COVID-19 Nosocomial Review Group minutes: 11 December 2020

Items and actions

1. CNRG heard a presentation from NHS Ayrshire & Arran on the implementation of a management response to board level PPE issues arising from the COVID-19 pandemic. The EMT made a conscious decision to work in a ‘hub’ which was embedded in the area where mask fitting was taking place. This allowed the team to understand the issues at a granular level and build relationships with the team that required help.

2. This was a small team of four people with the ability to expand and invite experts, there was no traditional hierarchy within the team and a mix of individuals with varied backgrounds. The team had collective responsibility and accountability and were not bound by traditional governance structures, allowing quick changes to be made and governance to be implemented with decision making. The model was perceived to be successful locally and CNRG suggested that the learning should be shared by members via the networks they represent and engage with.

3. CNRG reviewed the paper from Healthcare Safety Investigation Branch (HSIB) on managing risks associated with nosocomial COVID-19 transmission. Whilst it was noted that the investigation took place in England, a number of recommendations were noted as relevant to Scotland. Physical distancing (three recommendations), ward mapping exercise, built environment – hierarchy of controls (may be different depending on capacity). All of these recommendations were reflected in extant guidance in Scotland and support for implementation in hospitals of extant guidance was seen as key by CNRG currently, given the lessons learned to date in Scotland about nosocomial incidents and outbreaks.

4. CNRG reviewed a recent paper from Singapore to inform future pandemic proofing. Singapore made many changes to hospital ventilation systems after SARS and, whilst there is extant guidance in existing SHTMs about the requirements for hospital ventilation in Scotland, there are challenges in the extant older hospital estate in Scotland. The life cycle of an average hospital is around 50 years, therefore any changes made to the built environment need to add an appropriate level of value to the building. Improving ventilation needs considered more broadly and the lessons learned from the pandemic should feature in future hospital deign considerations.

5. CNRG noted that SAGE and the Chartered Institution of Building Services Engineers (CIBSE) have released advice and ventilation guidance in the context of SARS-CoV-2; this points to the uncertainty of long range aerosol involvement in transmission currently and that optimising ventilation is a key consideration in mitigating risk. This advice and guidance from SAGE and CIBSE mirrors the content of extant HFS SHTM guidance for hospitals in Scotland in relation to ventilation. Previous advice from CNRG has been issued to NHS boards by CNO around ensuring ventilation is adequate and using the hierarchy of controls to mitigate risk therein.

6. CNRG heard about the latest interim technical guidance published by WHO on 1/12/20 on masks. It was noted that extant UK IPC guidance was in line with the recommendations made in this document and a recent systematic review by ARHAI reported no change to the evidence about the benefit of FFP3 over FRSM beyond the current use for AGPs (airborne precautions) in SARS-CoV-2 in nosocomial transmission risk.

7. It was noted that the guidance states in the text that healthcare worker preference based on available supply and cost can be considered by countries, however this was not a specific recommendation from WHO. It was noted that WHO have asserted that masks with valves should be discouraged due to unfiltered, inhaled air risk. ARHAI reported that these two topics were subject to discussion by the UK IPC cell currently for consideration as part of the UK IPC guidance. CNRG noted that this required occupational health and procurement consideration, once the UK IPC cell had considered its IPC guidance position.

8. CNRG heard a summary of the clinical evaluation of LAMP testing from England. CNRG noted that there has been debates from many professional groups on this topic and its merits in comparison to PCR testing. Findings from a technical and clinical evaluation of OptiGene RT-LAMP tests confirm high sensitivity to the virus. This evaluation carried out by NHS trusts and universities and found the test to be highly effective in identifying infectious cases in people not displaying symptoms. Unlike PCR tests, LAMP tests do not require sequential changes of temperature and lab processing and so can turnaround test results more rapidly.

9. As part of the strategy to deliver asymptomatic testing to identify those who might otherwise unknowingly spread the virus, OptiGene RT-LAMP tests have been used to test some NHS staff and in asymptomatic testing pilots in Southampton, including at the University of Southampton, which has seen 55,000 people tested. Initial results from these pilots show the test supports early identification of positive cases and therein breaking chains of transmission.

10.It was noted that the previous advice on their use from CNRG pointed to the fact that these tests were not a replacement for PCR, rather an additional defence layer which was timely and therefore may support further transmission prevention. The importance of communication of what a negative test means to HCWs and the wider population was reinforced by CNRG and will be subject to policy advice.

11. In support of roll out of Lateral Flow Testing to patient-facing staff in hospitals, COVID-19 Assessment Centres and the Scottish Ambulance Service, the Scottish Government, with support from relevant NHS partners, have issued a pack of implementation materials and guidance. This includes: Departmental Letter; Frequently Asked Questions; Standard Operating Procedure; signed off pathway documentation; staff instruction guide; and a video from the CNO.

12. CNRG noted the high community prevalence of COVID-19 and subsequent impact, as expected, on hospitalisations and nosocomial risk therein. The differences in the incidence of nosocomial COVID-19 (probable and definite hospital onset) between the first and second peaks were also noted to be challenging to compare due to testing biases, case ascertainment and incidence, as well as differences in the way outbreaks and incidents are defined since this first peak due to guidance changes.  CNRG also noted that hospital activity was higher in this peak as all elective work had not been stopped as it had in the first peak.

13. CNRG noted that board areas with higher population prevalence had higher incidence of nosocomial COVID-19 in hospitals. Variation at board level between the peaks was noted to be important as was further investigation for explanatory variables such as demographics, occupancy and IPC indicators.