave provisions. One major issue that no one thought of… what happens when they want to come back?

The current advice from the Public Health Unit in Victoria is that they cannot return to the home until the home is completely cleared of COVID. Warn your relatives so they make informed decisions before taking their loved one home.

How has COVID-19 impacted staff?

The first issue was we lost most of them – about 80%. Be prepared, about one third have refused to return.

Your workforce needs will explode and so will the cost.

The cleaning & laundry bill alone for 6 weeks was $600,000 and prepare to be gouged for EVERYTHING so prepare the bean counters.

Donning & Doffing takes time and needs to be done right. Provide food and drinks for your staff because they can’t bring it with them. 

Documentation completely changes – you will have staff who don’t know your residents or your systems. Go basic!

Where is the money coming from?

Beware the Commonwealth COVID-19 reimbursement grant. It may not be the saviour it has been portrayed to be, especially by the Commission who originally directed “cost must not be a consideration. You will be fully reimbursed”. In the fine print the grant it is evident that it is not an automatic bottomless bucket of funds.

There is $56 million available over 2 years (split equally) and while there is provision for an exemption to be granted at the sole discretion of the authorised delegate, the grant amount available to each provider is CAPPED. The grant guide also states if the allocated money is exhausted, there is no more.

The cap amount is $20,000 + $2,000 per bed in the affected home. For my home the total amount claimable is just $258,000. Their current spend to date is almost $2,200,000.

Another 75-bed home here in Melbourne just received their FIRST invoice covering nursing agency and cleaning – $600,000.

Clinical waste is costing $30,000 a week. One delivery of N95 masks cost $10,400 – we are getting 2 deliveries a week. PCAs are costing $100 an hour, cleaners $125 because no one wants to come and put themselves at risk.

How much do you disclose?

We have followed my usual philosophy of transparency and honesty… but to a point.

We have emailed all relatives every evening, I have spoken in family webinars, we have called relatives every day, we have contacted each of the five hospitals daily and then related an update to families.

So what did I not disclose? Here’s an excerpt of an email I wrote:

I have been asked tonight why I chose not to openly disclose the number of deaths as they have occurred. While I have no doubt that some people would love to know about others outcomes, I took the stance that their privacy and supporting them in their grief was paramount and the outcomes for other families was not something the broader community needed to know at this time.

Giving a running daily tally doesn’t really achieve anything other than increasing everyone’s fear and anxiety. Families who were able to take their loved one home were offered this opportunity and have done so. Transfer to other homes was not possible. Residents who could be transferred to hospital were transferred.

We do not announce the death of a resident to the entire relative community under normal circumstances and I do not believe this should occur at this time either.

Image: Sam Thomas, iStock.

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