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Health - COVID-19

Dr Rosalie Woodruff MP

Dr Rosalie Woodruff MP  -  Monday, 6 September 2021

Tags: COVID-19, Health, State Budget

Dr WOODRUFF - Minister, throughout last year's COVID-19 briefings we heard Dr Veitch talk regularly about the importance of considering the mixing of people in the Tasmanian community as increasing the risk to the community if a case of the Alpha variant of COVID-19 entered the state. Since then the state has seen the gradual easing of most restrictions to the point that life for us seems pretty normal. That has been welcome. We are now in a situation where the majority of the Australian population is in lockdown due to the significant outbreaks of the Delta variant.

New Zealand had an immediate lockdown after one case. Despite that they have now got more than 700 cases in the country. What's the thinking behind Tasmania's current internal restriction settings? Have you given any consideration to modifying them to decrease the risk of an outbreak in the likely eventuality that Delta will enter the community?

Mr ROCKLIFF - Thank you for the question, Dr Woodruff. I might make some broader comments. Is your question leading towards the national plan?

Dr WOODRUFF - That is another question I will ask. It is about today and the fact that we have very minimal restrictions relative to the rest of the country and reflecting on Dr Veitch's comments last year.

Mr ROCKLIFF - More broadly, life has changed a lot notwithstanding more minimal restrictions as you point to at this time. Three years ago no-one saw any posters of COVID-19 safe behaviour, hygiene and washing hands, social distancing, tracking and tracing. So life has changed. It is different for us, even though we have zero cases at this present time. I don't doubt, based on the Public Health advice of Dr Veitch, that should Delta hit our shores there will be restrictions put in place. We have spoken about short, sharp lockdowns. I will hand to Dr Veitch. Without taking too much of the committee's time, Dr Veitch, you might want to make some broader comments as well as addressing Dr Woodruff's questions.

Dr VEITCH - At the risk of taking up too much of the committee's time I will focus on Dr Woodruff's question. It is a huge issue and I could talk at length about it, but I will try to focus on Dr Woodruff's very reasonable question. It is correct that we are in a risky time at the moment. All of the populous states of Australia are in or close to lockdown situations and have substantial numbers of cases occurring incompletely controlled. We have heard in the past week that there is a substantial likelihood that controlled to the point of a few cases is not likely to be possible in New South Wales. I think it is doubtful in Victoria, too.

That external threat is considerable. To date our measures to contain risk to Tasmania have been successful. A principal feature of that has been our approach to borders where we put in place border restrictions either based on hot spots at exposure or in some cases whole regions or states to prevent people who have been in those locations coming to Tasmania and posing a risk to us. With the single exception of the person who came from New South Wales a couple of weeks ago, albeit into quarantine, we have not seen people come across from these states with high burdens of disease since before late last year, when two people came from healthcare settings in Victoria into quarantine here. Again, their risk was contained.

The border settings are tremendously important. However, we know from the experience of most other states that cases get out, particularly in the case of a Delta strain. So unless the cases are limited by vigorous public health responses at the outset, including lockdowns and effective contact tracing and isolation, disease can escalate to the situations in New South Wales and Victoria very quickly.

We have eased many of our restrictions and we do live relatively normally. Our settings are pretty similar Western Australia, Northern Territory and South Australia, which are the three other States that have been relatively less touched by COVID-19. However, there are still some limits in place. We still have limits on the number of people that can gather in large crowds. We still have requirements for most settings for the density to be not more than one person per two square metres.

We still have some restrictions on the number of people who can dance or can drink standing up. We have some modest level restrictions in place. Public Health has been approached on occasions over recent weeks and months to move towards more liberalised settings in various circumstances. I think in the current climate it's not the time to be moving to a substantially more liberalised setting. That's partly to prevent a case in those settings causing an explosive outbreak. It's also to ensure that our response capacity can meet the challenge of the number of people who could be exposed to a case.

There are some settings in place. We have been looking at well advanced lockdown planning. There was distributed a couple of weeks ago an outline for what a lockdown would look like. Even in the face of Delta, it's evident that a well conducted early lockdown and contact tracing can bring the first few cases of Delta under control. A number of states have achieved that over the last few months. It's the misfortune of the states where it's got away to have a much more problematic thing to deal with. Our measures are aimed at, as the minister said, short, sharp but definitely hard lockdown. That really does minimise mixing and movement of society to give us a chance to make sure the Delta case doesn't get away.

Dr WOODRUFF - Minister, thank you very much. It's a concerning time for many Tasmanians. I want to recognise that people are already under pressure and anxious because of a whole lot of other pressures in Tasmania, unrelated to the outbreak of the disease in this state. Many Tasmanians are confused as they watch the news and listen to federal and state politicians and health officers - no comment at all on our health officer - talk about the Doherty modelling and the national plan and what it might mean for the ending of state border restrictions and the opening of borders around the country. The Doherty modelling doesn't nominate a day for a so-called Freedom Day. It has levels of restrictions when vaccinations levels would reach 70 and 80 per cent and it gives scenarios on the possible reduction of restrictions. You've talked about wanting to see Tasmania at 90 per cent. Were we in a situation where we had Delta in the state, are you saying that we'd be looking at 90 per cent or above for double dose vaccinations of people in Tasmania before we'd look at opening up restrictions and opening borders if we were in the situation that the rest of the country finds itself in?

Mr ROCKLIFF - Thank you for the question Dr Woodruff. A lot of Tasmanians are asking similar questions. The national plan is based on the Doherty modelling of that 70- 80 per cent figure where we can ease restrictions, if you like, and open up, to use your words.

The number one focus for us is to ensure that every person who is eligible for a vaccine in Tasmania is vaccinated. I want to see 90 per cent of people. More. I want to see every single person in Tasmania who is eligible for a vaccination to be vaccinated. That's why I'm pleased with the work that's being done more broadly within the Department of Health by what I call 'The Vaccination Team'. Indeed, we have pharmacists participating now, and our GPs as well.

The Premier reflected on this a bit yesterday. It doesn't mean we'll be opening up 'open slather'. There has to be a measured opening up based on good public health advice at the time. It's important to also recognise that our public health team and our Department of Health have worked very closely together with the Government and, indeed, the community, and this has served us well. We have a national plan in place, but we'll also be guided by public health advice, as I've spoken about before.

If you like, I can go through the phases of the national plan to provide some context.

Dr WOODRUFF - It's really about where Tasmania is in response to that.

Mr ROCKLIFF - The main thing is that the best way to protect our community is to be vaccinated, and that will absolutely continue to be our focus. The number one thing is to ensure that all those who are eligible for a vaccination receive a vaccination.

Dr WOODRUFF - Minister, this might be a question for Dr Veitch, but you might answer it. It is in relation to information we are receiving from the international peer-reviewed literature about the seeming waning efficacy of all vaccines, deteriorating their efficacy over time. This good data from the UK, some from Israel and other countries. Is there any consideration in the planning for Tasmania to provide third booster shots for AstraZeneca and Pfizer for the general population and health care workers?

Mr ROCKLIFF - Thank you for the question and I will throw to Dr Veitch who received this question last Friday at a media conference on potential boosters and the like, if my memory serves me correctly. We are still waiting on particular advice with respect to that matter. Would you like to talk about that booster?

Dr VEITCH - Thank you, Minister. The question of booster vaccination is obviously a really important one. And there is some evidence in some settings, breakthrough infections are beginning to occur some months after vaccination, in some populations. Particularly populations in high risk of exposure, such as health care workers. This is one reason why, when we think about preventing COVID-19, as well as thinking about booster vaccination, we also have in mind other measures such as masks. Recently, I recommended masks were required and be worn in health care settings. It was the vulnerability of those setting to disease transmission that was a driving factor in the decision. That includes the possibility of waning immunity.

There are data coming out of a number of countries on waning immunity. Few of them are going to be quite the same as Australia, because many of those countries would have actually experienced substantial amounts of disease transmission, which would have contributed to boosting immunity even in the absence of vaccination. It is likely that in the first instance, our health authorities will be recommending a booster vaccination sometime in the coming months or early next year. I would expect that advice would come from the Australian Technical Advisory Group on Immunisation, the peak scientific body that provides that guidance. They have access to all the information and the research to provide guidance to Australia on that and we will look to them for advice.

Dr WOODRUFF - Minister, if a Delta outbreak occurred in Tasmania before we reach very high population numbers of vaccinated people, there would on the numbers like be hospitalisations and possibly intensive care unit cases, so we will need to have dedicated ICU wards. What is the plan for when hot ICU's will be located in the state? I understand Calvary could be used as a non COVID-19 designated ICU area and the Royal Hobart Hospital could have a COVID-19 hot ICU area. But in the north and the north-west, there is no private hospital capacity to have ICU's used as flow overs. Could you please talk about the situation for the whole state and especially, the north and the north-west?

Mr ROCKLIFF - We mentioned operation last year capacity and intensive and critical care is a specialty. That addresses the lifesaving and life sustaining management of patients at risk of eminent death. An intensive care bedspace is defined as a ventilated bed space that has staffed one nurse to one patient. It is important to note ICU capacity will vary from time to time based on the funding and operational factors.

There are 34 operational funded and staffed ICU beds in Tasmania, comprising 28 beds in the public system and six beds in the private system.

There are 26 non-operational ICU beds in Tasmania, comprising 21 beds in the public system and five beds in the private system and if required, these non-operational ICU beds will be staffed to provide up to 60 ICU beds state-wide from within existing and available critical care resources.

A statewide COVID-19 ICU surge capacity plan has been developed and aligned with other service level escalation management plans. In accordance with the Australian and New Zealand Intensive Care Society COVID-19 guidelines, the plan provides for a phased and tiered response based on the impact of COVID-19. It includes strategies to reduce routine demand and increase capacity infrastructure, increase associated equipment and consumables, for example ventilators, and increase staffing and workforce requirements.

When considered together and with other enablers, for example medication stocks, these measures provide for up to 80 ICU beds statewide for COVID-positive patients. I'm advised that when combined with current operational ICU beds, total critical care capacity statewide is up to 114 beds.

As I have indicated before, we have some 267 ventilators at this present time. A partnership with the Commonwealth and state government will enable a further 100 ventilators that we have access to, taking our capacity for ventilators up to that 367 level.

Dr WOODRUFF - Spread across the state in the north and the north-west?

Mr ROCKLIFF - Ms Morgan Wicks, if you wouldn't mind talking about the other regions if it's possible.

Ms MORGAN-WICKS - Will do. At the outset I want to talk about what our hospital system would look like if there was a sustained COVID outbreak in the state, noting that we have already managed one significant outbreak, the north-west outbreak in early 2020. It was in the north-west and managed right across through to the north and to our Royal.

At the point at which we closed the North West Regional Hospital and the North West Private Hospital it required the decanting of some 28 patients at that time, many of whom, if not all, were potentially COVID-positive. They were shared across the Mersey Community Hospital. We had the ICU at the LGH in play and we also had one or two patients who had to be transferred to the Royal Hobart Hospital, from memory.

Every single day we are watching the hospitalisation rates in New South Wales and Victoria to also inform our modelling as to the potential impact in this state. I note from last night's reporting that New South Wales had 1030 hospitalised, 175 in ICU, and 72 who were ventilated. I think that's against a backdrop of some 20 000 cases in New South Wales. We look at that and try to make some determinations but, as Mark has already mentioned, it does depend on the rate at which Tasmanians are vaccinated which is changing on a day by day basis but we can make some assumptions.

Last year we also watched the Alpha variant and the need for ICU or ventilation of patients which in fact turned out to be very low. Nevertheless, we made significant plans in preparation, as the minister has outlined, in relation to the number of ventilators and to the number of beds and staffing because it's great to have 367 ventilators and it has given us an opportunity to actually replace some quite old ventilator stock within our ICUs. We've taken that advantage or opportunity but it is about the beds that are available and the staff. On a ventilated patient, we need one registered nurse per patient with three shifts a day, et cetera, to maintain a 24/7 operation.

Regarding what hospital might be COVID-hot or not - and we've had many discussions through our THS Emergency Operations Centre and the commander of that Emergency Operations Centre sits on my right, our Chief Medical Officer, Tony Lawler. Certainly, at the beginning of the outbreak, for example, we did consider Mersey not taking COVID-positive patients.

However, all of our four hospitals have emergency escalation management plans. They are based off triggers of how many COVID cases are in the environment, how many tests are being undertaken, et cetera. They make their hospitals at different escalation points configure to take the load that is turning up to each hospital point. If I can come back to the hospitals, they will look quite different in a sustained COVID outbreak to how they look today.

I note the AMA's and other employee organisations' comments in relation to whether or not our health system could cope. The health system of today would not be coping in the same way if we had a sustained COVID outbreak. We have deliberately prepared with our Escalation Management Plans which involve for example, the cessation of elective surgery or other health services should there be a sustained outbreak, and we are prepared for that.

Dr WOODRUFF - Minister, I understand that there are now a number of healthcare workers who are suffering from long COVID in Tasmania, many of whom were involved in the north-west coast outbreak. Can you please detail the specific support you provided those personnel who have long COVID-19, including monetary support via workers compensation if that is happening, and whether they have had group or individual psychological debriefings and access in relation to their ongoing suffering from long COVID-19?

Mr ROCKLIFF - Thank you. I will ask Ms Morgan-Wicks to provide some more detail to your question. Your question has focused on the north-west but -

Dr WOODRUFF - There are other people around the state, I understand.

Mr ROCKLIFF - I have met with some staff at the North West Regional Hospital. We had a long discussion and I listened to their experience during the outbreak, and their transition back to work. It was, at times, a very emotional meeting and I thank them for reaching out to me. I am scheduled to meet with them again in a few weeks' time. I use the term 'meet'; but it was more a sit down and listen exercise and I valued it a great deal. We spoke about some of the concerns and support needed for their transition back to work, and support needed if that is not immediately possible.

Ms MORGAN-WICKS - We have received some workers compensation claims from positive COVID-19 employees in the north west outbreak. We have tried to work very closely with each of these impacted people. We are all learning about long COVID-19 as we go, including the best symptom management and the best case management. We have worked to put significant support in place for our staff.

We have received 48 claims for positive COVID-19 employees - 47 in the north west and one in the north. Thirty-six of those claims initially closed. Three have been reopened due to the occurrence of an ongoing symptom, and one is under review and may be reopened due to ongoing symptoms. We have 15 active claims and they are all in the north west. Five employees are incapacitated for work due to significant post infection health complications. Five employees are on graduated return-to-work programs and five have returned to pre injury hours and/or duties.

To date, we have paid to date are $1 639 040.79. Our estimates for potential costs are $1 588 371.01. The full estimated is $3.22 million. All of these costs are including all associated costs such as wages, treatment, rehabilitation, legal, et cetera, and they are estimated costs. They could be over- or understated.

We supporting our long term COVID-19 sufferers through dedicated workplace rehabilitation providers, across all claims. This approach allows information sharing on options for referrals and support, and for workers to assist in identifying suitable medical treatments. We have referrals to various specialists across all claims, for investigations, tests, treatments and ongoing management advice. In accordance with legislative requirements, all entitlements have been provided to staff. Additional support has been provided where required and when it can be facilitated. We are learning about long COVID-19. The influencing factors on the progression of claims include limited understanding of ongoing and new symptoms and medical reasons for them.

We have the presentation of increased anxiety due to the COVID-19 situation on the mainland and the fear of COVID-19 cases occurring in Tasmania. That includes an increase in fear in social engagements in the community setting by people who have already suffered COVID-19, as well as work-related engagements. The work situation in the north-west is a factor - for example, the North West Regional Hospital and the proportion of the community who actually work there and are engaged there. We've had self isolation within family homes, which further impacts on mental health. We've also had an increase in the recommendation of mental health treatments being available for these sufferers. We are trying to work with each employee to provide them with the support that are required. It does change over time, given our learnings on long COVID-19.

Dr WOODRUFF - Minister, one of the recommendations from the North West Coast Independent Review was that a smartphone app be developed to provide staff with easy access to the latest advice about PPE and other things. Has that app been built and if it hasn't, when would it be completed?

Mr ROCKLIFF - Yes, I'm advised that the [inaudible] app has been launched.

Dr WOODRUFF - Minister, the decision was made recently to close the acute respiratory illness area, known as ARIA, at the Royal Hobart Hospital. I am not commenting on the quality or otherwise of that decision. I have a question about the flow on impact of the decision. Previously, ambulance crews who arrived at the hospital with an acute respiratory patient would keep that patient in the back of the ambulance on the ramp, because they knew space in the ARIA would open up relatively quickly.

Now that the ARIA doesn't exist, the waiting time to get those patients into the hospital has increased dramatically. For the safety of the patients, paramedics have no choice but to offload the patient into the ramp corridor while they wait. This means there is a mix of respiratory and non respiratory patients on the ramp in the hospital, and a mix of healthcare staff with differing levels of PPE.

Staff are understandably confused about how this can be compliant with COVID 19 best practice. Could you please tell me what is being done to mitigate the issues and to talk to Ambulance Tasmania staff about this issue?

Mr ROCKLIFF - Certainly, and perhaps I will throw to Professor Lawler or Ms Morgan Wicks shortly.

My understanding was that the closure of the ARIA was done largely to improve access and flow. I know you raised this in parliament, and I am not sure I had the opportunity to respond to you because it was during debate of a bill or for some other reason, but I believe we have said that when we need the ARIA again, we can stand it up again. It is not closed forever.

The decision was made at the Royal Hobart Hospital, in August, to close and repurpose the dedicated acute respiratory illness area, located in the emergency department. The decision opened up significant space and capacity in the ED, freeing up 10 beds and allowing for greater flow of patients through our hospital system.

The repurposing of this space has no detrimental impact on patients, I am advised. The Royal Hobart Hospital has strict protocols in place for anyone presenting to the hospital with respiratory symptoms, and I am assured that this type of acute respiratory unit would be again stood up rapidly in any future outbreak situation, as I have just outlined.

More broadly, all patients are screened upon arrival at our hospitals. The risk of COVID is assessed according to their symptoms, and appropriate clinical measures are put in place.

Staff use PPE for all patients who are at risk, and patients who show respiratory symptoms are allocated single rooms if they are assessed as high risk.

The decision to close the ARIA at the Royal Hobart Hospital is not unique, I am advised, with many other hospitals in New South Wales, Victoria, Queensland and South Australia closing or reducing their acute respiratory capacity.

In terms of the flow-on effects for Ambulance Tasmania staff, perhaps Ms Morgan Wicks can comment.

Ms MORGAN-WICKS - Through you, minister, I note that the plan to close the ARIA was a clinician-led plan. Dr Emma Huckerby, who has been head of the Royal emergency department for many years now - extremely experienced - came through to us with the suggestion. Dr Huckerby has been working in our integrated operations centre and has been quite pivotal in the steps to try to improve access and flow through the Royal - while not impacting in any way the safe treatment of patients presenting to the ED with respiratory symptoms.

The decision itself was made after consulting with Ambulance Tasmania, with experts in infection control, with the ED and medical staff, and also with the Royal's executive.

I might ask Professor Tony Lawler if he would like to add to that.

Prof LAWLER - It is worth noting that the ARIA was not the only mitigating factor that was being used within the hospital. There was a balanced decision that, as the secretary highlighted, was clinician led, and considered across the spectrum of the risk that has presented currently, and we have to respond in an appropriate way to manage the competing risks.

We do have that statewide escalation policy that looks to elements such as the presence or prevalence of disease in the community, and the number of presentations. Given that we don't have significant community transmission of COVID 19 currently within Tasmania, and the fact that there is significant pressure on the emergency department in terms of flow, and also the fact that we would be able to re establish the ARIA with short order, the decision was made as proposed and supported by clinicians to reconfigure to maximise the capacity to see patients presenting to the emergency department.

I would also highlight that there are other risks mitigations in place. The Director of Public Health is clearer on these than I, given that he has issued them, and that includes the requirement for staff within hospitals to wear masks.

We have robust protocols in place for the management of individuals who present with acute respiratory illness. That is not just for COVID 19, it is an issue for us every influenza season, and we manage and observe those protocols. Those requirements under the direction apply to any healthcare workers or patients presenting to the emergency department or any of our health facilities, and we keep constant surveillance on the numbers of presentations and regularly discuss the necessary urgent reconfiguration should that need arise.

Ms MORGAN-WICKS - If I may add to Professor Lawler's comment, the respiratory patients who are brought in via ambulance are triaged in the normal way, and patients are asked to wear masks. We don't support patients waiting outside in ambulances, with paramedics there triaged and managed in the airlock at the Royal.

Dr WOODRUFF - Thank you for those answers. A follow-up question on that. I want to be clear that I am not in any way being critical of the decision. It is obviously sensible and important. We are talking about unintended real-life consequences of decisions at the staff level. I didn't quite hear an answer and perhaps this is something that Professor Lawler or Ms Morgan-Wicks would follow up with Ambulance Tasmania.

It does appear that there's a lack of clarity about what paramedics should be doing in terms of the mixing of PPE and non-PPE - we're talking fully gowned PPE. In a Delta outbreak, we won't know if people with respiratory illnesses necessarily have Delta, and we need to be preparing for that in advance.

You said, minister, that there would be restarting of the ARIA with minimal time. What are the circumstances when that would occur ,and how long would it take for it to be restarted if it was needed?

Mr ROCKLIFF - I will seek the advice of Ms Morgan-Wicks and Professor Lawler for that operational question, if you are happy with that?

Dr WOODRUFF - I'm happy with that; yes.

Ms MORGAN-WICKS - The restarting of ARIA would be a clinician-led decision. We would await advice from the head of the emergency department which would factor in. It would be considered in a COVID situation so if there was, for example, community transmission starting, the THS Emergency Operation Centre would consider the configuration of every single emergency department across Tasmania. We would then assess do we maintain the requirements or do we reconfigure. At various levels of our escalation management plan we go to hot and cold emergency department configurations, for example. Our RHH escalation management plan would take the ARIA current configurations into account.