COVID-19 Nosocomial Review Group minutes: 28 August 2020

Items and actions

1. The CNRG received a summary presentation of the COVID-19 HAI onset all-cause mortality report published by NSS on the PHS website on 26 August 2020.  Limitations of the data were considered. Older patients have longer term hospital stays, multiple comorbidities and therefore are at an increased risk of HAI and increased mortality risk, irrespective of HAI. Mortality data are all-cause and therefore not necessarily HAI associated. A decrease in all-cause mortality has been seen since the previous peak in March/ April. The decrease in mortality may be due to higher number of cases seen in lower age groups, and possibly due to better treatment methods compared with earlier in the pandemic. Further analysis of this is required as validated datasets become available to enable this.

2. The CNRG noted that there remains limited evidence to inform routine testing of asymptomatic HCWs though it has been shown to be beneficial in identification and management of outbreaks and clusters in hospitals so remains recommended by the group in this context. There is some emerging evidence from modelling studies indicating efficacy of routinely screening asymptomatic HCW. Interpretation of these studies is limited by the model assumptions and their appropriateness in the current Scottish context of low prevalence in hospitals but will be monitored. Intelligence from the weekly HCW screening policy in high risk specialties and the SIREN study will support considerations for future HCW testing policy. Previous advice provided by CNRG in relation to testing asymptomatic HCW remains extant and wider testing capacity for HCWs should be used for the SIREN study.

3. CNRG noted that WHO and ECDC still consider respiratory droplets as the main transmission route for COVID-19. The most recent SAGE advice (July 2020) on transmission stands as supported by CNRG. UK IPC guidance on mask use and other IPC measures remain extant. The CNRG advice on extended mask use in healthcare is important and further guidance and support tools should be considered by CNOD and NSS ARHAI in support of implementation and quality improvement.

4. The group noted that there is some emerging evidence of aerosol transmission in confined spaces (over a prolonged period and without adequate ventilation). The healthcare built environment as a key control measure therefore has been a focus from HFS and ARHAI with colleagues across the UK in recent months. AGPs need additional consideration, as delays between procedures may prove to be a challenge in NHS remobilisation planning- it was noted a new CMO UK panel is examining this.

5. Other (non COVID-19) HAI surveillance routine monitoring is demonstrating fewer cases and this is related to lower activity. The SICSAG group recommenced ICU surveillance on 1 August 2020 so the only surveillance system not yet remobilised is SSI. The group considered this as important given elective surgery was being remobilised now.

6. It was noted that the use of respiratory antibiotics increased during the peak of the pandemic (March – June 2020), in particular there was a 20 percent increase in the use of Meropenem in ICUs.  In contrast in April there was a reduction in use which was sustained thereafter, and this is thought to be due a better understanding of COVID-19 and its treatment.  Antibiotic use of non-respiratory infections remained unchanged during the same time period. Dental use had increased, however all other AM indicators are on track in NHSScotland.

7. Updated UK Guidance was published 21 August 2020. NHS Boards now have a 2 week implementation period. It was highlighted to the CNRG that understanding risk pathways is the biggest challenge for NHS in Scotland. As NHS Scotland does not currently undertake blanket testing of all admissions, most patients would require to be managed in the medium risk pathway until a test result is produced. The CNRG noted its previous advice to CNO regarding admission testing as an enabler of supporting this guidance being implemented. Infographic materials are being developed for Boards to understand pathways. 

8. The CNRG received a presentation from HFS on the various configurations of bed bays and desks within NHS sites in line with physical distancing measures. Most newer estates can reconfigure layout and maintain bed numbers in most incidents. However, older estates will have a reduced number of beds due to spacing.

9.The group has agreed to review the evidence for the 2 metre physical distancing and examine options for outpatients consideration. It was noted there is a hierarchy of controls for IPC and all mitigating actions required to be addressed, inclusive of alternate service delivery plans, reducing occupancy where possible, optimising ventilation, with PPE being the last line of defence.