Corona Virus – Coming, Ready or Not… (COVID-19 in Rural and Remote Community Care)

Novel Corona virus, or COVID-19 as it is now referred to, is coming to our communities whether we’re ready or not. It’s already here in Australia and, as of 5th March 2020 it has claimed the lives of three people in this country – three of our seniors, the most at-risk people in this scenario.

Additionally, the number of cases in the broader community has risen and authorities are unsure whether people living in some remote Aboriginal communities have been infected with the virus after a tourist on a flight from Sydney to Darwin last week presented to the Darwin hospital with the virus.

The World Health Organisation (WHO) reports that the virus appears to have a higher mortality rate than the flu, although this could be because there may be many unreported mild cases of the disease.

However, although, (at the moment we think) COVID-19 spreads less effectively than the flu, it currently causes more severe illness than the flu. There are no vaccines currently available and it is rapidly spreading globally.

As aged care providers, particularly those operating in rural and remote areas, do you have an action plan to support your staff and the clients they care for should (or when) the virus become more prevalent in your community?

What do we know about the COVID-19 virus?

Well, we know that it spreads primarily via contact and that it can remain viable (alive) for up to 48 hours at room temperature, which means someone can get infected by touching a surface that an infected person has sneezed or coughed on, such as a door handle or table top, although this is less likely than through direct respiratory inhaling or contact with a contagious person.

We also know that the severity of the disease varies, with one person showing symptoms similar to that of a common cold, or even no symptoms (asymptomatic) through to another presenting with more severe symptoms, such as is encountered in cases of Severe Acute Respiratory Syndrome (SARS).

While COVID-19 can affect people of all ages, it appears the frail aged and other people with certain pre-existing health conditions are more vulnerable to experiencing more severe symptoms. According to a release by the Australian Medical Association (AMA) on the 28th February 2020, 94% of deaths have occurred in people over the age of 50 and all had a severe, significant illness prior to death.

While this might offer a degree of comfort to those of us who are younger and in good health, to many of the organisations we work with this will mean the majority of their staff and clients are at risk. Many Aboriginal people living in rural and remote areas carry a chronic health burden of Diabetes, Renal impairment, Rheumatic Heart Disease, Asthma and other heart and lung conditions, sometimes having multiple health conditions. The risk is exacerbated by overcrowded living conditions and sometimes indifferent hygiene practices. If you’re a care provider in these regions, what can you do to mitigate the risk?

First of all, if you don’t have one, develop a strategy that is aimed at appropriately responding to an infectious disease outbreak. If you already have an influenza response plan, this is a good start. For those who don’t, or where you need to review your influenza response plan consider the following issues or aspects.

Stakeholder Engagement

Who else is out there in the community who has a vested interest in planning for an outbreak and supporting your clients? This is the time to hold discussions with the health clinics and health care providers in your communities. Find out from them what response plan has been developed around an outbreak of COVID-19 in the community. Discuss with them how you can support this and how their plan will fit within your own organisation strategy. After all, it is likely that many of your clients are also their patients. Map out key responsibilities should an outbreak occur.

Education

Providing information sessions in an easy to understand format is key to ensuring your staff and clients understand the risks of the virus and how they can protect themselves and their families.

The Department of Health has developed a number of resources that cover off on protecting the vulnerable in the event of an influenza outbreak. This information is equally useful when dealing with the COVID-19 virus as they have a similar transmission pattern, although COVID-19 has a longer incubation period that the Flu.

Key information you will want to cover off on is:

• What are the symptoms of the virus and how it can impact on clients or themselves (fever, cough, runny nose and difficulty breathing)
• How the virus is transmitted
• How hand washing regularly with soap and water can help minimise the risk of picking up the virus
• Reminding people to keep hands away from the face – the virus can enter the body through the eyes, mouth or nose
• Sneeze into a tissue, not your hand (sneeze into your elbow if you have to, but understand that the virus can become trapped in clothing fibres so these will need to be washed regularly)
• Other practical habits to get into such as putting down the toilet seat when flushing and avoiding the use of electronic hand dryers to minimise the chance of the virus becoming airborne.
• The importance of wiping down surfaces with a sanitiser
• Reminding staff that if they or someone in their family or one of their clients has symptoms that are flu-like, they should immediately visit the clinic and speak to the staff there
• Stay home if sick or if a person in your household is identified as sick with the virus

Training and review of skills

This is also the time to review your staff infection control practices. Run your staff through a thorough hand-washing session: the recommended timeframe for cleaning hands using soap and water is two rounds of the Happy Birthday song.

Also monitor and check that your staff are wearing and using Personal Protective Equipment (PPE) correctly and that they are disposing of waste correctly and in a timely manner.

Ensure supplies of PPE and other resources are on hand

We are already seeing supplies run low on face masks in Australia, but you’ll probably find soap is in plentiful supply and washing hands is a key defence technique against picking up the virus. Make sure you have a good supply of paper towel to dry hands off.

Have a good stock of gloves for staff to use (this is probably just standard practice for most services) and remind staff to use them when handling laundry and other potentially contaminated items. Gloves should be changed between activities and between clients or their belongings.

You should also consider purchasing supplies of alcohol-based hand rub/sanitiser and encourage staff to use this throughout the day to supplement hand washing practices.

Face masks are not required unless the support worker is directly assisting a client with COVID-19 or where it is suspected that the client has the virus. (Note: this has changed since the publication of this post and it is a requirement for aged care workers in some areas to wear a face mask whenever they are assisting clients) The main problem with face masks is that people are not changing them often enough or they don’t understand how to use and dispose of them correctly.

Influenza Immunisation Awareness Training and Access

All residential providers are required under legislation to provide Influenza immunisation awareness training and provide staff with access to a free ‘Flu shot’ each year. While this is not a requirement in community care, it might be a good time for community care organisations to take a ‘leaf’ out of the residential care ‘book’ and provide both education and access to the Flu shot for all staff.

Although we don’t have access to a COVID-19 vaccine yet and it appears that it is unlikely that one will be available for some time (approximately 12-18 months), if we can minimise the impact of the influenza virus on our communities, our seniors should be stronger and more able to fight off the effects of COVID-19 should they come in contact with it.

It’s also a good idea to place posters and reminders up around your centres and educate and assist elderly clients to access their free flu vaccination when this becomes available in the coming months.

Be alert to staff illness

Sometimes staff will come to work despite ‘feeling a bit off’. There can be many reasons for this. It could relate to a mind set of ‘soldiering on because people are relying on me’ or it could be something as basic as ‘no work – no pay’.

Your organisation will need to work out how to support staff should they display symptoms of the virus and need to take time off, but are dependent on their job to pay the bills. After all, we all need to eat and pay our rent. As the incubation period is anywhere between 2 and 14 days, asking support workers to stand down for up to 14 days may be the tipping point for some people who have little financial reserves. (Refer to relevant Government guidelines and support for staff who are required to limit their work to one facility)

Additionally, you may find that some staff may also be fearful of attending work where an outbreak, or suspected outbreak has occurred. You may need to manage ‘panic’ responses and fear as well.

Sorry Business

In many remote Central Australian communities, one way of expressing your condolences to the family of the deceased is to shake hands with people in sorry (mourning) camp. While the rest of the world is coming up with ways of greeting people by patting someone on the back or touching toes or elbows or bowing rather than shaking hands, it may be difficult to change a cultural practice that quickly.

Given that there may be deaths in the community due to the disease and sorry camps are often set up in areas where there is no running water or other facilities, this has all the makings of an infection time bomb.

Your staff need to be vigilant. If they are delivering meals or picking up laundry to sorry camps, they should be sanitising their hands before and after handing over meals, shaking hands with mourners, and touching clothing or blankets used by clients. On return to the centre they should be washing their hands thoroughly.

In more urban contexts, attendance at the funeral of clients or residents, either by staff or other aged care consumers and family members, also heightens the risk of transmission of an infection. Additional precautions and the promotion of these is also important for the broader community. Where there are large gatherings of people, make sure that your staff are aware of the risks and that they continue to take precautions outside of the work environment, including maintaining a ‘1.5m’ distance from other people wherever possible.

Staff uniforms

Staff in remote communities don’t always have access to washing machines and therefore they may have their clothes laundered at the centre. Ensure that your washing machines are not overloaded, that they can reach temperatures of between 60ºC-90ºC and that they are sanitised at the end of each day.

If there is overcrowding at home and there is a strong chance that staff may inadvertently bring in an infectious agent, encourage them to change into their uniform at work and out of it at the end of the shift, placing the clothing directly into a washing machine ready for laundering.

For community services who don’t supply uniforms, remind staff to change out of clothing they have worn while carrying out their duties as soon as they get home, laundering between shifts. Staff may also consider going back to wearing aprons that are washed daily.

Follow food safety practices

If you provide food such as delivered meals or meals at a centre as one of your services, make sure that kitchen and support staff understand and adhere to standard food safety practices.

This includes washing and sanitising ingredients such as fresh fruit with a food-safe sanitiser and cleaning and sanitising kitchen work surfaces.

If you have access to a dishwasher – and I realise that not all remote services will have one – ensure that any reusable items such as cups, plates and cutlery are cleaned and run through the dishwasher to sanitise them. For those who don’t have a dishwasher, consider using single use containers or use chemical sanitisers instead. Make sure these chemicals are used according to manufacturer directions, as well as using them to sanitise items used by clients or staff and spray on surfaces such as bread boards and preparation benches.

Note: where there is a known outbreak the facility may need to provide meals using disposable cutlery and crockery.

This is a good time to review your food safety plan and make sure that it is up-to-date and that you are following correct practices. Check with your food safety inspector where you need additional information or clarification.

Cleaning the Centre or Service Environment

Corona virus can remain viable for up to 48 hours, sometimes longer, outside the host (person). Often the virus is found sitting on surfaces where an infected person has sneezed or coughed. This includes tables where clients and staff gather for meals and activities, door knobs, cutlery and crockery, fridge and freezer handles, toilets and taps, and phones. Make cleaning the centre and service environment space thoroughly a regular part of staff duties each day.

Support good antimicrobial stewardship

One aspect of antimicrobial stewardship is ensuring that people that are prescribed a course of antibiotics complete them. This means there is more chance that the ‘bacteria’ will be killed and therefore is less likely to develop resistance to the antibiotic.

Although the COVID-19 virus can cause symptoms and be dangerous in and of itself to a vulnerable person, sometimes, just like with the flu, it’s not the initial disease that causes complications or death, but it weakens the person to the point where they are more susceptible to other infections.

When you are working with other health stakeholders, check who will be following up with individuals to see that a course of antibiotics has been completed. Medication prompting or reminders may need to be added to the services provided in some instances.

Wellbeing Checks

A number of organisations already conduct wellbeing checks with vulnerable clients during times of extreme heat or where there are other concerns. Should an outbreak of the virus occur in your community, you may need to check in daily on all clients, either via the phone or face-to-face to monitor whether the person has become infected or if they need any additional support due to other family members or carers being unable to support them for a time. It would be good to have a series of set questions for the person carrying out the check to ask the client. 

If caught early enough, this could improve the outcome of the disease progression both in the community and for that person.

We have developed a free wellbeing checklist for Corona Virus – you can access it and many more COVID resources on our COVID-19 Resources page for free.

If you're a member of the Total Quality Package resource hub, log in to your account and you will find the same resources under the Care & Case Management section from your Dashboard.

Contingency plan

Of course, if there is an outbreak in your community it is likely that you will end up short-staffed due to staff illness and may need to restrict services to consumers. Consider:

• How do you maintain continuity of care, especially if you have clients who become infected?
• How do you limit the accidental transmission of the virus from one client to another as staff move around the community?
• Who are your most vulnerable clients?

You need to develop your plans for responding appropriately should the worst happen. You can’t simply shut your doors, as you will have vulnerable clients who require ongoing support and care. Think about it now, discuss it with your staff and other stakeholders and come up with solutions now, before you need to.

If you can think of someone else who might benefit from this article, please send them a link. We’d appreciate it! And if you’re looking for more helpful resources to keep your service or organisation compliant, why not check out our Total Quality Package resource hub? We have culturally appropriate, tailored resources that are designed to make your job simpler and help you provide quality care to your clients. Click here to find out more.

The following links may provide additional information, however the situation with the virus is evolving and there may be new developments on a daily basis.

• COVID-19 – What you need to know
• Information for health care and residential care workers
• Mandatory Flu Vaccination
• COVID-19 – Information for residents of residential care services, family and visitors
• Managing infectious diseases in aged care
• Corona Virus – events as they happen
• Frequently Asked Questions about Corona Virus