Hawke’s Bay water crisis: lessons learned

September 2016

The Hawke’s Bay water crisis unleashed a severe gastro bug that took its toll on the care homes and retirement villages of Havelock North. JUDE BARBACK talks to three facilities about how they coped and lessons learned from the experience. 

 

Water bug 2The team at Mary Doyle Lifecare Complex in Havelock North didn’t discover that their water was contaminated until they saw news of it on social media on the night of Friday 12 August this year.

It was a similar story at nearby Summerset in the Vines.

“How we found out was someone knocked on the care centre door at 8pm on the Friday night. The afternoon RN hopped on Google and sure enough, we had a challenging situation on our hands,” says nurse manager Jocelyn Pack.

How events unfolded

Hawke’s Bay District Health Board chief executive Dr Kevin Snee says the DHB became aware of a number of cases of gastroenteritis in the Hastings suburb on the Friday.

The nature of disease distribution and the fact that campylobacter was detected in patients suggested the Havelock North suburb’s water supply was the source. The decision was made to chlorinate the Havelock North water supply from two bores, one of which tested positive for E. coli.

By the time news reached the rest homes on the Friday night, some had already drawn their own conclusions that they were dealing with the dreaded norovirus. However, given that the sick residents were dispersed around the rest home and the village, staff at Mary Doyle felt something didn’t quite stack up. It wasn’t until Friday morning that testing revealed it was campylobacter.

“We’d heard earlier in the week other rest homes in the area were grappling with some kind of gastro so we automatically assumed it was norovirus,” says Pack of the situation at Summerset.

While bacterial and viral infections often share the same symptoms – typically diarrhoea, nausea and flu-like symptoms – they are two very different types of pathogen.

Campylobacter is a food-borne illness so is usually spread through water or food. Unlike viruses, bacteria can grow on the food they contaminate. Symptoms for people affected by campylobacter can last up to 10 days, but will usually abate without antibiotics.

By contrast, norovirus is a very contagious virus that can quickly pass from person to person through shared food or utensils, by shaking hands or through other close contact. The virus can survive temperature extremes in water and on surfaces.

Mary Doyle’s infection prevention and control coordinator Jo Miller says that while the campylobacter outbreak was challenging to deal with as it was so widespread, a norovirus outbreak would have been worse.

“Norovirus is an airborne virus, whereas campylobacter is passed by contact and only lives for one to four hours on hard surfaces and fabric.”

On the Saturday morning, aged care facilities went into crisis mode, working hard to control the infection. Being a weekend made things a little tougher – staff came in on their day off; facilities made use of their emergency supplies.

At Mary Doyle, Miller knocked on the door of every one of their 135 villas and reception rang all 89 apartments to let the residents know what was going on and to check if each of the 400 residents was okay and knew to boil their water. 

“Thirty-five per cent hadn’t even heard about it, so it was a useful exercise,” she says.

Some facilities were hit hard by the virus, while others escaped unscathed, including Oceania Healthcare’s Duart Care facility. Nine residents in the care facility and 40 in the village at Summerset were affected, plus a handful of staff.

Mary Doyle had 118 residents (out of 400) and 21 staff (out of 250) affected. A resident who was unwell with campylobacter passed away (although the coroner’s report revealed she had other significant underlying health issues), and two more became seriously ill with the infection. Surprisingly, the village was hit worse than the care facility. Miller is not sure why. She speculates that it may have been because villa residents take their tablets with tap water, while some care residents have them crushed with food or water from the purifier.

As the window for infection is up to 10 days, facilities at the time of writing were still coping with rolling illnesses. As at the end of the first week, some residents were getting better, while some were just beginning to
feel unwell.

By the second week some had relapsed. At this stage the decision was made at Mary Doyle to close the rest home to visitors as they were uncertain what else was in the water that could have been causing illness. As a result they are now testing faecal specimens for everything, including cryptosporidium, giardia and norovirus, in an effort to fully understand the bugs they are battling.

Fortunately, a wave of community support has helped them get through it.

The DHB’s Infection Control team arrived at the facilities on the Saturday afternoon and worked with nurses and staff to isolate people who were showing signs that they were affected.

Summerset kept their village residents informed via a mailbox drop and supplied them with bottled water. The district nurses completed follow-up visits to check on them.

The district nurses were “fantastic” according to Miller, helping to relieve their care staff and working well with the Mary Doyle team.

Mary Doyle manager Diana Triplow says they received great support from the community. A delivery of a pallet of 10-litre containers of water was followed by another delivery from Coca-Cola New Zealand of two pallets of bottled water. The local pharmacy also stepped up to help and delivered boxes of electrolyte ice-blocks. A kindly lady from the community brought in lots of daffodils to brighten everyone up. The New Zealand Aged Care Association was in touch to show its support. Clinical nurse specialist for gerontology Lorraine Price accompanied Miller around the village again.

Challenges

Despite community support, the nature of the illness provided the facilities with myriad challenges. There are all sorts of unexpected complications to deal with, given that the water was affected and couldn’t be used. 

Oceania’s senior clinical and quality manager, Tara Evans, says they had to rethink about how to wash residents.

“One thing that we felt worked at Duart to stop the spread of the bug was we stopped showering residents straight away as soon as we heard and washed them instead. It stopped water and the bug getting through mucous membranes,” she says.

“It’s not just about dealing with diarrhoea,” says Pack. Chlorinated water had to be used for washing clothes, washing dishes and during food prep. Even ensuring boiled water gets to everyone has its challenges. The Summerset facility sourced some giant urns to boil water.

The administrative effort involved with organising these things, as well as communicating with the DHB twice a day to provide information about everyone who is unwell has been huge, says Pack. She is full of praise for their office manager, who has been a great support.

It has also been challenging dealing with residents with cognitive decline. “Some don’t have a good understanding of what’s going on,” says Pack.

Miller says that cognitive decline has contributed to relapse of a few of their residents. “You tell them not to drink the tap water but then they brush their teeth with it, things like that,” she says.

Lessons learned

Clearer communication at the interfaces

While it transpires the DHB only realised on the Friday the full extent of what the region was dealing with, notification earlier that day could have been helpful.

“We would have appreciated better notice of what was going on,” says Pack. She also feels clearer communication from the DHB in general could have helped to keep the population better informed in the event of a public health situation like this. She felt there needed to be a coordinated response from the DHB and Council.

Pack says much of the village’s information about the unfolding crisis was sourced via Google and social media, which is unlikely to be useful for many older people. Radio would have been an effective medium to share updates and advice, she suggests.

“Lots of older people listen to the radio,” she said. “Many struggle with even simple things like boiling water.”

Miller feels the District Council could have been more forthcoming with information as well.

“It would have been nice if the District Council kept us as businesses in the know,” she said. “We did not receive any updates from them apart from what was on the radio, news and social media.”

The delayed notification and lack of updates and information meant the public was unsure of exactly what they were dealing with.

In the early stages, before the water contamination was widely known, doctors were telling affected people to drink lots of water. And some were prescribing Imodium to those affected, which only suppresses the bug and increases the likelihood of relapse cases. 

In terms of lessons learned, Miller thinks it is important to keep in closer communication with affected residents’ GPs.

Miller said she and the district nurses were aware of who was affected as they had daily contact with all their residents, but unless they were really unwell and dehydrated they did not notify the residents’ GPs.

However, after a week they decided that it was important to let the affected residents’ GPs know and to communicate with them about the medications these residents were taking. For example, those on diuretics needed them stopped to prevent getting really dehydrated; those on Warfarin needed International Normalised Ratios (INRs) as these were elevated; diabetics needed closer monitoring; those on laxatives needed to be warned to stop taking them, and so on.

Visitors

Pack says one of the best things they did at Summerset was keeping visitors out of the care centre. A note was placed on the door and staff spoke to visitors at the entrance way. Some were let in on a discretionary basis, but most were encouraged to chat to residents outside their windows of the single-level facility. Summerset also made the decision to operate their village café on a limited basis.

“It’s really important to limit the amount of foot traffic,” she says. “Once visitors are in, there is no controlling where they go within the care centre. It’s definitely helped our cross-infection rates.”

A softer line was taken at Mary Doyle, although they had three areas of lockdown. Miller feels they contained the outbreak well with their approach.

Both Summerset and Mary Doyle have had a lot of unwanted interest from the media as well. Pack says their no-visitor policy has also helped keep the press at bay.

Protocols in place

Mary Doyle, Summerset and Duart all felt they had good protocols in place and experienced staff at the helm, but fear for those that don’t when going through such a crisis.

Facilities typically have procedures in place for dealing with norovirus, but the contaminated water issue threw all manner of complications at them. Pack, who has a postgraduate qualification in infection
control, says she has really had to rely on
her knowledge.

Both Pack and Miller felt it was really important that DHBs and facilities didn’t have a reliance on one particular person, and knew the correct channels to convey important information to each other.

By way of example, Pack says the infection control person who deals with their portfolio was on holiday at the time of the water crisis.

Miller felt the DHB needed to review how they follow emergency plans. All information is listed, but not necessarily followed, she said. There had been some difficulty getting hold of the right person when their main contact was unavailable and this had also been the case in the aftermath of a bad storm a few weeks prior, which caused power outage to the area.

Despite that, Triplow doesn’t think they would or could have done anything differently at Mary Doyle.

“We have such a good team and such good processes in place,” she said. “The main lesson learned is that it is so important to have good, robust systems in place.”

Evans agrees. Last year, Oceania put together an outbreak kit for each of its facilities, including all the standard things needed in a situation like this one. Although they haven’t needed it on this occasion, Evans says the water crisis has been a timely reminder of the importance of having the kits assembled and ready to go.

She says many years ago a rest home would be besieged by an outbreak for as long as two to three weeks, but since the implementation of the kits they have been able to get outbreaks under control within three to four days.

Pack agrees that you can never be too prepared. She points to their civil defence supplies, which have come in handy.

“This is an area that some facilities might scrimp on, but it is so important to have water and a good amount of PPE [personal protective equipment] in stock.”

Training and education

Events like this always highlight the need for ongoing education and training for the workforce in the area of infection prevention and control.

“We’ve stressed things like the importance of being vigilant with hand hygiene, the importance of filling in fluid charts, of placing PPE on the tables directly outside the rooms,” says Pack. She says it comes down to simple things like not wearing long sleeves, which can easily pick up bacteria.

Evans says the outbreak has highlighted the importance of having a robust infection control policy in place. At Oceania workers must undergo infection control training as part of their yearly competency assessment. It is also covered in their annual study day.

“We use glow-germ lights to really drive home the importance of good hygiene. It makes it real for staff.”

The facilities all agree that, following an event like this, it is important to review systems and to evaluate how they coped and to discuss any changes to be made to their procedures.

In this case, the facilities of Havelock North all coped admirably, considering the suddenness and severity of the bug. The event serves as a timely reminder to care facilities throughout New Zealand to have their training up to date and their procedures clearly in place – just in case.

As Pack says, “This could happen anywhere.”

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