Written evidence submitted by the UK Infection Prevention Society (CLL0065)

The Infection Prevention Society (IPS) is pleased to make this submission of written evidence to the Health and Social Care and Science and Technology Select Committees’ joint inquiry into lessons learnt from coronavirus.

Summary

The Infection Prevention Society (IPS) has a membership of over 2000 registered healthcare professionals across the UK and Eire, in specialist infection prevention and control (IPC) roles.  IPC practitioners (IPCP) play a critical role in assessing infection hazards, designing prevention strategies and supporting and educating staff in the implementation of infection control precautions, including the use of personal protective equipment, application of administrative or engineering controls and decontamination of equipment and the environment.  Their skills are fundamental to supporting the effective management of COVID-19 across the whole health and social care economy and our members therefore have a unique insight into the challenges and important lessons that should be learnt to enable health and social care organisations to respond more effectively to future pandemics.  The IPS believes improvements could and should be made to address the provision of personal protective equipment (PPE); the development and promulgation of national guidelines; the failure to provide compassionate care in the name of ‘IPC’ ; locals demands on limited IPC teams and the lack of engagement at a national level with IPC expertise are outlined below:

1. Personal Protective Equipment (PPE)

1.1.   Centralised supplies and lack of planning for demands associated with pandemic resulted in severe problems with supplies of basic PPE and alcohol hand rub. NHS Supply Chain ‘PUSH deliveries’ often included items that were not fit for purpose e.g. travel sized soaps, and other critical items e.g. visors were not available and had to be sourced from local schools, masks to allow patients to lip read were of poor quality and limited supply e.g. 48 delivered to a community care Trust.  Items were commonly issued in different unit and box sizes which impacted on local distribution. IPC teams ended up counting PPE every day to make sure there was enough for high risk clinical areas and spending considerable time liaising with neighbouring Trusts to share PPE.

1.2.   Problems with PPE were often exacerbated by conflicting guidance being issued by other professional bodies and aggressive demands by some professional groups that their members should have access to high level PPE in situations where this level of PPE was not indicated and risked appropriate PPE not being available for those at defined risk.

1.3.   Out of date PPE caused considerable concern among staff and standard guidance indicating that it would be safe, and why it would be safe, to use out of date PPE would have been helpful to avoid confusion and concern at the front line. 

1.4.   The implications of training large sections of the workforce in the use of PPE was not considered in pandemic planning. Porters, security and housekeeping staff would not normally use respiratory PPE and therefore required training at pace by the IPC team - many of these staff were extremely fearful because they had to deal with challenging patients and visitors, would frequently be spat at and had seen their colleagues become seriously ill or die.

1.5.   The make and model of masks supplied was constantly changing, creating major difficulties in assuring staff were adequately fit tested. Each time the make or model of respirator mask is changed staff need to be fit tested again.  NHS Nightingale hospitals had limited prior information about of types of FFP3 masks available with many staff having to be fit tested per shift.

1.6.   Our experience indicates the need for much better planning for reserve supplies of respirators to ensure consistent access to more than one type of device and appropriate options to support prior fit testing. There needs to be more guidance on how to manage limited supplies (IPS had to form an expert group to develop guidance on safe use of PPE in the absence of any information from NHSE/PHE) and using PPE over prolonged periods.

1.7.   Staff required to wear respirators in high-risk areas had not been fit tested and in many organisations IPCP expertise ended up being diverted to support fit testing of the entire workforce.  This had a major impact on the availability of critical IPCP resources.  The problems of fit testing were compounded by the absence of the necessary equipment to undertake the tests at the beginning of the pandemic and the absence of guidance on re-usable equipment.  There need to be more robust strategies for assuring a consistent supply of specific respirators and a planned rolling programme for fit testing conducted by ‘competent fit testers’ as required by HSE.

1.8.   Equipment procured by the government was not always fit for purpose and suggests that the appropriate expertise was not involved in securing these supplies and quality control systems were inadequate. Not only did this result in a significant waste of public money but also IPCP time in assessing if PPE was fit for purpose.  E.g. ‘Turkish coveralls’ were of poor quality and not designed for use in clinical settings, poor quality respirators that did not meet EN standards and were therefore worthless, surgical type IIR masks with straps incorrectly attached and readily pulled apart, poor quality aprons, alcohol hand rubs/surface disinfection wipes not meeting required standards and not labelled in English.

2. Development of national IPC guidance

2.1.   Guidance was developed without consultation with the IPS, the only UK-wide member organisation that represents this critical expertise. The way in which guidance was developed was not transparent and appears to have been unduly influenced by people without direct experience of applying IPC in practice. As a result the guidance was produced in a piecemeal fashion, was muddled, contained errors and contradictions and was extremely challenging to implement in practice. The most recent iteration of infection control guidance included some consultation with professional bodies, however NHSE did not take notice of IPS advice, but favoured opinions from other professional groups with limited expertise in IPC e.g. BMA, GPs.

2.2.   Similarly, NHS hospital laboratories and existing private laboratories who have considerable expertise in collecting, processing and analysing specimens and should have been closely involved in test and trace decision making were excluded.

2.3.   Guidance was frequently delayed for long periods and meant that alternative guidance was established locally by IPCPs which then had to be ‘changed’ once different guidance from NHSE1 emerged.  This increased confusion and suspicion among front line staff.  Primary and community care guidance was different which confused healthcare staff as healthcare and domiciliary teams were all doing different things when wearing PPE.

2.4.   Clearer guidance on what procedures should not be considered high risk Aerosol Generating Procedures (AGPs) is required to ensure appropriate use of PPE.  The implications for children in education and personal health care budgets were not considered by NHSE/PHE guidance and resulted in high-level PPE (respirators and gowns) being used in community settings, with IPCP teams expected to fit test in schools and for family members.

2.5.   Conflict between PHE and NHSE1 about production of guidance made it difficult to know where to direct concerns and who was ultimately responsible.

2.6.   Updated guidance was difficult to find and IPCP would have to alert each other to a new releases rather than receiving direct communication nationally.  Guidance would regularly be published on Friday afternoons meaning that IPCPs had to spend weekends updating local guidance.  The previous version of guidance would be rapidly removed from the website making it difficult to refer back to and identify exactly where changes had been made.

2.7.   More specific information is required on how to assess local environmental ventilation in key areas and practical guidance on mitigating infection risks in poorly ventilated areas.  The lack of clear guidance has resulted in un-proven ‘enhanced ventilation’ systems being introduced ad-hoc across some NHS facilities, with little evidence of the need or efficacy and at significant cost to the NHS.

2.8.   Advice on use of PPE in ICU and other high-risk areas was appropriate for managing patients with Ebola or other high-consequence infectious diseases but over-zealous for a respiratory virus. The NHSE/PHE guidance did not take account of the risk of cross-infection associated with the use of the same PPE between multiple patients and as a result widespread transmission of antibiotic resistant pathogens occurred in ICUs. The guidance over-emphasises the requirement to use gloves, when hand hygiene is perfectly effective in many situations e.g. giving immunisations. This has resulted in conflicting messages about the risk of acquisition of the virus via the skin and increased rather than decreased the risk of virus transmission as staff touch many surfaces with the same pair of gloves.

3. IPC guidance for care homes

3.1.   There are scant resources to support IPC in the care home sector across the UK.  In England, CCGs have a very small IPC practitioner workforce and although they try to support education and training they have inadequate capacity to achieve this.  Systems for supporting education and advice on IPC in the care home sector are urgently required.

3.2.   The regulation of IPC in care homes is poor, it is not perceived as an integral part of quality and inconsistently and inappropriately monitored. The poor standards of IPC and lack of understanding of the issues by care home staff has been raised as a concern by IPCNs working with care homes for many years to a variety of organisations.  However, in England local authorities and CCGs disagree about who is responsible for IPC in Care Homes and with a lack of transparency in quality assurance reporting these IPCP concerns are frequently ignored. 

3.3.   During COVID homes were expected to be able to successfully prevent and manage outbreaks of a respiratory virus with little or no training and support.  The level of qualified IPC support to care homes on a national level is minimal and such services have been under resourced for many years. In some areas the qualified IPC support can be as little as one [i]

3.4.   Infection Control Nurse for 300 care homes.  Domiciliary care did not have any IPC provision in many areas and the already overstretched community-based IPC teams, where they exist, were expected to provide support to GP Practices, Care Homes and Domiciliary care.

3.5.   In many areas IPC teams were located within the NHS command structure and as a result were drawn into PPE procurement rather than focusing on supporting the implementation of IPC in the homes. In some areas the care homes received no expert IPC support as there were no staff qualified to do so, sometimes support was provided by administrative staff who had no experience of care homes or any IPC training.  Following the first wave of the pandemic, IPCPs identified many examples of recurrent unsafe practices that may have prevented the transmission within the care home if they had been addressed earlier.  Many homes experienced large outbreaks, with a significant number of deaths and particularly high numbers of staff testing positive

3.6.   The national IPC guidance for care homes was generated in different sources, often confusing and changed very frequently. It needed to be contained in one document and focused on the practicalities that were relevant to care homes, for example where and where to don and doff PPE and more detail on cleaning and disinfection, particularly explaining the complex terminology.

3.7.   For no apparent reason a decision was taken to use the GIRFT group (https://www.gettingitrightfirsttime.co.uk/) to create training for care homes.  This group is predominantly medical and acute care based and as such did not have the relevant knowledge or expertise to develop training for the care home environment.  IPC specialists with a knowledge of the environment were not involved or consulted in developing the training and as a result the original material was not fit for purpose as it did not take account of the care home environment and the specific training needs for controlling transmission in this setting.

3.8.   The training was rolled out to ‘super trainers’ who then trained care home staff to cascade the training within the home.  There was a lack of consultation on identifying ‘super trainers’, most were based in CCGs and due to the lack of IPCPs many did not have the relevant expertise.

3.9.   The NHSE system for monitoring the roll out of training focused on the number of homes accessing/refusing training with no assessment of the extent of subsequent cascading.  Monitoring was treated as a tick box exercise; once reports had been returned to NHSE no further super training opportunities were made available.

3.10.                      The IPS Care Home Special Interest Group created specific education resources for care homes but had difficulty in obtaining support from NHSE to disseminate this to the care home sector as they were focused on using the GIRFT training. Given the lack of knowledge and expertise of IPC in care homes, these delays in distributing appropriate training material left care homes unsupported and contributed to the problems of transmission.

4. Lack of compassionate care in the name of IPC

4.1.   The wholesale prevention of relatives visiting their sick or dying loved ones, in both health and social care settings on the basis of ‘infection prevention and control’ is unacceptable.  Whilst safe and sensible controls on visiting need to be in place, essential visiting with appropriate IPC precautions could and should be managed.

4.2.   In many care homes consultation with legal teams has enabled risk assessment and a policy to support safe visiting.  However, many homes still will not allow visitors because they are frightened, they do not have the staff to facilitate the visit and are concerned about managing the additional cleaning.  Many homes have had significant outbreaks, some have lost a lot of residents and some staff members. This has a massive impact on the mental health of the workforce and the staffing levels meaning there are insufficient staff to facilitate safe visiting in the home. Homes have been encouraged to spend vast amounts of money on visiting pods, when they could have been supported to facilitate safe visiting in the home with appropriate IPC input.

5. Local demands on limited IPC services

5.1.   IPC teams have limited expert personnel and routinely offer a week-day service for their healthcare organization across the whole range of clinical departments, facilities and non-clinical services such as porters and domestics.  In community NHS Trusts IPC resources are spread even more thinly, often covering a large number of primary care services and community hospitals. The demands on IPC services during the pandemic were huge, not predicted and their workload increased exponentially from early in 2020, with the need for IPC to provide a 7 day per week and on-call service for many months placing severe pressure on their staff.  In many organisations they were required to pick up wide ranging responsibilities that would be outside their usual remit, including setting up swabbing/testing clinics and fit testing facilities.

5.2.   Significant IPC team time was required to prepare all patient facing departments (not only wards and A&E but theatres, outpatients, diagnostics, radiology, renal dialysis etc) across complex healthcare organizations to develop safe pathways to manage patients with and without COVID, developing zones, admissions pathways and PPE guidance.

5.3.   The erosion in the skilled PHE and devolved administrations (DAs) Health Protection workforce due funding cuts in recent years meant that the resources to support the management of outbreaks was very stretched at the onset of the pandemic.  Once outbreaks began to occur in care homes IPC support for these highly vulnerable settings who have limited knowledge and expertise was overwhelmed.

5.4.   Delays in the implementation of Pillar 2 testing in care homes had a significant impact on the ability to control outbreaks in these settings.  Pressure on the IPC support to care homes was increased by political announcements about testing being made in advance of processes being put in place.  This created confusion and placed additional pressure on staff in Local Authorities, Public Health England and public health agencies across the Das to deal with a high volume of queries.

5.5.   Creating COVID-secure office space is a real challenge and the low priority given to space for staff to have breaks was a major contributing factor to clusters and outbreaks among staff.  Inconsistency and confusion around quarantining was also not helpful.

5.6.   Across the UK this pandemic has caused a significant number of IPCPs to be placed on sick leave due to stress caused by the excessive volume of work, extraordinary challenges of managing conflicting guidance, lack of PPE and fearful and angry staff.  In the community, IPCPs suffered the distress of not being able to provide the level of support for care homes despite repeatedly raising concerns about the significant need over many years.

5.7.   Better planning for rapidly expanding IPC services needs to be undertaken so that this critical support service can continue to function effectively.

6. Lack of engagement with IPC expertise

6.1.   IPC specialists familiar with the frontline delivery of IPC guidance in healthcare settings are not adequately represented on the national committees advising government on the pandemic, or within UK Government or DAs Departments of Health. Given that IPC is fundamental to managing the pandemic this is a significant oversight. It is not sufficient to assume that relevant expert advice can be provided by a generalist with a background in nursing or microbiology.  IPC is a highly scientific and technical area of practice that requires a detailed understanding of the delivery of care across all professional groups and health and social care settings.  The development and provision of IPC advice requires staff with specific training and experience of delivering IPC services. The inclusion of IPC specialists on national committees would have highlighted the major risks of transferring patients out of hospital into care homes at a far earlier stage, the lack of focus on social distancing among staff and its contribution to transmission in hospitals, and other IPC issues critical to protecting patients and staff.

About the Infection Prevention Society (IPS)

Our members work across a wide range of organisations including acute NHS Trusts and Health Boards, private healthcare providers, primary and social care, and public health departments. The Society’s vision is that “No person is harmed by an avoidable infection” and promotes this through education, research, dissemination of evidence and practice improvement initiatives, and the provision of evidence-based resources and guidelines.   Infection prevention and control services play a well-established and central role in assuring patient and healthcare worker safety and are focused on applying scientific, behavioural, environmental and organisational strategies to prevent healthcare associated infections and limit the spread of infectious diseases. 

Our multi-professional members provide expert IPC advice; inform and steer multi-modal IPC programs; provide education and training; develop local guidelines to operationalise national guidelines and implement evidence based best practice; undertake local and national surveillance of healthcare associated infections and antimicrobial resistance (to guide interventions and detect outbreaks);  monitor performance & compliance, and are engaged in research and development.

The IPS is a registered charity. More information can be found at   https://www.ips.uk.net/

For further information please contact Professor Jennie Wilson at IPS President