Coronavirus (COVID-19): care home outbreaks - root cause analysis

11. Guidance and local adoption

Guidance is complex and changing in light of emerging evidence for COVID-19. Keeping care homes informed, in a context-specific way, requires effective local leadership within the home, access to expertise and an implementation plan across the care homes within respective NHS Boards to support the prevention effort. We heard of a plan led by one HSCP for area-wide improvement for IPC in care homes being developed in support of this objective. We also heard of a good practice example where a home had established a local intranet site for staff with all guidance, and used a specific software work scheduling system as an information and communication tool for all staff. We heard that access to online systems for learning, emails, or general communication are often not available to care home staff, as the computer is located in the office, which is inaccessible to staff once the manager has completed their working day.  

We heard that particular difficulties arise when guidance is issued too close to the weekend. This often results in care home management having to read, understand what is required of them and implement new guidance during, or over, the weekend, when they should be taking time for rest and recuperation. Another problem arises when families expect any announced updates to be implemented immediately and care homes reported the challenges of guidance similarly being issued at weekends.  A review of five of the most used pieces of guidance issued by Scottish Government and Public Health Scotland^[18], revealed that out of 20 issue dates or updates, six were published on a Friday, Saturday or Sunday. There is a balance to be struck between publishing guidance in a timely manner and managing the dissemination process in a way which is helpful to the user.

Care home managers seek support from the HSCP, the HPTs and the care home group where applicable, to interpret all guidance sources (HPS/ PHS, SG and local HPT and care home group guidance). This approach varies by home, and is dependent upon existing relationships within the system.  Not all of these homes were aware of where to go to access IPC expert advice, and not all had any connection to the local HPT, other than to report outbreaks.

Local context is important; the built environment precludes the guidance being applied in some settings and needs adapted in a risk based and proportionate way. Risk of misinterpretations of guidance without access to expert advice is inherent in the system. We heard of examples about visor use, hand hygiene practice, glove use, visiting processes and cleaning products which needed expert input and support. COVID-19 has illuminated a care home system which is not IPC-resilient and needs considerable investment to ensure its future preparedness. The World Health Organisation (WHO)^[19] promote a multimodal improvement strategy for IPC in health and care settings. This is commonly being used for standardisation, improvement, monitoring and reporting worldwide and has been used in a variety of care settings to date. 

To date the COVID-19 guidance has had two routes of production. The first is public health guidance via PHS, and the second route is clinical guidance produced via SGHSCD. ARHAI Scotland have led the IPC components of these various guidance documents, so have worked with the existing guidance groups to date. There has been a recognition that the guidance landscape for IPC is challenging from the perspective of the IPCTs, HAI executive leads and wider care home sector. Recently, ARHAI Scotland has undertaken a process to co-produce a national infection prevention and control manual (NIPCM), specifically for care homes with all relevant IPC guidance in one place, and is working collaboratively with the NHS, the care home sector and other relevant stakeholders. This guidance is envisaged as a resource which enables a single source of national IPC guidance for the care home sector.  It is due for publication in December 2020. 

Recommendations:

• HSCP planning using a multimodal approach to IPC is required; this may be supported by national IPC lead organisations such as ARHAI Scotland
• The new national care home manual for IPC planned for completion in December 2020 should be produced with a multimodal strategy plan for dissemination and implementation
• National organisations should be mindful of the impact of publication of guidance on days towards the end of the week or over weekends, and the availability of senior managers to support interpretation, dissemination planning should be considered as part of the guidance development process
• Most recent versions of guidelines should clearly highlight the additional information or changes from the previous version