COVID-19 Nosocomial Review Group minutes: 5 March 2021

Items and actions

1. CNRG were presented with a guest presentation outlining the lessons learned in the Singaporean response to SARS-Co-V2.  CNRG were informed of the lessons learned in relation to patient placement, contact tracing within hospital sites, IPC learning, and PPE.
2. All suspected and confirmed cases were isolated in airborne infection isolation rooms (AIIR) in the National Centre for Infectious Diseases (NCID). Additionally, as the pandemic progressed, general wards were converted into cohort wards and managed confirmed COVID-19 patients. Suspected cases were managed in single rooms. Later, community isolation facilities were used for low risk COVID-19 patients who were unlikely to have severe outcomes in order to relieve the pressure on acute hospitals. This has involved state wide conversion of public spaces (convention centres, shopping malls etc.) into temporary care facilities. Cohorting of staff on rotas in these settings had been key.
3. CNRG members were informed that universal mask use for staff and visitors was adopted early on, starting February 2020. Additionally, all staff with direct and prolonged contact with suspected and confirmed cases used airborne precautions (N95 masks, gowns, gloves and eye protection). This was as a result of a Ministerial Directive after the SARS experience and following the precautionary principle, rather than IPC evidence per se and was subject to on-going evaluation. Risk based guidelines were issued in this regard as it was not for all staff in all settings. The digital intelligence which enabled staff and the hospital to keep records of PPE tests, temperature readings, and declarations of any planned travel; in addition to visitor logs and RFID tags to trace contacts in hospital grounds were exemplary.
4. CNRG also asked about the Singaporean experience of HCW transmission risks and evidence of the transmission routes. It was noted that Singaporean staff who were wearing surgical masks and had been exposed to COVID-19 patients, who had presented atypically (hence, not managed as suspected COVID-19 patients), did not contract SARS-CoV-2 infection from the patients. This was in a publication in ICHE. Many HCW infections were thought to arise from travel, the wider community or from close family contacts (community onset) in Singapore.
5. For the general population, the donning of surgical masks/cloth masks is mandatory at all times outside of home, with the exception of eating and drinking in restaurants and eateries. Adherence with these policies is very high in the community and in the hospitals.
6. CNRG were informed that there has been a sharp decline in the number of open clusters. It was also highlighted to members that a quarter of all ICU admissions (to date) occurred in January 2021, and that 70 percent of all admissions have occurred since October 2020. So the incidence of NI is lower than peak one, however is higher in general when community prevalence is higher.
7. CNRG were made aware of the report following the ICM deep dive session to enable national learning from clusters occurring in wave 2. CNRG were informed that key themes are about enabling adherence to all IPC measures outside the patient zone with respect to physical distancing and mask use. One of the main themes to come from this session was enabling adherence to surgical mask use for patients when in the hospital. Additionally, there were requests from ICMs for the revised visitation guidance in hospitals to be both clear and concise to make it easy to implement.
8. CNRG were informed that there was variation in what NHS Boards consider a patient contact when transferring and that, this needs clarified and improved. This topic will be the focus of the next ICM lessons learned session. The ICMs network had noted ARHAI Scotland facilitating sharing weekly lessons learned throughout the pandemic had been helpful.
9. CNRG were also made aware of the findings from the focus groups designed to test the latest supporting material for staff IPC messaging. CNRG were made aware of NHS Board local interventions, including having volunteer staff physical distancing champions and an observation toolkit. Both of which is something the subgroup are scoping for possible national adoption.
10. CNRG were updated on the latest information from the EMG SAGE group, including commissioned work on air scrubbers / UV technology. CNRG were also made aware that the WHO have published a roadmap to improve and ensure good indoor ventilation in the context of COVID-19. CNRG members agreed to a commission via CNOD and SG to SAGE EMG via Ian Storrar on how we can monitor and optimise ventilation in hospitals (and other health and care settings) in the UK context. CNRG were given a list of the considerations that have arisen from the EMG SAGE group on the use of temporary facilities.
11. The chair highlighted feedback from the Australian COVID-19 Taskforce discussions on the Australian response to COVID-19. The swift and efficient community suppression resulted in lower hospital activity. This allowed Australia to focus on proactive learning, rather than reactive/retroactive learning. The initial IPC guidance was based on rapid reviews as it has been in many countries. A new leadership group including experts, HCWs, unions and other organisations was formed in Australia to get agreement of all proposed clinical guidance. IPC has now been added to this group and they have commenced systematic reviewing for the guidance. They have agreed to share the outputs and approach and Scotland can then consider if using a similar approach may be helpful as we exit the immediate pandemic response back into the formal systematic reviewing undertaken for the NIPCM in Scotland.
12. CNRG were made aware of a recently published study that investigated the risk factors associated with severe COVID-19 both in clinically vulnerable individuals eligible for shielding, and the general population. The study describes increased risk of severe COVID-19 in individuals that had a hospital exposure in the 5-14 days before presentation date (in both the shielding group and the general population). CNRG noted that the study’s conclusions are similar to recently published data from PHE/LSHTM that indicates that a large proportion of COVID-19 cases have prior hospital exposure.
13. It was noted that the study reinforces the importance of optimisation existing IPC measures in hospitals and CNRG considered if any additional measures were warranted.  It was noted that continuing to reduce unnecessary admissions to hospital is key and potentially the isolation of these admissions may have been an additional consideration, however isolation capacity and competing pressures would not allow for this. The SG clinical cell had previously agreed that shielded patients should have all the same protections as other patients in hospital.
14. CNRG were given an update on the variants of concern. The B.1.1.7 (VOC-20DEC-01) remains the dominant strain in Scotland and the rest of the UK, and the other less common (in UK) VOC have not yet been seen in any sequenced nosocomial cases.
15. CNRG were informed of the Public Health England paper on nosocomial infection data linkage. The data period for this paper was March 2020 to August 2020. It was found that 5.3 percent of all COVID-19 in England was nosocomial (based on the probable and definite hospital onset case definition), which is similar to the 6.6 percent in Scotland during this time period.  Unlike the Scottish hospital onset data, the PHE data are not validated and are subject to risk of under-reporting. CNRG were made aware that comparisons across the UK are limited by different case definitions and denominators being used.