Characteristics and Preparedness for COVID-19 Outbreaks of Australian Residential Aged Care Facilities: a Cross-sectional Survey

Objective. To provi de an overvi ew of Au s t ralian re siden tial a g ed care fac iliti e s’ (RA C F s’) CO VI D -1 9 outbr eak prep ared ne s s and r es pon s e s, 1 2 months a f t e r t he pand emi c beg an in ea rly 2 020. Methods. A c r o s s- sec ti onal su rvey of RA C F ma n ager s wa s cond uc ted a s par t of an ove r v iew o f CO VI D -19 ex pe rienc e du r i ng 2020. Surve y ques t i on s were b as ed on find ings o f prev ious ou tbr eak revie ws .

. Comp a r i s on w ith av ailabl e da ta from the Au stra lian In sti tut e f or He alth and Wel fare sugge st ed t ha t su r v ey r e s ponde nts ( n = 331) w ere a repr e sen tat ive sampl e. Al most all RA CF s ha d outbr eak ma nag em ent pl an s, i ncludi ng provision f or a surge wo r k fo r c e . Howev e r , a nt i cipa ted sta f f replac em ent s f el l sh ort o f tho se of ten r e quir ed dur i ng outb r ea k s. S t a f f o f most (83%) RA CF s ha d co mpleted onli n e in fec t io n c ontr ol tr a ini ng, and a small e r propo rtio n (73% ) f a ce - to- fac e trai ning, by the time of the survey. Explor ato ry a nalys e s to iden ti fy RA CF c ha rac te r i sti cs a s s oc ia ted w ith inc r e a s e d outbre ak ri sk f ound a strong a s s o cia tion with loc a tion in Vic t or i a (adju st ed ri s k r a t i o [aRR ] 12.8 ) wher e mo st communi t y t ran s mi s s i on occ urr ed d ur i ng 2020 . The o nly othe r assoc ia tion wa s a n inc r e a s e d ri sk in fac iliti e s w here all s t a f f ha d no t com plet ed fac e- to -f ac e in fecti on c ontr ol trainin g (aRR 2 . 1). Re spond ent s r a nked l eade r shi p and manage men t; pl ann ing an d pr epa r ation; an d in fec t i o n co nt rol a s the to p thre e o f s even critica l lines o f de f e nce a gain st CO VI D-19. Conc lusion . S ur v ey resul t s sugge s t tha t, in early 2021, mos t Au s tr alia n R A C F s w e re be tte r p repa r e d for t he on going ri sk o f CO VI D-19 t h a n i n 2020. Conti nue d im plemen tati on o f t he Aged C are Royal Commis sio n’ s r ec ommenda tion s is ne e ded t o en s ure th e ag ed ca re s ector i s prepar ed fo r futu r e i n f e ct io us d is eas e e m e r g en ci es . Key words: C O VI D-19, re siden tial ag ed care f ac ilitie s , in fe ction c on tr ol , dis ea se o utbre ak . CC-BY-NC-ND 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted February 7, 2022. ; https://doi.org/10.1101/2022.02.05.22270416doi: medRxiv preprint INTR O DUC TIO N Bas ed on ex peri ence in China and Ital y in early 2020, ( 1 , 2) i t wa s a ppar ent that ol de r pe ople , partic ula rly tho se in r e s id en tial c are , wo uld be most se ver ely a f fect ed by C OVI D -19. The i nd ex c as e of the fi r s t outb reak i n an Au s tr a lia n r e si dential a ged c ar e faci lity (RA CF ) wa s di a gnosed on March 3 2020 in a nur sing a ssi stan t a t D oro thy H ender so n Lodg e, on Sy dney’ s North S ho re .(3 ) Two r e siden t s had been a dmitte d t o ho spita l s everal d a ys be for e w ith s e r i o us i ll ne s s e s t hat w e r e later di ag no s e d a s CO VI D -19 . Th e tot al numbe r o f c a se s i n tha t out bre ak w as li mi t e d to five sta ff m ember s a nd 1 7 re siden t s ( of who m six died ) by t h e dec isive action s o f f aci lity ma n agem en t and public h ea lt h authori tie s , inc luding r a pid imple menta ti on of s t ric t inf ectio n prev enti on and con trol (I P C) mea s ur e s and t ran s fe r of in fec ted r e s i den t s to ho spital . (4) Anoth er o utbr eak, a t New march H ou se i n out er we s t ern Syd ney in April 2020, in v olved 34 sta ff a nd 37 resi dent s , of w hom 19 di ed . Mo st in fe cted r e sid ent s we re manage d in the fa cili t y , by the ho s p ita l- in-th e -home t eam fr o m th e loca l h os pi tal. How ev er, a l a r g e pr opor tion o f sta ff, wh o w er e c lo se co nt a ct s o f c a s es, had t o b e qua ranti n ed and fi nding s ui tab le repl a ceme n t s w as di ffic ul t. Many re siden t s w ho r e main ed uni nfe ct ed su ff e r ed se riou s adver s e e ff ect s from is olati on, i mmobility a nd i n ad e q u at e ca r e. D ela y ed i m p le m e nt at ion of eff ect i v e I PC m ea su r e s a nd t he con t i n u e d p re se n ce of infec t ed re si dent s i n the home con tribu t ed to ong oing spr ead o f i nf ection .(5 ) During the firs t wav e o f C O VI D-19 ( Ma rc h-Jun e, 2020 ) in A ustrali a t h e re w er e m or e th an 60 R ACF outbr eak s – d e fined a s o ne or m ore ca se s in a sta f f member , re sid ent or fr equen t vi s itor . Apa rt from the two maj or Sy dney ou tbre ak s a n d o ne in Melbou rne in Ju ne (45 st af f a nd 3 7 res i d ent s, wi t h 15 dea t h s ), the se outb r e ak s invol ved few e r than fi ve ca s e s .(6 ) Howev er , when t he sec on d wav e bega n in Vict oria, in June 2 020, the si tua tion r a pidly cha ng ed. Of 226 ou tbr eak s d u r in g thi s p er i od , 5 0 ac counted f or the maj or i t y o f inf ec t i on s among re sid ent s , r ang ing f r om 10 to 102 cas e s. By m id- Se pt e mb er 20 20, approxima te ly 2050 r esid ent s had b een in fe c ted and 655 ha d died. In ad ditio n , around 220 0 RA CF st af f ha d be en in fec ted, r a nging from eigh t to 131 ac r o s s o utbre ak s, but many more w ere furlo ughed and r epla cem en t st af f we re of t e n po orly qu alif ied and in e x perienc ed . During 20 20 and early 2021, th e C ommonwe alth De par tment o f Hea lth (D oH) c ommi ssione d tw o o f the a utho r s ( G L G and AL ) to und e r tak e r evie ws o f fou r major R ACF out bre ak s (4, 5 , 7) a nd o f CO VI D- 19 outbre aks in Au stra lian R ACF s, g en e rally .(8 ) The ai m o f th ese revie w s w a s to id en tify l e sson s lea r n t from failu re s of ou tbre ak con trol in a mino rity of RA CF s a n d key fa c tors t hat con tribu ted t o preve nt i on o r ra pid c on tr o l o f o utbre a ks in oth er s . The indiv idual RA CF ou tbr eak r eview s (5, 7) , iden t i fi ed seve n lin e s o f d ef enc e t hat were cri tica l to s uc ce s sful ou tbre ak c o ntr ol but lack ing, to va r y ing deg r e e s, in tho se whe re ma jor COVI D-19 out break s occ urr e d. Th es e cri tica l de fe nc e s w er e : . CC-BY-NC-ND 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted February 7, 2022. ; https://doi.org/10.1101/2022.02.05.22270416doi: medRxiv preprint lea der s h ip a nd man ag emen t; e f fec t i ve c o mmunica t i on; pl anni ng and p rep a r a tio n ; inf ection c on tr o l ; patholo gy t es ting; w or k for c e ; em er g ency mana gement . AIMS AN D OBJECT IVES T h i s o n l i n e s u r v e y w a s p a r t o f t h e n a t i o n a l r e v i e w o f C O V I D - 1 9 o u t b r e a k s i n R A C F s . I t s a i m w a s t o provide a broad ove r v iew of th e prepa r edne ss for, a nd expe r i enc e of C OV ID - 1 9 outbr e ak s in RACF s from the pe r spectiv e o f se nior f a cili t y ma nager s. I t comp lem ent ed the f i ndi ngs o f int ervie w s a n d work s hop s wi t h key s tak eholde r s tha t co ntribu ted t o the rev iew .

Par ticpants and rec rui tment Par tic pant s wer e seni or ma n ager s or direc to rs o f nu rsing o f Au s tr alia n RA C Fs. The s ur v ey w a s initia lly a dver ti sed in th e Do H’ s new sle tt er to age d ca r e p r ov ider s. An invi ta t i on t o particip a te , with a link to the onli n e s urv ey, w a s emaile d on Februa r y 23, w it h a r eminde r on M a r c h 5 20 21, to the DoH Bulk Info rmation Di s tri bution S y ste ms (B IDS ) mai ling li s t , to wh ich repr e sen tative s (man a ger s/s enio r sta f f ) o f mo st indiv idual RA CF s s ub scri b e. Th e survey w a s ope n from March 2 to 17 20 21 . Su rvey que stion s wer e a cc e ssible only t o rec ipi e nts who agr eed to pa rtic ipa te. Survey design. The study w a s a c ro ss - s ec tional su rvey a dminis t e re d u s ing Qual itric s survey so f tware . The re s earc h t e a m a n d a c o n v e n i e n c e s a m p l e o f v o l u n t e e r s p i l o t - t e s t e d t h e i n s t r u m e n t t o a s s e s s t h e t i m e t a k e n to com ple te it and the c la rity a nd s equ e nce o f qu e stion s. The su rvey was de sign ed t o be comple te d in 1 0-15 minute s . The landi ng pag e o f th e su rvey incl uded a par t i cipa n t i nfo r ma ti on sh eet . Measures. Surve y que st ion s w e re b a sed on findin g s of prev iou s rev iew s by GLG and AL (4 , 5, 7) and re fined i n co llabora tion w ith au tho r KMcC . Th e su rvey instrumen t c onta ined q u e s ti on s rela ting to ch aracte ri st i c s o f r e sponde nt s an d th e RA CF s th ey repr e sen ted and a sp ec t s of the fac ili tie s ’ prepar edne ss for futu re C O VI D-19 ou t break s . R espo nden t s who indic at ed th at th ei r f acil ity ha d ex perienc e d a COVI D -19 outb reak d u r in g 2020 we r e a s ke d a s hor t s e t o f addi ti ona l que s t i on s . The full survey ins tr ume nt i s a vail abl e i n Sup ple ment ary Mat erial s. Statist ic al analyses . De scrip tive an al yse s (fr eque n cy and re la tive f r eque ncy ; media n s and i nt e r qu a r tile ra nge s [I QR ] ) we r e u sed to e xamin e cha ra cte ri s tic s of re sp onden t s and th e fac ilit ie s the y repr es ent ed a nd outco me s o f COV ID -19 outb reak s. . CC-BY-NC-ND 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted February 7, 2022. ; https://doi.org/10.1101/2022.02.05.22270416doi: medRxiv preprint Ex ploratory a naly se s w ere co nducted to identi fy poten tial organ i sation a l fac t or s a ssoci a te d w ith RACF s th at e xperienc ed at l ea st on e C OVI D-19 ca se. Nin e ex plora tor y varia bl e s we r e in clude d i n a gen erali s ed linea r model (mod i fied Poi s s on ap p r oa ch, wi t h a lo g -link func t i on a nd r o bu s t s tan d ard erro r s ) to e stima te r e la tive ri sk s an d c o r re spondi ng 9 5% confid enc e inte rva l s . Sub-g r ou p a naly se s we r e c onduc t e d f o r R ACF s l oca te d in Vi ctoria onl y, and re pea t e d u s i ng a mor e r e stric ted de fini t i o n of an ou tbr e ak (i. e . five or mor e r e s ide nt and/or sta ff c a s e s). Stati s tica l an aly ses were c o nducte d u sin g Stata /I C v1 6.1 (Sta ta Corp , C olleg e S ta t ion, TX, USA ). A p- va lue of l e ss th an ( <) 0 .05 w a s se t a s the thre sho ld fo r s t a t i stic al signific a nc e. Ethic s . This survey was ap prov ed by t he Commo nwe alth D oH a s par t of the r evie w of C O VI D-19 ou tbr eak s in Aus tr a li an RACF s . The r evi ew w as wid el y publ icise d in t h e age d ca r e s ec tor and poten tial partic ipan t s were as su r e d that a ny infor mation provid e d woul d contribu te to th e f i ndings of ou r revie w but not a ttribu table to any indivi dual w ithout expr e s s permi ssion . By co mpleting and retu rning the survey , p artici p ant s c on sen ted to the s e co ndition s. The ful l review r eport wa s publi s h ed on th e D O H w eb site and on Nov ember 1 2 021 an d is public ly a vail abl e. (8) The s urve y wa s re fe rred to onl y brie fly in the rev iew repo rt (8) bu t de t a ile d fin din gs were n o t inc luded. Thi s repo rt f u lfil s ou r commit men t t o s urvey pa rtici pan t s tha t th e find ings w ould be made av ailab le to them a nd the ag ed ca r e s e c t or , gene ral ly. The s urve y wa s a quali t y as s u ranc e and e val uation pr ojec t whic h co mplied w ith cr iteria out l in ed in the NH M R C Et hica l Con sid era tion s in Qu ality A s s urance a nd Ev alua t io n Activi t ie s (s ection 2 , p2- 4).(9 ). Da ta coll ect ed w ere co incid e nta l t o RACF st andar d op era t i ng proc e dure s (r outine organi s ati ona l in forma tion and CO VI D -1 9 r e s p on se situ ation a l f actor s ) . Only sel f - r e ported da ta we re ana lys ed, f or th e purpo s e of id e nti fying a rea s f or improvemen t i n RA CF out bre ak prepar edne s s, and not lin ked t o a ny sp eci f i c ind ividua l or or ganisa tion; the pri vac y and profe s si onal re puta tion s o f provide rs w ere maintai n ed. (9)p .4 DoH o ffic ial s ha d no par t in t h e de sign, a na lys is or re por t in g of the survey, but agree d t o public a tion o f t he re sul ts. The U n iversi ty of Sy dney H uma n R e sear ch Ethics C ommitt ee a ppr oved th e pr oj e ct, re tro s pe c tivel y, on Jan ua ry 13, 2022 (projec t no . 202 1/ 79 9). RESUL TS Responses. Surve y resp on se s we r e inc lud ed in the analy s i s if a) a t lea st 75% of the survey que stion s w ere co mpleted ; b) t he R ACF s r epr e s e n t e d h a d m or e t han fiv e reg i s t ere d pla ce s; a n d c) t he r e w er e n o . CC-BY-NC-ND 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted February 7, 2022. ; https://doi.org/10.1101/2022.02.05.22270416doi: medRxiv preprint log ical i ncon si s te nc ie s indic a tive o f pot e ntially unre liabl e r e spon se s (e .g. the nu mbe r o f r egi ste r e d pla ce s in th e fac ility exc e eded 40 0 or t he number o f r epor ted re sid ent ca se s or d eath s exc eede d t h e numbe r o f regi st ered plac e s in t h e facil i ty). Of 685 r e spo ns e s rec eiv ed, 354 w ere exc luded, le aving 331 vali d res po n se s fo r anal y s i s . We c ould no t de termin e a ccu r a t e ly h ow many of the 2,722 RA CF s i n A us tr al i a , as o f 3 0 J u ne 2019 ,(10) w e re repr e sen ted am ong su bscrib er s to t he D oH BI D S . As s umi ng t hat t he numb e r of sur v ey s di s t ribu ted t o e ligibl e r e s po nd en ts wa s a pp r o ximatel y 2500, t h e ra t e o f v alid re sp on se s w a s ~13 %. The jurisdi ctiona l di s t ributio n o f valid re s pons e s wa s: New S ou th Wale s 108 (3 3%) ; Vic t o r ia 92 (28% ) ; Qu een slan d 5 9 (18%); W e s t ern Au s t ra li a 33 ( 1 0%); S outh Au s t ralia 24 (7% ); Tasmani a 6 (2% ) ; Aus t ral i an Ca pi t a l Te rrit ory 6 (2% ); N o rth ern Te r ri tory 3 (1%) . Charac te ri stics of re s ponde nts and RACF s represented. Char ac te r i stic s o f re spon den ts ( N = 331 ) i nc luded i n th e a nal ysi s, and t he RAC Fs th ey r e p r e sen ted , a re shown in Ta ble 1 . Mo s t r e s po nd ent s (8 0%) w er e f a cili t y ma nage rs an d/o r direc tors o f n ursing an d 74% h eld a nur s ing q uali fic ati on; the R A C F s they rep re sen ted had be twe en s ix a nd 330 regi s tere d pla ce s. The me dia n numbe r o f regi s ter e d plac es , the ir Sta te / T er r ito ry lo cation s and the pr opor tion s of RA CF s w ith v ariou s ty pe s o f funding arrange m ent s we re c ons i sten t with tho s e r ec or d e d b y t he Aus t ral i an In s titu t e o f Heal th an d We l far e (A IHW ) GEN Ag ed Ca re Dat a (2020 ) - S er v ic e s a nd P la c es in Aged C are, 30 Ju n e 2019 . (10) Tab le 2 summa ris e s re s pon se s to que s t i o ns rel a ting to A) inf ormati on p r ov ided by of ficia l s our c e s; B ) IP C trai ni ng and C ) O M P s inc luding D ) p rov is i on for a surge w or k for c e. The hig he s t l ev el s o f s a t is fac t i on w e re w ith in foma tion p rovided by S ta t e/Ter rito ry H ea l th Depa rtmen t s an d P ubli c H e a lth unit s, a nd the low e st with t ha t from the Age d Ca re Q uali t y a nd Sa fe t y Commi s sion ( AC Q S C) . Mos t ( 8 3%) r e spond ent s re ported t ha t vi rtually all sta f f (>90% ) in thei r fac ili tie s h ad compl ete d onli ne I PC traini ng . F ace- to -f ac e t r a ining had bee n compl e ted by all sta f f in a s m a l ler prop ort i on (73% ) of faci liti e s. The survey did no t a s k when IP C tr a ining had oc curr ed. All but tw o (n=3 29) r e spond ent s i ndica t e d tha t thei r fac ilti e s had O MP s , of whi ch 81% had bee n dev eloped b ef ore July 31 2020, 73% h ad been pra ctice d a t l ea s t once an d, of tho s e, 95 % ha d m o d i f i e d t h e m a s a r e s u l t . T h e r e w a s a h i g h l e v e l o f c o n f i d e n ce t h a t O M P s w e r e f i t f o r p u r p o s e . 3 0 0 (91% ) f acil itie s had c on t i ngenc y pla n s for a n int ernal su rge w or k f or c e, but the anti cipa ted p ropo rt i o n of staf f r ep lac e ment s cha nged over tim e. B ef or e July 31 202 0, 18 % o f r es pon dent s h ad pla ns to . CC-BY-NC-ND 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted February 7, 2022. ; https://doi.org/10.1101/2022.02.05.22270416doi: medRxiv preprint replac e 50% or more st af f; t hi s pr opor ti on increa s ed to 28% aft er Jul y 31 2020 . Fewe r tha n ha lf o f the re sp onden t s indic at ed th at int ern al surge worker s had r ec eive d s pe ci fic tra ini ng. What counts mos t in defence against CO VID-19 outbreak s? Res ponde nt s we re a sked to rank t he se v en critic al ‘lin e s o f d ef enc e’ , ide n t i fi ed i n previou s revie w s, in orde r o f imp o r ta nc e from one (mo st ) t o s ev en (l ea st ). The r e sult s are s how n i n F igure 1 . De fen ce s ranke d m ost highly b y t he g r e ate st pro port i on s o f re s pon d ent s we re lea d er s hi p a nd ma nage ment (32% ), planni ng and p r e pa ra tion (28% ) a nd in f e ct ion c ont r ol (25%) . COV I D-19 outbrea k s . Of 33 1 fa cili t i e s r epr e sent ed in t h e survey , 32 (10%) had ex peri enc ed ou tbre ak s, o f w hich 19 (6% ) inv olved five or more c as e s ( sugge s ting SARS- Co V -2 t ran s m i s si on within the R ACF ). Twenty s eve n (84% ) ou t bre a ks w ere in Vic toria , th ree (9% ) i n New Sou th Wal e s and one ea ch in Qu een sl and an d Tasman ia . So me ou tcome s a nd e f fec ts o f the se ou tbre ak s are s umma r i s ed i n Tabl e 3. The r e w ere wi de varia t i on s but, ov er all, re siden t and sta ff ca s e numbe rs w er e si milar and the re w a s a po s i t i ve c orre lati on be tween th em, w ithin i ndividu al R ACF s (Sp earman ’ s /g2025 /g3404 0.82, p /g3407 0.001 ). The r e wa s al so w ide va r i a tion in th e num ber s of r e s ide n t dea th s. Mos t fa cili tie s we r e abl e to mai nt a in an ade qua te work forc e f or a t lea s t 6 0% of the time during t h e outbr eak , but a s ig ni fica nt minori ty coul d not. Some st af f ab sen te ei sm was due to c oncern for th ei r hea lth a nd w ell-b ein g. Tim ely a cce ss to a deq uat e P PE was pr oblema t ic fo r so me R ACF s. Ele ctronic r e siden t c ar e reco rd s were us ed, w ith o r withou t ad di tional p a per -ba se d r e co rd s, by mo s t fac iliti e s; d ocume nta tion o f resi den t c ar e wa s main tai ned f or mo s t o f the time d ur i ng out bre aks . A majo r ity of r es i d en ts (59% ) did no t w ear any form o f iden t i fi ca tion, suc h a s a w r i st band. A d d it i o nal o ut b r e ak f ind i ngs : 26 (81% ) RACF s e ngage d ex tr a st a f f t o r educ e resid en ts ’ lon eline ss during outbr eak s; 24 (75%) moni tor ed r e siden t s’ daily fo od and flui d intak e ; 2 2 (69% ) und ertook struc t u red ou t b rea k revi ew s and , of t hes e, 18 (82% ) provid ed a rep ort to t h e orga ni satio na l ex ecutiv e and 16 (73% ) to t h e Board . Ex plora tory analyses of org anisa tional fac tors as s oc iated with COVI D-19 outbre a ks . Ex ploratory analy s e s wer e condu cte d f or 328 fac iliti e s f o r whi ch dat a on all n ine of th e fol l owing va r i able s w ere a vail a ble: S ta te / T erritory ( Victori a/ o the r ); loc a t i on (non -met r o poli tan / metrop olitan ); o r g ani sati onal owne r sh ip (fo r pro f i t/ no t- for -p r ofi t) ; orga nis a t i onal s tr uc tu r e (s t a nd alone / gr oup) ; OMP de velop e d ( n o ne/ l at e/ ea r ly ); O M P te ste d (no n e or not te ste d/ t e sted ); regis te red plac e s ( > 75/ <7 5); s ha red ro o ms or bat hr o om s (bo th / eith er / none ); s taf f comple t e d on - . CC-BY-NC-ND 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted February 7, 2022. ; https://doi.org/10.1101/2022.02.05.22270416doi: medRxiv preprint l i n e t r ai n i n g ( 9 0 %) ; s t a ff co m p l ete d f a ce- to -f a ce t r a i n in g (9 0 % ). R es u lts a r e s h o w n in S u pp l e m e nt a r y T a b l e 1 . RACF s i n Vic toria we re at mu ch higher risk of out bre ak s (a djus t e d r elativ e ri s k [a RR] 2.08 ; 95% co nfidenc e in te r v al [C I ] 4.74 -30.7 5 ; p< . 001 ) . A f ter a djusting for all o ther v aria ble s, th e only oth er organi s ati ona l fac tor a ssoci a ted with an inc r ea sed outb reak r i sk wa s l e ss t han 90% of s ta ff having co mpleted IP C trai ning ( aRR: 2 .10; 95% C I: 1 . 17- 3 .79; p= .013) . The r e sult s wer e simila r f or a sub - group ana ly si s o f the 91 RAC Fs loca te d i n Vict oria tha t provid ed c omple te d ata , of wh ich 27 (30% ) ex perienc e d outbr eak s. Aga in , the only sig nific ant a ssoc ia tion w ith an ou tbre ak was le s s t h a n 90% of sta f f having comp let ed fac e- to - f a ce I P C t r a ining (a R R: 2.20; 9 5%C I: 1 .15 -4.19 ; p =. 017). The explo r a t ory analy s i s wa s r epe ated u sing a more re strict ed C OVI D -19 ou tbr ea k defini tion, namely five o r more r es iden t a nd / or s ta f f ca se s. The re sult s ar e show n in Suppl emen tary Tabl e 2. They should be i n t e r p re ted w ith ca ut i on s i nce the outbr ea k defini tion wa s arbit rary, th e numbe r of l arge r outbr eak s (th e outcom e of in ter e st) wa s small (n =19) and the timing o f outb re ak s rel ativ e to s ta f f training u nkn own . In t hi s subgr oup t he ris k wa s high er for Vict oria RAC Fs (a RR: 35.95; 9 5%CI : 4.2 5 , 304. 11; p=.001 ) , b ut l e ss for f ac iliti es ou tsid e, th an fo r t h o s e w ithi n, metr opoli ta n area s (a RR: 0.0 5 ; 95% CI: 0 .01, 0 .32 ; p= .002 ). The as soc iati on be t w een outbr eak s an d < 90% o f st af f having compl e t e d fac e -to -fa ce traini n g faile d to r each sta ti s tical s ig ni fica nce ( a RR : 2.58, 95%CI : 1.00, 6. 67; p=.0 51 ).

T h i s s u r v e y p r o v i d e d u s e f u l i n s i g h t s i n t o s o m e c h a r a c t e r i s t i c s o f A u s t r a l i a n R A C F s r e l e v a n t t o t h e i r ex perienc e with C OVI D-19 in 20 20. Ba se d on compa r i s on w ith th e mo st r e cen t data a vaila bl e fro m the A IHW, (10) the RA CF s sur v eyed we re a r epr es ent ative s a mpl e, with re spe ct t o juri sdicti ona l dist r i buti on; me tropo litan /non -me trop olitan loc a tion; num b er o f regi st e red pla ce s; a nd organi s ati ona l type . From ea r ly 2020, w hen th e SARS -C oV -2 pande mic beg an, R ACF s wer e iden tifi e d a s po ten tia lly hig h risk se tting s a nd age d care prov ide r s w e re pr ovided wit h in forma tion a nd guid e li nes abou t outb reak preve nt i on, p lan ning and ma nag eme nt from v ario us s ource s, i ncludi ng Commo nwe alth a n d S ta te hea lth dep artm ent s a nd th e A C Q S C. (11 ) A s in te rnati ona l and l oc al e xperienc e wi th R ACF ou t b r e a ks inc r e a s e d , (4 , 12 - 1 4) a dvic e w a s mod i fi ed. H o weve r, the fre quency o f c hange and inc onsi stenc i e s betwe e n s o ur c e s cau sed c on fu s ion a nd f rustra tion amon g RA CF ma na ger s. ( 5 , 7) This wa s con f i r m e d by survey re spo nden ts , some o f who m repor ted di s s a t i s f ac t i on with the qu ality and / or d eliv ery o f i n f o r m at i o n. R e s p o nd ent s w e r e m os t s a t is f i ed wi t h m a te r i a l f r o m St a te H e alt h D e par t m ent s a n d/ o r publi c hea lth uni t s, whic h may refl ect m o r e s pec i fic , up- to -da te know ledg e o f loc al RACF condi tion s . . CC-BY-NC-ND 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted February 7, 2022. ; https://doi.org/10.1101/2022.02.05.22270416doi: medRxiv preprint Inte rim int ern ation a l an d loc al I PC g uide line s f or RA CFs wer e al so i s s ue d ea rly in 20 20 and upda t e d periodi call y. (15 -17) Onlin e tra ini ng was provide d by Common weal th a nd most S tat e a utho r i t i e s an d RACF m anage rs we re ur g ed t o en sure th at all s ta f f c ompl ete d it . An onli ne s elf -a s s e ssmen t su r v ey by the A C Q S C in March 2020 , fo und t ha t v irt ua lly al l aged c are pr ovider s believ e d t heir or g ani sa tion s’ IP C prepa rati on s were a pp r op r ia t e . H ow ever, th e Roya l Commi ss i o n i nto Ag e d C are (R CA C) Qu ali t y and Safe t y ’ s s p e cial repo rt ‘Ag ed Car e and COVI D-19 ’ in Octobe r 2020, noted that many RACF s lac ked ade qu at e I PC e xperti se , a c ul ture of comp li anc e a nd ba s ic I PC ed ucati o n and tra ining. ( 1 8) Ev en prov ider s who r e cogni sed th e im po r tanc e o f I PC , admi tte d to having u nde r-e stima ted t h e enormou s impa ct o f C O V ID -19, i ncludi ng the quan t i tie s o f P PE t h a t had to be pu r ch ase d, stor ed a nd dispo s ed o f a ft er u s e , and the inc r e a se d workloa d and di sc om fort for staf f u sing i t .(19 ) By con tra s t, ag ed ca r e s ec t o rs in c o untr i e s that had e xperienc e d ou tbr eak s o f SA RS (2003) a nd/or MERS (201 5) , inc luding Hong Kon g, S ingapore, Taiw a n a nd So ut h Kor ea, had d e velop ed ro bust IP C mea s u re s befo re th e pand emic beg an, and s uc ce s sful ly li mited th e burd en o f COVI D -19. (12- 14 , 20-23) The ma jority of r e s pond e nt s repo rte d th at virtu ally a ll sta ff (>90 %) in thei r facil it i e s ha d compl e t e d onli ne (83% of r e spond e nts ) and /o r f ace -to - fac e (73% o f r e sp onde n ts) tr a ini ng. How ever, t he survey did not a s k whe n tra ining h ad oc curre d. Bas ed on r e po rts f r om pa rticipa n ts in p rev ious review s , (5, 7) and the nati on al rev iew, (8) s t af f of m any RA C F s had had li mited, i f any, COVI D-19 - speci fic I P C training by mid-2020; mo st tr ainin g occ u r red during or af ter th e Vic to r ia n sec o nd wav e. Ba s e d on recom menda tion s by the R CA C, mea s ur es have b e en in troduce d na tio nally , to i mprove IP C tr aining and prac tice ; a ll RAC Fs a re now requir e d to appoi nt a nurs e, w ho ha s comple t e d an approve d I P C co ur s e, as I PC l ea d . H ow eve r, d etai l s of their re s po n s i bil iti es, o ngoing s uppor t a nd furthe r t raining are a t t he di scr etion of pr ovi der s . Mos t R ACF s had a n OM P whic h t he y h a d te s t e d a nd modi fied be for e J uly 31 2 0 20. The survey di d not a sk for d etail s b ut m o st re sp onde nts rep orte d bei ng co nfid ent tha t th ei r OM P w a s fi t f or purpo se . O MP s gen er a lly i nclude d pla ns t o deploy a n int ernal surge work forc e , if required , but only a minority of r e s pon de n t s a n t i cipa ted a ne ed to repl ace 50% or more of t h e ir sta ff dur i ng a n outbr eak . Th e RC AC, in thei r final rep or t,(24 ) ob s erved - a s h ad o the rs , p r e viou sly (25) - tha t many Aus t ral i an RA CFs w er e c hronica lly un der sta f fed, eve n for bu s in e ss -a s-u sual . When C OV ID-1 9 outbr eak s occ ur r ed ma ny provide r s ha d to rely o n ex te r na l re so urce s t o repl a ce f urloughe d st af f , and a sig nifica n t p r opo rtion o f r e spo ndent s r ep o r t ed b e ing un ab le to mai ntain a n a dequa t e work f o r c e . Lo cal c ommunity tran smi s s ion i s th e strong est pr edic to r o f C O VI D-19 b eing i ntr oduc ed int o a R ACF , oft en by an a symptomatic ally -in fect ed s t a f f mem be r. ( 2 6) I t was t h ere fo r e no t s urp ri sing tha t t he . CC-BY-NC-ND 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted February 7, 2022. ; https://doi.org/10.1101/2022.02.05.22270416doi: medRxiv preprint majo r ity of ou tbre ak s rep orte d by s u rv ey re sponde n ts w e re in Vic toria wher e mo s t communi t y tran s m i ssion oc curr ed in 202 0. In the su bgroup an al ysi s o f Vic to r ia n RA CF s, outb r e ak risk wa s low e r in no n-me tr opo li tan t han me tropoli t a n f aci litie s. The onl y oth er signific an t findi n g of the exp lora tor y ana lys e s , w a s an incre a s ed ou t br ea k ri sk i n f a cil it i e s w he re no t all sta ff ha d co mple t e d f a ce - to- fac e IP C t r a ining. This ma y re fle c t pr e- ex isti ng IP C s t an dard s and sta ffing rati os ( e speci a lly regi ste r e d nurse h our s) , sinc e de nov o f a ce -to - fac e I PC t raining i n the cont ex t o f a pa nd emic is pa rt i cula rly ch alleng ing. La r g e surve ys of nur s i ng hom e s and l on g-te rm care f ac ilitie s ( L TCF s) over se a s h a ve fou nd th at t he seve rity o f COVI D -19 ou tbr eaks corr ela t es w ith, among o ther t h ing s, f ac ility size , r eg iste red n ur s e hour s, s har ed ac como dati on, implem en tatio n of rec ommende d I P C p r ec au tion s and organis ation a l funding . (27-30 ) Our ex plora tory ana lys e s di d no t i d enti fy a s s oc a tion s o f outb r e a ks with f ac ility siz e , organi s ati ona l funding or s h a r e d room s. Howev er, t hi s p robably re f l ect s th e re l a t iv ely small su rvey siz e and une ven out bre ak di st ri bution , s i n ce a study o f all 77 4 nur s i ng home s in Vi ctoria, in t h e lat te r hal f o f 20 20, f ound that la r g e r Victori an outb reak s w e re as s ocia ted wi t h m e tropoli tan l oca t io n, large r fa cili t y s i z e, s ha red room s, a nd pri vate owner ship .(31 ) CON CL U S ION Of th e s even critica l RA CF line s o f de fe nce id enti fied in pr evi ous rev iews , r esp onden t s ranke d lea der s h ip an d manag ement , pl annin g and p repa rati on a nd in fec tion co ntrol mo s t h ighly . Ex perienc e with CO VI D -19 outb reak s in a ged care sugg e s t s tha t the se ar e th e mo s t import ant fac tor s that d et ermine an organi sation ’ s re s i li e nc e. O u r fin dings s ug ge s t th at, by the ti me thi s survey w a s co nducted in early 202 1, mo s t Au s t rali an RAC F man ager s (and , by in f e r e nc e, age d c are p rovider s gen erally) had recog ni sed the impor tan c e of the s e facto r s and we r e b et ter prep are d f or po ssibl e CO VI D -19 outb r e ak s . Howev er , th er e i s an o ngoing chal l enge t o en s ure t ha t t h e long st anding defic ie nc ie s o f quali t y and s af ety i n aged care, i de nti fied by th e R CA C and furthe r ex pose d by CO VI D - 19, continue t o be add re s sed a nd i mprov ement s s u st aine d in to th e fu ture . STRE NGTHS AND LIMIT ATION S This sur v ey ac hiev ed i t s go al o f providin g a wide p erspec t i ve of the p repa redn e s s a nd re s pon se s o f RACF s a c ro ss S t a t e s a nd T er r ito rie s a n d metrop oli t a n, r egion al a nd remo te a rea s. Re spon s es t o some que stion s r a i s e d ad di tional i s s ue s t ha t we r e c ove red in mo r e det ai l by i n-de p th i nte rvi ew s during RACF o utbr eak r e view s , w ith smal ler s ample s o f a ged -c are stak ehol de rs . The s urve y w a s limi ted i n s c op e a nd det ail a s we w er e aw are of th e eno r mous stre s s t hat partic ipan t s ha d endu red du ring th e pr e v ious yea r, and f rom w hich th ey were s til l r e cov er i ng whe n . CC-BY-NC-ND 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted February 7, 2022. ; https://doi.org/10.1101/2022.02.05.22270416doi: medRxiv preprint the su rvey w as condu ct ed. Th e ini tial re s pons e from an e s timat ed ~2 500 sur v ey i nvitation rec ipi ent s wa s p le a sing. W e surmi se tha t th e signifi c ant prop ort ion o f r es ponde nt s did n ot c omplete the s urvey refl ec ts ot her , more p re ss ing, c ommitme nts . Practic e/Poli cy I mpact Statement W h e n t h e C O V I D - 1 9 p a n d e m i c b e g a n m a n y A u s t r a l i a n R A C F s w e r e i l l - p r e p a r e d . T h i s s u r v e y s u g g e s t s that le sso ns l earn t fr om s e riou s C O V ID - 19 outbr e aks i n 202 0 c ontribu ted to ag e d c are pr ov ide r s ' and gov ernmen t a genc ie s ' bei ng m uch bett er p repa red in 2021 . Howeve r, fu rth er and su staine d improve ment s in staf fing l evel s, outb r eak p rep are dne s s and i nf ection pr ev e ntion and c on tr ol prac t i ce s and o the r me a s u re s are requ ire d. Acknowledg em ents: The author s w ish t o t hank the Resi d ential Aged Care Managers who responded t o this sur v ey. . CC-BY-NC-ND 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted February 7, 2022. ; https://doi.org/10.1101/2022.02.05.22270416doi: medRxiv preprint REF EREN C ES 1. W orld H e a lth Orga niza tion . Repo rt o f th e WHO-Ch i na Joi nt Mi s s i on on Coro nav ir us Di s ea se 2019 (CO VI D -19). F e br u a r y 2020. https :/ / ww w.w ho.int /doc s/ d e fa ult - s ou rc e/ c o ronaviru s e/who -ch ina -joint -mi s s io n - o n -covi d-19 - final -re por t.pd f Ac ce s s e d Janua ry 20, 20 22 2. O nde r G, Re zza G , Bru s a ferro S . Ca se - fat ality r a te and c har acte ris tic s of p atie nts dyi ng in r l ation to C OV ID-19 in I taly . J AMA. 2020; 32 3(18):1775 -6. htt p s: / / ww w.nc bi.nlm. nih .gov / pubm ed /32 203977 3. Alexa nder H. 'No one k now s whe r e i t ca me fr om ': In sid e Au stral ia's fir st CO V ID - 1 9 clu s t er. Sydne y Morning H eral d. 2020 . ht t p s: // w ww.smh.c om. au/n ation al / n sw /no -one -k now s-w here - it-cam e- from -in side -a us tr a l ia- s - f i rst -covi d - 1 9-clu s ter - 2 0200506 - p 54qdy.h tml A c ce ss ed Janu a r y 20, 20 22 4. G i lber t G L . CO VI D-19 in a Sydne y nur s i ng home : a c a s e s tudy and l e ss on s learn t. Med J Au s t. 2020;21 3(9) :393-6 e1 . ht t p s:/ / w ww. ncbi. nl m.nih.gov / pu bm ed/3303764 6 5. G i lber t G L , Li lly, A . New march H ou se CO VI D-19 Outb r ea k [April - June 20 20 ]. Ind e pe nden t Revie w. 20 Augus t , 2020. htt p s: / / ww w.he alth .gov .au / s it es / d e f ault / fil e s /d ocu ment s/2020/08 /coron av iru s -c ovid-19- newma r c h-h ou se -covi d-19 -ou tbre ak-ind e pend ent -revi ew -newma r c h -ho us e -covi d-19- outbre ak-in de pe nden t- review - fin al- repo rt.pd f Acc e sse d Jan u ary 20, 2022 6. COVI D-19 ou t br ea k s in Au strali an r e side ntial aged c ar e f ac ilitie s . Au stral ian Gove rnme nt , D e pa rt m en t o f Heal th. h ttp s : / /www .heal th.g ov.au /new s/heal th -a le rts /novel -c or o n avirus - 2019-nc ov-h eal t h -a l er t /co rona viru s-c ovid-19 -c as e -number s - a nd - stati s tics #ca s e s - in-age d -car e - s e rvi ces . Ac ce s s e d J anuary 2 0, 2022 7. G i lber t G L , Li lly, A . I ndep ende n t Revie w of C OV ID - 1 9 ou tbre aks a t S t B asi l’ s Hom e for the Age d in Fa wkne r , Vic toria a n d Her i t a ge Ca re Epping G a r d e n s in Epping , Victo ria. 20 N o vembe r , 2020. h t tp s: //ww w.hea lt h.gov. au /sit e s/ d efa ul t / fil e s/docum e nts /2020/12 /coron a v ir u s-co vid- 19-indep e nden t -r e view - o f-c ovid -19 -ou t b rea k s - a t- st - b a s i l - s - and -ep ping -gard en s- a ge d-car e- facil iti e s . pd f. Acc ess ed Ja nu ary 20, 2022 8. G i lber t G L , Li lly, A . I ndep ende n t Revie w. CO VI D- 1 9 ou tbr eak s in Au st r a lian R e s id e ntial Age d Car e Fa cili t i e s. 1 N o vembe r, 20 21. htt p s: / / w ww.he alth .gov .au / s it es / d ef ault / fi l e s /d oc ument s/2021/11 /coron a viru s -c ovid-19- indepen d ent -rev iew-o f -c ovid-19 -ou tbre a k s -i n-a u str alian -re sid enti a l- aged -c are - fac il it i e s- . CC-BY-NC-ND 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted February 7, 2022. ; https://doi.org/10.1101/2022.02.05.22270416doi: medRxiv preprint indepen d ent -rev iew-o f -c ovid-19 -ou tbre a k s -i n-a u str alian -re sid enti a l- aged -c are - fac il it i e s _ 0 .pd f Acce ss ed Janu a r y 20, 2 020. 9. N atio n al Heal th a nd M edic al Re s earc h C ounc il. Ethic al c on side ra tion s in qual i ty as s u r a n ce a nd evalu ation ac tivitie s . March 2014. h ttp s ://ww w.nhmrc. gov.a u / ab ou t - us /re sourc e s/et hica l- consid era tion s -quali ty-a ssura nce -a nd -ev alu ation -ac tiv itie s . Acc e ssed Ja nuary 20 , 2022. 10. A u strali an In st i tut e o f Hea lt h and Wel f a re. G E N Ag ed C are Dat a: P r ov ider s, S ervic es an d Plac e s i n Aged Ca re . 2020. h tt p s: / / ww w.g en-age d cared ata . gov.a u / Top ic s/Prov ide rs , - se rvic e s - and-pl ac e s- i n-a ged-c are . Acc e ssed Ja nua ry 20, 2022 11. Communic able Di sea s e Ne twork Au st r a li a. C D NA Nati onal Guid elin e s fo r the Prev e nt i on , Cont r ol and Pub lic Hea l th Man age ment of C OV ID-19 O u tbr eak s i n Re siden tial Car e Fac ilitie s in A u strali a. Ma rch 15 2021. 12. W ong K, L um, T., W on g, G. Th e COVI D -1 9 L ong-Term Ca r e s itua t i on in Hong Kong : impa ct and measu r e s. L TCc ovid.org, In te r n ati onal L o ng-Te r m C are Polic y Netwo rk. 9 July, 202 0. ht tp s: //ltcc ovid. o r g / 20 20/ 0 7/ 09 /upda t e d - r epo rt- the -cov id-19 -long -t erm -ca r e -si t uation -in - hong-kong /. A c ce s sed 20 Ja nura ry, 202 2 13. G raha m W , Wong, CH. Re sp onding to CO V I D -19 in R e siden tial C are : The Sing apor e Experien ce.L TCc ovid c oun tr y repo rt. Int e rnation al Long-Te r m Car e Poli cy N etwork , CPE C-L SE, ; A u gust 2 1 2020. htt p s :/ / ltc covi d. or g / 20 2 0/ 0 8/ 2 1 / re sp onding- to -c ovid-19 -in -re sid ential -car e - t he -sing apor e- expe r i e nce/ . ht tp s : //l tcco v id.org/2020 /08/21 /r e s p ondi ng- to -covi d-19-in - r e siden tia l -car e- the - singap o r e -e xperi enc e/. Acc e s s ed J anua r y 20, 2022. 14. Kim H. The impac t of C O V ID -19 o n long -t erm c are in S ou th Kore a an d mea sur e s to addre ss it . LTCc ovid.o r g , In tern ation al Long-T e r m C are P oli cy Netwo r k , Augus t 21, 202 0. ht tp s: //ltcc ovid .o r g / 20 20/ 0 8 / 21 / re spo n ding-to -cov id -19-in -r e siden tial -c ar e- the - s in gapo re - experien ce / Acc e sse d Ja nu ary 20, 2022 15. W orld H e a lth Orga ni s a t i on. I nf ec t i on p re vention and c on tr ol guida nc e fo r lo ng- te r m care f a cili t i e s i n the c on t e xt o f C OV ID-19 upda te. 8 J anuary 2 021. ht tp s: //app s.wh o .int / iri s / h andl e/10665 / 3384 81.Acc e ssed Ja nuary 20 , 2022 16. Cen ter s for Dis ea se Con trol and Pre venti on. P rep a ring for CO VI D-19 in Nur s ing Ho mes.; 20 N ov ember , 20 20. http s:/ / s tac k s.cdc .gov/vie w/cdc / 976 11 Acc e s s ed J a nu ary 20 , 2022 17. Inf ection C ontrol Expert Group . C OVI D-1 9 Infec tion P r e ven tion a nd Cont rol f or Re side ntial Car e Fac iliti e s. 3 N ov embe r, 202 0. ht tp s: //ww w.hea lth .gov. au / r es ource s /p ublic ation s/co r on a viru s- c ovid -19 -guid eli nes- for - infecti on -prev en tion -and -c on t rol -in -r esi dentia l -car e -f ac ilitie s Acc e ss ed Ja n uary 2 0, 2022. . CC-BY-NC-ND 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted February 7, 2022. ; https://doi.org/10.1101/2022.02.05.22270416doi: medRxiv preprint 18. Royal Commis s i on into Aged C a r e Q ua l it y an d Safe ty. Aged C are an d CO V ID -19 - a Spec ial Repor t . 1 Oct ober 2020 . https :/ / a ge dca re .r o yalc ommi s s ion . gov.a u / publ icati on s/ aged-c a re - and-cov id -19- sp ecia l -r e p or t Ac ce sse d 20 Ja nuary, 2022. 19. A g ed Ca re Qual i t y and Sa fety C o mmissio n. “We s aw the be st i n peeo p le” Les s o ns le arned by aged c are pr ovi der s e xperi enc ing o ut b re a ks o f COV ID -19 i n Vic toria , Au s t ralia . ht tp s: //ww w.ag edca r e q uality. gov. au / m e di a/ 8 9099 Ac ce s s e d 20 J anu ary, 202 2. A cc es s ed 20 january, 2022. 20. Lum T , Shi C, Wong G, Wong K. CO V I D -19 an d L ong-Term C a r e Polic y fo r Olde r Peopl e in Hong Kong. J Agi ng So c Pol icy. 2020;32 (4 -5 ):373-9. 21. Tan L F, S eetha raman S . Pr eve nting th e S pr e ad o f C OV ID -19 t o Nursing H om e s: E xperienc e f rom a Sing apo re G eria tric Ce ntre . J Am G e r i a tr S oc . 2 020;68(5 ):94 2. 22. Tan L F, S eetha raman SK. CO VI D - 1 9 outbr eak in nur s i ng home s in Singa por e. J Microbi ol Immunol Inf e ct . 2021 ;54(1 ):123 -4. 23. Lai CC, Yen M Y , Le e PI , Hs ueh P R. How to Keep COVI D -19 at Ba y: A Ta iwan e s e Per s pe c tive. J Epidemio l Glob H ealth . 2021 11(1):1-5 . 24. Royal Commis s i on into Aged Ca r e Q ua l it y and Safe ty. Fina l Rep ort . Ca re D ig nity a nd Resp ect . 1 March, 2 021. ht tp s: / / aged car e.r oya lco mmissi on.gov .a u/pub lic ation s /fina l -r e po r t- exe cutive - s umma r y Acc e ssed 2 0 J anuary, 2022. 25. Eaga r K, We s t era A , K obel C . A u st ralian resid en t i a l ag ed ca re is un der sta ff ed. Me d J Au s t. 2020;212 ( 1 1):507-8 e 1 . 26. G orge s R J, Kon e tz ka RT. S ta ffi ng Le vel s a nd COVI D-19 Ca s e s an d O utb reak s i n U . S . Nursing H ome s. J Am Geria t r S oc . 20 20;68(11 ):24 6 2-6. 26. A b r a m s HR, L oomer L, G a ndhi A , Gr abow ski DC . C harac t e r i s tic s of U .S. N ur s i ng Ho mes with COVI D-19 Ca s e s . J Am G eria tr Soc . 2020 ; 68(8):1653 -6. 28. Shall cro ss LB , D. , Abbo tt, O ., D on al ds on, A., Happ a tt, G ., Hay ward, A ., H opk in s S. , Krutik ov, K.S., Wa rdman , L., Thome , S . Fa ct or s a ss ocia t e d with S ARS -Co V -2 inf ec tion a nd o ut b r e a ks in long - t erm c are fac iliti e s in E ngland : a n ation al c ros ss ec t i on al su rvey . Lan cet H ea lth L ongev . 2021;2(3) ; e 129- e142 . 29. H a r ringt on C, Ro ss L , C hapma n S, H a li fax E , Spurloc k B, Bakerjia n D. N u rse S ta ffin g and Cor o n aviru s In fecti on s in Cali forni a N ur si ng Homes . Pol icy Poli t Nurs Prac t. 2020;2 1 (3):174 -86. . CC-BY-NC-ND 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted February 7, 2022. ; https://doi.org/10.1101/2022.02.05.22270416doi: medRxiv preprint 30. Rolland Y, La cos te MH, de Maul e on A , G hisol fi A, De S ou to Ba rr e t o P , Blai n H, e t al. G uid a nce f o r t he P r e ven tion o f t he COVI D -19 E pidemic in L ong-Te r m Ca re Fac ilit ie s: A S h ort-Te rm Pr o spec tive S t u dy. J Nu tr H ea l th Aging . 2 020;24 (8) :812-6 . 31. Ibr a him JE, L i Y, McKee G , Eren H, B rown C, Ait k en G, et a l . Cha rac te r i stic s o f nur si ng ho mes associ a ted wi t h COVI D -19 outb reak s and mortality among r esi den ts in Vic to r i a, A ustral ia . A u stral a s J Agein g . 2021 ;40(30) : 283 -292 . CC-BY-NC-ND 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted February 7, 2022. ; https://doi.org/10.1101/2022.02.05.22270416doi: medRxiv preprint Tabl e 1. Charac ter i s tics of sur v ey respondents a nd t he res ident ia l aged care fac ilities (RA CFs ) they repres e nted (N=33 1). R ESPO ND ENT S n ( % ) Ro le M a n a g e r 1 65 (49.8% ) D i r e c to r of Nu rs in g (D ON ) 5 0 (15.1% ) Cli ni c a l Ca re Co- ordi n a t or 14 (4.2% ) Mana g er/D O N (c ombi ned) 4 9 (14.8% ) Ot her 5 3 (16.0% ) Nursin g qualif icati o n Yes 2 46 (74.3% ) No 8 5 (25.7% ) R E SI D E NT I A L AGE D C AR E FAC I L I TY Su r ve y me d ia n (IQ R 2 ) AIH W , 201 9 1 me di a n (IQ R) Acc o mm od a ti on Re g i st e re d places 3 8 0 (5 4 , 1 19 ) 61 (32 , 99 ) Shared be droo ms 0 ( 0, 8 ) - Shared ba th r o o ms 1 ( 0 , 10) - n ( % ) % Geo gr a ph i ca l a r e a M e t r o 17 4 ( 5 2. 6 % ) 5 5.8% R e gi o n al 9 2 ( 27. 8%) 2 3.2% R u ral/rem o t e 6 4 ( 19. 3%) 2 1.0% Sta t e/ Te rrit o r y Ne w S out h W a le s 10 8 ( 3 2. 6 % ) 3 2.0% Aus tralia n Capi tal Territ o r y 6 (1 .8 %) 0 .9 % Q ueen sla nd 5 9 ( 17. 8%) 1 7.3% Vi c tori a 9 2 ( 27. 8%) 2 5.4% So ut h Au stral i a 2 4 ( 7. 3%) 9. 6 % We s te r n A ustral ia 3 3 ( 10. 0%) 1 0.5% Tas man i a 6 (1 .8 %) 2 .8 % N o r th e rn T e rr i to ry 3 (0 .9 %) 1 .5 % Or g a n i sa t io n F or pr ofit 10 0 ( 3 0. 2 % ) 2 8.8% N o t f or profi t 19 8 ( 5 9. 8 % ) 5 1.8% P u blic sect or 2 8 ( 8. 5%) 1 9.4% Gr oup or s ta nd alon e S t an d- a l one 13 9 ( 4 2. 0 % ) - Group 19 2 ( 5 8. 0 % ) - No. of hom es i n group 50 3 0 ( 15. 6%) - Notes: 1 Se l e cted d a ta fro m respo n dents w ere c o m p a red w i t h da ta repo rte d by t h e Austral ian Insti tute of H e alth a nd W e lf a re (AI HW), w here ava il a b le . ‘–‘ in dicate s d a ta were u nav ail a ble htt p s:// gen-agedca r edata . g o v . a u/ R e so urce s /Acc e s s- data/ 20 1 9/Se p te mber/Aged-car e - se rv i ce-list-3 0-Ju ne-2 0 1 9 2. I Q R = inte rq uart ile range 3. R e g iste red place s - ra n ge 6 -3 30. F aci litie s wi t h fiv e o r fewer r egi s t er e d pla ces we r e exclu ded as t h e y we r e con s idere d a t rela ti v ely lo w risk of e xp e ri encin g a C OV ID -1 9 o u t brea k. . CC-BY-NC-ND 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted February 7, 2022. ; https://doi.org/10.1101/2022.02.05.22270416doi: medRxiv preprint Table 2. Survey respondents’ answers to selected survey questions (number of responses) Q. A ) H ow s atis f i ed w e r e y o u with i nf or mati on pr o vid ed and d el ive ry ? (n= 3 31) So u r c e o f i n fo rm a t ion C omm on w ea l th De p a rtm e n t o f H ea l th V e ry/ qu i t e diss at isfied 7 1 ( 21. 5%) N e u tr a l 62 (18 . 7 % ) Ver y/q ui t e sat isfi e d 19 7 ( 5 9. 5 % ) U n aw ar e o f a d vi c e 1 ( 0. 3 % ) S ta te /T e rri t o ry D e p a rtme n t o f H ea l t h Very /q uit e di ssa tisf ied 5 2 ( 15. 7%) Neut ra l 5 2 ( 15. 7%) Ver y/q ui t e sat isfi e d 22 2 ( 6 7. 1 % ) Un a w a r e o f a dv i c e 5 (1 .5 %) St a t e/ Terr it o r y P u b lic H e a lth U n it Ve ry/ q ui t e dis sat isfi e d 4 5 ( 13. 6%) N e u tr a l 54 (16 . 3 % ) Ver y/q ui t e sat isfi e d 21 8 ( 6 5. 9 % ) U n aw ar e o f a d vi c e 1 4 ( 4. 2%) A ged Car e Q u alit y and Safet y C om mi s sion Ve ry/ q ui t e dis sat isfi e d 8 7 ( 26. 3%) Neut ra l 7 2 ( 21. 8%) Ve ry /q uite sat isfi e d 16 9 ( 5 1. 1 % ) U n aw ar e o f a d vi c e 3 ( 0. 9 % ) Q. B ) What p r opor tio n o f y our staf f c o m p l eted: (n= 3 31) O nl in e I P C tr a i ni n g ? A l l ( > 90 % ) 2 76 (83 .4 %) M ost ( 6 1 -9 0% ) 4 0 ( 12. 1%) S o me ( 40 - 6 0% ) 1 1 ( 3. 3%) Few ( 90 %) 24 2 ( 7 3. 1 % ) Mos t ( 6 1 - 9 0%) 6 2 ( 18. 7%) S ome (4 0 -60 %) 16 (4 .8 % ) Few (<4 0%) 1 1 ( 3. 3%) Q. C ) For R ACF s with an OM P ( 9 9 % of t otal ) (n= 3 29) O M P deve l op ed b e fo re J u l y 3 1 2 020? 26 6 ( 8 0. 9 % ) OMP pr actic e d d ur in g 2 020 ? 23 9 ( 7 2. 6 % ) Q. D) Fo r RA CF s w ith s u r ge w or kf orc e p l an ( 9 1% of t ota l ) (n= 3 00) Ant i c ipat ed p e rc e n ta ge of st aff r e pl a c em ents ? 50 % B e fo r e J uly 31 202 0 55 (1 8 .3 % ) A f te r Ju ly 31 202 0 85 (28 .3 %) Di d s urg e s ta ff rec ei ve s p ec ial t raini n g ? 14 6 ( 4 8. 7 % ) . CC-BY-NC-ND 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted February 7, 2022. ; https://doi.org/10.1101/2022.02.05.22270416doi: medRxiv preprint Tabl e 3. Out c omes and effec t s in residential a ged c are faci lit i es that ex perienced at least one COV I D-19 outbrea k (n=32) * OUT C OM E me d ia n (r a ng e; I QR) R e s i d en t ca se s 11 (0 -90 ; 1 ,30 ) Re s ide nt d eat hs 3 ( 0 - 3 8; 0 ,11. 5) S taff case s 1 0.5 ( 0- 53; 2 , 4 0) EFF E C T n (% ) Q. W hat p r oport io n of ti m e c o u ld yo u m a int a in a n a dequ a te w ork f orc e d u r i n g the ou t b r eak? > 9 0 % 12 (37 . 5 %) 6 1- 90% 8 ( 2 5. 0 % ) 40- 60% 9 ( 2 8. 1 % ) < 40% ) 3 ( 9. 4% ) Q . Did a n y st aff sta y awa y f r o m w ork b eca u se o f c onc er n f or th eir h e a lth/w ellb e i ng ? 20% ) 1 3 ( 41%) Q. H ow m uch o f th e t i m e d i d you h a v e t im el y a c cess t o ade qua t e P P E suppli es ? > 90% 1 6 ( 50%) 6 1- 90% 7 ( 22% ) 4 0- 60% 7 ( 22% ) 90% 1 2 ( 38%) 6 1- 90% 1 1 ( 34%) 4 0- 60% 4 ( 13% ) < 40% 5 ( 16% ) Q. W ha t ty pe o f re si de n t c a r e re co r d s sy s te m di d y o u u se? El e c tro n ic 1 7 ( 53%) P a pe r -bas ed 4 ( 13% ) S ome o f b ot h 1 1 ( 34%) Q . D i d r esid e nts w e a r an y f or m o f id e nti fica tion du rin g outb r e a k ? N o 1 9 ( 59%) *32 of 3 3 1 (9.7%) RACFs e xperi ence d an o u tb re ak bas ed o n t he of fic ial d e fi ni tio n ( on e or m ore COVI D-1 9 c ase s . CC-BY-NC-ND 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted February 7, 2022. ; https://doi.org/10.1101/2022.02.05.22270416doi: medRxiv preprint Figure Legend. Figure 1. Cumulative relative frequency of perceived importance of different lines of defence, ranked from 1 (most important) to 7 (least important). Lea der s hip an d ma nage me nt w a s mos t freq ue n t l y r a nked as mo s t impor tan t (3 2 .3%), follow ed by planni ng and pr e p ara tion (27 .9% ) and i n fe ction c ont r ol (25 .1% ) . . CC-BY-NC-ND 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted February 7, 2022. ; https://doi.org/10.1101/2022.02.05.22270416doi: medRxiv preprint Figure 1. Cumulative relative frequency of perceived importance of different lines of defence, ranked from 1 (most important) to 7 (least important). “L eader ship and ma nageme nt ” wa s mo s t f r eq u ently r anke d a s mo st impor tan t ( 32.3% ), followe d by “pla nning a nd prepa rati on” (27.9% ) and “ infec t io n con trol” (25 .1%). . CC-BY-NC-ND 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted February 7, 2022. ; https://doi.org/10.1101/2022.02.05.22270416doi: medRxiv preprint