COVID-19 Nosocomial Review Group minutes: 22 January 2021

Items and actions

Items and actions

1. CNRG reviewed the IPC strategy and interventions to support reductions in nosocomial COVID-19. A summarised review of the evidence and lessons learned to date was presented by ARHAI Scotland in relation to nosocomial transmission.

2. It was also highlighted that, based on the current evidence, the UK IPC cell do not recommend a change to the PPE guidance but highlighted the importance of strict adherence to the extant guidance and measures. Particular emphasis on importance of in-patients wearing facemasks (where possible and not detrimental to care) and of limiting the number of times a patient is moved/transferred within the hospital setting. The paper pointed to the importance of rapid testing, which was the subject of CNRG advice last year, to enable safe patient placement to reduce transmission in hospitals and for prompt detection of healthcare workers who may be positive but asymptomatic. CNRG noted that ensuring high uptake of this is key.

3. CNRG were informed of the work of the SG compliance group focussed on behavioural insights work. CNRG agreed that to minimise nosocomial transmission a focussed multimodal strategy, in line with WHO IPC guidance, is needed now to continue to support improvements to IPC practices. The chair noted that a sub group to support development of this work connected to CNRG advice to date should be set up to further enable adherence and improvement strategies.

4. The outputs of the UK Independent Panel on High Risk AGPs were noted by CNRG. The Independent Panel assessed the evidence for complex and unclear cases, where there are differing views on defining AGPs, taking into account the potential route of transmission and making recommendations for the appropriate classification. No additions to the extant list were proposed from this review. CNRG noted the international review undertaken on country level lists of AGPs, which found that the UK aligned with the majority of other countries – with the exception that the UK does not consider CPR and suctioning to be AGPs in their own right, however they are accounted for on the UK list under intubation and ventilation.

5. Some of these differences between nations are about how the procedures are classified and the language used to describe them. It was noted that Scotland’s CNO, CMO and National Clinical Director published a position statement in May 2020, stating that CPR within a hospital setting should be considered as a continuum which is likely to include an AGP as part of airway management.  In this case, the precautionary principle should apply and the healthcare professional should be supported by their organisation to make a professional judgement about whether to apply airborne precautions. The statement can be accessed here: https://www.gov.scot/publications/coronavirus-covid-19-letter-on-aerosol-generating-procedures-agp/. It was advised that no change to IPC guidance was required at this time.

6. CNRG noted recent rapid reviews are currently being undertaken by ARHAI Scotland on: the new variant; HCW transmission and acquisition; and appropriate use of respirators. CNRG were also informed of an updated IPC rapid review – where a section has been added to the guidance in relation to COVID-19 reinfection.

7. The latest review of IPC guidance regarding the new variant and evidence in relation to aerosol risk was considered. It was noted that the transmission route has not changed for the Variant of Concern (VOC,) however the transmissibility is higher and there is uncertainty about impact on hospitalisation and mortality.  CNRG noted that the main transmission route remains droplet / contact in all the international guidance to date, however other transmission routes have always been acknowledged, included airborne in specific circumstances, hence why the IPC guidance takes account of this.

8. CNRG were also informed of the SAGE Non-Pharmaceutical Interventions (NPI) paper which found that a better level of protection can be achieved with higher performance face coverings and masks, and noted their advice remained that face coverings should be worn for the wider population, inclusive when visiting hospitals and this is in extant guidance.

9. CNRG were presented with the key bed and desk spacing diagrams guidance from Health Facilities Scotland to support implementation of extant guidance, including for pre- and post-1995 built hospital environment. CNRG asked that this information be disseminated via NHS estates colleagues, and via NES with training material incorporated. A  task group to further consider the support required support for the built environment is being established.

10. CNRG were presented with the latest validated hospital onset data up to week ending 27th December. Figures show during this time that there was a decrease in nosocomial infection, and there was a decrease in emergency and elective admissions – however it was highlighted to CNRG members that data includes Christmas which might account for some of the decreases in admissions. There is a clear trend between community cases, hospitalisation and nosocomial infection in the data over the duration of the pandemic and COVID-19 occupancy is a driver of nosocomial risk.

11. Clusters of cases are predominately seen in surgical, general medicine, care of the elderly, and long term mental health settings. Additionally, CNRG were made aware of cases of COVID-19 in elective patients indicating a risk of transmission within green patient pathways, in these circumstances maximising adherence to self-isolation for patients pre admission and testing guidance (especially for asymptomatic patients and HCWs) is seen as critical to preserve the green pathways. It was noted that comparison with peak one in terms of clusters/ outbreaks is challenged by changes to reporting to enhance the information in the intervening period and implementation of increased testing and case ascertainment.  It was also noted that the incidence did not appear as high when accounting for reduced activity in wave 1, indicating early intervention appears to be in place in wave 2 and impacting on control.

12. CNRG noted reports of Gram-negative bacteria outbreaks related to contaminated gown sleeves and were informed that, at present, short sleeve gowns were not classed as COVID-19 PPE by the Health and Safety Executive (HSE) and there is a need to move away from the sessional use of gowns where possible to mitigate this risk. The approved use of short sleeved gowns for HCWs would address this possible contamination route and will be subject to further guidance consideration after discussion with HSE.

13. The latest antibiotic prescribing data were presented to CNRG and it was noted that prescribing was trending below 2019 levels currently, with the exception of dental prescribing which has seen an increasing trend – much of which may be due to delays in dental treatment during the pandemic. Comparisons across the UK demonstrate Scotland to be in a good position with respect to antimicrobial stewardship.

14. CNRG were also made aware of the International Severe Acute Respiratory and Emerging Infections Consortium (ISMRIC) study. This study found that 4.3 percent of patients with COVID-19 had a co-infection, this is subject to further analysis by ARHAI Scotland, which will be reviewed at a future meeting.