Reshaping risk with COVID-19

By Dr Jan Gralton and Professor Anne Duggan, Australian Commission on Safety and Quality in Health Care
Saturday, 11 July, 2020

Reshaping risk with COVID-19

The rapid increase in coronavirus cases across the globe has sharpened the healthcare sector’s focus on risk assessment and mitigation, with constructive outcomes in Australia.

A silver lining from the first wave of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which causes COVID-19 disease, has been the demonstration of our health service organisations’ preparedness to respond.

Since January, guidance for safe and high-quality health care during the pandemic has been rapidly developed by a range of organisations, including the Australian Commission on Safety and Quality in Health Care (the Commission). This evidence-based advice spans clinical management, health service planning and operation, and infection prevention and control.

Australia’s relatively successful response to COVID-19 since the outbreak began has highlighted the value of readily available information to enable health service organisations to respond quickly and effectively. It is clear a risk-management approach is critical to minimise transmission of the infection.

Framework for the future

The National Safety and Quality Health Service (NSQHS) Standards provide a robust foundation for continuing to provide high-quality care and addressing risks to patient safety.

The NSQHS Clinical Governance Standard1 requires health service organisations to identify and document organisational risks; use data to support risk assessments; act to reduce risks; regularly review and act to improve the effectiveness of their risk management system; and plan for and manage internal and external emergencies and disasters.

Complementing this, the NSQHS Preventing and Controlling Healthcare-Associated Infection Standard1 provides the framework for identifying, assessing and mitigating infection risks related to COVID-19.

This risk-assessment approach can be applied at an individual service level or organisational level and, ideally, is integrated with routine corporate and clinical risk-management processes. Reporting on COVID-19 risks and mitigation strategies should be incorporated into an organisation’s clinical governance monitoring and reporting processes. In addition to the NSQHS Standards, the processes described in AS/NZO ISO 31000:2019 Risk Management Principles and Guidelines should inform development of a COVID-19 risk-management plan.

Risk assessment matrix

The principles for prevention and control of any infectious agent are applicable in healthcare settings responding to the risks associated with COVID-19.

To promote the provision of safe health care, health service organisations should apply standard and transmission-based precautions that are consistent with the current Australian Guidelines for the Prevention and Control of Infections in Healthcare.2 For COVID-19, combined Contact and Droplet Precautions in addition to Standard Precautions are required. Where aerosol-generating procedures (AGPs) are performed, Airborne precautions are required in addition to Standard and Contact precautions.

Table 1 outlines how to assess the level of risk of transmission of COVID-19 based on the probability of exposure to infectious material and the level of contact with that material. These risks will be mitigated if staff are fully compliant with Standard, Contact and Droplet precautions (or Standard, Contact and Airborne precautions if aerosol-generating procedures are being undertaken), cough etiquette and respiratory hygiene, and physical distancing, except when unavoidable during physical examination and care.

Table 1: Risk matrix for likelihood of exposure to COVID-19
  Patient with no exposure to known COVID-19 case or contact Patient with exposure to known COVID-19 contact Patient with exposure to suspected COVID-19 case Patient with exposure to known COVID-19 case Patient with COVID-19
Indirect patient contact (eg, cleaner, food services, admin) LOW LOW LOW MODERATE MODERATE
Direct patient contact — procedure, no AGP LOW LOW LOW MODERATE HIGH
Direct patient contact — procedure, AGP or dental LOW LOW MODERATE HIGH VERY HIGH

Time to act

With COVID-19 far from over, the adage it will be a marathon rather than a sprint rings true. Ongoing vigilance in managing infection risks in healthcare settings will remain critical. This includes comprehensively reviewing and updating policies and procedures such as:

  • Screening of patients, visitors and staff for signs and symptoms of COVID-19 infection, and managing their access to health service facilities.
  • Management of healthcare workers with acute respiratory illness and requiring them not to attend work, and encouraging them to seek medical care and COVID-19 testing, if appropriate.
  • Management of patients with respiratory symptoms.
  • Staff and contractor understanding of infection control and prevention practices for COVID-19, and training and education requirements.
  • Business continuity.

Protecting patients, healthcare workers and the whole community from harm is paramount. Undertaking strong management and mitigation of infection risks will ensure the safety and quality of care is maintained during the COVID-19 pandemic and help avert a potential second wave resurgence of the disease.

Dr Jan Gralton is the Senior Advisor to the Healthcare-Associated Infections and Infection Prevention and Control program at the ACSQHC. She has previously worked in the Healthcare-Associated Infections program at the NSW Clinical Excellence Commission and led the NSW CAUTI prevention project. Dr Gralton completed her PhD in 2012 on the transmission and infection control of respiratory viruses and maintains her research interest in these topic areas.

Conjoint Professor Anne Duggan is a Clinical Director at the ACSQHC. Professor Duggan is a highly respected gastroenterologist with significant operating and leadership experience in a range of healthcare settings. She is passionate about improving healthcare services through sharing knowledge and collaborating across all aspects of the health system. Professor Duggan leads the development of the Australian Atlas of Healthcare Variation series and the Commission’s COVID-19 Rapid Response Unit.


1. Australian Commission on Safety and Quality in Health Care. National Safety and Quality Health Service Standards. 2nd ed. Sydney: ACSQHC; 2017.
2. Australian Guidelines for the Prevention and Control of Infection in Healthcare, Canberra: National Health and Medical Research Council, 2019.

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