This prospective patient safety investigation looks at how hospitals can minimise the likelihood of patients catching coronavirus (COVID-19) on acute hospital wards.

Hospital acquired infections (nosocomial infections) are significant because of the effect on the health of patients and staff, and the risk of transmission between patients and staff.

Fear of contracting COVID-19 can deter people with healthcare needs from attending hospital. Healthcare staff who contract COVID-19 or are required to isolate can be absent from work for prolonged periods, often at a time of maximum strain on the workforce.

Trigger for investigation

We identified transmission of COVID-19 in hospitals as a priority for investigation, due to concerns raised which suggested that people were being admitted to hospital without signs of COVID-19 and by the time they were discharged, or soon after, they had contracted COVID-19.

Investigation summary

Our investigation aims to help the NHS understand how to reduce the risks of hospital transmission of COVID-19. We have reviewed all the structures and processes in place designed to reduce hospital transmission and identified ways that these might operate more effectively.

The investigation looks at:

  • How national guidance, aimed at reducing nosocomial transmission, reflects the accepted international scientific knowledge as stated by the Scientific Advisory Group for Emergencies (SAGE).
  • The use of national policies to develop local policies and procedures at NHS trust level.
  • The implementation of these procedures at an operational level in acute hospital medical wards.

Factors examined include the development and use of guidance, testing for COVID-19 status, personal protective equipment (PPE), infection prevention and control practices, hospital design, staff and organisational response.

As part of the investigation we interviewed:

  • Frontline NHS healthcare workers on hospital wards
  • Patients and relatives who experienced hospital care over the last few months and believe they may have contracted COVID-19 whilst in hospital
  • NHS trust leaders
  • Senior national and regional healthcare leaders
  • Senior members of national bodies

As well as safety recommendations for national bodies, the investigation report also highlights key findings that may assist NHS trusts to immediately identify:

  • the factors influencing the risk of nosocomial transmission
  • considerations about what action may be taken to mitigate this risk

Download and read the full report.

Safety recommendations

We’ve made eight safety recommendations as a result of this investigation. Safety recommendations have been made to the Department of Health and Social Care, NHS England and NHS Improvement, and NHSX.

We have now received responses to our recommendations, which are shared below.

Department of Health and Social Care

It is recommended that the Department of Health and Social Care, working with NHS England and NHS Improvement, Public Health England, and other partners as appropriate, develops a transparent process to co-ordinate the development, dissemination and implementation of national guidance across the healthcare system to minimise the risk of nosocomial transmission of COVID-19.

Response

Thank you for sharing the report with the Department of Health and Social Care. The Department accepts the recommendation made in the report and will work with partners to develop a transparent process to support and implement guidance across the healthcare system to minimise the risk of nosocomial transmission of COVID-19.

The recommendation will give us the opportunity to build on existing plans and activities, for example, the publication of the national Infection Prevention and Control (IPC) guidance available at: https://www.gov.uk/government/publications/wuhan-novel-coronavirus-infection-prevention-and-control

This process will benefit from enhanced, proactive professional stakeholder engagement to support both content and ensure the avoidance of concerns raised following publication. Where there is an absence of evidence of a structured engagement process, we will support consensus and allow guidance development or implementation challenges to be raised proactively.

Actions:

  1. We will continue to work with partners to agree roles and responsibilities with NHSE/I, PHE and other system partners for IPC guidance development (or review) at a national and system level.
  2. We will work with partners to agree a clear process and timescales for development (or review) of IPC guidance.
  3. We will give supportive recommendations to enable effective engagement and communication between system partners, if appropriate.
  4. We will encourage contributions to IPC guidance development (or review) from partners across the system.

Timeline: February – May 2021.

Response received 25 January 2021

Department of Health and Social Care

It is recommended that the Department of Health and Social Care reviews and identifies the mechanisms which enabled regional and local organisations to adapt and respond with agility during the pandemic. This should inform the development of a strategic approach to national leadership models at times of crisis and under normal conditions.

Response

Thank you for sharing the report with the Department of Health and Social Care. The Department accepts the recommendation made in the report and will work with partners to develop a transparent process to support and implement guidance across the healthcare system to minimise the risk of nosocomial transmission of COVID-19.

The recommendation will give us the opportunity to build on existing plans and activities, for example, the publication of the national Infection Prevention and Control (IPC) guidance available at: https://www.gov.uk/government/publications/wuhan-novel-coronavirus-infection-prevention-and-control

This process will benefit from enhanced, proactive professional stakeholder engagement to support both content and ensure the avoidance of concerns raised following publication. Where there is an absence of evidence of a structured engagement process, we will support consensus and allow guidance development or implementation challenges to be raised proactively.

Actions:

We thank HSIB for this recommendation, which highlights the critical importance of effective response models at local, regional, and national levels. We are committed to continually testing and improving our response policies and command, control, and coordination mechanisms.

One way we do this is through exercises like Exercise Cygnus, which we ran in 2016 to assess our level of preparedness to respond to a pandemic influenza pandemic. We are also committed to working with our partners to learn the lessons from the COVID-19 response, particularly where there have been examples of rapid and effective adaptation as highlighted by the HSIB report.

The Government has always been clear that there will be opportunities to look back, analyse and reflect on all aspects of COVID-19. As the Prime Minister has said, this will include an independent inquiry at the appropriate time. For now the Government is focused entirely on responding to the pandemic and saving lives.

There are several pieces of work which will help inform lessons learned in the coming months. These include the National Audit Office’s studies into how well prepared the government was for the COVID-19 pandemic.

This will cover an assessment of the operation of the early months of the pandemic response and is due to report in Spring 2021. There are also ongoing changes to the structure of the health and care system, most notably the establishment of the National Institute for Health Protection (NIHP).

We expect that these activities will produce valuable insights into response mechanisms and leadership models which will supplement the HSIB findings and help us to continue to strengthen our response models at local, regional, and national levels.

Response received 25 January 2021

NHS England and NHS Improvement

It is recommended that NHS England and NHS Improvement:

  • supports additional capacity for testing for NHS patients and staff (Pillar 1 testing)
  • facilitates the accessibility of rapid testing for NHS trusts, as soon as an increase in rapid testing supplies becomes available.

Response

Nosocomial infections are a national priority for the NHS and a range of teams have been taking and continue to take actions to maintain patient safety.

The NHSE/I Infection Prevention and Control (IPC) team works alongside PHE to provide leadership to the NHS in England. NHS providers work to ensure that the latest Public Health England IPC guidance is implemented rigorously, best practice is shared and direct support is provided to trusts that require this.

The IPC team works alongside other teams to support local action to minimise nosocomial infections, particularly the testing, people and estates teams.

Since the start of the pandemic, the availability of testing for staff and patients has increased, which has supported the early identification of potential sources of nosocomial infections.

The impact of the hospital estate is a key consideration and constraint in IPC and trusts have taken this into account to support local implementation of measures to prevent hospital infections.

Finally, the effort that staff have made in working through this pandemic, particularly in terms of fatigue and distress, has been recognised and a wide range of national support has been provided to help NHS organisations support their staff.

Actions: Ensuring adequate testing capacity for NHS staff and patients has been a top priority throughout the pandemic in line with Government decisions about who is eligible for testing.

In terms of additional capacity for staff testing, the following actions have been taken by DHSC:

  • From 12 April testing has been available to symptomatic staff and their household members across the NHS, including individuals working in the NHS outside of acute care.
  • From 9 November plans were implemented to make asymptomatic testing available to all NHS patient facing staff. 34 trusts were early adopters of lateral flow antigen tests before a wider rollout to all trusts by the end of the month.
  • Lateral flow antigen testing kits were provided to all NHS trusts by the end of November so that patient facing st+P226aff can test twice a week. Lateral flow technology is the main mechanism for staff testing and this can continue to be used alongside PCR and LAMP testing.
  • In December, we confirmed that lateral flow antigen testing would be rolled out to the whole of primary care (around 40,000 organisations) for asymptomatic patient facing staff, including GP practices, pharmacies, opticians, community health services, and vaccinators. More than 16 million tests will be available for staff to test themselves twice a week. Positive tests will be followed up by a confirmatory PCR test.

In terms of extra capacity for testing patients, the following actions have been taken, following DHSC decision:

  • Provision is in place so that all elective and emergency patients can be tested, and this includes people who are attending via emergency admission, whether or not they have symptoms.
  • There are processes in place to retest patients at intervals whilst they are in hospital even if they do not show COVID symptoms; at days 3 and 5 - 7.
  • All patients are tested 48 hours before they are discharged to other care settings, including care homes and hospices, in line with DHSC policy and requirements.
  • In December we published guidance for trusts on supporting maternity patients. This included patients and their support person having access to lateral flow testing so they can attend scans and be present at birth.

In addition to this, we are currently facilitating rapid turnaround testing for patients where a fast result is needed, reducing risk for patients and staff.

Depending on the testing platform, rapid turnaround testing can be completed in anything from 15 to 120 minutes. However, there is no perfect test available currently which provides very rapid near patient testing alongside appropriate sensitivity and specificity levels for that use case, and which has sufficient available supplies for a national rollout. Access to rapid turnaround testing is being prioritised for emergency pathways.

Therefore, we are continuing to work with regional pathology and clinical networks on the clinical operational aspects of deploying the different rapid testing technologies in the most useful ways to frontline clinical teams to reduce the risk of nosocomial transmission.

These include the supply of reagent for the differing platforms, the license agreements and terms of use for the platforms and funding for any additional workforce requirements. We continue to work with DHSC’s Test and Trace teams to verify and validate new technologies and consider their appropriateness for NHS deployments as these become available.

Timeline:

Staff and patient testing – complete – sufficient capacity available to test as regularly as is recommended by CMO – evaluation is underway and will be reviewed on an ongoing basis.

Rapid testing – ongoing as new technologies become available.

Response received 25 January 2021

NHS England and NHS Improvement

It is recommended that NHS England and NHS Improvement:

  • develops a national intensive infection prevention and control (IPC) safety support programme for COVID-19 which focuses on leadership, IPC technical support, education, practice, guidance and assurance
  • develops a national IPC strategy which focuses on developing IPC capacity, capability and sustainability across the NHS in England.

Response

The national IPC team, part of the Chief Nursing Officer’s Directorate, provides national leadership and a coordinated IPC programme for the NHS in England in conjunction with PHE and DHSC. The team works with Regional Chief Nurses and Regional IPC leads to offer leadership, technical advice, safety support, education and the sharing of best practice across the country.

To support implementation of PHE’s IPC guidance in NHS organisations, the key actions for IPC and testing were published initially on 17 November with a revised version published on 23 December. The national IPC team has established an assurance system through regional teams on delivery of these key actions by NHS provider organisations. This complements existing board-level assurance of IPC practices through the IPC Board Assurance Framework.

The IPC team’s work is supported by a daily data collection of COVID 19 infections from all NHS providers in England. These data provide a live update on any issues and organisations which require expert support, which is provided through regional teams. Weekly infection data is published on NHS England’s website since early August to support transparency.

To deliver their support, the national IPC team established a regionally-led intensive support programme for IPC in October 2020. This programme provided funding for IPC expertise in each region to allow for direct IPC support to be delivered to NHS organisations reporting increased nosocomial infections.

Proposals are currently being developed by the Nursing Directorate for a programme of work to further improve IPC capacity and capability. This programme will also support delivery of strategic objectives in the NHS Long Term Plan relating to the Antimicrobial Resistance 5 year national action plan.

It will entail the delivery of 4 pillars to build the capacity and capability of IPC resource and function by:

  • Development of a nationally recognised education framework for IPC and leadership training,
  • Resourcing of national team or building national capability,
  • QI approach to delivery of programmes -AMR/GNBSI/Covid-19 nosocomial
  • Workforce reviews.

Timeline: Development and approval of a national strategy by mid 2021.

Response received 25 January 2021

NHS England and NHS Improvement

It is recommended that NHS England and NHS Improvement reviews the principles of the hierarchy of controls in its health building notes (HBN) and health technical memoranda (HTM) for the design of the built environment in existing and new hospital estate to reduce the risk of nosocomial transmission.

Response

The General Principles of Prevention recommended in the management of Health and Safety at Work Regulations 1999, Regulation 4, Schedule 1 are equally as applicable to Covid-19 as they are to risk avoidance from other hazards.

These principles have been applied in the development of ventilation guidance and answers to FAQ shared with NHS Trusts.

The hierarchy in order of priority is

  • a) eliminate
  • b) evaluate risk
  • c) combat risks at source
  • d) adapting work to the individual
  • e) adapting to technical progress
  • f) substitute
  • g) develop a coherent overall prevention policy
  • h) group protection, over personal protection
  • i) giving appropriate instruction.

The first, a), covers actions like digital/telephone consultation and zoning between COVID/suspect COVID/no COVID, b) includes workplace and system risk assessments, that is embedded in the HTMs; c) includes dilution of air through ventilation and environmental cleanliness and surface cleaning; working down to h) that includes Screens and PPE.

All of which have been written into FAQs and Guidance. All FAQs, Guidance and Instructional SOPs are consulted on with the IPC Cell before sharing as a consultative draft more widely.

Response received 23 March 2021

NHS England and NHS Improvement

It is recommended that NHS England and NHS Improvement responds to emerging scientific evidence and shared learning when reviewing guidance for NHS trusts on the role of hospital ventilation systems in nosocomial transmission.

Response

The learning from UK and international experience has informed development of ventilation guidance, and specifically in a review of HTM 03-01, which has included academics and devolved nations NHS staff with expertise in building ventilation and healthcare ventilation.

We note that in the most recent WHO guidance a minimum standard of 12 ACH where AGPs are performed has been proposed; and whilst the minimum in the new HTM 03-01 is 10 ACH, we recognise that the WHO guidance is reflective of the international practice of recirculatory air, which is not advised in the English guidance (in effect the recirculatory element, with 12 ACH gives a lower dilution rate that the English HTM standard of 10 ACH) .

In addition to the new HTM 03-01, In collaboration with IPC, leading academics and a sub group of SAGE EMG, we have proposed a range of air change rates to achieve appropriate dilution, alongside minimum fallow periods where AGPs are performed, alongside IPC and cleaning advice.

Response received 23 March 2021

NHS England and NHS Improvement

It is recommended that NHS England and NHS Improvement investigates and evaluates the risks associated with the potential impact of staff fatigue and emotional distress on nosocomial transmission of COVID-19.

Response

NHS England and Improvement recently published a suite of products to support excellence in infection prevention and control measures. These are available at https://www.england.nhs.uk/coronavirus/publication/every-action-counts/.

This work was based on extensive engagement with frontline staff, with over 6,000 responses received to a survey and virtual roundtable discussions and webinars.

The issues of fatigue and stress were raised in this feedback and the final products propose actions to tackle this issue. The key factors in this were creating a culture of kindness and support, which would set the mood to enable a speak up culture.

This change in culture will be supported by IPC leadership training, situational reminders and creating IPC champions to reinforce the messages around protecting yourself and others.

Embedding this work in the NHS will also focus on changing behaviours in non-clinical areas, where staff have been found to be at greater risk of contracting COVID-19 as they step away from the intensity of delivering patient care. We will be evaluating impact measures of the ‘Every Action Counts’ campaign to inform any further changes or support required by frontline staff.

The issue of workforce stress due to working through the pandemic has been highlighted by work led by Kevin Fong on the experience of intensive care staff.

Professor Fong’s work found a substantial burden of mental health symptoms being reported by ICU staff towards the end of the first wave of the pandemic in July and July 2020. The severity of symptoms identified were considered likely to impair some ICU staff’s ability to provide high quality care as well as negatively impacting on their quality of life.

In recognition of the need for targeted support to ICU/critical care staff, the NHS has put in place a range of health and wellbeing resources for this staff group, including sessions for critical care leaders on support resources available and training at least one nurse per critical care team in restorative clinical supervision by April to enable wider support.

This work complements NHSE/I’s wider wellbeing support offer for all staff, which features a confidential staff support helpline, offering staff access to trained advisers by phone or text, f+Q22urther bereavement and counselling services and a range of wellness resources and professional line manager support.

Further to this, NHSE/I has been piloting an enhanced health and wellbeing offer across 14 systems, with systems focusing their enhanced service on priority areas/sectors/groups where they had identified the greatest need locally.

In addition to the health and wellbeing offer, NHSE/I has also put in place integrated staff mental health support through 40 system-wide mental health and wellbeing hubs which provide proactive outreach and assessment services, ensuring staff receive rapid access to evidence based mental health services and psychosocial support, including a national enhanced mental health service for staff with complex needs.

Response received 24 March 2021

NHSX

It is recommended that NHSX considers how technology can assist in mitigating nosocomial transmission in the ward environment with regard to:

  • the use of digital communication technologies in assisting with the deployment of staff and the dissemination and circulation of key information
  • the increased use and availability of personal computing devices and electronic health record systems.

Response

As the report highlights, there has been a dramatic shift towards the use of digital tools and systems to replace face-to-face communications in response to COVID-19.

NHSX has worked with its partner organisations to support staff and organisations to make this change - including the rapid, national roll out of Microsoft Teams and video consultation platforms.

NHSX has also established a procurement framework to make it easier for organisations to purchase the communication tools they need for clinical staff.

In light of your recommendations, NHSX will conduct further work to consider the role of communication tools in reducing transmission of infections in hospitals - including tools to support staff deployment, bed management and corporate communications.

Actions:

In recognition of the need to reduce face to face communication, NHSX has supported:

● ‘Attend Anywhere’; enabling virtual consultations.

● The procurement of Microsoft 365 licences for all NHS staff, mading a significant impact on direct clinical care.

● Promoting virtual meetings, chats and video calls has enabled remote working and Covid secure communication.

● Microsoft Teams has been used to deliver large teaching programs and mandatory training.

● We are also working with the front line to share examples of excellence and shared learning.

● An interim COVID-19 Digital Staff Passport to enable safe and rapid staff movements between NHS organisations.

● To support the upgrading of legacy systems we have also created a Clinical Communication Tools procurement framework which provides;

○ Financial support for local organisations to access their user needs and procure a product suitable for their locality.

○ Dependent on which tool is chosen, some can link with electronic health record systems, task management and clinical prioritisation.

● NHSX’s national programme of work is now prioritising support for the deployment of shared care record systems across local health and care systems, but with regional collaboration, which align better with the regional Nightingale locations as regional centres.

● NHSX is also Opening up safe and secure remote access to shared care record systems also means that HCPs forced to isolate can work remotely where they are able to access those systems.

Timeline: To complete by September 2021.

Response received 25 January 2021

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