The four phases of a COVID-19 outbreak for Aged Residential Care The four phases of a COVID-19 outbreak for Aged Residential Care The four phases of a COVID-19 outbreak for Aged Residential Care

Please note: This page is currently being reviewed following the end of the traffic light system on 12 September 2022. Find out more about the changes.

Acknowledgments

The Ministry of Health would like to acknowledge the Health Quality & Safety Commission, the Northern Region Health Coordination Centre, Ryman Healthcare and Oceania Healthcare for contributing their documents to be adapted as tools and resources for national use by other aged residential care providers.[1]

The Ministry would also like to thank the members of the working group who worked collaboratively with the Ministry to draft this toolkit, acknowledging the time and expertise they and their organisations contributed to this toolkit’s completion. Along with those named below, the Ministry is grateful to all of the health care and support professionals and organisations who contributed through the review of this document.

  • Bridget Richards, College of Gerontology Nursing, New Zealand Nurses Organisation
  • Cheyne Chalmers, Ryman Healthcare
  • Deborah Witheford, Health Quality & Safety Commission
  • Emma Prestidge, Ministry of Health
  • Frances Hughes, Oceania Healthcare
  • Graham Upton, Bupa Aged Care Homes
  • Janine Snape, Ryman Healthcare
  • Karla Powell, Waitematā District Health Board
  • Mardi Postil, Canterbury District Health Board
  • Richard Scrase, Canterbury District Health Board
  • Marg Bigsby, New Zealand Nurses Organisation
  • Dr Osman Mansoor, Tairāwhiti District Health Board
  • Dr Phil Wood, Ministry of Health
  • Rhonda Sherriff, New Zealand Aged Care Association
  • Dr Sarah Merry, Waitematā District Health Board
  • Dr Tess Luff, Ministry of Health
  • Clinical Oversight Group, Ministry of Health
  • IPC sub-TAG, Ministry of Health
  • Jade Cincotta, Ministry of Health

[1] The Health Quality & Safety Commission document was based on guidance developed by the Communicable Diseases Network Australia and adapted to New Zealand. The guide incorporates guidelines from global health authorities, including the World Health Organization and the United States Centers for Disease Control and Prevention.

COVID-19 Outbreak Response Toolkit for Aged Residential Care: Definitions

  • ARC: Age-Related Residential Care
  • ARC OMT: Aged Residential Care Outbreak Management Team, a team formed in response to one of more confirmed cased in a resident, health care or support worker, or visitor of an ARC facility. It will include representatives from the relevant PHU, DHB, ARC provider, and an IPC or laboratory expert.
  • Anosmia: Loss of sense of smell
  • Casual contact: Casual Contacts are people who have been in the same place (Location of Interest) at the same time as someone infectious with COVID-19 but may not have been near the infectious person. Casual Contacts are at lower risk of getting sick with COVID-19.
  • Care plans: Care plan is a term used in include advance care planning, advance directives, resuscitation orders, or similar.
  • CCE: Close Contact Exemption Scheme
  • CIMs: the Coordinated Incident Management System (CIMS), is New Zealand Aotearoa’s official framework to achieve effective coordinated incident management involving multiple responding agencies 
  • Close contact: Close Contacts may live or work with someone infectious with COVID-19, or have been in the same place at the same time as someone infectious with COVID-19 Without appropriate personal protective equipment (PPE). A list of exposures can be found in ‘How will I know if I’m a Close Contact’.
  • Cluster: Cluster refers to an aggregation of cases grouped in place and time that are suspected to be greater than the number expected, even though the expected number may not be known
  • Cohorting: In this context, ‘cohorting’ refers to grouping people together within the ARC facility who will then remain separate from other groups.  For example, cohorting a group of ARC residents who have tested positive for COVID-19 within the same area or wing so that the same health care and support workers are caring for them
  • Confirmed case: A case that has laboratory definitive evidence. For more information on what is considered laboratory definitive evidence, visit Case Classification: Confirmed Case.
  • COVID-19 Protection Framework (with traffic lights): New Zealand is in the COVID-19 Protection Framework, also known as the traffic lights. There are three levels (red, orange, and green) and each level tells us what measures we need to take. The key component of the framework are: vaccination, my vaccine pass, capacity limits, record keeping, localised protections and lock downs. For more information visit ‘COVID-19 Protection Framework (with traffic lights)’
  • COVID-19 Community Response Framework: The COVID-19 Community Response Framework was developed in 2020 as a guide for the primary and community health sector when moving between different alert levels. To see the framework visit ‘COVID-19 Community Response Framework’
  • CPF: COVID-19 Protection Framework (with traffic lights)
  • GP: General Practitioner
  • Historical Case: A confirmed case that is deemed to have recovered (no longer considered infectious) at the time of testing
  • Household Contact: Someone who shares a house or flat with someone who has tested positive for COVID-19 (a case) on a permanent or part time basis (eg shared custody) AND spent at least one night or day (>8hr) in that residence while the case was infectious. People who live in the same group accommodation (eg aged residential care) as the case are not considered Household Contacts, but may be Close Contacts. For more information visit COVID-19: Information for Household and Close Contacts
  • COVID-19: Coronavirus disease 2019, the disease caused by infection with the SARS-CoV-2 virus
  • Isolation: Separating a person who has COVID-19 to prevent the spread of disease
  • IPC: Infection Prevention & Control
  • MSD: Ministry of Social Development
  • Not a case: An ‘under investigation’ case who has a negative test and has been assessed as not a case; a person where SARS-CoV-2 has been detected where the detection is determined to be due to a previous COVID-19 infection which has already been recorded either in New Zealand or overseas; a person who has detection of SARS-CoV-2 from a clinical specimen but, following further investigations such as serology, repeat testing, history and symptoms, they are deemed to not be a case (eg, a likely false positive).
  • NP: Nurse Practitioner
  • Outbreak: One or more cases of COVID-19 in an ARC resident, health care or support worker, or visitor that has been at the ARC facility during their infectious period.
  • Person/People in ARC: Used to refer to all people in ARC, this includes ARC facility management, health care and support workers, residents and whānau, and visitors
  • PHU: Public Health Unit
  • 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
  • SARS-CoV-2: The virus that causes coronavirus disease 2019 (COVID-19)
  • Quarantine: Separating/isolating a person who may be infectious to prevent spread of disease
  • Under investigation case: A case where information is not yet available to classify it as confirmed, probable or not a case 

Introduction

The New Zealand Aotearoa experience of COVID-19 has highlighted the importance of ensuring ARC facilities are prepared for an outbreak. Protecting older people is a priority in the response to COVID-19, as age is a risk factor for severe disease and death. Older people in residential care are especially vulnerable due to communal living, the number of health care and support workers and visitors they are in close contact with, and the wider network of connections those people have in their local communities.

An outbreak of COVID-19 in an ARC facility will require a swift and well-coordinated response from key stakeholders across different organisations. District health boards and PHUs will work closely with an ARC facility to contain the outbreak and minimise the impact.

During times when the risk of community transmission is assessed to be Mild-Moderate (see Age Residential Care Guidance for Operation under the COVID-19 Response Framework, ARC facilities are encouraged to review their response to-date and prepare for future changes in CPF traffic lights within the COVID-19 Protection Framework.

This toolkit is based on the principles and framework outlined in the New Zealand Aotearoa Pandemic Response Policy for Aged Residential Care. This toolkit should be used alongside the policy, as the toolkit makes frequent reference to the Aged Residential Care Outbreak Management Team (ARC OMT), which is described in detail in the policy.

Ethical decision-making during the COVID-19 pandemic

ARC facilities, DHBs, and PHUs must prepare for the difficult ethical decisions that may arise during an ARC outbreak, as individual liberties may need to be limited to protect people in ARC.

This can be a challenging experience as external pressures increase, because some decisions may have a negative impact – for example, initiating a lockdown knowing that this means only minimising the bad outcomes; transferring residents whilst understanding how disruptive this can be; standing down health care and support workers whilst increasing workload; or arranging alternative accommodation for ‘live in’ health care and support workers. This toolkit includes guidance for ways to help make the best decisions, but they may not necessarily be the most comfortable, nor beyond dispute.

The ethical principles to think about include:

  • Proportionality. Doing just what is necessary to maximise the good vs harm.
  • Minimise harm. Taking action in the least restrictive way.
  • Reciprocity (give and take). Spreading the load, providing for some reward, helping people feel safe, expressing gratitude.
  • Fairness. Paying attention to factors that disadvantage some people more than others.
  • Transparency. Providing the reasons behind decisions and the options that were considered, and sharing that decision with those who need to know.

Ethical decision-making must also follow the principles of Te Tiriti o Waitangi. Meeting our obligations under Te Tiriti o Waitangi is necessary if we are to ensure iwi, hapū, whānau, and Māori communities and organisations are active partners in preventing and addressing the potential impacts of COVID-19. This is crucial to realising the overall aim of Pae Ora, the Government’s vision for healthy futures for Māori, under He Korowai Oranga, the Aotearoa New Zealand Māori Health Strategy.

Explaining and holding a constructive conversation with those who promote a different opinion about matters addressed in this guidance will be necessary – for example, an advocate who identifies the adverse effects of social isolation during prolonged lockdown. Day-to-day liberties will be traded for the health and wellbeing of other residents and health care and support workers. The Director General of Health and the local Medical Officer of Health will have mandated such policies during a pandemic.

How to use the toolkit

This toolkit supports ARC facilities to prepare for an outbreak of COVID-19 within their facility in a nationally consistent, four-phased structure with a focus on communication and collaboration.

The four phases are described as follows.

Mild-Moderate-Severe impact of COVID-19 in community

Prevent and Prepare phase: Mild-Moderate-Severe impact of COVID-19 in community

Maintain vigilance to reduce the risk of COVID-19 entering the ARC facility. Prepare for different outbreak scenarios and check policies and protocols are up-to-date.

 

Standby phase: Possible COVID-19 in the ARC facility

A person in the ARC facility is considered a potential case of COVID-19 and is being tested.

 

Outbreak phase: One or more active cases of COVID-19 within the  ARC facility

A resident, a health care or support worker, or a visitor who has been at the ARC facility during their infectious period is determined to be a COVID-19 case. The ARC OMT is convened.

 

Review phase: After the outbreak

The PHU has declared the outbreak of COVID-19 over, and the outbreak response is reviewed by the ARC OMT. The ARC facility returns to the Prevent and Prepare phase.

 

This toolkit is structured around these four phases. At the start of each section is a table that summarises the key actions, roles, and responsibilities the main responding organisations, ARC facility, regional PHU, and local DHB will have throughout the four phases.

This toolkit provides guidance with links to tools, templates, and other resources to enable ARC facilities to tailor this toolkit to their local context.

 

Understanding COVID-19

Recognising COVID-19

COVID-19 is caused by the virus SARS-CoV-2 that can affect your lungs, airways and other organs. Coronaviruses are a large and diverse family of viruses which cause illnesses such as the common cold.

Presentation can range from no symptoms (asymptomatic) to severe illness with potentially life-threatening complications, including pneumonia. Some people experience a loss of smell or taste at the beginning of the illness, and others have only gastrointestinal symptoms such as diarrhoea alone. This means that any new respiratory or gastrointestinal illness in an ARC resident must be taken seriously, with appropriate actions implemented immediately. 

Our COVID-19 case definition is updated to align with best available evidence. Common symptoms of COVID-19 are similar to colds or influenza. A person may have one or more of the following symptoms:

  • new or worsening cough
  • sneezing and coryza (runny nose)
  • fever (at least 38˚C)
  • sore throat
  • shortness of breath
  • temporary anosmia (loss of sense of smell)
  • temporary altered sense of taste.

Less common symptoms of COVID-19 may include diarrhoea, headache, muscle aches, nausea, vomiting, malaise, chest pain, abdominal pain, joint pain or confusion/irritability. These almost always occur with one or more of the common symptoms.

Older people may present with mild or atypical symptoms but still be at high risk of deterioration, particularly if they have other health conditions. As with other infectious diseases, symptoms of COVID-19 in older people may be very non-specific but may include increased confusion, behavioural change, worsening chronic conditions or a rapid decline in their usual abilities.

Whilst most people with COVID-19 have mild disease and recover, ARC residents are more likely to have severe disease and higher mortality. The illness may appear stable for several days, followed by rapid deterioration. Complications include:

  • respiratory failure
  • septic shock
  • multi-organ dysfunction/failure.

Variants of SARS-CoV-2

The SARS-CoV-2 virus that causes COVID-19 has undergone genetic mutations over time. The Omicron variant has spread worldwide rapidly and is now the major variant in many countries, including New Zealand. Omicron is much more transmissible than previous variants of the COVID-19 virus, including Delta.

Incubation and infectious periods

People with COVID-19 usually develop symptoms 3 to 7 days after exposure, but they can develop symptoms from 1 to 14 days after exposure.

People are considered infectious from 48 hours before onset of symptoms until recovery. Recovery is usually 10 days after the onset of symptoms and 72 hours after symptoms resolve (whichever is longer). Different criteria apply for those who have a mild illness and are not hospitalised. There are different criteria if the person has had a more severe illness and has been admitted to hospital.

Routes of transmission

There is a growing body of evidence that airborne or aerosol transmission for respiratory viruses including SARS-CoV-2 does occur. Scientific studies have shown that exhaled particles generated by talking, shouting, singing, sneezing or coughing are predominantly small particles. These small, exhaled particles (less than 5 µm) can carry viable infectious viruses and bacteria, for longer distances than first understood. Larger aerosols, > 100 µm, remain suspended for short periods of time (seconds) and can travel < 1m before falling to the ground under the influence of gravity. They may deposit on mucus membrane and upper airways of exposed individuals at close range to the infected individual.

In ARC facilities, transmission between health care and support workers is an important factor in spread. Health care and support workers can have multiple short interactions with each other without personal protective equipment (PPE) (at least early in the outbreak), so their additive exposure if any health care and support workers are infectious can be substantial. Interrupting transmission among health care and support workers and residents is critical for stopping an outbreak in this communal living setting.

While faecal shedding of the virus has been described, there have not been any reports of faecal–oral spread.

Prevent and Prepare phase

In the Prevent and Prepare phase, ARC facilities must ensure that they are prepared for both an outbreak of COVID-19 in ARC (including the first case of COVID-19) and for the changes in the ways of working required with any increases in community transmission, either nationally or locally or regionally. The following roles and responsibilities draw from the New Zealand Aotearoa Pandemic Response Policy for Aged Residential Care.

ARCs

  • Keep up-to-date on the latest Ministry COVID-19 guidance for ARC providers.
  • Establish and maintain links with ARC OMT. Work collaboratively and know who to contact, when, and why.
  • Understand ARC facility role and responsibility in ARC OMT.
  • Localise national guidance so it works for the ARC facility.
  • Develop COVID-19 Outbreak Management Plan. Ensure this addresses psychosocial welfare of health care and support workers and residents and their whānau.
  • Specify who will hold key roles and responsibilities within the ARC facility during an outbreak.
  • Ensure residents’ care plans and photo identification are up-to-date. Monitor medicines expiry dates.
  • Strengthen relationships with iwi and Māori to support outbreak preparedness.
  • Establish training and education plan for health care and support workers and visitors.
  • Develop communication plan for residents and their whānau, health care and support workers, and visitors.
  • Practice scenario training with DHB, PHU, and other local stakeholders.
  • Undertake preparedness assessment as requested by DHB.
  • Ensure measures are being taken to prevent infection from being introduced into ARC facility.

Hospitals

  • Establish and maintain links with ARC OMT. Work collaboratively and know who to contact, when, and why.
  • Understand DHB role and responsibility in ARC OMT.
  • Maintain contact information for the core ARC OMT.
  • Localise national guidance so it works for the region.
  • Facilitate iwi and Māori representation on the ARC OMT, and ensure their roles and responsibilities are effectively communicated.
  • Support ARC with primary care support for in-person assessments and testing as required.
  • Plan for assisting with procurement of equipment and consumables, if necessary, during an outbreak.
  • Support education and training on CIMS roles and responsibilities, particularly for intended ARC OMT members.
  • Plan and coordinate ARC OMT scenario training at defined intervals.
  • Work together with PHU to provide specific, regional guidance for ARC providers on:
    • the preferred notification process for when a resident or health care and support worker requires a test for COVID-19
    • what happens in the first 24 hours
    • lines of communication, including names, roles, phone numbers, and after-hours details.

PHUs

  • Work with DHB to establish and maintain links with core ARC OMT members. Work collaboratively and know who to contact, when, and why.
  • Understand PHU role and responsibility in ARC OMT.
  • Localise national guidance so it works for the region.
  • Build relationships with local whānau, hapū, iwi and Māori communities to support outbreak preparedness planning, including scenario training.
  • Link to DHB and ARC facility and check status on infection prevention and control (IPC) preparation.
  • Practice scenario training with DHB, ARC, and other local stakeholders.
  • Work together with DHB to provide specific, regional guidance for ARC providers on:
    • the preferred notification process for when a resident or health care and support worker requires a test for COVID-19
    • what happens in the first 24 hours
    • lines of communication, including names, roles, phone numbers, and after-hours details.

Prevent COVID-19 introduction and transmission

Measures should be taken to prevent infection from being introduced into the facility and for infection being transmitted within the facility. While the risk is lower during times where there is no known community transmission, it is critical that preventative measures are maintained at all times.

The following actions, discussed in detail below, will help prevent the introduction and transmission of COVID-19:

  • Keep track of movements for contact tracing
  • Follow key principles of New Zealand’s COVID-19 Vaccine Strategy
  • Reduce the risk of visitors introducing and transmitting infection
  • Reduce the risk of health care and support workers introducing and transmitting infection
  • Reduce the risk of residents introducing and transmitting infection
  • Implement effective IPC measures.

Ensure your facility is up-to-date on the latest Ministry COVID-19 guidance for ARC providers. The Ministry’s website continues to be regularly updated with new guidance as information evolves and we adapt to the changing global environment.

Keep track of movements for contact tracing

Register for, create, and display the NZ COVID Tracer QR code in accordance with guidance to support rapid contact tracing.

Encourage health care and support workers, residents and visitors to keep a record of their movements for contact tracing purposes. Encourage visitors to use the app on arrival and encourage them to turn the Bluetooth function on.

Follow COVID-19 Vaccine Strategy

Getting a COVID-19 vaccine and booster is an important step people can take to protect themselves, their kaumātua and whānau from the effects of the COVID-19 virus. It’s one- way people can protect the welfare and wellbeing of others from COVID-19.

The New Zealand Government has secured enough vaccines for everyone in New Zealand. The vaccine and booster are free and available to everyone aged 5 and older. 

Vaccines and health care and support workers

All health care and support workers within ARC facilities are required to be fully vaccinated and have had their vaccine booster by 24 February 2022. 

Vaccines and visitors

The below table provides a short overview of vaccination requirements for visitors across the COVID-19 Response Framework. 

Reduce the risk of visitors introducing and transmitting infection

Manage visitors according to current CPF traffic light setting and community transmission impact.

Communicate with residents and their whānau on the current and likely visitor restrictions and explain why they are necessary. Reinforce to visitors the importance of public health measures including: hand hygiene, staying away if unwell, physical distancing, vaccination against COVID-19, and using the COVID Tracer app (and Bluetooth feature).

Work with residents and their whānau to identify ways to meet their psychosocial needs across different CPF traffic light settings, including how contact between residents and their whānau can be maintained during visitor restrictions. This can be noted in their care plan.

Reduce the risk of health care and support workers introducing and transmitting infection

Any health care or support worker who has been identified as a close contact with a probable or confirmed case of COVID-19 (without appropriate PPE) may be required to undergo a COVID-19 test or self-isolate. During the pandemic, the New Zealand Government advice has been to not travel overseas, with the exception of a very few countries. Health care workers who travel according to the New Zealand Government’s quarantine-free travel guidance do not require a stand-down or quarantine period on their return. Visit the SafeTravel website for more information. 

Support health care and support workers to leave work, get tested, and go home if they develop symptoms whilst on shift. Provide information on where health care and support workers can be tested and let them know they may be eligible for support from MSD. For more information see ‘If you’re sick or need time off work because of COVID-19’ on the MSD website. They can also call the free COVID-19 Welfare Line on 0800 512 337 (8am to 5pm Monday to Friday and 8am to 1pm on a Saturday).

There may be instances where a health care or support worker is unable to return home (eg, they are living with an older person or young children). Consider how you might support these health care and support workers to keep residents and their whānau safe while they await direction from Healthline or their GP. Health care and support workers are encouraged to notify the facility if they are being tested for COVID-19. Health care and support workers who have been tested should follow self-isolation and quarantine requirements in accordance with the latest testing guidance  (refer to Standby section).

Health care and support workers should undergo a pre-shift checklist at the beginning of each shift for:

  1. symptoms of COVID-19, including assessing for fever
  2. any contact with a probable or confirmed case of COVID-19 or a person under investigation to have COVID-19.

Note that there are some instances where people need to remain in self-isolation even after they have had a negative test, as advised by their GP, NP, or the COVID-19 Healthline (0800 358 5453).

Where possible, provide changing areas for health care and support workers to change out of personal clothes into their uniforms at work and back into personal clothes at the end of the shift. Where possible, provide facilities for health care and support workers to shower before changing into personal clothing.

Health care and support workers who work in multiple locations may pose a higher risk of transmission between facilities. ARC management should work with health care and support workers who work in multiple locations to plan for strategies to mitigate this risk should there be community transmission or an outbreak in the facility.

Allied health professionals

Providers should support allied health professionals to continue to see residents as appropriate to the current COVID-19 community transmission level and CPF traffic light setting. Always consider the impact of any delayed care or treatment to the resident’s health and wellbeing. 

Surveillance testing of ARC health care and support workers

Up-to-date information on asymptomatic surveillance testing of ARC health care and support workers can be found at Case definition and clinical testing guidelines for COVID-19. Some ARC facilities have engaged private providers to undertake surveillance testing.

The Ministry of Health is providing rapid antigen tests (RATs) to ARC facilities who will be working directly with COVID-19 cases and contacts. RATs are available for surveillance testing purpose. To order your RATs under this scheme and learn about RATs use, visit: Rapid antigen testing

Managing volunteers in ARC

Providers must be thoughtful about how different COVID-19 CPF traffic light settings and community spread will impact how they work with volunteers, especially in an outbreak situation. 

Reduce the risk of residents introducing and transmitting infection

Evaluate and manage residents with symptoms

Carefully monitor residents for symptoms of COVID-19 and respond rapidly if detected. See Standby section for next steps.

Resident admission into ARC facilities

Manage admission into ARC facilities in accordance with current national guidance. See:

Residents with dementia

Risk of infection transmission is particularly high in secure dementia or psychogeriatric care settings Implement effective IPC practice. For advice to support Māori living with dementia, visit the New Zealand Dementia Foundation web page Best Practice Links: Supporting Māori.

Basic hand hygiene

Implement effective IPC practice. Basic hygiene measures are essential to effectively reduce the spread of infection. These include:

  • hand hygiene
  • cough and sneeze etiquette
  • cleaning.

Hand hygiene should be performed on entry and exit of a resident’s room. Hand hygiene is required before putting gloves on and immediately after taking them off. Gloves are not considered an alternative to hand hygiene.

Ensure that every resident’s room has:

  • facilities for hand washing
  • alcohol-based hand gel (a risk assessment should be made based on safety of the resident to prevent accidental ingestion)
  • Staff should have individual bottles of hand sanitiser for point of care use in areas where it is not safe for alcohol hand gel to be left unattended
  • tissues
  • rubbish bins.

ARC facilities should place signs at the entrances and other strategic locations within the facility to inform visitors and remind health care and support workers of the IPC requirements. Contact and droplet precautions signage must be placed outside symptomatic residents’ rooms to alert health care and support workers and visitors to the requirement for appropriate transmission-based precautions.

Increased ARC IPC environmental cleaning

Clean and disinfect all high-touch surfaces (like doorknobs, taps, handrails) frequently and routinely (eg, daily, before/after meals) and also immediately when visibly soiled. Cleaning products should be a 2-in-1 product (which contains both detergent and disinfectant properties) to increase efficiency. Cleaning/disinfecting agents should be effective against usual pathogens, such as norovirus, as well as coronaviruses and used according to manufacturer instructions.

Prepare for a COVID-19 outbreak in the facility

To complement activities that help to prevent introduction and transmission of COVID-19, each facility should consider a variety of activities to prepare for an outbreak. This section provides key elements to consider.

Develop a COVID-19 outbreak response plan

Each facility needs a written COVID-19 outbreak response plan. This should sit alongside the ARC facility’s pandemic plan and will serve as a basis for outbreak management under the ARC OMT. An outbreak response plan will be unique to each facility and will draw on the entire ARC COVID-19 toolkit in its development. Facilities may choose to use the headings provided in the toolkit.

Plan for being part of an ARC OMT, and allocate roles and responsibilities

There are several key roles and responsibilities that should be identified and designated in advance of an outbreak. This will support familiarity between key people who will be required to work together to make significant decisions during an outbreak of COVID-19.

ARC facilities should identify who will participate in the ARC OMT and ensure they are trained appropriately. This training may include CIMS training. There should be at least one back-up in case of absence.

Develop business continuity plans

ARC health care and support workers can be stood down for a variety of reasons, which may include:

  • being identified as a close contact
  • being identified as vulnerable
  • sickness
  • their housing situation
  • their whānau or flatmate health needs or isolation requirements.

Workforce

Plan to manage health care and support workers’ absences to reduce the impact on business as usual. Identify how to maintain essential service delivery for a range of absentee rates, including up to 100% of health care and support workers. Consider how the ARC facility will manage the impact of absences amongst:

  • health care and support workers
  • management
  • clinical staff
  • cleaning, catering, and laundry service workers.

Plan rosters to reduce the risk of transmission between health care and support workers

Consider alternative rostering arrangements to minimise transmission between health care and support workers and to reduce absences. Where possible, plan to create bubbles for health care and support worker to consistently work in specific areas, such as a particular wing or unit, and minimise crossover between teams. Minimise contact between care, cleaning, kitchen, laundry, and other health care and support workers.

Keep readily accessible records of staff rosters and any changes made, such as replacement due to late sick calls.

Replacement health care and support workers

Identify sources of replacement health care and support workers, including developing and maintaining a contact list for casual staff members and external nursing agencies to enable timely activation of a surge workforce in an outbreak situation.

Temporary health care and support workers are likely not to be familiar with the residents or the facility processes and procedures, including access to the IT systems to access care plans or other resident information. Develop and maintain induction information for support staff during an outbreak.

The COVID-19 Hands Up Database

The Ministry of Health collects expressions of interest from people looking or paid work in clinical and non-clinical roles to join the COVID-19 Response via the Hands Up Database. The Database is a searchable database of people that ARC facilities can search in order to fill any open roles you may have. Access to the database may be arranged through your DHB.

Enabling health care and support workers to work off-site

Some health care and support workers may be stood down even when they are not unwell, and they may be available to work off-site. ARC facilities are encouraged to consider how these health care and support workers may be used in an outbreak context by identifying tasks that can be delegated to health care and support workers who are unable to work within the facility. Ensure the resources they will need in order to undertake this work, such as remote computer access and the ability to participate in video conference meetings, can be made available.

Vulnerable health care and support workers

Some ARC workers have underlying health conditions that can make them more susceptible to respiratory infection or to severe consequences of infection.

Health care and support workers who are at greater risk of severe illness must be given the choice to not attend in-person work duties in the event of an outbreak or risk of one. Workforce risk assessment guidance and assessment tools have been developed by DHBs for the health and disability sector to identify health care and support workers vulnerable to the effects of COVID-19 (see Protecting vulnerable DHB health care and support workers during COVID-19, and Appendix 7 of this toolkit).

Critical Worker – The Close Contact Exemption Scheme

To help keep New Zealand Aotearoa going during the Omicron outbreak, ARC facilities (amongst other critical business/organisations) can keep their critical health care workers working if they become a household contact of someone with COVID-19 or are confirmed or probable cases of COVID-19. This is known as the Close Contact Exemption Scheme (the CCE Scheme).

The CCE Scheme allows vaccinated, asymptomatic or mildly symptomatic (ie they are not acutely unwell) critical health care workers who are household contacts or are confirmed or probable cases of COVID-19 to be able to return to work, if the worker has agreed to work (it must be clear to the worker they are not required towork) and if their work is critical to service continuity.

The CCE Scheme will clear health care and support workers to only go to work and return back to their place of isolation (eg home). They may not to go anywhere else like the supermarket or a family/whānau member’s residence.

Rapid Antigen Testing information under the Close Contact Exemption Scheme for Critical Health care workers

Under the Scheme, critical health care workers will be able to report self-administered RATs in My Covid Record. For additional information, see Rapid antigen testing and refer to the following resources: 

Risk Assessment and Health and Safety of others under the Close Contact Exemption Scheme

This CCE Scheme should only be used in exceptional circumstances, following a thorough risk assessment of your facility’s circumstances and confirming that the facility is short-staffed to the extent that it puts the care of residents at risk To support your facility’s preparation for an outbreak of COVID-19 see: Guidance for managing return to work for critical healthcare workers who are COVID-19 cases or contacts during an Omicron outbreak.

Should your facility need to make use of the CCE Scheme, you must implement a plan to protect staff and residents who are not currently cases and are not recently recovered cases. Areas of particular concern will be the nurse’s station and other communal staffing areas. It will be up to the ARC facility to manage this from a Health and Safety perspective.

Proactively notify visitors, couriers, and other delivery personnel if you have staff working under the CCE Scheme. This will enable visitors to make an informed decision about coming on site, especially if the visitors are frail and elderly themselves. Safe forms of contactless delivery should be employed to minimise the risk to couriers and other delivery personnel. It is important not just to consider the risk to residents and staff but to all others that enter or may enter the facility.

Medicines, equipment and consumables

Each ARC facility should develop their own plan to determine adequate stock because the situation for each will be different. Ensure you have adequate stocks of required consumables, including medicines, thermometer covers, soap, hand sanitiser, linen skips, non-touch rubbish bins, and PPE. Identify a process to monitor stock and rate of consumption.

The Ministry’s guidance provides a few factors that ARC facilities should consider in developing their plan, such as the facility’s location and the reliability of their supplier. PPE sourcing changes in alignment with the current risk assessment. For the latest guidance, visit COVID-19: Personal protective equipment central supply.

Pharmacies are essential services and will be available at all COVID-19 CPF traffic light settings. ARC facilities should replace medicines at usual pattern and frequency (usually monthly). The Ministry advises against stock piling or early ordering as this negatively effects the supply chain. If there are shortages of certain medicines, your pharmacists will liaise with your facility on the best way to manage those shortages.

Resident care

Ensure the following are up-to-date:

  • resident room list (with numbers and photos to support rapid rounds/team briefing)
  • resident risk assessments (with copies available if required for hospital transfer)
  • enduring power of attorney (EPOA) contact details and activation status
  • resident care plans, including:
    • advance care plan
    • shared goals of care plan
    • palliative plan.

Plans should be reviewed any time there is a change in a resident’s health status.

Identify whether residents usually receiving aerosol-generating procedures can have these discontinued or substituted with alternatives. Consider standing orders for influenza immunisation for all residents and visitors.

Residents at higher risk of contracting COVID-19 or severe disease include those who:

  • require aerosol-generating procedures (eg, tracheostomy care, non-invasive ventilation such as BiPAP or CPAP)
  • receive hospital-based dialysis
  • are severely immunocompromised
  • are obese
  • have poorly controlled blood pressure or diabetes
  • have chronic obstructive pulmonary disease (COPD).

Plan resident placement

Plan how cohorting, or grouping together, might be implemented in the ARC facility. If no rooms with en-suites could be made available, consider how shared bathrooms might be used exclusively for confirmed cases (with strict cleaning protocols between uses). For those in isolation, consider how residents will be transferred there, and cleaning procedures after use. Clean and dirty flow for cohorted areas needs to be planned to avoid cross contamination.

Consider how residents who are in isolation because of an outbreak might be cohorted together within the facility. Residents who have had a positive test need to be cohorted separately from other residents. If the facility is large, consider how different areas or wings may be kept separate – for example, by restricting access between them.

Ensure that there are sufficient equipment/consumables for these isolation rooms, including hand-washing facilities, non-touch rubbish bins, linen skips and dedicated clinical equipment.

Ventilation

Ensuring that the facility has effective ventilation is an important part of pandemic preparedness.  There is growing evidence that SARS-CoV-2 can be transmitted by the airborne route, and for this reason, effective ventilation, natural or mechanical, can minimise the risk of transmission of COVID-19 within facilities. ARC facilities are encouraged to understand the air movement within their buildings (including rooms, corridors, staff rooms, etc) when identifying isolation rooms/areas. 

Ensure adequate primary care support

ARC facilities are recommended to establish a nominated primary care provider to ensure continuity of primary care services during an outbreak, including weekends and out of hours. The local DHB can assist if the ARC facility is unable to secure the required primary care support.

Psychosocial support and welfare of residents

Experience with previous outbreaks in ARC facilities has demonstrated that these are highly stressful events with impacts on both residents and health care and support workers. Prepare a documented process for anticipating and responding to the psychosocial support and welfare of residents and their whānau. Take into account the different requirements and challenges of each CPF traffic light setting. Ensure health care and support workers are educated to recognise and administer psychological first aid, and are able to recognise signs of psychosocial deterioration in residents (see COVID-19: Mental health and wellbeing resources). To understand more about supporting the wellbeing of Māori, see Whānau Ora’s Kaumātuatanga: The needs and wellbeing of older Māori. The Ministry of Health’s COVID-19 Kia Kaha, Kia Māia, Kia Ora Aotearoa: Psychosocial and Mental Wellbeing Plan offers additional insight into the psychosocial stressors for people during COVID-19 and a useful tool for ARC providers.

Health care and support worker wellbeing

Managing an outbreak response will be challenging and require a lot from front-line workers. The ARC facility should have a plan in place to support their health care and support workers to maintain morale and inspire each other to overcome the challenges faced. Implement measures to monitor and support staff psychosocial wellbeing during an outbreak. This may include pastoral and cultural support (especially for Māori health care and support workers), access to formal employee assistance programmes, and on-site counselling (see Appendix 5).

High coverage of influenza vaccination will help to reduce the additional burden influenza places on ARC facility staffing. Ensure that there is a strong organised health care and support worker influenza immunisation policy and campaign.

Health care and support worker education and training

ARC facilities are responsible for ensuring that all health care and support workers (not only those providing care) are adequately trained in the relevant components of an outbreak response, including understanding the facility’s IPC practices and recognising and responding to signs and symptoms of COVID-19.

Topics for health care and support workers’ education and training should include:

  • good hand hygiene
  • symptoms and signs of COVID-19 in residents and appropriate response
  • exposure risks for COVID-19 (Higher Index of Suspicion criteria)
  • personal hygiene (particularly the ‘5 moments for hand hygiene’) and sneeze and cough etiquette
  • keeping your family safe (see Keep people in your home safe)
  • standard and transmission-based precautions
  • appropriate use of PPE such as gloves, gowns, eye protection and masks, including how to ‘don’ (put on) and ‘doff’ (remove) PPE correctly for actions to take if unwell with symptoms of COVID-19
  • actions to take if a health care and support worker becomes a close contact of a COVID-19 case
  • handling and disposal of clinical waste
  • cleaning of reusable equipment
  • environmental cleaning
  • management and laundry of potentially contaminated linen
  • food handling and cleaning of used food utensils.

Consider liaising with primary care or other appropriate health professionals to train ARC health care workers to perform a test for COVID-19. See the Ministry’s COVID-19 learning modules, which have been developed to support health care workers, including kaiāwhina, to perform COVID-19 swabbing under supervision.

Scenario training

Review the COVID-19 response plan at defined intervals and undertake scenario testing for COVID-19 outbreak preparedness.

Scenario training can provide a good opportunity to strengthen relationships and partnerships with local communities, whānau, hapū, iwi and Māori communities to support outbreak preparedness planning (see Appendix 1 and Appendix 2).

Collate outbreak investigation information

Specific information will be requested by the PHU and the ARC OMT at the start of an outbreak investigation (see Appendix 10). Prepare and maintain the following outbreak investigation information to speed up response time in containing the infection:

  • a detailed floorplan, including residents’ rooms, communal areas, food preparation areas, wings, and how health care and support workers are appointed to each area
  • an up-to-date list of residents (with details as outlined in the Standby section)
  • a list of all health care and support workers employed by the facility, including up-to-date contact details
  • previous health care and support workers’ rosters, including any changes to hours worked.

Communications

Proactive communication with health care and support workers and residents and their whānau is part of a good outbreak response. Ensure that privacy is maintained as much as possible. Good communication can be time-intensive; however, it is vital to maintain the confidence of health care and support workers and residents and their whānau. The ARC OMT and the Ministry of Health will provide guidance on media communications (see Appendix 3).

A wide range of resources, for a variety of audiences, have been prepared by a number of organisations in order to support your organisation to have good communication with your health care support workers and residents and their whānau. Below is a selection of sources for resources that may be relevant to the services you provide.

Resources in other languages

A wide range of resources are available in a variety of languages on the COVID-19 website. For COVID-19 updates and resources in te reo Māori, see Te reo Māori | Ngā tohutohu Reo Māori. For resources in a variety of Pacific island, Chinese and other languages, see Help and advice in other languages.


[1] These include heart disease; lung disease; diabetes; cerebrovascular disease; conditions causing immune-compromised states; liver/kidney disease; cancer; individuals on immunosuppressant medications, including long-term treatment with steroids; pregnancy.

Standby phase

The Standby phase takes effect when a person in ARC (health care and support worker, resident, visitor) develops COVID-19 symptoms and requires testing but there are no active cases of COVID-19 within the ARC facility. There may be one or more people requiring a COVID-19 test within the ARC facility. Extra IPC protocols are put in place and contact tracing for close contacts is undertaken. The Standby phase will be in place until a test result is returned – in most cases this should be within 24 hours.

ARCs

  • Support early case recognition through early identification of COVID-19 symptoms.
  • Support people in ARC to be tested as quickly as possible.
  • Get residents tested by GP/NP, notify PHU, and highlight to laboratory to prioritise the test.
  • Isolate cases of COVID-19 under investigation.
  • Begin close contact tracing of those under investigation.
  • Increase IPC protocols.
  • Contact DHB if concerned about ARC facility’s ability to respond.
  • As appropriate, liaise with Māori NGOs or other providers to provide additional support to residents and their whānau.

Hospitals

  • Provide support if facility raises concerns about ability to respond to the Standby phase

PHUs

  • If negative test result, provide advice, if required, to ARC facility.
  • If positive test result, notify ARC OMT members and convene first meeting.

Identification and testing

Facilities should have a low threshold for testing symptomatic people in ARC, as this is an essential step in identifying and preventing the spread of COVID-19. Testing needs to be done as soon as possible after identifying that a person in ARC has a symptom that may be due to COVID-19.

Residents

A resident with symptoms of COVID-19 should be managed as a potential COVID-19 case.

If a symptomatic resident requires a COVID-19 test, immediately isolate the resident in a single room with its own bathroom if possible. IPC protocols should be strictly followed, including contact and droplet precautions.

Arrange for the resident to be tested as soon as possible. This should be done within the ARC facility.

Primary care providers should see Case definition and clinical testing guidelines for COVID-19 for requirements for notification to the PHU for people who are being tested for COVID-19. The process for this will differ in different regions, and in the ARC setting this may include informing the DHB in addition to the PHU.

Monitor the resident’s condition, including vital signs and oxygen saturation, according to clinical indications. Liaise with the resident’s GP or NP where there is a significant change in health status.

ARC facility health care and support workers

During the Standby phase where there is concern that there is a case of COVID-19 in an ARC facility, it continues to be essential that health care and support workers and visitors who have new respiratory symptoms do not attend work and immediately arrange testing.

Encourage ARC health care and support workers to advise the community testing centre or their GP that they are an ARC health care or support worker so that their case is linked to the ARC facility as rapidly as possible.

Visitors

Visitors must not attend an ARC facility if they have any respiratory symptoms of COVID-19. ARC facilities are encouraged to provide communications and education to visitors.

While awaiting test results

  • Check all other residents and health care and support workers for symptoms consistent with COVID-19.
  • Isolate any other residents with symptoms and arrange for testing.
  • Ensure best practice IPC protocols are maintained.
  • Begin to identify close contacts of people who are under investigation for COVID-19. This will assist in saving time if a test is positive. Refer to Contact tracing for COVID-19: Close Contacts.

Note that residents who are close contacts of a person awaiting a test result for COVID-19 do not need to be isolated/quarantined, unless there is a high degree of suspicion and they are therefore considered likely to test positive.

Test results

The following does not refer to ARC health care and support workers who are being tested for surveillance purposes.

Negative test result

No COVID-19 outbreak is declared. If the result is negative, the health care and support worker or resident may not be able to leave self-isolation for a number of reasons. For example, people who are close contacts of a confirmed case will need at least 14 days in isolation since last contact with the case and may need repeat testing, or there may be concern of an alternative infectious disease outbreak, such as influenza.

For information about what to do after a negative test result, see Information for People with Negative Covid-19 Results’. For further advice, health care and support workers and visitors should contact their GP or Healthline (0800 358 5453). The ARC facility should contact the resident’s GP or NP for advice. Consider discussing with the PHU.

IPC precautions should continue in alignment with Ministry of Health guidance. This may include physical distancing and ongoing isolation with transmission-based precautions. Consider testing for other respiratory infections, such as influenza, which will also require reporting if found to be an outbreak. After a suspected case has tested negative, the ARC facility returns to the Prepare and Prevent phase.

Positive test result – confirmed case of COVID-19

Health care or support worker

If the person who has tested positive for COVID-19 works within an ARC facility, the PHU will notify the facility directly as quickly as possible.

If the health care or support worker has been working during their infectious period (48 hours prior to symptoms) the PHU will convene the ARC OMT.

ARC resident

If a resident of an ARC facility is identified as a case, the PHU will work with the ARC facility to determine how best to notify the resident and their whānau. The PHU will convene the ARC OMT.

Visitor

Following discussion with the visitor and the facility, the PHU will make a decision on whether to convene the ARC OMT. This decision will be informed by factors such as the amount of time the visitor spent in the facility and the type of interactions the visitor has had.

In the event of a confirmed case of COVID-19, the ARC facility immediately moves to the Outbreak phase.

Outbreak phase

The Outbreak phase is initiated when a person in ARC has tested positive for COVID-19. The PHU convenes the ARC OMT. The ARC OMT oversees the outbreak response. This Outbreak phase is likely to last several weeks.

ARCs

  • Participate in daily ARC OMT meetings.
  • Notify GP/NP of resident of positive test.
  • Complete and submit ‘ARC Facility Outbreak Investigation Information for PHU’ to PHU (Appendix 11).
  • Tailor and implement COVID-19 Outbreak Response Plan.
  • Establish and maintain Daily ARC Facility Situation Report.
  • Identify and manage close contacts of cases within the ARC facility.
  • Appoint GP/NP to work with PHU to develop testing plan.
  • GP/NP or PHU to highlight to laboratory to prioritise tests.
  • Implement strengthened IPC measures, including PPE retraining.
  • Implement alternative rostering arrangements to minimise transmission.
  • Implement surge staffing plan.
  • As appropriate, liaise with Māori NGOs or other providers to provide additional support to residents and their whānau. Consider how to cohort health care and support workers to look after specific groups of patients and minimise movement within ARC facility.
  • Consider how rosters may be managed to reduce the number of sites or facilities health care and support workers are working across (including GP/NP).
  • Screen health care and support workers at the start of each shift, and implement ongoing self-monitoring for symptoms.
  • Implement physical distancing.
  • Review roles and responsibilities of vulnerable health care and support workers.
  • Maintain clinical monitoring, assessment, and testing of residents and on-site health care and support workers.
  • Monitor residents for acute respiratory symptoms, fever, or other deterioration. Notify GP/NP as required and place in isolation.
  • Communicate with residents and their whānau any changes to visiting requirements.
  • Implement detailed visiting policies and protocols.

Hospitals

  • Facilitate daily ARC OMT meetings.
  • Support development and implementation of tailored COVID-19 Outbreak Response Plan.
  • Provide IPC support and advice and identify the control measures that need to be in place.
  • Following initial assessment of ARC facility conditions, coordinate any required additional clinical, cultural, or workforce support.
  • Support ARC facility with any identified areas of concern, including linking to Māori NGOs for extra support.
  • Support ARC facility with testing as guided by PHU.
  • Provide resource support with testing. This may include a mobile service.
  • Support ARC OMT with media queries.
  • Assist with assessment of cases, consideration of hospitalisation, or staffing support in place (including gerontology nurse specialist, community geriatrician, or cultural assessment and support).

PHUs

  • Receive notification of positive test result from laboratory.
  • Confirm an outbreak.
  • Convene the core ARC OMT meeting within 2 hours of notification.
  • Participate in ARC OMT meetings.
  • Lead outbreak investigation plan through ARC OMT.
  • Lead the contact tracing of probable and confirmed COVID-19 cases.
  • Support contact tracing appropriate to the CPF setting.
  • Advise on testing requirements.
  • Advise on isolation and quarantine requirements.
  • Monitor for severity of illness (record deaths and hospitalisations).
  • Inform relevant stakeholders of outbreaks, including local whānau, hapū, iwi and Māori communities, where appropriate.
  • Work in partnership with GP/NP to develop testing plan for residents.
  • Monitor outbreak progress.
  • Decide when to declare an outbreak ‘over’.

Notification

An outbreak will be declared when one or more confirmed COVID-19 cases were present in the ARC facility during their infectious period.

COVID-19 is a notifiable disease in Aotearoa New Zealand. The PHU is directly notified of all positive SARS-CoV-2 tests by the laboratory. As soon as the positive test has been linked to an ARC facility, the PHU will inform the core ARC OMT members and convene the first meeting. This process is described in the New Zealand Aotearoa Pandemic Response Policy for Aged Residential Care (‘the ARC Pandemic Policy’).

Convening the core ARC OMT – within the first two hours of notification

ARC facility outbreak management requires a close collaboration between the ARC facility, the DHB, and the PHU. As defined in the ARC Pandemic Policy, a positive test result will trigger the PHU to convene the core members of the ARC OMT.

Within the first two hours of notification, the small group of core members of the ARC OMT should meet. If the notification is received after hours, flexibility may be required (see Appendix 9). The ARC OMT should consider all of the CIMS roles and responsibilities noted in Appendix 2 of the ARC Pandemic Policy and consider which key stakeholders should be assigned those tasks. Membership, roles, and responsibilities should be assigned in proportion to the scale and risk of the outbreak (see Appendix 8).

The ARC facility should notify the GPs/NPs of residents of the positive case and access clinical care as required. If there is no primary care medical care available, the ARC facility should inform the DHB as soon as possible so support can be arranged.

COVID-19 outbreak investigation

If there is a confirmed case, investigation and contact tracing will begin. The aim of the case investigation is to identify the source of the outbreak, other close contacts, and other cases. Outbreak investigation is undertaken in parallel with outbreak management. This should ideally commence within 4–6 hours of the outbreak being declared (see Appendix 11). What outbreak investigation will look like will be dependent on the current CPF traffic light and the impact of local community spread. For the lastest guidance, refer to the relevant phase guidance within Omicron in the community: what this means for you.

The ARC facility will be asked to provide the information outlined in Appendix 10. The ARC facility is responsible with starting and maintaining a COVID-19 daily situation report. The COVID-19 daily situation report will be reported to the ARC OMT daily.

COVID-19 outbreak management

The ARC facility should have their COVID-19 Outbreak Response Plan drafted (as noted in the ‘Prepare’ section. This should be reviewed by the ARC OMT and then tailored to the specific outbreak. This outbreak response plan should be implemented by the ARC OMT as soon as possible. Outbreak management is undertaken in parallel with outbreak investigation.

Infection prevention and control during a COVID-19 Outbreak

There are a number of IPC measures that should be undertaken by the ARC facility during an outbreak. In the event of an outbreak, your DHB IPC team can provide advice regarding IPC measures and PPE use for your facility.

The IPC measures include:

1. Ensuring that Standard Precautions are adhered to.

  • Hand hygiene (‘5 moments for hand hygiene’)
  • PPE fit, use, and disposal
  • Respiratory hygiene/cough etiquette
  • Regular environmental cleaning and disinfection
  • Linens/laundry handling, transporting, and processing
  • Waste disposal
  • Patient care equipment
  • Prevention of needle stick and injuries from sharp instruments
  • Use of aseptic practices to prevent contamination of wounds, medical devices etc.

2. Use of Transmission-based Precautions when providing care to residents with suspected or confirmed SARS-CoV-2 infection

  • Contact and Airborne Precautions

In an outbreak, the ARC facility will need to significantly increase attention to IPC. ARC providers should engage their IPC lead and discuss any specific requirements with the ARC OMT. At a minimum this should include higher priority placed on ensuring basic hygiene measures are followed, appropriate use of transmission-based precautions and regular cleaning and disinfection.

During an outbreak, refresher training is recommended for all existing health care and support workers and as required for new staff. Consider requesting an IPC specialist to perform an IPC walk-around inspection within 24 hours of notification. This could be completed either in person or virtually via laptop or tablet.

ARC facilities must ensure their health care and support workers know when PPE is required and how to use and dispose of it correctly and safely. Health care and support workers should be trained in the use of a ‘buddy system’ to observe and correct PPE donning and doffing and use this where possible. A range of information about the correct use of PPE in different contexts is available on the Ministry website, see COVID-19: Infection prevention and control recommendations for health and disability care workers.

Use the PPE Competency Checklist (Appendix 5) to support increased vigilance in these IPC areas.

DHB staff

The ARC facility may receive health care and support worker assistance from the DHB. If this is the case, ensure they are properly orientated upon arrival. Health care and support workers should not work across more than one workplace.

Medical mask use by health care and support workers

Consider at what point in the outbreak it is appropriate to introduce continuous targeted medical mask wearing in all areas.

Check the Ministry website for the latest guidance (see COVID-19: Infection prevention and control recommendations for health and disability care workers).

Environmental cleaning and disinfection

Undertake thorough cleaning and disinfection at frequent and defined intervals during an outbreak. Increase cleaning of common areas, staff rooms, and well-residents’ rooms. Clean and disinfect unwell residents’ rooms. Consider how cleaning should be undertaken – for example, clean well-residents’ rooms before cleaning unwell residents’ rooms. Refer to the Ministry’s COVID-19: General cleaning and disinfection advice.

Reusable resident care equipment should be dedicated for the use of an individual resident. If it must be shared, it must be cleaned and disinfected between each resident use.

Clean the following frequently touched surfaces more often: counters, tabletops, doorknobs, light switches, lift buttons, railings, phones, bathroom fixtures, toilets, and other objects. More information on cleaning and disinfecting can be found on the Ministry website (see COVID-19: General cleaning and disinfection advice.

Health care and support workers should be familiar with ARC cleaning practices when dealing with linen or crockery and cutlery.

Managing contacts

Work exposure

It is essential ARC facilities establish and maintain good protocols around managing staff that are identified as having a high-risk exposure to a positive case whilst at work. The identification will be guided by the PHU using the Risk Assessment and Categorisation of Healthcare Workers Exposed to COVID-19 available from the PHU. In most exposure situations, no stand-down is required. ARC facilities should be aware that health care and support workers may be stood down midshift if identified by the PHU as highest exposure risk and have plans in place for what to do if this should occur.

Household exposure

In the CPF framework, household contacts are now referred to. Household contacts are people who live with a person who has tested positive for COVID-19, see COVID-19: Information for Household and Close Contacts for full definition of a household contact. ARC facilities are not considered households under this definition, which means the requirements for isolation do not apply when there is a positive case within an ARC facility.
 
If a health care or support worker has someone who they live with who has tested positive from COVID-19, they may be considered a household contact, and may be required to isolate.  See Guidance for household contacts and refer to the Ministry website for the latest guidance on contact and isolation requirements.  

Physical distancing

Ensure physical distancing (two meters) is implemented wherever possible and practical. Consider health care and support worker interactions with each other, such as staggering breaks and ensuring physical distancing in common areas and tea rooms.

Staffing

ARC health care and support workers

Health care and support workers caring for residents who are confirmed cases of COVID-19 should maintain meticulous IPC practices and adhere to Ministry guidance on PPE use (see COVID-19: Infection prevention and control recommendations for health and disability care workers).

  • Dedicate health care and support workers to care for cases, ideally not caring for other residents.
  • Keep detailed records of all health care and support workers who are caring for cases, including who they come into contact with on each shift.
  • Health care and support workers should not be working elsewhere.

Supporting ARC staff who are symptomatic or a household contact

ARC health care and support workers who are symptomatic or a household contact can now order free RATs directly through the newly launched RAT requester site.  
Let them know there are many services to support them, many of which can be found on Advice for people with COVID-19 and on Preparing to self-isolate.

Funded temporary accommodation for front-line workers

ARC health care and support workers may be eligible for government-funded temporary accommodation. This initiative ensures the health and disability workforce remains safe while at work, and it supports those who need to stay away from their homes during a COVID-19 outbreak.

Clinical monitoring, assessment, and testing during the Outbreak phase

Clinical monitoring and assessment

Monitor residents for acute respiratory symptoms, fever or other deterioration. If symptoms include shortness of breath, monitor oxygen saturation. If a resident becomes unwell, their GP or NP should be notified to arrange an assessment. The resident should be isolated in a single room and use appropriate standard and transmission-based precautions. Residents who develop symptoms consistent with COVID-19 should be treated as probable cases – inform the PHU and provide testing.

The ARC OMT will consider clinical management support. This may include the assessment of cases and consideration of hospitalisation.

Testing

When an ARC facility is in an Outbreak phase, testing protocols will change because there is a higher risk of transmission. The PHU will develop a testing plan, which may include testing of asymptomatic people in ARC (as advised by the PHU). The DHB may provide support with testing, and this may include a mobile service. The receiving laboratory should be notified to prioritise testing.

Cohorting and room management for positive and suspected cases of COVID-19

Residents who are confirmed, probable or close contacts awaiting a test for COVID-19 will need to be isolated as advised by the PHU. Isolation requires a single room, with an ensuite where possible. Cohorting should consider both confirmed or probable cases and separating people who are likely to be close contacts (unless they are in the same cohort).

Providing care after death

The risk of transmission from handling the body of a deceased person who had or was suspected to have had COVID-19 is low. However, health care and support workers should continue following contact and droplet precautions and place deceased bodies in a leak-proof bag. For further guidance, see COVID-19: Deaths, funerals and tangihanga.

Ensure this information is shared with any whānau of the deceased person and explained in a way that they understand the risks associated with handling the deceased person and why these processes are in place.

ARC residents transfer and admissions

As part of their daily meetings, the ARC OMT should continually assess the ARC facility’s capacity to safely care for residents during an outbreak.

Apart from usual transfer via ambulance of residents who require acute hospital services to hospital, all transfers of residents into or out of the facility should be avoided until the outbreak is declared over by the PHU. If a resident requires transferring to a higher level of care, this should be discussed within the ARC OMT. Advise the hospital and ambulance in advance when an ARC resident is being transferred from an ARC facility where there is confirmed or probable COVID-19 and/or the resident is a confirmed or probable case of COVID-19.

The ARC facility should not accept new COVID-19 negative residents until the outbreak is declared over.

Visitors during an outbreak

During an outbreak, visitors should only be entering the building to provide essential services or if pre-arranged with the facility manager on compassionate grounds. Ensure the process or application for determining compassionate grounds is inclusive of practising tikanga Māori. Visitors should be supported by trained health care and support workers, including in donning and doffing PPE. Ensure visitors who do attend the ARC facility are recorded on a register of visitors and comply with the following:

  • Pre-arrange the visit.
  • Only enter the facility if necessary – for example, deliveries could be left outside.
  • Report to the designated area on arrival.
  • Sign in using the NZ COVID Tracer QR code.
  • Provide evidence of their vaccination status, and if not vaccinated, a negative COVID-19 test 48-72 hours before their visits may be required.  
  • Receive a negative RATs (Phase 3)
  • Complete a wellness declaration and temperature check prior to visiting.
  • Wear PPE as directed by health care and support workers.
  • Enter and leave the facility directly without spending time in communal areas.
  • Perform hand hygiene before donning and after doffing PPE, and before entering and after leaving the resident’s room and the facility.
  • Visit only the specified resident in their room.

Keep a detailed log of all visitors, including contact details, time of visit, use of PPE, and health care or support worker contacts.

Recognise that, although necessary, visitor restrictions can have a psychosocial impact on residents and their whānau. Consider other ways for residents to stay in touch with their loved ones, including writing cards or letters, using telephone or video calls, and using photographs.

Monitoring outbreak progress

The ARC OMT may choose specific indicators to monitor the outbreak management process. These could include monitoring whether the outbreak comprises more cases than can be managed by the ARC facility or if the rate of new cases is not decreasing as expected. These indicators can be used by the ARC OMT as triggers for a review of the current outbreak management plan.

Declaring the outbreak over

It is likely an outbreak will be considered ‘closed’ after 28 days after the last day of exposure to a confirmed case. The 28-day count will start on the day after the last day of isolation of the last confirmed or probable resident case and/or on the last day of contact with a health care or support worker or visitor case. Close contact residents who have not completed their quarantine period should finish that period if the outbreak is declared over.

The ARC OMT may continue to provide oversight after the outbreak is over at their discretion. After the PHU declares an outbreak is over, the ARC facility moves on to the Review phase.

Review phase

The outbreak has been declared over by the PHU. There are no active or probable cases within the ARC facility. The ARC OMT is ready to be deactivated.

ARCs

  • Participate in ARC OMT debrief and review meeting.
  • Record learnings. Anonymise and share learnings with other ARC facilities.

Hospitals

  • Participate in ARC OMT debrief and review meeting.
  • Record learnings. Anonymise and share learnings with other DHBs and the Ministry of Health.
  • Deactivate ARC OMT.

PHUs

  • Participate in ARC OMT debrief and review meeting.
  • Record learnings. Anonymise and share learnings with other PHUs.

Once an outbreak has been declared over, it is important for all parties to reflect on what worked well and what changes could improve processes and outcomes in future outbreaks (see Appendix 13).

The debrief should not be used to allocate blame for weaknesses identified. It should involve all members of the ARC OMT, ARC facility health care and support workers, and any others who participated in the response to the outbreak. Reviewing all aspects of the outbreak will create a comprehensive and coherent picture. General learning may be shared to improve preparation and response to outbreaks in similar health care settings.

A general summary of the outbreak should be provided at the beginning of the debrief meeting. This summary should include a timeline of events, a map of the facility, and any high-level data that has been captured. At the end of the debrief, the team should agree an action plan with recommendations, responsible person, and deadline for each task/action. The action plan should be distributed to all individuals involved in the debrief. Ensure all relevant plans, protocols, and policies are updated as necessary.

Outbreak summary report, suggested template for OMT use

An outbreak summary report can be a valuable reference for DHBs, PHUs and the ARC facility. The OMT will decide if this is a useful document to produce. The OMT may also choose to circulate this document to other agencies, such as the Ministry, for the purposes of systems learning. It is important to consider privacy and confidentiality if this is the case.

The outbreak summary report collates the information in summary form, encompassing a summary of the outbreak and actions taken as well as an overview of lessons learned that were developed at the outbreak debrief session (see Appendix 14).

Appendices & summary of changes