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COVID-19 Insight 12: Infection prevention and control in NHS trusts

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Introduction

Infection prevention and control (IPC) is an essential part of safety in hospitals. In response to the COVID-19 pandemic, we carried out a review of IPC board assurance in NHS trusts during the summer of 2020. Following this, we carried out 13 unannounced focused well-led inspections within acute NHS services to monitor IPC. These took place between January and March 2021.

This article reviews the first nine of the inspection reports published in response to these inspections. The full reports can be found on this website:

Summary

The inspections highlighted that good IPC practices have been implemented in most trusts inspected. They have adapted existing guidance and processes to respond to the COVID-19 pandemic to ensure the safety of staff and patients. This is despite challenges to good infection prevention, which included the layout of some hospital buildings limiting patient flow, and vacancies in the IPC team reducing staff support.

The trusts had dedicated IPC directors and teams that provided expertise to staff and regular updates to the board. In most occasions, these teams were comprised of staff from across the trust who had been redeployed.

Prior to inspection, several trusts had seen an increase in the number of nosocomial infections (infections acquired in the hospital), particularly around December 2020 to January 2021. This article details some of the measures trusts have taken to reduce infection and prevent outbreaks.

The key factors identified as affecting services’ ability to provide IPC in trusts were:

  • Leadership
  • Culture and communication
  • Strategy plans and guidance
  • Risk management and prioritisation
  • Monitoring and record keeping
  • Engagement, collaboration and information sharing
  • Learning and improvement.

Leadership

A dedicated leadership team who supported staff, had oversight of IPC processes, managed priorities and mitigated risk was essential for good infection prevention within the trusts.

The leadership teams had oversight over hospital wards to ensure risks were well managed. Some executive teams used ward rounds to monitor compliance with IPC protocols. Visibility, approachability and engagement of the senior leadership team was key to staff buy-in.

Members of the leadership team undertook ward rounds called 'Safety Walks', to ensure cooperation with IPC practices and compliance. Alongside this, IPC team visited wards daily to review IPC practices. The antimicrobial team supported the IPC team with daily ward visits to ensure antibiotics were being administered correctly and documented in line with trust and national guidelines.

 

Good oversight by the leadership team enabled issues to be identified and interventions to be implemented quickly during the evolving pandemic.

Leaders identified staff compliance with wearing the correct personal protective equipment, especially in non-ward areas, as an area for improvement. They had improved signage throughout the hospital and ensured mandatory IPC donning and doffing training was completed by staff.

 

They provided ongoing support to staff and were responsive to requests for advice and assistance. At one trust, staff told us that "the IPC team was available seven-days a week, including evenings and nights on-call".

Staff valued when managers supported their development, particularly in relation to improving their IPC skills. This included the provision of additional training and the opportunities for extra responsibilities.

The trust’s IPC nursing team had development posts for nurses to gain the skills and experience needed to proceed to a more senior role.

 

Culture and communication

Services with an open culture, where staff mental and physical health were considered, performed well in relation to IPC. Clear communication channels, where leaders spoke candidly when updating staff, also encouraged good IPC practice within a trust.

A no-blame culture was vital to ensuring IPC concerns were raised and handled appropriately. Staff who could challenge colleagues on IPC processes in a constructive manner, without fear of retribution said they "felt heard" by the leadership team.

The trust had devised a number of ways in which staff could raise safety concerns relating to IPC. These included hotlines, through incident reporting, by speaking to a freedom to speak up ambassador, staff support groups or networks, a Facebook question and answer facility and a live Facebook session with the chief executive where staff could ask them questions or raise concerns directly.

 

Trusts had implemented initiatives to ensure staff felt valued and that their wellbeing was still considered, despite issues such as social distancing in break areas.

Measures taken and long-term plan for health and wellbeing team included provision of support by the chaplaincy team, and by a newly formed health and wellbeing team... who could provide psychological support to individuals or small groups. There were helplines and other support services advertised around the trust for staff to access with regard to practical and emotional support, counselling, and financial help etc.

 

A whole team approach to IPC promoted a positive culture. This involved working cooperatively and constructively with staff across the trust, including non-clinical staff, to ensure patient safety was the main priority.

The IPC team worked closely with the hospital bed management team and acted together as one team to ensure patients were moved in accordance with safe IPC practices.

 

Efficient and timely information cascading ensured staff felt informed on IPC protocols and changes. The trusts had a variety of methods to communicate with staff including daily safety huddles or IPC meetings, cascading via team structures, bulletins, posters, staff intranet pages and social media.

The chief executive officer sent out a daily email to all managers providing updates and information. Managers told us this was appreciated and meant they felt informed of concerns, challenges and actions to overcome these. All staff we spoke with, reported they felt well informed and information was cascaded effectively.

 

Strategy plans and guidance

All trusts had action plans and guidance in place at the time of inspection; these were used to monitor progress. While these were individual to the trust, they aimed to align them with the wider systems goals and to enable continuous improvement in services.

The trust strategy included team objectives, annual priorities, strategic objectives, values and vision with the patient being the main focus.

 

Action plans and guidance documents reviewed at inspection contained a wide variety of IPC themes which support safe, high-quality, sustainable care. Some of the topics included were staff training and compliance targets, COVID-19 and Influenza vaccination programmes, measures implemented for visitation and environmental changes in response to social distancing. For example, staff movement was minimised within trusts to prevent infection spread.

There was daily oversight of safe staffing levels. Part of this process was to ensure that staff were not moved between COVID-19 positive and negative areas to minimise the risk of spread of infection.

 

All trusts implemented enhanced cleaning processes, particularly in ‘high-touch’ areas. For example, some trusts used ultraviolet light to check the effectiveness of cleaning on frequently touched services. Trusts monitored increases in nosocomial infections and had action plans and objectives to reduce them. They carried out reviews and shared learning from any outbreaks.

The IPC action plan included achieving or improving performance targets against healthcare associated infections with alert organisms and bacteraemia; sepsis; reduction in surgical site infections; surveillance; development of the IPC team; uptake of flu vaccination; training and improvement of estates.

 

One of the trusts had introduced rapid on-site testing to reduce the risk of infection outbreaks. Patients were then allocated to 'red' and 'green' wards depending on their test result. Another trust identified that poor ventilation contributed to their nosocomial transmission rates and therefore are investing in air purifying equipment for additional areas of the hospital.

Risk management and prioritisation

Leaders and the board had oversight of risks across the trusts’ departments through regular meetings. Trusts reported no financial constraints to implementing effective IPC and said personal protective equipment supplies throughout the pandemic have been adequate.

Risks and actions were updated and the trust board reviewed risks monthly. The board had a summary report that highlighted to them the most significant risk level changes from the previous month with a short explanation for the change.

 

Staff completed COVID-19 risk assessments for all patients and recorded these in their notes. Patients were triaged on admission to identify those at higher risk, such as people from Black and minority ethnic groups. Risk assessments were also completed when patients were moved between different wards. Staffing, pathways and personal risk assessments were also carried out.

Elective pathways had been fully risk assessed and this included assessment of environment and staffing. Staff worked in bubbles and if they needed to go from the elective area to work in another area, they were not able to return until they had been tested and cleared.

 

Some examples of actions taken to reduce risks included: washable bags for staff to take uniform home, streaming of patients, one-way systems, Perspex sheets around reception areas and nurses’ stations, use of appropriate signage to identify cleaned rooms and equipment and to identify restrictions to access.

 

Monitoring and record keeping

Staff completed detailed, up-to-date records of patients’ care and treatment to help keep them safe. In most of the trusts inspected, these records were consistently updated. However, in a small number of trusts, staff did not always keep clear patient records (for example, there were inconsistencies in reporting COVID-19 test results). This meant information sharing was less efficient and there was an increased risk of staff being unaware of a patient’s care and treatment needs.

Four antibiotic medication records had a diagnosis, name, dose, route, frequency, and pharmacy review recorded. However, three had no reason for continuing [to give medication] beyond five days, and none had an intended duration recorded.

 

The trusts that used effective IT systems to record and present patient data enabled staff to easily monitor risk. Accessible electronic systems also allowed staff to communicate and collaborate effectively. Information on outbreaks could then be shared with external partners.

The computer system used by the acute and community services in the trust provided the IPC nurses with a trust-wide dashboard of relevant and up-to-date information. The information provided a clear oversight of patient infection status and enabled reports to be run. This meant decisions could be made more easily to improve patient management and safety.

 

IT systems enabled the gathering of outbreak data to allow earlier and focused responses. Outcomes, actions and recommendations were shared with all trust staff and external agencies such as Public Health England and NHS England and NHS Improvement.

 

Engagement, collaboration and information sharing

All the trusts inspected engaged actively and openly with staff members, patients, families, the wider public and partner organisations, with the aim of improving services and IPC methods.

Collaboration with wider organisations, such as partners in the trusts’ Integrated Care Systems, supported good IPC practices, for example by facilitating patient pathways, with easier discharge to suitable accommodation.

Staff described helpful links and effective working with external agencies including the local County Council, the Mental Health and Community trust, Public Health England, NHS England and NHS Improvement. IPC professionals from the trust were involved in sharing their experiences at national groups, such as the Hospital Onset COVID-19 Committee for Infection. They shared challenges and solutions the trust had experienced and took learning from other participants.

 

One of the trusts also worked with external partners to deliver training to support their local care providers.

The trust had delivered training and support to local care homes at the start of the pandemic. Elderly care clinicians and the IPC team met with care home staff to talk through guidelines, discharge and held virtual follow-up calls. This was received positively by staff and patients. It also helped to facilitate smoother discharge and aided flow through the hospital.

 

The pandemic caused trusts many challenges in communicating IPC measures, including to relatives visiting patients. Trusts listened to concerns from families and patients and reassured them using their engagement channels. New methods of virtual visiting and communication had been embedded within many trusts, based on people’s feedback.

Staff told us that, during the first wave, patients understood why they couldn’t accompany their relative. However, as restrictions had begun to ease, some patients became frustrated at the restrictions. Staff overcame this by taking the time to explain why this was still important and told us that this had been received well by that patient group.

 

The website had an option of ‘virtual visiting’ where a video call could be arranged. There was also a ‘message to a loved one’ service, where relatives and friends could send letters, photographs, etc to a designated email address, and staff would print these out and deliver them to the intended patient.

 

We saw there was a variety of leaflets for patients being discharged home after having a hospital admission for COVID-19. These were available in different languages for patients whose first language was not English.

 

Changes had been implemented based on engagement. The trusts presented these back through posters and on their websites.

Noticeboards with ‘you said, we did’ were displayed in wards and departments. For example, we saw on the ward that patients were not getting enough information about their discharge so now all patients received a copy of their discharge summary.

 

Learning and improvement

The trusts demonstrated systems and processes for learning, continuous improvement and innovation of IPC practices. This included documenting and learning from incidents, disseminating findings from audits and working with external partners to share learning.

Outbreaks in nosocomial infections were investigated by the trusts and learning shared among staff. One trust shared evidence where improved external engagement may have prevented a potential outbreak.

Leaders gave an example where information regarding the patient’s COVID-19 status was not shared with the trust in a timely manner and this contributed to a nosocomial outbreak. They stated the trust had learnt from this to improve communication with nursing and care homes.

 

The trusts worked with system partners and external organisations to share updates on outbreaks. This improved the sustainability of the services and ensured capacity throughout the system could be managed during peak times. Established links between organisations also allowed resources to be shared where necessary.

The critical care unit offered mutual support to other hospitals when demand for intensive care beds extended their capacity. Information was shared effectively in the South West Critical Care Network and extended to sharing of equipment when this was required.

 

The trusts sought to learn from external partner reviews, such as from Public Health England, NHS England and NHS Improvement and CQC. Where possible, trusts used learning from other partners to introduce new processes internally.

The trust had received feedback from CQC and NHS England and NHS Improvement on IPC. The trust had used this feedback to produce an improvement plan with 117 actions and set up an IPC improvement group to ensure a focus on this action plan.

 

Conclusion

Despite the pressures of the pandemic, during these inspections we mainly observed both good practice and many examples of close attention by all staff from executive level to those in ward areas to keeping patients safe. Trusts have achieved this by adapting their existing infection prevention and control guidance and processes.

Our inspection findings of what was happening in these providers paint a positive picture of how they responded to the unprecedented impact of the pandemic to try and protect their patients and staff.

Last updated:
21 July 2021