Missed diagnoses, PPE failures: How the Misericordia COVID-19 outbreak unfolded

A little under four monthsinto the COVID-19 pandemic, on June 21, 2020, an outbreak was declared at MisericordiaCommunity Hospital in Edmonton.

Less than three weeks later, a full facility-wide outbreak was announced, which would ultimately beone of the largest acute-care COVID-19 outbreaks in Alberta.

The hospital stopped new admissions and transfers.

But the novel coronavirus continued to spread; 58 people, including staff, visitors and patients, ultimately became infected before the outbreak was declared over on Aug.14, 2020. Eleven patients died.

While a report was orderedand officials said it would be made public, thathas not happened until now.

CBC News obtained a copy of the 38-page final report into the Misericordia outbreak through a freedom-of-information request.

It is the first public glimpse into what went on behind the scenes at the hospital during the outbreak,revealinghow transmission spread and the factors that allowed for that.

The report, dated Aug.27, 2020, identifies missed diagnoses and missed opportunities for testing, and outlines how shared rooms, wandering patients and transfers of patients contributed to the spread of COVID-19.

"[Redacted] had a wet cough on June 10. Their respiratory status worsened on June 15, followed by diarrhea on June 16, with persistent cough noted from June 16-19. COVID-19 testing was not done until the [cyclical patient testing] prevalence screen on June 21," the report reads.

The report also reveals failures on the part of staff who dismissed subtle symptoms that later turned out to be linked toCOVID-19 and who wore personal protective equipment (PPE) improperly or did not wear it continuously when distancing was not possible.

"[One staff member] also used a common work area in [redacted] for charting, where staff were not masked or socialled distanced," the report reads.

Staff who became infected included nurses, physicians, health-care aides, housekeeping staff, pharmacists, security guards and service attendants.

The ages of those who became sick ranged from 19 to 97.

Colin Furness, an infection control epidemiologist at the University of Toronto, reviewed the report at the request of CBC News, and said there is"no question" there were lapses there.

"These lapses, in terms of training, in terms of available PPE,knowing how to wear it correctly, following procedures, doing signageall of these sorts of things may have gotten lax simply because it hadn't spawned a crisis before," he said.

Furness also noted, however, that while COVID-19 is very infectious, at the time, there was little acknowledgment that COVID-19 was airborne. In November, the Public Health Agency of Canada updated its guidance to mention the risk of aerosol transmission.

"I think the real lesson here is to look at how inadequate the response was in 2020and to understand that, so that we can have an effective response to COVID in hospitals in 2021," Furness said.

Cluster B

In one hospital cluster, which ultimately spawned 20 cases, this is how transmission spread, according to the final report:

• One symptomatic patient was not tested upon admission to the hospital;they were later found to be COVID-positive.

• A total of three of their roommates later tested positive, as did two staff linked to them.

• One of those roommates transferred rooms and their new roommate also became infected.

• Five staff members acquired infection after caring for unknown positive patients but before wearing appropriate PPE.

• Eight other patients also tested positive, likely through other patients or staff.

Dr. James Talbot, Alberta's former chief medical officer of health and an adjunct professor at the School of Public Health at the University of Alberta, also read through the final report.

"There were people who were mildly symptomatic who should have been tested," he said.

He further expressed concern that the building infrastructure, with its shared rooms, contributed tothe virus's spread.

"Once somebody in that room became infected with COVID, it was almost automatic that other patients were going to be infected," he said.

Report recommendations

The final report includes a slew of recommendations, including developing public communication plans during an outbreak, clarifying PPE requirements, avoiding patient transfers unless absolutely necessary and standardizing patient symptom screening.

All of the report's recommendations have been implemented not only at the MisericordiaCommunity Hospital,but in all acute-care facilities in Alberta, since many were provincial in nature, saidDr. David Zygun, medical director for the Edmonton zone with Alberta Health Services (AHS).

"We certainly responded to that and [have] seen fairly successful implementation of what we did," he said.

In regards to missed testing opportunities, Jon Popowich, chief quality and privacy officer with Covenant Health, which oversees the Misericordia, said it wasn't a matter of everyone not being tested.

"There was a lot of variability at the time in testing and protocols and so everything got a lot more settled as a result, I think, going forward," he said.

Staff are now paying particular attention to extended symptoms, Zygun said, and it is now routine that all patients suspected of COVID-19 be tested and that staff regularly review guidance as it changes.

In response to the concerns over breaches in PPE use, Zygun said PPE fatigue "certainly became prominent."

"This is people going to work who are trying to do their best. The reality is that protocols are complex and,at times, there are breaches, and then we have to look at why and try to maximize the adherence to those protocols," he said.

In light of the outbreak atthe Misericordia, Zygun said,coaches who check a staff member as they put on and take off PPE were introducedaninitiativethat has now spread to other AHS facilities.

As for shared rooms, the Misericordia is not the only hospital to have and use shared rooms,Zygun said. But he notedprotocols were reviewed around what could be shared, what could not be shared and what circumstances would allow for sharing.

Patient transfers are being minimized, he said, though they are sometimes necessary because of capacity issues;however, there is now more followup and re-screening of patients.

Calls for transparency

Despite provincial officials saying several times that the review would be made public, close to 16 months after the report's completion, that still hasn't happened.

"I would agree that it is important that those findings are released and we're currently working with Alberta Health Services to determine which parts of the report are able to be shared," said Chief Medical Officer of Health Dr. Deena Hinshaw on Oct. 16, 2020.

Talbot, the former chief medical officer of health, said once investigations are over, they should be a matter of public record."It isn't good that it required a freedom-of-information request to have this information made public," he said.

When asked by CBC News why the report is not being sharedpublicly, as promised, Zygun said health officialsdid not want to concentrate on one site.

"We want to get away from focusing on one site or one practice, and look at the system response. I do believe we have shared the system response and we will continue to do that," Zygun said.

"I think we have shared the learnings pretty broadly throughout all the facilities," he said."Obviously we've changed those and evolved those over time since this report."

After several email exchanges with CBC News about the report, Alberta Health spokesperson Chris Bourdeau said work to release a version of the report was slowed by responses to subsequent COVID-19 waves.

"Ultimately, the mechanism for releasing this information was to submit the content for publication in a peer-reviewed journal. This work has been accepted for publication in the Canadian Medical Association Journal and will be published soon," Bourdeau said in a statement to CBC News.

Moving forward

Popowichcalledthe Misericordia outbreak"profoundly heartbreaking" for families affected and the community.

"All of our hearts go out to anybody who is affected by this," he said. "This was a circumstance that was very, very trying on everybody."

But he said there is a commitment to learnfrom the incident.

"I don't think that they [the Misericordia] weren't prepared," Popowich said."I think the spread of this disease, the different things that people became aware of as we were reviewing it, really point to the need to be constantly vigilant."

When asked whether the outbreakwas a wake-up call, Zygun said it highlighted for him how serious things can become.

"It's just a very uniqueand hopefully will remain a uniqueevent in health care in Alberta."

Were you or your loved ones affected by the outbreak at the Misericordia? Email reporter Julia Wong in confidence at julia.wong@cbc.ca