Written evidence submitted by The Healthcare Infection Society (CLL0071)
The Healthcare infection Society (HIS) is a charitable incorporated organisation, which aims to advance knowledge, foster scientific interest in, and disseminate information about the prevention and control of healthcare-associated infections (HCAIs). Our Society membership comprises over 1000 experts in infection prevention and control (IPC), who are predominantly based in the UK, and are medical consultants, doctors in specialty training, specialist nurses, and clinical and research scientists; the vast majority are active in the front-line delivery of IPC services in healthcare.
The following is a summary of the issues that have been raised by our members relating to the SARS-CoV-2 pandemic.
The main themes address inadequacies in national IPC leadership and infrastructure, forward planning, communication, contribution from practising IPC experts, and the timeliness of and content of guidelines.
- Although some pandemic planning had taken place at national and Trust level before the advent of SARS-CoV-2, plans proved inadequate when faced with an actual challenge.
- Bed occupancy was chronically high with relatively low staffing ratios of qualified staff and an inadequate number of side rooms in most hospitals. These are undesirable in IPC terms. Not only are infections more likely to spread and be more difficult to control, but the deficiencies hinder the ability to respond to unusual IPC challenges.
- A robust pandemic plan for all NHS organisations across both community and acute settings should include regular desktop exercises for different pandemic scenarios and pathogens with different routes of transmission. These should be more than an annual box-ticking exercise. Although compliance of the process and outcomes could be mandated within a legal framework, this is probably impractical. Not only would extensive inspection be required to ensure this, but there is a real possibility that the inadequacies of current NHS estate would render compliance impossible.
- Lack of forward planning meant that, at the start of the pandemic, IPC management commonly fell to small IPC teams (IPCTs). This placed them under enormous pressure as the huge increase in IPC workload was, unsurprisingly, not matched by an increase in IPC staffing and resources. Although Trust-wide emergency responses followed, the pressure on IPCTs has remained. The pandemic (both waves and the period between) has been highly stressful for IPC practitioners as they have struggled to deal with COVID-19 (responding to incomplete guidance, implementing strategy, managing episodes of cross-infection, staff illness) as well continuing to deal with their pre-existing workload, which has not abated.
- The pandemic has highlighted the absence of strong national IPC leadership and expertise and a failure to recognise the critical importance of IPC as a fundamental part of healthcare delivery. This, and the failure to roll-out a coherent national IPC strategy, led to inefficiency, uncertainty and massive duplication of effort across the NHS as a whole.
- There needs to be a clear IPC structure nationally, regionally and locally. Currently, the membership of advisory committees is dominated by high-profile, non-IPC specialists (such as theoretical modellers, academics and physicians) rather than individuals with actual experience in Public Health or IPC.
- The central lack of support for local IPCTs undermined and devalued their experience and expertise, weakening the pandemic response. Decision-making on the application of guidance has been at national or regional level, with obvious limitations given the substantial variation in prevalence of COVID-19. Local IPCTs are critical to implementation of strategy as they are expert in the context, structure and practices of their organisation. Local experts should have been a crucial resource, particularly early on in the pandemic. On a number of occasions local IPCTs issued guidance, only for it to be blocked at regional level, but then for something almost identical to be released as national guidance a couple of weeks later. This lack of support caused uncertainty and conflict, led to delays and made it almost impossible for IPCTs to act in their capacity as local IPC experts.
- There is an over-emphasis on gaining ‘assurance’ that the latest instruction is being followed - and usually within a totally unrealistic timeframe.
- Possible routes of transmission of SARS-CoV-2 were uncertain as the pandemic began, and have become clearer as evidence has emerged. Whilst this is understandable, the early dismissal of aerosols as a means of transmission, but subsequent recognition that they do play a role, has been challenging for IPCTs. Changing guidance and, thus, changing risk mitigation strategies undermines confidence in the IPCT and creates conflict with clinicians. It would make sense for any future pandemic response to an unknown infectious agent not to dismiss a route of transmission until there is clear evidence that this is appropriate.
- Ventilation, spacing and isolation facilities in most areas of hospitals were not compliant with recommendations in Health Building Notes (HBN) and Health Technical Memoranda (HTM). No practical solutions were available to address this.
- The guidelines in the Health Building Note and Health Technical memoranda for healthcare premises and IPC should become law rather than guidance to ensure that the NHS estate is fit for purpose for future pandemic challenges.
- A major challenge for IPCTs was dealing with the tidal wave of guidance was released.
- While the IPC guidance from PHE was regularly updated and was a key reference for IPCTs, there were times when the IPC guidance was not consistent across the various PHE documents and release of updates were not coordinated.
- Throughout the pandemic, PHE/NHSE guidance has been (and remains) one step behind, or out of line with CDC and ECDC.
- The precise changes in updates of lengthy documents were not specified, requiring the entirety of lengthy documents to be reviewed. Previous versions became unavailable for reference rendering comparison impossible. Clear signposting to key changes, with clear date of publication on guidance/documents should be standard.
- Routes of direct communication from PHE/NHSE to IPCTs were poor, often delayed by internal communication within Trusts.
- There was no formal forum for Q&A around the implementation of IPC guidance. An informal e-forum run by the British Infection Association (BIA) for their members formed the primary means by which Infection Control Doctors communicated, allowing early warning of new guidance and discussion of the practicalities of implementation. Fortuitously, some senior PHE staff were members of this group and could to clarify some issues on an ad-hoc basis and facilitate the transfer of queries to PHE/NHSE. This important resource was not available to IPC practitioners who were not member of the BIA, including the majority of IPC nurses.
- Communication around release of PHE/NHSE documents was poor; often by a press release.
- The release of guidance was poorly timed, with guidance and updates regularly appearing late on a Friday afternoon. The difficulty of implementing changes over a weekend should not be under-estimated.
- PHE / NHSE IPC guidance was, at times, internally inconsistent or had not been proofread. On occasion, it was evident that nobody with practical IPC experience had “walked through it” to assess how it could be applied in real life situations nor considered the impact on hospital service delivery.
- At the start of the pandemic IPC guidance was in different documents for first responders, community and acute settings which initially led to inconsistencies.
- PHE / NHSE IPC guidance was rarely sent to professional IPC societies for consultation. On the few occasions it was, comment was invited on only one or two paragraphs and usually with an unrealistic deadline (on one occasion of less than 24 hours). In the first wave of the pandemic, where all IPC practitioners were fully occupied on the front line, this short timescale was completely impractical and the “consultation” felt like a box ticking exercise.
- Going forwards, if urgent changes are required to existing guidance, a rapid IPC advice and guidance review committee, drawing on expertise from front-line professional IPC groups such as HIS, the Infection Prevention Society (IPS) and others, could sense check and approve any changes. The practicality of securing input from experts at a time when they are busy on the front line would need to be factored in.
- Many professional medical societies mobilised quickly to provide IPC advice to their members (eg. around PPE or ventilation), but it was largely opinion-based, lacking evidence or professional IPC input, and frequently conflicted with advice from PHE/NHSE. Unsurprisingly, therefore, it was often inconsistent between different specialist bodies. Every clinical specialty defaulted to following its own society guidance and, as this was generally more stringent than required by PHE/NHSE or the evidence, it rendered local pathways very difficult to manage. The differences in guidance caused massive anxiety among staff that was challenging to dispel, and it led to conflict between the clinical teams and the IPCT.
- PHE / NHSE failed to take a firm stance in repudiating guidance from specialist societies that conflicted with national guideline, consequently failing to support local IPCTs whose experience and expertise was undermined.
- The conflict between PHE/NHSE guidance meant that there were significant variations in practice, particularly surrounding personal protective equipment (PPE). The lack of standardisation PPE led to extreme staff anxiety and conflict and wasted time for frontline staff.
- The implementation of a number of initiatives eg. testing pods, was rushed, poorly considered and unsupported by guidance. Consequently, as these were rolled out, local guidelines evolved based on shared learning and feedback from patients and staff. This was an inefficient and risky process and led to considerable duplication of effort across multiple organisations.
- Changes in the brands of PPE being supplied, as a result of shortages, meant that education around PPE use (eg. gowns, masks, visors) and fit testing for the use of respirators (FFP3 masks) had to be updated frequently.
- Fit testing for FFP3 masks had to be performed each time a new brand of FFP3 mask was issued. This was a further drain on limited supplies, consumed educational resources and wasted the time of busy clinical staff. In addition, it led to lack of confidence in the PPE being provided.
- Adequate forward planning would have identified the possibility of PPE shortage and could have allowed production of clear evidence-based national guidelines on safe re-use of PPE e.g. detailed procedures for reprocessing of different types of gowns and masks and recommendations on how often an item can safely be re used.
- The deadlock between the reality of needing to re-use PPE during periods of extreme shortage and the refusal of HSE to consider this approach needs to be resolved.
- The guidance on management and prevention of nosocomial cases and outbreaks was issued far too late (half way through the second wave) and, when it was finally provided, was out of line with what many Trusts were trying or, importantly, able to do. Informing Trusts that nosocomial cases are not acceptable, but failing to provide any tools to address the problem is unhelpful and pointless. There has even been confusion over fundamental concepts such as a clear definition of HCAI.
- As yet, there has been no guidance on outbreak management from PHE, which ironically, has derogated this important activity to local IPCTs. This is a consistent theme, with local IPCTs only being empowered to act independently when it is difficult for a national position to be taken.
- The expectations of a return to normal service after the first wave were extremely challenging within the limitations of estate and staffing. Patient pathways have been difficult to manage and too many questions remain unanswered on isolation, testing of staff and patients, managing staff and coordinating discharge. There is no formal no forum to seek answers, and decisions have to be made locally with inadequate support.
- The learning from this pandemic should be embedded in IPC practice eg. better advance planning, new ways of working, reducing overcrowding and better use of space, improved ventilation, standardisation of PPE and, perhaps most importantly, improved communication and leadership.