COVID-19 Nosocomial Review Group minutes: 19 March 2021

Items and actions

Items and actions

1.    The chair introduced a paper which had been developed by a sub group of CNRG to address HCW risk, mask type and ventilation. The evidence and options were overviewed. It was noted that the COVID-19 guidance for IPC in Scotland needed considered in the light of the recent Occupational Health WHO advice, which indicates use of these is required ‘to work with infected people in indoor, crowded places without adequate ventilation’, in addition to extant advice on AGPs already in place (Feb 2021) and the WHO mask guidance in (Dec 2020) which recommended that FFP3 could be used for COVID-19 cases beyond AGPs based on ‘clinician preference, if supply and cost is not an issue’. It was noted that the UK IPC cell did not intend to change the UK guidance in response to this WHO advice.

2.    CNRG asked ARHAI to add further risk assessment detail to the existing Scottish guidance on hierarchy of controls risk assessment in Scottish COVID-19 NIPCM addendum, to take account of the recent WHO guidance, with respect to covering the aspects of poor ventilation specifically and FFP3 use. CNRG noted that policy of wider FFP3 use, based on clinician choice, is not only a matter for IPC evidence guidance, and should be considered in the context of occupational health risks and national supply and costs. 

3.    CNRG were made aware that the NSS ARHAI response to the Royal College of Nursing (RCN) report had been published online. The response had been published given there were factual inaccuracies in the content of that report, the media reporting of it, and fundamentally flawed assumptions about the intent of the ARHAI rapid reviews. It was noted that IPS had also published their concern about the RCN report. It was noted that the report had come from the UK RCN, rather than the RCN Scotland, which to date had been broadly supportive of the Scottish IPC COVID-19 guidance.

4.    CNRG were updated on the work of the Behavioural Insights task sub group. The proposed work plan of the task group was agreed. Research proposals, campaign work and support for implementation using a multimodal approach in line with WHO advice were included in the plan. HCW focus groups have taken place to evaluate the proposed marketing and communication materials created by the marketing agency.

5.    Feedback was that the materials were generally well received, and now being progressed. Additionally, members were also made aware that intelligence from lessons learned to date from ARHAI cluster and outbreak intelligence and inspection reports from Health Improvement Scotland were being used to inform the focus, the later of these had noted that most PPE and other mitigation breaches tend to occur outside the ward and in entrances/exits of buildings, thus the whole built environment of the hospital required considerations in this work.
6.    CNRG were informed that the incidence of probable and definite hospital onset cases continues to mirror the wider community decline in infection rates. The latest week of reporting of validated data (to week ending 28th February) of nosocomial COVID-19 (those meeting the case definition of probable or definite hospital onset and in the published validated dataset), indicates there were 91 cases that week which is halved from 201 the previous week. The incidence of nosocomial COVID-19 continues to mirror the decline in the incidence in the wider population, with a lag of approximately 2 weeks.

7.    Members were also informed that cases of the VOC-1 variant are found in hospitals as the dominant strain, in line with what is currently circulating more widely in Scotland and the UK now. To date, there have been no cases of other emerging VOC or VUI reported in validated nosocomial cases in Scotland.

8.    A report on the lessons learned from all reports of cluster and outbreaks in hospitals from ARHAI Scotland to CNRG indicated that where leadership was visible (both ward level and senior management), adherence with IPC controls was high. High risk (red) pathways have had very few staff outbreaks and ICMs reported that staff in high risk pathways are confident and competent in application of IPC controls. This may be an indicator of high reliability with adherence of IPC measures in these pathways.

9.    Most NHS Boards reported that improvements were required to support the use of masks by the patient population. Physical distancing, outwith the clinical area, was a notable challenge and this was also where staff were noted to be most likely to remove their masks (i.e. cafeteria, changing rooms). Support for risk assessment of the environment beyond the patient zone, and in the patient zone, where bed spacing and ventilation may not be optimal, were identified as requiring further guidance. This has been subject to work led by the ARHAI Scotland IPC team with HFS architect and design teams, as a sub group of CNRG, in support of the NHS Boards’ needs.

10.    The majority of NHS Boards reported patient and staff movement as a significant factor in the number of patient contacts and staff requiring self-isolation. 

11.    A review of the largest clusters of cases reported by hospitals between 18th March 2020 and 11th March 2021 in Scotland was undertaken to identify factors which may have led to the outbreak, and to the continued spread on the ward. In the reports submitted by local IPC teams, there were rarely strong hypotheses on the direction of transmission and challenges in determining the denominator and attack rates therein. This reflects the difficulties in determining transmission dynamics in healthcare settings particularly in periods of high prevalence The review indicated factors that likely contributed to transmission.

12.    These included reopening/partial reopening of wards due to bed pressures; maintaining specialist services when bed pressures were high; lack of physical distancing by staff; staff absence; staff movement; patient movement within the system.  Local teams rarely provided a strong hypothesis about direction of transmission. Ventilation issues were noted in three reports (5% of the large clusters reported) and none of the reports included specific hypotheses related to air-mediated or airborne transmission. 

13.    In summary higher occupancy and managing throughput in a COVID-19 secure way, is critical to reducing risk of higher attack rates at ward and hospital level. Testing at admission and staff testing have a key role in mitigating this risk and need optimised. This learning has been included prospectively in CNO policy letters to NHS boards to date.

14.    CNRG were informed of a genomic investigation, that had been undertaken on samples from a number of wards in a single hospital (9th November 2020– 26th December 2020). The investigation found diversity within the samples – 3 global lineages, 4 UK lineages and 8 phylotypes. CNRG noted that where phylotypes differ significantly in an outbreak it can be indicative of multiple introduction events to the sampled population. Conclusions found that multiple introductions into the hospital were responsible for the outbreak clusters, and that some of these introductions became established and spread between multiple wards, while other introductions were contained within a single ward. 
  
15.    It was highlighted to members that transmission within hospitals is complex and multidirectional and one limitation of the investigation is that it is a snapshot, and as such, does not capture the complete picture of transmission within outbreaks. Further epidemiological characterisation continues with the GS work and CNRG noted the importance of this work for further learning.

16.    CNRG members were updated on the latest developments in the HCW and LFD testing policy workstream.

17.    Additionally, CNRG were further updated on the expansion of the HCW testing to beyond patient facing HCW to include all staff within the clinical areas. This expansion had been approved by the Cabinet Secretary and work is continuing to progress.