Public health guidance for acute respiratory illnesses in residential aged care facilities

Influenza and COVID-19 cases in residents

Ensure the resident is isolated in their own single room with ensuite, wherever possible, with appropriate IPC measures (See Step 3: Zone management and Step 4: Infection prevention and control measures)

• COVID-19 cases should be isolated and be cared for with additional infection prevention control precautions, for at least 7 days from their positive test date (day 0 is the date of the positive test).
• Influenza cases should isolate for:
  • 5 days from symptom onset, or until their symptoms have significantly improved, whichever is longer
  OR
  • 72 hours after antiviral medication is commenced.
• Cases with other ARI should isolate for 5 days following symptom onset or until their symptoms have significantly improved, whichever is longer.
• Cases can be cleared from isolation once they have completed the isolation period AND their symptoms have significantly improved. No further respiratory testing is required to leave isolation.
• Whenever possible, a resident with COVID-19 or influenza should not share a room or facilities with residents who do not have the same respiratory infection. If this is not possible, appropriate additional risk mitigations should be worked through in consultation with ACT Health.
• Essential off-site appointments such as dialysis should continue during the case’s isolation period, following prior discussion with the service provider and transportation team to arrange for appropriate risk mitigations to be put in place.

A resident who has tested positive for influenza or COVID-19 should not be retested during their isolation period.

On diagnosis, arrange for early clinical assessment, care and treatment.

• Identify any Advanced Care Directive, pre-assessment or consent for treatment the resident may have. Clinical guidance on antiviral therapy is available online and outlined in the Resources section.
• To reduce risk of severe illness, residents who meet the criteria for anti-viral treatment should be commenced on medication as soon as possible in consultation with their treating clinician.
• If the resident requires transfer to hospital for clinical care, please notify the ambulance provider that the resident is known to have influenza or COVID-19

If a resident tests positive for COVID-19 with a RAT, the RACF can notify ACT Health through the ACT Health Outbreak Hub rather than completing the online RAT Declaration form.

Influenza and COVID-19 in staff and visitors

Staff and visitors who have respiratory symptoms should not attend the facility while unwell.

Staff members and visitors who test positive with a COVID-19 RAT are strongly encouraged to report their positive result to ACT Health directly themselves by using the online form.

Generally, if a person tests positive with a RAT they will be considered a COVID-19 case and do not need to have a PCR test to confirm the result.

However, a confirmatory PCR may be recommended in certain situations.

Staff members who test positive as part of a workplace RAT screening program should follow the protocols developed by their workplace that support them to isolate and, if indicated, obtain a confirmatory PCR test.

Contact Identification

Following an exposure at a facility from someone with an ARI, RACFs should undertake a risk assessment to determine if any staff or residents have been exposed. A management plan should then be implemented based on the exposure risk. This plan should include details of the relevant precautions to minimise risk to the entire facility, which may include a quarantine period, testing plan, relevant PPE use and zoning and cohorting of staff and residents.

Contact management of people exposed to influenza

• Residents living in the same zone/wing as an influenza case should be monitored for symptoms and be tested for COVID-19 and influenza if symptoms develop.
• Asymptomatic residents living in the same zone/wing as a case do not need to undergo influenza or respiratory panel testing.
• Wherever possible, principles of cohorting and zone management (see Step 3: Zone management) should be applied. This includes cohorting influenza cases separately from other residents.
• Post-exposure prophylactic use of antivirals may be considered in an influenza outbreak, in consultation with ACT Health.
  • If recommended by ACT Health, antiviral prophylaxis should be offered to all asymptomatic residents (regardless of vaccination status) and all unvaccinated staff.
  • Forward planning including pre-assessment and pre-consent for antivirals can facilitate effective deployment of antiviral prophylaxis.
  • For symptomatic residents with a known influenza exposure, anti-viral medication can be administered prior to receiving pathology confirmation.

Contact management of people exposed to COVID-19

Where there have been cases of COVID-19 among staff, visitors or residents who have been at the facility during their infectious period, facilities should identify those who may have been exposed (contacts):

• Determine the infectious period. For COVID-19, the infectious period starts two (2) days before the person with COVID-19 developed COVID-19 symptoms or had their positive COVID-19 test taken, whichever came first.
• Identify people who have been exposed to the case and their last date of exposure. Templates to assist with tracing the movements of cases and their contacts are found in Templates.
• Assess the risk to staff and residents using the Risk assessment guidance.
• Notify contacts and advise staff on next actions
  • If there is a positive COVID-19 case in the facility, you should notify any staff, residents, and visitors who have been identified as contacts (those with a potential exposure) and direct them to follow the relevant advice on the ACT Health website.
  • Guidance to inform discussions with staff members regarding risk mitigations when returning to work following a COVID-19 exposure is available at Staff return to work guidance . This guidance is updated regularly. Please always refer to the online version.
  • When notifying staff, residents, and visitors of their contact status, you should advise them of their last date of exposure. This is the last date that they had contact with the person with COVID-19 during their infectious period. Be mindful of not compromising the privacy of the person with COVID-19 when providing this information. For contacts, the last date of exposure is considered day 0. All advice about testing, risk mitigation measures and return to work is calculated from this date.
  • If a person who is identified as a contact has recently recovered from COVID-19, they should follow the advice on the ACT COVID-19 website for recovered cases.
  • If a resident is identified as a higher risk contact or household contact and has since been transferred to hospital, another facility or home, notify the relevant person at the hospital to advise them of the resident’s contact status and date of last exposure.

Testing and quarantine guidance for COVID-19 contacts

Lower risk contacts are advised to monitor for symptoms and seek PCR testing if symptoms develop.

^ Last day of exposure is day 0

* if initial test was done on day 5, a day 6 test is not required

Principles of cohorting/zone management in an outbreak

Identify the areas of the facility that are at risk. Where only a wing or floor of the RACF is impacted that area should be managed as an outbreak site, separate to the rest of the facility.

• Cases with the same respiratory pathogen (COVID-19 or influenza) should be cohorted in the same zone/wing wherever possible (Red zone). If there are concurrent outbreaks, residents with influenza should be cohorted separately to residents with COVID-19.
• Residents who are identified as higher risk contacts of COVID-19 should follow the relevant quarantine requirements. They should be cohorted separately (Amber zone).
• Higher risk contacts after their quarantine period can be managed with stepped-down precautions for the next 7 days in Yellow zone.
• For guidance on testing and risk mitigation measures, including when to step down through various zones, see Testing and quarantine guidance for COVID-19 contacts under Step 2: Contact Management.

Below is guidance on how to manage red, amber and yellow zones and when they can be used.

Use the hierarchy of controls to minimise the risk of transmission in RACFs. Infection, prevention and control strategies to minimise risk of transmission of COVID-19 and influenza, include physical distancing (>1.5 metres), hand hygiene, respiratory etiquette, surface cleaning, ensuring adequate ventilation of rooms, isolating the infected resident, and PPE.

The Infection Control Expert Group (ICEG) has developed national guidelines for COVID-19 infection prevention and control in residential care facilities in Australia. These documents are also useful to consider in responding to influenza outbreaks. Please review this document for the most up-to-date advice.

Key IPC considerations include:

• Vaccination:
  • Facilitate access to influenza and COVID-19 vaccination for residents to ensure they are up to date.
  • Obtain consent for vaccination from the resident, guardian or substitute decision-maker prior to vaccination day, using the recommended written consent form for COVID-19 vaccination or the recommended procedure for pre-vaccination screening.
• Physical Distancing:
  • Maintain physical distancing of >1.5 metres where possible
  • Use PPE if unable to maintain physical distancing
  • Strategies include: moving chairs and tables to encourage residents to sit >1.5 metres apart and reducing the number of residents attending communal activities in small rooms.
  • During breaks, staff should maintain physical distancing or stagger breaks where practicable
  • Initiate contactless staff handovers
• Hand-hygiene:
  • Encourage frequent hand-hygiene for staff and residents
  • Use signage and posters as reminders. Signs are available in the  National Guidelines for the Prevention, Control and Public Health Management of Outbreaks of Acute Respiratory Infection (including COVID-19 and Influenza) in Residential Care Facilities
  • Facilitate good practice by appropriate placement of hand sanitiser
  • Use ‘spotters’ or IPC leads to remind staff when to use hand hygiene
  • Encourage staff to complete hand-hygiene education
  • Use ‘Five Moments of Hand-hygiene'
• Ventilation:
  • Ventilation strategies – increase airflow throughout the room and the facility by:
    • Opening windows and doors if safe to do so
    • Turn on air-conditioners (turn OFF recirculation)
    • Turn on bathroom exhaust fans and leave them on
    • Consider use of air purifiers with a HEPA filter in areas with less ventilation or in wings with cohorting cases.
  • Rooms with positive cases should have the door closed as much as possible
  • Review ACT Health’s COVID-19 guidance on ventilation for more information
• Cleaning:
  • Develop a cleaning plan for the facility, this includes a clear process for who is cleaning the rooms of residents with COVID-19 or influenza
  • Cleaners should be trained in donning and doffing practices and wear full PPE when cleaning
  • Clean high touch surfaces with either detergent and disinfectant (a 2-step process) or with a detergent/disinfectant wipe. Use a TGA approved cleaning and disinfection product for COVID-19.
  • All surfaces should be cleaned 2-3 times per shift
  • Floors should be vacuumed using a vacuum with HEPA filter
  • Floors should be cleaned using the standard procedure. This includes using an approved floor cleaning solution, mopping from clean areas to dirty areas and discarding the mop-head (if disposable) or sending the re-useable mop-head to the laundry in an alginate bag after use
  • Always mop the floor in a positive case’s room last. If there is more than one positive case a separate mop-head will be used for each room
• Laundry:
  • Residents who are in isolation with COVID-19 or influenza should have their laundry collected and laundered separately to the laundry of other residents
  • Staff collecting laundry during an outbreak should wear PPE (P2/N95 respirator, eye protection, gown and gloves)
  • If using a commercial laundry service, notify the service. Contaminated laundry should be placed in alginate bags and managed according to the commercial laundry’s policy for infectious laundry
• Waste management:

  General Waste

  • Most waste generated from a room with confirmed positive cases of COVID-19, influenza or other ARIs is general waste, and if unsoiled can be discarded into the general waste bin. Unsoiled waste means that it is not contaminated with blood or body substances (e.g. mucous, faeces, urine, vomit)
  • Double bag the general waste bags from rooms with confirmed cases to prevent spillage. The general waste bag can then be placed into the general waste bin / skip.

  Clinical Waste

  • Waste that is contaminated with blood or body substances, such as mucous, faeces, urine, vomit, (e.g. soiled bed linen or blood-soaked disposable PPE) or medical waste (i.e. catheters, intravenous cannulas) is classified as clinical waste.
  • All staff handling clinical waste should be trained and have access to appropriate PPE.
  • Clinical waste should be disposed of in clinical waste (yellow) bags and discarded into an approved clinical waste (yellow) bin.
  • Clinical waste should be stored in a secure area and removed by an approved waste management operator.
• Use combined standard and transmission-based infection control precautions:
  • Standard precautions are the primary strategy to minimise transmission of healthcare associated infections.  Standard precautions are used when providing care to all residents, regardless of whether they have an infection or not. Standard precautions include hand hygiene, the use of appropriate PPE to ensure staff are not exposed to blood or body substances, routine environmental cleaning, respiratory hygiene and cough etiquette, aseptic technique, waste management and appropriate handling of laundry.
  • To reduce transmission of COVID-19 and influenza a combination of standard precautions and transmission-based precautions are recommended.
  • Standard + Contact + Airborne precautions are recommended when providing care to, or visiting, residents in isolation for COVID-19 and influenza. This includes full PPE (Fit checked P2/N95, eye protection, long-sleeved impermeable gown, gloves) and will require the room or wing to be set up as a red zone with donning and doffing at the entrance to the room or wing).
  • Use appropriate infection control signage when quarantining or isolating a resident.
• Reducing risk of transmission of respiratory illness using PPE:
  • Staff and visitors entering a high-risk setting, including RACFs, should follow the facility’s guidance for the use of masks and other PPE
  • Following a risk assessment, affected areas will be zoned according to risk. This will help you to identify PPE requirements for each zone/wing.
  • Provide ongoing PPE education programs in your facility. IPC leads can use resources to assist with PPE education – NSW Clinical Excellence Commission has resources available here
  • Cohort staff to zones and limit roles (e.g. kitchen and administrative staff should not enter exposed wings/zones)
  • Donning/doffing posters in English, Nepali, Malayalam, Hindi and Filipino are available from the Advice for staff and operators of aged care facilities page
• Death of a resident:
  • Develop a plan for how to manage the death of a resident during an outbreak
  • This includes precautions when handling the deceased person. For more information, follow advice for funeral directors

It is important to raise any potential issues as soon as possible with ACT Health or the Commonwealth Aged Care COVID enquiries as delivery of resources can take several days.

Personal Protective Equipment

• Consider your immediate and ongoing PPE requirements. If there are additional cases you may need additional PPE for a longer period.
• It is the responsibility of the RACF to initially have enough PPE on-hand to manage an exposure or outbreak.  Providers have a responsibility to source PPE through commercial and retail suppliers.
• Additional PPE can be supplied from the Australian Government Department of Health and Aged Care during an outbreak. To request PPE go to the COVID-19 Support Portal via the My Aged Care (MAC) service provider portal. Depending on your outbreak status, a RACF service can request a standard outbreak PPE pack (14-day supply) or an emergency PPE pack (3-day supply) with evidence of your attempts to source PPE from commercial and retail suppliers.

If you are in a COVID-19 outbreak and do not have enough PPE, complete the request for PPE on the COVID-19 support portal and alert the Commonwealth Case Manager by email (AgedCareCOVIDEnquiries@health.gov.au). If after following these steps, you do not have enough PPE for the next 24 hours, contact ACT Health by calling 02 5124 6320 or emailing  and flag the email as urgent. This inbox is monitored from 8.30am to 4.30pm Monday to Friday.

Testing

• Consider your immediate and ongoing rapid antigen testing kit and specimen collection needs. You will need to collect specimens from residents where possible.
• To access PCR testing, you will need a pathology request form from the resident’s GP or a nurse practitioner.
• Any staff requiring PCR testing may be able to access testing through their primary care provider or directly through participating pathology centres if they are a concession card holder.
• See where to get tested in the ACT to support testing of staff members.

Workforce

Advice on when a recovered case who is a staff member can return to work is available on the Staff return to work guidance.

If you have a workforce shortage because staff are unwell or COVID-19 household/higher risk contacts, you should:

• discuss with your Commonwealth case manager available at AgedCareCOVIDEnquiries@health.gov.au
• follow your staff contingency plan in your outbreak management plan
• review the return to work arrangements for household contacts/higher risk staff
• consider the following strategies:
  • move to a 12-hour roster, with appropriate breaks for staff
  • call back staff from leave
  • move casual and part-time staff to full-time
  • source staff from non-outbreak sites within the approved provider
  • outsource ancillary services such as cleaning and laundry to free up staff for other functions
  • how staff who are furloughed, from head office or working at non-outbreak sites can complete tasks that can be done remotely

If, after working through the above options, you continue to have a critical workforce shortage, please contact your Commonwealth Case Manager (AgedCareCOVIDEnquiries@health.gov.au) or ACT Health (outbreak.response@act.gov.au).

If you have an exposure at your facility, the following outbreak precautions should be applied to the exposed areas of your facility e.g. the exposed wings or zones.

If you have an outbreak at your facility, the following outbreak precautions should be applied to your entire facility. If there are discrete areas of the facility that are separate from the exposed areas (i.e. exposed wing/zone), outbreak precautions do not need to apply to the discrete areas. Please discuss with ACT Health if you require advice on whether areas of your facility can be considered separate and do not need to be managed under outbreak precautions.

During an outbreak of COVID-19 or influenza, your facility should follow full outbreak precautions for 7 days, where day 0 is the date the last resident case was confirmed or the date of isolation of the last case in a resident, whichever is later. In some circumstances, if there have been additional staff cases without use of appropriate PPE, outbreak precautions may need to be continued – please discuss with ACT Health.

Where there is extensive or poorly understood transmission, or where there are significant numbers of residents not up to date with immunisations or transmission is within a memory support unit, ACT Health may advise the RACF to continue to manage as an outbreak until at least 14 days have passed since the last case tested positive.

For COVID-19 outbreaks, additional mitigation measures are recommended for Days 8-14.

*Additional risk mitigation measures should be followed for COVID-19 outbreaks until day 14, where day 0 is the date the last resident case was confirmed and effectively isolated

Visitor restrictions during an outbreak

• ACT Health supports visitors for resident wellbeing. ACT Health supports essential visitors (such as partners-in-care and end-of-life visits) to confirmed cases and non-essential visitors may visit unaffected zones of the facility
• RACFs should use screening mechanisms to ensure unwell visitors do not enter the facility.
• Essential visitors are best if identified ahead of time, to enable these essential visitors to be educated in PPE donning and doffing. An Industry code for visiting in Aged Care Homes is available online and will assist RACFs to develop their visitor policy.
• Essential visitors during an outbreak may include:
  • Visitors who provide personal care to a resident including a partner-in-care that is needed to assist a resident with their meals, personal hygiene and behaviour management. A partner-in-care is a person who has a close and continuing relationship with the resident such as a family member, loved one, friend or representative. There may be some residents who will only accept this care from a known care partner.
  • Visitors who support residents who wander/display responsive behaviours related to dementia or cognitive impairment. Such visits may also reduce transmission.
  • Visitors who support mental health (including dementia) – this may include maintaining routines, and providing emotional support to help prevent loneliness, anxiety, fear and depression.
  • In some situations, staff shortages may require care partners to step into a caring role if they volunteer to do so. Such carers should be identified ahead of time and supported with appropriate personal protective equipment and training.
  • Healthcare professionals and emergency services, including vaccination providers
• End-of-life visitations can continue for all residents during an outbreak including those residents who have had medium or high-risk exposures or who are cases.
• When on-site during an outbreak, visitors should follow the same facility protocols and requirements as is required by staff at the same facility (e.g. entry screening and wearing of appropriate PPE).
• All visitors should be assisted with donning and observed during doffing.

New and returning resident admissions when your facility is under full outbreak precautions

Follow the below steps when a new or returning resident needs to be admitted/re-admitted to the RACF in the 7 days after the last exposure in a facility:

1. Do a risk assessment to determine how the resident can be admitted/re-admitted to the RACF with appropriate risk mitigation measures. Consider the following:
   • The best care of the resident, considering the risks of unnecessarily prolonged hospital admission.
   • Can the resident be appropriately cohorted away from residents who are COVID-19 cases and in isolation? Where they can be appropriately cohorted away from residents who are COVID-19 cases, this supports admission/re-admission. If cohorting is not possible, consider implementing risk mitigation measures including the case or resident wearing a mask and minimising time in shared spaces.
   • How urgent is the admission? An admission/re-admission from the hospital is likely urgent. An urgent admission/re-admission should be facilitated where possible and appropriate.
   • Is the outbreak uncontrolled and are ongoing cases being detected? Re-admission to an affected area of the facility should be avoided if possible, where an outbreak is uncontrolled and ongoing cases are being detected, balancing the best care of the resident.
2. If the risk assessment supports admission/re-admission, inform the family/resident of the COVID-19 situation in the facility and seek consent where needed.
3. If the resident is in hospital, liaise with the treating team regardless of the outcome of the risk assessment.

There are RAT testing recommendations for residents who are returning from a hospital admission and for new permanent or respite residents. A PCR test is not needed, unless the resident has COVID-19 symptoms. For further information see Advice for staff and operators of aged care facilities.

Residents who have recently recovered from COVID-19 , do not need a COVID-19 test prior to being admitted/re-admitted to a RACF.

Readmission of residents who have COVID-19

• Facilities should facilitate admission/re-admission of new and returning residents who are COVID-19 cases. Follow the advice for managing a resident who is a COVID-19 case.
• The resident should be admitted/re-admitted to the facility and move directly to their room, avoiding time spent in communal spaces, wear a mask where tolerated, and avoid contact with other residents.

You should follow your outbreak management plan and communicate when your facility is experiencing an acute respiratory illness outbreak:

• Communicate to residents, staff and families
• Communicate Healthcare providers and other relevant service providers

You should also notify ACT Health and the Commonwealth Department of health in the following situations:

After you have notified ACT Health that your facility is experiencing an acute respiratory illness outbreak via the ACT Health Outbreak Hub, please update your line list in the outbreak portal:

• Each time another COVID-19 case is diagnosed at the facility.
• Each time another confirmed influenza case is diagnosed at the facility
• If a resident who has COVID-19 is hospitalised, please notify ACT Health using the line list in the ACT Health Outbreak Hub
• If a resident who has COVID-19 or has recently recovered from COVID-19 dies, please notify ACT Health using the ACT Health Outbreak Hub
  • Please ensure that the family are aware that ACT Health publishes de-identified data on all COVID-19 deaths – the only information that will be published is the person’s gender and the decade of life that they were in when they died. Don’t hesitate to contact ACT Health to discuss further if there are any concerns.

• Update your notification line list daily.
• Remind staff and visitors of the importance of informing you if they have a positive COVID-19 RAT or PCR test and were at your facility while infectious.
• Continue to implement entry screening for staff and visitors.
• Keep a record of which residents and staff are contacts and their last exposure date. Monitor and record the testing results of resident contacts and any staff contacts who are returning to work early.
• Keep a record of your risk assessment and plan following each COVID-19 case at your facility, including details of when it was last updated and which cases the risk assessment and plan has accounted for. This information does not need to be reported to ACT Health.

If your facility needs additional support, this information may be requested by ACT Health. You should have this information ready to provide if needed.

If there are any further cases at your facility, repeat the above steps, update your plan, notify contacts, undertake relevant actions, communicate again and continue to monitor.

Any residents or staff who are re-exposed should have their testing and quarantine requirements reset to reflect the updated date of last exposure if relevant.

You should keep a track of the last exposure date at your facility to know when you can anticipate standing down and lifting outbreak precautions. The last exposure date is the date the last resident case was confirmed and effectively isolated. In some circumstances, if there have been additional staff cases without use of appropriate PPE, outbreak precautions may need to be continued – please discuss with ACT Health.

If there are further cases at your facility, you should recalculate the anticipated date for lifting precautions with ACT health guidance.

Full outbreak precautions should be followed for:

• 7 days following the last date of exposure for both COVID-19 and influenza outbreaks.

Additional mitigation measures are recommended for COVID-19 outbreaks for Day 8-14. See Step 6: Implementing outbreak precautions in your facility for further detail.