It has been widely recognised that the infection prevention and control (IPC) teams around the country have been stretched beyond compare throughout the past 30 months or so. In my view, IPC teams have been nothing short of remarkable in leading the healthcare response to the SARS-CoV-2 global pandemic, through an ever-changing environment, and while dealing with their own personal challenges. Our multidisciplinary colleagues have responded incredibly and collaborated like never before.
The IPC team I have the pleasure of leading, at the East and North Hertfordshire NHS Trust, has consistently gone above and beyond by reviewing every COVID-19-positive case within the inpatient environment, to ensure that any hospital-acquired cases are reviewed quickly. Team members could go onto the wards to give proactive advice, and hopefully prevent onward transmission.
This agile response has led to several initiatives to support ward staff, such as developing a closure handover, to allow the site team and other relevant stakeholders to get a daily update on areas that were closed due to any infections. The IPC team also developed a COVID-19 care plan, to ensure that the changing guidance was captured and laid out in an understandable way for the nurses to follow.
The work of the team led to us achieving a Silver Award in the Infection Prevention Nurse of the Year category of the BJN Awards 2022.
Changing guidance
We are all aware of the numerous iterations of guidance that were issued in response to the changes in epidemiological information, growing scientific knowledge, stakeholder feedback and the evolving picture of the virus. This presented countless challenges that could not be ignored; rather, they had to be overcome rapidly. This was the case with the rapid changes in guidance regarding COVID-19 inpatient swabbing. Swabs – either lateral flow tests (LFTs) or polymerase chain reaction (PCR) tests – were taken from the back of the throat or the top of the nostrils. Frequently changing guidance left the ward staff confused and unsure about the regimen that their patients should be following from day to day. Inevitably, this led to late or missed swabbing opportunities as well as incorrect and unnecessary swabbing. This in turn led to patients with increased lengths of stay, as they were not able to be discharged to care homes or home with packages of care on time, and to cross-transmission and outbreaks – with negative consequences. Undoubtedly, at times patient care may have unfortunately suffered, partly because requirements changed based on new knowledge, and the situation became confusing for staff. We needed to help the already stretched frontline clinicians.
A COVID-19 care plan
The COVID-19 care plan initiative was conceived of, and led by me and my deputy, Mae Cometa, who are both nurses. It was supported by members of the IPC team, who are a mixture of nurses, clinical support workers, clinical auditors, and administrators. We also worked closely with the nurse ward leaders, Jenny Pennell, the clinical audit lead, Dr Eleni Mavrogiorgou, an infection control doctor, Dr Alex Wilkinson, the lead TB consultant and COVID-19 medical lead, and others. It was important that not everyone involved were nurses, so that it had all the benefits of a collaborative project. A small group of us, including non-IPC colleagues, worked on creating a care plan that would reflect the complicated swabbing regimens and the resultant actions, in an uncomplicated and accessible way. Unfortunately, we do not yet have electronic patient records here at the trust, although we are on that journey, so we decided to produce physical care plans, particularly as staff members were already familiar with them.
Care plans have always been useful in IPC, and this one could be invaluable as we moved through different stages of this virus's infection cycle. We were not aware that any other acute trust had created such a care plan during the pandemic. Therefore we were not able to look at prototypes or examples. However, when we had developed our care plan, and it had gone through the appropriate governance structures, we were able to share our care plan within our integrated care system and the region to help others.
We spent many hours working through official guidance to see what was needed. We wanted to produce an accessible and intuitive document that would not be seen as a burden. The care plan needed to support the staff to identify the appropriate swabbing regimen for each patient, dependent on factors such as their clinical status and pathway. We produced a prototype care plan, on which we asked for feedback from members of the IPC team and other stakeholders, including the multidisciplinary members of the specialist advisory group (SAG), which is chaired by the Director of IPC (DIPC) and Chief Nurse, Rachael Corser, and was formed during the pandemic so that clinical and non-clinical experts could discuss, scrutinise and review new guidance and proposals.
Challenges
The DIPC and members of SAG were extremely supportive of the idea, and helped with pointing out likely challenges. Ward leaders were largely positive but concerned that overstretched and tired staff would feel burdened by having yet more documentation, which was understandable considering the already challenging circumstances. It was important to persuade the ward nurses and medical teams that this would not increase staff stress, but would help alleviate some of the challenges. Once they saw the actual care plan documents and were involved in the discussions at weekly nursing quality huddles, they could see that it would help to make guidance less complicated. Others, who felt more challenged with staffing levels and other issues due to the pandemic, were often convinced of the value of the care plan during outbreak meetings where a missed swabbing event was identified as being a possible cause.
Improving patient safety
The COVID-19 care plan improved patient testing by supporting staff to carry it out in a timely manner. It helped the staff to better prepare for assisted discharges; and allowed for asymptomatic positive patients to be picked up by swabbing routinely through the day on days 1, 3 and 7, then every seventh day, and 48 hours before discharge, according to the regimen. Many COVID-19-positive patients may not have been identified otherwise, leading to silent hospital outbreaks or patients leaving and unknowingly spreading the virus to friends, family and others.
It is difficult to directly relate the reduction in the number of outbreaks and cross-transmissions to this initiative alone, but what is clear is that the number of outbreaks, the number of patients involved in outbreaks, and the number of cross-transmission incidents began to settle and then decrease during the period in which the care plan was introduced in January 2021 compared with the periods of previous waves of COVID-19 infection, and relative to other organisations. This has not only improved patient safety, it has also helped to keep the staff safe through knowing their patients' status.
Evolving plans
Our goal was always to keep evolving and innovating as we learned the lessons of the pandemic. Although the requirements that were present at the beginning of this project are no longer the same today, this does not mean that this innovation has been wasted.
A couple of nurses who work on a medical ward designed a Microsoft Excel swabbing record system to use on their ward, in an attempt to create an electronic version. Due to issues such as some information governance challenges, this was initially explored but not pursued in this format. However, it did lead to work by the IT team, who began to create a completely bespoke system that could be used with existing platforms, was intuitive, was based on existing guidance and had clever algorithms that ensured that the staff felt supported. This was timely, as the nursing teams were moving forward with our trust digital transformation, highlighting the need to convert to a digital format that supported living with COVID-19. This work has already begun; and new algorithms, which can be complicated as they depend on whether a patient needs an LFT, a PCR test, or a combination, will be made accessible on a digital platform, with paper versions for areas not yet digitally linked; all with the help of our amazing IT colleagues.
The swabbing requirements have changed recently, and the need for asymptomatic swabbing has decreased – with a pause in asymptomatic patient swabbing in most inpatient circumstances. However, the beauty of the new IT care plan is that it can be adapted and modified as the requirements change, to help keep our patients and staff as safe as possible.
Who knows what the winter will bring, but one thing I do know is that the IPC team that I work alongside, along with others up and down the country, will continue to strive to be flexible, adaptable, and focused on doing the best we can, with the best available evidence to hand, and with our multidisciplinary colleagues' collaboration and support.