Coronavirus Disease 2019 (COVID-19) Outbreaks in Residential Care

Facilities

CDNA National Guidelines for the Prevention, Control and Public

Health Management of COVID-19 Outbreaks in Residential Care
Facilities in Australia

Revision history
Version Date Reason / Changes Endorsed by
1.0 13/03/20 Initial Release CDNA

This guideline was developed by the Communicable Diseases Network Australia (CDNA), in
consultation with the Aged Care sector, and noted by the Australian Health Protection
Principal Committee (AHPPC). The document is adapted from previous work on Influenza
Outbreaks in Residential Care Facilities (RCF) in Australia, Australian state and territory
guidelines for respiratory illness outbreak management in RCF, documents and guidelines
from the Australian Department of Health and other Australian health agencies, and
documents and guidelines from various international health authorities including the World
Health Organisation, Centres for Diseases Control and Prevention, and the Public Health
Agency of Canada.

This guideline is provided to assist public health authorities, residential care services,
healthcare workers and carers by providing best practice information for the prevention and
management of COVID-19 outbreaks in RCF. This guideline captures the knowledge of
experienced professionals and provides guidance on good practice based upon the available
evidence at the time of completion. Readers should not rely solely on the information
contained within this guideline. Guideline information is not intended to be a substitute for
advice from other relevant sources including, but not limited to, advice from a health
professional. Clinical judgement and discretion may be required in the interpretation and
application of these guidelines.

The membership of CDNA and AHPPC, and the Commonwealth of Australia as represented
by the Department of Health (the department), do not warrant or represent that the
information contained in the guideline is accurate, current or complete. CDNA, AHPPC and
the department do not accept any legal liability or responsibility for any loss, damages, costs
or expenses incurred by the use of, reliance on, or interpretation of, the information
contained in the guideline.
TABLE OF CONTENTS

1. INTRODUCTION......................................................................................................... 5

1.1. COVID-19 Outbreaks .......................................................................................................................... 5

1.2. Legal Framework ................................................................................................................................ 5

1.3. Roles and Responsibilities .................................................................................................................. 6

1.3.1. Residential Care Facility ....................................................................................................................... 6
1.3.2. The State/Territory Department of Health and Human Services ........................................................ 6
1.3.3. Australian Aged Care Quality and Safety Commission ........................................................................ 6

2. UNDERSTANDING COVID-19 ...................................................................................... 7

2.1. Recognising COVID-19 ........................................................................................................................ 7

2.2. Incubation Period............................................................................................................................... 8

2.3. Routes of Transmission ...................................................................................................................... 8

2.4. People at risk of complications from COVID-19 .................................................................................. 8

2.5. Complications of COVID-19 ................................................................................................................ 8

3. PREPAREDNESS AND PREVENTION ............................................................................ 9

3.1. Preparation ........................................................................................................................................ 9

3.1.1. Prepare an Outbreak Management Plan ............................................................................................. 9
3.1.2. Education ........................................................................................................................................... 10
3.1.3. Workforce Management ................................................................................................................... 11
3.1.4. Staff Education and Training ............................................................................................................. 11
3.1.5. Consumable Stocks ............................................................................................................................ 11

3.2. Prevention ....................................................................................................................................... 12

3.2.1. Exposure Prevention ......................................................................................................................... 12
3.2.2. Prevention of Introduction into the Facility ...................................................................................... 13
3.2.3. Prevention of Spread Within and Between Facilities ........................................................................ 13

4. IDENTIFYING COVID-19 ........................................................................................... 14

4.1. Identification ................................................................................................................................... 14

4.2. Case Definition ................................................................................................................................. 15

4.3. Testing for COVID-19 ........................................................................................................................ 15

4.4. Notification – State/Territory Department of Health ....................................................................... 15

4.5. Notification – Resident and Facility General Practitioners ................................................................ 16

5. COVID-19 CASE AND OUTBREAK MANAGEMENT ..................................................... 17

5.1. Response to a Suspected Case of COVID-19 in a Resident ................................................................ 17

5.2. Response to a Suspected Case of COVID-19 in a Staff Member ........................................................ 17

5.3. Response to an Outbreak of COVID-19 ............................................................................................. 17

5.3.1. Declaring an Outbreak ....................................................................................................................... 18
5.3.2. Establishing an Outbreak Management Team .................................................................................. 18

5.4. Implementing Infection Prevention and Control Measures .............................................................. 18

5.4.1. Isolation and Cohorting ..................................................................................................................... 18
5.4.2. Standard Precautions ........................................................................................................................ 19
5.4.3. Transmission-based Precautions ....................................................................................................... 21
5.4.4. Environmental Cleaning and Disinfection ......................................................................................... 21
5.4.5. Signage .............................................................................................................................................. 22
5.4.6. Visitors and Communal Activities ...................................................................................................... 22
5.4.7. Staff ................................................................................................................................................... 23
5.4.8. Admissions and Transfers .................................................................................................................. 23

5.5. Monitoring Outbreak Progress ......................................................................................................... 24

5.6. Declaring the Outbreak Over............................................................................................................ 25

5.7. Reviewing Outbreak Management ................................................................................................... 25

APPENDIX 1. FLOW CHART FOR COVID-19 MANAGEMENT IN RCF IN AUSTRALIA ........... 26

APPENDIX 2. COVID-19 OUTBREAK PREPAREDNESS CHECKLIST...................................... 28

APPENDIX 3. LETTER TO FAMILIES – PREVENTING SPREAD OF COVID-19 ........................ 29

APPENDIX 4. SWAB COLLECTION PROCEDURE ............................................................... 31

1. Before performing swab......................................................................................................................... 31
2. Performing the swabs ............................................................................................................................ 31
3. After performing the swab ..................................................................................................................... 32

APPENDIX 5. LETTER TO GPS – COVID-19 OUTBREAK ..................................................... 33

APPENDIX 6. TRANSFER ADVICE FORM.......................................................................... 35

APPENDIX 7. COVID-19 OUTBREAK MANAGEMENT CHECKLIST ...................................... 36

APPENDIX 8. FORMING AN OUTBREAK MANAGEMENT TEAM ....................................... 38

APPENDIX 9. HAND HYGIENE ........................................................................................ 39

APPENDIX 10. PERSONAL PROTECTIVE EQUIPMENT REQUIREMENTS ............................. 42

APPENDIX 11. PROPER USE OF PERSONA PROTECTIVE EQUIPMENT (PPE) ...................... 43

APPENDIX 12. RESPIRATORY ETIQUETTE ......................................................................... 46

APPENDIX 13. TRANSMISSION-BASED PRECAUTIONS ...................................................... 47

1. Introduction
This guideline applies to all residential care facilities (RCF) in Australia. This refers to any
public or private aged care, disability services or other congruent accommodation setting in
Australia where residents are provided with personal care or health care by facility staff.
However, given individuals over the age of 65 are more susceptible to COVID-19 and are
more likely to develop complications, the guidelines have a strong focus on residential aged
care facilities.

Older people living in RCF are susceptible to outbreaks of respiratory illness, which
commonly occur in winter. Respiratory illnesses due to CODIV-19 is to be expected now, as
there are outbreaks occurring globally and in Australia. Managing a COVID-19 outbreak
(suspected or confirmed) effectively requires a number of required actions. These guidelines
are designed to assist RCF to plan, prepare, detect and respond to COVID-19 outbreaks in
their facility.

Appendix 1 provides a summary of COVID-19 management in RCF in Australia.

While this guideline focuses on RCF, the principles are applicable to many settings including
residential facilities for people with physical and mental disabilities, other community based
health facilities (e.g. Drug and alcohol services, community mental health), detention and
correctional centers, military barracks, boarding schools, hostels and any other setting
where residents sleep, eat and live either temporarily or on an ongoing basis.

1.1. COVID-19 Outbreaks

It can be difficult to tell the difference between a respiratory illness such as COVID-19 and a
respiratory illness caused by other viruses based on symptoms alone. Suspected COVID-19
cases are referred to as a ‘suspect case’ until a causative pathogen is identified through
diagnostic testing (for example, nose and throat swab collection). If the COVID-19 virus
(SARS-CoV-2) is detected during an outbreak this is referred to as a COVID-19 outbreak.

While all respiratory viruses can cause outbreaks and significant morbidity and mortality,
COVID-19 is acknowledged as a significant health risk particularly for the elderly and
individuals with co-morbidities or low immunity. These guidelines will assist RCF to manage
all types of respiratory outbreaks, but the focus is predominantly on COVID-19.

1.2. Legal Framework

It is the responsibility of RCF to identify and comply with relevant legislation and
regulations. RCF must fulfil their legal responsibilities in relation to infection control by
adopting standard and transmission-based precautions as directed in the Australian
Guidelines for the Prevention and Control of Infection in Healthcare (2019) and by
state/territory public health authorities. RCF are also required to operate under the Aged
Care Act 1997 to be accredited and be eligible for funding. Accreditation requires adherence
to infection control standards. The Aged Care Quality and Safety Commission expects
organisations providing aged care services in Australia to comply with the Aged Care Quality
Standards.

COVID -19 is a notifiable condition under the Australian National Notifiable Diseases
Surveillance System (NNDSS). This means that in all Australian states and territories, either
the medical officer requesting the test and/or the laboratory performing the test, are
responsible for notifying the relevant jurisdictional public health authority of the case of
COVID-19, as per local legislative requirements.

1.3. Roles and Responsibilities

1.3.1. Residential Care Facility

The primary responsibility of managing COVID-19 outbreaks lies with the RCF, within their
responsibilities for resident care and infection control. All RCF should have in-house (or
access to) infection control expertise, and outbreak management plans in place.

RCFs are required to:

 detect and notify outbreaks to state health departments.
 self-manage outbreaks in accordance with this guideline, the Australian Guidelines
for the Prevention and Control of Infection in Healthcare (2019), and the Australian
Health Sector Emergency Response Plan for Novel Coronavirus (2020).
 Confirm and declare an outbreak.
 Provide advice on infection control measures and use of PPE.
 Confirm and declare when an outbreak is over.

1.3.2. The State/Territory Department of Health and Human Services

The relevant state/territory Department of Health will act in an advisory role to assist RCF to
detect, characterise and manage COVID-19 outbreaks. This includes:
 Assisting facilities in confirming outbreaks by applying the case definition correctly
and providing advice on obtaining testing samples
 Providing guidance on outbreak management
 Monitoring for severity of illness (record deaths and hospitalisations)
 Informing relevant stakeholders of outbreaks
 Monitoring the number of COVID-19 outbreaks occurring as the epidemic progresses
 Contributing to national surveillance.

1.3.3. Australian Aged Care Quality and Safety Commission

The Aged Care Quality and Safety Commission (the Commission) is the national regulator of
aged care services. It takes a proportionate risk-based approach in responding to the COVID-
19 situation. The role of the Commission is to:
 independently accredit, assess and monitor aged care services against the Aged Care
Quality Standards, including the requirement to minimise infection-related risks
 through implementing standard and transmission based precautions to prevent and
control infection;
 resolve complaints about the delivery aged care services; and
 provide education to providers, including with respect to best-practice infection
prevention and control.

2. Understanding COVID-19
2.1. Recognising COVID-19

COVID-19 is a contagious viral infection that generally causes respiratory illness in humans.
Presentation can range from no symptoms (asymptomatic) to severe illness with potentially
life-threatening complications, including pneumonia. COVID-19 is spread by contact with
respiratory secretions and fomites.

The most common signs and symptoms include:

 fever (though this may be absent in the elderly)
 dry cough

Other symptoms can include:

 shortness of breath
 sputum production
 fatigue

Less common symptoms include:

 sore throat
 headache
 myalgia/arthralgia
 chills
 nausea or vomiting
 nasal congestion
 diarrhoea
 haemoptysis
 conjunctival congestion

Older people may also have the following symptoms:

 increased confusion
 worsening chronic conditions of the lungs
 loss of appetite

Elderly patients often have non-classic respiratory symptoms; RCF should consider testing
any resident with any new respiratory symptom.
2.2. Incubation Period

People with COVID-19 generally develop signs and symptoms, including mild respiratory
symptoms and fever, on an average of 5-6 days after infection (mean incubation period 5-6
days, range 1-14 days).

2.3. Routes of Transmission

COVID-19 is transmitted via droplets and fomites during close unprotected contact with an
infected person. Airborne spread has not been reported for COVID-19; however, it may
occur during certain aerosol-generating procedures1 conducted in health care settings.
Faecal shedding of the virus has been demonstrated from some patients, and viable virus
has been identified in some cases. Although the faecal-oral route does not appear to be a
driver of COVID-19 outbreaks, it may become important in RCF, as such cases with ongoing
diarrhoea or faecal incontinence who may have limited capacity to maintain standards of
personal hygiene should continue to be isolated until 48 hours after the resolution of these
symptoms.

2.4. People at risk of complications from COVID-19

People at risk of complications from COVID-19 include:

 people 65 years of age and over
 Aboriginal and Torres Strait Islander people
 people with chronic or other medical conditions
 people with a weakened immune system (due to a disease or medication)

2.5. Complications of COVID-19

Most people with COVID-19 have mild disease and will recover. Some people can develop
complications which may be life-threatening and can result in death.

Complications include:
 pneumonia (secondary bacterial infection)
 respiratory failure
 septic shock
 multi-organ dysfunction/failure

Elderly residents may experience a worsening of chronic health problems such as congestive
heart failure, asthma and diabetes.

1
Aerosol-generating procedures include manual ventilation before intubation, tracheal intubation, non-
invasive ventilation, tracheostomy suctioning, cardiopulmonary resuscitation, bronchoscopy and high flow
nasal oxygen
3. Preparedness and Prevention
3.1. Preparation

RCF must ensure that they are prepared for outbreaks of COVID-19 including for the
occurrence for their first case of COVID-19. A well-functioning infection prevention control
(IPC) program working in concert with a well-functioning occupational health (OH) program,
is the basis for an effective IPC response during a COVID-19 pandemic.

Australian healthcare facilities will likely be impacted by a COVID-19 pandemic. It is

therefore essential for RCF, in coordination with local and state/territory governments, to
ensure that they can manage residents with COVID-19 while maintaining the level of care
required for all other residents. This might include caring for residents who would usually
be managed in the hospital setting.

The information provided in this guideline has been developed to provide RCF and their staff
with the information they need to plan for and execute IPC and OH processes intended to
prevent exposure to and transmission of COVID-19.

3.1.1. Prepare an Outbreak Management Plan

Preparing an outbreak management plan will help staff identify, respond to and manage a
potential COVOID-19 outbreak; protect the health of staff and residents, and reduce the
severity and duration of outbreaks if they occur. At a minimum, facilities must identify a
dedicated staff member to plan, co-ordinate and manage logistics in an outbreak setting as
well as communicate and liaise with the state/territory health department.

The prevention strategies outlined in this guideline should be included in the RCF outbreak
management plan. A checklist to assist in outbreak preparedness can be found in Appendix
2.

3.1.1.1. Planning Assumptions

It is important to note that assumptions about the epidemiology and impact of COVID-19
may change as knowledge emerges.

The following public health assumptions are relevant to infection prevention control and
outbreak management planning:
 A COVID-19 pandemic will affect the entire health care system and the community.
Hospitals, local public health units and other services may have limited capacity.
RCFs may not be able to rely on the same level of support they receive now from
other parts of the health care system or from other community services during an
outbreak.
 Pandemic COVID-19 plans developed by individual RCFs are:
- coordinated with the plans of other organizations in their communities and
local/regional pandemic plans; and
 - consistent with the Australian Government Department of Health Australian
Health Sector Emergency Response Plan for Novel Coronavirus (2020).
 The number of health care workers available to provide care may be reduced by up
to one-third because of personal illness, concerns about transmission in the
workplace, and family/caregiving responsibilities.
 Usual sources of supplies are disrupted or unavailable.
 A vaccine will not be available for at least twelve months. It will not be available in
time for the first wave of illness but may be available in time to reduce the impact of
the second wave. Once available, the vaccine will be in short supply and high
demand.
 The efficacy of antivirals against COVID-19 is unknown but, if antivirals are shown to
shorten the length of time people are ill, relieve symptoms and reduce
hospitalizations; they may be introduced into standards of care. They will, however,
be in short supply and high demand. Organisations will have to rely on traditional
infection prevention and control practices (e.g., hand hygiene, appropriate personal
protective equipment, and isolating sick individuals) as the main line of defence.
 Because Australia will not have a large enough supply of either antivirals or vaccine
(when it is first developed) for the entire population, the government will have to set
priorities for who receives them. RCFs must follow commonwealth and
state/territory guidance for priority groups for immunisation and antiviral treatment
and prophylaxis when available. During the course of the pandemic, priority groups
may change based on the epidemiology of COVOID-19 (i.e., the nature of the virus,
the people most affected).
 To meet community needs during a pandemic, resources – including staff, supplies
and equipment – may have to be reassigned or shifted.
 Care protocols may change and new practice may have to be adapted.
 RCF will need effective ways to communicate with residents’ family and friends, in
order to meet their needs for information but reduce the demands on staff.

3.1.2. Education

Education for staff, residents and their families is vital to inform their behaviour and help
manage the potential occurrence for ongoing transmission in an outbreak setting.

Prompt and clear information needs to be provided to residents and families regarding the
outbreak including respiratory hygiene and cough etiquette, hand hygiene and restrictions
on visitation if they have any symptoms of COVID-19. A sample letter outlining the
preventative steps families and visitors can take to reduce the risk of bringing COVID-19 into
the facility can be found at Appendix 3.

Staff should be informed, and supported, to exclude themselves from work when they have
any kind of respiratory illness and to notify the facility if they were confirmed to have
COVID-19. Staff exclusion during an outbreak is discussed further in section 5.2.6.

The principle underlying staff and visitors staying away from the facility if they are unwell
should be reinforced by placing signage at all entry points to the facility.
3.1.3. Workforce Management

Facilities should have a staff contingency plan in the event of an outbreak where unwell
staff members need to be excluded from work for a prolonged period until cleared to return
to work. Health care workers may also require exclusion from the workplace if they have
returned from travel to a country considered high risk for COVID-19, and such requirements
will impact the workforce nationally. RCF should regularly review the CDNA COVID-19
Interim National Guideline for requirements relating to the exclusion of healthcare workers
from clinical settings.

The workforce management plan should be able to cover a 20-30% staff absentee rate.
Developing and maintaining a contact list for casual staff members or external nursing
agencies is essential to timely activation of a surge workforce should an outbreak occur.
Leave planning should also consider the nature of the pandemic and current outbreaks.

3.1.4. Staff Education and Training

Each RCF is responsible for ensuring their staff are adequately trained and competent in all
aspects of outbreak management prior to an outbreak. Staff should know the signs and
symptoms of COVID-19 in order to identify and respond quickly to a potential outbreak.
Additionally, all staff (including casual, domestic, hospitality and volunteer workers) need to
understand the infection control guidelines and be competent in implementing these
measures during an outbreak.

Topics for staff education and training should include:

 Symptoms and signs of COVID-19
 Exposure risk levels for CODIV-19, including international travel
 Personal hygiene, particularly hand hygiene, sneeze and cough etiquette
 Appropriate use of PPE such as gloves, gowns, eye protection and masks, including
how to don and doff PPE correctly
 Actions on experiencing symptoms of COVID-19 (do not work or visit an RCF)
 Handling and disposal of clinical waste
 Processing of reusable equipment
 Environmental cleaning
 Laundering of linen
 Food handling and cleaning of used food utensils

3.1.5. Consumable Stocks

Facilities should ensure that they hold adequate stock levels of all consumable materials
required during an outbreak, including:
 personal protective equipment (gloves, gowns, masks, eyewear)
 hand hygiene products (alcohol based hand rub, liquid soap, hand towel)
 diagnostic materials (swabs)
 cleaning supplies (detergent and disinfectant products)
Facilities should have an effective policy in place to obtain additional stock from suppliers as
needed. In order to effectively monitor stock levels, facilities should:
 undertake regular stocktake (counting stock)
 use an outbreak kit / box

3.2. Prevention

There is currently no vaccination to prevent COVID-19. Avoidance of exposure is the single

most important measure for preventing COVID-19 in RCF. RCF must have, and be vigilant in
implementing, effective infection control procedures. RCFs are expected to use risk
assessments to ensure the risks of a COVID-19 outbreak are as low as possible. This can
involve examining the RCF’s service environment, equipment, workforce training, systems,
processes or practices that affect any aspect of how they deliver personal and clinical care.

The general strategies recommended to prevent the spread of COVID-19 in RCFs are the
same infection prevention control strategies used every day to detect and prevent the
spread of other respiratory viruses like influenza. During a COVID-19 pandemic, or when
local community transmission of the disease is identified, RCF should focus on preventing
introduction of the disease into the facility, or spread within or between facilities if infection
has been identified within the RCF.

3.2.1. Exposure Prevention

Exposure prevention actions include:

 Self-screening for staff, volunteers and visitors (including visiting workers)
- RCF should instruct all staff to self-screen for symptoms, and to observe any
exclusion requirements related to returning from travel to a high-risk country.
- Staff should be made aware of early signs and symptoms of COVID-19. Staff
must not come to work if symptomatic and must report their symptoms to the
RCF. Sick leave policies must enable employees to stay home if they have
symptoms of respiratory infection.
- RCF should use signage at entrances and reception to inform visitors to self-
identify if they have relevant symptoms, travel history or exposure. Visitors
must be instructed not to enter the RCF until any symptoms have completely
resolved.
 Monitor residents and employees for fever or acute respiratory symptoms
- Restrict residents with fever or acute respiratory symptoms to their room. If
they must leave the room for medically necessary procedures, have them wear a
facemask (if tolerated).
- In general, for care of residents with undiagnosed respiratory infection use
Standard, Contact, and Droplet Precautions with eye protection unless a
procedure requires Airborne Precautions.
 Active screening for resident admissions or re-admissions/returning residents
- Assess residents for symptoms of COVID-19 upon admission to the facility and
implement appropriate infection prevention practices for incoming symptomatic
residents.
 Implementation of non-pharmaceutical measures, which include:
 - Hand hygiene and cough and sneeze etiquette
- Use of appropriate personal protective equipment
- Environmental cleaning measures
- Isolation and cohorting
- Social distancing

3.2.2. Prevention of Introduction into the Facility

Family members of residents and other visitors (including visiting workers) can potentially
transmit SARS-CoV-2 to residents. The following actions should be taken:
 RCF should advise all regular visitors to be vigilant with hygiene measures including
social distancing, and to monitor for symptoms of COVID-19, specifically fever and
acute respiratory illness. They should be instructed to stay away when unwell, for
their own and residents’ protection, and to observe any self-quarantine
requirements.
 Signage and other forms of communication (i.e. information and factsheets) must be
used to convey key messages including what actions the facility is taking to protect
them, and explaining what they can do to protect themselves and residents.
 RCFs must ensure that adequate hand washing facilities and alcohol based hand rub,
as well as tissues and lined disposal receptacles are available for visitors to use; at
the entrance of the facility and in each resident’s room.

3.2.3. Prevention of Spread Within and Between Facilities

To prevent the spread of COVID-19, the following actions should be taken:

 Keep residents and staff informed through regular communication.
- Support personal protection measures including respiratory hygiene, cough and
sneeze etiquette, and hand washing.
 Monitor residents and employees for fever or acute respiratory symptoms
- Restrict residents with fever or acute respiratory symptoms to their room. If
they must leave the room for medically necessary procedures, have them wear a
facemask (if tolerated).
- In general, for care of residents with undiagnosed respiratory infection use
Standard, Contact, and Droplet Precautions with eye protection unless a
procedure requires Airborne Precautions.
 Healthcare personnel should monitor Commonwealth Department of Health and
state public health information sources to understand COVID-19 activity in their
community to help inform their evaluation of individuals with unknown respiratory
illness. If there is transmission of COVID-19 in the community, in addition to
implementing the precautions described above for residents with acute respiratory
infection, facilities should also consult with public health authorities for additional
guidance.
 Identify dedicated employees to care for patients with COVID-19 and provide
infection control training.
- Guidance on implementing recommended infection prevention practices is
available in section 5.4.
 Provide the correct supplies to ensure easy and correct use of PPE.
 - Make PPE, including facemasks, eye protection, gowns, and gloves, available
immediately outside of the resident room.
- Position a disposal receptacle near the exit inside any resident room to make it
easy for employees to discard PPE.
- Post signs on the door or wall outside of the resident room clearly describing the
type of precautions needed and required PPE.
 Notify facilities and transport service providers prior to transferring a resident with
an acute respiratory illness, including suspected or confirmed COVID-19; or
transferring to a higher level of care.
 Notify any possible COVID-19 illness in residents and employees to the relevant
jurisdictional public health authority.

4. Identifying COVID-19
4.1. Identification

Prevention and management of influenza outbreaks in RCF have been built around
surveillance of influenza-like illness (ILI). Building on that model, RCF should establish
systems to monitor staff and residents for COVID-19 with a high level of vigilance and have a
low threshold for investigation. Surveillance for fever or acute respiratory illness2 (ARI, with
or without fever), rather than ILI, is very sensitive for detecting possible cases of COVID-19
in the context of confirmed local transmission of COVID-19. Effective surveillance will
facilitate early recognition and management of cases.

The aim of surveillance in RCFs is to ensure early identification of symptoms in residents and
staff that may precede, or indicate early stages of, an outbreak. Identification of a resident
or staff member with ARI should be followed by prompt testing for a causative agent. While
confirmation of SARS-CoV-2 infection is pending, immediate and appropriate infection
control management of the person with ARI may prevent further spread of the disease.

Facilities should have the capacity to count those with ARI and other severe respiratory
illnesses each day and identify a potential COVID-19 outbreak. Prompt detection of
outbreaks allows early implementation of control measures.

Healthcare personnel should monitor Commonwealth Department of Health and

state/territory public health sources to understand COVID-19 activity in their community to
help inform their evaluation of individuals with undifferentiated respiratory illness. If there
is confirmed local transmission of COVID-19 in the community, in addition to implementing
the precautions described in this, facilities should consult with public health authorities for
IPC guidance.

2
Acute Respiratory Illness (ARI) is defined in the CDNA COVID-19 Interim National Guideline as shortness of breath or cough.
4.2. Case Definition

The CDNA COVID-19 Interim National Guideline provides a case definition for COVID-19
suspect and confirmed cases. Case definitions provide the criteria that allows unambiguous
classification of an ill person as a confirmed case, or a suspect case. COVID-19 should be
suspected in any resident with fever or acute respiratory infection (with or without fever) in
a setting where there is confirmed local transmission of COVID-19.

4.3. Testing for COVID-19

The recommended test and methods of sampling for COVID-19 is outlined in the CDNA
COVID-19 Interim National Guideline. Once requested by a medical officer, collection by an
appropriately trained GP or pathology provider is the preferred option for obtaining
appropriate respiratory samples. RCF staff who have received the applicable training in
respiratory sample collection and the proper use of PPE may also collect the appropriate
samples. Residents do not need to be transferred to hospital for the purpose of testing for
COVID-19. Guided by the clinical picture, the responsible medical officer may request
testing for additional respiratory pathogens.

Procedures for obtaining nose and throat swabs are at Appendix 4.

4.4. Notification – State/Territory Department of Health

Laboratory confirmed COVID-19 is a notifiable disease in all Australian states and territories.
The requesting medical officer and/or the testing laboratory is obligated to notify the
infection to the jurisdictional communicable disease authority, depending on local
legislative requirements; this notification is confidential.

If an outbreak is suspected, the local state/territory Department of Health must be notified

immediately. A Public Health Unit (PHU) will assist with advice and guidance on appropriate
follow on actions. A sample reporting template is available at Appendix 5.

RCF must be prepared to provide the following information to the PHU:

 Information on the setup of the facility
 total number of residents and/or staff with fever and/or ARI
 date of onset of illness of each person
 symptoms of each person
 number of people admitted to hospital with fever and/or ARI (if applicable)
 number of people with influenza-like symptoms who have died
 total number of staff that work in the facility and in the affected area
 total number of residents in the facility and in the affected area
 whether appropriate respiratory specimens have been collected
 results of any respiratory specimens already tested

The PHU will advise and assist with the following:

 confirming the presence of an outbreak
 identifying the control measures that need to be in place
  testing of the initial respiratory specimens.

The PHU will provide the RCF with a preferred case list (also called a ‘line list’) template to
use when an outbreak is notified. If any deaths occur during an outbreak, the department
must be notified within 24 hours. Hospitalisation of residents should be noted on the case
list and sent to the department daily (see section 5.5.1).

4.4.1. State/territory Public Health Unit Contact details

State Contact Details

Queensland 13 432 584 (13 HEALTH)

New South Wales 1300 066 055
Australian Capital Territory Business Hours: 02 5124 9213
After Hours: 02 9962 4155
Victoria 1800 675 398
Tasmania 1800 671 738
South Australia 1300 232 272
Western Australia 08 9222 4222
WA Health
Northern Territory 08 8922 8044

Up to date local state and territory health department contact details are available on the
Commonwealth Department of Health website.

4.5. Notification – Resident and Facility General Practitioners

Unwell residents must be reviewed by their GP regardless of whether an outbreak is present

or not. If a COVID-19 outbreak is present, all visiting GPs should be informed at the start of
the outbreak. A sample letter for GPs can be found in Appendix 6.

This will facilitate appropriate testing samples being obtained, early implementation of
infection control procedures, and treatment for symptomatic. It is important to speak with
the PHU to confirm the presence of an outbreak before issuing the outbreak letter to
visiting GPs.
5. COVID-19 Case and Outbreak Management
5.1. Response to a Suspected Case of COVID-19 in a Resident

Residents with suspected or confirmed COVID-19 require appropriate healthcare support,

including access to their primary care provider for medical management.

Special considerations in the management of residents with suspected or confirmed COVID-

19 in an RCF include:
 Immediately isolate ill residents (or cohort) and minimise interaction with other
residents.
 If COVID-19 is suspected, have a low threshold for requesting medical review and
testing.
 Transfer residents to hospital only if their condition warrants. If transfer is required,
advise the hospital in advance that the resident is being transferred from a facility
where there is potential or confirmed COVID-19. A sample transfer advice form is
provided at Appendix 7.
 Notify the appropriate authorities as outlined in section 4.4 and 4.5.

In the instance of confirmed COVID-19, RCF management should consider this an

opportunity to:
 Identify and implement enhanced infection control measures
 Implement surveillance for further cases
 Review outbreak plans and requirements for implementation.

5.2. Response to a Suspected Case of COVID-19 in a Staff Member

Health care workers and other members of staff who develop symptoms of respiratory
illness should immediately be excluded from the facility and remain away whilst a diagnosis
is sought. If COVID-19 is excluded, the staff member may be able to return to work once
well and as guided by the infections period for their condition. If a diagnosis of COVID-19 is
confirmed, the staff member must be excluded until they meet the criteria for release from
isolation outlined in the CDNA COVID-19 Interim National Guideline. The RCF must make
appropriate notification to the relevant authorities as outlined in section 4.4 and 4.5.

As above, RCF management should consider this an opportunity to:

 Identify and implement enhanced infection control measures
 Implement surveillance for further cases
 Review outbreak plans and requirements for implementation.

5.3. Response to an Outbreak of COVID-19

This section provides detailed information on the required actions to be implemented once
an outbreak has been identified. An outbreak management checklist is provided at
Appendix 8.
RCF should engage an infection control consultant or make contact with the residential in-
reach service at their local health service should they require additional support in an
outbreak. They may also be available to assist RCF to avoid the transfer of residents to
hospital where possible.

5.3.1. Declaring an Outbreak

A potential COVID-19 outbreak is defined as:

Two or more cases of ARI in residents or staff of a RCF within 3 days (72 hrs).

A confirmed COVID-19 outbreak is defined as:

Two or more cases of ARI in residents or staff of a RCF within 3 days (72 hrs)
AND
At least one case of COVID-19 confirmed by laboratory testing.

While the definitions provided above guidance, the state/territory PHU will assist the RCF in
deciding whether to declare an outbreak.

5.3.2. Establishing an Outbreak Management Team

The RCF is responsible for managing the outbreak. An internal outbreak management team
(OMT) should be established to direct, monitor and oversee the outbreak, confirm roles and
responsibilities and liaise with the state/territory Department of Health. It considers the
progress of the response, undertakes ongoing monitoring, deals with unexpected issues,
and initiates changes, as required. When an OMT is formed, it is important to meet
regularly, usually daily, at the height of the outbreak to monitor the outbreak, initiate
changes to response measures and to discuss outbreak management roles and
responsibilities. In reality, a small number of staff will perform multiple roles in an OMT.

For detailed information on forming and implementing an OMT, refer to Appendix 9.

5.4. Implementing Infection Prevention and Control Measures

5.4.1. Isolation and Cohorting

A resident with an ARI should be placed in a single room with their own ensuite facilities, if
possible, while a diagnosis is sought. Where possible, residents requiring droplet
precautions should be restricted to their room. Residents may attend urgent medical or
procedural appointments but should wear a mask if tolerated.

If the resident requires transfer to another facility, including hospital, advise the hospital
and transport provider in advance that the resident is being transferred from a facility
where there is potential or confirmed COVID-19.
If a single room is not available, the following principles should be used to guide resident
placement:
 Give highest priority to single room placement to residents with excessive cough and
sputum production.
 Place residents together in the same room (cohort) with similar signs and symptoms
or infected with the same pathogen (if known) and assessed as being suitable
roommates.
 When a single room is not available, and cohorting of ill residents is not possible, a
resident with a respiratory illness may be cared for in a room with a roommate(s)
who does not have a respiratory illness. This is the least favourable option. In this
case:
- residents’ beds should be separated by at least 1.5 metres
- the curtain should be kept drawn between residents’ beds
- the roommate should be vaccinated against influenza with the current season’s
vaccine at least two weeks prior to being in the same room as the ill resident.
 In shared rooms (both cohorted with like illness, and residents with and without
illness), staff must ensure they change their PPE and perform hand hygiene when
moving between residents.

Once resident isolation or cohorting measures are in place, to further reduce the risk of
transmission, it is preferable to allocate specific RCF staff to the care of residents in
isolation. A register of staff members caring for patients with COVID-19 should be
maintained by the RCF. The RCF must ensure that staff members:
 do not move between their allocated room/ section and other areas of the facility, or
care for other residents.
 self-monitor for signs and symptoms of acute respiratory illness and self-exclude from
work if unwell.

5.4.2. Standard Precautions

Standard precautions are a group of infection prevention practices always used in

healthcare settings, and must be used in RCF with a suspected or confirmed COVID-19
outbreak. Standard precautions include performing hand hygiene before and after every
episode of resident contact (5 moments), the use of PPE (including gloves, gown,
appropriate mask and eye protection) depending on the anticipated exposure, good
respiratory hygiene/cough etiquette and regular cleaning of the environment and
equipment.

5.4.2.1. Hand Hygiene

COVID-19 can be spread by contaminated hands, hence frequent hand hygiene is important.
Hand hygiene refers to any action of hand cleansing, such as hand washing with soap and
water or hand rubbing with an alcohol based hand rub. Alcohol based hand rubs are the
gold standard for hand hygiene practice in healthcare settings when hands are not visibly
soiled. However, if hands are visibly soiled or have had direct contact with body fluids they
should be washed with liquid soap and running water then dried thoroughly with disposable
paper towel. Refer to Appendix 10 for detailed information on hand hygiene.
Online hand hygiene courses are available and staff should be encouraged to do refresher
training. There must be adequate access for staff, residents and visitors to hand hygiene
stations (alcohol based hand rub or hand basins with liquid soap, water and paper towel)
that should be adequately stocked and maintained. Hand basins for staff should, wherever
possible, be hands-free (for example, elbow operated) to facilitate appropriate hand
hygiene practices and prevent recontamination of hands when turning off taps. Staff should
be made aware of the proper hand hygiene technique and rationale.

Encouraging hand hygiene among residents and visitors is another important measure to
prevent the transmission of infectious organisms. Residents should wash their hands after
toileting, after blowing their nose, before and after eating and when leaving their room. If
the resident’s cognitive state is impaired, staff caring for them must be responsible for
helping residents with this activity. Visitors should be reminded to perform hand hygiene
on entering and leaving the facility, and before and after visiting any resident.

The use of gloves should never be considered an alternative to hand hygiene. Hand hygiene
is required before putting on gloves and immediately after they have been removed.

5.4.2.2. Personal Protective Equipment (PPE)

Staff must wear appropriate PPE when caring for infected residents requiring contact and
droplet or airborne precautions. A gown, eye protection, mask and gloves may be required
depending on the level of precaution required. PPE requirements for caring with patients
with suspected or confirmed COVID-19 are outlined in Appendix 11.

RCF staff must be trained and deemed competent in the proper use of PPE, including
donning and doffing procedures. Refresher training is recommended for all existing staff,
including non-clinical support staff, and as required for new staff. PPE should be removed in
a manner that prevents contamination of the HCW’s clothing, hands and the environment.
PPE should be immediately discarded into appropriate waste bins. Hand hygiene should
always be performed before putting on PPE and immediately after removal of PPE, as well
whilst wearing PPE. Useful educational and promotional material for the proper use of PPE
can be found at Appendix 12.

RCF staff must change their PPE and perform hand hygiene after every contact with an ill
resident, when moving from one room to another, or from one resident care area to
another.

5.4.2.3. Cough and Sneeze Etiquette

Cough and sneeze etiquette relates to precautions taken to reduce the spread of virus via
droplets produced during coughing and sneezing. Residents, staff and visitors should be
encouraged to practice good cough and sneeze etiquette, which includes coughing or
sneezing into the elbow or a tissue, and disposing of the tissue then cleansing the hands.
Useful educational and promotional material can be found at Appendix 13. Specific advice
should be given to any resident with ARI as a reminder.
5.4.3. Transmission-based Precautions

Transmission based precautions are infection control precautions used in addition to

standard precautions to prevent the spread of COVID-19. COVID-19 is most commonly
spread by contact and droplets. Less commonly airborne spread may occur e.g. during
aerosol generating procedures3 or care of severely ill patients.

Contact and Droplet precautions are the additional infection control precautions required
when caring for residents with suspected or confirmed COVID-19. Contact and Airborne
precautions are required when conducting aerosol generating procedures4 or caring for
severely ill patients who are coughing excessively.

For further information about transmission-based precautions when caring for residents
with suspected or confirmed COVID-19, see Appendix 14.

5.4.4. Environmental Cleaning and Disinfection

Regular, scheduled cleaning of all resident care areas is essential during an outbreak.
Frequently touched surfaces are those closest to the resident, and should be cleaned more
often. During a suspected or confirmed COVID-19 outbreak, an increase in the frequency of
cleaning with a neutral detergent is recommended.

Cleaning AND disinfection is recommended during COVID-19 outbreaks. Either a 2-step

clean (using detergent first, then disinfectant) or 2-in-1 step clean (using a combined
detergent/disinfectant) is required.

The following principles should be adhered to:

 Patient room/zone should be cleaned daily
 Frequently touched surfaces should be cleaned more frequently. These include:
- bedrails, bedside tables, light switches, remote controllers, commodes, doorknobs,
sinks, surfaces and equipment close to the resident.
- Walking frames, sticks
- Handrails and table tops in facility communal areas, and nurses station counter
tops
 Cleaners should:
- observe contact and droplet precautions
- adhere to the cleaning product manufacturer’s recommended dilution instructions
and contact time
- use a Therapeutic Goods Administration (TGA) listed disinfectant with claims of
efficacy against enveloped viruses (as the easiest class of microorganisms to kill). If
unsure, a chlorine-based product such as sodium hypochlorite is suitable for
disinfection.

3, 3
Aerosol-generating procedures include manual ventilation before intubation, tracheal intubation, non-
invasive ventilation, tracheostomy suctioning, cardiopulmonary resuscitation, bronchoscopy and high flow
nasal oxygen
 The room should be terminally cleaned when the ill resident is moved or discharged

Equipment and items in patient areas should be kept to a minimum. Ideally, 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.

Linen should be washed and sanitised using hot water (>65 degrees for 10 minutes) and
standard laundry detergent. Linen should be dried in a dryer on a hot setting. There is no
need to separate the linen for use by ill residents from that of other residents. Appropriate
PPE should be used when handling soiled linen.

Crockery and cutlery should be washed in a hot dishwasher or if not available, by hand using
hot water and detergent, rinsed in hot water and dried. There is no need to separate the
crockery and cutlery for use by ill residents from that of other residents.

More information on environmental cleaning and disinfection is available in the

Commonwealth Department of Health factsheet – Environmental cleaning and disinfection
principles for COVID-19.

5.4.5. Signage

RCF should place signs at the entrances and other strategic locations within the facility to
inform visitors of the infection prevention control requirements. A droplet precaution sign
must be placed outside symptomatic residents’ rooms to alert staff and visitors to the
requirement for transmission-based precautions.

Standardised signs are available to all RCF to increase the awareness of healthcare workers,
patients and visitors to the necessary precautions to be applied for all patients (Standard
Precautions) and for those patients who require Transmission-based Precautions, due to
COVID-19. These resources are available at the Australian Commission for Safety and
Quality in Health Care website: https://www.safetyandquality.gov.au/our-work/healthcare-
associated-infection/infection-control-signage

5.4.6. Visitors and Communal Activities

During a COVID-19 outbreak, where possible, the movement of visitors into and within the
facility should be restricted.

Facilities should implement the following:

 Suspend all group activities, particularly those that involve visitors (e.g. musicians).
 Postpone visits from non-essential external providers (e.g. Hairdressers and allied health
professionals).
 Inform regular visitors and families of residents of the COVID-19 outbreak, and request
that they only undertake essential visits. Young children should not visit the facility as
they are generally unable to comply with standard precautions and PPE requirements.
 Ensure visitors who do attend the RCF to visit an ill resident are recorded on a register of
visitors and comply with the following guidance:
 - Report to the reception desk on arrival
- visit only the ill resident
- wear PPE as directed by staff
- enter and leave the facility directly without spending time in communal areas
- perform hand hygiene before entering and after leaving the resident’s room and
the RCF.

5.4.7. Staff

For suspected or confirmed cases of COVID-19 it is preferable that only staff who have been
designated to care for patients with COVID-19 provide care for these residents. During an
outbreak of COVID-19, wherever possible, healthcare workers should not move between
wings or units of the facility to provide care for other residents. This is particularly important
if not all wings/units are affected by the outbreak. It is preferable to cohort staff to areas (in
isolation or not in isolation) for the duration of the outbreak.

During a confirmed COVID-19 outbreak staff should attend work only if they are
asymptomatic. All staff members should self-monitor for signs and symptoms of COVID-19
and self-exclude if unwell. Refer to section 5.2 for further guidance regarding the
management of staff members with suspected or confirmed COVID-19.

5.4.8. Admissions and Transfers

5.4.8.1. New admissions

An ongoing outbreak does not mean the facility has to go into complete “lock down”. It is
preferable that admission of new residents to an affected unit during an outbreak does not
take place. Where new admissions are unavoidable, new residents and their families must
be informed about the current outbreak and adequate outbreak control measures must be
in place for these new residents. Families may wish to make alternative arrangements until
the outbreak is over.

5.4.8.2. Re-admissions of confirmed cases

The re-admission of residents who met the case definition and have been hospitalised for
their illness is permitted, provided appropriate accommodation and infection prevention
and control requirements can be met.

5.4.8.3. Re-admission of non-cases

The re-admission of residents that have not been on the COVID-19 outbreak case lists (i.e.
they are not a known case) should be avoided during the outbreak period if possible. If non-
cases are re-admitted, the resident and their family must be informed about the current
outbreak and adequate outbreak control measures must be in place. Families may wish to
make alternative arrangements (e.g. family care) until the outbreak is over.
5.4.8.4. Transfers

If transfer to hospital is required, the ambulance service and receiving hospital must be
notified of the outbreak/suspected outbreak verbally and through using a resident transfer
advice form (see Appendix 4).

5.4.8.5. Unaffected residents

In some circumstances, it may be feasible to transfer residents who are not symptomatic, to
other settings (e.g. family care) for the duration of the outbreak. The family or receiving
facility should be made aware that the resident may have been exposed and is at risk of
developing disease. They should be provided with information regarding the symptoms of
COVID-19 and the use of appropriate personal protective measures.

Note: In Residential Aged Care settings, security of tenure provisions of the Aged Care Act
1997 will need to be considered.

5.5. Monitoring Outbreak Progress

Increased and active observation of all residents for the signs and symptoms of COVID-19 is
essential in outbreak management to identify ongoing transmission and potential gaps in
infection control measures. Facilities should have the capacity to monitor or count residents
and staff displaying signs and symptoms of COVID-19 daily, to ensure swift infection control
measures are implemented or strengthened to reduce transmission and the duration of the
outbreak.

Updates to information in the line list should occur through daily meetings of the OMT, or
more frequently if major changes occur. The line list should be provided to the PHU each
day (or as arranged) until the outbreak is declared over.

Updated information will be reviewed by the PHU for evidence of ongoing transmission and
effectiveness of control measures and prophylaxis. The PHU will discuss this with the RCF
OMT and advise of any required changes to current outbreak control measures.

The OMT should review all control measures and consider seeking further advice from PHU
if:
 The outbreak comprises more cases than can be managed.
 The rate of new cases is not decreasing.
 Three (3) or more residents are hospitalised related to COVOID-19, OR
 A COVID-19-related death has occurred: telephone to notify the PHU of this.
Specialised advice is available from the following sources:
 A local state, territory or regional PHU.
 Infection control practitioners may be available for advice in local hospitals, state and
territory health departments, or as private consultants.
 Geriatricians or Infectious Disease physicians may be approached for specialist
management of complex infections.
5.6. Declaring the Outbreak Over

The time from the onset of symptoms of the last case until the outbreak is declared over can
vary. Generally, A COVID-19 outbreak can be declared over if no new cases occur within 14
days (maximum incubation period) following the date of isolation of the case. A decision to
declare the outbreak over should be made by the OMT, in consultation with the PHU.

The OMT may make decisions about ongoing RCF surveillance after declaring the outbreak
over, considering the following needs:
 To maintain general infection control measures.
 To monitor the status of ill residents, communicating with the public health authority if
their status changes.
 To notify any late, COVID-19-related deaths to the PHU.
 To alert the PHU to any new cases, signalling either re-introduction of infection or
previously undetected ongoing transmission.
 To advise relevant state/territory/national agencies of the outbreak in a RCF, if
applicable.

5.7. Reviewing Outbreak Management

Following a declaration that an outbreak is over, it is important for all parties to reflect on
what worked well during the outbreak and which policies, practices or procedures need to
be modified to improve responses for future outbreaks. Although a debrief may seem
unnecessary for outbreaks of short duration involving a small number of cases, the OMT in
collaboration with the local PHU should consider a debrief for any outbreak, a prolonged
outbreak, or one with unusual features in relation to outbreak management. A debrief
provides the opportunity to identify strengths and weaknesses in outbreak response and
investigation processes, and provide information to help improve the management of
similar outbreaks in the future. It should involve all members of the OMT and any others
who participated in the response to the outbreak.

Audits are commonly used in clinical medical and nursing practice as part of continuous
quality improvement, and may be an appropriate method by which to review the
management of the outbreak. Australian public health practitioners and researchers have
developed an outbreak audit process, with a framework for deciding which outbreak
investigations to audit, an approach for conducting a successful audit, and a template for
trigger questions. This tool enables agencies such as RCFs to assess their outbreak response
against best practice and is available at
https://bmcpublichealth.biomedcentral.com/articles/10.1186/1471-2458-9-472
 Appendix 1. Flow Chart for COVID-19 Management in RCF

Flowchart forCOVID-19 Management in

Residential Care Facilities in Australia
This guideline is intended for use within residential care facilities in Australia and has been adapted from Coronavirus Disease 2019
(COVID-19) CDNA National Guidelines for Public Health Units.
https://www1.health.gov.au/internet/main/publishing.nsf/Content/cdna-song-novel-coronavirus.htm
Note: the case definition may change over time

TASK ACTION / INFORMATION

• Develop a facility management plan

Plan for cases
• Ensure all staff and general practitioners (GPs) are aware of this plan.

• Ensure all staff, residents and volunteers are aware of the importance of
annual influenza vaccination.
• Provide free influenza vaccination for all staff on site at times that cater for
all shifts.
Vaccinate all residents and staff
• Encourage GPs to vaccinate residents against influenza.
against influenza
• Create a list of staff and residents by influenza vaccination status; ensure it
is kept updated and accessible.

• Provide annual infection control training to all staff that includes information
about COVID-19
• Ensure personal protective equipment (PPE), hand washing facilities and
alcohol based hand rubs are available near point of care.
• Encourage frequent and appropriate hand hygiene at all times (5 Moments).
Infection control preparedness
• Ensure infection control signage is available for use.
• Consider how case isolation will be managed.
• Develop contingency staffing plans in event of staff illness and isolation.
• Ensure stocked respiratory hygiene stations are at each visitor entrance

1. Risk Assessment for COVID-19:

A. Epidemiological criteria:
 Travel to (including transit through) a country considered to pose a risk of
transmission in the 14 days before the onset of illness Refer to the CDNA Series of
National Guidelines (SoNG) for Country transmission risk assessment:
RISK ASSESSMENT FOR COVID-19

https://www1.health.gov.au/internet/main/publishing.nsf/Content/ohp-covid-19-countries.htm
OR
 Close or casual contact in 14 days before illness onset with a confirmed case of
Assess residents for signs & COVID-19. See SoNG for contact definitions:
symptoms of COVID-19 www1.health.gov.au/internet/main/publishing.nsf/Content/cdna-song-novel-coronavirus.htm

B. If the patient has severe community-acquired pneumonia (critically ill) and no other
cause is identified, with or without recent international travel, they are classified as a
suspect case.
C. If the patient has moderate or severe community-acquired pneumonia (hospitalised)
and is a healthcare worker, with or without international travel, they are classified as a
suspect case.

2. Identify signs/symptoms of COVID-19:

CLINICAL CRITERIA
Fever OR acute respiratory infection (e.g. shortness of breath or cough) with or
without fever.
 • Discuss each resident with suspected COVID-19 with treating GP.
• Obtain laboratory request forms for respiratory viral testing INCLUDING
MANAGE A SUSPECTED OR CONFIRMED CASE OF COVID-19

CORONAVIRUS.
Collect specimens • Collect the appropriate respiratory sample. Use a single viral transport
collection swab for each person.
• Observe droplet precautions when collecting specimens i.e. gown, gloves,
fluid resistant surgical mask and eye protection (goggles). Wash hands
before and after collection.

• Commence droplet precautions including gown, gloves, eye protection

(goggles) and a fluid resistant surgical mask when caring for residents with a
COVID-like illness. Maintain a 1.5 metre distance between an infected
person and others.
• Isolate residents with COVID-like illness, if feasible. (Single room with
Implement additional infection ensuite)
control measures immediately • Staff and volunteers with a COVID-like illness must stay away from the
facility until well and see medical advice.
• Request that visitors do not visit the facility if unwell.
• Inform all visitors about cough etiquette and hand hygiene.
• Immunise residents and staff who have not been immunised with the current
influenza vaccine as soon as possible.

• Symptomatic and supportive treatment under the guidance of the GP

Ensure appropriate
management of cases • Use of antiviral medication is a clinical decision made by the GP
• Transfer to hospital as indicated.

• Two or more new cases of COVID-like illness in residents or staff within 72

MANAGE A SUSPECTED OUTBREAK OF COVID-19

Confirm outbreak
hours, at least one of which is laboratory confirmed as COVID-19.

• Nominate an outbreak coordinator and management team at the facility.

Document and monitor • Create a detailed list of residents and staff with COVID-like illness including
outbreak daily location, influenza vaccination status, onset date, symptoms, specimens
taken and results, treatment and outcome. Update the list daily.

• Inform the relevant state or territory Public Health Unit. Contact again if
Inform death or hospitalisation of resident or staff occurs.
• Inform GPs, facility staff, residents and families of residents.

• No new cases for 14 days from onset of symptoms in last case.

End outbreak • Send final detailed list to the relevant state or territory Public Health Unit
Review and evaluate outbreak management.
Appendix 2. COVID-19 Outbreak Preparedness Checklist

Planning actions

Does your RCF have a respiratory outbreak plan that covers all the areas identified below?

Has your RCF updated its respiratory outbreak plan this year?
Have the relevant health care providers/organisations in the community (e.g. associated GPs, infection
control consultants) been involved in the planning process?

Are all RCF staff aware of the plan including their roles and responsibilities?

Staff, resident and family education

Has your RCF staff undergone education and training in all aspects of outbreak identification and
management, particularly competency in infection control?

Has your RCF run one or more staff education sessions?

Has your RCF provided resident families with information regarding prevention of transmission?

Staffing actions
Does your RCF have a staffing contingency plan in case 20% to 30% of staff fall ill and are excluded for
14 days?

Has your RCF developed a plan for cohorting staff in an outbreak?

Stock levels
Has your RCF acquired adequate stock of PPE, hand hygiene products, nose and throat swabs and
cleaning supplies?

Outbreak recognition actions

Does your RCF routinely assess residents for respiratory illness, particularly for fever or cough (with or
without fever)?

Does your RCF encourage staff to report COVID-19 symptoms during the pandemic?
Does a process exist to notify the facility manager and the state/territory Department of Health and
Human Services as soon as practicable (and within 24 hours) of when a COVID-19 case is suspected?

Communication actions
Does your RCF have a contact list for the state/territory health department and other relevant stake
holders (e.g. facility GPs and infection control consultants)?

Does your RCF have a plan for communicating with staff, residents, volunteers, family members and
other service providers (e.g. cleaners) during an outbreak?
Does your RCF have a plan to restrict unwell visitors entering the facility as well as limitation of well
visitors during an outbreak to reduce risk of transmission both within the facility and externally (e.g.
security, signage, restricted access)?

Cleaning
Does the plan identify who is responsible for overseeing increased frequency of cleaning, liaison with
contractors or hiring extra cleaners as necessary?
Appendix 3. Letter to Families – Preventing Spread of COVID-19
[Facility Letterhead]

……/……/……

Dear family member

There is local transmission of Coronavirus Disease 2019 (COVID-19) in the community.

COVID-19 primarily causes respiratory illness in humans, and while all types of respiratory
viruses can cause sickness in the elderly, COVID-19 is a particularly contagious infection that
can cause severe illness and death for vulnerable people.

COVID-19 Pandemic
COVID-19 has caused outbreaks of illness in the Australian community, and local
transmission has occurred in some communities. Residential care facilities are particularly
susceptible to COVID-19 outbreaks. Even when facilities actively try to prevent outbreaks
occurring, many external may lead to residents or staff contracting the COVID-19 and
outbreaks in residential care facilities.

Families play an important role in protecting their relatives from community viruses.
Practical steps you can take to prevent COVID-19 from entering residential care facilities are
outlined below.

Avoid spreading illnesses

Washing your hands well with liquid soap and water or alcohol-based hand rub before and
after visiting and after coughing or sneezing will help reduce the spread of disease. Cover
your mouth with a tissue or your elbow (not your bare hand) when coughing or sneezing
and dispose of used tissues immediately and wash your hands.

Follow any restrictions the residential care facility has put in place
Facilities will post signs at entrances and within their units to inform you if an outbreak is
occurring so look out for these warning signs when entering the facility.

It is important to follow the infection control guidelines as directed by the facility staff. This
may include wearing a disposable face mask and/or other protective equipment (gloves,
gowns) as instructed. Certain group activities may be postponed during an outbreak.

Stay away if you’re unwell

If you have recently been unwell, been in contact with someone who is unwell or you have
symptoms of respiratory illness (e.g. fever, cough, shortness of breath, sore throat, muscle
and joint pain, or tiredness/exhaustion) please do not visit the facility until your symptoms
have resolved. If you have been in contact with a confirmed case of COVID-19 you must stay
away until you are released from self-isolation.

Limit your visit

If there is an outbreak in the residential care facility, we ask that you only visit the person
you have come to see and keep children away if they or your resident family member is
unwell. Avoid spending time in communal areas of the facility if possible to reduce the risk
of spreading infection.

Thank you for your assistance in adhering to these steps. These measures will greatly assist
residential care facilities and protect the health of your relatives in the event of a COVID-19
outbreak.

Should you require further information regarding COVID-19, please refer to the
Commonwealth Department of Health website:

https://www.health.gov.au/news/health-alerts/novel-coronavirus-2019-ncov-health-alert

Yours sincerely,

[Name]
[Position]
[Facility/Organisation]
Appendix 4. Swab Collection Procedure
Swab Collection Procedures
1. Before performing swab

Obtain required materials:

 Personal protective equipment (PPE) for the health care worker taking the swab,
including gown, gloves, eye protection (goggles or face shield), and surgical mask.
 One dry, sterile, flocked swab.
 One viral culture swab with viral culture medium.
IMPORTANT NOTES:
 Contact your laboratory provider for current local advice about swabs.
 Do not use bacterial swabs for specimen collection. If in doubt, check!

2. Performing the swabs

Preparation:

1. Perform hand hygiene.

2. Don PPE in the order of gown, surgical mask, eye protection, and gloves.
3. Explain the procedure to the patient and obtain consent.
4. Place patient standing or sitting with head tilted at 70 0, supported against a bed,
chair or wall.

Deep nasal swab procedure: (refer to figure 1)

1. Stand at the side of the patient’s head and place your non-dominant hand on the
patient’s forehead with your thumb at the tip of the nose.
2. With the other hand, insert the flocked end of a dry, sterile swab horizontally into
the patient’s nostril, approx. 2-3 cm (gently pushing the swab directly back rather
than up).
3. Place lateral pressure on the swab to collect cells from the midline nasal septum.
4. Rotate the swab twice (2 x 360 degree turns) against the turbinate in the nostril to
ensure the swab contains epithelial cells (not mucus) from the nostril.
5. Withdraw the swab from the nostril. Place the swab back in its labelled tube or
bottle.
Figure 1
Throat swab procedure: (refer to figure 2)

1. Stand at the side of the patient’s head and ensure their head is resting against a wall
or supporting surface.
2. Place your non-dominant hand on the patient’s forehead.
3. Ask the patient to open his/her mouth widely and say “aaah”.
4. Use a wooden spatula to press the tongue downward to the floor of the mouth.
This will avoid contamination of the swab with saliva.
5. Using the viral culture swab, insert the swab into the mouth, avoiding any saliva.
6. Place lateral pressure on the swab to collect cells from the tonsillar fossa at the side
of the pharynx.
7. Rotate the swab twice (2 x 360 degree turns) against the tonsillar fossa to ensure the
swab contains epithelial cells (not mucus).
8. Remove the swab, and place directly into its labelled tube or bottle.
Figure 2

IMPORTANT NOTES:
 Choose an area for the procedure where the patient can rest their head against a wall or
on a high-backed chair with room for you to stand beside (not in front of) the patient.
 Ensure the area is well lit, with hand washing and infectious waste disposal facilities.
 Remember to WASH AND DRY HANDS before and after the procedure!
 Gloves, gown, surgical mask and eye protection MUST be worn when collecting nose and
throat swabs.
 Masks should NOT be touched during wear and should NOT be worn around the neck at
any time. When removed, handle the mask by the ties of the mask only.

3. After performing the swab

5.7.1.1. Labelling and storage of specimen:

1. Label the tube or bottle containing the swabs with the patient’s full name, date of
birth, specimen type and date of collection. The accompanying request form should
include the RCF facility name.
2. Remove PPE safely (remove gloves, perform hand hygiene, remove goggles or face
shield, gown and mask and perform hand hygiene again).
3. Specimens should be sent on the day of collection. Refrigerate the specimen until it
is sent to the laboratory (do NOT freeze the specimen). Specimens should be
packaged in a small insulated bag/box (with ice bricks) for transport to the pathology
laboratory.

IMPORTANT NOTE: Dispose of gloves, gowns and masks in an infectious (biohazard) waste
bag.
Appendix 5. Initial RCF report to a PHU – COVID-19 Outbreak
Date/time: ___________________ Public Health Officer:_____________________

Contact details:
Person notifying outbreak: _______________ Position: ______________________

Telephone number: ____________________ Email: _________________________

Facility details:
Name of Facility_______________________________________________________

Address: _____________________________________________________________

Facility Manager / Director: ______________________________________________

Telephone number: _____________________ Fax number: ____________________

Email address: _________________________

Description of facility: __________________________________________________

Total number of residents: _______________ Total number of staff: ____________

Age range of residents: ___________________

Number of units / wings / areas in facility: __________________________________

Floorplan provided: Yes / No

Residents:
Unit name Resident Long term Short term High Care Dementia / Other
no. / Respite Secure

RCF Staff:
Staff type No. of RCF staff No. agency staff No. Causal staff No. volunteers
Management
Administrator
Cleaner
Nurse
Carer / Care
Assistant
Agency
Other (specify)
Appendix 6. Letter to GPs – COVID-19 Outbreak
[Facility Letterhead]

……/……/……

Respiratory outbreak at [Facility Name]

Dear Doctor,

There is an outbreak of acute respiratory illness affecting residents at the facility named
above. The outbreak may involve some of your patients who may require review.

It is important to establish if the outbreak is caused by SARS-CoV-2. Coronavirus Disease

2019 (COVID-19), caused by SARS-CoV-2, is a notifiable condition.

We recommend that you:

 Establish if any of your patients are affected
 Help determine if the outbreak is caused by SARS-CoV-2:
- Obtain/order appropriate respiratory samples from residents who meet the case
definition, for respiratory PCR testing.
 Ensure that your patients are vaccinated against influenza, if there are no
contraindications
 Ensure that you observe hand hygiene procedures and use appropriate PPE when
visiting your patients.

Limit the use of antibiotics to patients with evidence of bacterial superinfection, which is
uncommon. There is significant evidence that antibiotics are over-prescribed during the
during institutional respiratory illness outbreaks.

Control measures that the facility has been directed to implement include:
 Isolation of symptomatic residents
 Use of appropriate PPE when providing care to ill residents
 Exclusion of symptomatic staff from the facility
 Restriction/limitation of visitors to the facility until the outbreak has resolved
 Promotion of thorough hand washing and cough and sneeze etiquette.

Should you require further information regarding COVID-19, please refer to the
Commonwealth Department of Health website:
https://www.health.gov.au/news/health-alerts/novel-coronavirus-2019-ncov-health-alert

If you require any further information or advice please contact [insert details].
.
Yours sincerely,
[Name]
[Position]
[Facility/Organisation]
Appendix 7. Transfer Advice Form
[Facility Letterhead]

Date: ……/……/……

To: [Admitting Officer, Facility Name]

Please be advised that: [Resident Name]

is being transferred from a facility where there is a cluster/outbreak of COVID-19. At this

stage the outbreak is:
 suspected
 confirmed

Please ensure that appropriate infection control precautions are taken upon receipt of this
resident.

At the time of transfer:

 The resident does not have an acute respiratory illness
 The resident has an acute respiratory illness
 The resident is a suspected case of COVID-19
 The resident is confirmed case of COVID-19

Resident details: __________________ ____________________________

Given name Surname

Date of birth:
Name of originating facility:
Name of contact person:
Phone number:
Appendix 8. COVID-19 Outbreak Management Checklist

Identify
Identify if your facility has an outbreak using the definition in the guideline
Implement infection control measures
Isolate / cohort ill residents
Implement contact and droplet precautions

Provide PPE outside room

Display sign outside room
Exclude ill staff until symptom free (or if confirmed cased of COVID-19, until
they meet the release from isolation criteria)
Reinforce standard precautions (hand hygiene, cough etiquette) throughout
facility

Display outbreak signage at entrances to facility

Increase frequency of environmental cleaning (minimum twice daily)
Collect respiratory specimens
Collect appropriate respiratory specimens from ill residents or staff

Notify
The state/territory Department of Health and Human Services
Contact the GPs of ill residents for review
Provide the outbreak letter to all residents’ GP’s
Inform families and all staff of outbreak
Restrict
Restrict movement of staff between areas of facility

Avoid resident transfers if possible

Restrict ill visitors where practical
Cancel non-essential group activities during the outbreak period
Monitor

Monitor outbreak progress through increased observation of residents for

fever and/or acute respiratory illness
Update the case list daily at the facility and provide to the public health unit
daily
Add positive and negative test results to case list
Declare
Declare the outbreak over when there are no new cases 14 days from the
date of isolation of the most recent case.
Review
Review and evaluate outbreak management – amend outbreak management
plan if needed
Appendix 9. Forming an Outbreak Management Team
Several functions are critical within the outbreak management team (OMT), and some roles
may be performed by the same person.

The OMT should initially meet daily to:

 direct and oversee the management of the outbreak
 monitor the outbreak progress and initiate changes in response, as required
 liaise with GPs and the state/territory Department of Health, as arranged.

The OMT should include the following roles and functions:

Role Function

Chairperson (facility Director, The chairperson is responsible for co-ordinating

Manager or Nursing Manager) outbreak control meetings, setting meeting times,
agenda and delegating tasks.

Secretary The secretary organises OMT meetings, notifies team

members of any changes, and records and distributes
minutes of meetings.

Outbreak Coordinator (Nurse, The coordinator ensures that all infection control
Infection Control Practitioner decisions of the OMT are carried out, and coordinates
or delegate) activities required to contain and investigate the
outbreak. This role is often given to an Infection Control
Practitioner (ICP) or delegate.

Media Spokesperson (facility Significant media interest in outbreaks in RCFs is

Director, Manager or Nursing common, especially if there are adverse outcomes. The
Manager) department is available to assist facilities should media
interest arise. It is recommended that facilities liaise
with the department in this instance prior to making
media statements.

Visiting General Practitioners Some GPs may be available to participate in the OMT
and their role should be identified during the planning
process. It is valuable to identify a clinical lead amongst
those GPs who attend a facility. In the management of
an outbreak, the role of this person is important in
facilitating assessment and management of ill residents,
and in working with the RCF and the department to
implement control strategies.

Public Health Officers An understanding of what assistance can be provided by

PHUs and role/responsibility clarification should be
confirmed at the initial OMT meeting, although it is
usually not necessary for PHUs to be part of the OMT.
Appendix 10. Hand Hygiene
Source: Hand Hygiene Australia, adapted from ‘5 Moments for Hand Hygiene’, 'How to
Handwash', and 'How to Handrub' © World Health Organization 2009. All rights reserved.
Appendix 11. Personal Protective Equipment Requirements

Personal Protective Equipment Requirements by Precaution

Personal Precaution
Protective
Equipment Contact Droplet Airborne

Gloves Yes As per standard As per standard

precautions precautions
Gown/Apron When healthcare As per standard As per standard
(impermeable) worker's clothing is precautions precautions
in substantial
contact with the
patient, items in
contact with the
patient, and their
immediate
environment

Surgical Mask When in close Yes No

contact (less than
1m)

P2/N95 Respirator Not required Not required Yes

Goggles/face Not required As per standard As per standard

shield precautions precautions
Appendix 12. Proper Use of Persona Protective Equipment (PPE)
Source: Centres for Disease Control and Prevention https://www.cdc.gov/hai/pdfs/ppe/PPE-
Sequence.pdf
Appendix 13. Respiratory Etiquette

Cough and Sneeze Etiquette

• When coughing or sneezing, use

a tissue to cover your nose and
mouth
• Dispose of the tissue afterwards
• If you don’t have a tissue,
cough or sneeze into your elbow

• After coughing, sneezing or

blowing your nose, wash your
hands with soap and water
• Use an alcohol-based hand
cleanser if you do not have
access to soap and water

Remember:
Hand hygiene is the single most effective way to reduce the spread of
germs that cause respiratory disease!
Anyone with signs and symptoms of respiratory infection:
• should be instructed to cover their nose/mouth when coughing or
sneezing;
• use tissues to contain respiratory secretions;
• dispose of tissues in the nearest waste receptacle after use; and
• wash or cleanse their hands afterwards.
Appendix 14. Transmission-Based Precautions

Transmission-Based Precautions

Infection Control Route of transmission

Measure
Contact Droplet Airborne

Gloves For all manual As per Standard As per Standard

contact with patient, precautions precautions
associated devices
and immediate
environmental
surfaces

Gown When healthcare As per Standard As per Standard

worker's clothing is precautions precautions
in substantial
contact with the
patient, items in
contact with the
patient, and their
immediate
environment

Surgical Mask As per Standard Yes No

precautions

P2/N95 Respirator Not required Not required Yes

Goggles/face shield As per Standard As per Standard As per Standard

precautions precautions precautions

Standard single Yes Yes No

room with own OR OR
ensuite Cohort patients with Cohort patients with
door closed door closed

Negative pressure Not required Not required Yes

ventilation room

Special handling of Single use or if Standard Precautions Standard Precautions

equipment reusable, reprocess Avoid contaminating Avoid contaminating
according to IFU environmental environmental
before reuse. surfaces and surfaces and
 Avoid contaminating equipment with used equipment with used
environmental gloves. gloves.
surfaces and
equipment with used
gloves.
Transport of Surgical mask if Surgical mask if Surgical mask if
patients coughing/sneezing coughing/sneezing coughing/sneezing
and other signs and and other signs and and other signs and
symptoms COVID-19. symptoms COVID-19. symptoms COVID-19.
Notify the facility Notify the facility Notify the facility
receiving patient. receiving patient. receiving patient.
Advise transport staff Advise transport staff Advise transport staff
of level of precautions of level of precautions of level of precautions
to be maintained. to be maintained. to be maintained.
Patients on oxygen Patients on oxygen
therapy must be therapy must be
changed to nasal changed to nasal
prongs and have a prongs and have a
surgical mask over the surgical mask over the
top of the nasal top of the nasal
prongs for transport prongs for transport
(if medical condition (if medical condition
allows). allows).

Alerts Remove gloves and Visitors to patient Visitors to patient

gown/apron and room must also wear room must also wear
perform hand hygiene surgical mask and P2/N95 mask and
on leaving the room. perform hand perform hand
Patient Medical hygiene. hygiene.
Records must not be Patient Medical Patient Medical
taken into the room. Records must not be Records must not be
Signage of room. taken into the room. taken into the room.
Signage of room. Signage of room.
Room cleaning Standard cleaning Cleaning and Cleaning and
protocol. Disinfection - Consult Disinfection - Consult
with infection with infection
prevention and prevention and
control professional. control professional.