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

3. Data landscape and Digital infrastructure

Data recording and reporting is challenging in care homes and was a common concern in the homes involved in this review. We heard that some care homes had no digital infrastructure and little previous history of reporting in relation to IPC issues to the HPT, other than by fax when outbreaks happened pre COVID-19. Many care homes are now working at pace to adopt new digital systems and they do require support with this. The commitment and enthusiasm to use data to manage the pandemic and the potential for improvement, was apparent from some of the care home managers we spoke with. Care homes which are part of larger groups had more positive experiences; we viewed as good practice that one care home group was using a bespoke App to report COVID-19 measures across the care homes group. The App required reporting of many of the same data items which are now part of the TURAS safety huddle reporting, therefore it had created some duplication of data entry. The challenge for this group of care homes, operating on a UK-wide basis, is that the TURAS system is exclusive to Scotland. We also heard that the group was integrating the winter planning requirements in relation to norovirus and flu preparedness, inclusive of vaccine uptake, into this App. 

There are currently 1067 care homes registered to use the TURAS safety huddle tool and this equates to 98.7% of all adult and older peoples care homes in Scotland. The widespread adoption at pace is a credit to all of those involved in this and is a good start in developing information for improvement.  We noted that in some homes there was dependence on an individual in the use of this system, as only the care home manager could submit the data or access the system (or the computer in the care home in some cases). Whilst we heard of circumstances where some care home managers had been working at weekends (on days off, or whilst on annual leave) to submit data, weekend lapses were common in submission of the data. A process that relies on an individual is not indicative of a resilient systematic approach; review of the arrangements is required to ensure that resilience and surge capacity, particularly during an outbreak, is available at individual care home level. There is an opportunity in the use of this system, to move from one of data capture, to using the data to drive improvement. There was some variability between the homes we interviewed in their perceptions about what the purpose of the system was, and there is a risk that it was viewed as a data collection system for analysis and exclusive use by others, rather than data the care home could use to drive local improvement. Support in building capacity and capability for the system to be used in this way by care home staff will be required.  

We heard from DPHs that electronic systems at board level for HPT use are not connected and inhibit system oversight.  'HP zone' (which is the case management system used by the HPTs) does not connect to TRACK care (administration system in hospitals) or ICNet (infection prevention and control patient management system) used in the hospitals, meaning that HPTs need to look at data from a variety of sources, with manual management and analysis required to create the whole picture about where care home residents have moved within the system. These data are critical to enable detection of time, place and person in managing COVID-19 outbreaks. It was noted that there is little data sharing between NHS Boards, other than nationally when there is a multi-board outbreak, and that the borders between boards are porous, in terms of staffing for care homes (i.e. staff may live in a different geographical area to the one they work in). This is important because instances of positive cases of care home workers, who are resident in one board, but work in a neighbouring board, require to be shared to enable care home risk to be managed, and this was identified as a contributory factor in one of the homes. 

There are some challenges with respect to information governance permissions to share data, which the DPHs we spoke to were keen to see overcome. They also identified a need to have better registration data to enable the linkage to enhance epidemiology capability. Care homes are required to submit a list of all residents and staff members, and their personal information such as GP, CHI numbers, date of birth and address, in order that the laboratories are able to cross-reference and transmit results to the appropriate location. We noted that much of this information is not routinely available at care home level, and that it caused the homes difficulty in gathering this information at pace, as it had never previously been required, and also that many care home staff are not registered with a General Practitioner and have no CHI number (anecdotally there are a larger percentage of overseas staff who work in care homes). Without the aforementioned information, the system is not able to undertake network analysis to understand the transmission of COVID-19 within the whole system, and delays in reporting results are possible. 

We heard from PHS that 'HP zone' has variability in the way it is used by HPTs, as it has been adapted locally. As a result, data on some of the information related to outbreaks are inconsistently reported between Boards, thus the ability to obtain consistent data nationally to clarify the overall situation is challenged. PHS is currently supplementing 'HP zone' data with other national data such as ECOSS (Laboratory results data). The TURAS safety huddle data is also part of the data landscape and PHS now has access to this, however they reported that it is not comprehensive in reporting of cases as yet. ARHAI Scotland stated their need to also access these data and other intelligence from the care inspectorate and HIS in relation to local IPC challenges; this would enable intelligence and outputs to inform national IPC action planning, and thus provide further support for care homes.

Recommendations:

• IMT systems need connected within and between boards to enable outbreak management and network analysis to be further enabled
• Intelligence sharing across the system of national organisations supporting the pandemic needs strengthened to inform national action planning in support of local needs. 
• The TURAS safety huddle system should consider wider winter preparedness and broader IPC needs as part of planned future developments and how the system might move to be used for local improvement 
• Support in building capacity and capability for data systems to be used by care home staff for quality improvement is required
• Care homes should ensure preparedness for any potential outbreak by maintaining a current register of all required staff and resident data