The global alert on 24 January 2020, that Wuhan, China, had an escalating outbreak of respiratory infections, caused by a novel coronavirus subsequently named SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2), was a signal to infection prevention specialists that this was to be a global pandemic. The World Health Organization (WHO) declared the novel coronavirus outbreak a pandemic on 11 March 2020, with confirmed cases in 114 countries, increasing fatalities and thousands of patients critical in hospitals with fulminant pneumonia and requiring intensive respiratory support (WHO, 2020).
As an advanced nurse practitioner for community infection prevention in Hywel Dda University Health Board (HDUHB), West Wales, I was suitably experienced and placed to operationalise the community COVID-19 response. I anticipated that the community COVID-19 response and journey to mitigate transmission was to move us as specialists beyond existing competencies and boundaries. This pandemic was also to present inimitable challenges in terms of the epidemiology, changing guidance and the complexities of behavioural and human factors.
The initial COVID-19 response in the community in early 2020 was to detect, assess and test any returning travellers to the UK with symptoms of respiratory illness. I developed COVID-19 screening protocols and my team initially screened patients in their own homes. I then scoped and commissioned community buildings to serve as community testing units (CTU) with the main objective that these buildings would facilitate safe infection prevention processes. Despite immense logistical problems with procuring equipment, furniture and personal protective equipment (PPE), my team managed, through partnership working, to ensure that the CTUs had the required resources.
In line with health and safety regulations, and the classification of COVID-19 as a high-consequence infectious disease (Public Health England, 2021), I ensured that all staff were effectively trained and competent in the strict PPE procedures and screening processes in place at the time.
In the first phase of the community pandemic response, it was difficult to recruit staff to work with my team screening symptomatic travellers and key workers. This was due to the anxiety among staff regarding COVID-19, as the full consequences of this infection was yet unknown and staff perceived the risk to be too high. Thus, we engaged as a team with staff and successfully recruited staff from community services, hospitals and redeployed services. Due to the scale of COVID-19, and the requirement to mass screen residents in care homes, we had a regiment of the British army deployed to our team to support us with the logistics of the extensive screening programme.
My responsibilities also included COVID-19 advice and guidance across primary care and HDUHB community services. Community hospitals also succumbed to COVID-19 outbreaks and this required significant work in the management of the outbreaks.
I developed COVID-19 community hospital protocols to reduce the risk of further outbreaks. My expertise was directed to a newly commissioned asylum camp within HDUHB, to assess COVID-19 infection prevention measures and isolation facilities. I worked collaboratively with other agencies to develop COVID-19 and communicable disease protocols for the asylum camp.
The care home infection prevention and control work to mitigate COVID-19 transmission and outbreaks became a significant component of the daily response during the pandemic. The 212 care homes and other closed care settings across HDUHB posed a geographical challenge. I made links with many professionals and service leads to forge collaborative working to support care homes and reduce the COVID-19 risks to residents and staff. I worked with the local authority and environmental health practitioners (EHPs) to develop a proactive model of COVID-19 infection prevention standards for care homes. Through remote working, EHPs worked with care home mangers to ensure that all COVID-19 prevention contingencies and procedures were in place to mitigate any risks of transmission and outbreaks. Any concerns were escalated to me for further assessment, visits and support.
COVID-19 outbreaks in care homes in HDUHB occurred from early April 2020 and the scale of spread and transmission was rapid and extensive in some care homes. Care homes are high-risk settings due to the number of extremely clinically vulnerable older adults with advancing age and underlying comorbidities and this meant that residents were extremely susceptible to developing severe disease with COVID-19 and had an increased risk of mortality. Many of the care homes with outbreaks early on were homes that cared for residents with dementia, who often ‘walked with purpose’ and because of their cognitive impairment could not comprehend the social distancing concept or comply with isolation measures—this all compromised COVID-19 infection prevention efforts. I worked with the care homes to find solutions—ways to mitigate risks and prevent onward transmission of COVID-19.
The challenge with this novel coronavirus was that it often had atypical presentation in the older adult and not the generally acknowledged symptoms of temperature, new-onset cough and anosmia. This will have influenced the ability to rapidly identify suspected COVID-19 cases in care homes. I worked with care home mangers to ensure any new-onset symptom or behaviour change in a resident was assessed in terms of COVID-19. I found that residents could present with a variety of symptoms and these included influenza-like illness, sore throats, headaches, sore eyes, runny noses, muscle aches, confusion, delirium, behaviour changes, altered mood, diarrhoea, vomiting, reduced mobility, lethargy, fatigue, loss of appetite, altered mood or just being ‘off their feet’ or ‘not themselves’. There was also the difficulty that many care home residents and staff returned positive tests on mass screening of the care home and were asymptomatic but still able to transmit the virus to others.
I worked with staff in care homes with COVID-19 outbreaks to ensure that robust infection prevention measures and guidance from Public Health Wales were implemented and monitored. Many of the care homes found staffing levels significantly depleted during outbreaks and local authority and community mangers worked diligently to supplement staffing levels, during a time when the acuity of care was rapidly increasing, due to the deteriorating health of residents with COVID-19 infection.
There are many challenges in care homes in relation to the age of the building, design and shared facilities presenting problems for infection prevention that needed further risk assessment and mitigation. My initial response on assessment of a COVID-19 outbreak in a care home was to look at ways of implementing an isolation area for residents with COVID-19 infection and a separate staffing model to reduce risks of cross infection. I would then assess the entire home environment, flows of work in and around the home (including laundry, waste and meal delivery processes along with all care practices) and I worked further with the care home managers to reduce any potential cross infection risks.
I gave expert advice, reassurance and on-the-spot education and training to care home staff on COVID-19 transmission, standard infection prevention and control precautions and PPE. I demonstrated PPE donning and doffing procedures and stressed how important it was that all PPE in the care environment must be protected from contamination and protected within closed dispensers or lidded plastic containers. For care homes that had residents with aerosol-generating procedures (AGP), such as continuous positive airway pressure (CPAP) machines, I trained staff on AGP procedures and fitted masks and supplied enhanced FFP3 protective respirators. All care homes were asked to provide changing facilities for staff as best practice to reduce staff anxiety and reduce the possibility of taking contaminated uniforms home. Compliance with dress code policy was another focus and mangers were asked to monitor this carefully in terms of ‘bare below the elbow’, no nail varnish or jewellery to support effective hand decontamination. Isolation principles were reinforced with all staff in line with airborne, droplet and contact transmission based precautions. Enhanced cleaning and disinfection processes were important with skilled staff to perform this critical element to reduce the risk of environmental contamination and cross infection. It is acknowledged that care homes are not clinical environments but residents' homes; in order to facilitate effective cleaning and disinfection and reduce risks it was necessary to minimise non-essential items in the environment and declutter the home as much as possible. It was important to ensure that all approved decontamination procedures covered all reusable equipment after each use. Any means to increase ventilation through windows and doors in the home and application of social distancing was emphasised to combat transmission.
A holistic approach to the care of residents within an outbreak home was imperative and I spent time reinforcing fundamentals of care and optimising hydration with all residents to aid improved outcomes. Maintaining mobility and exercise within an isolation room was crucial to increase morale and prevent functional deterioration, tissue viability issues and the risks of pneumonia. High standards of oral care were promoted for patient comfort and to prevent risks of aspiration pneumonia from substandard oral hygiene.
The last year, with the COVID-19 pandemic, has posed many challenges with extensive risk assessments and problem solving required. It has also allowed much learning and significant forging of professional and multiagency relationships, which will further inform and support the high profile of infection prevention as we go forward. I am thankful that throughout this pandemic I have had a dedicated and innovative community infection prevention team to support me with all the challenges faced along the way.